MONOGRAPH SIXTEEN 

16 

ASSIST 

NCI TOBACCO CONTROL MONOGRAPH SERIES 

T l 

National Institutes of Health 

National Cancer Institute 

Shaping the Future of Tobacco Prevention and Control 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 
DEPARTMENT OF HEALTH AND HUMAN SERVICES 

National Institutes of Health 

National Cancer Institute 

16 MONOGRAPH SIXTEEN 

ASSIST 

Shaping the Future of Tobacco Prevention and Control 

NCI TOBACCO CONTROL MONOGRAPH SERIES

Other NCI Tobacco Control Monographs


Strategies to Control Tobacco Use in the United States: A Blueprint for Public Health Action in 

the 1990’s. Smoking and Tobacco Control Monograph No. 1. NIH Pub. No. 92-3316, December 

1991. 

Smokeless Tobacco or Health: An International Perspective. Smoking and Tobacco Control 

Monograph No. 2. NIH Pub. No. 92-3461, September 1992. 

Major Local Tobacco Control Ordinances in the United States. Smoking and Tobacco Control 

Monograph No. 3. NIH Pub. No. 93-3532, May 1993. 

Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. Smoking 

and Tobacco Control Monograph No. 4. NIH Pub. No. 93-3605, August 1993. 

Tobacco and the Clinician: Interventions for Medical and Dental Practice. Smoking and Tobacco Control Monograph No. 5. NIH Pub. No. 94-3693, January 1994. 

Community-based Interventions for Smokers: The COMMIT Field Experience. Smoking and Tobacco Control Monograph No. 6. NIH Pub. No. 95-4028, August 1995. 

The FTC Cigarette Test Method for Determining Tar, Nicotine, and Carbon Monoxide Yields of 

U.S. Cigarettes. Report of the NCI Expert Committee. Smoking and Tobacco Control Monograph No. 7. NIH Pub. No. 96-4028, August 1996. 

Changes in Cigarette Related Disease Risks and Their Implications for Prevention and Control. 

Smoking and Tobacco Control Monograph No. 8. NIH Pub. No. 97-4213, February 1997. 

Cigars: Health Effects and Trends. Smoking and Tobacco Control Monograph No. 9. NIH Pub. 

No. 98-4302, February 1998. 

Health Effects of Exposure to Environmental Tobacco Smoke. Smoking and Tobacco Control 

Monograph No. 10. NIH Pub. No. 99-4645, August 1999. 

State and Local Legislative Action to Reduce Tobacco Use. Smoking and Tobacco Control 

Monograph No. 11. NIH Pub. No. 00-4804, August 2000. 

Population Based Smoking Cessation. Smoking and Tobacco Control Monograph No. 12. NIH 

Pub. No. 00-4892, November 2000. 

Risks Associated with Smoking Cigarettes with Low Machine-Measured Yields of Tar and Nicotine. Smoking and Tobacco Control Monograph No. 13. NIH Pub. No. 02-5047, October 2001. 

Changing Adolescent Smoking Prevalence. Smoking and Tobacco Control Monograph No. 14. 

NIH Pub. No. 02-5086, November 2001. 

Those Who Continue to Smoke. Smoking and Tobacco Control Monograph No. 15. NIH Pub. 

No. 03-5370, September 2003. 

Note, when citing this monograph in other works, please use the following format: 

National Cancer Institute. ASSIST: Shaping the Future of Tobacco Prevention and Control. Tobacco Control Monograph No. 16. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute. NIH Pub. No. 05-5645, 

May 2005. 

ii 
Dedication


This monograph is dedicated to the thousands of people across the United States 

and beyond who participated in the ASSIST project in one way or another. ASSIST 

was a unique, groundbreaking effort in tobacco prevention and control that changed 

the landscape of the field over the decade of the 1990s. This project could not have 

been successfully completed without the commitment and tireless efforts of the many 

people who were part of ASSIST—this book is dedicated to all of you! Numerous 

practitioners, advocates, and scientists were oriented or trained in the discipline of tobacco prevention and control during the ASSIST years. Many of them have gone on to 

become or have continued as leaders in tobacco prevention and control and public 

health across the United States and in several other countries as well. 

Virtually every major public health organization in the United States that is a significant player in the tobacco control movement includes people who spent important formative years of their careers contributing to the success and innovations of ASSIST. 

These people are far too numerous to mention by name, but you know who you are! 

The Senior Scientific Editors are extraordinarily grateful for your efforts and your resolve. 

Of these, three important leaders completed their long, dedicated careers of public service 

in the federal government pursuing the tobacco-use-reduction goals of ASSIST and deserve special recognition for their critical contributions to the project and the field: 

Mary P. “Mimi” Henry, William R. Lynn, and Donald R. Shopland. Together, they provided more than 101 years of dedicated public service. The tobacco control community 

and the Senior Scientific Editors are indeed eternally indebted to them. 

iii 
A Note from the Series Editor


With this volume, the National Cancer Institute (NCI) presents the 16th monograph 

of the Tobacco Control Monograph series and a new design to facilitate readability. 

NCI remains strongly committed to furthering the science of tobacco prevention and 

control through the timely discussion of evidence-based research, emerging issues, and 

program and policy applications. By producing and disseminating the Tobacco Control 

Monographs, NCI seeks to increase the impact of tobacco control research and enhance the translation of research to practice and policy. 

Preventing, reducing, and treating tobacco use and tobacco-related cancers across all 

ages and populations are critical to and in keeping with NCI’s goal to reduce the suffering and death due to cancer. 

Several other monographs are in production at this time on a wide range of topics. 

Further details about the new series will be presented in future volumes. 

Stephen E. Marcus, Ph.D. 

Epidemiologist and Monograph Series Editor 

Tobacco Control Research Branch 

Behavioral Research Program 

Division of Cancer Control and Population Sciences 

May 2005 

iv 
Foreword


I have long been committed to eliminating tobacco use in all its forms throughout 

the United States and around the world. I have been widely quoted, including in this 

monograph, as working tirelessly toward a smoke-free society by the year 2000 because I firmly believed that this was then and is now our most important public health 

goal. I regret that we have not fully achieved this lofty goal. However, I believe that by 

setting such ambitious goals and working diligently toward their achievement, we have 

made tremendous strides toward reducing the incredible addiction, disease, disability, 

and death caused by tobacco use. 

The American Stop Smoking Intervention Study for Cancer Prevention, widely 

known as ASSIST, was conceived while I was Surgeon General and was implemented 

during the 1990s, a decade of significant progress throughout the entire field of tobacco prevention and control. ASSIST contributed to many of these advances in important 

ways, including (1) demonstrating a strong emphasis on comprehensive policy change, 

(2) using a strategic approach to media interventions, (3) creatively using media advocacy to achieve policy goals, and (4) defining a new standard for training and technical 

assistance to ensure that public health practitioners have the skills and resources needed to attain successfully their ambitious objectives. In addition, ASSIST staff and volunteers learned a great deal about the vast resources of the tobacco industry and its 

fierce determination to use those resources to thwart any public health efforts that 

might encroach on their huge profits. This monograph provides new insights regarding 

tobacco industry strategies to interfere with ASSIST and its public health objectives. 

From my vantage point at the national level, I have seen the important role that 

ASSIST leaders and coalitions played in advancing smoking cessation efforts and tobacco containment. They were in the vanguard of these efforts and helped to fashion 

the next phase of comprehensive tobacco control interventions. I know that many of 

the readers of this monograph will have their own views about the lessons from 

ASSIST but as I have traveled the country, I have heard many of their stories and insights about the impact of this program on broader tobacco prevention and control efforts. In my estimation, several key points stand out as legacies of ASSIST: (1) the 

field of tobacco control continues to be staffed by many experts who learned about tobacco control issues and skills during ASSIST and who played key roles in implementing the conceptual model of ASSIST, (2) the strong emphasis on policy and media 

strategies to shift the focus from the individual to population-based interventions has 

had a long-lasting impact on behavioral health, and (3) designing interventions around 

a reliable evidence base is critical for building effective programs. I would add—since 

the ASSIST evaluation pointed out that states with more tobacco control activity had 

lower per capita cigarette consumption—(4) the lessons of ASSIST are broadly applicable to many public health disciplines and can be used immediately by others attempting to design and implement community-based health interventions. 

v 
F o r e w o r d 

Unfortunately, we have not yet fully achieved a smoke-free society. Even today, tobacco use remains the leading preventable cause of death in the United States, responsible for the deaths of over 440,000 people annually. But I see this smoke-free society 

as a clear goal that can be, indeed must be, reached in the foreseeable future. Working 

together, we have created an active, viable, committed tobacco control movement in 

the United States that has dramatically reformed our social norms about the acceptability of smoking and tobacco use. Smoking in public is no longer accepted, and the 

health risks of exposure to environmental tobacco smoke, also widely referred to as 

secondhand smoke, are known throughout the land. In fact, seven states have prohibited smoking in all workplaces, including restaurants and bars, and four more require all 

restaurants to be smoke-free. As state legislatures convene, many are considering similar legislation to protect the health and well-being of their citizens. These policies are 

important for many reasons, including, of course, protecting the health of employees 

and patrons of these establishments, but also because comprehensive workplace smoking policies do much to encourage quitting among smokers. Furthermore, between 

1998 and 2003, 35 states and the District of Columbia raised their excise taxes on tobacco products, a policy device known to all of us as one of the best tools for reducing 

cigarette consumption. 

Now, as better resources and support are available for smokers attempting to quit, 

we hope to increase their success rates. The National Network of Tobacco Cessation 

Quitlines is just one new resource available to provide services to smokers who are trying to stop by building on existing state efforts and the expertise of federal health agencies. Many employers are increasingly aware of the costs of their employees’ smoking 

habits and are using a broad range of strategies to address this problem—from shifting 

costs of higher health insurance premiums to individual employees, to providing additional coverage for cessation medications and counseling, to prohibiting all smoking in 

company facilities and throughout the surrounding grounds. 

One such example is a recent effort by the U.S. Department of Health and Human 

Services, called Tobacco-Free HHS, to eliminate the use of any tobacco products on all 

its properties, including buildings and grounds, and provide smoking cessation services 

to employees who smoke. The goal is to improve employee health by reducing smoking rates among all its employees and to provide a model policy for other employers. 

We must remember the importance of both supporting individual tobacco users who 

are trying to stop and providing supportive policies and an environment that encourages positive behavior change. It is critical to remain vigilant in our efforts not to blame 

the victim, but rather to provide support and evidence-based policies that help move individual behavior change in the right direction. We must never forget that the real 

source of the problem is an industry that has lied about and misrepresented the addictiveness and health hazards of their products for decades, with the intent of recruiting 

additional users. 

vi 
M o n o g r a p h 1 6. A S S I S T 

These successes—lower smoking prevalence rates, higher tobacco prices, clean indoor air that is free from secondhand smoke, reduced youth access to tobacco, and reduced exposure to tobacco advertising and promotion—were developed by a large 

group of individuals, organizations, and programs working collectively to reduce the 

addiction, disease, disability, and death caused by tobacco use. The public health professionals of ASSIST made key contributions that are described, with numerous case 

studies and vivid examples, throughout this monograph. 

The lessons of ASSIST are essential to the tobacco prevention and control movement and, perhaps even more important, to the entire field of public health. The concepts of building on a strong evidence base; designing interventions that will have 

broad population impacts; changing social norms in pursuit of greater justice; developing strong partnerships based on common goals and mutual respect; maintaining a determination not to be swayed or pushed off target by one’s adversaries; and ensuring a 

serious commitment to evaluation, self-reflection, and adaptation of strategies in midcourse are not unique to ASSIST. However, ASSIST brought these concepts to life and 

offered clear examples of how they can be used for advancing tobacco control and 

public health objectives. 

I am sure the reader will find this volume on ASSIST to be a helpful resource as 

public health practitioners and researchers work toward eradicating tobacco use in our 

society and designing other effective community-based interventions to improve the 

public’s health. I am grateful to those who made ASSIST the template for public health 

endeavors that it was. 

C. Everett Koop, M.D., Sc.D.


Surgeon General, U.S. Public Health Service, 1981–89


vii 
Preface


Just as the American Stop Smoking Intervention Study for Cancer Prevention 

(ASSIST) was a major shift in the National Cancer Institute’s (NCI’s) tobacco prevention and control research and dissemination efforts, this monograph is a significant 

departure from NCI’s previous tobacco control monographs. For many, the ASSIST 

project represented a logical progression of NCI’s phased-research approach to reducing tobacco use. For others, it represented a controversial and overly ambitious leap in 

a new direction. Similarly, this monograph departs from the traditional quantitative evidence review format to emphasize instead the practical, hands-on experience of program implementation. Traditional research investigators who defend the sanctity of the 

randomized clinical trial, many of whom were uncomfortable with ASSIST at its outset, will also be uncomfortable with the personal and anecdotal flavor of this monograph. Public health practitioners, on the other hand, as well as those investigators who 

have immersed themselves in the untidy world of implementation research, will appreciate the detailed historical accounts of the complexities, politics, and outright opposition encountered by the ASSIST team. The collective experiences described in this 

monograph provide a rich understanding of the gritty struggle against the powerful 

forces of the tobacco industry and its allies. For students in public health training programs, this work also provides a unique view of the world outside of academia, where 

commercial, political, and public health interests collide in a struggle to define the policies, norms, and practices that will affect the health of generations. 

Moving forward into a new millennium brings a renewed sense of commitment to 

tobacco prevention and control. Results from the Lung Health Study (LHS), a randomized smoking cessation clinical trial sponsored by the National Heart, Lung, and Blood 

Institute, strengthen the evidence that smoking is causally responsible for the increased 

risk for death in smokers.1

 In an editorial about the study, Dr. Jonathan Samet states, 

“No one can make a serious claim to the contrary in light of this randomized trial 

evidence.”2(p300) Released in February 2005, the findings show that lung cancer deaths 

decreased by more than 50% within 15 years of complete smoking cessation. Lead author Dr. Nicholas Anthonisen relates that lung cancer risk is probably still elevated after 15 years and that the biggest survival benefit accrued to participants 45 years of age 

and younger; therefore, “it could be argued ... that smoking cessation was most effective in preventing truly premature death.”1(p238) 

These findings also contain a key public health message—the importance of preventing tobacco use in the first place. Fewer than one-quarter of LHS’s participants 

were able to stop smoking. The addictive nature of nicotine has been well documented, 

including in a comprehensive report on this subject in 1988, The Health Consequences 

of Smoking: Nicotine Addiction: A Report of the Surgeon General.

3 ASSIST used an 

ecological approach not only to help smokers who wanted to quit but also to prevent 

tobacco use primarily among children, teens, and young adults. A statistically signifiviii 
M o n o g r a p h 1 6. A S S I S T 

cant decrease in smoking prevalence in ASSIST states was found compared with that 

in non-ASSIST states, and per capita decreases in consumption were associated with 

policy outcomes. It has been estimated that if the ASSIST project had been implemented nationwide, there would be at least 1,213,000 fewer smokers, with a corresponding 

decrease in premature death and disease. The evaluation and quantitative results of 

ASSIST are discussed in detail in a separate publication, Monograph 17 (Evaluating 

ASSIST: The Blueprint for Understanding State-Level Tobacco Control), and are briefly described at the beginning of this volume. 

The history of ASSIST began long before 1991, and its impact has continued since 

its end in 1999. ASSIST was based on research, conducted over the years at NCI and 

by other researchers, about which interventions were most likely to produce behavior 

change. Like other studies of this scope conducted in a government setting, ASSIST 

underwent a thorough concept review process. When conceived, it was called the 

American Stop Smoking Intervention Study for Cancer Prevention, which over time 

was informally shortened to the American Stop Smoking Intervention Study, and finally became know by its acronym. As tobacco use is a risk factor for many diseases, deleting “for cancer prevention” from the ASSIST name broadened the focus of the 

project and helped to expand the partnership to include other agencies and organizations such as the American Heart Association and the American Lung Association. 

ASSIST was launched through a collaborative public/private partnership between 

NCI and the American Cancer Society (ACS) that funded 17 state health departments. 

While continuing to recognize the importance of helping people to stop smoking, the 

ASSIST project focused on four policy changes that in turn would support a tobaccofree norm: (1) eliminating exposure to environmental tobacco smoke, (2) promoting 

higher taxes for tobacco, (3) limiting tobacco advertising and promotions, and (4) reducing minors’ access to tobacco products. 

ASSIST was the first comprehensive tobacco prevention and control program of its 

scope. It was originally conceived as a 7-year demonstration project, but leadership 

within the U.S. Department of Health and Human Services (DHHS) believed that it 

was important to maintain a commitment to national tobacco control activities and 

transitioned the administration of state-based programs to one governmental agency. 

An additional year was required to ensure a seamless transition that merged ASSIST 

into the newly established National Tobacco Control Program at the Centers for Disease Control and Prevention (CDC). 

This monograph is a product of authors and editors who were involved in the 

project—who had lived and experienced ASSIST for many years. With the exception 

of part 1 in chapter 8, “Tobacco Industry Challenge to ASSIST,” the monograph provides a qualitative and subjective view of the 8-year ASSIST project. The writers are 

dedicated to tobacco prevention and control and remain passionate about ASSIST. Numerous case studies are presented, not in the form of formal social research, but as stories and vignettes from state and local public health staff and volunteers that describe 

ix 
P r e f a c e 

their efforts—processes used, barriers encountered, lessons learned, and insights 

gleaned from these experiences. These case studies provide a flavor of the scope of 

ASSIST and give voice to the different perspectives of those involved. 

The scientific editors envision Monograph 16 being used by a variety of audiences, 

but the primary audiences are public health practitioners and their community partners. 

In keeping with NCI’s increased focus on the dissemination of research methods and 

tools, this monograph provides in-depth descriptions of intervention processes, examples of materials and best practices, and resource lists and guidance for activities such 

as media advocacy campaigns. Also included in appendix 5.A is a bibliography of 

ASSIST articles of interest and use to readers. 

As we release Monograph 16, it should be noted that the world’s first tobacco control treaty, the Framework Convention on Tobacco Control, which was negotiated by 

the World Health Organization, went into effect earlier this year. In addition to requiring ratifying nations to place graphic health warnings on cigarette packs, the treaty 

calls for actions that were key elements of ASSIST—imposing a ban on tobacco advertising, taking measures to protect nonsmokers from secondhand smoke, and increasing 

the cost of tobacco products. Although this monograph focuses on the experience in 

the United States, international readers may find it useful for garnering insight into effective processes for working with communities, the media, governing bodies, and the 

challenges presented by the tobacco industry. However, it is important to recognize differences in political and economic contexts that may influence efforts to implement 

policy-level interventions. 

Monograph 16 begins with the historical context of ASSIST and the scientific base 

that informed the design of the project. The conceptual framework and the development of organizational infrastructures for implementation and evaluation are then described. The heart of this monograph is the in-depth descriptions of ASSIST’s media 

advocacy and policy development interventions and the challenges posed by the tobacco industry. The monograph concludes by describing ASSIST’s contributions to tobacco control and other behavioral health interventions and the significant challenges that 

remain. 

Chapter 1: The Historical Context. Chapter 1 describes the activities and research 

foundation at NCI, ACS, and throughout the United States that led to the development 

of the ASSIST project and presents the evidence-based rationale for its conceptual 

model. 

Chapter 2: The Conceptual Framework. Chapter 2 chronicles the development of 

the conceptual framework used for planning and implementing each state’s ASSIST 

program. 

Chapter 3: Structure and Communications. Chapter 3 describes the national partners and state agencies in their respective roles and the communication linkages among 

all the structural units that promoted collaborative decision making and were essential 

for the project to function as a whole. 

x 
M o n o g r a p h 1 6. A S S I S T 

Chapter 4: Building National, State, and Local Capacity and Capability. This chapter describes the training of project staff and coalition members (1) to plan interventions that were responsive to each community’s needs and that were realistic in terms 

of the program’s readiness and resources and (2) to implement tobacco control policy 

and media advocacy interventions. 

Chapter 5: Media Interventions to Promote Tobacco Control Policies. Chapter 5 relates ASSIST’s approach to using a variety of media interventions to promote public 

health policies and illustrates how media advocacy was used to promote policies for a 

tobacco-free environment. 

Chapter 6: Public and Private Policy Interventions. Chapter 6 presents the ASSIST 

states’ intervention strategies to achieve policies that advance objectives in four tobacco control areas: eliminating exposure to environmental tobacco smoke, increasing the 

price of tobacco products, restricting tobacco advertising and promotions, and reducing 

youth access to tobacco products. Case studies of interventions and insights of staff 

and coalition members illustrate the process of mobilizing ordinary citizens to effect 

major policy change, despite opposition from the tobacco industry. 

Chapter 7: Program Services: Reaching the Individual. Chapter 7 describes the 

ASSIST approach to the delivery of program services. Rather than directly providing 

program services, ASSIST contractors encouraged, advised, and partnered with appropriate community organizations to ensure that such services were provided. 

Chapter 8: Tobacco Industry Challenge to ASSIST. The two parts of chapter 8 

present the tobacco industry’s challenges to ASSIST. Part 1 affords insights gleaned 

from previously confidential industry documents that became available as a result of 

the Minnesota settlement and the Master Settlement Agreement. Part 2 describes the 

tobacco industry challenges from the point of view of ASSIST personnel who experienced those challenges firsthand and sought ways to respond. 

Chapter 9: Planning Strategically for the Future. Chapter 9 chronicles the strategic 

planning approaches used from 1994 through 1998 at the local, state, and national levels to ensure that tobacco prevention and control programs would be incorporated into 

state and national infrastructures and would have sufficient funding to sustain the programs. 

Chapter 10: From Demonstration Project to Nationwide Program. Chapter 10 describes NCI’s and CDC’s processes and challenges in disseminating research and demonstration project results to public health practice as ASSIST came to an end. 

Chapter 11: The Promise of ASSIST. Chapter 11 relates how the effective application of the ASSIST core elements contributed to a fundamental shift in the approach to 

tobacco use prevention and control and other behavioral health interventions. 

ASSIST represents the continuation of an ongoing evolution in public health, from 

its roots in controlling diseases to a more activist role in addressing underlying social 

xi 
P r e f a c e 

determinants of health. As a demonstration project, the most effective interventions 

were incorporated into ASSIST’s community-based study design and successfully implemented in 17 states. The insights and lessons learned from ASSIST that are described in this monograph have (1) advanced our understanding of translating and 

disseminating research studies and demonstration project results; (2) increased our appreciation of the dose-response relationship between funding levels and effective tobacco prevention and control programs; (3) broken new ground in evaluation 

methodology for complex public health interventions that are diffused throughout a 

population; and (4) informed NCI’s research agenda to encourage partnerships among 

scientists, state tobacco control programs, and tobacco control advocates. 

Maintaining the capacity built by demonstration projects has been one of our greatest challenges in dissemination. As described in chapter 10, in 1999 NCI achieved one 

of its major ASSIST-related goals: by the year 2000 to advance from phase V—demonstration and implementation—to phase VI—mass application for the benefit of public 

health. The processes used to maintain ASSIST’s capacity during the transition from 

NCI to CDC underscore the importance of one of ASSIST’s strongest elements for implementing effective community-based, policy-focused public health programs: participatory decision making and inclusion of all partners. 

I believe that the experiences and insights described in this monograph provide valuable and practical guidance for public health workers and tobacco prevention and control advocates and provide a rich source of new hypotheses to guide future research. 

Robert T. Croyle, Ph.D.


Director, Division of Cancer Control and Population Sciences


References 

1. Anthonisen, N. R., M. A. Skeans, R. A. Wise, J. Manfreda, R. E. Kanner, and J. E. Connett. 

2005. The effects of a smoking cessation intervention on 14.5-year mortality. Annals of Internal Medicine 142 (4): 233–9. 

2.	 Samet, J. M. 2005. Smoking kills: Experimental proof from the Lung Health Study. Annals 

of Internal Medicine 142 (4): 299–301. 

3.	 U.S. Department of Health and Human Services. 1988. The health consequences of smoking: 

Nicotine addiction: A report of the surgeon general. Atlanta: U.S. Department of Health and 

Human Services, Centers for Disease Control and Prevention, National Center for Chronic 

Disease Prevention and Health Promotion, Office on Smoking and Health. 

xii 
The Evaluation of the American Stop Smoking 

Intervention Study for Cancer Prevention (ASSIST) 

The ASSIST evaluation had to address daunting challenges—the project was complex, it was a natural experiment with no clear control sites, and the resources for the 

evaluation were limited. By necessity, it focused only on those components of the 

project that could be quantified as part of the evaluation conceptual framework—not 

all components of the ASSIST project could be evaluated. This monograph, ASSIST: 

Shaping the Future of Tobacco Prevention and Control, and the next in this series, 

Monograph 17, Evaluating ASSIST: A Blueprint for Understanding State-Level Tobacco Control, are designed as companion documents. Whereas Monograph 16 focuses on 

the conceptualization of the ASSIST project, the processes and interventions used to 

implement ASSIST, and the transition of ASSIST from a demonstration project to the 

National Tobacco Control Program, Monograph 17 addresses the evaluation framework, the details of the ASSIST evaluation, and the results of this effort. Following is a 

brief overview of this upcoming NCI publication. 

Monograph 17. Evaluating ASSIST: A Blueprint for Understanding 

State-Level Tobacco Control 

The ASSIST evaluation broke new ground in the assessment of public health interventions that are diffused throughout a population and outside the bounds of a randomized controlled clinical trial through the use of a validated metric known as the 

Strength of Tobacco Control (SoTC) index and a policy outcomes measure, the Initial 

Outcomes Index (IOI). These measures correlated with eventual public health outcomes, such as changes in smoking prevalence and consumption, and the individual 

constructs of SoTC—namely, resources, capacity, and efforts—and relate directly to 

measurable indicators at the state level. 

This evaluation demonstrates that the ASSIST project clearly benefited public 

health. It also documents a successful approach to assessing complex public health 

programs and can serve as a guide for current and future tobacco control efforts. The 

evaluation methodologies and indices may also be applied to other complex community-based interventions beyond the field of public health. 

Below are the major topics addressed in Monograph 17: 

■	 The ASSIST evaluation framework and key constructs 

■	 The development of the SoTC index, its descriptive characteristics, and examples of 

how it can be used to assess and improve state tobacco control programs 

■	 Difficulties associated with attempts to measure tobacco industry counterefforts, 

along with potential solutions 

xiii 
A S S I S T E v a l u a t i o n 

■	 Documentation of the ASSIST media interventions, including methods used to 

identify, code, and analyze newspaper coverage of the four priority policy areas 

■	 Methods used to track and measure changes in state and local clean indoor air laws 

■	 A measure created to reflect a state’s dependence on tobacco, which may affect 

implementation of comprehensive tobacco control programs 

■	 Demographic, economic, sociopolitical, and geographic factors that might affect the 

evaluation of a tobacco control program 

■	 The development of the IOI, which assessed the policy outcomes of states’ tobacco 

control efforts 

■	 The methodology and outcomes of the ASSIST evaluation 

■	 Econometric techniques used to assess the cost-effectiveness of the ASSIST project 

■	 The generalizability of the ASSIST evaluation efforts to other public health 

initiatives 

The evaluation found that ASSIST states showed a statistically significant decrease 

in smoking prevalence compared with non-ASSIST states and that per capita decreases 

in consumption were associated with policy outcomes. The evaluators estimated that if 

the ASSIST program had been implemented nationwide, there would be at least 

1,213,000 fewer smokers, with a corresponding decrease in premature death and disease. 

Beyond its desired outcomes in tobacco use and public health, the lessons learned 

from the ASSIST evaluation have important implications for the future of public health. 

It broke new ground in the assessment of evidence-based public health practices, particularly in situations where randomized controlled trials are not possible. Because of its 

size and scope, the ASSIST evaluation represents a trend away from simple cause-andeffect relationships toward understanding the behavior of systems. It serves as a precursor to growing systems and network approaches that are helping us to understand more 

complex and interdependent behavior in real-world public health interventions. 

xiv 
Acronyms List


ACLF American Constitutional Law Foundation 

ACS American Cancer Society 

AFL-CIO American Federation of Labor-Congress of Industrial Organizations 

AHA American Heart Association 

ALA American Lung Association 

ALE Division of Alcohol Law Enforcement (North Carolina) 

AMA American Medical Association 

ANR Americans for Nonsmokers’ Rights 

ASSIST American Stop Smoking Intervention Study for Cancer Prevention 

ASTHO Association of State and Territorial Health Officials 

CDC Centers for Disease Control and Prevention 

CEC Colorado Executive Committee 

COMMIT Community Intervention Trial for Smoking Cessation 

CPS Current Population Survey 

CTFC Coalition for a Tobacco-Free Colorado 

CTFK Campaign for Tobacco-Free Kids 

CVD cardiovascular disease 

DCPC Division of Cancer Prevention and Control 

DDA Downtown Development Authority (Grand Rapids, MI) 

DHHS Department of Health and Human Services 

DHS Department of Human Services (Maine) 

DOC Doctors Ought to Care 

DOH Department of Health 

ECS electronic communications system 

EPA Environmental Protection Agency 

ETS environmental tobacco smoke 

FAR Federal Acquisition Regulations 

FASA Federal Acquisition Streamlining Act 

FASS/T Females Against Secondhand Smoke and Tobacco 

FCC Federal Communications Commission 

FDA Food and Drug Administration 

FOIA Freedom of Information Act 

FSHC Fair Share for Health Committee 

FTC Federal Trade Commission 

GASO Great American Smokeout 

HCFA Health Care Financing Administration 

IMPACT Initiatives to Mobilize for the Prevention and Control of Tobacco Use 

INFACT Infant Formula Action Coalition 

IOI Initial Outcomes Index 

xv 
A c r o n y m s L i s t 

IOM Institute of Medicine 

IQ Health Institute for Quality Health (University of Virginia) 

IRC Internal Revenue Code 

JOFOC Justification of Other Than Full and Open Competition 

MASCOT Multicultural Advocates for Social Change on Tobacco (New Mexico) 

MDH Minnesota Department of Health 

MMWR Morbidity and Mortality Weekly Report 

MSA Master Settlement Agreement 

MSEC Mountain States Employers Council 

MTCP Massachusetts Tobacco Control Program 

NAAAPI National Association of African Americans for Positive Imagery 

NAACP National Association for the Advancement of Colored People 

NACCHO National Association of County and City Health Officials 

NALBOH National Association of Local Boards of Health 

NCAB National Cancer Advisory Board 

NCI National Cancer Institute 

NCTFK National Center for Tobacco-Free Kids 

NHLBI National Heart, Lung, and Blood Institute 

NIAID National Institute of Allergy and Infectious Diseases 

NIDA National Institute on Drug Abuse 

NIH National Institutes of Health 

NIOSH National Institute for Occupational Safety and Health 

NTCP National Tobacco Control Program 

OSH Office on Smoking and Health 

OSHA Occupational Safety and Health Administration 

PM Philip Morris Inc. 

PSA public service announcement 

RJR R.J. Reynolds Tobacco Company 

RWJF The Robert Wood Johnson Foundation 

SAMHSA Substance Abuse and Mental Health Services Administration 

SCARCNet Smoking Control Advocacy Resource Center Network 

SoTC Strength of Tobacco Control 

STAT Stop Teenage Addiction to Tobacco 

STCP Smoking, Tobacco, and Cancer Program 

STN site trainers network 

TAT training and technical assistance 

TRISCI Tobacco Research Initiative for State and Community Interventions 

TRU Teenage Research Unlimited 

TTAC Tobacco Technical Assistance Consortium 

UMF University of Maine at Farmington 

VDH-TUCP Virginia Department of Health Tobacco Use Control Program 

xvi

Acknowledgments


This monograph was developed by the National Cancer Institute under the editorial 

direction of Senior Scientific Editors Brenda McAdams Motsinger and Robert E. 

Vollinger Jr. An Editorial Review Board was established to provide guidance and 

technical assistance for monograph development and, along with others, to provide 

content review of chapters. In addition, individual chapters of this monograph and the 

entire volume were subjected to extensive peer review and revision. 

The Senior Scientific Editors gratefully acknowledge the Editorial Review Board, 

and the many authors, contributors, and reviewers who made this monograph possible 

through their numerous hours of writing and review. Authors and contributors for each 

chapter are listed below, and the list of reviewers and members of the Editorial Review 

Board follows. 

Darla Havlicek Authors and Contributors 

Health Integration Advisor 

HealthPartners, Inc.


Center for Health Promotion


Chapter 1 

Authors Minneapolis, MN Robert E. Vollinger Jr., M.S.P.H. John M. Garcia, M.Sc. Program Director, Public Health Advisor Director of Chronic Disease Prevention Tobacco Control Research Branch 

Behavioral Research Program and Health

Division of Cancer Control and Population Promotion Branch, Public Health Division 

Ministry of Health Sciences


National Cancer Institute Toronto, Ontario, Canada


Bethesda, MD Robert E. Vollinger Jr., M.S.P.H. 

Robert W. Moon, M.P.H. Program Director, Public Health Advisor 

Tobacco Control Research Branch Senior Partner 

Northwest Health Partners, LLC Behavioral Research Program 

Helena, MT Division of Cancer Control and Population 

Sciences 

Peter Greenwald, M.D., Dr.P.H. National Cancer Institute 

Director, Division of Cancer Prevention Bethesda, MD National Cancer Institute 

Bethesda, MD Brenda McAdams Motsinger, M.S. 

Head, Health Promotion Branch 

Division of Public Health Chapter 2 North Carolina Department of Health and

Authors Human Services 

Raleigh, NC 

Senior Partner 

Northwest Health Partners, LLC 

Helena, MT 

Robert W. Moon, M.P.H. 

xvii 
A c k n o w l e d g m e n t s 

Contributor 

Frances A. Stillman, Ed.D. 

Co-Director, Institute for Global Tobacco 

Control 

Associate Research Professor, Department 

of Epidemiology 

Johns Hopkins University 

Baltimore, MD 

Chapter 3 

Authors 

John K. Beasley, M.A. 

Program Director 

Center for Tobacco Use Prevention and 

Research 

Okemos, MI 

John M. Garcia, M.Sc. 

Director of Chronic Disease Prevention 

and Health Promotion Branch 

Public Health Division 

Ministry of Health 

Toronto, Ontario, Canada 

Jerie Jordan 

Program Consultant 

Program Services Branch 

Office on Smoking and Health 

Centers for Disease Control and 

Prevention 

Atlanta, GA 

Donna Grande, M.G.A. 

Director 

Office of Program Development 

American Medical Association 

Chicago, IL 

Contributors 

Thomas J. Kean, M.P.H. 

President


Strategic Health Concepts, Inc.


Englewood, CO


Gael A. O’Sullivan, M.B.A. 

Project Manager 

American Institutes for Research, Health 

Program 

Silver Spring, MD 

Chapter 4 

Authors 

Robert H. Anderson, M.A., CHES 

Deputy Director 

Centers for Public Health Research and 

Training 

Department of Community Medicine 

West Virginia University 

Morgantown, WV 

Amber Hardy Thornton, M.P.H., CHES 

Executive Vice President for Program 

Development 

American Legacy Foundation 

Washington, DC 

Brenda McAdams Motsinger, M.S. 

Head, Health Promotion Branch 

Division of Public Health 

North Carolina Department of Health and 

Human Services 

Raleigh, NC 

Contributors 

Milly Krakow, Ph.D. 

Krakow Consulting 

Chestnut Hill, MA 

Harriet Robbins, M.Ed. 

Special Advisor 

Massachusetts Department of Public 

Health 

Boston, MA 

xviii 
M o n o g r a p h 1 6. A S S I S T 

Chapter 5 

Authors 

Patrick L. Remington, M.D., M.P.H. 

Director, Wisconsin Public Health and 

Health Policy Institute 

Associate Professor, Population Health 

Sciences 

University of Wisconsin 

Madison, WI 

C. Ann Houston, CHES 

Director of Public Education and 

Communication 

Tobacco Prevention and Control Branch 

Division of Public Health 

North Carolina Department of Health and 

Human Services 

Charlotte, NC 

Lynn C. Cook, M.H.S., CHES 

Prevention Project Director 

Danya International, Inc. 

Silver Spring, MD 

Contributors 

Germaine Dennaker, M.A. 

Coordinator 

Rhode Island Department of Health 

Providence, RI 

Brenda Grant 

Charleston Area Medical Center 

Charleston, WV 

Carol Hall-Walker, M.P.A. 

Manager, Media and Communications 

Chronic Disease Prevention and Control 

Rhode Island Department of Health 

Providence, RI 

Thomas J. Kean, M.P.H. 

President


Strategic Health Concepts, Inc.


Englewood, CO


Johnny Kincaid 

Executive Director 

Smokefree Communities 

Evansville, IN 

Helen Matheny, M.S. 

Director of Communications and Health 

Programs 

West Virginia State Medical Association 

Charleston, WV 

Sally Herndon Malek, M.P.H. 

Head, Tobacco Prevention and Control 

Branch 

Division of Public Health 

North Carolina Department of Health and 

Human Services 

Raleigh, NC 

Dianne May 

Project Officer 

Program Services Branch 

Office on Smoking and Health 

Centers for Disease Control and 

Prevention 

Atlanta, GA 

Anne Marie O’Keefe, Ph.D., J.D. 

BETAH Associates, Inc. 

Bethesda, MD 

Harriet Robbins, M.Ed. 

Special Advisor 

Massachusetts Department of Public 

Health 

Boston, MA 

Margaret Thomas 

Editor 

Smoke Free Zone 

Providence, RI 

Marge White 

Deputy Director 

Virginia Tobacco Settlement Foundation 

Richmond, VA 

xix 
A c k n o w l e d g m e n t s 

Chapter 6 

Authors 

Sally Herndon Malek, M.P.H. 

Head, Tobacco Prevention and Control 

Branch 

Division of Public Health 

North Carolina Department of Health and 

Human Services 

Raleigh, NC 

Robert E. Vollinger Jr., M.S.P.H. 

Program Director, Public Health Advisor 

Tobacco Control Research Branch 

Behavioral Research Program 

Division of Cancer Control and Population 

Sciences 

National Cancer Institute 

Bethesda, MD 

Stephen Babb, M.P.H. 

Health Education Specialist 

Health Communications Branch 

Office on Smoking and Health 

Centers for Disease Control and Prevention 

Atlanta, GA 

Karla S. Sneegas, M.P.H. 

Executive Director 

Indiana Tobacco Prevention and Cessation 

Indianapolis, IN 

Donald R. Shopland 

Ringgold, GA 

Contributors 

Kenneth Adami 

American Cancer Society, Massachusetts 

Division 

Boston, MA 

Patrick Cobb, M.D. 

Oncologist 

Billings, MO 

Lori Fresina 

Regional Advocacy Representative for 

New England 

Campaign for Tobacco-Free Kids 

Wilmington, MA 

Jim Harrington, M.S. 

Health Educator 

Marquette County Health Department 

Negaunee, MI 

C. Ann Houston, CHES 

Director of Public Education and 

Communication 

Tobacco Prevention and Control Branch 

Division of Public Health 

North Carolina Department of Health and 

Human Services 

Charlotte, NC 

Anne Landman 

Independent Tobacco Document 

Researcher and Consultant 

Glade Park, CO 

Patricia Lindsey, M.S. 

Editor and Program Director 

Tobacco-Free Missouri 

St. Louis, MO 

Jim D. Martin, M.S. 

State Advisor on Preventing Teen Tobacco 

Use 

Tobacco Prevention and Control Branch 

Division of Public Health 

North Carolina Department of Health and 

Human Services 

Raleigh, NC 

Tim Nichols 

Director of Government Affairs 

American Lung Association of New York 

State 

Albany, NY 

Krista V. Schaafsma, MT (ASCP), 

NCTAS 

Principal 

Prevention Pointe, LLC 

Orem, UT 

Russell Sciandra, M.A. 

Director 

Center for a Tobacco Free New York 

Albany, NY 

xx 
M o n o g r a p h 1 6. A S S I S T 

Sue Vermeulen 

Executive Director 

King County Nurses Association 

Seattle, WA 

Gregory White 

American Lung Association of South 

Carolina 

Columbia, SC 

Marge White 

Deputy Director 

Virginia Tobacco Settlement Foundation 

Richmond, VA 

Chapter 7 

Authors 

Jane Pritzl, M.A. 

Intervention Scientist 

Centers for Disease Control and Prevention 

Division of Adolescent and School Health 

Atlanta, GA 

Walter ‘Snip’ Young, Ph.D., M.A. 

Scientist 

The Cooper Institute 

Golden, CO 

Contributors 

Melissa Albuquerque 

Atlanta, GA 

John K. Beasley, M.A. 

Program Director 

Center for Tobacco Use Prevention and 

Research 

Okemos, MI 

G. Lea Bryant, Ph.D. 

Professor 

Department of Community Health and 

Recreation 

University of Maine at Farmington 

Farmington, ME 

Sandra Colt 

Tobacco Prevention and Control Branch 

Division of Public Health 

North Carolina Department of Health and 

Human Services 

Asheville, NC 

Lynn C. Cook, M.H.S., CHES 

Prevention Project Director 

Danya International, Inc. 

Silver Spring, MD 

Glenna Davenport-Cook 

Catawba Springs Elementary School 

Denver, NC 

Linda Gamble, M.A., M.Ed. 

Special Projects Coordinator 

University of Maine at Farmington 

Farmington, ME 

Kitty Jerome, M.A. 

Senior Program Consultant 

Robert Wood Johnson Foundation 

Jim D. Martin, M.S. 

State Advisor on Preventing Teen Tobacco 

Use 

Tobacco Prevention and Control Branch 

Division of Public Health 

North Carolina Department of Health and 

Human Services 

Raleigh, NC 

Gael A. O’Sullivan, M.B.A. 

Project Manager 

American Institutes for Research, Health 

Program 

Silver Spring, MD 

Tracy Enright Patterson, M.A. 

Deputy Director 

Substance Abuse Policy Research Program 

Center for Creative Leadership 

Greensboro, NC 

Mikelle Robinson, M.A. 

Manager 

Michigan Tobacco Control Program 

Lansing, MI 

xxi 
A c k n o w l e d g m e n t s 

Chapter 8, Part 1 

Authors 

Jenny White, M.Sc., M.P.H. 

Research Analyst 

Department of Clinical Pharmacy 

University of California, San Francisco 

San Francisco, CA 

Lisa Bero, Ph.D. 

Professor 

Department of Clinical Pharmacy and 

Institute for Health Policy Studies 

University of California, San Francisco 

San Francisco, CA 

Chapter 8, Part 2 

Authors 

Anne Marie O’Keefe, Ph.D., J.D. 

BETAH Associates, Inc. 

Bethesda, MD 

Timothy W. Filler 

TimFiller.com 

Indianapolis, IN 

Jerie Jordan 

Program Consultant 

Program Services Branch 

Office on Smoking and Health 

Centers for Disease Control and Prevention 

Atlanta, GA 

Walter ‘Snip’ Young, Ph.D., M.A. 

Scientist 

The Cooper Institute 

Golden, CO 

Contributors 

Russell Sciandra, M.A. 

Director 

Center for a Tobacco Free New York 

Albany, NY 

Jeanne Weigum 

President 

Association for Nonsmokers’ Rights 

St. Paul, MN 

Randy H. Schwartz, M.S.P.H. 

Senior Vice President for Cancer Control 

American Cancer Society, New England 

Division 

Framingham, MA 

Chapter 9 

Authors 

Nancy Salas, M.B.A. 

Consultant 

Tobacco Prevention 

Denver, CO 

Brenda McAdams Motsinger, M.S. 

Head, Health Promotion Branch 

Division of Public Health 

North Carolina Department of Health and 

Human Services 

Raleigh, NC 

Kelly Bishop Alley, M.A., CHES 

Executive Director 

Alliance for Health Promotion 

Indianapolis, IN 

Contributors 

Deborah Borbely, M.S., CHES 

Lead Health Education Specialist 

Program Services Branch 

Office on Smoking and Health 

Centers for Disease Control and 

Prevention 

Atlanta, GA 

Neil Bracht, M.S.W., M.P.H. 

Professor Emeritus, University of 

Minnesota, and Community Health 

Consultant 

Stacy, MN 

Joy Epstein, M.P.A. 

Special Assistant to the Director 

Office of International and Refugee Health 

Department of Health and Human Services 

Rockville, MD 

xxii 
M o n o g r a p h 1 6. A S S I S T 

John M. Garcia, M.Sc. 

Director of Chronic Disease Prevention 

and Health Promotion Branch 

Public Health Division 

Ministry of Health 

Toronto, Ontario, Canada 

David Harrelson 

Tobacco Prevention and Control Specialist 

Washington State Department of Health 

Olympia, WA 

Gloria Latimer, Ed.S. 

Program Director 

Cardiovascular Disease and Stroke 

Prevention 

Colorado Department of Public Health and 

Environment 

Denver, CO 

Dearell R. Niemeyer, M.P.H. 

Pearson Education 

Atlanta, GA 

Marianne Ronan, M.P.A. 

Bureau Chief 

Bureau of Cancer Control 

Division of Chronic Disease and Health 

Promotion 

Missouri Department of Health 

Columbia, MO 

André G. Stanley, M.P.H. 

Assistant Director 

Office of Minority Health 

South Carolina Department of Health and 

Environmental Control 

Columbia, SC 

Gael A. O’Sullivan, M.B.A. 

Project Manager 

American Institutes for Research, Health 

Program 

Silver Spring, MD 

Carol A. Winner 

Vice President 

Division of Health Promotion 

Z-Tech Corporation 

Rockville, MD 

Chapter 10 

Authors 

Brenda McAdams Motsinger, M.S. 

Head, Health Promotion Branch 

Division of Public Health 

North Carolina Department of Health and 

Human Services 

Raleigh, NC 

Dearell R. Niemeyer, M.P.H. 

Pearson Education 

Atlanta, GA 

Jerie Jordan 

Program Consultant 

Program Services Branch 

Office on Smoking and Health 

Centers for Disease Control and 

Prevention 

Atlanta, GA 

William R. Lynn 

The Villages, FL 

Contributors 

Gretchen Griffin, M.P.H. 

Coordinator, Youth Risk Behavior 

Endowment 

Minnesota Department of Health 

St. Paul, MN 

R. Neal Graham, M.S.Ed.

Executive Director 

Virginia Primary Care Association 

Richmond, VA 

Chapter 11 

Authors 

Brenda McAdams Motsinger, M.S. 

Head, Health Promotion Branch 

Division of Public Health 

North Carolina Department of Health and 

Human Services 

Raleigh, NC 

xxiii 
A c k n o w l e d g m e n t s 

Robert E. Vollinger Jr., M.S.P.H. 

Program Director, Public Health Advisor 

Tobacco Control Research Branch 

Behavioral Research Program 

Division of Cancer Control and Population 

Sciences 

National Cancer Institute 

Bethesda, MD 

Dearell R. Niemeyer, M.P.H. 

Pearson Education 

Atlanta, GA 

Contributor 

Frances A. Stillman, Ed.D. 

Co-Director, Institute for Global Tobacco 

Control 

Associate Research Professor, Department 

of Epidemiology 

Johns Hopkins University 

Baltimore, MD 

Reviewers 

Chapter Reviewers 

Cathy L. Backinger, Ph.D., M.P.H. 

Acting Branch Chief 

Tobacco Control Research Branch 

Behavioral Research Program 

Division of Cancer Control and Population 

Sciences 

National Cancer Institute 

Bethesda, MD 

John K. Beasley, M.A. 

Program Director 

Center for Tobacco Use Prevention and 

Research 

Okemos, MI 

Michele Bloch, M.D., Ph.D. 

Medical Officer 

Tobacco Control Research Branch 

Behavioral Research Program 

Division of Cancer Control and Population 

Sciences 

National Cancer Institute 

Bethesda, MD 

Deborah Borbely, M.S. 

Lead Health Education Specialist 

Program Services Branch 

Office on Smoking and Health 

Centers for Disease Control and 

Prevention 

Atlanta, GA 

Helene G. Brown 

Associate Director 

Jonsson Comprehensive Cancer Center 

University of California at Los Angeles 

Los Angeles, CA 

Gregory N. Connolly, D.M.D., M.P.H. 

Instructor 

Harvard School of Public Health 

Division of Public Health Practice 

Boston, MA 

Richard Daynard, J.D., Ph.D. 

Chief, Tobacco Product Liability Project 

Northeastern University School of Law 

Boston, MA 

Monica H. Eischen 

Program Consultant 

Program Services Branch 

Office on Smoking and Health 

Centers for Disease Control and 

Prevention 

Atlanta, GA 

Joy Epstein, M.P.A. 

Special Assistant to the Director 

Office of International and Refugee Health 

Department of Health and Human Services 

Rockville, MD 

Allan Erickson 

Atlanta, GA 

Harmon Eyre, M.D. 

Chief Medical Officer 

American Cancer Society 

Atlanta, GA 

xxiv 
M o n o g r a p h 1 6. A S S I S T 

Pebbles Fagan, Ph.D., M.P.H. 

Health Scientist 

Tobacco Control Research Branch 

Behavioral Research Program 

Division of Cancer Control and Population 

Sciences 

National Cancer Institute 

Bethesda, MD 

Brion J. Fox, J.D. 

Associate Scientist 

University of Wisconsin Comprehensive 

Cancer Center 

Madison, WI 

Thomas J. Glynn, Ph.D. 

Director, Cancer Science and Trends 

Director, International Tobacco Programs 

American Cancer Society 

Washington, DC 

R. Neal Graham, M.S.Ed.

Executive Director 

Virginia Primary Care Association 

Richmond, VA 

Dan Grauman, M.S. 

Computer Specialist 

Office of the Director 

Division of Cancer Control and Population 

Sciences 

National Cancer Institute 

Bethesda, MD 

Jessie Gruman, Ph.D. 

Director 

The Center for the Advancement of Health 

Washington, DC 

Carol Hall-Walker, M.P.A. 

Manager, Media and Communications 

Chronic Disease Prevention and Control 

Rhode Island Department of Health 

Providence, RI 

David Harrelson 

Tobacco Prevention and Control Specialist 

Washington State Department of Health 

Olympia, WA 

Elizabeth Harvey, M.A., M.S. 

Program Manager, Tobacco Control 

Program 

Chronic Disease Prevention and Control 

Rhode Island Department of Health 

Providence, RI 

C. Ann Houston, CHES 

Director of Public Education and 

Communication 

Tobacco Prevention and Control Branch 

Division of Public Health 

North Carolina Department of Health and 

Human Services 

Charlotte, NC 

Corinne Husten, M.D., M.P.H. 

Acting Director 

Office on Smoking and Health 

Centers for Disease Control and 

Prevention 

Atlanta, GA 

Graham E. Kelder Jr., J.D. 

Project Director 

Center for Community-Based Research 

Dana-Farber Cancer Institute 

Boston, MA 

Robert “Brick” Lancaster, M.A., CHES 

Chief, Program Services Branch 

Office on Smoking and Health 

Centers for Disease Control and 

Prevention 

Atlanta, GA 

Gloria Latimer, Ed.S. 

Colorado Department of Public Health and 

Environment 

Denver, CO 

Scott J. Leischow, Ph.D. 

Senior Advisor for Tobacco Policy 

Office of the Secretary 

U.S. Department of Health and Human

Services 

Washington, DC 

xxv 
A c k n o w l e d g m e n t s 

Sally Herndon Malek, M.P.H. 

Head, Tobacco Prevention and Control 

Branch 

Division of Public Health 

North Carolina Department of Health and 

Human Services 

Raleigh, NC 

Dianne May 

Project Officer 

Program Services Branch 

Office on Smoking and Health 

Centers for Disease Control and 

Prevention 

Atlanta, GA 

Rebecca Murphy-Hoefer, Ph.D., M.P.H. 

Health Communications Specialist 

Health Communications Branch 

Office on Smoking and Health 

Centers for Disease Control and 

Prevention 

Atlanta, GA 

David E. Nelson, M.D., M.P.H. 

Senior Scientific Advisor 

Health Communications Branch 

Office on Smoking and Health 

Centers for Disease Control and 

Prevention 

Atlanta, GA 

Dearell R. Niemeyer, M.P.H. 

Pearson Education 

Atlanta, GA 

Ann Marie O’Keefe, Ph.D., J.D. 

BETAH Associates, Inc. 

Bethesda, MD 

Mark Parascandola, Ph.D. 

Epidemiologist 

Tobacco Control Research Branch 

Behavioral Research Program 

Division of Cancer Control and Population 

Sciences 

National Cancer Institute 

Bethesda, MD 

Barbara Z. Park, R.D.H., M.P.H. 

Assistant Branch Chief 

Program Services Branch 

Office on Smoking and Health 

Centers for Disease Control and Prevention 

Atlanta, GA 

Tracy Enright Patterson, M.A. 

Deputy Director 

Substance Abuse Policy Research Program 

Center for Creative Leadership 

Greensboro, NC 

Terry F. Pechacek, Ph.D. 

Associate Director for Science 

Office on Smoking and Health 

Centers for Disease Control and Prevention 

Atlanta, GA 

Michael Pertschuk, J.D. 

Co-Chair, Board of Directors, and CoFounder 

Advocacy Institute 

Washington, DC 

Jane Pritzl, M.A. 

Intervention Scientist 

Division of Adolescent and School Health 

Centers for Disease Control and Prevention 

Atlanta, GA 

Harriet Robbins, M.Ed. 

Special Advisor 

Massachusetts Department of Public 

Health 

Boston, MA 

Mikelle Robinson, M.A. 

Manager 

Michigan Tobacco Control Program 

Lansing, MI 

Nancy Salas, M.B.A. 

Consultant 

Tobacco Prevention 

Denver, CO 

Donald R. Shopland 

Ringgold, GA 

xxvi 
M o n o g r a p h 1 6. A S S I S T 

Gloria Simpson 

Arlington, VA 

Karla S. Sneegas, M.P.H. 

Executive Director 

Indiana Tobacco Prevention and Cessation 

Indianapolis, IN 

Frances A. Stillman, Ed.D. 

Co-Director, Institute for Global Tobacco 

Control 

Associate Research Professor, Department 

of Epidemiology 

Johns Hopkins University 

Baltimore, MD 

Amber Hardy Thornton, M.P.H., CHES 

Executive Vice President for Program 

Development 

American Legacy Foundation 

Washington, DC 

Ron Todd, M.S.Ed. 

Health Education Specialist 

Cardiovascular Health Branch 

Heart Disease and Stroke Prevention 

Program 

Centers for Disease Control and 

Prevention 

Atlanta, GA 

Julie E. Volkman, M.A. candidate 

Health Communications Intern 

Tobacco Control Research Branch 

Behavioral Research Program 

Division of Cancer Control and Population 

Sciences 

National Cancer Institute 

Bethesda, MD 

Jeanne Weigum 

President 

Association for Nonsmokers’ Rights 

St. Paul, MN 

Cassandra Welch 

Director of National Advocacy 

American Lung Association 

Washington, DC 

Phillip M. Wilbur 

Arlington, VA 

Seth R. Winick 

Austin, TX 

Myra Wizotsky, M.S.P.H. 

Office on Smoking and Health 

Centers for Disease Control 

Atlanta, GA 

Walter ‘Snip’ Young, Ph.D., M.A. 

Scientist 

The Cooper Institute 

Golden, CO 

Editorial Review Board 

Erwin Bettinghaus, Ph.D. 

Senior Scientist 

Klein Buendel, Inc. 

Golden, CO 

John M. Garcia, M.Sc. 

Director of Chronic Disease Prevention 

and Health 

Promotion Branch, Public Health Division 

Ministry of Health 

Toronto, Ontario, Canada 

Donna Grande, M.G.A. 

Director 

Office of Program Development 

American Medical Association 

Chicago, IL 

Jerie Jordan 

Program Consultant 

Program Services Branch 

Office on Smoking and Health 

Centers for Disease Control and Prevention 

Atlanta, GA 

William R. Lynn 

The Villages, FL 

xxvii 
A c k n o w l e d g m e n t s 

Marc W. Manley, M.D., M.P.H. 

Executive Director 

Center for Tobacco Reduction

 and Health Improvement 

Blue Cross and Blue Shield of Minnesota 

Eagan, MN 

Victor Medrano 

CDC/DASH Liaison 

Office of Safe and Drug-Free Schools 

Drug-Violence Prevention-State Programs 

U.S. Department of Education

Washington, DC 

Nancy Salas, M.B.A. 

Consultant 

Tobacco Prevention 

Denver, CO 

Randy H. Schwartz, M.S.P.H. 

Senior Vice President for Cancer Control 

American Cancer Society, New England 

Division 

Framingham, MA 

Russell Sciandra, M.A. 

Director 

Center for a Tobacco Free New York 

Albany, NY 

Senior Peer Reviewers 

Ross C. Brownson, Ph.D. 

Chair, Department of Community Health 

Professor, Community Health in 

Epidemiology 

Saint Louis University School of Public 

Health 

St. Louis, MO 

Pekka Puska, M.D., Ph.D. 

Director General 

National Public Health Institute 

Helsinki, Finland 

Beti Thompson, Ph.D. 

Full Member 

Cancer Prevention Program 

Fred Hutchinson Cancer Research Center 

Seattle, WA 

Series Editor 

Stephen Marcus, Ph.D. 

Epidemiologist and Monograph Series 

Editor 

Tobacco Control Research Branch 

Behavioral Research Program 

Division of Cancer Control and Population 

Sciences 

National Cancer Institute 

Bethesda, MD 

The editors gratefully acknowledge the 

editorial contribution of Barbara S. Lynch, 

Ph.D. 

Finally, the editors would like to 

acknowledge the contributions of the 

following current and former staff 

members of the American Institutes for 

Research (formerly Prospect Associates), 

who provided technical and editorial 

assistance in the preparation of this 

monograph: 

Gael O’Sullivan, Paige Jackson, and 

Rebecca I. Strüb, Project Managers 

Mary Nishioka, Researcher 

Francesca R. Oneto and Karen Ward, 

Graphic Designers 

Elizabeth Bruce, Don Cunningham, 

Laurene Jackson, Heather Banks, Sue 

Bratten, and Jean Carlick, Editors 

Barbara Dolan, Gwen Brown, and 

Matthew Koenig, Administrative 

Assistants 

xxviii 
Contents


Chapter 1. The Historical Context ............................................................................1


Needed: A New Approach ................................................................................................................... 3


The Context for Creating ASSIST ........................................................................................................ 4


Approval Is Sought ........................................................................................................................... 12


Readiness to Go Forward ................................................................................................................. 14


References ....................................................................................................................................... 15


Additional Resource ......................................................................................................................... 17


Chapter 2. The Conceptual Framework .................................................................19


The Fundamental Premises of ASSIST: Preventing Tobacco Use through the Public Health Model ... 21


The ASSIST Conceptual Framework: Priority Populations, Channels, and Interventions ................... 24


ASSIST Program Objectives and Evaluation ..................................................................................... 28


The Selection of States .................................................................................................................... 35


Time to Act ....................................................................................................................................... 38


References ....................................................................................................................................... 38


Chapter 3. Structure and Communications ...........................................................41


Linking the Units of a Complex Structure ......................................................................................... 43


The Major Organizational Units ........................................................................................................ 46


Mechanisms for Coordination, Decision Making, and Communication ............................................. 53


Readiness to Build Capacity and Capabilities ................................................................................. 67


References ....................................................................................................................................... 76


Chapter 4. Building National, State, and Local Capacity and Capability ...............77


Creating the Capacity to Act ............................................................................................................ 79


Building the Capability to Act .......................................................................................................... 93


Willing and Ready ............................................................................................................................ 99


References ..................................................................................................................................... 118


Chapter 5. Media Interventions to Promote Tobacco Control Policies ............... 119


The Power of the Media .................................................................................................................. 121


Preparing for Media Interventions .................................................................................................. 122


Media Strategies and Tactics ......................................................................................................... 127


Monitoring Newspaper Coverage .................................................................................................... 149


From Media to Policy Change ......................................................................................................... 152


References ..................................................................................................................................... 164


xxix 
C o n t e n t s 

Chapter 6. Public and Private Policy Interventions ............................................167


Policy as an Intervention ................................................................................................................ 169


Interventions in Four Policy Areas .................................................................................................. 170


Challenges to Public Policy Interventions ...................................................................................... 183


Insights from Policy Advocacy Experiences .................................................................................... 187


The Influence of Policy ................................................................................................................... 218


References ..................................................................................................................................... 278


Additional Resources ..................................................................................................................... 282


Chapter 7. Program Services: Reaching the Individual ...................................... 283


The Challenge of Services Delivery: Setting Priorities .................................................................... 286


The Role of ASSIST in Service Provision .......................................................................................... 289


Interaction between Policy and Program Services .......................................................................... 300


Strength in Comprehensiveness .................................................................................................... 305


References ..................................................................................................................................... 306


Additional Resources ..................................................................................................................... 307


Chapter 8. Tobacco Industry Challenge to ASSIST ...............................................309


Part 1. The Tobacco Industry’s Response to ASSIST: An Analysis of Tobacco Industry


Internal Documents ...................................................................................................................... 312


Methods for Researching the Tobacco Industry Documents ........................................................... 312


Results of the Research ................................................................................................................. 315


Discussion ..................................................................................................................................... 349


Part 2. ASSIST’s Response to the Tobacco Companies: Facing the Opposition .......................... 350


Understanding the Obligation to Respond to FOIA Requests .......................................................... 350


Understanding the Regulations on Lobbying ................................................................................. 352


Case Studies .................................................................................................................................. 354


Onward after the Opposition .......................................................................................................... 354


References ..................................................................................................................................... 372


Additional Resources ..................................................................................................................... 383


Chapter 9. Planning Strategically for the Future ................................................ 385


At the Turning Point ....................................................................................................................... 387


The States Work to Sustain Their Programs ................................................................................... 388


Developing Strategic Plans for a Sustained National Program ...................................................... 391


Taking Action to Get Commitment .................................................................................................. 398


Affirming the Commitment ............................................................................................................ 409


Turning to Transition ...................................................................................................................... 410


References ..................................................................................................................................... 441


Additional Resource ....................................................................................................................... 442


xxx 
M o n o g r a p h 1 6. A S S I S T 

Chapter 10. From Demonstration Project to Nationwide Program .....................443


The Challenge of Dissemination .................................................................................................... 445


Transition from Agency to Agency: Administrative Issues .............................................................. 449


Integrating and Maintaining Core Program Elements .................................................................... 451


The National Environment for Tobacco Control: A Consideration .................................................... 460


Toward the Future .......................................................................................................................... 469


References ..................................................................................................................................... 474


Chapter 11. The Promise of ASSIST ......................................................................477


Beyond ASSIST ............................................................................................................................... 480


A Visible Promise: An Evolving Infrastructure ................................................................................ 481


The Promise of ASSIST: Shaping the Future .................................................................................... 484


Influencing Public Health Initiatives .............................................................................................. 496


Advancing Evaluation Methodology ............................................................................................... 502


Future Interventions and Research Initiatives ............................................................................... 504


Onward from ASSIST ...................................................................................................................... 505


References ..................................................................................................................................... 508


Index .....................................................................................................................513


Case Studies 

Case Study 4.1. Albuquerque: A Multicultural Coalition ................................................................... 84


Case Study 4.2. Regional Networks in the Massachusetts Tobacco Control Program ....................... 85


Case Study 4.3. Evaluating ASSIST Coalitions in North Carolina ..................................................... 86


Case Study 5.1. Tobacco State Turns Opinion Around .................................................................... 134


Case Study 5.6. The Tobacco Master Settlement Agreement—A National Event


Case Study 5.8. ASSIST–Wisconsin State Medical Society Partnership for Publishing


Case Study 5.9. Todo a Pulmón (“With Full Breath”): A Rhode Island Radio Campaign


Case Study 5.2. Strengthening Youth Access to Tobacco Laws: North Carolina .............................. 136


Case Study 5.3. The Media Network of the Tobacco-Free Michigan Action Coalition ...................... 137


Case Study 5.4. Winston Additive-Free Media Advocacy Campaign ............................................... 138


Case Study 5.5. Charleston, West Virginia, Bids So Long to the Marlboro Man .............................. 143


Covered Locally .............................................................................................................................. 144


Case Study 5.7. The Indiana Countercampaign—A Local Event Covered Nationally ..................... 144


Tobacco Research .......................................................................................................................... 145


for Hispanic Youths ........................................................................................................................ 150


Case Study 6.1. Kids Make Crucial Appeal to Policymakers in St. Louis County ............................. 190


Case Study 6.2. Tobacco and Sports Don’t Mix in Virginia! ............................................................ 192


Case Study 6.3. ASSIST Unites with Faith Leaders to Ban Tobacco Advertising in St. Louis ........... 195


Case Study 6.4. Filling the Roles in Las Cruces, New Mexico ......................................................... 197


xxxi 
C o n t e n t s 

Case Study 6.5. Shining the Light on Tobacco Advertising and Promotions ................................... 199


Case Study 6.6. Massachusetts Increases Tobacco Tax to Fund Healthcare for Children ............... 201


Case Study 6.7. Youth Advocates Make Michigan Arena Tobacco Free ........................................... 204


Case Study 6.8. Teens Lead the Way in Silver City, New Mexico ...................................................... 206


Case Study 6.9. New York Counters Tobacco Industry Claims with Data ........................................ 208


Case Study 6.10. Collecting Local Numbers in North Carolina ....................................................... 209


Case Study 6.11. Point of Purchase: Operation Storefront ............................................................. 210


Case Study 6.12. An Historic Opportunity: South Carolina Bans Smoking in Its State House ......... 214


Case Study 6.13. Twice North Carolina Makes Gains for a Smoke-free School Environment .......... 215


Case Study 6.14. Indiana’s Battle against Preemption .................................................................. 217


Case Study 6.15. Persistence Pays Off in Mesilla, New Mexico ...................................................... 219


Case Study 6.16. Changing Policy on Public Transportation: Smoke-free Washington


State Ferries .................................................................................................................................. 221


Case Study 6.17. Protecting the Gain in Las Cruces, New Mexico .................................................. 223


Case Study 7.1. Helping Schools Shift to a Tobacco-Free Norm in North Carolina ......................... 293


Case Study 7.2. Diapers, Dishes, and Deep Breathing: Stress Management and


Smoking Cessation for Low-income Mothers in Massachusetts ..................................................... 295


Case Study 7.3. Smoking Cessation Quitline for Michigan Medicaid Recipients ............................ 296


Case Study 7.4. Colorado Tobacco-Free Schools Law Creates Demand for Cessation


and Prevention Programs ............................................................................................................... 297


Case Study 7.5. Employers: “Anybody Going to Tell Us What’s Going On?” ..................................... 301


Case Study 7.6. Clearing the Smoke at the University of Maine ..................................................... 302


Case Study 7.7. Strengthening the Enforcement of the Youth Access Law in


North Carolina ............................................................................................................................... 304


Case Study 8.1. Full-Scale Challenge in Colorado ......................................................................... 355


Case Study 8.2. Work Disruptions in Washington State ................................................................. 361


Case Study 8.3. In Minnesota: Multiple Strategies, Multiple Defeats—Ultimate Victory ............... 362


Case Study 8.4. On Alert in Maine .................................................................................................. 367


Case Study 8.5. New York State Defeats Tobacco Industry’s Attempt to Impose Preemption .......... 369


Case Study 10.1. Transition at the State Level: Minnesota’s Experience ........................................ 465


Case Study 10.2. Establishment of the Virginia Tobacco Settlement Foundation ........................... 467


Tables 

Table 2.1. ASSIST Program Objectives by 1998 ................................................................................ 29


Table 4.1. Number of ASSIST State and Local Coalitions, 1992 and 1996 ........................................ 83


Table 5.1. Number of Newspaper Editorials in North Carolina, 1993–98 ....................................... 135


Table 5.2. Media Analysis Quarterly Report for Michigan: October 1, 1993, to March 31, 1994 ..... 154


Table 6.1. Number of Municipalities per State with Clean Indoor Air Ordinances,


as of August 25, 2003 ................................................................................................................... 175


xxxii 
M o n o g r a p h 1 6. A S S I S T 

Table 6.2. State Tax Rates for 2000 and Rate Increases, 1991–99 (per pack) ............................... 177


Table 6.3. Number of Municipalities per State with Advertising Ordinances,


Table 6.4. Number of Municipalities per State with Youth Access Ordinances,


as of August 25, 2003 ................................................................................................................... 181


as of August 25, 2003 ................................................................................................................... 184


Table 8.1. Search Terms Used with Tobacco Industry Document Sites ............................................ 313


Table 10.1. Comparison of the ASSIST and IMPACT Programs ........................................................ 448


Table 11.1. State Cigarette Excise Taxes for 1998 and 2003 .......................................................... 490


Figures 

Figure 1.1. National Cancer Institute’s Five Phases of Cancer Control Research ............................... 7


Figure 1.2. The National Cancer Institute Funding for Smoking, Tobacco, and Cancer ...................... 8


Figure 2.1. The Public Health Model ................................................................................................. 22


Figure 2.2. The ASSIST Conceptual Framework ................................................................................ 25


Figure 2.3. The ASSIST Evaluation Model ......................................................................................... 33 


Figure 2.4. States Awarded ASSIST Contracts .................................................................................. 37


Figure 3.1. ASSIST: National Organizational Structure ..................................................................... 45


Figure 5.1. Number of Policy-Related Tobacco Articles: Michigan, October 1, 1993, to


March 31, 1994 ............................................................................................................................. 153


Figure 5.2. Percentage of Articles by Policy Type: Michigan, January 1 to March 31, 1994 ............. 153


Figure 9.1. ASSIST Strategic Planning Subcommittee Long-term Planning Products, 1995–98 ..... 392


Figure 9.2. Tobacco Settlement Negotiation Milestones ................................................................. 400


Figure 10.1. Goals Set for ASSIST in 1988 ...................................................................................... 446


Figure 10.2. Organizational Structure during the Transition .......................................................... 452


Figure 11.1. The ASSIST Cube and Subsequent Adaptations to Cardiovascular Disease ................ 485


Figure 11.2. Map of State Cigarette Tax Rates—2004 .................................................................. 489


Appendices 

Appendix 3.A. Memo of Understanding Between the National Cancer Institute and


the American Cancer Society ........................................................................................................... 68


Appendix 3.B. ASSIST Key Required Resources ................................................................................. 73


Appendix 4.A. Example of Membership in an ASSIST State Coalition: Rhode Island ....................... 101


Appendix 4.B. ASSIST Responsibility Matrix from Minnesota .......................................................... 103


Appendix 4.C. Wisconsin ASSIST’s Comprehensive Smoking Control Plan: Selected Channels ....... 104


Appendix 4.D. Wisconsin ASSIST’s 1993–94 Annual Action Plan: Selected Channels ..................... 106


Appendix 4.E. Minnesota ASSIST’s Comprehensive Tobacco Control Plan: Community


Environment Channel .................................................................................................................... 108


xxxiii 
C o n t e n t s 

Appendix 4.F. Minnesota ASSIST’s 1993–94 Annual Action Plan: Community


Environment Channel .................................................................................................................... 109


Appendix 4.G. Minnesota ASSIST’s 1998–99 Annual Action Plan: Community


Environment Channel .................................................................................................................... 110


Appendix 4.H. Washington State ASSIST’s Project Management Plan: Selected Components ......... 111


Appendix 4.I. Training Events of the Implementation Phase .......................................................... 113


Appendix 5.A. ASSIST Bibliography ................................................................................................ 155


Appendix 6.A. Excerpts from Youth Access to Tobacco: A Guide to Developing Policy ..................... 224


Appendix 6.B. Excerpts from Clean Indoor Air: A Guide to Developing Policy .................................. 235


Appendix 6.C. Excerpts from Tobacco Advertising and Promotion: A Guide to Developing Policy .... 253


Appendix 9.A. Executive Summary from “Planning for a Durable Tobacco Prevention Movement:


Sustaining Tobacco Prevention beyond the American Stop Smoking Intervention Study” ............... 411


Appendix 9.B. Executive Summary from “Turning Point for Tobacco Control: Toward a


Appendix 9.D. Realizing America’s Vision for Healthy People: Advancing a Federal


National Strategy to Prevent and Control Tobacco Use” ................................................................. 414


Appendix 9.C. Helene Brown Testimony .......................................................................................... 418


Commitment to Fund Effective Tobacco Control ............................................................................. 421


Appendix 10.A. Recommended Benchmarks for Multicultural Programs and Activities ................. 470


Appendix 11.A. Tobacco Control Professionals Who Shared Their Insights regarding ASSIST ......... 507


xxxiv 
M o n o g r a p h 1 6. A S S I S T 

1. The Historical Context

Robert E. Vollinger Jr., Robert W. Moon, and Peter Greenwald 

Contents 

Needed: A New Approach ............................................................................................... 3


The Context for Creating ASSIST .................................................................................... 4


The National Cancer Institute Is Ready ................................................................................. 4


Creation of the Smoking, Tobacco, and Cancer Program and the Tobacco


Prevention and Control Strategy ..................................................................................... 5


The Five Phases of Cancer Control ................................................................................. 6


Studies Establish a Scientific Basis for Community-based Interventions ............................. 7


The Rationale for a Commitment to the Community Approach ..................................... 10


The American Cancer Society as a Partner .......................................................................... 11


Approval Is Sought ...................................................................................................... 12


Readiness to Go Forward ............................................................................................. 14


References .................................................................................................................. 15


Additional Resource .................................................................................................... 17


Figures 

Figure 1.1. National Cancer Institute’s Five Phases of Cancer Control Research ....................... 7


Figure 1.2. The National Cancer Institute Funding for Smoking, Tobacco, and Cancer .............. 8


1 
1. T h e H i s t o r i c a l C o n t e x t

2
M o n o g r a p h 1 6. A S S I S T 

1. The Historical Context

model. 

The American Stop Smoking Intervention Study for Cancer Prevention (ASSIST)* 

dramatically changed the face of tobacco prevention and control efforts in the 

United States and perhaps around the world. As a public health intervention, ASSIST 

represents a major shift from primary focus on the individual to include a major 

focus on the community and the social environment that affect health behavior. This 

chapter describes activities at the National Cancer Institute (NCI), at the American 

Cancer Society (ACS), and throughout the United States leading to the development 

of the ASSIST project and presents the evidence-based rationale for its conceptual 

“Create a smoke-free society in the United States by the year 2000”—that was the 

challenge made to Americans in 1984 by U.S. Surgeon General C. Everett Koop.1 

Since then, a smoke-free society has been a major goal of the tobacco prevention and 

control movement and the public health establishment. Through the efforts of state and 

local governments, local health organizations, and many individuals, the United States 

has advanced steadily, although perhaps slowly, toward achieving that goal. The continuing challenge, however, is of immense proportions. In 2002, approximately 22.5% 

of adults (46 million people) in the United States were smokers.2 

Needed: A New Approach 

T

he year was 1987. For 5 years, NCI had been supporting an ambitious research 

program with the goal of reducing cancer mortality by 50% in the United States by 

the year 2000. Accomplishing that goal would require reducing the prevalence of smoking by adults to 15% or less. 

Research on interventions in the 1960s and 1970s had focused on smokers and potential smokers as individuals and had enabled them to alter their behaviors and resist 

environmental influences that support smoking. Findings from more than 100 intervention studies (trials) revealed that although many individuals were successful in quitting 

smoking as a result of these early approaches, overall tobacco use in the United States 

did not decrease substantially. A major conclusion from these studies was that largescale reductions in smoking prevalence were unlikely to be achieved solely through interventions that were directed primarily at the individual. Research then shifted toward 

approaches that included changing the social and environmental influences themselves. 

*The official name for ASSIST was the American Stop Smoking Intervention Study for Cancer Prevention. 

The title was often shortened to the American Stop Smoking Intervention Study, and it is this shortened 

form that is used in this monograph. 

3 
1. T h e H i s t o r i c a l C o n t e x t 

At the same time, two important reports documented the health hazards of 

environmental tobacco smoke on nonsmokers: the 1986 National Academy of 

Sciences report, Environmental Tobacco 

Smoke, 3 and the 1986 surgeon general’s 

report, The Health Consequences of Involuntary Smoking. 4 The realization was 

growing that smoking behavior is 

strongly influenced by one’s social and 

physical environment; therefore, new research strategies for preventing smoking 

and promoting cessation were needed. 

To address this need, in 1987 NCI 

convened more than 250 smoking control experts at its 50th anniversary meeting, “NCI Smoking, Tobacco, and 

Cancer Program and Its Goals for the 

Year 2000.”5 These experts made recommendations about the types of prevention and cessation programs needed to 

reduce the use of tobacco. They specifically recommended that NCI focus on 

large-scale efforts that would affect major segments of the population. The involvement of broad-based coalitions 

representing entire states and large metropolitan areas was envisioned as the 

centerpiece for an intervention strategy. 

Approval first of the Community Intervention Trial for Smoking Cessation 

(COMMIT), a community intervention 

research trial, and then later of ASSIST, 

a demonstration project, marked a turning point in NCI’s battle to reduce smoking and tobacco-related cancers. It was a 

bold, strategic decision that moved NCI 

forward from the scientific testing of hypotheses to the translation of accumulated scientific knowledge into effective, 

multilevel actions that would address the 

nation’s largest public health epidemic. 

ASSIST Logo 

The Context for Creating


ASSIST


T

he idea of a coalition-based community intervention was not new to NCI 

in 1987. In the early 1980s, NCI program 

staff had discussed the concept and 

COMMIT, a project at that time involving community organizations, had provided important insights about this kind 

of approach to addressing public health 

issues. The same science base informed 

the community-involvement design of 

both COMMIT and ASSIST. (See page 

10.) Leaders at NCI and their external 

advisors had been conscientious about 

establishing a science-based rationale before approving and funding a multilevel 

intervention involving national, state, and 

community governments and organizations. As the historical context below indicates, three elements essential to 

support and implement a coalition-based 

community intervention were brought together: a favorable program structure at 

NCI, a supportive science base, and a collaborating national voluntary organization. 

The National Cancer Institute Is Ready 

The first major studies linking cigarette smoking with lung cancer were 

published in 1950, a little more than a 

4 
M o n o g r a p h 1 6. A S S I S T 

decade after the founding of NCI in 

1937. Reports on studies by Wynder and 

Graham6 and Levin and co-workers7 

appeared in the Journal of the American 

Medical Association. The results of two 

other studies also were published.8,9 All 

four studies observed that lung cancer 

rates were higher for men who were 

smokers than for men who were nonsmokers. These studies were the foundation of the evidence linking tobacco to 

cancer. They generated media attention 

and stimulated efforts to substantiate the 

far-reaching health consequences of 

tobacco use. 

At that time, although Congress had 

identified prevention of cancer as one of 

NCI’s three specific functions, the prevailing view of National Institutes of 

Health (NIH) officials was that the agency’s role was to present the facts, not to 

undertake an organized education campaign to tell citizens to stop smoking. 

(For a history of the Public Health Service, see M. Parascandola’s article.10) 

When pressure mounted from outside 

the Public Health Service in the early 

1960s, the situation began to change, 

and more substantive action was taken. 

With passage of the 1971 National Cancer Act, a collaborative system began to 

mobilize resources in the public and private sectors for prevention. It was not 

until 1974 that the concept of cancer 

control included a research approach. In 

its report from a 1974 conference, the 

NCI Cancer Control Working Group 

embraced developmental research as a 

key program element: 

Cancer control includes developmental 

research, i.e., the identification of new 

methods and techniques and their field 

testing and evaluation in limited 

community settings, and community 

demonstration and application 

activities, i.e., the promotion of 

community-tested cancer control 

methods and techniques to ensure their 

appropriate application and use.11(p329) 

Creation of the Smoking, Tobacco, and 

Cancer Program and the Tobacco 

Prevention and Control Strategy 

In 1981, Dr. Peter Greenwald joined 

NCI to lead the Division of Cancer Prevention and Control (DCPC), and he recruited Dr. Joseph W. Cullen as deputy 

director of the division. Cullen initiated 

the Smoking, Tobacco, and Cancer Program (STCP). STCP was the focal point 

for NCI’s disease prevention and health 

promotion research activities related to 

tobacco use and cancer. The goal of the 

program was to decrease the incidence 

and mortality of cancers caused by or 

related to smoking and the use of other 

tobacco products. 

The following year, to set national 

priorities, DCPC launched a participatory process (described later in this 

chapter). These activities were undertaken with several guiding principles in 

mind. The first is that the scientific 

method—close observation, measurement, quantitative analysis, and analytic 

thought—is as important to cancer control as to basic or clinical research. The 

second is that the pursuit of excellence 

in science has priority over other considerations. The third premise, wrote 

Greenwald and Cullen, is that 

we must build on our strengths, across 

the spectrum from etiology to 

treatment. We aim to integrate cancer 

5 
1. T h e H i s t o r i c a l C o n t e x t 

program at NCI was straightforward. Greenwald and Cullen concluded, 

This orderly approach should assure 

that adequate research precedes widewidescale programs must be mutually 

reinforcing. Only the coordinated 

planning and implementation of a 

cancer control research strategy will 

assure maximum yield from the dollars 

invested, maximum scientific quality of 

the activities supported, and maximum 

lead to nationwide public benefits. 

control. CA-A Cancer Journal for Clinicians 

34 (6): 331–2. 

Research Precedes Interventions 

The basic philosophy guiding the development of ASSIST and the entire cancer control 

scale intervention efforts. Research and 

probability that the research effort will 

Source: Greenwald, P. G., and J. W. Cullen. 

1984. The scientific approach to cancer 

control as a research effort into the 

programs of institutions across the 

country, including cancer centers, 

universities, community hospitals, 

state and local governments, and 

schools of public health.12(p331) 

They explained cancer control to be 

the reduction of cancer incidence, 

morbidity, and mortality through an 

orderly sequence from research on 

interventions and their impact in 

defined populations to the broad, 

systematic application of the research 

results. 

“Interventions” is a key word. For 

example, an epidemiologic study that 

examines an etiologic factor, but does 

not involve interceding for the benefit 

of a specific patient or the general 

public, would not be considered cancer 

control.12(p329) 

The Five Phases of Cancer Control 

This focus on cancer control, with its 

specific emphasis on interventions, provided the foundation on which the ASSIST 

project was built. DCPC developed a 

sound model that covered all the phases 

of cancer control research and provided 

a structure to guide innovative cancer 

control efforts. As a management and 

planning tool, the model was instrumental in developing NCI’s cancer control 

plans. This model of cancer control 

phases classifies research efforts according to an organized sequence of five progressive phases from hypothesis 

development (phase I) through largescale demonstration projects (phase V). 

Operational criteria are applied between 

the phases to determine whether research outcomes warrant a progression 

to the next phase of research. At the 

completion of phase IV, a proven intervention with a demonstrated public 

health benefit in reducing cancer incidence, morbidity, or mortality would be 

ready for implementation nationwide. 

(See figure 1.1.) 

The research priorities for the new 

STCP grew from a systematic, participatory planning process that used state-ofthe-art reviews and consensusdevelopment techniques involving hundreds of scientists and public health professionals. The process was a two-part 

strategy. The first part was to study intervention methods—interventions that 

were school based, community based, or 

self-help; were delivered by physicians 

or dentists; or involved the mass media. 

The second part of the strategy was to 

identify specific populations that were at 

greatest risk for developing cancer or 

6 
M o n o g r a p h 1 6. A S S I S T 

Studies Establish a Scientific Basis for 

Community-based Interventions 

During the 1970s and 1980s, a number 

impact of broad community-based preyouths, minority and ethnic groups, 

tobacco users.5 

search program, initially including phase 

III and IV trials from 1982 to 1989, to 

more than 10 million people in 33 states 

spent on this systematic research, maktestable hypothesis. 

Phase II: 

monitored in subsequent studies and ensures that procedures are valid. 

individuals (case-control, cohort, or cross-sectional studies). 

distinct, well-characterized population. 

and measures the public health impact. 

CA-A Cancer 

34 (6): 330–1. National Cancer Institute. 1990. 

(NIH publication no. 90-3107). Bethesda, MD: U.S. Department of Health and Human 

Services (p. vi). 

Basic 

Biomedical 

Research 

I 

Hypothesis 

Development 

II 

Methods 

Development 

III 

Controlled 

Intervention 

IV 

Defined 

Population 

Studies 

V 

Demonstration 

and 

Implementation 

Nationwide 

Prevention 

and Health 

Services 

Programs 

ing NCI’s STCP the largest program of 

its kind in the world. (See figure 1.2.) 

By 1982, sufficient phase I and II 

studies on smoking already existed, enabling NCI to move directly to funding 

phase III and IV intervention studies. 

of multifactor studies of heart disease 

prevention demonstrated the potential 

vention programs and contributed to the 

knowledge base for the design of the 

ASSIST interventions. This type of research contributed to the shift from a 

that were receptive to prevention approaches. These populations included 

women, heavy smokers, and smokeless 

Building on this two-part strategy, in 

1982 Cullen and other STCP staff developed an aggressive plan to decrease tobacco use in the United States. The 

strategy proposed a comprehensive retest a variety of interventions with selected populations. These trials involved 

across more than 200 North American 

communities. Nearly $250 million was 

Phase I: Hypothesis Development: Synthesizes available scientific evidence to develop a 

Methods Development: Characterizes the variables that must be controlled or 

Phase III: Controlled Intervention Trials: Tests the efficacy of an intervention on a group of 

Phase IV: Defined Population Studies: Measures the effects of an intervention in a sizable, 

Phase V: Demonstration and Implementation: Applies the intervention in a community at large 

Sources: Greenwald, P. G., and J. W. Cullen. 1984. The scientific approach to cancer control. 

Journal for Clinicians Smoking, tobacco, and cancer program: 

1985–1989 status report 

Trials 

Figure 1.1. National Cancer Institute’s Five Phases of Cancer Control Research 

7 
1. T h e H i s t o r i c a l C o n t e x t 

$0 

$5 

$10 

$15 

$20 

$25 

$30 

$35 

$40 

$45 

1982 1983 1984 1985 1986 1987 1988 1989 

program to reduce heart disease in 

of high school, the smoking rate for 

15 

■ 

middle/junior high schools in Kansas 

media, parent and community 

programs that focused on resistance 

5,13 The 

pre-ASSIST community-based studies: 

■ 

14 

■ One study component of the 

(NIH 

publication no. 90-3107). Bethesda, MD: U.S. Department of Health and Human Services. 

Year 

Dollars in Millions 

entire communities. After the program 

ended and at the cohort’s completion 

adolescents in the intervention 

community was 40% lower than in the 

reference community. 

The Midwestern Prevention Project 

was another longitudinal intervention 

study that was implemented in 50 

City and Indianapolis. The mediabased interventions included schools, 

organizations, and health policy 

skills training and environmental 

support for not using cigarettes or 

drugs. The smoking rates for students 

in intervention schools increased 

primary emphasis on individual-based 

interventions to interventions designed 

to reach large population groups and 

helped to verify the importance of the 

community and environmental factors in 

tobacco prevention and control.

following examples are representative of 

The Stanford Three-Community 

Study, initiated in 1972, demonstrated 

the effectiveness of mass media and 

intensive face-to-face interventions in 

decreasing the number of cigarettes 

smoked per day and the risk for 

cardiovascular disease.

Minnesota Heart Health Program was 

the Class of 1989 Study, which tested 

the efficacy of a smoking prevention 

intervention as one part of a larger 

Figure 1.2. The National Cancer Institute Funding for Smoking, Tobacco, and Cancer 

Source: National Cancer Institute. 1990. Smoking, tobacco, and cancer program: 1985–1989 status report 

8 
M o n o g r a p h 1 6. A S S I S T 

significantly less than those for 

students in comparison schools.16 

■	 The Australian North Coast health 

lifestyle program, “Quit for Life,” 

used a social marketing approach to 

community intervention.17 Among 

smokers who reported quitting, most 

reported that they quit smoking on 

their own, a finding that emphasized 

the importance of creating a social 

environment that encourages and 

supports self-initiated quit attempts. 

■	 The Sydney Quit for Life antismoking 

campaign used mass media to reduce 

smoking prevalence in two Australian 

cities, Sydney and Melbourne. Longterm effects were greatest for men in 

Sydney, where smoking prevalence 

dropped 2.5% in the first 6 months of 

the intervention and continued to 

decline at a rate of 1.12% per year.18,19 

■	 The North Karelia Project, a 

comprehensive community program 

to reduce cardiovascular disease in the 

province of North Karelia in Finland, 

initiated in 1972, reduced cigarette 

smoking by men in one community. 

The study also showed lower smoking 

rates after classroom interventions 

were taught to 13- to 15-year-old 

students. The lower rates were 

attributed to the context of the 

community program in which the 

school interventions were 

implemented. The health education 

component of the project included 

introducing environmental changes 

such as heart-healthy menus in 

institutions and smoking 

prohibitions.20 

■	 The National Research Program in 

Switzerland found that light and 

A Major Shift 

the Subcommittee on Smoking of the 

objective [a smoke-free society by the 

year 2000] requires the development 

and implementation of public policies 

designed to facilitate the transition from 

need for public policies recognizes the 

role of the contemporary social and 

legal environment in encouraging the 

initiation and maintenance of smoking, 

and hence the need for social and legal 

steps to alter this environment to one 

Holbrook, E. M. Lewit, M. Pertschuk, J. L. 

smoke-free generation by the year 2000. 

73:381A. 

“At its meeting of October 26–27, 1984, 

American Heart Association concluded 

that attaining the Surgeon General’s 

a smoking to a nonsmoking society. The 

supportive of a nonsmoking society.” 

Source: Warner, K. E., V. L. Ernster, J. H. 

Steinfeld, and E. M. Whelan. 1986. Public 

policy on smoking and health: Toward a 

Circulation 

moderate smokers were more likely to 

quit than were heavy smokers as a 

result of a community education 

intervention that mobilized personal 

and community resources to promote 

a healthful lifestyle. The program was 

integrated into existing local health 

and social services, and efforts toward 

individual action were supplemented 

by mass media and other community 

interventions.21 

Positive effects on the prevalence of 

cigarette smoking also were produced 

by the Community Hypertension, Atherosclerosis, and Diabetes Program in Israel,22 the Cardiovascular Disease 

Prevention Program in an Austrian community,23 and the Coronary Risk Factor 

Study in South Africa.24 

9 
1. T h e H i s t o r i c a l C o n t e x t 

contracts, explained the relationship between 

the two major NCI initiatives: 

In COMMIT we were blinded to the 

outcome; we could not scientifically 

alter the intervention course based on 

intervention altered—it was designed 

in a controlled, clinical trial fashion. 

ASSIST and COMMIT were parts of 

the same path, with COMMIT as a 

being approved during the planning 

stages before we had the outcome of 

From COMMIT to ASSIST 

In a conversation with Robert E. Vollinger Jr. 

(April 26, 2000), William R. Lynn, who 

served as the NCI project officer for the 

COMMIT contracts and for some ASSIST 

outcome data. We didn’t want the 

controlled clinical trial and ASSIST as 

the demonstration project. ASSIST was 

COMMIT. 

As of 1988, STCP had supported 60 

studies. At that time, 20% were complete, but by 1991, when ASSIST was 

slated to begin, 90% would be complete, 

adding to the body of knowledge guiding 

the ASSIST interventions during its 2­

year planning stage that preceded the 5­

year implementation phase to begin in 

1993. All the studies were scheduled to 

be completed by 1992.25 

COMMIT (1986–92) was a very ambitious research project, designed to significantly reduce smoking prevalence 

and to assess the effectiveness of comprehensive, community-based interventions in helping all smokers, particularly 

heavy smokers, quit smoking and remain tobacco-free.26 COMMIT was a 

phase IV defined population study that 

involved 11 experimental communities 

and 11 control communities. At the 

time, this community-based focus was 

considered to be innovative and was 

based on an increasing knowledge that 

the decision to smoke takes place in a 

complex web of formal and informal 

policies and actions that reflect 

community norms and values. An 

important feature of the COMMIT trial 

is the move to a community level 

intervention designed to influence not 

only individuals, but also the broader 

social context.27(p188) 

The Rationale for a Commitment 

to the Community Approach 

These community studies provided 

several observations on which to base a 

rationale for designing and moving forward on the ASSIST concept as a phase 

V intervention. First and most obvious, a 

community approach has a wider reach 

than do individual-based interventions. 

Organizing an entire community around 

a health promotion project requires that 

more people and organizations get involved. Messages about behavioral 

change become widespread throughout 

the community, and it becomes difficult 

to avoid exposure to them.27 (The 

ASSIST guidelines and early documents 

frequently used the term consistent and 

inescapable cues to reinforce this point.) 

Second, a community-based approach 

can integrate interventions into the community’s institutions, thereby enhancing 

the likelihood of long-term sustainable 

change. Interventions conducted through 

community groups and with their financial support can become a permanent 

part of the local resources and services, 

extending their life beyond the period of 

federal funding. In ASSIST, this concept 

10 
M o n o g r a p h 1 6. A S S I S T 

was termed institutionalization after extensive discussion and some hesitation 

about the potential negative connotations 

of the word. 

Third, a community approach can 

cast a health issue as a public health issue that affects the entire population 

rather than as a problem of individuals. 

This approach considers health behavior 

such as smoking within a social context 

and builds on the principles that largescale change requires a change in the social context and that change is more 

likely to occur when the people affected 

by a particular problem are defining the 

problem and are engaged in solving it. 

Partnership and collaboration among 

multiple organizations are essential to 

success. Community members must be 

involved throughout the whole project, 

and they must have significant decisionmaking authority. 

A fourth observation emerged during 

the early years of ASSIST and became 

fundamental to the interventions. Evidence had accumulated showing that an 

effective way to reduce tobacco use is to 

promote a tobacco-free norm through 

public and private policies that pose barriers to the marketing, purchase, and use 

of tobacco—for example, cigarette taxes, 

restrictions against smoking in the workplace, and placement of tobacco ads. 

(See chapter 6 regarding the ASSIST focus on policy interventions.) 

The American Cancer Society 

as a Partner 

NCI recognized the value of a community-based approach in changing the 

social and physical environment to 

support a tobacco-free norm and sought 

the best mechanisms for implementing 

ASSIST as a multilevel, national-statecommunity-based intervention. A community-based intervention at the local 

level is sometimes best implemented and 

sustained when a key leadership role is 

assumed by a private-sector partner—especially a voluntary organization with 

links to local chapters. Given the coalition nature of the ASSIST project and 

the strong focus on policy change, NCI 

would need a strong private partner to 

make the project fully successful. 

ACS, as a nonprofit voluntary health 

organization, had consistently been on 

the frontline of tobacco prevention and 

control efforts. ACS viewed the ASSIST 

concept as an opportunity to further engage in activities to reduce tobacco use 

and cancer. ACS was willing to join NCI 

as a partner in ASSIST, an arrangement 

that would establish a unique partnership between a government agency and 

a voluntary organization. In fact, ACS 

approached NCI and asked, as phrased 

by Cullen: 

“How come we are not doing this with 

you?” And we said, “Well, why not?” 

So, I give the credit to the American 

Cancer Society for opening this door, 

and I think it is a door that is of 

immense importance because of the 

number of people who can get to what 

I like to call the fabric of America.25(p230) 

Clearly it was important for ACS to 

be a strong partner in this initiative, and 

partnership would provide ACS with 

valuable visibility. At the same time, 

NCI was aware of the importance of balancing its need for a partner with the interests of other health organizations that 

11 
1. T h e H i s t o r i c a l C o n t e x t 

wanted to be involved. However, NCI 

needed a primary partner that would 

make a commitment of the magnitude 

that ACS was offering. Together, NCI and 

ACS, working with state health departments and their coalitions, could provide 

critical leadership for individuals at the 

state and local levels to organize their 

communities to achieve policy and environmental changes for tobacco control. 

Approval Is Sought 

T

o proceed with the ASSIST concept as 

a major phase V demonstration 

project derived from the effective interventions in the previous phases, STCP 

had to have approval from DCPC’s 

Board of Scientific Counselors. This outside technical scientific review group 

had to endorse all new initiatives before 

they could go forward for NCI funding 

approval and allocation. NCI staff members realized that much of the future of 

tobacco prevention and control efforts 

was at stake and that they needed to 

present a strong, science-based rationale 

to convince the board of the merits of 

this bold undertaking. Failing to win the 

board’s approval would seem to make all 

the models of sound scientific theory 

meaningless. With these realizations, 

NCI staff presented the ASSIST project 

to the board on Friday, October 7, 1988. 

Dr. Joseph W. Cullen, representing 

STCP, and Dr. Harmon J. Eyre, representing ACS, made the principal presentations to the Board of Scientific 

Counselors and outlined the history of 

STCP and NCI and selected intervention 

trials that had already been funded. 

Cullen provided the history, context, and 

rationale for the project. He also explained the proposed, unprecedented arrangement between ACS and NCI. 

Although NCI was quite familiar with 

funding scientific research grants, it had 

no track record of partnering with voluntary health organizations. To explain and 

to reassure this board of scientists about 

this new model for demonstrating tobacco prevention and control programs, he 

used the metaphor that NCI cannot do 

tobacco prevention and control without 

an army and that ACS could provide this 

army because it had 3,400 units, 57 divisions, and 2,000,000 volunteers. Cullen 

said that these large numbers would be 

required as NCI moved from science to 

public health application.25(p231) 

Anticipating questions about why 

STCP was seeking approval in 1988 for 

a project that was not expected to begin 

until 1991, Cullen explained that 

ASSIST was a very large demonstration 

project, requiring many coalitions and a 

great amount of complex planning. In 

addition, approval from the ACS Board 

was necessary, though the ACS Executive Committee had already endorsed the 

concept. 

Donald R. Shopland, one of the key 

NCI staff working on ASSIST in the early phase, emphasized the importance of 

the coalition model: 

First of all, we have to recognize that 

tobacco control is both too large and 

too complex an issue for any one 

organization to address independently. 

Coalitions are, also, the best vehicle 

for tobacco control because they serve 

very useful functions . . . they allow for 

comprehensive planning of the 

interventions.25(pp243–4) 

12 
M o n o g r a p h 1 6. A S S I S T 

Shopland pointed out that comprehensive tobacco prevention and control 

required active participation of all interested parties in a community or a state 

in a coordinated manner, that diverse 

groups must be involved in both the 

planning and delivery of the intervention, and that these coalitions are important because they build on existing local 

resources and “promote a sense of local 

ownership of the project.”25(p244) 

A number of questions focusing on 

the scope of the project and its management structure and mechanisms were 

raised and answered at the board meeting. Dr. Kenneth E. Warner, an experienced tobacco researcher, took issue 

with a reference to a smoke-free generation and recommended adopting terminology (e.g., tobacco free) that would be 

more inclusive and reflect a broader 

scope. He expressed concern about the 

potential for segmentation of the health 

community by the exclusive focus on 

cancer—tobacco use also causes heart 

disease, chronic obstructive lung disease, and many other health problems. 

He commended the American Cancer 

Society, the American Heart Association, and the American Lung Association 

for forming the Coalition on Smoking 

OR Health, a major step in collaboration 

among three of the most powerful voluntary health organizations in the nation. 

He raised the potential problem of naming a single primary partner in states 

where one of the other health voluntaries 

is the strongest tobacco prevention and 

control organization. (In fact, this issue 

of primary partners persisted throughout 

ASSIST.) Warner also emphasized the 

importance of including an evaluation 

component at the outset and raised questions about the wisdom of proceeding 

with ASSIST before all data from the 

COMMIT trials were analyzed. 

Cullen acknowledged that these were 

difficult issues that had been raised, but 

he addressed them to the satisfaction of 

the board. He explained that to sustain 

the momentum of NCI’s tobacco prevention and control efforts, STCP wanted to 

begin ASSIST before results were available from COMMIT. The ASSIST site 

analyses and planning would already be 

underway while analyses of the COMMIT 

data were being completed. A readiness 

would be established for ASSIST’s implementation phase to be immediately 

informed by results and lessons learned 

from COMMIT during ASSIST’s implementation of interventions.28,29 To resolve the problem of segmenting the 

health community, he suggested building 

a model that would involve other health 

and community groups in the coalitions. 

Eyre also brought up this issue in his remarks and referred to the Rocky Mountain Tobacco-Free Challenge, a regional 

coalition of eight states, formed by the 

directors of health education of each 

state. The coalition annually assessed 

progress in tobacco control with specific 

measures of policy change, new programs, coalition development, national 

data surveys, and others. Eyre noted that 

each of the eight states already had coalitions that involved the major health organizations. He said that the coalitions 

were evolving and finding solutions— 

for example, they found ways to deal 

with the issue of who has the lead role. 

In fact, this process of evolving was to 

become the experience in many states 

13 
1. T h e H i s t o r i c a l C o n t e x t 

■ Broaden the terminology to tobacco free. 

■ 

■ 

■ 

partnership. 

■ 

■ 

departments of health. 

■ 

Concerns and Issues Expressed to the 

Board of Scientific Counselors 

Avoid segmenting the public health 

community by disease categories. 

Involve all in coalitions. 

Prevent alienation of other voluntary 

organizations as a reaction to the ACS 

Clarify the different roles of NCI and ACS. 

Prepare for the lack of administrative 

experience in contracting with state 

Include an evaluation design from the 

beginning. 

throughout the life of the ASSIST 

project. To promote collaboration, the 

ACS leaders had already met with the 

chief executive officers of the American 

Heart Association and the American 

Lung Association. 

Dr. William Darrity asked why contracts, not grants, would be awarded, and 

Cullen responded that awarding funds as 

contracts to the state health departments 

would retain NCI’s legal responsibility 

to manage the funds: 

The reason for the contract is that I 

cannot imagine that a grant would ever 

work here because we would have no 

control over it. People could do what 

they wanted. It would be the end. We 

would give up the money, and we 

would run into nothing but difficulties 

in dealing with problems and 

negotiations and difficulties that 

developed.25(p274) 

A benefit of the contract mechanism 

rather than the grant mechanism later 

became apparent once the ASSIST 

project was underway. In contrast to the 

grant mechanism, the contract required 

that the states agree to specific deliverables. By having these deliverables built 

into the funding commitment, NCI was 

able to maintain consistency and the 

states were able to resist the pressures of 

individuals who might have been politically motivated. 

The funding arrangement between the 

states and NCI would require ongoing 

discussion throughout the duration of 

the project. However, the benefits of 

making the awards to state health departments were recognized. The states 

were to channel a significant portion of 

the funds to local organizations and to 

various subcontractors who would be 

members of the coalitions and who 

would be involved in delivering the interventions. 

ACS would have a clear responsibility as a resource to the states regarding 

activities focused on policy issues. Legislation and policy go hand in hand, and 

ACS had the ability to lead legislative 

efforts. ACS was preeminent in its ability to effect state and national policy 

changes and would continue to do so in 

pursuit of public health goals for preventing tobacco use. 

After the discussion ended, the Board 

of Scientific Counselors approved the 

concept as proposed and unanimously 

recommended funding for the ASSIST 

project. 

Readiness to Go Forward 

Despite the scientific, organizational, political, and other challenges to undertaking an innovative initiative of such 

14 
M o n o g r a p h 1 6. A S S I S T 

scope as the proposed ASSIST project, 

NCI was ready to undertake the project. 

Fundamental factors that motivated STCP 

staff and NCI are listed below. 

■	 Tobacco is the number one 

preventable cause of death in the 

United States. 

■	 Tobacco is responsible for more than 

one-third of all cancers. 

■	 Leaders with perseverance were 

committed to implementing a new 

approach to tobacco control. 

■	 NCI had been conducting trials and 

funding tobacco prevention and 

control research for many years—the 

time had come to build and to test a 

phase V demonstration project based 

on the findings generated from years 

of research. 

■	 The time was right for a major shift— 

to change the way tobacco prevention 

and control efforts were conducted in 

the United States from interventions 

focused on individuals to a 

population-based, public health 

approach. 

This historical context built on the 

foundation provided in the first NCI tobacco monograph, Strategies to Control 

Tobacco Use in the United States: A 

Blueprint for Public Health Action in the 

1990’s: 

The NCI’s Smoking and Tobacco 

Control Program has operated under 

the philosophy that research, in and of 

itself, is not capable of producing 

large-scale national change in smoking 

prevalence rates. It was recognized 

from the outset that there must be a 

concerted effort to systematically and 

comprehensively apply the knowledge 

gained from the intervention trials. 

Thus, from its inception, the STCP has 

continually used information from 

such studies to plan the next steps for 

implementation of a national strategy 

to significantly reduce smoking in the 

1990’s.30(px) 

Having the approval to go ahead with 

the ASSIST project, NCI’s next task was 

to clearly define the essential principles, 

or standards, of the conceptual framework that would be described in a request for proposals to conduct 

comprehensive tobacco prevention and 

control interventions. 

References 

1. Koop, C. E. 1985. Call for a smoke-free 

society. Pediatric Pulmonology 1:4–5. 

2. Centers for Disease Control and


Prevention. 2004. Cigarette smoking


among adults—United States, 2002.


Morbidity and Mortality Weekly Report 

53 (20): 427–31. www.cdc.gov/mmwr/ 

preview/mmwrhtml/mm5320a2.htm. 

3. National Academy of Sciences. 1986. 

Environmental tobacco smoke: 

Measuring exposures and assessing 

health effects. Washington, DC: 

National Academies Press. 

4. U.S. Department of Health and Human 

Services. 1986. The health consequences 

of involuntary smoking: A report of the 

surgeon general (CDC publication no. 

87-8398). Rockville, MD: U.S. 

Department of Health and Human 

Services, Public Health Service. 

5. National Cancer Institute. 1990. 

Smoking, tobacco, and cancer program: 

1985–1989 status report (NIH 

publication no. 90-3107). Bethesda, 

MD: U.S. Department of Health and 

Human Services. 

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1. T h e H i s t o r i c a l C o n t e x t 

6. Wynder, E. L., and E. A. Graham. 1950. 

Tobacco smoking as a possible etiologic 

factor in bronchogenic carcinoma: A 

study of six hundred and eighty-four 

proved cases. Journal of the American 

Medical Association 143 (4): 329–36. 

7. Levin, M. L., H. Goldstein, and P. R. 

Gerhardt. 1950. Cancer and tobacco 

smoking: A preliminary report. Journal 

of the American Medical Association 

143 (4): 336–8. 

8. Mills, C. A., and M. M. Porter. 1950. 

Tobacco smoking habits and cancer of 

the mouth and respiratory system. 

Cancer Research 10:539–42. 

9. Schrek, R., L. A. Baker, G. P. Ballard, 

and S. Dolgoff. 1950. Tobacco smoking 

as an etiologic factor in disease. I. 

Cancer. Cancer Research 10:49–58. 

10. Parascandola, M. 2001. Cigarettes and 

the U.S. Public Health Service in the 

1950s. American Journal of Public 

Health 91:196–205. 

11. Cancer Control Working Group. 1975. 

Report of working group 8: Summary 

report of the Cancer Control Working 

Group on the national cancer program 

planning conference, Los Angeles, 

California, 1974. Bethesda, MD: 

National Cancer Institute. Quoted in P. 

Greenwald and J. W. Cullen. 1984. The 

scientific approach to cancer control. 

CA-A Cancer Journal for Clinicians 34 

(6): 329. 

12. Greenwald, P. G., and J. W. Cullen. 

1984. The scientific approach to cancer 

control. CA-A Cancer Journal for 

Clinicians 34 (6): 328–32. 

13. Hopkins, D. P., P. A. Briss, C. J. Ricard, 

C. G. Husten, V. G. Carande-Kulis, J. E. 

Fielding, M. O. Alao, et al. 2001. 

Reviews of evidence regarding 

interventions to reduce tobacco use and 

exposure to environmental tobacco 

smoke. American Journal of Preventive 

Medicine 20 (Suppl. 2): 16–66. 

14. Farquhar, J. W., N. Maccoby, P. D. 

Wood, J. K. Alexander, H. Breitrose, B. 

W. Brown Jr., W. L. Haskell, et al. 1977. 

Community education for 

cardiovascular health. Lancet 1:1192–5. 

15. Perry, C. L., S. H. Kelder, D. M. 

Murray, and K.-I. Klepp. 1992. 

Communitywide smoking prevention: 

Long-term outcomes of the Minnesota 

Heart Health Program and the Class of 

1989 Study. American Journal of Public 

Health 82 (9): 1210–6. 

16. Pentz, M. A., D. P. MacKinnon, J. H. 

Dwyer, E. Y. I. Wang, W. B. Hansen, B. 

R. Flay, and C. A. Johnson. 1989. 

Longitudinal effects of the Midwestern 

Prevention Project on regular and 

experimental smoking in adolescents. 

Preventive Medicine 18:304–21. 

17. Egger, G., W. Fitzgerald, G. Frape, A. 

Monaem, P. Rubinstein, C. Tyler, and B. 

McKay. 1983. Results of large scale 

media antismoking campaign in 

Australia: North Coast “Quit for Life” 

programme. British Medical Journal 

287:1125–8. 

18. Pierce, J. P., T. Dwyer, G. Frape, S. 

Chapman, A. Chamberlain, and N. 

Burke. 1986. Evaluation of the Sydney 

“Quit for Life” anti-smoking campaign. 

Part 1: Achievement of intermediate 

goals. Medical Journal of Australia 

144:341–4. 

19. Pierce, J. P., P. Macaskill, and D. Hill. 

1990. Long-term effectiveness of mass 

media led anti-smoking campaigns in 

Australia. American Journal of Public 

Health 80:565–9. 

20. Puska, P., K. Koskela, H. Pakarinen, P. 

Puumalainen, and V. Soininen. 1976. 

The North Karelia project: A 

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programme for community control of 

cardiovascular disease. Scandinavian 

Journal of Social Medicine 4 (2): 57–60. 

21. Gutzwiller, F., B. Nater, and J. Martin. 

1985. Community-based primary 

prevention of cardiovascular disease in 

Switzerland: Methods and results of the 

National Research Program (NRP 1A). 

Preventive Medicine 14:482–91. 

22. Gofin, J., R. Gofin, J. H. Abramson, and 

R. Ban. 1986. Ten-year evaluation of 

hypertension, overweight, cholesterol, 

and smoking control: The CHAD 

program in Jerusalem. Preventive 

Medicine 15:304–12. 

23. Rhomberg, H. P. 1991. Ten years’ 

experience in a cardiovascular disease 

prevention programme in Austria. Cor et 

Vasa 33 (2): 103–6. 

24. Steenkamp, H. J., P. L. Jooste, P. J. C. 

Jordaan, A. S. P. Swanepoel, and J. E. 

Rossouw. 1991. Changes in smoking 

during a community-based 

cardiovascular disease intervention 

programme. South African Medical 

Journal 79:250–3. 

25. Board of Scientific Counselors, Division 

of Cancer Prevention and Control. 1988. 

Transcript of proceedings, Board of 

Scientific Counselors meeting, October 

7, 1988. Bethesda, MD: National Cancer 

Institute, National Institutes of Health. 

26. Lynn, W. R., and B. Thompson. 1995. 

Community intervention trial for 

smoking cessation: Description and 

evaluation plan. In Community-based 

interventions for smokers: The 

COMMIT field experience (Smoking 

and tobacco control monograph no. 6, 

NIH publication no. 95-4028). 

Bethesda, MD: National Institutes of 

Health. 

27. Thompson, B., L. Wallack, E. 

Lichtenstein, and T. Pechacek. 1990– 

1991. Principles of community 

organization and partnership for 

smoking cessation in the Community 

Intervention Trial for Smoking 

Cessation (COMMIT). International 

Quarterly of Community Health 

Education: A Journal of Policy and 

Applied Research 11 (3): 187–203. 

28. The COMMIT Research Group. 1995. 

Community Intervention Trial for 

Smoking Cessation (COMMIT): I. Cohort results from a four-year community 

intervention. American Journal of Public Health 85 (2): 183–92. 

29. The COMMIT Research Group. 1995. 

Community Intervention Trial for 

Smoking Cessation (COMMIT): II. 

Changes in adult cigarette smoking 

prevalence. American Journal of Public 

Health 85 (2): 193–200. 

30. National Cancer Institute. 1991. 

Strategies to control tobacco use in the 

United States: A blueprint for public 

health action in the 1990’s (Smoking 

and tobacco control monograph no. 1, 

NIH publication no. 92-3316). Bethesda, 

MD: National Cancer Institute. 

Additional Resource 

1. Guide to Community Preventive 

Services: Tobacco Use Prevention and 

Control. www.thecommunityguide.org/ 

tobacco/default.htm. 

17 

M o n o g r a p h 1 6. A S S I S T 

2. The Conceptual Framework

Robert W. Moon, Darla Havlicek, John M. Garcia, Robert E. Vollinger Jr., 

and Brenda McAdams Motsinger 

Contributor: Frances A. Stillman 

Contents 

The Fundamental Premises of ASSIST: Preventing Tobacco Use through the


Public Health Model .................................................................................................... 21


Coalition Building: Involving and Mobilizing the Community .............................................. 23


The ASSIST Conceptual Framework: Priority Populations, Channels, 

and Interventions ........................................................................................................ 24


Axis 1: Priority Populations.................................................................................................. 24


Axis 2: Channels.................................................................................................................. 25


Axis 3: Interventions............................................................................................................ 26


ASSIST Program Objectives and Evaluation ................................................................ 28


Community Environment ..................................................................................................... 28


Worksites ............................................................................................................................. 29


Schools ................................................................................................................................ 30


Healthcare Settings ............................................................................................................. 30 


Community Groups .............................................................................................................. 30


The Evaluation Plan for ASSIST ........................................................................................... 31


The ASSIST Evaluation Model .............................................................................................. 32


Strength of Tobacco Control Index ................................................................................ 32


Data Sources ................................................................................................................ 32


The Selection of States ................................................................................................ 35


Time to Act .................................................................................................................. 38


References .................................................................................................................. 38


19 
2. T h e C o n c e p t u a l F r a m e w o r k 

Table and Figures 

Figure 2.1. The Public Health Model ......................................................................................... 22


Figure 2.2. The ASSIST Conceptual Framework ........................................................................ 25


Table 2.1. ASSIST Program Objectives by 1998 ........................................................................ 29


Figure 2.3. The ASSIST Evaluation Model ................................................................................. 33


Figure 2.4. States Awarded ASSIST Contracts .......................................................................... 37


20 
M o n o g r a p h 1 6. A S S I S T 

2. The Conceptual Framework

During the year following the approval of the American Stop Smoking 

Intervention Study (ASSIST) project by the Board of Scientific Counselors, the 

National Cancer Institute (NCI) staff formalized a description of the components— 

programmatic, organizational, and operational—that would be required in a 

comprehensive tobacco prevention program. Those components would be 

incorporated as program standards in a request for proposals, the mechanism the 

government uses to offer contracts for work to be performed. The standards 

presented the critical elements for an effective comprehensive intervention for 

tobacco prevention and control. They were based on the NCI research database, the 

cumulative body of smoking and behavioral change research literature, and the 

experience of public health professionals. As such, the standards represented the 

state of the science in smoking prevention and control at that time. 

The standards informed the development of the “ASSIST Program Guidelines for 

Tobacco-Free Communities” and later served as the foundation for The Robert Wood 

Johnson Foundation’s SmokeLess States Program and the Initiatives to Mobilize for 

the Prevention and Control of Tobacco Use (IMPACT) program of the Centers for 

Disease Control and Prevention. They also provided guidance for programs in 

California, Massachusetts, and other states. This chapter describes the conceptual 

framework used for planning and implementing each state’s ASSIST program. 

The Fundamental Premises of ASSIST:


Preventing Tobacco Use through the Public Health Model


C oncurrent with the efforts to formalize the concept for the ASSIST model, public 

health professionals throughout the United States were beginning to understand 

more fully the relationships between health behaviors and social and physical environments. Tobacco use is developed and shaped by social context in addition to an individual’s biological responses. Changes in the social and physical environment that can 

influence the initiation and cessation of tobacco use and exposure to environmental tobacco smoke include tobacco prices, antitobacco media campaigns, declining social acceptability of smoking, limitations on where tobacco use is permitted, and limitations 

on access to tobacco products. 

Given the broader perspective, smoking was seen as a public health problem requiring population-based interventions that extend beyond individual counseling and education. The agent-host-environment triad is commonly used to conceptualize and 

address public health problems, thereby providing more strategic options for controlling diseases and promoting health. (See figure 2.1.) 

21 
2. T h e C o n c e p t u a l F r a m e w o r k 

“Health departments, because of their 

commitment to public health, their 

institutional partnerships to accomplish their 

presence, will be the only eligible recipients 

The 

American Stop Smoking Intervention Study 

(Publication 

no. NCI-CN-95165-38). Bethesda, MD: 

National Cancer Institute, 30. 

This public health model is a fundamental component of epidemiology and 

relationships between people and their 

Applied to tobacco control, it focuses attention on four priority actions: 

and media messages 

nicotine addiction 

1 

Based on the ecological model, the 

societal phenomena, such as public poliFigure 2.1. The Public Health Model 

Host (tobacco user) 

clinics and cessation aid 

(e.g., drugs, nicotine 

gum, patch). 

Agent 

(tobacco, 

tobacco 

industry) 

substances from 

tobacco. 

Prohibit smoking in public places. 

Change social norms. 

Note: p. 51, for a 

discussion of the triad. 

Eligibility for ASSIST Contracts 

experience in working in a society of 

goals, their access to target populations of 

smokers, and their guaranteed continued 

of ASSIST contracts.” 

Source: National Cancer Institute. 1990. 

(ASSIST) request for proposals

health behavioral sciences. The ecological 

systems model, or a social-environmental 

model, depicts connections and interenvironments and builds on the triad. 

1. Promoting a tobacco-free social norm 

through widespread policy changes 

2. Preventing the initiation of tobacco 

use and thereby the development of 

3. Making support for quitting widely 

available to tobacco users 

4. Protecting nonsmokers from exposure 

to environmental tobacco smoke

ASSIST conceptual framework emphasizes how the influences of social relationships, environmental conditions, and 

cies that affect tobacco use and health, 

provide a structure for designing media 

and policy interventions for multiple 

channels and populations. (See figure 2.2.) 

Provide smoking cessation 

Environments 

(social and physical) 

Remove harmful 

Increase taxes. 

See the 2003 Institute of Medicine report, The Future of the Public’s Health in the 21st Century, 

22 
M o n o g r a p h 1 6. A S S I S T 

Given the public health conceptualization of the tobacco problem, important assumptions were identified and 

articulated as ASSIST program guidelines: 

1. When a community affected by 

change is involved in initiating and 

promoting the development of that 

change, there is an increased probability that the change will be successful and permanent. This 

involvement includes participation 

by community representatives in 

defining the problem and in planning and instituting steps to resolve 

the problem. 

2. Smoking control interventions 

should be targeted at broad social 

and environmental change rather 

than individual change. Therefore, 

efforts to achieve priority public 

policy objectives should take precedence over efforts to support service 

delivery. 

3. Interventions should be directed toward efforts that will have the greatest potential for producing a major 

impact on smoking control. Usually, 

this would suggest targeting at the 

highest structural level of the site 

(i.e., state or region). However, this 

should not unduly preempt a careful 

weighing of the strategic benefits of 

local efforts. 

4. Interventions targeted at populations at higher risk for smoking are 

likely to be more cost effective than 

undifferentiated initiatives targeted 

at the population as a whole. However, where policy advocacy is the 

appropriate intervention, the defined target audiences may not be 

representative of the target population but of other segments of the 

general public that would have a 

greater impact on implementing the 

policy. 

5. Staff energies should be devoted to 

building capacity within the coalition and the site rather than directly 

carrying out interventions. 

6. ASSIST resources will augment the 

existing resources of coalition 

members and other community organizations to accomplish ASSIST 

objectives. Rather than supplanting 

resources, ASSIST will stimulate 

and enhance existing resources to 

expand beyond their current smoking control activities. Conversely, 

ASSIST staff resources will be amplified by contributions of coalition 

members and other community 

organizations.1(Overview, pp4–5) 

Coalition Building: Involving 

and Mobilizing the Community 

Working with and through communities was a central operational and 

structural approach of ASSIST. If a program’s primary focus is on social- and 

system-oriented changes, stakeholders 

and key influential persons in the system 

must be involved and active. 

The ability to develop and use statewide 

and local tobacco control coalitions was a 

fundamental underpinning for operationalizing the ASSIST conceptual framework 

and was a requirement in the request for 

proposals. The requirement conveyed 

NCI’s commitment to the communitybased approach. The coalition model,2,3 

as the organizational structure for the 

ASSIST framework, enables diverse 

groups to work together to plan, support, 

and coordinate tobacco control efforts. (An 

extensive description of the coalition 

model is presented in chapter 4.) ASSIST 

coalitions would be responsible for a variety of functions, including the following: 

23 
2. T h e C o n c e p t u a l F r a m e w o r k 

■	 Reaching out and engaging community 

groups and individuals who have the 

potential to contribute to community 

tobacco control mobilization on all 

intervention fronts and in all channels 

■	 Mobilizing the organizations and 

human resources needed to 

collaborate with ASSIST staff in 

conducting site analyses, developing 

comprehensive tobacco control plans, 

and developing annual action plans 

■	 Overseeing and implementing the 

program interventions defined in the 

annual action plans 

Whatever the chosen structure and 

form of governance, each coalition was 

required by the ASSIST program guidelines to develop responsive leadership 

and certain capabilities to conduct interventions successfully. 

The ASSIST Conceptual 

Framework: Priority 

Populations, Channels, 

and Interventions 

T

he ASSIST conceptual framework, 

an adaptation of the ecological model, 

approaches the prevention of tobacco use 

through three priority strategies: community organization and mobilization 

through coalition-building, mass media 

interventions, and policy advocacy. The 

framework incorporates three axes, 

which became the project’s planning 

model: priority populations,* channels, 

and interventions. The ASSIST conceptual framework (known as the cube) 

depicts the channels for delivering intervention activities to priority populations. 

(See figure 2.2. This early version of the 

cube has four channels. The Community 

Environment channel was added later.) 

Axis 1: Priority Populations 

ASSIST was designed to reach 

groups with high rates of tobacco use, 

with limited access to information about 

tobacco use and cessation services, and 

at high risk for initiating tobacco use. 

National prevalence data revealed that 

the population groups with the highest 

rates of tobacco use were adolescents, 

ethnic minorities, blue-collar workers, 

unemployed people, and women. Because of the potential for the greatest 

long-term impact, youths were identified 

as a major priority population. 

The ASSIST model readily integrates 

the social marketing concept of priority 

populations with a community development orientation; that is, it views involvement of community groups as important 

for reaching the priority populations and 

even engages the priority populations in 

implementing interventions. For example, 

to reach adolescents, the coalitions 

*At the outset of ASSIST, the term target populations was used. The term target is commonly used in 

marketing disciplines to refer to population groups. However, in the early 1990s, because many in the 

public found the term target offensive and even threatening, ASSIST replaced the term with priority. In the 

glossary to the “ASSIST Program Guidelines for Tobacco-Free Communities,” target (priority) populations 

are defined as follows: “segments of the general population that merit special attention based on their 

higher risk for cancer (e.g., heavy smokers), potentially higher risk of smoking (e.g., youths and teenagers), 

or lack of access to smoking control services” (p. 6). 

24 
M o n o g r a p h 1 6. A S S I S T 

worked with adolescents themselves and reinforces a tobacco-free norm commugave them the lead in advocacy interven- nity-wide. The channel of community 

tions, such as media events and making environment includes smoke-free restaupresentations to city councils. rants, bars, and other public buildings. 

Through the worksite channel, businessAxis 2: Channels es can become involved in creating 

smoke-free workplaces and in develop- The following channels for prevention ing cessation programs for employees and control of tobacco use are the setand their spouses who use tobacco. tings through which intervention pro- Schools are settings in which tobacco gram activities reach the specific use policies should be enacted and en- individuals and groups: forced—in school buildings, on school ■ Community environment grounds, at school sporting events, and ■ Worksites at school-related meetings. Schools also ■ Schools offer the means for outreach to teachers ■ Healthcare settings and students with strategies and inter- ■ Community groups ventions to prevent tobacco use and to 

Promoting a tobacco-free social norm become an empowering vehicle for 

in each of these settings establishes and change. Healthcare settings ensure that 

Program Services 

Mass Media 

Schools 

Health 

Care 

Settings 

Community 

Groups 

Axis 2

Channels 

Axis 3 

Axis 1 

Figure 2.2. The ASSIST Conceptual Framework 

Policy 

Worksites 

Interventions 

Target Populations 

Source: ASSIST Coordinating Center. 1991. Overview of ASSIST. In ASSIST program guidelines for tobaccofree communities. Internal document, ASSIST Coordinating Center, Rockville, MD (p. 9). 

25 
2. T h e C o n c e p t u a l F r a m e w o r k 

Critical Planning Issues 

be considered: 

that all communications describe the issue 

as a problem for all members of a commutracizing tobacco users can polarize the 

location of resources. Such an assessment 

the potential of the healthcare system, 

Several elements are critical to planning a 

comprehensive smoking prevention and control program. Whether for a small community, city, major metropolitan area, state, or 

the nation, the following three issues should 

1. Tobacco use is a public health problem. 

Participants in the program must ensure 

nity, not just for smokers. Blaming and ospublic and cause hard feelings that undermine tobacco prevention and control efforts. 

2. A careful assessment of the community’s 

needs and assets is essential to effective alincludes defining the tobacco problem; 

identifying priority groups; surveying the 

current level of program services, policies, 

and various types of media; and analyzing 

worksites, schools, community networks, 

and the community environment to reach 

smokers. This process is time-consuming 

and delays moving into action but is critical to the success of tobacco control efforts. 

3. A comprehensive long-term plan must be 

developed to integrate and coordinate the 

use of various types of media, develop 

policies, and deliver program services to 

the appropriate audiences to achieve significant reductions in tobacco use. 

smoking is an element in the patient assessment. Community groups, such as 

Rotary clubs, agree to no smoking at 

their meetings. (The subsection below 

on program objectives elaborates on 

these channels.) 

Axis 3: Interventions 

In the ASSIST conceptual framework 

and planning model, three types of interventions are delivered through the channels—policy, mass media, and program 

services. Tobacco control research 

shows that the social and physical environment surrounding smokers and potential smokers influences their 

behavior. Smoking rates among large 

populations appear to be related to certain public and private policies on tobacco use and to tobacco marketing. 

Policies can take the form of legislation, 

such as excise tax increases, access and 

advertising restrictions, or private rules, 

such as voluntary adoption of workplace 

or restaurant smoking bans that are implemented without a public mandate. 

Each category of intervention includes a 

variety of specific activities, some that 

can be delivered through all five channels (e.g., self-help materials or large 

community-based magnet events, such 

as the Great American Smokeout) and 

some that are most appropriately delivered within a specific channel (e.g., brief 

counseling by healthcare providers, 

school-based smoking prevention programs, or messages designed specifically for priority populations). 

The aim of the interventions is to alter 

the environmental and social influences 

affecting the population’s use of tobacco; therefore, the strongest emphasis is 

on media and public and private policy 

interventions. In the ASSIST model, 

four policy areas are priorities: 

1. Eliminating exposure to environmental tobacco smoke 

2. Promoting higher taxes for tobacco 

3. Limiting tobacco advertising and promotions 

4. Reducing minors’ access to tobacco 

products 

26 
M o n o g r a p h 1 6. A S S I S T 

ASSIST Program Guidelines 

For example, policy efforts can be 

directed at promoting clean indoor air 

policies, promoting higher excise taxes 

for tobacco products, limiting tobacco 

advertising, and restricting minors’ access to tobacco. Media activities should 

support these policy initiatives through 

well-designed media campaigns, especially campaigns that generate news 

coverage (sometimes termed earned media coverage), although the paid media 

approach is sometimes preferred to ensure prime-time and adequate coverage. 

Engaging the media strategically to 

bring attention to an issue or to promote 

a policy is known as media advocacy. 

Media advocacy was a critical strategy 

in the ASSIST project, which advanced 

its application as an intervention in the 

public health model of prevention. 

Though proven to be effective interventions, the relative impacts of these 

different types of policies and restrictions 

have not yet been conclusively established. 

However, the Community Guide to Preventive Services is an excellent resource 

that considers the strength of the evidence 

base for policy interventions and provides 

very helpful recommendations regarding 

their relative effectiveness. See http:// 

www.thecommunityguide.org/tobacco/ 

default.htm.4 (For more information about 

the scientific basis and rationale behind 

these policy areas, see chapters 5–7.) 

At the time the conceptual framework 

was developed, the impact of increases 

in cigarette excise taxes on smoking behavior was already documented.5 Analyses demonstrated that a price increase of 

10% produces a decrease of about 4% in 

demand for cigarettes, particularly 

among men 20 to 25 years old. This decrease results largely from people 

choosing not to smoke at all; the remainder is attributable to decreases in daily 

consumption rates by men 35 and older 

who continue to smoke.5 Analyses also 

showed that youths are sensitive to price 

changes. An 8-cent decrease in the federal tax would induce up to 1 million 

young persons aged 12 to 25 to smoke, 

whereas without the tax decrease, they 

would not smoke. Conversely, an 8- to 

16-cent tax increase would influence 

from 1 to 2 million persons ages 12 to 

25 and from 800,000 to 1.5 million 

adults to quit smoking or not to start. 

Thus, the effect of a tax increase would 

translate into the prevention of hundreds 

of thousands of premature smoking-related deaths.6 

Restrictions on indoor smoking and tobacco advertising may also influence 

27 
2. T h e C o n c e p t u a l F r a m e w o r k 

smoking behavior. By the time the 

ASSIST framework was developed, several longitudinal studies had documented 

decreases in prevalence and increases in 

smoking cessation after the enactment of 

smoking restrictions in individual worksites and healthcare settings, whereas other studies did not.7–11 Several studies had 

suggested that reductions in smoking 

prevalence can be achieved by implementing significant restrictions on tobacco promotion and advertising.12–16 Many 

types of restrictions had been suggested. 

These restrictions included a total ban on 

advertising; removal of cartoon characters, color, or people from ads; bans on 

point-of-purchase advertising; bans on 

event sponsorship; and removal of outdoor advertising near schools and parks. 

Program services are likely to be 

needed once media and policy efforts 

have been successful in putting tobacco 

use policies in place and in creating a tobacco-free norm. Program services were 

originally defined in the ASSIST program guidelines as those smoking control activities involved in directly 

assisting individuals to make behavioral 

changes consistent with nonsmoking 

norms, but the concept later evolved to 

include all forms of tobacco use. For 

purposes of ASSIST, three main kinds of 

services were identified: 

1. Use of cessation resources to help 

people stop smoking 

2. Services to prevent smoking initiation 

3. Smoking education for the general 

public 

ASSIST Program Objectives 

and Evaluation 

T

he request for proposals set forth program objectives based on a public 

health perspective. The program objectives would provide strategic direction 

and priorities for the coalitions, but it 

would be the responsibility of the coalition members to develop the tactics, or 

intervention activities, that would 

achieve the objectives. The ASSIST approach to achieving the objectives encompassed two phases: 

1. A 2-year planning phase, during 

which state-level analyses of resources were made and comprehensive 

smoking control plans were developed 

2. A 5-year implementation phase* 

The program objectives were revised 

early in the ASSIST project and were set 

forth in the “ASSIST Program Guidelines for Tobacco-Free Communities,” as 

presented in table 2.1. 

The following sections elaborate on 

the program objectives in terms of the 

channels to be used in implementing the 

ASSIST planning model. 

Community Environment 

All urban areas and regions of the 

country comprise various smaller communities that can be geographically, 

ethnically, or culturally defined. Community environment refers to the general 

physical and social environment in identified areas within the intervention site. 

*The ASSIST project was originally scheduled to end in 1998 but was later extended through the end of 

September 1999. 

28 
M o n o g r a p h 1 6. A S S I S T 

Table 2.1. ASSIST Program Objectives by 1998 

Channel Objective 

Community Environment	 By 1998, cues and messages supporting nonsmoking will have in­


creased, and pro-smoking cues and messages will have decreased.


By 1998, sites will substantially increase and strengthen public support 

of policies which a) mandate clean indoor air; b) restrict access to tobacco by minors; c) increase economic incentives and taxation to discourage the use of tobacco products; and d) restrict the advertising and 

promotion of tobacco. 

Community Groups	 By 1998, major community groups and organizations that represent the 

priority populations and have broad-based statewide reach should be involved in ASSIST activities. 

Worksites	 By 1998, proportion of worksites with a formal smoking policy that 

prohibits or severely restricts smoking at the workplace should increase 

to at least 75 percent. 

By 1998, worksites reaching major populations will adopt and maintain 

a tobacco use cessation focus. 

Schools	 By 1998, 100 percent of schools serving grades K through 12 and public vocation/technical/trade schools will be tobacco free. 

By 1998, 100 percent of all schools serving grades K through 12 will 

use a tested, efficacious tobacco use prevention curriculum. 

Healthcare Settings	 By 1998, at least 75 percent of primary medical and dental care providers will routinely advise cessation and provide assistance and followup 

for all of their tobacco-using patients. 

By 1998, all public health facilities, both outpatient and inpatient, will 

have enforced smoke-free policies. 

Source: ASSIST Coordinating Center. 1992. Resource materials section. In ASSIST training materials. Vol. III. Site


analysis and comprehensive smoking control plan. July 20–21. Internal document, ASSIST Coordinating Center,


Rockville, MD.


The community environment as a chan­ the tobacco control issue and changing 

nel consists of the multiple community the social environment is to involve nuoutlets that reach all citizens regardless merous organizations and groups in planof employment, educational, health, so­ ning, initiating, and implementing tobacco 

cial, or smoking status. The presence control activities at the local level. 

and salience of messages promoting Worksites tobacco use or cessation, the availability 

(or lack) of cigarettes and smokeless Worksites are ready-made locations 

tobacco, and the social norms for smok­ for implementing and supporting tobacing in public places all contribute to a co-free policies and smoking cessation 

community environment that may or programs. Worksites also provide an opmay not support tobacco use. An effec­ portunity to reach the ASSIST priority 

tive strategy for increasing awareness of populations: women, blue-collar workers, 

29 
2. T h e C o n c e p t u a l F r a m e w o r k 

and people of low educational attainment. Worksites are an important channel for involving nonsmokers in 

tobacco control efforts, particularly 

through the promotion of nonsmoking 

policies. Restrictions on smoking in the 

workplace protect nonsmokers from exposure to the tobacco smoke of others. 

Thus, successful worksite smoking 

control programs consist of two major 

components: 

1. Motivation and support for smoking 

cessation attempts 

2. A clear nonsmoking policy that is 

strictly enforced 

It is important in implementing worksite smoking control programs that employees take responsibility for planning 

and implementing smoking control policies and programs in their own worksites. 

Schools 

Schools provide another important 

channel for preventing tobacco use because they represent a primary channel 

for reaching youths and adolescents and 

provide an opportunity for reaching individuals who may not be reached 

through worksites. Schools also provide 

a forum for reinforcing parental messages delivered through worksite programs. 

The school environment is established to 

support learning and, thus, naturally provides the skills and support for the delivery of prevention and cessation 

programs to students, faculty, and staff. 

Further, during class time, students may 

be receptive to learning about the health 

consequences of tobacco use and the 

benefits of cessation. Finally, as selfgoverning establishments, schools provide important opportunities for implementing tobacco-free policies. Schoolbased prevention and control activities 

should be conducted through all private 

and public primary, secondary, and postsecondary schools. 

Healthcare Settings 

Because of the potential for healthcare providers to reach a substantial 

number of smokers, healthcare settings 

can be highly effective channels for 

smoking cessation and prevention activities. In addition, influential healthcare 

providers who are interested in playing a 

leadership role in tobacco control should 

be identified. They should be encouraged to influence their colleagues directly by training their peers in intervention 

techniques and indirectly by raising the 

topic at meetings and social events. 

Community Groups 

Community groups of individuals 

who gather regularly for some mutual 

purpose are considered to be networks. 

Such networks range in structure from 

formal (social clubs and some service 

organizations) to informal (e.g., block 

associations, neighborhood centers) and 

are representative racially and ethnically 

of the community. Community groups 

are an important channel for preventing 

tobacco use because they provide an opportunity to reach individuals who may 

not be reached through healthcare settings, worksites, or schools. In addition, 

the groups create an expanded capacity 

for ongoing support of nonsmoking 

norms at all levels of the community. 

Community networks include youth organizations, service and social clubs, 

30 
M o n o g r a p h 1 6. A S S I S T 

and religious and professional organizations. They include large organizations 

that meet regularly and small groups that 

have the potential to reach priority 

groups of smokers. Small groups vary 

greatly in structure and function and may 

be uniquely able to reach certain groups 

of smokers. They include such entities as 

childcare co-ops, block associations, after-school programs, and social clubs. 

The Evaluation Plan for ASSIST 

The main outcome expected from the 

ASSIST project was a trend of decreasing smoking prevalence in ASSIST 

states that would be greater than a trend 

in non-ASSIST states. To evaluate those 

trends, data would be needed at the state 

level and the national level. Because 

ASSIST was a national demonstration 

project, it would have been difficult for 

individual states to independently evaluate their own efforts and then combine 

those evaluations with evaluations from 

the other states. Consequently, no funds 

were allocated to the states for evaluation. Rather, as recommended by the 

ASSIST Scientific Advisory Committee, 

NCI staff decided to have the evaluation 

conducted centrally at NCI. Even so, the 

resources devoted to evaluation were 

quite modest relative to the total budget 

of the project. Thus, for the most part, 

existing databases had to be used, and 

designing the evaluation of this complex 

project proved to be a considerable challenge.17 In addition, during the planning 

process, the lack of adequate scientific 

methodology for evaluating such a 

large-scale, multi-site demonstration became evident, and a number of revisions 

to the original plan became necessary. 

To help address the inherent challenges of the ASSIST evaluation, ad hoc advisory groups were convened in 1990 

and met during several months to assist 

NCI in developing the initial design for 

process and outcome evaluations and for 

impact substudies. Later in 1992, a 

broad-based ASSIST Evaluation Committee was established to advise NCI 

and the ASSIST Coordinating Center 

(which provided technical assistance to 

the states) on the evaluation plan and to 

address the various issues surrounding 

the evaluation. The committee identified 

potential evaluation and research questions, suggested secondary data sources, 

recommended priorities for evaluation 

activities, reviewed proposed analytic 

approaches and data collection and measurement methodologies, and provided 

feedback on draft documents related to 

the ASSIST evaluation.18 

The advisory groups and the committee had to address a number of theoretical challenges. As a demonstration 

project, ASSIST was not a randomized 

experiment but rather a purposeful sample. Would comparisons to non-ASSIST 

states be valid measures of the effect of 

ASSIST? States were selected for participation in ASSIST because of their capabilities to deliver the three types of 

interventions to reach populations having 

the highest smoking rates. These criteria 

set them apart from most other states. 

Complicating the concept was the fact 

that two states, California and Massachusetts, received financial windfalls 

about the time that ASSIST was being 

funded. Massachusetts was an ASSIST 

state, but the committee had to consider 

whether California should be included 

31 
2. T h e C o n c e p t u a l F r a m e w o r k 

for comparison and if so, how it fit in 

because of the large spectrum of capabilities represented by the tobacco control program. In addition, some 

non-ASSIST states had started to implement programs that had elements similar 

to components of the ASSIST model, 

and a large amount of natural contamination (diffusion) to non-ASSIST states 

was to be expected from a nationwide 

program (personal communication from 

L. Kessler to C. Backinger, 2001). 

In 1996, a technical expert panel was 

formed to address the methodological issues implied by the theoretical challenges. The panel developed a conceptual 

model to guide the evaluation, to determine the research questions and the specific set of measures to be used in the 

evaluation, and to identify the data collection needs and existing data sources.19 

The ASSIST Evaluation Model 

The evaluation plan took into consideration the fact that environmental 

change occurs incrementally at a modest 

pace; therefore, multiple outcome points 

would be needed for tracking the continuum of change over the course of the 

project.17 To put the evaluation in perspective, the evaluation model explains 

the sequential process of change resulting from statewide tobacco control efforts. The evaluation model shows all the 

components to be measured that led to 

the reduction of tobacco use. Since 1996, 

the model has been simplified. The current model is depicted in figure 2.3. 

Strength of Tobacco Control Index 

A method was developed as an indirect measure for the program effects of 

ASSIST—the Strength of Tobacco Control index (SoTC). The method summarizes three constructs (resources, 

capacity, and antitobacco efforts) to 

form an overall exposure measure of tobacco control efforts at the state level: 

strength of tobacco control. Instead of 

measuring the individual effects of all 

the different tobacco control programs, 

this exposure measure summarizes this 

complex construct and the multiple facets and components of tobacco control 

efforts.19 SoTC data were collected for 

1998–99 from key informants at statelevel tobacco control organizations in all 

50 states. Analyses of the data were conducted at the end of the ASSIST project. 

Peer-reviewed articles have been published, and an NCI monograph on the 

ASSIST evaluation is forthcoming. 

Data Sources 

Conducting an evaluation required 

consistent, comparable data across all 

the states in the country—data that 

would enable analyses of state-level 

norms and tobacco control outcomes, 

such as media coverage, worksite clean 

air policies, and legislation. These data 

would be independent measures collected 

about all the states and not tied directly 

to ASSIST. A number of data sources, 

described below, were considered for the 

outcome and process evaluations of 

ASSIST. Two of these—site analyses 

and coalition assessment—guided the 

states during the planning and implementation phases. The other sources became integral to the ASSIST evaluation 

model: Tobacco Use Supplement— 

Current Population Survey, cigarette 

consumption data, databases on state 

32 
M o n o g r a p h 1 6. A S S I S T 

tracking database. 

Site Analyses. 

required to conduct a site analysis to 

bacco control plan and to monitor the 

implementation of its plan and progress 

use; and the social and political climate 

for enacting and enforcing tobacco control policies. It included an assessment 

strengths and weaknesses for implecontrol, and media relationships. (See 

chapter 4 for more details.) Using the 

information from the site analysis, each 

initiate tobacco use.20 

Coalition Assessment. Because the 

Figure 2.3. The ASSIST Evaluation Model 

State Conditions 

Strength of 

Protobacco 

Initial 

Outcomes 

Intermediate 

Outcomes in 

Attitudes and 

ASSIST & 

Other 

23 (3): 259–80. 

Final Outcomes 

and 

Consumption 

and local legislation, and the media 

Each ASSIST state was 

provide the baseline information that it 

needed to develop a comprehensive totoward its objectives. The site analysis 

documented the distribution of tobacco 

use by age, gender, and geographical 

area; the economic burden of tobacco 

of the state’s potential resource 

menting ASSIST, including finances, 

equipment, facilities, personnel, expertise, organizational relationships and 

structure, existing policies for tobacco 

state developed site-specific numerical 

objectives that expressed the number of 

persons in the state who would quit 

smoking as a result of interventions and 

the number of persons who would not 

statewide coalition approach was a relatively new concept in health promotion, 

NCI undertook a study to examine how 

this approach was implemented in different contexts. The study was based on 

Tobacco Control 

(SoTC) Efforts 

Efforts 

Behavior Initiatives 

Source: Adapted from Stillman, F., A. Hartman, B. Graubard, E. Gilpin, D. Chavis, J. Garcia, L.-M. Wun, 

W. Lynn, and M. Manley. 1999. The American Stop Smoking Intervention Study: Conceptual framework and 

evaluation design. Evaluation Review 

in Prevalence 

33 
2. T h e C o n c e p t u a l F r a m e w o r k 

a conceptual framework of factors hypothesized to influence coalition effectiveness. The factors represent specific 

coalition characteristics identified in a 

review of research on community coalitions. A coalition advisory group of 11 

individuals selected for their expertise in 

assessing or developing community coalitions made recommendations for the 

study design. The underlying theoretical 

proposition was that certain environmental, structural, and functional characteristics of coalitions are indicative of 

their intermediate success as well as 

their long-term effectiveness. The assessment focused on the concept and experience of using state and local 

coalitions to implement tobacco control 

activities rather than on the relative performance of individual sites.18 (See 

chapter 4 for more details.) 

Tobacco Use Supplement for the Current 

Population Survey. For a national measure 

of outcome goals for smoking prevalence, the committee chose the Current 

Population Survey (CPS) with its statespecific estimates on smoking. The CPS 

is a household sample telephone survey 

of the civilian noninstitutionalized population. Since 1950, the U.S. Bureau of 

the Census has conducted the CPS at 

regular intervals to provide estimates of 

employment, unemployment, and other 

characteristics of the general labor force, 

the population as a whole, and various 

other subgroups of the population. It 

was chosen for ASSIST because it is the 

only ongoing survey funded by the federal government that provides a sufficient state-level sample size to compare 

all states and individual states. 

To acquire state-specific year-by-year 

data, NCI contracted the Bureau of the 

Census to conduct a Tobacco Use Supplement to the CPS that could be used to 

compare data over time and across 

states. The supplement was designed to 

closely mirror other surveys for comparability. It includes questions about attitudes toward tobacco use as well as 

individual patterns of smoking and using 

smokeless tobacco. The supplement consists of 40 self-report items that are 

asked of persons who are 15 or older residing in sampled households. 

The baseline survey was conducted in 

three waves during a 1-year period— 

September 1992, January 1993, and 

May 1993—with approximately 115,000 

individuals being interviewed for each 

wave. The surveys were repeated during 

the same months in 1995 to 1996 and 

1998 to 1999. Computer-generated tables summarizing national and state-specific baseline findings were distributed 

to the ASSIST states, as were data tapes 

that included all of the baseline data.19,21 

Cigarette Consumption Data. Another 

important source of data for tracking the 

effect of ASSIST was per capita cigarette consumption. These estimates, 

which are derived from tobacco sales tax 

data, are more sensitive than prevalence 

data to intervention effects. National and 

state-level per capita consumption data 

for cigarettes are available on a monthly 

basis and were included in the overall 

outcome evaluation.22 

Legislative Databases. The State Cancer 

Legislative Database, developed and 

maintained since 1989 by NCI, is the pri34 
M o n o g r a p h 1 6. A S S I S T 

mary data source for measuring changes 

in state tobacco control policies. (The 

Americans for Nonsmokers’ Rights 

[ANR] data are referenced in chapter 6.) 

The database includes information about 

all enacted state legislation related to cancer control, including tobacco control, 

breast cancer early detection, cervical 

cancer early detection, diet modification, 

state-of-the-art treatment, and selected 

topics on environmental and occupational 

exposures. Information about each law, 

including an abstract describing the provisions of each law, is maintained in a 

single computerized record. 

To meet the needs of the ASSIST 

evaluation, the database was expanded 

to enable annual tracking of state legislation in each of the four policy areas: 

1. Clean indoor air 

2. Restricted access to tobacco by 

minors 

3. Economic disincentives to discourage 

the use of tobacco products 

4. Restricted advertising and promotion 

of tobacco 

The database also tracks legislation 

related to smokers’ rights. (The database 

can be accessed at www.scld-nci.net.) 

Similarly, the ANR Foundation maintains a database that tracks information 

on tobacco-related legislation and policies at the local level. This data source 

was used in the evaluation to assess the 

outcomes of ASSIST activities in communities, especially clean indoor air and 

tobacco taxes. 

ASSIST Newspaper Clippings Database. A 

study was designed to systematically 

track local newspaper coverage of tobacco-related policy issues during the 6­

year implementation period of ASSIST. 

The expectation was that tobacco control 

advocacy would increase in general 

across the United States during the 

project period, with the ASSIST sites 

taking the lead in comprehensiveness 

and frequency of activity, and that this 

pattern would be reflected in the print 

media. Burrelle’s Press Clipping Service 

was contracted to collect the print articles for the media analyses, and ASSIST 

Coordinating Center staff categorized 

the articles for relevance to type of 

smoking policy (clean indoor air, restriction of access by minors, economic incentives, advertising and promotion of 

tobacco, or miscellaneous), point of 

view (pro–tobacco control, anti–tobacco 

control, or neutral), origin of story (national or local), type of article, and 

whether the article appeared on the front 

page of the newspaper. Quarterly reports 

were produced summarizing the frequency of articles in each category and 

comparing ASSIST sites with nonASSIST sites. (See chapter 5 for a detailed description.) 

The Selection of States 

On January 15, 1990, NCI issued its request for proposals for tobacco 

control programs from state health agencies in collaboration with state-level affiliates of the American Cancer Society 

(ACS). More than 35 states initially responded by submitting proposals. NCI 

formally reviewed all proposals for their 

technical merits, which included their 

proposed infrastructure and ability to 

mobilize community coalitions. The 

35 
2. T h e C o n c e p t u a l F r a m e w o r k 

proposals were reviewed in three review 

meetings, and 23 were judged to be technically acceptable.23 However, technical 

merit was only one of several criteria applied in the award process. 

The process of reviewing and scoring 

the proposals raised a complex decision 

problem: how to follow a process for 

making awards among the competing 

proposals that not only would consider 

technical merit and cost, but also would 

balance other considerations critical to 

the long-term viability and effectiveness 

of tobacco prevention and control. Those 

considerations included representing the 

United States geographically and ethnically in the states to be chosen for the 

ASSIST project. To address the problem, 

the director of NCI’s Division of Cancer 

Prevention and Control engaged the services of NCI’s Applied Research Branch 

to develop a mathematical optimization 

model for making ASSIST project funding decisions that would take into account various configurations of three 

major considerations: technical merit, 

cost, and secondary criteria mentioned 

in the request for proposals. The model 

was to provide a process both for scoring the proposals and for ranking them.23 

Experts in the division were involved 

in a modified Delphi approach (a process of interviewing and group techniques to acquire input) to determine 

which criteria to include in the model 

and the relative weight of their values 

(see the Hall et al. article for details on 

the modifications).23 From these experts, 

in a series of input formats, it was determined that geographical distribution was 

an unambiguous concept needing no further specification except that three states 

from each of the Census Bureau’s four 

regions would be an appropriate standard. 

In contrast, the criterion of smoking prevalence had numerous interpretations. The 

main question was whether states should 

be selected according to overall smoking 

rates (states with large numbers of 

smokers) or according to how smokers 

in the states were statistically distributed 

by demographics (e.g., socioeconomic 

status, ethnic group, age) and historical 

factors (e.g., rate of decline of smoking 

prevalence between 1985 and 1989). 

The resulting three constraints were set 

for the model: 

1. At least 2 states would be chosen 

from each quartile of the distribution 

of smoking rates across the 50 states 

and the District of Columbia. 

2. At least 2 states would be chosen 

from each quartile of the distribution 

of decline in smoking rates for the 

preceding few years across the 50 

states and the District of Columbia. 

3. The proportions of African Americans 

and Hispanics/Latinos in state 

populations would be assessed as 

more important than the absolute 

numbers.23 

Although the ranking of the proposals 

according to technical merit was to be 

given primary importance in the award 

assessments, the constraints also figured 

into the formula. 

In October 1991, NCI awarded contracts to 17 state health departments to 

partner with their state-level ACS affiliate and other community organizations 

to design and implement statewide public health interventions based on the 

ASSIST conceptual framework. The 

36 
M o n o g r a p h 1 6. A S S I S T 

of health departments for those funds 

mitment to protect and promote the pubinstitutional partnerships to accomplish 

their goals, access to priority populaa third of the U.S. population and closemillion people of Hispanic/Latino or 

other ethnic minority groups.20 

In a press release announcing the conphasized the role of communities in the 

ASSIST project: 

community-based coalitions throughchange attitudes about smoking and 

counter the sinister marketing strate­ 24 

states that were awarded contracts are 

highlighted in figure 2.4. The eligibility 

was appropriate because of their comlic’s health, experience working in 

tions, and guaranteed longevity. Combined, the population of the ASSIST 

states was 91 million people, more than 

ly reflecting the total American population in ethnic and geographic diversity. 

The ASSIST population included more 

than 10 million African Americans and 7 

tract awards on October 4, 1991, U.S. 

Department of Health and Human Services Secretary Louis W. Sullivan emWhat sets ASSIST apart from other 

government antismoking programs is 

its emphasis on the development of 

out entire states. Ultimately, it will be 

our communities and individual Americans that decide how best to tackle 

their tobacco problems. ASSIST will 

empower them by providing the information and help that they need to 

gies of the tobacco industry. 

Figure 2.4. States Awarded ASSIST Contracts 

37 
I

2. T h e C o n c e p t u a l F r a m e w o r k 

Time to Act 

n summary, the ASSIST conceptual 

framework casts tobacco use as a public health problem and presents tobacco 

use as a social behavior; therefore, tobacco use is an issue that can be effectively addressed only at a population 

level through a combination of societal 

and individual interventions. In the late 

1980s and early 1990s, the ASSIST 

model represented a major change in 

perspective—a paradigm shift—and 

changed the orientation of tobacco control across the United States. 

All of the pre-ASSIST preparations 

were complete by October 1991. NCI had 

completed all the important processes: 

1. Clearly describing the ASSIST 

project as a conceptual framework 

2. Writing a request for proposals based 

on that framework 

3. Releasing the request for proposals 

and receiving the proposals from the 

states 

4. Reviewing the proposals and 

awarding 17 contracts 

5. Awarding a contract for a coordinating center to provide technical 

assistance and training to the states 

The principal mechanisms and the 

major forces were all in place. It was 

time to bring the ASSIST partners together and begin. The first task for the 

partners, as described in chapter 3, was 

to clarify and solidify the operational infrastructure and establish linkages 

among the participants. 

References 

1. ASSIST Coordinating Center. 1991.


ASSIST program guidelines for


tobacco-free communities. Internal


document, ASSIST Coordinating


Center, Rockville, MD.


2. Butterfoss, F. D., R. M. Goodman, and 

A. Wandersman. 1993. Community 

coalitions for prevention and health 

promotion. Health Education Research 

83 (3): 315–30. 

3. Kaye, G., and T. Wolff, eds. 1997. From 

the ground up: A workbook on coalition 

building and community development. 

2nd ed. Amherst: Univ. of 

Massachusetts, AHEC/Community 

Partners. 

4. Task Force on Community Preventive 

Services. 2003. Guide to community 

preventive services: Tobacco use 

prevention and control. 

www.thecommunityguide.org/tobacco/ 

default.htm. 

5. Lewit, E. M., and D. Coate. 1982. The 

potential for using excise taxes to reduce 

smoking. Journal of Health Economics 

1 (2): 121–45. 

6. Warner, K. E. 1986. Smoking and health 

implications of a change in the federal 

cigarette excise tax. Journal of the 

American Medical Association 255 (8): 

1028–32. 

7. Stillman, F. A., D. M. Becker, R. T. 

Swank, D. Hantula, H. Moses, S. 

Glantz, and H. R. Waranch. 1990. 

Ending smoking at The Johns Hopkins 

Medical Institutions: An evaluation of 

smoking prevalence and indoor air 

pollution. Journal of the American 

Medical Association 264 (12): 1565–9. 

38 
M o n o g r a p h 1 6. A S S I S T 

8. Sorenson, G., N. Rigotti, A. Rosen, J. 

Pinney, and R. Prible. 1991. Effects of a 

worksite nonsmoking policy: Evidence 

for increased cessation. American 

Journal of Public Health 81 (2): 202–4. 

9. Stave, G. M., and G. W. Jackson. 1991. 

Effect of a total work-site smoking ban 

on employee smoking and attitudes. 

Journal of Occupational Medicine 33 

(8): 884–90. 

10. Borland, R. 1992. Changes in prevalence of and attitudes to restrictions on 

smoking in the workplace among indoor 

workers in the state of Victoria, Australia, 1988–90. Tobacco Control 1:19–24. 

11. National Cancer Institute. 2000. State 

cancer legislative database program. 

Bethesda, MD: National Cancer


Institute. www.scld-nci.net.


12. Lewit, E. M., D. Coate, and M. 

Grossman. 1981. The effects of 

government regulation on teenage 

smoking. Journal of Law and 

Economics 24:545–69. 

13. Cox, H., and R. Smith. 1984. Political 

approaches to smoking control: A 

comparative analysis. Applied 

Economics 16:569–82. 

14. Tye, J. B., K. E. Warner, and S. A. 

Glantz. 1987. Tobacco advertising and 

consumption: Evidence of a causal 

relationship. Journal of Public Health 

Policy 8 (4): 492–508. 

15. Warner, K. E. 1979. Clearing the 

airwaves: The cigarette ad ban revisited. 

Policy Analysis 5:435–50. 

16. Roemer, R. 1982. Legislative action to 

combat the world tobacco epidemic. 2nd 

ed. Geneva, Switzerland: World Health 

Organization. 

17. Kessler, L. G., M. Carlyn, R. Windsor, 

and L. Biesiadecki. 1995. Evaluation of 

the American Stop Smoking 

Intervention Study. In Health survey 

research methods conference 

proceedings (PHS publication no. 96­

1013), 215–20. Washington, DC: U.S. 

Department of Health and Human 

Services, National Center for Health 

Statistics, and the Centers for Disease 

Control and Prevention. 

18. ASSIST Coordinating Center. 1998. 

ASSIST orientation guide. Internal 

document, ASSIST Coordinating 

Center, Rockville, MD. 

19. Stillman, F., A. Hartman, B. Graubard, 

E. Gilpin, D. Chavis, J. Garcia, L.-M. 

Wun, W. Lynn, and M. Manley. 1999. 

The American Stop Smoking 

Intervention Study: Conceptual 

framework and evaluation design. 

Evaluation Review 23 (3): 259–80. 

20. Manley, M., W. Lynn, R. P. Epps, D. 

Grande, T. Glynn, and D. Shopland. 

1997. The American Stop Smoking 

Intervention Study for Cancer 

Prevention: An overview. Tobacco 

Control 6 Suppl. no. 2: S5–S11. 

21. Shopland, D. R., K. K. Gerlach, D. M. 

Burns, A. M. Hartman, and J. T. Gibson. 

2001. State-specific trends in smokefree workplace policy coverage: The 

current population survey tobacco use 

supplement, 1993 to 1999. Journal of 

Occupational and Environmental 

Medicine 43 (8): 680–6. 

22. Orzechowski, W., and R. C. Walker. 

2000. The tax burden on tobacco: 

Historical compilation 1999. Arlington, 

VA: Authors. 

23. Hall, N. G., J. C. Hershey, L. G. Kessler, 

and R. C. Stotts. 1992. A model for 

making project funding decisions at the 

National Cancer Institute. Operations 

Research 40 (6): 1040–52. 

24. Sullivan, L. 1991. Project ASSIST— 

Smoking control. Press release, October 

4, 1991, U.S. Department of Health and 

Human Services. www.hhs.gov/news/ 

press/pre1995pres/911004.txt. 

39 

M o n o g r a p h 1 6. A S S I S T 

3. Structure and Communications

John K. Beasley, John M. Garcia, Jerie Jordan, and Donna Grande 

Contributors: Thomas J. Kean and Gael A. O’Sullivan 

Contents 

Linking the Units of a Complex Structure .................................................................... 43


The Major Organizational Units ................................................................................... 46


The National Cancer Institute .............................................................................................. 46


The American Cancer Society .............................................................................................. 47


State Health Departments and ACS State Affiliates ............................................................ 48


State Project Executive Committees ............................................................................. 49


Local Organizational Structures ................................................................................... 50


Policy Advocacy Issues ................................................................................................. 51


Coalitions ..................................................................................................................... 52


Mechanisms for Coordination, Decision Making, and Communication ........................ 53


The ASSIST Coordinating Center .......................................................................................... 54


Platform for Collaboration: The Work of Committees ........................................................... 55


The ASSIST Coordinating Committee ............................................................................ 55


The Strategic Planning Subcommittee ......................................................................... 58


The Multicultural Subcommittee .................................................................................. 59


The Technical Assistance and Training Subcommittee ................................................. 62


The Research and Publications Subcommittee ............................................................ 62


The Project Managers Subcommittee ........................................................................... 63


Communication Vehicles .............................................................................................. 64


ASSIST’s Electronic Communication System ................................................................. 65


Planning for Strategic Communication ............................................................................... 65


Readiness to Build Capacity and Capabilities ............................................................ 67


References .................................................................................................................. 76


41 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

Figure 

Figure 3.1. ASSIST: National Organizational Structure ............................................................. 45


Appendices 

Appendix 3.A. Memo of Understanding Between the National Cancer Institute and


the American Cancer Society ................................................................................................... 68


Appendix 3.B. ASSIST Key Required Resources ......................................................................... 73


42 
M o n o g r a p h 1 6. A S S I S T 

3. Structure and Communications

ASSIST states. 

In 1989, the National Cancer Institute (NCI) and the American Cancer Society 

(ACS) signed a memorandum of understanding to join in an unprecedented 7-year* 

collaboration to mobilize state and local communities around tobacco control issues. 

In October 1991, NCI and the state health agencies of 17 states also signed contracts for 

7 years. The state agencies would be responsible for planning and implementing 

tobacco control strategies and activities according to the American Stop Smoking 

Intervention Study (ASSIST) conceptual framework, under the codirection of NCI 

and ACS. In 1990, NCI signed a contract with Prospect Associates Ltd., which would 

serve the states as a coordinating center for technical assistance and training. The 

organizational units and the contracts were in place to begin ASSIST. 

This chapter describes the national partners and state agencies in their respective 

roles and the communication linkages among all the structural units that were 

essential for the project to function as a whole and for collaborative decision 

making. The strong structure and the rapid communication systems were the 

organizational forces supporting the implementation of interventions throughout the 

Linking the Units of a Complex Structure 

T o achieve a strong and lasting effect on tobacco use and its health consequences, the ASSIST project required strategic alliances among organizations and agencies 

with common or compatible missions. Although numerous groups across the nation 

were involved with tobacco control efforts, no large, coordinated tobacco control movement existed. Structurally, ASSIST was a network of partnerships between governmental agencies and nongovernmental organizations that linked national, state, and local 

agencies and organizations to work toward common goals. At the national level, NCI 

was the agency providing vision, direction, and most of the funding to the states. In 

partnership with NCI at the national level, ACS provided some funding to the states, 

program direction through its state and local divisions, and access to networks of essential volunteers in all states. At the state level, each health department was required to perform three tasks: 

1. Establish a comprehensive tobacco control program 

2. Build a coalition for tobacco control 

3. Provide leadership for additional coalitions at the community level 

Although each ASSIST state had individual needs and autonomy in implementing 

interventions tailored to those needs, the project as a whole had to function as a coher-

*The project was originally planned to end in 1998 but was extended through the end of September 1999. 

43 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

ASSIST Coordinating Committee Materials 

ent, unified program. Achieving that cohesiveness was a challenge. The structural units of ASSIST were numerous, 

complex, and geographically distant, 

with the needs of the partners and coalitions evolving in response to unforeseen 

circumstances. By 1996, the 17 ASSIST 

states had 255 state and local coalitions 

with more than 2,900 members.1 Linking 

all these units required clearly defined, 

effective systems of communications 

and decision making throughout the 

structure. 

As a phase V demonstration project, 

in contrast to a research trial, ASSIST 

did not have a fixed protocol for all 

states to follow. However, there were tobacco control standards, fundamental 

program objectives, priority populations 

and channels, and specific types of interventions that had to remain intact and be 

reasonably consistent among the 17 

states and the national organizations during the 8-year life of the project. In other 

words, the theoretical basis for ASSIST 

had to be developed into a practical, reality-based plan of action. Many systems, processes, and materials were 

needed, and multiple decisions had to be 

made. NCI funding for ASSIST through 

contracts with state health departments 

(in contrast to the more common cooperative agreements of the Centers for Disease Control and Prevention [CDC]) 

meant that many new checks and balances had to be established and consistently put in place. The requirements for 

the contracts were more prescriptive 

than the requirements for cooperative 

agreements, which the state health departments were accustomed to, and the 

contracts required specific, scheduled 

deliverables. 

To enable orderly operation of the 

project according to established federal 

policies and procedures, systems for 

communication and collaborative decision making were put in place to serve 

the administrative functions and for networking and conducting outreach to 

those not directly funded by the project. 

For example, support, involvement, and 

effective communication mechanisms 

with the media, school systems, local 

government, and potential coalition 

members were critical to explain the 

project activities and efforts to the community at large, to counter tobacco industry attacks, and to protect program 

resources. As the project unfolded, new 

communication requirements emerged, 

and new issues and priorities evolved; 

44 
M o n o g r a p h 1 6. A S S I S T 

ties established by NCI, the training emphasized the elements essential in the 

paradigm shift from primarily an indias state decision-making structures, 

Figure 3.1 depicts the interrelationfor the design and implementation of the 

ASSIST project in terms of technical 

munication processes and decision-making systems. 

Most of the mechanisms used for 

were replicated at, or adapted to, the 

states conducted meetings that included 

been presented to state personnel at na1992. In 1994, all states participated in a 

a 

Notes:

a 

Planning 

Subcommittee 

Multicultural 

Subcommittee 

Research and 

Publications 

Subcommittee 

Coordinating Committee Cochairs 

Standing Subcommittee Chairs 

ASSIST Coordinating Committee 

DOH Project Directors (17) 

Subcommittee Chairs (5) 

Assistance and 

Subcommittee 

Project 

Managers 

Subcommittee 

vidual behavioral change to a major emphasis on policy interventions and media 

advocacy. Because other features, such 

were by design different from the national model, a more diverse array of 

mechanisms was developed to meet the 

specific circumstances of each state. 

ships of the national organizational units 

of ASSIST. NCI’s Division of Cancer 

Prevention and Control was responsible 

they necessitated revisions to the comcommunication at the national level 

state and local levels. For example, all 

orientation and training events on the 

core concepts of ASSIST, which had 

tional training workshops in 1991 and 

national training workshop on policy advocacy, and by the end of June 1995, 

nine states had conducted similar trainings locally. Reflecting the initial prioriFigure 3.1. ASSIST: National Organizational Structure

Source: This chart was developed by the ASSIST Coordinating Center, Rockville, MD. 

 DOH indicates Department of Health. ACS indicates American Cancer Society. 

This structure developed over time. 

Strategic 

Executive Committee 

ACS Project Directors (17) 

Senior Advisors (3) 

At-Large Members (4) 

Technical 

Training 

45 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

scope, financial resources, and contracting mechanisms. NCI’s Board of Scientific Counselors provided guidance and 

feedback regarding the ASSIST model 

and objectives. 

The structure of ASSIST nationally 

comprised the Division of Cancer Prevention and Control of NCI, the national 

office of ACS, the health departments of 

the 17 contracted states, and the ACS division in those states. The ASSIST Coordinating Committee was established as 

a liaison to bring together representatives of each of those organizational 

units for purposes of coordination, planning, and communication. 

Two NCI-led committees were established specifically to support the 

ASSIST project. The Scientific Advisory 

Committee regularly reviewed the overall progress of the 17 states in reaching 

their objectives and provided strategic 

input regarding science and policy issues. This group also shared pertinent 

information from other tobacco control 

interventions occurring throughout the 

United States. Membership of this committee included representatives of federal and state government agencies, ACS 

staff and volunteers, the ASSIST senior 

advisors, social scientists, and other 

researchers. 

The Evaluation Committee was established to provide input and advice to the 

overall ASSIST evaluation plan. This 

committee identified key evaluation and 

research questions and answers, suggested secondary data sources, recommended priorities for evaluation activities, 

reviewed proposed analytic approaches 

and data collection methodology, and 

provided feedback on draft evaluation 

documents. Membership of this committee was composed of representatives 

from federal agencies and public health 

and academic settings. 

At the national level, representatives 

of the ACS home office were members 

of both the Scientific Advisory Committee and the Evaluation Committee. Similarly, health department and ACS 

representatives from the 17 ASSIST 

states played a role at the national level 

primarily as members of the ASSIST 

Coordinating Committee. 

The Major Organizational Units 

The National Cancer Institute 

T he Smoking, Tobacco, and Cancer 

Program (see chapter 1), which 

spearheaded the ASSIST project, was 

part of NCI, 1 of 11 institutes (at the 

time) of the National Institutes of 

Health (NIH) supporting research on 

health and disease conditions. NIH is 

an agency within the U.S. Department 

of Health and Human Services established to acquire new knowledge 

through research to help prevent, detect, diagnose, and treat disease and 

disability. NCI was established as “the 

Federal Government’s principal agency 

for cancer research and training.”2 Beginning in September 1990, NCI contracted 

with Prospect Associates Ltd. to serve as 

a coordinating center for the project over 

a period of 10.5 years for a total of more 

than $23 million. 

Historically, NCI had funded cancer 

research mainly through grants awarded 

to public and private universities and 

46 
M o n o g r a p h 1 6. A S S I S T 

health departments, agencies that typiand state health departments posed 

challenges that had to be addressed 

to the implementation phase. In adproposals 

As will become apparent in subsequent 

and the public trust. 

The American Cancer Society 

epidemiologic studies in the 1950s and 

1960s that were important in establishing 

including memorable public service announcements and stop-smoking messagorganizations throughout the United 

States. In contrast, through ASSIST, 

NCI would directly contract with state 

cally had not received funds directly 

from NCI. The unique nature of the 

contractual relationship between NCI 

throughout the first several years of the 

project as it advanced from the planning 

dressing those challenges, NCI’s roles 

and relationships became multifaceted 

and complex. NCI served in the following six roles: 

1. Scientific authority 

2. Issuer of the project’s request for 

3. Reviewer of the states’ proposals 

4. Funder and contract administrator 

5. Technical consultant 

6. Partner 

chapters, all of the roles evolved over 

time; they required NCI to be decision 

maker in some instances, to seek consensus in others, to yield to peer views, and 

to support and encourage the ASSIST 

staff and coalitions, while always being 

mindful of regulations, responsibilities, 

ACS had supported groundbreaking 

the link between smoking and cancer. 

Public education exhorting smokers to 

quit had long been part of ACS activities, 

es during its annual Great American 

Smokeout. ACS had developed smoking 

cessation programs over the years; these 

programs were offered in communities 

Left to right: Marc Manley, former Chief, Tobacco Control Research Branch, NCI; Jerie 

Jordan, former National Manager, ASSIST Project, ACS; and R. Neal Graham, Executive 

Director, Virginia Primary Care Association; ASSIST conference, Bethesda, MD, 1999. 

to smokers at no charge. 

Name recognition of 

ACS was high, and the 

organization maintained 

strong credibility with 

the American public. 

ACS, along with the 

American Lung Association and the American 

Heart Association, 

formed the Coalition on 

Smoking OR Health in 

1982. This coalition 

gave the three organizations a unified voice 

with which to support 

diverse efforts to advocate for tobacco 

prevention and control. 

47 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

The coalition prepared information for 

its state-level groups, including position 

statements, drafts of model legislation, 

and tracking of state laws affecting tobacco. 

The organizational structure of ACS 

offered the ASSIST project a nationwide 

network of people already committed to 

preventing cancer and tobacco use. The 

ACS structure comprised a national office in Atlanta and typically one division 

in each state. Divisions were further 

subdivided into local units. The national 

organization had a board of directors, as 

did each division and, in most cases, 

each unit. ACS took great pride in its 

volunteers, who served on boards and 

committees, administered programs, 

raised funds, and spoke on behalf of the 

organization. 

ACS shared with NCI a mission of reducing the burden of cancer in the United States. As a nongovernmental 

organization, however, ACS could advocate for public policies and speak out 

against the tobacco industry in ways that 

a government agency was precluded 

from doing. As a member of the Coalition on Smoking OR Health, ACS had 

challenged the tobacco industry on several issues. With their long histories of 

cancer research and applications and 

their different advantages in legal status, 

staff, and membership, ACS and NCI 

formed a strategic alliance that was a 

natural evolution in the new approach of 

public-private partnerships for preventing and controlling tobacco use. 

To document the partnership between 

NCI and ACS, the two entities signed a 

memorandum of understanding outlining their agreement and their respective 

contributions to the ASSIST project. 

(See appendix 3.A.) In this document, 

ACS pledged to contribute 15% of the 

amount that NCI would spend on 

ASSIST each year. This 15% would cover staff, training, travel, and materials. 

ACS specifically agreed to receive “no 

Federal, state, or local public funds for 

its participation in this effort, in keeping 

with its longstanding national policy.”3(p3) 

Although ACS later changed its policy 

about accepting government funds, the 

organization continued to use only its 

own funds for ASSIST. These funds had 

fewer legal restrictions and allowed ACS 

to continue its advocacy and lobbying 

activities at the national and state levels. 

The ACS national office provided the 

states with a tobacco control manager 

and technical assistance resources, and 

the divisions provided resources of funding, staff, and volunteer efforts. Staff directed advocacy efforts, built coalitions, 

participated in all aspects of national 

planning, and developed and delivered 

training programs. The total value of resources committed by ACS to the ASSIST 

states and national or state organizations 

was estimated to be between $25 million 

and $30 million over the life of the 

project.4 By the end of the seventh year 

of the project, the ACS national office 

had spent $4.4 million in direct grants to 

ACS divisions for ASSIST.5 

State Health Departments and 

ACS State Affiliates 

ASSIST guidelines required state 

health departments to form a primary 

public-private partnership at the state 

48 
M o n o g r a p h 1 6. A S S I S T 

vigorously promoted this partnership 

nically other primary partnerships were 

possible under the guidelines, all 17 state 

member of their state health department 

as a project director and a member of the 

Committee. (See page 55.) In some inmittee meetings, conference calls, and 

State Project Executive Committees 

lines prescribed decision-making strucmaximum of 12 members, with equal 

imum of 2 members from other 

for making decisions and for creating 

encourage their full participation in the 

ing responsibility to their coalitions than 

did other states. Some state health departand Minnesota, found it unnecessary for 

ASSIST informational brochure 

level to mirror that of NCI-ACS at the 

national level. The national ACS office 

with their state divisions. Although techhealth departments in fact partnered with 

state divisions of ACS. Although slight 

variations existed, most states named a 

state ACS division as a project manager. 

All state health departments and ACS divisions were linked to the national structure through the ASSIST Coordinating 

stances, the health department ASSIST 

manager served as the state’s representative to the ASSIST Coordinating Comalong with their respective state project 

executive committees, oversaw the proInitially, the ASSIST contract guidetures. Each state was required to 

establish a small executive committee, 

with membership specified as follows: a 

representation from the state’s health department and from ACS and with a maxagencies. These bodies were responsible 

mechanisms for operations. As the program developed, however, coalition 

leaders took on this role. Moreover, 

many states found the initial formula too 

restrictive; in effect, it excluded potentially important partners from a significant decision-making role that would 

project. As a result, some states, such as 

Minnesota and Wisconsin, included additional representatives on an ex officio 

basis, that is, they participated on committees and attended meetings but did 

not have voting privileges. New Mexico 

and Michigan gave more decision-makments, for example, those of Michigan 

the committee to meet on a regular 

ASSIST Orientation Guide 

project director and the ACS project 

workshops. Directors and managers, 

grams at the state level. 

49 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

basis, because members communicated 

daily. 

The effectiveness of the primary partnership between state health departments and state ACS divisions varied 

considerably among states on the basis 

of many factors, including prior history 

of relationships between ACS and state 

health departments, tobacco control 

leadership contributions made by other 

voluntary health associations and agencies, and the collaborative arrangements 

already in place. In many states, the 

ASSIST-mandated partnership opened 

new lines of communication between the 

state health agency and the state division 

of ACS. 

Local Organizational Structures 

Organizational structures of state 

health departments and ACS are different from state to state. For example, in 

Colorado, all local health agencies are 

independent units, not state entities. 

Each county office in Colorado has autonomy and is on equal footing with the 

state office based in Denver. In Wisconsin, the state health department funds the 

65 county health departments, each of 

which reports directly to the state. In 

North Carolina, the local health departments functions largely independently of 

but under contract to the state. 

Along with the organizational structure came staff linkages. Most of the 

ASSIST programs were housed within 

the chronic disease program or the 

health education branch of a state health 

department. Where ASSIST was housed 

often determined the overall approach 

that the staff took in working with local 

affiliates and in developing coalitions. 

For example, in Maine, the ASSIST program was located in the Division of 

Health Promotion and Education and 

had direct linkages with the state health 

commissioner. In Indiana, the program 

was housed in the health education area 

and was a component of the overall media and public health education program 

without direct links to appointed staff or 

elected officers. Often the level of visibility or authority within the state health 

department was a direct reflection of the 

type of support that the staff received 

from top-level administrators in moving 

issues forward. In some cases, when 

ASSIST staff members were further removed, they became skilled at involving 

top-level management in tobacco prevention and control issues. 

The project spanned several electoral 

cycles; therefore, changes in governors, 

state legislators, and department heads 

occurred in many ASSIST states during 

its 8 years. As these changes occurred, 

some state projects that were initially organized in environments supportive of 

active advocacy later found themselves 

in less-supportive environments. For example, the health departments of New 

York, Michigan, and New Mexico were 

restrained from submitting official comments on the need for the regulations 

proposed by the Food and Drug Administration that would limit tobacco industry marketing to youths. 

Like the state health departments, 

ACS also had different organizational 

structures and linkages in the different 

states. The ACS ASSIST staff included 

one full-time person per state, except for 

New York, which had one project man50 
M o n o g r a p h 1 6. A S S I S T 

ager serving metropolitan New York City 

and a second serving the rest of the state. 

Initially, most ACS ASSIST staffs were 

located in the ACS division’s public education department; later, they tended to 

be housed in the cancer control department. 

At the time ASSIST states were moving from the planning phase to the implementation phase, ACS was reorganizing, 

with different financial demands and 

constraints being placed on the affiliates. 

Overall, linking the program internally 

with other state health department priorities and ACS priorities was challenging 

yet necessary for overall consistency in 

delivering interventions and later for institutionalization. ACS found that another key challenge at the beginning of the 

program was that it was not the lead 

nonprofit organization on tobacco issues 

in a number of states. In many states, the 

American Lung Association or the 

American Heart Association was the key 

organization. These groups questioned 

the designation of their ACS counterpart 

as the lead voluntary health organization 

in their states, which posed organizational challenges for many coalitions. 

Policy Advocacy Issues 

Because of the tobacco industry’s determined efforts to undermine ASSIST 

and to prevent the states from conducting policy advocacy activities (described 

in chapter 8), some ASSIST personnel 

were extremely conservative in interpreting the federal policies restricting 

lobbying and even feared restrictions 

that were actually legitimate practices of 

policy support and advocacy. Some 

commissioners and legislative staff beASSIST states were careful to comply 

with federal restrictions prohibiting use 

Newsletter covers from Kent County Health Department, 

came concerned about even the appearance of impropriety, so they placed even 

higher restrictions on staff than was required by federal law. 

of program funds for lobbying activities, 

defined as activities that directly support 

a specific bill proposed for legislation. 

Federal regulations did not restrict policy advocacy and educational activities. 

Over the course of ASSIST, federal restrictions on lobbying activities became 

more extensive. The restrictions prohibited activities first at the federal level; 

then at the state level; and, in 1998 

through the Federal Acquisition and 

Streamlining Act, at the local level. 

Thus, the advocacy and lobbying roles 

Grand Rapids (MI) and Coalition for a Tobacco-Free West 

Virginia, Charleston (WV) 

51 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

of ACS and other private partners became increasingly important with time. 

Many ASSIST staff within state governments and many subcontractors receiving federal funds began to rely more 

heavily on nongovernmental partners, 

such as ACS, to take on the responsibility for advocacy-related communications, 

including many of the media advocacy 

activities supporting policy change. 

Resources and support for advocacy 

varied widely among ACS divisions, especially at the beginning of the project. 

Although the national office had signed 

the memorandum of understanding with 

NCI, not every ACS state executive was 

fully committed to a partnership with 

such a strong policy emphasis. However, 

over time, ACS leaders began to better 

understand their roles as spokespersons 

and advocates. Within ACS there was reluctance, especially among the staff, 

when divisions, such as the one in Massachusetts, took on the leadership of 

campaigns for state cigarette excise taxes. The massively funded tobacco lobby 

fiercely opposed these campaigns. However, when such campaigns were successful, they reinforced the public 

identity of ACS volunteers and staff.6 

As with health departments, whether 

ACS staff had organizational support for 

the ASSIST approach to policy and media advocacy depended on where the 

staff was located within the division’s organizational structure. In Indiana, for example, the staff was housed in the cancer 

treatment section. The emphasis was on 

cancer research, not policy change; 

therefore, these staff members had an internal obstacle to overcome in addition 

to their task of educating external audiences. Later, when the national ACS office made changes that included a policy 

advocacy component, the Indiana ASSIST 

staff received the necessary internal support. In Minnesota, the staff was housed 

in the director’s office and had direct access to the organization’s leaders. 

To help in the transition to the new 

approach, the ACS national staff produced a video centered on the paradigm 

shift in tobacco control from individual 

interventions to public health and policy 

approaches. The video featured Michael 

Pertschuk, codirector of the Advocacy 

Institute, commenting on various news 

segments; the video was shown at numerous ACS meetings of staff and volunteers. ACS also created ASSIST: A 

Guide to Working with the Media, a 

compendium of fact sheets, questions 

and answers, and sample press releases 

describing the project.7

 The guide was 

helpful to states in translating the complexities of ASSIST into more mediafriendly terms. 

Coalitions 

With the underlying assumption that 

social change is more likely to occur 

when those who will be affected are involved in planning, initiating, and promoting the change, coalitions became the 

backbone of ASSIST. (See chapter 4 for 

more on coalitions.) Each ASSIST state 

was required by contract to already have 

in place or to establish a state-level coalition for tobacco control and coalitions in 

communities. The state health departments and the ACS divisions formed coalitions with health organizations, social 

service agencies, community groups, and 

private citizens to develop and to imple52 
M o n o g r a p h 1 6. A S S I S T 

ment comprehensive tobacco control 

plans. 

Public agencies participating in coalitions included state health departments 

and various levels of local government, 

including counties, municipalities, townships, school districts, and boards of 

health and local health departments. Often these entities held subcontracts and 

were encouraged to form similar partnerships with private agencies, such as 

local units of voluntary associations, 

hospitals, clinics, local businesses, service 

organizations, civic clubs, and youth organizations. Typically, the formation of 

local coalitions facilitated communication between these local entities. 

While the request for proposals had prescribed the state structures, it did not prescribe the operational style and structure of 

the local coalitions. In Wisconsin, each of 

the 65 county health departments received 

state funds through ASSIST to develop 

and design coalitions replicating the 

state model. Challenges arose because 

ACS did not have affiliates or representation in each of those 65 counties and 

thus could not structure the coalitions in 

the same manner. However, in other 

states, such as South Carolina, local coalitions were effectively developed with 

both ACS and health department representation. Several states developed or identified local coalitions as the need or desire 

arose. New York grouped its statewide efforts by region: the western region, which 

included Buffalo; the capital region, which 

included Albany; and the metropolitan region, which included New York City. In 

other states, such as New Jersey, local 

coalitions emerged on their own through 

the efforts of community leaders. 

In an attempt to assist the staff in the 

field, NCI identified key organizations 

having state or local affiliates that could 

eventually be drawn into the coalitions. 

Organizations having a stake in tobacco 

control and affiliates in the field included 

the American Public Health Association, 

American Medical Association, League 

of Women Voters, National Association 

for the Advancement of Colored People, 

National Organization for Women, and 

Girl Scouts of America. These groups could 

be potential allies in the field if national 

buy-in and support were established. 

The states identified and enlisted key 

individuals at the state and local levels, 

who became committed tobacco control 

leaders and advocates in their communities. These individuals brought passion 

and commitment to the project. They 

acted as grassroots counterparts to the tobacco industry’s grassroots efforts. Widespread involvement reflected the ASSIST 

project’s basic principle that optimal tobacco control occurs when communitybased strategies are implemented by 

partnerships composed of strong health 

advocates and local leaders. 

Mechanisms for Coordination, 

Decision Making, and 

Communication 

Because of the diversity of the ASSIST partners and coalition members, 

maintaining a common goal and spirit, 

advancing the planning and implementation phases of the project simultaneously 

among all 17 states, and coordinating all 

partners and activities often were major 

challenges. Mechanisms for communica53 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

tion and decision making among the 

partners and coalitions were critical 

needs. Partly through NCI’s leadership 

and partly through ideas coming from 

the states, several mechanisms were set 

in place. 

The ASSIST Coordinating Center 

The ASSIST project was designed to 

make a substantial investment in developing the skills of the staff of the contracted 

states; therefore, the project’s structure 

included a coordinating center to provide technical assistance and training. 

NCI developed a statement of work and 

released a request for proposals to conduct 

the work of an ASSIST Coordinating 

Center. NCI’s use of a contracted coordinating center allowed for more rapid 

recruitment and hiring of staff and provision of technical assistance and training. 

On September 25, 1990, NCI awarded a 

contract to Prospect Associates Ltd.* 

The ASSIST Coordinating Center 

worked with the staff at NCI to meet the 

needs of the project through technical 

assistance, training, communication, netbecame the hub through which training and

technical support services and materials were

■ 

■ 

■ Resource materials 

■ A centralized information and materials

center 

■ 

committee meetings 

■ An electronic communications system to

and NCI 

■ 

■ 

community coalitions, assessing needs,

■ 

Types of Technical Assistance Provided 

From ASSIST’s inception to the end of the

project, Prospect Associates Ltd. staffed

NCI’s ASSIST Coordinating Center. It

delivered, such as the following: 

Technical support to the NCI program

office 

Training programs and materials 

Administrative support for ASSIST

facilitate communications among the sites

Development and implementation of state

plans to reduce smoking prevalence 

Technical support in organizing

and building consensus 

Legal consultation 

working, and monitoring of performance. Throughout the project, the 

ASSIST Coordinating Center provided 

strategic technical consultation and support to the ASSIST committees and subcommittees. The center helped identify 

the states’ priorities and strategic needs 

for each committee and subcommittee 

through regular bimonthly and monthly 

conference calls and semiannual meetings. The ASSIST Coordinating Committee (described in the next section) 

*In April 2000, Prospect Associates joined the American Institutes for Research (AIR), enhancing AIR’s 

communications capabilities and strengthening the services provided to clients. 

met at least 17 times, and the subcommittees met semiannually from 1994 to 

1995. The amount of staff support required to organize and coordinate all the 

project’s meetings and conference calls 

was considerable. 

The ASSIST Coordinating Center 

was a critical mechanism for facilitating 

communication among the 17 states and 

between NCI and the project sites. In addition, the center developed and produced relevant materials, provided 

conference support, and conducted data 

analyses and ancillary studies. The center staff met weekly with NCI staff to 

discuss the states’ needs. 

54 
M o n o g r a p h 1 6. A S S I S T 

The ASSIST Coordinating Center assigned specific technical assistance specialists to work collaboratively with the 

NCI project officers and the state and 

ACS project managers for the duration 

of the project to provide technical assistance, information, and resource materials for capacity building, and to consult 

with NCI on the states’ issues and needs. 

In addition to phone conferencing and 

electronic communications, technical assistance specialists made site visits and 

were in frequent contact with staff members in the 17 states to discuss their 

needs for technical support and assistance. 

(See appendix 3.B for a list of “Key Required Resources.”) The technical assistance specialists provided information 

on how other states were addressing specific problems and put staff members in 

direct contact with one another to share 

the ideas and expertise developed in individual states. The ASSIST Coordinating Center shared materials produced by 

the individual ASSIST states with the 

other states through monthly mailings. 

The technical assistance specialists also 

served as liaisons between the states and 

NCI staff by gathering information from 

the states as needed, reporting on the 

states’ progress, and informing NCI staff 

of states’ requests. 

The ASSIST Coordinating Center 

was also responsible for tracking and analyzing newspaper coverage of tobacco 

control issues. The center designed an 

ongoing ASSIST newspaper analysis 

study using a clipping service and database to systematically track newspaper 

coverage of tobacco-related policy issues 

in all states. Analyses of the data provided information to the staff on newspaper 

coverage in their states. 

During the early phases of the project, 

conferences occurred frequently for 

training and information exchange. The 

conferences brought together project directors, managers, and key staff from the 

state health departments and state divisions of ACS, as well as NCI staff, consultants, and support staff from the 

ASSIST Coordinating Center. The states 

also were encouraged to send key staff 

or volunteers from the state and local coalitions and projects. 

Platform for Collaboration: 

The Work of Committees 

Committees and their subcommittees 

played important roles in facilitating and 

maintaining internal communications 

among states, NCI project ASSIST staff, 

and other elements of NCI. The membership, structure, and function of the 

ASSIST Coordinating Committee and 

subcommittees evolved over the course 

of the project as new decision-making 

issues and communication requirements 

emerged. 

The ASSIST Coordinating Committee 

As defined in the ASSIST request for 

proposals, NCI created the ASSIST Coordinating Committee at the project’s 

inception to 

1. help disseminate intervention 

information, 

2. bring unresolved field issues to the 

attention of project staff, 

3. formulate policy questions and 

recommendations for consideration by 

the ASSIST Scientific Advisory 

committee, 

4. identify project-wide needs and 

resources, and 

55 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

5. oversee project management and 

accountability. 

Membership on the ASSIST Coordinating Committee consisted of two representatives from each state: the project 

director for the health department and the 

project director from ACS, or a designee, 

as depicted in figure 3.1. 

During the planning phase, the 

ASSIST Coordinating Committee 

played an important role in building collaboration and commitment to the 

project among the states. Although all 

project directors had the same role and 

responsibilities in ASSIST, their backgrounds and preparedness varied in 

terms of their knowledge of the ASSIST 

assumptions and contract deliverables. 

The national meetings were important in 

providing a platform for developing a 

common understanding of the project 

and for decision making. 

The meetings were well attended, and 

state representatives played a pivotal 

role in determining the agenda and often 

led discussions on key issues. Leadership for the committee was provided by 

the following three senior advisors: 

Helene Brown, an ACS volunteer in California; Sister Mary Madonna Ashton, a 

Minnesota state health department director; and Dr. Erwin Bettinghaus, a Michigan State University researcher in 

tobacco control. They were instrumental 

in guiding the committee during its critical planning phase and served as the link 

between the NCI ASSIST program and 

the NCI scientific community. Sister 

Ashton was the link between the program and state health departments, and 

Mrs. Brown, a long-time leader with 

ACS and an immediate past member of 

NCI’s National Cancer Advisory Board, 

was the link with the national and state 

ACS affiliates. Dr. Bettinghaus was the 

study chair for the Community Intervention Trial for Smoking Cessation 

(COMMIT) and a member of the National Cancer Advisory Board until early 

1995, with the responsibility of reporting on ASSIST to that board.8 

The ASSIST Coordinating Committee 

played an important role in protecting 

ASSIST resources. In response to legislative interest in increasing research on 

breast cancer (and other priorities) and 

to pressure from the traditional grantee 

research community, NCI funding priorities shifted away from ASSIST, and the 

state contracts were reduced in the first 

year of the ASSIST implementation 

phase. The initially proposed total budget of $23.3 million for 1993 was reduced to $18.2 million.9 Through 

resolutions and letters from the committee, individual state letters, and personal 

contacts, the ASSIST Coordinating 

Committee communicated its objections 

and concerns directly to the NCI administrative authorities responsible for budget cuts. In addition, the committee took 

the lead in communicating with and organizing the response from those elements of the NCI cancer prevention 

constituency that continued to be supportive of ASSIST as originally designed. 

In an e-mail to the editorial team of 

this monograph, on June 4, 2002, former 

ASSIST Senior Advisor Helene Brown 

noted that at the early date of 1993, the 

ASSIST states were not prepared to 

spend all of the funds that would be provided; thus, each state had carry-over 

56 
M o n o g r a p h 1 6. A S S I S T 

funds from money that had not been 

spent by the end of the year. In a sense, 

the cut funds represented a delay in 

funding rather than a cut because an additional year of funding for the project 

was proposed. In fact, with the addition 

of the sixth implementation year, total 

funding for the project was increased. 

This experience profoundly reinforced 

the conviction of the members of the 

ASSIST Coordinating Committee that a 

strong participant-defined role for the 

committee would benefit the project. 

The first 2 years of ASSIST were 

dedicated primarily to translating the 

ASSIST theoretical model into an operational process, which staff from various 

organizations with varied backgrounds 

would implement. NCI staff members 

viewed initial meetings of the ASSIST 

Coordinating Committee as opportunities (1) to educate project directors 

about the objectives of ASSIST, the requirements of the contract, and the contributions that various entities within 

NCI and national ACS were making to 

its operation and (2) to discuss how 

project directors could most effectively 

implement the project according to the 

guidelines. NCI staff planned agendas 

for the meetings; these agendas were 

based on individual discussions with 

state project staff and a conference call 

with the executive committee, which included senior advisors. Meetings consisted of a series of presentations by 

ACS and NCI staffs, senior advisors, or 

consultants. At that time, the role of 

project directors was to receive the information provided, to discuss the implications, and to return to their states 

better equipped to administer the project 

according to the prescriptions of NCI 

staff and senior advisors. As the projects 

matured, project managers were able to 

take on more of the leadership roles. 

The first 2 years of ASSIST required 

states to plan a comprehensive and effective program and to develop and mobilize a foundation of coalition partners. 

All states were operating under the same 

criteria, but they were in various stages 

of readiness. The first 2 years were spent 

getting people from various regions of 

the country with different backgrounds 

and expertise to understand the contractual agreement with NCI. 

By the committee’s meeting on May 

13, 1993, the project was in transition 

from the planning phase to the implementation phase.10 The project directors 

believed that a constructive approach 

would be to recognize and use their considerable state-level experience in implementing tobacco control programs 

and other health agendas and to involve 

them in a more interactive and collaborative way. As a result, the project directors took an active role in reorganizing 

the ASSIST Coordinating Committee, 

elected officers, took charge of developing and approving the agenda, and expressed the need for flexibility and 

judgment in determining which planning 

and intervention steps were appropriate 

for each state. Recognizing that the approach was consistent with the strategy 

of community organizing being applied 

in the ASSIST project sites, NCI supported these changes. 

The reorganization of the ASSIST Coordinating Committee created the potential for more effective communication 

57 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

The Cancer Letter, a privately published newsletter (used 

with permission of The Cancer Letter), and The Link, 

published by Smokefree Indiana 

among the states, the ASSIST Coordinating Center, and NCI staff. A number 

of subcommittees emerged to provide 

forums for discussion and to identify 

needs that NCI and the ASSIST Coordinating Center might address: the Program Managers Subcommittee, the 

Strategic Planning Subcommittee, the 

Research and Publications Subcommittee, 

the Technical Assistance and Training 

Subcommittee, and later the Multicultural Subcommittee. The ASSIST Coordinating Committee and its subcommittees 

were important linkages through which 

the states participated in project-wide 

decision making and shared issues of 

concern or interest with NCI staff. Also, 

they were a useful mechanism for communicating with key administrators, policymakers, and opinion leaders at the 

national and state levels. Most of the 

subcommittee work was accomplished 

through regularly scheduled conference 

calls, but meetings were also held, 

sometimes in conjunction with the national training and information exchange 

meetings. 

The Strategic Planning Subcommittee 

The Strategic Planning Subcommittee 

began as a task force and was changed 

to a subcommittee in 1993. This group 

was charged with the responsibilities of 

developing plans and making recommendations to the ASSIST Coordinating 

Committee for those activities that required consideration or decision making 

at the national level and could have a 

synergistic effect in advancing policy 

advocacy goals for tobacco prevention 

and control. The subcommittee addressed short-term and long-term strategic issues and as needed established 

working groups to gather more information and make recommendations for action to the full subcommittee. Position 

papers and recommendations for action 

were brought before the ASSIST Coordinating Committee once the subcommittee had reached a consensus. 

From the beginning, the subcommittee established strong links with the 

Technical Assistance and Training Subcommittee. Representatives of the two 

groups were routinely invited to attend 

each other’s conference calls, and the 

Strategic Planning Subcommittee occasionally provided suggestions for specific training topics related to strategic 

58 
M o n o g r a p h 1 6. A S S I S T 

planning issues. For example, in October 

1996, a Site Trainers’ Network module 

on durability planning was delivered at 

the suggestion of the Strategic Planning 

Subcommittee. This collaboration 

helped integrate project activities to ensure that learning occurred at the appropriate levels and times. 

The Strategic Planning Subcommittee 

played a principal role in the following 

five noteworthy accomplishments: 

1. The 1-year extension of ASSIST 

support 

2. Collaboration with the Multicultural 

Subcommittee to promote diversity 

and cross-cultural competence 

throughout all aspects of the ASSIST 

project 

3. Substantial increase in financial 

support for the 33 states participating 

in CDC’s Initiatives to Mobilize for 

the Prevention and Control of 

Tobacco Use (IMPACT) project 

4. Development of visionary papers for 

advancing a national comprehensive 

tobacco prevention and control plan 

5. Leadership for developing a national 

tobacco control movement that 

included participation by all 50 states, 

the District of Columbia, and the U.S. 

territories 

As the ASSIST project reached the 

midpoint of the implementation phase, 

issues related to the planned termination 

became important for the ASSIST Coordinating Committee. As a result, the 

Strategic Planning Subcommittee was 

charged with new priorities and objectives. Eventually, this led to the creation 

of new communication and decisionmaking structures to provide a basis for 

joint planning that included states outside of the ASSIST project. (See chapter 

9.) 

Initial efforts were directed internally 

to raise consciousness about the implications that the termination of ASSIST 

would have for ASSIST participants, for 

health department administrations, for 

state ACS affiliates, and within NCI. 

Later, communication efforts focused on 

multiple outreach activities to engage 

non-ASSIST states, national organizations, and other appropriate groups in 

forging a consensus of support for a plan 

that had been developed to address the 

critical issues. (See chapter 9.) 

The Multicultural Subcommittee 

When it became apparent that 

ASSIST was not successfully engaging 

communities of color, a multicultural 

task force, which later became the Multicultural Subcommittee, was formed to 

serve as a forum for discussing and providing input to the national program requirements for ASSIST. The cochairs of 

the Multicultural Subcommittee were 

appointed to the ASSIST Coordinating 

Committee. 

The ASSIST project’s response to the 

need to address ethnic minority and cultural diversity issues more effectively 

was an example of a communication 

process that began at the local level 

among field staff and worked its way 

back through the project structure to 

project managers, directors, and NCI 

staff. At training and information exchange conferences held in October and 

December of 1993, a number of project 

field staff expressed concern that ASSIST 

59 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

was not adequately addressing the needs 

of minority communities. As a result, the 

Strategic Planning Subcommittee sponsored an ad hoc task force of those interested in multicultural issues. Nearly all 

participants were field staff from the ASSIST project sites or members of local 

coalitions. The task force had several 

teleconferences with support from the 

ASSIST Coordinating Center before the 

May 1994 training and information exchange conference. At this conference, 

the task force developed recommendations to be presented at the ASSIST Coordinating Committee meeting that 

followed the conference. The conference 

included participants from projects funded by the CDC and The Robert Wood 

Johnson Foundation, and a number of 

these individuals joined the multicultural 

task force. Their participation stimulated 

the task force to articulate the need for a 

national effort that would extend beyond 

the ASSIST states. 

The task force reported to the ASSIST 

Coordinating Committee that states 

should be doing a better job of conducting outreach to minority communities 

and of meeting the objectives related to 

the needs of these communities and that 

NCI should make addressing these objectives a higher priority in training and program evaluation. The task force pointed 

out that the coordinating committee was 

seriously underrepresented by persons of 

color—only 3 persons of color out of 68 

ACS and state health department project 

managers and directors sat on the committee. The task force made the following 

recommendations regarding its own role 

and composition: 

■	 It should be given a permanent status. 

■	 Its membership should include 

persons from states not participating 

in ASSIST. 

■	 It should be given the responsibility of 

developing specific criteria by which 

to evaluate each state project’s 

performance in reaching objectives 

related to minority communities. 

■	 It should be given the responsibility of 

assessing performance relative to 

those criteria. 

The report was received with mixed reactions. Most controversial was the report’s recommendation that the task 

force develop criteria and evaluate state 

efforts to reach minority communities. 

Some project directors felt that the very 

formation of the task force represented 

unjust criticism of their efforts. They felt 

that they had not been adequately 

consulted about the formation of the task 

force and questioned the inclusion of individuals who were not with ASSIST. 

NCI staff members attempted to reassure task force members that reaching 

minority populations was an important 

priority and cited examples of efforts being made to address the issue. However, 

many task force members interpreted 

this response as minimizing the problem. When the ASSIST Coordinating 

Committee closed its initial session by 

adopting a resolution thanking the task 

force for its work but essentially ignoring its recommendations, task force 

members were disillusioned. Several 

committee members, after talking with 

other task force members, agreed to ask 

the committee to revisit the issue the 

next day. At the next session, the committee voted to rescind its initial resolu60 
M o n o g r a p h 1 6. A S S I S T 

tion, passed a new resolution that adopted a mission statement drafted by the 

task force, and asked the task force to 

develop specific suggestions for improving ASSIST’s ability to obtain input 

from culturally diverse communities and 

for more effectively achieving ASSIST 

objectives related to reducing tobacco 

use in minority communities. 

Subsequently, the cochairs of the 

ASSIST Coordinating Committee met 

with NCI staff and the cochairs of the 

multicultural task force. It was decided 

that a permanent multicultural subcommittee should be formed and that a cochair of the subcommittee would be a 

full member of the ASSIST Coordinating Committee. It was also decided that 

the membership and business of the new 

subcommittee would be specific to the 

ASSIST project, that others could consult with the subcommittee, and a member of the Multicultural Subcommittee 

would be involved in responding to requests about multicultural issues. All 

cultural groups were not represented on 

the ASSIST Coordinating Committee 

because membership was a function of 

who occupied the positions of project 

director and ACS project director in the 

states. Therefore, it was agreed that, in 

addition to a representative of the Multicultural Subcommittee, four at-large positions would be created to introduce 

additional ethnic diversity to the ASSIST 

Coordinating Committee. The Multicultural Subcommittee would be asked to 

recommend and help recruit persons to 

provide input from African American, 

Hispanic/Latino, American Indian/Alaska Native, and Asian American/Pacific 

Islander communities. Last, it was 

agreed that at least two project directors 

should serve on the Multicultural Subcommittee to help ensure improved 

communications. The ASSIST Coordinating Committee adopted the recommendations at its next meeting in 

December 1994.11 

Although the early efforts of the Multicultural Subcommittee to deal with 

multicultural issues were challenging, 

throughout the life of ASSIST the members of this subcommittee became quite 

adept at pursuing and advocating for 

their priorities and at utilizing the communication mechanisms available, especially the ASSIST Coordinating 

Committee structure. The following actions resulted from the formation of the 

Multicultural Subcommittee: 

■	 Cultural diversity was given higher 

priority within the ASSIST project. 

■	 The diversity mission of the 

Multicultural Subcommittee expanded 

to include tobacco-related issues in 

gay and lesbian communities. 

■	 Specific multicultural training 

meetings were held, and more effort 

was made to identify and disseminate 

culturally sensitive materials. 

■	 ASSIST training and information 

exchange conferences devoted more 

time to multicultural topics. 

■	 NCI staff carefully reviewed state 

annual action plans to ensure that 

adequate attention was given to 

multicultural issues. 

■	 Representation from the Multicultural 

Subcommittee was included on all 

standing and ad hoc committees to 

improve access to and participation in 

the communication and decisionmaking processes at all levels. 

61 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

■	 The Multicultural Subcommittee 

participated in the development of the 

multicultural training module From 

Sensitivity to Commitment. 

The events surrounding the formation 

of the Multicultural Subcommittee also 

affected communication and decisionmaking processes within ASSIST. The 

ASSIST Coordinating Committee structure was reorganized and made more inclusive. A new Project Managers 

Subcommittee was formed, and each 

subcommittee had a seat on the committee. Also, an effort was made to recruit 

staff members other than managers and 

directors to the subcommittees. This resolution of multicultural issues and the 

general opening of the lines of communication and decision making for the 

project could not have occurred had NCI 

staff not recognized and supported at the 

national level organizational development that was consistent with the 

ASSIST assumptions being applied in 

the individual states. 

The Technical Assistance and Training 

Subcommittee 

The role of the Technical Assistance 

and Training Subcommittee was to plan 

and review the development of training 

activities and to make recommendations 

regarding project-wide technical assistance strategies. All ASSIST staff and 

coalition members were eligible to serve 

on this subcommittee. The members selected a chairperson. 

The subcommittee provided substantive 

input to such initiatives as the following: 

■	 Agendas, presenters, and formats for 

the information exchange conferences 

and national conferences 

■	 The site trainers’ network program 

and relevant training materials 

■	 Training modules on youth advocacy, 

policy advocacy, media advocacy, 

multicultural, and post-ASSIST 

program continuance issues 

In 1996, the Technical Assistance and 

Training Subcommittee conducted a 

training needs assessment to revise the 

original Strategic Training Plan from 

1991. Input was sought from health department and ACS project managers regarding training needs, interests, and 

priorities. Most of the issues identified 

as priorities concerned building skills 

and capacity for long-term success after 

ASSIST funding ended. In addition, 

throughout the ASSIST project, members of this subcommittee regularly participated in the conference calls and 

discussions held by the Strategic Planning Subcommittee. As the end of 

ASSIST drew near, members of the 

Technical Assistance and Training Subcommittee participated on the advance 

teams that studied various aspects of resources for building a national tobacco 

prevention and control program. 

The Research and Publications 

Subcommittee 

The role of the Research and Publications Subcommittee was to develop and 

review project policy regarding scientific 

publications and presentations about 

ASSIST. This subcommittee also provided guidance to ASSIST states on the 

strategic use of data in professional publications to further ASSIST objectives. 

Members of the subcommittee regularly 

tracked and reported on the status of 

commissioned papers covering national 

62 
M o n o g r a p h 1 6. A S S I S T 

and state issues in ASSIST and maximized opportunities for presentations on 

ASSIST at important national conferences, such as those of the American Public 

Health Association. All ASSIST staff 

and coalition members were eligible to 

serve on the subcommittee. The members selected the cochairs. The subcommittee conferred regularly via telephone 

conference calls and also met in conjunction with ASSIST conferences. 

In 1999, as ASSIST drew to a close, 

the Research and Publications Subcommittee responded to a request from the 

ASSIST Coordinating Committee to 

propose a role for the committee in the 

evaluation and dissemination stage of 

ASSIST. Participation by the committee 

was an important issue because decision 

making for the governance, operations, 

and future of ASSIST had evolved into a 

highly participatory process. While NCI 

emphasized that the evaluation must remain objective, the committee favored 

continuing the participatory process and 

pushed for an action evaluation that 

would involve ASSIST staff. The outcome was the formation of the Documentation and Dissemination Workgroup. 

The ASSIST Coordinating Committee 

submitted to NCI recommendations for 

membership of this workgroup. 

The responsibilities of the workgroup 

were to identify conferences and other 

opportunities at which to present 

ASSIST findings, to promote and facilitate publication of data from ASSIST 

studies, and to be a communication link 

between NCI and the evaluation group.12 

The workgroup was also asked to assist 

with the development of a monograph 

that would describe how ASSIST was 

organized, how it operated, the types of 

activities it conducted, and the insights 

gained that were applicable to other tobacco prevention and control efforts. 

The workgroup developed an outline for 

the monograph, identified authors and reviewers, developed timelines and work 

schedules, and determined relevant citations and sources of information. The 

workgroup sought input from individuals 

in all the ASSIST states and from members of the various project committees. 

This culminated in the writing and development of this monograph. 

The Project Managers Subcommittee 

The Project Managers Subcommittee 

was established to provide project managers with opportunities to exchange 

ideas, identify issues of mutual concern, 

and communicate these to NCI staff. It 

also provided a means for NCI staff to 

communicate priorities, policies, and 

procedures and to obtain feedback on 

their feasibility and progress in implementation. This exchange was essential 

because project directors varied greatly 

in their knowledge of ACS divisions and 

in their knowledge of and their involvement in specific ASSIST activities and 

day-to-day issues. Some project directors 

provided close direction and had detailed knowledge of the project activities; others delegated most of the 

decision making to project managers 

and had very little knowledge about the 

details of the project. 

The subcommittee was divided into 

three groups. The first group consisted 

of state health department and ACS 

project managers, who discussed issues 

relevant to both partners’ roles in the 

63 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

project. The second group included only 

the state health department project managers, because most of the discussion 

was related to the responsibilities of 

state health departments as the prime 

contractors for the ASSIST project. The 

third group consisted of ACS project 

managers, who met periodically to discuss issues related to the administration 

of state divisions and their relationship 

with the national ACS. One additional 

reason for forming separate groups was 

that both ACS and the state health department project managers felt that there 

were topics affecting project management that might be more freely discussed among colleagues of the same 

partner type. The members planned their 

own agenda to parallel the conference 

agenda. For example, speakers from the 

Food and Drug Administration and the 

Substance Abuse and Mental Health Services Administration presented information to the project managers about 

implementation of their agencies’ regulations, and NCI staff presented an overview of legislative tracking systems. The 

subcommittee also discussed issues that 

the managers had to deal with, such as 

burnout toward the end of the project 

and how to plan for program continuation after ASSIST. 

Communication Vehicles 

As the technology of electronic communication advanced, the state partners 

and subcontractors, following the general trend of business communication, increasingly relied on e-mail, listservs, 

and Web sites for rapid communication 

on advocacy-related issues. At the time, 

the use of electronic communication was 

forward thinking for a public health program, and the new technology enabled 

quick response to the states’ needs, simultaneous reception of news, and rapid 

sharing of successful strategies. Most 

states developed phone and fax trees to 

reach individuals and organizations that 

did not have easy access to e-mail. Several states established state Web sites as 

the project was ending. 

All states developed brochures and 

brief publications—some modest, others 

quite sophisticated—to describe the 

ASSIST project and its core assumptions to potential participants, opinion 

leaders, government officials, the news 

media, and the general public. All states, 

except Massachusetts and Wisconsin 

(which had other mechanisms in place), 

developed newsletters to communicate 

information to ASSIST participants 

within the state and to other interested 

parties. The newsletters provided information about state and local coalition 

activities, news, facts and statistics on 

tobacco and the tobacco industry, types 

of policy interventions, specific legislation and legislative activities, and advocacy approaches to specific state and 

local bills and laws. 

Formats and editorial policies varied 

widely. For example, some states, such 

as North Carolina, used the newsletter to 

establish the ASSIST “brand name” for 

their tobacco control activities. Other 

states chose to identify tobacco control 

activities with a preexisting state coalition, program effort, or other entity that 

was already widely recognized, such as 

Tobacco-Free Indiana and the Coalition 

for a Tobacco-Free West Virginia. The 

mix of topics and the emphasis on facts, 

64 
M o n o g r a p h 1 6. A S S I S T 

educational activities, general news, or 

specific advocacy-related topics varied 

considerably among states and over 

time, especially in light of strategic factors. For example, projects in tobaccogrowing states tended to emphasize 

news, health facts and figures, and neutral descriptions of legislative events in 

newsletters and relied on ACS or other 

nongovernmental partners to communicate advocacy issues to the public. In 

states where governors and the heads of 

health departments were supportive of, 

or at least tolerant of, an advocacy approach, ASSIST projects included advocacy content in their newsletters. 

Controversy did arise; at one point in 

Missouri, the ASSIST newsletter editor 

decided not to publish an issue because 

an attorney from the state’s health department censored a large amount of 

text. The staff subsequently reached a 

better understanding with the state’s 

public information office and resumed 

publication. 

ASSIST’s Electronic Communication 

System 

Through a subcontract from the 

ASSIST Coordinating Center, the Advocacy Institute developed an electronic 

communications system (ECS) for 

ASSIST to facilitate rapid communication and access to information. ECS was 

modeled on the Advocacy Institute’s 

Smoking Control Advocacy Resource 

Center Network (SCARCNet), an information exchange service for tobacco 

control advocates. The ASSIST ECS was 

a monitoring system for receiving and reporting on the states’ progress, and a service for providing current published 

articles on tobacco control news. All 

ASSIST sites were required to purchase 

computers, modems, and software that 

met specific standards to facilitate communication with NCI and among the 

states. Periodic upgrades were required to 

keep pace with the rapid advances in 

technology. All sites were linked with one 

another, NCI, and the ASSIST Coordinating Center through ASSIST-only bulletin 

boards that were attached to SCARCNet. 

ECS was a critical element in supporting 

policy issues and countering the tobacco 

industry. 

As ASSIST matured, listservs and 

e-mail began taking precedence for 

project-specific communications, and 

the larger SCARCNet environment was 

preferred for strategy exchanges. Although 

such modes of electronic communication were in common use by the end of 

the 1990s, the systems used in ASSIST 

represented a forward-thinking approach 

for public health early in the decade. 

Planning for Strategic Communication 

Within a short time after the ASSIST 

states began implementing interventions, 

the tobacco industry vigorously attempted 

to thwart the project not only by discrediting the project itself, but also by attacking the credibility of those involved 

with the project. The industry used the 

media to challenge the tobacco control 

policies supported by ASSIST coalitions 

and to create the impression that more 

damage than good would be done to the 

population because of economic implications. For example, a criticism raised 

in numerous locations was that efforts to 

decrease youth access to tobacco were 

clearly antibusiness. More alarming 

65 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

even were vague implications that the 

project was somehow illegally using its 

resources to engage in activities inappropriate to federal and state government 

agencies. These issues are discussed in 

depth in chapter 8. 

The electronic and other communication mechanisms enabled ASSIST 

staff members at all levels to communicate with one another and to respond 

quickly to crises. However, these repeated challenges necessitated a planning process that would enable ASSIST 

partners to respond strategically and effectively as crises or urgent situations 

arose and even to take the initiative in 

placing these issues before the public 

and decision makers. 

Recognizing the ability of the private 

sector to respond to issues that could affect its credibility and public image, NCI 

staff sought expertise about applying 

these methods to a public health program. 

Accordingly, NCI and the ASSIST Coordinating Center worked with experts in 

the field of strategic and crisis communication to isolate the elements that are critical to a strategic communication plan. 

These elements address the need for an 

appropriate visible leader, the need for 

quick decision making, and the need to 

protect credibility: careful consideration 

of how to respond and what to communicate must occur before the credibility of 

the program or agency is damaged. Along 

with other fundamentals depicted in the 

sidebar, timeliness in responding is critical. 

Using these fundamentals, the ASSIST 

Coordinating Center provided seminars, 

training workshops, and onsite technical 

assistance to ASSIST staff and partners to 

develop strategic communication plans. 

The resulting plans varied from location 

to location but generally included the 

following three elements: 

1. Concise, hard-hitting main messages 

about what the ASSIST project was to 

accomplish 

2. Scenarios in which key, hard-toanswer questions about ASSIST were 

developed with concise, specific 

answers to the questions, along with a 

strategy for delivering them 

3. Strategies for transitioning from the 

crisis response mode to proactively 

delivering the main messages about 

ASSIST and the facts of tobacco use 

During the training sessions, the 

states shared experiences and insights, 

such as successful and unsuccessful 

methods of coping with or even capitalizing on tobacco industry efforts. (See 

chapter 8.) The states were prompted to 

carefully review advocacy activities for 

compliance with federal and state laws 

and with policies of their agencies. National-level NCI and ACS staff participated in strategic planning and training 

to be spokespersons for issues regarding 

ASSIST at the national level. A Communications Action Team was created to 

meet crisis needs. The partnership empowered this team to respond very 

quickly to any accusations against 

ASSIST and then to disseminate information throughout the ASSIST networks 

to make everyone aware of what was 

happening. By authorizing the team to 

act independently, they successfully circumvented the otherwise cumbersome 

process of obtaining a series of approvals from various committees. 

66 
M o n o g r a p h 1 6. A S S I S T 

Readiness to Build 

Capacity and Capabilities 

T hroughout the course of ASSIST, 

coordination, decision making, and 

communication mechanisms were continually evolving and adapting to changing circumstances and needs. This 

responsiveness was apparent in the initial 

redefinition of the role of the ASSIST 

Coordinating Committee. It was also apparent in certain reforms. These reforms 

were made to the decision-making process after the staff and local participants 

told project directors and NCI staff that 

greater attention should be given to serving the needs of ethnically and culturally 

diverse communities. The mechanisms 

in place made it possible for the 17 

ASSIST states to implement the interventions and to function as a coordinated 

tobacco prevention and control program. 

Chapter 4 describes the systems and 

products that were offered to and utilized by the states to build their strength, 

especially through coalitions, and their 

skills, through training and practice, to 

plan for and implement comprehensive 

tobacco control interventions. 

Fundamentals of a Strategic 

Communication Plan 

■ 

■ 

■ 

■ 

■ 

■ Identify and mobilize resources. 

■ 

Opportunities 

■ 

■ The circumstance is not routine; it is out of 

■ 

addressed. 

■ The circumstance is a one-time 

■ 

response 

■ 

■ 

■ 

■ 

■ 

health issue 

■ 

■ 

partnerships 

■ 

Purpose 

To respond to urgent program issues 

To take advantage of unique opportunities 

Steps of a Strategic Communication Effort 

Define the situation. 

Collect and review available information. 

Identify the messages, strategies, and 

spokespersons to be used. 

Evaluate the effort. 

Criteria for Identifying Threats and 

Time is of the essence. 

the ordinary. 

There is a policy issue that must be 

advantageous occurrence. 

Reactive Strategic Objectives 

To discern issues that need a rapid, public 

To present the most effective partners as 

spokespersons 

To use national resources as appropriate 

To monitor the effectiveness of response 

and shift strategies if necessary 

Proactive Communication Objectives 

To maintain a central focus on health 

To legitimize tobacco control as a public 

To present a unified voice for ASSIST 

To maintain solidarity for ASSIST 

To evaluate and learn from experiences 

67 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

Appendix 3.A. Memo of Understanding Between the National 

Cancer Institute and the American Cancer Society 

July 20, 1990 

Re: The American Stop Smoking Study for Cancer Prevention (ASSIST) 

This Memorandum of Understanding defines the respective roles and responsibilities of 

the National Cancer Institute and the national organization of the American Cancer Society relative to the American Stop Smoking Intervention Study for Cancer Prevention 

(ASSIST). The Memorandum assumes that the American Cancer Society Divisions will 

serve as the voluntary health agency collaborating with the local health department in 

the vast majority of ASSIST sites to be funded in 1991. If the American Cancer Society 

is not the lead voluntary health agency in at least 75% of the ASSIST sites, this Memorandum will need to be modified to reflect the relative contribution of each organization 

to the collaborative relationship. 

Background 

The American Stop Smoking Intervention Study for Cancer Prevention represents a collaborative effort between the National Cancer Institute and the American Cancer Society, along with State and local health departments and other voluntary organizations to 

develop comprehensive tobacco control programs in up to 20 states and metropolitan 

areas. The ASSIST intervention model is based on proven smoking prevention and control methods developed within the National Cancer Institute’s intervention trials and 

other smoking and behavioral research. The purpose of ASSIST is to demonstrate that 

the wide-spread, coordinated application of the best available strategies to prevent and 

control tobacco use will significantly accelerate the current downward trend in smoking 

and tobacco use, thereby reducing the number and rate of tobacco-related cancers in the 

United States. 

The primary objective of ASSIST is to demonstrate and evaluate ways to accelerate the 

decline in smoking prevalence sufficiently in all ASSIST sites to reduce smoking prevalence to less than 15% of adults by the year 2000. Site selection criteria and program 

planning guidelines have been developed so that populations among whom smoking 

prevalence rates remain a problem can be emphasized in ASSIST intervention sites. 

This includes groups in which smoking rates are elevated relative to the majority population or groups which have displayed slower rates of decline (e.g., women, the medically underserved, the less educated, and several ethnic minority populations). 

Therefore, both the National Cancer Institute and the American Cancer Society will 

need to be prepared programmatically to address the special needs of these priority 

populations within ASSIST efforts. 

ASSIST is the largest health promotion initiative ever undertaken by the National Institutes of Health. It is anticipated that between 15 and 20 contracts will be awarded to 

State and local health departments throughout the country. These health departments 

68 
M o n o g r a p h 1 6. A S S I S T 

will join with American Cancer Society Divisions or other qualified voluntary health agencies to convene state-wide coalitions and/or local coalitions in major metropolitan areas. 

These coalitions will consist of community groups and agencies and will work to a) define the smoking problem in each site; b) develop a comprehensive smoking prevention 

and control intervention plan (Phase I); and c) implement the plan through coalition 

member groups (Phase II). Each plan will describe the delivery of proven smoking prevention and control interventions through schools, worksites, religious and social 

groups, professional organizations, health care professionals, and health care institutions in a manner which will reach targeted groups of smokers and potential smokers. 

During a five-year intervention period between 1993 and 1998, the coalitions in each of 

the funded sites will initiate, coordinate, and deliver a level of tobacco use prevention 

and control programs throughout their service areas far in excess of current activities. 

To meet these challenges, ASSIST will require a significant collaboration between the 

National Cancer Institute and the American Cancer Society. Both institutions agree that 

the shared leadership of this project will be of great benefit: 

* The National Cancer Institute has invested over $250 million in research to produce 

state-of-the-art behavioral strategies and products in smoking prevention and control 

that are ready for national dissemination to achieve the Institute’s Year 2000 goals 

and objectives. 

* The American Cancer Society possesses a vast national network of 57 Divisions, 

3400 Units, and 2.5 million volunteers active in cancer (and smoking) control 

through which the knowledge and products from the National Cancer Institute 

research can be distributed across the United States. 

*	 ASSIST offers the opportunity to join the unique strengths of the National Cancer 

Institute and the American Cancer Society to achieve the nation’s objectives in 

smoking prevention and control. 

National Cancer Institute Support 

As with any project of the federal government, the National Cancer Institute funding of 

ASSIST depends upon availability of funds. The ASSIST concept was approved by the 

Division of Cancer Prevention and Control Board of Scientific Counselors at their October 1988 meeting for funding up to $120 million over 10 years. 

In addition to its responsibility for the management and support of ASSIST site, coordinating center, and other related contracts, the National Cancer Institute will print and 

make available to the American Cancer Society certain core materials for the ASSIST 

intervention effort. These materials will be distributed directly by the American Cancer 

Society at no cost in ASSIST sites. 

American Cancer Society Support 

As with any project of the American Cancer Society, the funding of ASSIST depends 

upon availability of funds. The ASSIST concept was approved by the American Cancer 

69 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

Society Board of Directors at their October 1988 meeting to support full ACS participation in this effort. 

The American Cancer Society will receive no Federal, State, or local public funds for 

its participation in the project, in keeping with its longstanding national policy. The 

American Cancer Society will provide programmatic assistance through its staff dedicated to the project and the large network of volunteers. 

The American Cancer Society will contribute staff, training, travel, and materials equivalent to a minimum of 15% of total contract funds in each funded site to be distributed 

annually throughout the project. This contribution will include a minimum of one fulltime equivalent (FTE) staff person in each funded site devoted exclusively to the project 

and does not include in-kind contributions. However, the direct cost of materials, travel, 

and additional staff time will be used as the basis for the calculation of a Division’s required 15% match. The American Cancer Society estimates its support at approximately $16 million, depending on the number of collaborative partnerships established in 

funded ASSIST sites. 

The American Cancer Society will work with the National Cancer Institute to develop 

improved program materials and/or repackage existing materials for use as core ASSIST intervention support resources. These materials will reflect the current state of the science 

of smoking cessation and prevention intervention and will be labeled to reflect joint 

sponsorship of the American Cancer Society and National Cancer Institute. 

Local ACS Participation 

Federal government procurement regulations require that Justification of Other Than 

Full and Open Competition (JOFOC) be prepared when competition will be limited. In 

the case of ASSIST, a JOFOC was developed to restrict competition for awards to state 

and certain local health departments which will form a partnership with a voluntary 

health agency meeting a set of criteria, e.g., specified minimal contributions of financial, material, and staff resources, an existing network of volunteers, and a commitment 

to the long-term institutionalization of the ASSIST intervention after federal funding is 

completed. This agency will receive no public funds to support participation in the project. 

The health department and the qualified voluntary health agency will lead coalition activities through an executive committee structure which also includes representation 

from the coalition. 

The JOFOC does not mandate that the American Cancer Society serve as the only 

health agency eligible to work in partnership with the health department, and it is possible that other qualified voluntary health agencies may assume that role. The American 

Cancer Society will urge full partnership and support of ASSIST among American Cancer Society Divisions nationwide, bringing to bear its network of volunteers, its experience in serving as a convener of groups and agencies, and a substantial commitment of 

financial and in-kind resources dedicated to ASSIST. 

70 
M o n o g r a p h 1 6. A S S I S T 

Administrative Oversight 

ASSIST has been developed and will be conducted as a collaborative effort between the 

National Cancer Institute and the American Cancer Society. However, because the National Cancer Institute is the lead Federal agency in the National Cancer Program and is 

responsible for the management of public funds associated with ASSIST, certain decisions must remain the prerogative of the National Cancer Institute alone. Details are 

provided below on a number of issues related to the shared administration and management of the project: 

1. Institutional Authority: The Director of the National Cancer Institute shall retain 

his regular statutory authority over ASSIST. The National Cancer Institute will 

authorize the release of trial findings and results as appropriate. 

2. Management and Committee Structure: On the national level, American Cancer 

Society staff and volunteers will work closely with National Cancer Institute project 

staff in planning and coordinating the ASSIST intervention effort. American Cancer 

Society senior staff and national volunteers will be represented on the ASSIST 

Management Committee, which will serve as the on-going mechanism for the 

planning and coordination of the ASSIST intervention effort within our respective 

organizations. Additionally, a Scientific Advisory Committee will be appointed by 

the National Cancer Institute as the principal external oversight body for ASSIST. 

This committee will report on policy and scientific issues related to ASSIST planning, timelines, and progress. This committee will be specifically charged with 

advising on advancing ASSIST from the planning phase (Phase I) to implementation 

(Phase II). Scientists and others regarded as national experts in cancer prevention 

and control will be selected to serve on this committee, including representatives of 

both the National Cancer Institute and American Cancer Society advisory committees and the populations to be targeted in the intervention efforts, particularly ethnic 

minorities and women. 

3. The Community Intervention Trial for Smoking Cessation (COMMIT) — 

ASSIST Relationship: COMMIT is National Cancer Institute’s ongoing $45.3 

million community intervention trial which is testing models for comprehensive 

smoking prevention and control intervention in 11 matched pairs of communities. A 

variety of data from ongoing process evaluation and annual assessments of cohorts 

of smokers in the 22 COMMIT sites will inform ASSIST planning. The proposed 

timeline permits emerging data from COMMIT to be carefully monitored and Phase 

II of ASSIST to be delayed until COMMIT provides statistically significant documentation of the efficacy of community-wide intervention strategies. DCPC 

Biometry Branch statisticians feel that this finding could emerge in 1991 or 1992 

cohort follow-ups and be fully evaluated in the 1993 assessments. Thus, the start of 

Phase II of ASSIST is now projected for July, 1993. 

4. Periodic Scientific Review of ASSIST Implementation: Findings from COMMIT 

as well as other smoking and behavioral research related to the ASSIST intervention 

71 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

will be reviewed on a regular basis by the ASSIST Scientific Advisory Committee 

and other National Cancer Institute advisory committees in order to ensure that the 

plan for ASSIST interventions reflects the consensus of scientific evidence about 

effective intervention methods. These committees also will review progress in the 

implementation of these proven methods within sites and across the ASSIST project 

as a whole to assure that the objectives for the project are being met. 

5. Decision-making Criteria for ASSIST Continuance: While the National Cancer 

Institute remains organizationally committed to the ASSIST project, it is only 

scientifically prudent to consider the potential situations that could bring the justification for continuing ASSIST into question. Specifically, the Scientific Advisory 

Committee will be charged with developing criteria to judge the scientific appropriateness for advancing ASSIST from Phase I to Phase II. Interim criteria for not 

continuing ASSIST into Phase II are as follows: 

a) Progress on smoking as measured by change in national prevalence (for both males 

and females, and for both blacks and whites) from the 1985 Current Population 

Survey (CPS) to the 1989 CPS and continuing through the 1992 CPS is so positive 

that the U.S. Public Health Service Year 2000 objectives to reduce tobacco use can 

be anticipated to be reached without the ASSIST intervention effort. 

b)	 Results from COMMIT fail to demonstrate that community-wide smoking 

control efforts lead to significant increases in quit rates. This outcome is most 

likely to occur if the quit rates in the comparison communities are greater than 

anticipated due to increased smoking cessation influences occurring on the 

national level which substantially affect the comparison sites but the increased 

resources in the intervention sites fail to increase the effect. This finding would 

suggest that providing additional smoking control resources to individual communities or metropolitan areas would be an inefficient method to increase the 

national decline in smoking prevalence. 

c)	 Some combination of a) and b) above, particularly if differences in community 

quit rates in COMMIT are in the expected direction but show smaller differences 

between pairs than expected and national smoking prevalence rates are decreasing at 

an accelerated rate between 1985 and 1989 and continuing through 1992. 

Conclusion 

ASSIST offers the National Cancer Institute and the American Cancer Society an 

unique and challenging opportunity. Through ASSIST both our organizations can build 

on complementary strengths, and through the synergy of our efforts, we can prove true 

the adage that the whole is greater than the sum of its parts. By working together we 

have the opportunity to make significant progress toward the attainment of our mutually 

endorsed objectives to reduce smoking in the United States and thereby save thousands 

of lives now and in the future. 

72 
M o n o g r a p h 1 6. A S S I S T 

Appendix 3.B. ASSIST Key Required Resources 

Action Handbook for Tobacco Control.


ASSIST: A Guide to Working With the


Media.


ASSIST Ad Hoc Advisory Committee


Meeting.


ASSIST Coalition Profiles.


ASSIST Coordinating Committee Meet­


ing Materials.


ASSIST Information Resources.


ASSIST Media Kit.


ASSIST Operations Manual. Volume I.


Introduction to Contract Administration.


ASSIST Operations Manual. Volume II.


Electronic Communications System.


Version 1.3.


ASSIST Orientation Guide.


ASSIST Program Guidelines for Tobacco-


Free Communities.


ASSIST Scientific Advisory Committee


Meeting. 1992.


ASSIST Scientific Advisory Committee


Meeting. 1993.


ASSIST Slide Collection: What Is


ASSIST?


ASSIST Slide Collection: Why Tobacco


Control?


ASSIST State Summaries. Volume I. De­


mographics and Selected Program Char­


acteristics.


ASSIST Training Materials. Volume I.


Orientation.


ASSIST Training Materials. Volume II.


Site Analysis and Related Activities.


ASSIST Training Materials. Volume III.


Site Analysis and Comprehensive Smok­


ing Control Plan.


ASSIST Training Materials. Volume IV.


Planning and Coalition Building.


ASSIST Training Materials. Volume V. 

Development of the Annual Action Plan. 

ASSIST Training Materials. Volume VI. 

Media Advocacy: A Strategic Tool for 

Change. 

ASSIST Training Materials. Volume VII. 

From Phase One to Page One: Refining 

Our Media Skills. 

ASSIST Training Materials. Volume 

VIII. Implementing Policy Advocacy: 

Steps to Success.


ASSIST Training Materials. Volume IX.


Implementing Policy Advocacy: Steps to


Success—Part II.


Clean Air Health Care: A Guide to Es­


tablish Smoke-Free Health Care Facilities.


Clean Indoor Air: A Guide to Develop­


ing Policy.


COMMIT Community Mobilization Ex­


perience: Lessons Learned. Summary


Report of a Trial-Wide Study.


COMMIT Project: Forming Partnerships


With Religious Organizations.


Community-Based Interventions for


Smokers: The COMMIT Field Experi­


ence.


Community Collaboration Manual.


Curriculum for ‘Death in the West.’


Death in the West.


Death or Taxes: A Health Advocate’s


Guide to Increasing Tobacco Taxes.


Draft.


Environmental Tobacco Smoke in the


Workplace: Lung Cancer and Other


Health Effects.


Essential Elements of School-Based 

Smoking Prevention Programs. 

73 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

Essential Elements of Self-Help/Mini-


mal Intervention Strategies for Smoking


Cessation.


Evaluation Information Exchange. To­


bacco Prevention. The Next Generation.


Federal Trade Commission Report to


Congress for 1992: Pursuant to the Fed­


eral Cigarette Labeling and Advertising


Act.


Group Techniques for Idea Building.


Growing Up Tobacco Free: Preventing


Nicotine Addiction in Children and


Youths.


Guide to Public Health Practice: State


Health Agency Tobacco Prevention and


Control Plans.


Health Promotion at the Community


Level.


How to Help Your Patients Stop Smok­


ing: A National Cancer Institute Manual


for Physicians.


How to Help Your Patients Stop Using


Tobacco: A National Cancer Institute


Manual for the Oral Health Team.


How to Make Meetings Work: The New


Interaction Method.


Incentive Programs Workbook.


Information Exchange Conference:


Breaking the Grip of Tobacco State by


State.


Information Exchange Conference: A


Partnership for Building Diverse Com­


munity Involvement.


Information Exchange Conference: To­


bacco Prevention: The Next Generation.


New Approaches to Youth Policies, Sec­


ondhand Smoke, and Institutionalization.


Information Exchange Conference:


Youth Access.


It’s Your Business: Smoking Policies for


the Workplace.


Legislative Approaches to a Smoke Free


Society. [Narrative and Appendix].


Major Local Tobacco Control Ordinanc­


es in the United States.


Making Health Communication Pro­


grams Work: A Planner’s Guide.


Manual for Training Health Care “Influ­


entials.”


Mass Communication and Public Health:


Complexities and Conflicts.


Media Advocacy and Public Health:


Power for Prevention.


Media Strategies for Smoking Control:


Guidelines.


Model Policy for Smoking in the Work­


place.


No Smoking: A Board Member’s Guide


to Nonsmoking Policies for the Schools.


Nurses: Help Your Patients Stop Smoking.


On the Air: A Guide to Creating a


Smoke-Free Workplace.


Organizing. A Guide for Grassroots


Leaders. Rev. ed.


Physician’s Guide to Preventing Tobacco


Use During Childhood and Adolescence.


Preventing Tobacco Use Among Young


People: A Report of the Surgeon General.


Promoting Smoking Control Through


Worksites in the Community Intervention


Trial for Smoking Cessation (COMMIT).


Report on Tobacco Advertising: Give


Children a Chance.


Respiratory Health Effects of Passive


Smoking: Lung Cancer and Other


Disorders.


Review and Evaluation of Smoking Ces­


sation Methods: The United States and


Canada, 1978-1985.


74 
M o n o g r a p h 1 6. A S S I S T 

School Programs to Prevent Smoking:


The National Cancer Institute Guide to


Strategies That Succeed.


Self-Guided Strategies for Smoking Ces­


sation: A Program Planner’s Guide.


Selling the Smokeless Society: Fifty-six


Evaluated Mass Media Programs and


Campaigns Worldwide.


Site Trainer’s Network: Policy Advocacy


Module.


Site Trainer’s Network: Administrative


Handbook.


Site Trainer’s Network: Youth Advocacy


Module.


Smoke Fighting: A Smoking Control


Movement Building Guide.


Smoke Signals: The Smoking Control


Media Handbook.


Smokefree Workplace: An Employer’s


Guide to Nonsmoking Policies.


Smokeless Tobacco or Health: An Inter­


national Perspective.


Smoking Cessation: What Have We


Learned Over the Past Decade?


Smoking Policy: Questions and Answers.


State Legislated Actions on Tobacco


Issues.


Stopping Teenage Addiction to Tobacco.


A Community Organizer’s Manual.


Strategies to Control Tobacco Use in the


United States: A Blueprint for Public


Health Action in the 1990’s.


Taxing Tobacco.


Tobacco Advertising and Promotion: A


Guide to Developing Policy.


Tobacco and the Clinician: Interventions


for Medical and Dental Practice.


Tobacco Effects in the Mouth.


Tobacco Free Youth: How to Reduce


Sales to Minors in Your Community.


Tobacco Taxation and Economic Effects


of Declining Tobacco Consumption.


Tobacco Use: An American Crisis. Final


Conference Report and Recommendations


from America’s Health Community.


Tobacco Use in America Conference: Fi­


nal Report and Recommendations From


the Health Community to the 101st Con­


gress and the Bush Administration.


Tobacco-Free Young America: A Guide


for the Busy Practitioner.


Toward a Tobacco-Free California: A


Master Plan to Reduce Californians’ Use


of Tobacco.


Truth and the Consequences of Cigarette


Advertising: An Advocate’s Guide to Ar­


guments in Support of Banning Cigarette


Advertising and Promotions.


What Works? A Guide to School-Based


Alcohol and Drug Abuse Prevention


Curricula.


Where There’s No Smoke: Helping to


Create a Smoke-Free Environment. An


Advocacy Guide for Public Education


Volunteers.


Where There’s No Smoke: Helping to


Create a Smoke-Free Environment.


Scripted Speeches for Primary and Sec­


ondary Targets.


Where There’s Smoke: Problems and


Policies Concerning Smoking in the


Workplace. 2nd ed.


Who Profits from Tobacco Sales to


Children?


Working with Unions to Reduce Ciga­


rette Smoking.


Youth Access to Cigarettes.


Youth Access to Tobacco: A Guide to


Developing Policy.


75 
3. S t r u c t u r e a n d C o m m u n i c a t i o n s 

References 

1. ASSIST Coordinating Center. 1991–99. 

Quarterly reports. Internal documents, 

ASSIST Coordinating Center, 

Rockville, MD. 

2. National Cancer Institute. n.d. NCI


mission statement. www.cancer.gov/


about_nci.


3. ASSIST Coordinating Center. 1990. 

Memo of understanding between the 

National Cancer Institute and the 

American Cancer Society re: The 

American Stop Smoking Intervention 

Study for Cancer Prevention (ASSIST). 

Internal document, ASSIST 

Coordinating Center, Rockville, MD. 

4. ASSIST Coordinating Center. 1991. 

ASSIST training materials, volume 1: 

Orientation. Internal document, ASSIST 

Coordinating Center, Rockville, MD. 

5. Shisler, J., and C. DiLorio. 1999. The 

role of the American Cancer Society in 

ASSIST. Final report. Atlanta: American 

Cancer Society. 

6. Pertschuk, M. 1996. Public health 

advocacy and the future of cancer 

prevention and control. In Horizons 

2013: Longer, better life without cancer, 

ed. H. G. Brown and J. R. Seffrin, 308– 

12. Atlanta: American Cancer Society. 

7. American Cancer Society. 1993. 

ASSIST: A guide to working with the 

media. Atlanta: American Cancer 

Society. 

8. ASSIST Coordinating Committee. 1997. 

ASSIST Coordinating Committee bylaws. Internal document, ASSIST 

Coordinating Center, Rockville, MD. 

9. NCI stands firm on ASSIST 

“downscaling” despite 150 letters from 

states, volunteers. 1993. The Cancer 

Letter 19 (3): 1–4. 

10. ASSIST Coordinating Center. 1993. 

Summary report of the ASSIST 

Coordinating Committee meeting of 

May 13–14, 1993. Internal document, 

ASSIST Coordinating Center, 

Rockville, MD. 

11. ASSIST Coordinating Center. 1994. 

Summary report of the ASSIST 

Coordinating Committee meeting of 

December 16, 1993. Internal document, 

ASSIST Coordinating Center, 

Rockville, MD. 

12. ASSIST Coordinating Committee. 1999. 

Summary report of the ASSIST 

Coordinating Committee meeting of 

August 26, 1999. Internal document, 

ASSIST Coordinating Center, 

Rockville, MD. 

76 
M o n o g r a p h 1 6. A S S I S T 

4. Building National, State, and Local

Capacity and Capability 

Authors: Robert H. Anderson, Amber Hardy Thornton, and 

Brenda McAdams Motsinger 

Contributors: Milly Krakow and Harriet Robbins 

Contents 

Creating the Capacity to Act ....................................................................................... 79


Coalitions: The Force behind the Interventions .................................................................... 79


Challenges to Working Collaboratively ................................................................................. 81


Differences in Organizational Culture .......................................................................... 81


Planners and Activists ................................................................................................. 82


Participatory Decision Making ...................................................................................... 82


Laborious Process ........................................................................................................ 83


Did the States Build Capacity? ............................................................................................ 83


Creating Capacity during the First 2 Years: Planning for Comprehensive Tobacco Control .... 90


Site Analyses ................................................................................................................ 91


Comprehensive Tobacco Control Plans and Annual Action Plans ................................. 91


Project Management Plans .......................................................................................... 92


Building the Capability to Act ..................................................................................... 93


Technical Assistance and Training: The Forces behind the Coalitions ................................. 93


Training during the Planning Phase .................................................................................... 94


Transitioning to Implementation ......................................................................................... 96


Building Capabilities Back Home: The Site Trainers Network .............................................. 98


Willing and Ready ....................................................................................................... 99


References ................................................................................................................ 118


77 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

Case Studies 

Case Study 4.1. Albuquerque: A Multicultural Coalition ........................................................... 84


Case Study 4.2. Regional Networks in the Massachusetts Tobacco Control Program ............... 85


Case Study 4.3. Evaluating ASSIST Coalitions in North Carolina ............................................. 86


Table 

Table 4.1. Number of ASSIST State and Local Coalitions, 1992 and 1996 ................................ 83


Appendices 

Appendix 4.A. Example of Membership in an ASSIST State Coalition: Rhode Island ............... 101


Appendix 4.C. Wisconsin ASSIST’s Comprehensive Smoking Control Plan:


Appendix 4.E. Minnesota ASSIST’s Comprehensive Tobacco Control Plan:


Appendix 4.F. Minnesota ASSIST’s 1993–94 Annual Action Plan: Community


Appendix 4.G. Minnesota ASSIST’s 1998–99 Annual Action Plan: Community


Appendix 4.H. Washington State ASSIST’s Project Management Plan:


Appendix 4.B. ASSIST Responsibility Matrix from Minnesota .................................................. 103


Selected Channels ................................................................................................................. 104


Appendix 4.D. Wisconsin ASSIST’s 1993–94 Annual Action Plan: Selected Channels ............. 106


Community Environment Channel .......................................................................................... 108


Environment Channel ............................................................................................................ 109


Environment Channel ............................................................................................................ 110


Selected Components ............................................................................................................ 111


Appendix 4.I. Training Events of the Implementation Phase .................................................. 113


78 
M o n o g r a p h 1 6. A S S I S T 

4. Building National, State, and Local Capacity and Capability

Once the structural components and communication mechanisms were in place, 

the process of preparing the states for action began. Throughout the American Stop 

Smoking Intervention Study (ASSIST), the states’ project staff and coalition members 

were trained to achieve two major goals. First, they sought to create the capacity to 

implement tobacco control interventions statewide, especially by building and 

linking strong coalitions in communities throughout the state. Second, they sought to 

build the capabilities of all coalition members. To do this, they trained them (1) to 

plan evidence-based interventions that were responsive to each community’s needs 

and that were realistic in terms of the program’s readiness and resources and (2) to 

implement tobacco control interventions, especially policy and media interventions. 

The substantial investment that ASSIST made in developing the capacity of the states 

and the capabilities of the state participants is reflected in the effectiveness of their 

intervention efforts. 

Creating the Capacity to Act 

At the outset, the National Cancer Institute (NCI) recognized the key role that state 

and local coalitions play in planning and implementing tobacco control activities. 

Effective tobacco control occurs with the implementation of community-based strategies by partnerships comprising strong health advocates and community leaders. NCI 

selected the coalition model as the basic organizational structure for ASSIST because 

of the potential strength of coalitions to mobilize diverse community organizations and 

individuals to work together to influence social norms and policies. In the request for 

proposals for the ASSIST project, each state was required to develop a state coalition. 

Most states also developed local coalitions. 

Coalitions: The Force behind the Interventions 

The effectiveness of coalitions in health promotion and disease prevention had been 

demonstrated in the research studies underlying the rationale for a community-based 

tobacco control project. (See chapter 1.) Community initiatives designed by a diverse 

group of citizens are likely to be feasible for that community, supported by that community, and ultimately successful. By joining together around an issue of mutual interest, organizations and agencies reduce competing and duplicative efforts. Also, there is 

strength in numbers; therefore, coalitions can be especially effective in addressing issues relating to policy changes and the enforcement of existing policies and laws. 

Generally, coalitions follow predictable stages and take time to develop and flourish, 

and ASSIST coalitions were no exception. Typically, the developmental stages are formation, implementation, maintenance, and reaching goals and objectives.1 During the 

79 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

formation stage, a coalition defines its 

mission and goals. A diverse membership that participates in planning, action, 

and advocacy is essential. During the 

implementation stage, a coalition initiates activities designed to meet its 

goals. During the maintenance stage, a 

coalition builds on its activities and, on 

occasion, revisits its mission and goals. 

Process evaluation is important during 

the implementation and maintenance 

phases to determine whether plans and 

interventions have been implemented as 

designed. Most coalitions have frequent 

meetings of a steering committee and 

less frequent meetings of the general 

membership. Officers and committee 

chairs need clear job descriptions. A system for regular and clear communication 

must be in place and must be used. During the final stage, in an ideal model, outcome measures examine a coalition’s 

effectiveness in meeting its mission, goals, 

and objectives. 

Ideally, coalitions reach a state of institutionalization, or permanence, and 

have a base of substantial long-term 

funding. Such coalitions are usually respected by policy makers in the jurisdiction that they serve and are seen as 

authorities on policy issues; often, they 

are invited to join the efforts of other 

groups. Coalitions can fail to sustain 

themselves for a variety of reasons: lack 

of direction, turf battles, failure to plan 

or act, dominance of professionals, insufficient community linkage, weak organization, funding problems, leadership 

problems, inadequate sharing of responsibility and decision making, time and 

loyalty conflicts, lack of training, and 

burnout of members or staff.2 

coalition memberships. 

■ 

■ 

■ Establish a shared vision. 

■ Agree to disagree in the process. 

■ 

■ 

■ 

■ 

■ Institutionalize change. 

■ Publicize your success. 

1991. 

Education and Human Services Consortium. 

Guidelines for New Partnerships 

During training, the following guidelines 

were offered to ASSIST staff members to 

consider as they developed their states’ 

Involve diverse and key players. 

Choose a realistic strategy. 

Make promises you can keep. 

“Keep your eye on the prize.” 

Build ownership at all levels. 

Avoid “red herrings.” 

Source: Melaville, A. I., and M. J. Blank. 

What it takes: Structuring interagency 

partnerships to connect children and families 

with comprehensive services. Washington, DC: 

As the ASSIST coalitions developed, 

they experienced the growth stages, and 

many of the predictable issues arose. In 

meeting the challenges, however, the coalitions became strong internally and 

forceful externally. The fourfold purpose 

of the ASSIST coalition design was as 

follows: 

1. To increase the tobacco control 

capacity for existing community 

groups and organizations 

2. To sustain and enhance the coalitions’ 

role as a tobacco control agent 

3. To recruit organizations (including 

those not related to health) that had 

not participated in tobacco control 

efforts 

4. To amplify the coalitions’ potential to 

create community change for tobacco 

control 

The relationship of the state coalitions 

and the local networks of affiliates was 

80 
M o n o g r a p h 1 6. A S S I S T 

designed to be interactive throughout the 

project.3 

Challenges to Working Collaboratively 

The elements of coalition development played out in the ASSIST project 

as changes in coalition leadership and 

the environment occurred. In the beginning, NCI’s imposed structure of contract accountability implied a formalized 

process from which coalitions should be 

formed. Some state ASSIST staff members encountered community leaders 

who would not readily accept the formation of new bodies or committees solely 

because a new NCI contract prescribed 

structure and required certain functions. 

States varied greatly in their ability to 

mobilize and organize their partners. 

However, coalitions continued to be 

formed for several years into the project. 

Even those coalitions that were developed had mixed success. 

Differences in Organizational Culture 

During the planning phase of 

ASSIST, many coalitions were new and 

were forming organizational cultures. 

Other tobacco control coalitions, however, had been in existence for years prior 

to ASSIST and had operated independently from government funding. For 

those coalitions, issues of ownership and 

direction surfaced; for example, an existing coalition may have worked collaboratively with state staff members 

during the ASSIST proposal development process. Afterward, however, the 

coalition leadership may have changed, 

with a resulting change of focus to new 

opportunities. Insistence by state staff 

members—having been awarded an 

On T a rget, published by New Mexicans Concerned about 

Tobacco 

ASSIST contract—that the coalition 

work on contract deliverables, such as 

the site assessment, sometimes resulted 

in friction between the paid contract 

staff and volunteers. 

Another difference in organizational 

culture that presented a challenge to 

some coalitions was the ASSIST contract requirement of deliverables—items 

produced by the state health department 

contractors and submitted to NCI. In the 

first 2 years, the contract required the 

coalitions and staff to work on assessments, environmental analyses, and 

sound strategic plans for a 5-year implementation phase. Although these tasks 

may have been agreed to during the proposal process, issues of “why wait for 

action?” to “we want to spend the funds 

now” caused splintering among groups 

within existing and new coalitions. For 

the action-oriented coalitions, accepting 

81 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

the strings attached to the ASSIST 

funds—primarily the requirement to engage in careful long-term planning—was 

a serious challenge. Some coalitions lost 

initial members who, though strongly 

committed to tobacco control, found the 

process to be too slow, particularly since 

in the meantime the tobacco industry 

continued to lobby at the federal and 

state levels, to work against clean indoor 

air initiatives, and to market its products 

very aggressively. Other coalitions, 

however, were just getting started and 

wanted to do everything by the book. 

The value of careful planning became 

more and more appreciated during the 

implementation phase, when multifaceted activities were initiated. 

Planners and Activists 

The types of individuals who served 

best during the planning phase tended to 

be different from those who served well 

during the implementation phase. In 

some states with mature coalitions that 

were reluctant to perform ASSIST planning, the staff met the challenge by developing small committees to address 

the deliverables required by the contract. 

In these situations, some coalition members worked on advocacy issues while others were planning advocacy activities. 

Early in the third year, planning and implementation merged, and the coalition 

members worked collaboratively. ASSIST 

funds could then be turned into full-scale 

action—even as plans were modified in 

response to a changing environment. 

Participatory Decision Making 

The ASSIST project initially had a 

highly formalized structure and imposed 

modes of accountability on the coaliSurgeon General David Satcher addresses an ASSIST 

conference 

tions. The coalitions wanted more participation in decision making, which 

implied changing to a flatter management structure for coalitions, committees, and staffing. As this need became 

widespread among the coalitions and the 

program advanced, the formalized structure of ASSIST at the national level was 

changed to be less rigid and more inclusive. It provided “seats at the table” for 

field directors and program managers to 

offer various perspectives of program 

needs, as described in chapter 3. This 

evolution from a hierarchical form of 

management, also experienced to some 

degree in the Community Intervention 

Trial for Smoking Cessation (COMMIT), 

provided many opportunities for better 

feedback and decision making for program direction and resource allocation 

by the coalitions. 

82 
M o n o g r a p h 1 6. A S S I S T 

Laborious Process 

Coalition work is demanding and 

must be done with an understanding of 

the environment and the stages of development of an alliance. As the ASSIST 

project evolved, its national leadership 

became more open to opinions and ideas 

from the states but also had the responsibility to balance immediate needs with 

long-term vision. Would it be better to 

spend more time planning, so that all 

implementation staff could ponder the 

process and learn the systems for 

change? Or would it be better to provide 

more direction and leadership to achieve 

immediate outcomes? The challenge 

was addressed by NCI and the ASSIST 

Coordinating Center largely through tailored responses to needs for technical 

assistance and training in the various 

states. 

Case studies 4.1, 4.2, and 4.3 point to 

some of the challenges that the coalitions addressed in developing collaborative working relationships. To attract 

coalition members representative of 

New Mexico’s rich diversity of populations, ASSIST staff sought outside professional marketing help. Massachusetts, 

an ASSIST state with a long history of 

conducting tobacco control programs, 

formed regional networks to advance its 

capacity and capabilities. North Carolina 

took advantage of an evaluation to identify the most effective elements in forming effective coalitions. 

Did the States Build Capacity? 

Most states completed the 8-year 

project period with more local coalitions 

than were anticipated initially, and five 

Table 4.1. Number of ASSIST State and Local 

Coalitions, 1992 and 1996 

State 1992 1996 

CO 8 13 

IN 1 6 

ME 3 2 

MA 4 20 

MI 4 62 

MN 3 26 

MO 3 19 

NJ 3 3 

NM 5 8 

NY 9 23 

NC 11 10 

RI 8 8 

SC 8 12 

VA 6 17 

WA 5 10 

WV 1 20 

WI 13 33 

Total 87 285 

Sources: ASSIST Coordinating Center. 1992. ASSIST 

coalition profiles. Internal document, ASSIST Coordinating Center, Rockville, MD. ASSIST Coordinating 

Center. 1996. Draft of ASSIST coalition profiles. 

Internal document, ASSIST Coordinating Center, 

Rockville, MD. 

states decreased their number of coalitions. For example, the coalition in 

Maine’s largest city, Portland, was started through ASSIST and is still in operation, as are some small coalitions in 

small towns and cities, now supported 

with funds that Maine obtained as a result of the Tobacco Master Settlement 

Agreement. In contrast, Washington 

State discontinued its state coalition, as 

did Maine. Table 4.1 indicates the number of ASSIST coalitions in each state in 

1992 (toward the end of the planning 

phase) and in 1996 (toward the end of 

the implementation phase). Appendix 

4.A provides an example of the diverse 

83 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

Case Study 4.1 

Albuquerque: A Multicultural Coalition 

Situation: 

minority groups. 

Strategy: 

coalition. In 565–74 (Sessions and case studies of 

New Mexico has a rich mix of cultures and includes some communities that 

predate the founding of Jamestown. Also, New Mexico is one of the poorer states 

and, overall, registers low on a list ranking quality of life. Poor, uneducated citizens 

of New Mexico are targets for tobacco companies. In Albuquerque, a coalition, 

Tobacco-Free New Mexico, was already in existence when the ASSIST staff determined that a second tobacco control coalition was needed to focus on tobacco use by 

ASSIST supported the development of a coalition known as Multicultural 

Advocates for Social Change on Tobacco (MASCOT). The ASSIST staff employed 

an advertising and marketing firm to identify and attract coalition members, especially leaders in the minority communities. The resulting community-based coalition 

initially had 20 volunteer members and subsequently became a core of 6 to 10 

regular members. Members included, among others, coordinators of tobacco education in county and city fire departments, representatives of New Mexico’s Department of Substance Abuse and its Office of Indian Affairs, representatives of the 

Adolescent Social Action Program at the University of New Mexico, a medical 

doctor, and an American Indian. Progress in enlisting additional American Indians 

was slow. 

MASCOT meetings were held weekly. Initially, the group engaged in a period of 

self-training, using publications and videos, and of sharing information. The group 

developed a logo for branding its activities. The members tackled issues of leadership, mission, and goals and objectives. An ASSIST field director chaired meetings 

until the members elected a chair. The coalition then focused on educating individuals in diverse ethnic communities in Albuquerque about youth access to tobacco, 

industry promotional tactics, and achieving self-efficacy. At the same time, the 

coalition secured a fiscal agent (the New Mexico Public Health Association) to 

manage antitobacco money received through grants, contracts, and donations. Some 

members tracked tobacco control measures that occurred in the state and attended 

national ASSIST meetings. Early on, MASCOT planned to become independent of 

the ASSIST program, eventually applying for nonprofit status. 

Source: Adapted from O. S. Harris and M. F. Herrera. 1996. The first year in the life of a multicultural 

Communities for tobacco-free kids: Drawing the line,

the National Tobacco Conference, May 29–30, 1996). Rockville, MD: ASSIST Coordinating Center. 

84 
M o n o g r a p h 1 6. A S S I S T 

Case Study 4.2 

Situation:

phase to its program implementation phase. In a matter of months, program dollars 

Strategy: 

by a steering committee, composed primarily of program managers from local 

—

Regional Networks in the Massachusetts Tobacco Control Program 

 In Massachusetts, the contract award of ASSIST energized the American 

Cancer Society (ACS) and the tobacco control advocacy community. As a result, 

ACS and the Massachusetts Coalition for a Healthy Future financed the passage of 

ballot question 1, the Massachusetts tobacco excise tax, and created the Health 

Protection Fund. The Health Protection Fund provided funding for the Massachusetts 

Tobacco Control Program (MTCP) of the Massachusetts Department of Public 

Health. This program development occurred as ASSIST moved from its planning 

rose from $1.195 million (ASSIST fiscal year 1993) to an additional $58.1 million 

(from the department of health funds) for the first year of funding for MTCP. 

Although ASSIST funding was a small part of MTCP’s overall funding, it played an 

important role in shaping the program model and providing funds to create a programmatic infrastructure. The Massachusetts legislature initially voted to provide 

funds for program services but not for administrative infrastructure. Therefore, 

ASSIST funds were used to support the organizational structures that allowed MTCP 

to become a successful and comprehensive tobacco prevention and control program. 

In 1995, a field operations unit replaced program-specific contract managers 

who were overseeing community-based programs. Regional field directors organized 

local programs funded by MTCP into regional networks. Small and large regional 

meetings, convened monthly by MTCP regional field directors, served as forums for 

regional action planning, information dissemination, provider collaboration, identification of best practices, and training. Each of the six regional networks was guided 

programs. Steering committees worked on goal alignment, strategic planning, 

regional public relations campaigns, and quality improvement. This organizational 

strategy facilitated communication and planning within larger geographic areas and 

across agency and program boundaries. Linking programs together played an 

important role in creating a successful social movement in Massachusetts. 

Harriet Robbins, Massachusetts Department 

of Public Health, and Milly Krakow, 

Krakow Consulting 

85 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

Case Study 4.3 

Evaluating ASSIST Coalitions in North Carolina 

Situation: 

Strategy and Results: 

participation, the quality of action plans, resource mobilization, and implementation 

about the program. 

13 

(2): 225–38. 

In North Carolina, the operations of 10 ASSIST coalitions offered an 

opportunity to compare and contrast the effectiveness of procedures, personnel, and 

other factors. 

The North Carolina ASSIST coalitions were evaluated with 

interviews, surveys, observations of meetings, and a review of documents. A conceptual model of factors that might influence coalition effectiveness was developed. The 

factors were leadership, decision making, communication, conflict, costs and benefits of participation, organizational climate and structure, staff roles, capacity building, member profiles, recruitment patterns, and community capacity for tobacco 

control. Coalition effectiveness was measured by observing member satisfaction and 

of activities. 

The study revealed that coalitions were more effective in implementing activities 

when they provided a vision for the coalition at the local level, involved members in 

planning actions, fostered frequent communication among staff, and hired skilled 

staff who saw their roles as “coaching” the communities in activities rather than 

taking full responsibility for the activities. 

Personal accounts by coalition members revealed insights into the composition of the 

coalitions and the ability to recruit, as illustrated in the following examples: 

I wanted to get people involved, but, early on, there was so much that was nebulous 

We said, ‘Will you be on this task force? Here’s what we’ll be doing’—but it wasn’t 

specific enough. Now we are a little more directed. 

So you sort of have to have something under your belt ... to say ‘Well look what we 

have done.’ Without that, I don’t feel like I can go out [and expand the coalition]. 

—Michelle Kegler, then doctoral candidate, University of 

North Carolina at Chapel Hill, and current Program 

Specialist/Evaluator, Tobacco Technical Assistance Consortium 

Source: Kegler, M. C., A. Steckler, S. H. Malek, and K. McLeroy. 1998. A multiple case study of 

implementation in 10 local Project ASSIST coalitions in North Carolina. Health Education Research

86 
M o n o g r a p h 1 6. A S S I S T 

ASSIST Coordinating Center staff 

membership of the Rhode Island statelevel coalition; the number and diversity 

of members were typical of the coalitions. 

To examine aspects of the coalition 

approach to implementing tobacco interventions, NCI engaged an independent 

contractor to conduct a pilot study during the first 6 months of 1995 to assess a 

number of characteristics of three state 

coalitions.4 New Jersey, New York, and 

South Carolina participated in the pilot 

study designed to investigate the feasibility of conducting coalition assessments of all ASSIST state-level 

coalitions. Three types of coalition characteristics—environmental, structural, 

and functional—were examined as measures that could influence a coalition’s 

effectiveness. 

The environmental characteristics 

were state history of tobacco control, 

geographical and cultural diversity, and 

previous collaboration. Pilot study results showed that these characteristics 

played a role, though not a critical one, 

in the effectiveness of the statewide coalition networks. Rather, the most important characteristics were the size of the 

geographic area and the extent of previous collaboration among key individuals 

and organizations. South Carolina’s history as a tobacco-producing state, New 

York’s large geographical area, and the 

racial and ethnic diversity found in all 

three states presented challenges that 

slowed progress but were not insurmountable factors. 

In terms of structural characteristics, 

matters of complexity (numbers of coalitions and bureaucratic processes) and 

membership of the coalitions related 

strongly to coalition effectiveness, 

whereas formalization of policies and 

procedures was considered relatively unimportant. The evidence showed that 

managing a large number of coalitions 

presented major challenges and strained 

staff resources. At the same time, however, a large network of local coalitions 

can be very important to defeating tobacco industry legislation. Frustration 

87 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

was high in all three states regarding extensive bureaucratic red tape and regulations. Regarding membership, all three 

states found that recruiting members to 

state and local coalitions was difficult. 

Broad membership was especially important because different types of coalition members increased the diversity of 

skills and could play different roles at 

different times, thereby enhancing a coalition’s ability to respond quickly to unexpected events. There was strong 

evidence that additional training in community outreach skills was needed for 

coalition organizers, particularly at the 

local level, in order to broaden coalition 

membership beyond the public health 

community. 

The results showed that two functional characteristics—leadership and vision—were considered essential for 

effectiveness; four other functional characteristics—management, communication, resource allocation, and conflict 

resolution—related strongly to effectiveness but were not easily distinguishable 

from one another and were merged into 

a single functional characteristic called 

management/communication. Vision 

was defined as “the extent to which coalition members have a clear sense of direction and a common understanding of 

coalition goals and objectives.” ASSIST 

staff in all three states reported that it 

took much longer than expected to train 

coalition members in the new paradigm 

of tobacco control. The results showed 

that leadership is a very important factor 

in moving a coalition forward but that a 

dynamic leadership style is not required. 

Low-key, well-respected leaders were 

adept at motivating the members and advancing their agendas. An unexpected 

finding that emerged was the importance 

of two additional but related functional 

characteristics—strategic planning and 

community outreach. A major conclusion of the pilot project was that the six 

functional characteristics—vision, leadership, management/communications, 

shared decision making, strategic planning, and community outreach—are important for coalitions focusing on policy 

and media advocacy.5 Although the assessments were not conducted in all 

states as originally planned, the pilot 

project provided valuable information 

that served the ASSIST Coordinating 

Center staff in planning technical assistance and training. 

A review of the states’ final reports 

provides insight into the opinions of 

ASSIST state managers about coalitions, 

the role that coalitions played in their respective states, and the likelihood that 

coalitions will be maintained in the future. NCI asked the coalitions to comment on the following topics in their 

final quarterly reports: 

■	 List several of the most important 

lessons that have been learned 

through your ASSIST interventions, 

and describe how these experiences 

will guide the development and 

implementation of future tobacco 

prevention and control efforts in your 

state. 

■	 Based on what you learned from other 

states or national organizations 

throughout ASSIST, what major tobacco control activities or policies are 

yet to be achieved in your state? Do 

you plan to attempt these activities 

over the next several years? 

88 
M o n o g r a p h 1 6. A S S I S T 

■	 What factors or resources contributed 

most to the success of activities in 

your state and throughout ASSIST? 

How? Why? 

■	 Was the coalition model effective in 

bringing together various partners or 

organizations in your state? Would 

you use this model again? Why? 

Why not? 

Fourteen states found the coalition 

model to be very effective. Most stated 

that they planned to maintain, if not 

expand, their support for coalitions 

with funds from their new cooperative 

agreement with the Centers for Disease 

Control and Prevention (CDC). Missouri and Washington State felt that 

while their state coalitions were not 

successful, their local coalitions 

worked well. Maine substituted the coalition model for a partnership model. 

The following sampling of comments 

from six of the states illustrates the 

range of insights from participants. 

■	 Colorado—Key to the success of 

Colorado ASSIST was the efforts of 

volunteers from the 12 coalitions 

throughout the state. They multiplied 

staff efforts many times. Dedicated 

(funded positions) staff charged with 

leading and guiding the coalitions 

provided a consistency and built on 

each year’s accomplishments within 

the project. Colorado planned to continue the model within the CDC 

framework and increase the number 

of coalitions when tobacco settlement 

monies become available to the state 

health department.6 

■	 Minnesota—The coalition model is a 

valuable though time-consuming 

strategy requiring continuous mainteASSIST Information Exchange and Training 

conference materials 

nance. In most cases, a full-time local 

coordinator is needed to provide staff 

leadership for a coalition. The benefit 

of a coalition is that it is a means for 

many community members, organizations, and decision makers to come 

together for a common cause. Coalitions provide a strong community 

base of support for policy change and 

are a means of reaching people at the 

local level (educating and involving 

them) and mobilizing them to influence policies to reduce tobacco use.7 

■	 Rhode Island commented as follows 

on the challenges of forming a coalition: “It was idealistic to get a large 

coalition up and running quickly, especially without lots of staff. Coalitions 

are messy and not always efficient. 

They can be very costly in terms of staff 

89 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

ASSIST Training Materials 

time and energy. You


experience a loss of control. They are


slow, and the more ownership they


have, the more need there is to consult


them and allow them to make decisions.


This can hurt, given how fast the tobac­


co industry is. However, the trade-off


is important. Coalitions provide ac­


cess to community, multiple perspec­


tives, and political clout.”8(p22) The


comments from Rhode Island should


not be construed as criticisms of coa­


litions. Rather, they merely point out


that working with a large group of


people is time-consuming and that one


must be prepared to cede some control


to others.


■	 Washington State’s experience with 

coalitions was less positive: “Initial 

efforts were successful in bringing 

various partners and organizations in 

Washington to the table, but two years 

of site analysis and planning discouraged them from staying. Stronger efforts were required to ensure their return, but often were not undertaken. 

The coalition model was far more effective at the local 

level and is being 

continued.” 9

 Washington State voted 

to discontinue its 

state coalition. 

However, the problems described reflect administrative 

challenges more 

than a belief that 

coalitions are inherently ill-advised. The loss of 

volunteers in 

Washington State was a problem that 

some of the other ASSIST states encountered. 

Creating Capacity during the First 2 

Years: Planning for Comprehensive 

Tobacco Control 

To most effectively change people’s 

behavior, and especially to promote policies that would reinforce the behavior 

change, the ASSIST coalitions needed 

strategic plans for interventions. An intensive and extensive strategic planning 

phase was guided by NCI staff and by 

the departments of health, with assistance 

from the ASSIST Coordinating Center. 

The ASSIST project, funded at a total 

of about $22 million annually, began on 

October 1, 1991, with a 2-year planning 

phase. The 2-year planning phase gave 

the states—many of which had no tobacco 

90 
M o n o g r a p h 1 6. A S S I S T 

control resources prior to ASSIST—ample time to plan and build the requisite 

infrastructure for initiating a comprehensive tobacco control initiative. During that time, each of the 17 states, 

working with their coalitions, conducted 

a site analysis (for which the state was 

defined as the site) and a needs assessment and developed a 5-year comprehensive tobacco control plan, tailored to 

the needs of the state but within the 

guidelines provided by NCI. The plans 

included goals related to public policy 

and mass media. All states emphasized 

the opportunities available for working 

with priority populations. 

Site Analyses 

The purpose of the site analysis was 

to provide each state with the baseline 

information that it needed to develop a 

comprehensive tobacco control plan. 

The site analysis documented the distribution of tobacco use by age, gender, 

and geographical area; the economic 

burden of tobacco use; and the social 

and political climate for enacting and 

enforcing tobacco control policies. The 

analysis included an assessment of the 

site’s potential resource strengths and 

weaknesses for implementing ASSIST, 

including finances, equipment, facilities, 

personnel, expertise, organizational relationships and structure, existing policies 

for tobacco control, and media relationships. With the information from the site 

analysis, the following planning tactics 

were formulated: 

■	 Each coalition translated the ASSIST 

primary objectives into site-specific 

quantitative objectives that expressed 

the number of persons in the state 

who would quit smoking as a result of 

interventions and the number of 

persons who would not initiate 

tobacco use. These objectives were 

also expressed as tobacco prevalence 

objectives. These quantitative 

objectives provided the coalition a 

clear picture of the magnitude of its 

undertaking. 

■	 Each coalition made final decisions 

about which populations would be the 

priority focus of its interventions. 

■	 Each coaliton determined which 

policy and media intervention 

strategies would likely be the most 

effective in influencing the behavior 

of the priority populations. 

■	 Each coalition reaffirmed or modified 

its preliminary decisions about 

geographical regions in the states for 

interventions. For each intervention 

region, a local coalition was identified 

to participate in the process of 

developing the comprehensive plan.10 

Comprehensive Tobacco Control Plans 

and Annual Action Plans 

Each state’s site analysis was the basis 

for the state’s 5-year comprehensive tobacco control plan to be implemented 

during the project. (Initially, the plan 

was referred to as the comprehensive 

smoking control plan, but later “tobacco” replaced “smoking” to include 

smokeless tobacco.) Through a series of 

objectives, strategies, and tactics, each 

plan set forth initiatives developed and 

approved by the state’s coalition to address 

the ASSIST program objectives for interventions and channels. (See chapter 2.) 

Each year, an annual action plan was developed, based on the comprehensive 

91 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

plan, that charted a yearly course for 

implementing the interventions in the 

tobacco control plan. Roles and responsibilities for carrying out the activities in 

the action plan were specified, along 

with resource allocations and monitoring 

procedures. Budgets were allocated for 

training and support. The annual action 

plan allowed each coalition to reassess 

its original plans and define its course 

yearly based on changing priority populations, channel conditions and opportunities, and other key environmental 

changes (economic, social, and political 

factors). The annual action plans afforded the coalitions the opportunity to emphasize specific objectives and related 

strategies for specified periods in coordination with the goals of the broader 

plan.3

 (See appendix 4.B for an example 

of a responsibility tracking form from 

Minnesota.) 

The process of constructing the tobacco control plan and the annual action 

plans required the coalitions to formulate measurable objectives applicable to 

the priority populations that they sought 

to reach.3 For intervention regions, the 

objectives, strategies, and tactics had to 

be specific to the regions. The plans 

were ambitious yet realistic. The criteria 

for selecting strategies included the potential reach and influence relative to the 

priority population, resources available, 

and the developmental stage and readiness of the program and coalitions. Each 

strategy listed specific actions or activities that would be implemented to 

achieve an objective. Over the years, the 

states became more proficient at expressing the outcomes as quantifiable 

objectives. 

The sample plans in appendices 4.D– 

4.H were derived from the comprehensive plans and annual action plans of 

two states. The examples illustrate that 

different states developed different strategies and a broad range of activities. The 

strategies developed were for decreasing 

environmental tobacco smoke (also referred to by advocates as secondhand 

smoke, passive smoking, and involuntary 

smoking). The comprehensive plans set 

forth 5-year objectives. Appendices 4.C 

and 4.D contain passages from Wisconsin’s plans that illustrate objectives and 

strategies for two channels (community 

environment and worksite) for 1993–94. 

The passages from Minnesota’s plans in 

appendices 4.E through 4.G show activities for the same channel in two different 

periods (1993–94 and 1998–99) and reflect a change from fundamental formative activities to detailed, targeted 

activities. As is apparent in the 1993 and 

1998 annual action plans, the nature of 

the interventions changed and grew over 

time in reach and sophistication. The 

early annual action plans tended to focus 

on resource development and distribution, whereas the later plans called for 

media campaigns and interaction with 

high-priority population groups. 

Project Management Plans 

To guide the implementation of each 

state’s comprehensive tobacco control 

plan, the sites were also required to produce a project management plan to cover 

the same 5-year period as the comprehensive tobacco control plan. In the 

project management plan, the states 

explained how they would organize, 

manage, and monitor their work. Orga92 
M o n o g r a p h 1 6. A S S I S T 

nizational issues, such as the interrelationships between state and local coalitions, were clarified, along with 

decision-making roles, lines of communication, and responsibility for various 

tasks. Monitoring mechanisms were 

identified to demonstrate how the states 

would stay on schedule and ensure that 

activities occurred as planned. Each 

state outlined a crisis communication 

plan as well, in an effort to anticipate 

how information would be transmitted in 

a crisis and who would serve as spokespersons to the public. Last, the plan included a summary of the budget 

allocated and a description of how that 

budget would be allocated and tracked. 

Appendix 4.H contains a sample plan 

that was derived from the project management plan of ASSIST in Washington. 

Building the Capability to Act 

When the ASSIST project began, changing the social environment 

through media interventions and policy 

advocacy was a public health strategy to 

which the states were unaccustomed. 

The health department personnel, ACS 

members, and the organizations in the 

coalitions required technical assistance, 

support, and training to develop the 

knowledge and skills that they needed to 

mobilize their respective local communities to implement tobacco interventions. 

NCI established the ASSIST Coordinating Center as the project’s hub for ongoing technical assistance and training, 

information coordination, and leadership 

support. ACS also played a vital role by 

providing coordination for and participation in training events. 

Technical Assistance and Training: 

The Forces behind the Coalitions 

The project’s technical assistance and 

training services, provided throughout 

both phases of the project, were designed to build the capabilities of 

ASSIST’s participants by developing 

their general skills and by providing specific information. The needs assessment 

(see the earlier section on creating capacity) helped to determine which services to provide. The basic technical 

assistance and training services provided 

are listed below: 

■	 Customized consultation through site 

visits, a dedicated electronic 

communications system (ASSIST 

ECS), and frequent teleconferences 

■	 Information on specific tobacco issues 

in packets of materials 

■	 Facilitation of networking and sharing 

of information among the sites 

■	 Building of linkages and 

communications among state, federal, 

and community activities 

■	 Development and dissemination of 

resource materials, including training 

manuals, modules, policy guidelines, 

and fact sheets 

■	 Referrals to experts in tobacco 

control, policy development, and 

media relations 

■	 Training events and creation of 

resource materials focused on: 

–	 project management and 

administration;


– strategic planning;


– building, developing, and


managing coalitions; 

– developing and implementing 

effective educational programs; 

93 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

–	 supporting policies (including 

voluntary policies) for tobacco 

control; 

–	 using the media to change the 

social environment to discourage 

tobacco use; and 

– creating rapid responses (e.g., to 

promotional actions by the tobacco 

industry). 

The planning phase (October 1991– 

September 1993) was a critical period 

for the sites. The expectation during this 

time was one of “getting everyone oriented,” while allowing sufficient time to 

concentrate on knowledge development, 

environmental scanning, and planning 

for the upcoming implementation phase. 

NCI staff and the ASSIST Coordinating 

Center’s team of technical assistance 

specialists assisted the states. Generally, 

team members were public health professionals with experience working in 

health departments or voluntary agencies. Team members were assigned to 

specific states to provide rapid response 

and proactive customized consultation to 

help the states develop their plans. During this planning phase, the training 

goals were to build a foundation of 

skills, to develop a common understanding of ASSIST and its approach to tobacco control, and to help staff develop 

project plans. 

Training during the Planning Phase 

As could be expected with a project 

of this size and scope, experience in environmental tobacco control varied among 

the states. Overall, the respective state 

and local staffs had little or no experience in using policy advocacy approaches for tobacco control interventions; instead, most had concentrated on changing individual smoking behavior. Some 

staffs had already sponsored programs 

with policy components; few had experience in developing coalitions. 

Five training events and information 

exchange conferences were held in the 

first year, four in the second. These 

training workshops were instrumental 

during the planning phase in bringing 

the staffs of all 17 states to a level of 

skill and understanding necessary to 

plan ASSIST tobacco control interventions. The primary participants of these 

workshops were the health department 

and ACS project managers. Tobacco 

control consultants with expertise in the 

relevant topics were retained to design 

and deliver the training, supplemented 

by NCI, ACS, and ASSIST Coordinating 

Center staff members. The first training 

was a project overview. Each of the next 

four training events was designed to 

help ASSIST staff develop the required 

planning documents. The titles, dates, 

and objectives of each of the five training workshops are presented in the sidebar on planning phase training. 

After the first year into the project, 

the participants were eager to conduct 

interventions and to start making a difference in their states, and many project 

managers had the challenge of explaining to coalition members why activities 

could not begin as quickly as they would 

like. In retrospect, many participants felt 

that this planning and training period 

was essential because it provided the 

time and resources necessary to establish a solid foundation for each state. 

94 
M o n o g r a p h 1 6. A S S I S T 

■ 

ASSIST conceptual model, goals, and 

operations 

3–5, 1992 

■ 

to conduct an acceptable coalition-based site 

■ 

■ Understand the relationship among the site 

plan, annual action plan, and project 

management plan ■ Understand the components and requireplan ■ Address coalition issues 

Planning and Coalition-Building—October 14– 

15, 1992 

■ Reinforce the understanding of the big 

■ Brainstorm possible problem-solving 

process ■ 

group dynamics, communications, and 

contract issues ■ Enhance the understanding of the 

process ■ 

analysis and priority-setting methods) 

■ 

■ 

■ 

plan 

materials. 

nical assistance and training needs of coPlanning Phase Training 

ASSIST Orientation—November 8, 1991 

Orient the staff of ASSIST states to the 

Site Analysis and Related Activities—February 

Provide the staff of the 17 ASSIST states 

with the knowledge and skills that they need 

analysis, including key informant interviews 

Site Analysis and Comprehensive Smoking 

Control Plan—July 20–21, 1992 

Revise and refine the site analysis 

analysis, comprehensive smoking control 

ments of the comprehensive smoking control 

picture of ASSIST and how the components 

fit together 

strategies for issues occurring in the coalition 

Expand knowledge and skills in addressing 

requirements of the ASSIST planning 

Become oriented to and practice specific 

planning tools in ASSIST (i.e., stakeholder 

Development of an Annual Action Plan— 

January 25–26, 1993 

Present expectations for achieving ASSIST 

national objectives 

Study the lessons learned from effective 

tobacco control strategies (e.g., California’s 

experience) 

Develop strategic steps of the annual action 

Source: ASSIST Coordinating Center training 

Others believed that this process took 

too long. Training in partnership with 

site-specific technical assistance was 

key in helping the states prepare their 

plans and strategies. Few, if any, public 

health projects have the opportunity to 

give adequate preparation time before 

implementation—the ASSIST experience was unusual in this regard. 

A year into the planning phase of the 

program, the ASSIST Coordinating Center hired a consultant from Georgetown 

University to informally assess the techalitions. This assessment, based on 

interviews with project managers, ACS 

staffs, and members of the state-level 

ASSIST coalitions, found wide differences among them in their training and 

development.5

 The report listed the following needs (among others): 

■	 Make training diverse so that it 

reaches, for example, persons who are 

not close to tobacco control issues 

■	 Make goals and strategies very clear 

■	 Define relationships among and roles 

of coalition groups 

■	 Identify skills needed for good 

coalition functioning 

■	 Adapt general planning skills to 

specific planning requirements 

■	 Provide training on policy advocacy 

■	 Provide training on how to conduct 

media advocacy 

The report also noted that many coalitions had been applying successful training methods, and many managers 

brought to their training processes sophisticated strategies for addressing the 

diverse experiences of the members. 

95 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

Transitioning to Implementation 

During the planning phase, the assumption underlying the training program was that all states would become 

capable—more or less simultaneously— 

of implementing tobacco control interventions. In reality, the staffs had 

different skill levels, and the policy environments for which they developed their 

plans varied. While the staff members of 

some states produced strong annual action plans, others struggled with how to 

put into practice ASSIST’s conceptual 

framework. (See the “cube” in chapter 2.) 

The first intervention year was essentially a transition period during which it 

became apparent that certain capabilities 

had to be further developed. Each training event included a process evaluation 

questionnaire. Feedback from these 

questionnaires was considered in planning the technical assistance and training for the implementation phase. The 

training strategy was revised to provide 

more support for the “how-to” and incorporated the following tactics: 

■	 A continued explication, illustrating 

applications, of the policy advocacy 

model of ASSIST. Most states were 

having problems understanding the 

strategy of changing public policies to 

create an environment that does not 

support tobacco use. They also needed 

a clarification regarding the 

differences between advocacy 

activities and lobbying activities. 

■	 More tailoring to the range of individual state needs in designing 

training sessions. Trainings were initially didactic and formatted to include thematic information in plenary 

presentations. The format was 

changed to provide specific sessions 

on media and policy topics and issues 

as the participants’ skills were developed and applied in their states. The 

participants were given the freedom to 

attend those sessions that best fit their 

individual needs. Also, the sessions 

became more interactive. Plenary session lectures were minimized in number and length, and more sessions 

were participatory. Training tools included the use of more case studies, 

interactive role playing, and practice 

exercises. University professors conducted the trainings, and these progressed to peer trainings. Direct 

technical assistance supported state 

personnel after training. 

■	 Finding new ways of continuously 

assessing and responding to state 

needs. In addition to gathering input 

from the states about their technical 

assistance and training needs through 

written questionnaires and through 

insights provided by technical 

assistance staff, a new direct link to 

the field was established. A new 

training committee, composed of state 

staff members representing both 

management and operations, was 

established. The committee provided 

information for needs assessment 

purposes and recommendations for 

specific training content. When the 

ASSIST Multicultural Subcommittee 

was formed, the members’ ethnicspecific expertise was solicited in the 

development of all subsequent 

training activities. 

■	 Using a variety of trainers. 

Consultants in policy, media, and 

coalition development continued to be 

involved; however, peer-to-peer 

96 
M o n o g r a p h 1 6. A S S I S T 

training was given more prominence. 

Selected state staff members were 

invited to serve as training facilitators 

and share their experiences in 

implementing a range of interventions 

in worksites, schools, and community 

settings. Efforts were made to 

incorporate sessions on cultural 

diversity. 

During the implementation phase of 

the project (October 1993–September 

1999), the comprehensive intervention 

plans were critiqued and revised, and the 

annual action plans were critiqued, revised, and implemented. Funding levels 

were increased from a planning level of 

approximately $400,000 per year per 

state to more than $1,000,000 per year 

per state. 

During this phase, the principal technical assistance and training goals were 

to mobilize and build momentum for tobacco control; implement and refine 

strategies; and institutionalize tobacco 

control within health departments, voluntary agencies, and community-based 

organizations. 

Technical assistance was much in demand by the states during the implementation phase. Staff members in each state 

had regular access to their designated liaison at the ASSIST Coordinating Center and their assigned NCI project 

officer. These resources were responsible 

for assessing and responding to requests—either personally or by assigning the request to other ASSIST 

Coordinating Center content specialists 

or consultants. Technical assistance was 

provided in a variety of ways—via site 

visits, conference calls, and meetings 

during training events between state 

staff members and their assigned technical assistance specialist. The states and 

NCI noted that an advantage of having 

the ASSIST Coordinating Center deliver 

the technical assistance was that the center provided a collaborative environment 

in which the states could be frank about 

their needs. The ASSIST Coordinating 

Center was not responsible for the 

states’ funding and contractual obligations; thus, the requests and assistance 

relevant to programmatic issues could 

occur without concern about seeming 

weaknesses in the states’ programs. 

As the implementation phase approached late 1993, the training program 

began to incorporate opportunities for 

the states to share their experiences at 

information exchange conferences. 

Unlike the earlier training sessions in 

tobacco interventions, the new approach 

allowed for more networking and discussion breakout sessions facilitated primarily by conference participants. 

Many sessions presented a variety of 

case studies—state experiences that 

shared successes and lessons learned in 

implementing policy interventions and 

media advocacy. In addition to being 

well received by the ASSIST states, this 

change of training format also generated 

interest outside ASSIST and caught the 

attention of the California Tobacco Control Program. In May 1994, ASSIST and 

the California program sponsored a cooperative information exchange conference, followed by a conference in 

Massachusetts in June 1995. Their successes in sharing cutting-edge approaches to tobacco interventions led to the 

first of four annual national conferences 

97 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

beginning in May 1996, cosponsored by 

NCI, ACS, various other federal agencies and voluntary organizations, and 

national ethnic organizations that provided training. Bringing together all 

these players was challenging but gave 

impetus to an emerging national tobacco 

control movement that continues today. 

Process evaluation from these training 

events was very positive, and the 

ASSIST Coordinating Center staff and 

the Technical Assistance and Training 

Subcommittee closely reviewed the results. Modifications were made to future 

conferences and training sessions as 

seemed warranted by the feedback and 

by observations of field activities. As a 

result, vast improvement began to appear in the states’ annual action plans in 

addition to a difference in the strategies 

and activities that they implemented. 

Appendix 4.I describes the 17 training 

events offered during the implementation phase. 

Building Capabilities Back Home: 

The Site Trainers Network 

During the planning phase, the training workshops brought together all 17 

state health department project managers 

and all 17 ACS project managers. The 

centralized training reinforced a common approach to tobacco control and 

linked the states to one another for exchange of experiences. During the implementation phase, the training 

program addressed the need to build the 

skills of coalition members and staff 

members in the communities. A Site 

Trainers Network (STN) was created. 

The STN, basically a “train-the-trainers” 

network, provided the support that states 

needed to organize and implement their 

intrastate tobacco control advocacy 

trainings. Topic-specific modules and 

materials were developed. 

To build their cadre of in-state trainers, each state was expected to send two 

to four representatives to module training sponsored by the ASSIST Coordinating Center. Each training candidate 

had to make a commitment to teach the 

module in his or her home community 

for at least 1 year. Each state designated 

a training coordinator to plan and coordinate the intrastate training events and 

to lead the cadre of state trainers. 

Between 1994 and 1999, the following six STN modules were created and 

presented: 

■	 Policy Advocacy and Administrative 

Handbook, December 13, 1994, 

Washington, DC 

■	 Youth Advocacy, September 26–28, 

1995, Crystal City (Arlington), 

Virginia 

■	 Planning for Durability: Keeping the 

Vision Alive, October 20–21, 1996, 

Arlington, Virginia 

■	 Multicultural STN Workshop: From 

Sensitivity to Commitment, April 13– 

14, 1997, Washington, DC 

■	 Advanced Media Advocacy Module 

Workshop, April 18–19, 1998, Detroit, 

Michigan 

■	 Advanced Policy Advocacy Workshop, 

June 11–12, 1999, Bethesda, Maryland 

All modules incorporated the following five elements: 

1. Objectives, lesson plans, and optional 

teaching formats 

2. A variety of delivery techniques 

98 
M o n o g r a p h 1 6. A S S I S T 

3. Encouragement for states to develop 

short- and long-term training plan 

4. Options for 1- or 2-day delivery 

5. Flexibility for delivery based on a 

state’s needs 

Additional technical assistance systems were put into place after STN 

training was delivered. Quarterly teleconference calls were held from 1994 to 

1997 for the training coordinators as a 

vehicle for problem-sharing, networking, and support. One of the challenges 

that developed, particularly noticeable 

during 1997, was state staff turnover, 

which created a shortage of training 

coordinators. In response, technical assistance shifted to provide more one-onone assistance to health department staff 

members who had been assigned training responsibilities. In addition, some 

states developed their own training materials, often incorporating and adapting 

module components. 

How well did the STN program 

work? An evaluation of the project was 

undertaken in 1998. State training coordinators and project managers participated in a survey, which found that the 

project was valuable for its usability, 

flexibility, and utility. Even after the 

ASSIST project ended, the module materials continued to be used, and a few 

states had more formalized intrastate 

training programs than before the inception of the STN. For example, New York 

used the multicultural module not only 

within ASSIST, but also within its state 

office of minority health. NCI, Prospect 

Associates, and ASSIST’s Multicultural 

Committee received an award of appreciation from the New York City Intercultural Cancer Council in 1999. 

cultural, social, and religious norms of 

Coordinating Center felt that the site trainers 

subcommittee, editorial consultants, and 

multicultural issues. 

Commitment, comprised six distinct sections 

Assessment” and “Create a Culture” were 

Site Trainers Network Modules 

Each module was developed with the priority 

needs of the states at the forefront. For 

example, an ongoing state multicultural 

training mechanism was needed to help the 

states develop and implement interventions 

that would be responsive to the distinct 

diverse groups (e.g., ceremonial usage of 

tobacco in American Indian cultures). The 

Multicultural Subcommittee of the ASSIST 

network (STN) approach would be effective 

in establishing a common base of knowledge 

and sensitivity among health professionals 

and advocates in the ASSIST project. In early 

1997, a planning group was formed; it 

consisted of representatives of the 

ASSIST Coordinating Center staff 

knowledgeable in tobacco control and 

The completed module, From Sensitivity to 

with activities and exercises: developing 

awareness, community assessment, creating 

partnerships, building collaborations, 

developing leadership, and planning for 

action. The module was designed to be 

experiential rather than merely didactic. To 

internalize multicultural awareness, 

participants needed to experience issues and 

situations encountered by diverse ethnic 

groups. Exercises such as the “Iceberg Selfcore activities. By mid-1997, 67 new trainers 

in 15 states were ready to deliver the module. 

Willing and Ready 

Over the life of the ASSIST project, 17 national training workshops, information exchange conferences, and national tobacco control conferences were 

held for more than 6,600 participants. It 

is clear that the technical assistance and 

99 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

training provided over the years had a 

positive impact on the outcomes of the 

project. Over the life of the project, as 

the ASSIST model became more effectively implemented and as state staff became more skilled, the approach to 

technical assistance and training evolved 

to be responsive to the states’ needs in 

the following major ways. 

■	 From a relatively top-down, directed 

program to one that became more 

bottom-up, that is, more interactive 

with the participants in planning and 

delivery 

■	 From external experts to internal 

experience, relying less on consultants 

and more on information exchange 

and peer-to-peer learning experiences, 

which allowed for sharing of state 

experiences 

■	 From a predetermined plan to flexibility in responding to state needs as 

they developed, including needs for 

assistance in developing planning 

reports, intervention plans, media and 

policy advocacy skills, capabilities in 

addressing specific issues (e.g., youth 

access, cultural diversity); in coalition-building; and in planning for the 

future (program institutionalization) 

Case study materials 

The capacity and capability developed by the states, combined with the 

flexibility of the ASSIST Coordinating 

Center in delivering ongoing technical 

assistance and training, readied the coalitions to implement the media and policy interventions described in chapters 5 

and 6. 

100 
M o n o g r a p h 1 6. A S S I S T 

Appendix 4.A. Example of Membership in an ASSIST State Coalition: 

Rhode Island 

ASSIST Program Objective Area 

Community Community Health Work 

Coalition Member Environment Groups Care Schools Sites 

ACS, Rhode Island Division


American Fed. of State, County and


Municipal Employees
 x 

American Heart Assoc., Rhode Island


Affiliate


AMICA Mutual Life Insurance Co.


Blue Cross/Blue Shield of Rhode Island


x 

x 

x 

x 

City of Pawtucket


x 

Health Dept.


x 

Fleet Bank


Greater Providence Chamber of Commerce


x 

Healthy Mothers/Healthy Babies


Hospital Assoc. of Rhode Island


x 

x 

x 

Laboratory/Cancer Prevention Research


Consortium


Local 1199 of Service Employees Intl.–


New England Health Care Employees


Manufacturing Jewelers and Silversmiths


x 

x 

x 

x 

x 

National Educational Assoc. of Rhode Island


x 

x 

New Visions for Newport


x 

x 

x 

Opportunities Industrialization Ctr. of


x 

Pawtucket Heart Health Project


Planned Parenthood of Rhode Island


Portuguese-American Journal


Progresso Latino


x 

x 

x 

x 

Boys and Girls Clubs of Warwick


Boy Scouts of America, Narragansett Council


Brown University Program in Medicine
 x x 

Citizens Bank


Cumberland School Committee


Comm. Coll. of Rhode Island, Allied


Davol Inc.


Harvard Comm. Health Plan


Institute for Human Development


Kenny Manufacturing Co.


Kent County Occupational Health


Assoc.


Memorial Hospital of Rhode Island


Miriam Hospital Health Promotion Ctr.


Monam Hospital, Brown Program in Medicine


Narragansett Electric Co.


Newport Hospital


Newport School Committee


Occupational and Environmental Health


Ocean State Physicians Health Plan


Office of Substance Abuse


Rhode Island


Providence Ambulatory Health Care Fndtn.


Providence College


Providence Fire Dept.


Providence Journal Co.


x x x x x 

x x x x x 

x x x 

x x x 

x x 

x x x 

x x 

x x 

x x 

x x x 

x x x 

x x 

x x 

x x 

x x x x x 

x x 

x x 

x x 

101 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

Appendix 4.A (continued) 

ASSIST Program Objective Area 

Community Community Health Work 

Coalition Member Environment Groups Care Schools Sites 

Providence School Dept.
 x 

PHHP STOP Coordinator


x 

x 

Rhode Island Cancer Prevention Research


x 

x 

x 

x 

x 

x 

x 

x 

Rhode Island Assoc. of School Administrators


x 

Rhode Island Business Group on Health


x 

Rhode Island Council of Comm. Mental


x 

x 

x 

Rhode Island Hospital x


x 

x 

Rhode Island Lung Assoc. x


x 

Rhode Island School Health Assoc.


x 

Rhode Island Women’s Health Collective


Roger Williams Cancer Ctr. x


x 

Socio-Economic Development Ctr. for


x 

State Dept. of Elementary and Secondary Educ.


State Dept. of Health x


State Dept. of Human Services x


x 

x 

x 

x 

United Way of Southeastern New England x


x 

x 

x 

x 

x 

Women and Infants Hospital


Raytheon Co.


Rhode Island Anti-Drug Coalition


Consortium


Rhode Island Committee on Safety and Health


Rhode Island Hospitality Assoc. x


Rhode Island Human Rights Commission x


Rhode Island Interscholastic League


Rhode Island Middle Level Educators


Rhode Island Pharmaceutical Assoc. x


Rhode Island State Assoc. of Fire Fighters x


Rhode Island Thoracic Society


Rhode Island Black Ministerial Alliance


Rhode Island Chamber of Commerce Fed. x


Health Centers


Rhode Island Dental Assoc.


Rhode Island Health Ctr. Assoc.


Rhode Island Indian Council


Rhode Island League of Cities and Towns x


Rhode Island Medical Society


Rhode Island State Nurses Assoc.


Rhode Island AFL/CIO


Southeast Asians


St. Joseph Hospital

The Gathering


Tobacco Free Teens


United Black and Brown Fund


University of Rhode Island Self-Change


Urban League of Rhode Island


University of Rhode Island, Urban Field Ctr.


Warwick Veterans Memorial High School


Westerly Hospital


WCRD AM x


WPRO AM and FM x


x x 

x x 

x x 

x x x x 

x x 

x x 

x x 

x x 

x x x x 

x x 

x x 

x x 

Source: ASSIST Coordinating Center. 1992. ASSIST coalition profiles. Internal document, ASSIST Coordinating 

Center, Rockville, MD. 112–6. 

102 
M o n o g r a p h 1 6. A S S I S T 

Appendix 4.B. ASSIST Responsibility Matrix from Minnesota 

Name of Organizational Unit:


Primary Function of Organizational Unit:


TASKS PARTICIPANTS 

PD PM FD 

ACS 

PM 

Stwd. 

Coal 

Mbrs. 

Local 

Coal 

Mbrs. 

Unit 

Chr. 

Unit 

Mbrs.

Stwd. 

Exec 

Comm. 

C&A 

Comm. 

Develop operating guidelines/ 

parameters 

Develop work plan and schedule 

Recruit new members 

A 

C 

R 

R 

C R 

R 

R 

R R 

A A 

Plan/coordinate training of 

members 

Prepare meeting agendas— 

Local/State 

Chair Meetings 

Take meeting minutes and 

distribute 

Hire staff 

Staff committee 

A 

R 

A 

A 

R 

R 

C 

R 

C/I 

R 

C 

R 

A/R 

C/R 

C 

I 

I 

I 

I 

R 

R 

I 

C 

I 

I 

C 

R 

R 

DK 

Develop & maintain 

communication protocols 

Gather information for planning 

purposes 

Determine action priorities 

Develop contract reports/ 

deliverables (CTCP, APP) 

Develop public information 

reports 

Identify resource needs 

A 

A 

A 

A 

R 

R/C 

R 

C/A 

R 

R 

R 

R/C 

R 

R 

R 

R 

R/C 

R 

R 

R 

R/C 

R 

R/C 

R 

A 

A 

C 

C 

R/A 

A/I 

C 

Manage/allocate resources A R R A I 

Manage purchases/acquisitions/ A R C C 

subcontracts 

Maintain program records A R R R 

Participate on ECS I R R R I I I I 

Liaison with other networks/ R R R R 

programs 

Identify/recruit intermediaries R R R R R R 

Serve as spokesperson C C C R R R R 

Represent site on National 

Coordinating Committee 

R C I I I I 

Evaluate projects A R R R R A A 

Distribute funds A R C C C I A A 

A – Approve; R – Responsible; C – Consulted; I – Informed; DK—Don’t Know; NA—Blank 

103 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

Appendix 4.C. Wisconsin ASSIST’s Comprehensive Smoking Control 

Plan: Selected Channels 

Community Environment Channel 

Objective 1: By 1998, cues and messages supporting nonsmoking will have increased, 

and prosmoking cues and messages will have decreased. 

Strategies 

1. Build a corps of skilled advocates at state and local levels to promote, educate, and 

train volunteers and intermediaries on mass media opportunities for supporting 

policy initiatives and approaching media gatekeepers (1993–95) 

2. Generate media coverage surrounding tobacco policies to generate support for 

controls, reinforce nonsmoking norms, and increase individual understanding of the 

health hazards of smoking (1993–98) 

Objective 2: By 1998, ASSIST Wisconsin will substantially increase and strengthen 

public support for policies that mandate clean indoor air; restrict access to tobacco by 

minors; increase economic incentives and taxation to discourage the use of tobacco 

products; restrict the advertising and promotion of tobacco; and remove financial 

barriers to prevention, detection, and remediation of illnesses related to use of tobacco 

products. 

Strategies 

1. Educate and inform public authorities and the media through briefings, hearings, and 

epidemiologic data (1993–98) 

2. Develop a rapid communications system to offer a system of communications for 

and provide current information about tobacco control activities, research, resources, 

and policy opportunities and to alert tobacco control activists of new policy initiatives (1993–94) 

3. Inform the public and policymakers how public and private policies and strengthened 

policy enforcement can decrease tobacco promoters’ access to minors and can 

decrease the percentage of minors who smoke (1993–95) 

Worksite Channel 

Objective 1: By 1998, the proportion of worksites with a formal smoking policy that 

prohibits or severely restricts smoking at the workplace should increase to at least 75%. 

Objective 2: By 1998, worksites reaching priority populations will adopt and maintain a 

tobacco use cessation focus. 

(a) By 1998, all employers in Wisconsin, and especially health organizations, should 

have ongoing smoking cessation programs for their staff and clients. 

104 
M o n o g r a p h 1 6. A S S I S T 

(b) By 1998, all Wisconsin social service and education organizations should provide 

or provide access to or identify ongoing smoking cessation programs for their 

staff. 

Objective 3: By 1998, all public and private employees in Wisconsin will have the legal 

right to not be exposed to environmental tobacco smoke in their places of work. 

Source: Wisconsin Department of Health. 1992. Wisconsin comprehensive smoking control plan, 

10–3. Madison: Wisconsin Department of Health. 

105 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

Appendix 4.D. Wisconsin ASSIST’s 1993–94 Annual Action Plan: 

Selected Channels 

Community Environment Channel 

Annual Objective 1: Provide support—technical information and assistance in strategy 

development—upon request to all local ASSIST coalitions that are engaged in efforts 

involving local policies (clean indoor air, smoke-free restaurants and workplaces, 

tobacco promotion and distribution, and youth access issues). 

Annual Objective 2: Recruit and train at least 30 state and local coalition members to 

effectively represent smoking control issues within their constituencies, within their 

communities, before public policymakers, and in the media. 

Annual Objective 3: Develop an alert system to inform state and local coalition members 

of the latest developments in tobacco-control activities, research, resources, and policy 

opportunities and to motivate them to take action. 

The following state and local activities were designed to support objectives for fiscal 

year 1993–94. 

■	 Activity 1: Coordinate trainings for state and local coalition members in policy and 

media advocacy. 

■	 Activity 2: Support the development of state and local coalitions to work effectively 

in the community environment. 

■	 Activity 3: Distribute action alerts and other rapid communications on tobacco 

control initiatives to key state and regional coalition contacts. 

■	 Activity 4: Develop local coalition policy guidelines for initiatives to decrease youth 

access to tobacco products specific to current Wisconsin statutes. 

■	 Activity 5: Support key magnet events that facilitate statewide media attention on 

tobacco control efforts in local and state coalitions. 

■	 Activity 6: Identify important local, regional, and statewide conferences for key 

channels and/or priority groups, and integrate tobacco control issues into their 

agendas. 

■	 Activity 7: Develop a plan to increase the utilization of paid advertising and public 

service announcements that promote tobacco control in newspapers, and on billboards, television, and radio. 

■	 Activity 8: Promote media coverage of successful smoking control policy implementation in worksites, schools, and other community settings. 

■	 Activity 9: Develop, adapt, and disseminate research findings to provide a continuous stream of information about the health and economic impact of tobacco use in 

Wisconsin. 

106 
M o n o g r a p h 1 6. A S S I S T 

Worksite Channel 

Annual Objective 1: By October 1994, the proportion of worksites with a moderate smoking 

policy that includes restrictions of smoking in meeting rooms and other common areas 

should increase by at least 5%, and the proportion of companies with a strong smoking 

policy that protects the health of nonsmokers by prohibiting smoking or limiting 

smoking to separately ventilated “smoking lounges” should increase by at least 5%. 

Annual Objective 2: Provide resources to at least 500 employers to assist them in adopting 

smoke-free worksite policies, in disseminating smoking cessation materials to employees wishing to stop smoking, and/or in maintaining worksite-oriented prevention 

services (e.g., for young adults at risk for beginning smoking). 

Annual Objective 3: Develop and maintain a group of at least 30 individuals trained to 

serve as smoking control resources on worksite smoking issues. 

■	 Activity 1: Develop a worksite committee for the Tobacco-Free Wisconsin Coalition. 

■	 Activity 2: Adapt and provide smoking control policy models to present to business 

organizations. 

■	 Activity 3: Provide materials and outreach efforts that show workers how smoking, 

sidestream smoke, and use of smokeless tobacco affect their individual, co-worker, 

and family health and economic status. 

■	 Activity 4: Identify key regional and statewide conferences, and integrate tobacco 

control and prevention education into their agendas. 

■	 Activity 5: Coordinate up to four regional workshops to train a cadre of state and 

local coalition members, management and labor representatives, health educators, 

and other influential individuals who will provide models, information, presentations, materials, and training to local coalitions. 

■	 Activity 6: Provide smoking control policy workshops to representatives of business 

organizations and unions. 

Source: Wisconsin Department of Health. 1993. Wisconsin annual action plan. Madison: Wisconsin 

Department of Health. 

107 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

Appendix 4.E. Minnesota ASSIST’s Comprehensive Tobacco Control 

Plan: Community Environment Channel 

Objective 1: By 1998, increase the number of public places in Minnesota that will be 

tobacco free. 

Strategies 

■	 Educate property owners and managers, business owners, and the general public on 

environmental tobacco smoke hazards and policy issues. 

■	 Promote and enlist public support for tobacco-free environments. 

■	 Encourage public policymakers to take action by providing healthful, smoke-free 

environments. 

■	 Strengthen the Minnesota Clean Indoor Air Act by removing current exemptions. 

■	 Increase the enforcement of the Minnesota Clean Indoor Air Act. 

Source: Minnesota Department of Health. 1992. Minnesota comprehensive tobacco control plan. St. Paul: 

Minnesota Department of Health. 

108 
M o n o g r a p h 1 6. A S S I S T 

Appendix 4.F. Minnesota ASSIST’s 1993–94 Annual Action Plan: 

Community Environment Channel 

Objective: By September 1994, local coalitions will enact policies to reduce environmental tobacco smoke. 

■	 Activity 16: Involve chamber of commerce, restaurants and retail associations, 

private industry councils, similar business group associations, and community 

organizations to promote clean indoor air policies. 

■	 Task 1: Coalition staff and members will prepare and compile environmental 

tobacco smoke information, sample policies, and smoking cessation resources. 

(December 1993) 

■	 Task 2: Coalition staff and members will identify organizations interested in receiving 

smoke-free workplace materials and implementing policies. (January 1994) 

■	 Task 3: Coalition staff and members will conduct presentations and incorporate articles 

in appropriate organizational newsletters. (December 1993–September 1994) 

■	 Task 4: Coalition staff and members will provide ongoing technical assistance and 

resources to organizations in the community. (December 1993–September 1994) 

Source: Minnesota Department of Health. 1993. Annual action plan. St. Paul: Minnesota Department of 

Health. 

109 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

Appendix 4.G. Minnesota ASSIST’s 1998–99 Annual Action Plan: 

Community Environment Channel 

Objective 1: By September 1999, encourage rental property owners and housing developers to provide and promote smoke-free housing. 

Activities 

■	 Increase the awareness of landlords and housing developers of the economic and 

health benefits of providing smoke-free housing. 

■	 Provide information and consultation to property owners and housing developers 

interested in smoke-free housing. 

■	 Support these activities through media advocacy. 

Objective 2: By September 1999, increase awareness of the impact of secondhand 

smoke. 

Activities 

■	 Work with the Minnesota Department of Human Services and with foster care and 

daycare providers to increase their knowledge of the dangers of secondhand smoke 

to children, especially children with asthma or other chronic health conditions. 

■	 Increase awareness of secondhand smoke’s impact in vehicles. 

■	 Support these activities through media advocacy. 

Source: Minnesota Department of Health. 1998. Minnesota annual action plan. St. Paul: Minnesota 

Department of Health. 

110 
M o n o g r a p h 1 6. A S S I S T 

Appendix 4.H. Washington State ASSIST’ s Project Management 

Plan: Selected Components 

Management and Coalition Organization 

Overall Organization of Washington State ASSIST 

ASSIST in Washington is comanaged by the Washington State Department of Health 

(DOH) and ACS, Washington Division. DOH is responsible for the fiscal and administrative management of the project; all other project decisions are made jointly by DOH 

and ACS. The project managers from the DOH and ACS staff the state coalition and its 

committees. Four DOH field directors staff four local coalitions that participate in 

Washington State ASSIST. Washington State ASSIST is governed by an executive 

committee composed of three DOH representatives, three ACS representatives, one 

state coalition representative, and two ex officio members (one each from DOH and 

ACS). The executive committee reviews and approves all decisions related to ASSIST. 

The relationship of Washington State ASSIST to the Tobacco Free Washington Coalition is created through a written agreement between the ASSIST Executive Committee 

and the Tobacco Free Washington Coalition Steering Committee. This agreement sets 

forth the responsibilities of each organization in implementing ASSIST in Washington 

State. The agreement states that the coalition will incorporate the accomplishment of 

the ASSIST objectives into their goals. The Tobacco Free Washington Coalition created 

six task forces to coincide with the ASSIST channels. 

Monitoring Progress 

Fiscally, contractually, and programmatically, each annual objective of the state and 

local coalitions will be monitored by the ASSIST project manager at DOH and the local 

field directors, respectively, with input from the appropriate task force. Each task force 

at the state and local levels will monitor the progress of each annual objective that 

pertains to the associated channel by conducting progress meetings every month. 

Subcontractors of the various activities will be required to send a written report or 

attend these meetings to report on progress. If progress is not adequate, the task forces 

will make adjustments as necessary. Project managers and field directors will attend 

task force meetings to assess programmatic progress. Subcontracts will also be monitored by the respective project manager or field director. For objectives not requiring a 

subcontract, budgets will be monitored closely by the respective project manager or 

field director. The steering committee of the state coalition will monitor overall 

progress toward the accomplishment of the annual objectives. At least six steering 

committee meetings will be held per year to monitor overall statewide progress at both 

state and local levels. 

111 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

Communications between Staff, between ACS and DOH, 

and between State and Local Coalitions 

The primary mode of communication between the ASSIST project manager and the 

ASSIST field directors is the electronic communications system. DOH has its own 

system called DOHNet to which all ASSIST staff and the project manager are connected. In addition to the use of electronic mail, the staff members, including the ACS 

project manager, regularly communicate via conference calls. 

Project managers from the ACS and DOH communicate on a regular basis by phone. 

Regular meetings of the project managers are also held to plan for coalition meetings 

and to strategize coalition activities. The ASSIST project directors, project managers, 

and the DOH cancer program manager meet on a regular basis to discuss issues that 

affect the entire project. 

At least two members from each of the local coalitions attend all the full coalition 

meetings of the Tobacco Free Washington Coalition. Each of the local coalition presidents is a member of the state coalition’s steering committee and thus receives regular 

communications about the progress of the coalition and has input into setting the 

direction for the coalition. Periodically, the chairs of each task force from each of the 

coalitions (state and local) hold a conference call to discuss strategies within their 

channels. These conference calls facilitate continuity and collaboration among coalitions at the state and local levels. 

Technical Assistance and Training 

The ASSIST project manager attends the national ASSIST trainings and periodically 

attends other tobacco-related conferences and workshops to increase knowledge and 

skills needed to perform the duties of the position. The ASSIST field directors receive 

quarterly trainings from the project manager, the cancer control manager, and the 

project director on the topic of the most previous national training and on other topics 

identified by the field directors as a training need. Selected coalition members have 

been and will continue to attend ASSIST national trainings when they relate to the 

members’ respective task force. The Tobacco Free Washington Coalition membership 

will be surveyed annually to assess the training needs of coalition members. 

The ASSIST project manager will assess the technical assistance needs of the field 

directors with input by the field directors through individual conferences. Coalition 

members will regularly assess their own technical assistance needs at the task force 

level. 

Source: Washington State Department of Health. 1993. Washington ASSIST project management plan: 

October 1, 1993–September 30, 1998. Olympia: Washington State Department of Health. 

112 
M o n o g r a p h 1 6. A S S I S T 

Appendix 4.I. Training Events of the Implementation Phase


No.


Date Place Participants Training Content


Training Workshop: “Media Advocacy: A Strategic Tool for Change” 

Mar. 1993 Washington, DC 180 ■	 Developing a working understanding of media 

advocacy ■	 Building effective volunteer and staff teams 

■	 Fiscal and resource allocation requirements 

■	 Lessons learned—Uptown Coalition Campaign 

■	 Developing the project management plan 

■	 Model policies and their appropriateness 

■	 Using the electronic communications system to 

support media advocacy 

Training Workshop: “From Phase One to Page One: Refining Our Media Skills” 

July 1993 Washington, DC 180 ■	 The changing perspective of prevention—how 

media advocacy supports policy change ■	 “Piggybacking” the electronic communications 

system’s local media advocacy activities ■	 National stories: creating media advocacy 

opportunities ■	 Developing and defining media skills for 

advocacy purposes ■	 Training spokespersons 

■	 Accessing multicultural media channels 

■	 “Pitching” local stories-skills session 

■	 Translating science into media language 

■	 Working together in partnership: ACS and state 

departments of health 

Oct. 1993 162 ■ 

■ Sharing information and resources 

■ 

Information Exchange Conference: “Youth Access” 

Washington, DC Forum for sites to discuss ASSIST issues 

Learning from experiences of allied organizations and individuals 

Training Workshop: “Implementing Policy Advocacy: Steps to Success—Part One” 

Dec. 1993 Washington, DC 160 ■	 Utilizing direct and indirect advocacy methods 

to achieve tobacco control ■	 Identifying tools needed to support the following policy areas 

– Clean indoor air 

– Youth access 

– Advertising and promotion ■	 Building coalition capacity 

■	 Applying planning skills to achieve policy 

objectives 

113 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

Appendix 4.I (continued) 

No. 

Date Place Participants Training Content 

Training Workshop: “Implementing Policy Advocacy: Steps to Success—Part Two” 

Mar. 1994 Washington, DC 162 ■	 Improving the process for developing annual action plans 

■	 Increasing sites’ knowledge and skills needed 

for planning pertaining to policy issues on clean 

indoor air and economic disincentives 

■	 Identifying tools available to sites in the areas of 

clean indoor air and economic disincentives and 

increasing sites’ understanding of how to use these 

tools 

■	 Building coalition capacity for conducting advocacy activities related to clean indoor air and 

economic disincentives 

294 ■ 

■ 

studies and other resources to increase their 

■ 

co control, using case studies and other methods 

■ 

periences, using case studies and other resources 

Dec. 1994 224 ■ 

■ 

bacco control 

June 1995 Boston, MA 616 ■ 

■ 

■ 

■ 

■ 

the tobacco industry 

■ 

■ 

Information Exchange Conference: “Breaking the Grip of Tobacco—State by State” 

May 1994 San Francisco, CA Providing a forum for the 17 ASSIST sites to 

discuss issues specific to their work 

Providing an opportunity for sites to use case 

knowledge and helping them meet their ASSIST 

objectives 

Learning from California’s experience in tobacLearning about international tobacco control exInformation Exchange Conference: “Building Diverse Community Involvement” 

Washington, DC Exploring strategies to increase involvement of 

ethnic and nontraditional groups in ASSIST 

Increasing coalition-building skills to support toInformation Exchange Conference: “Tobacco Prevention: The Next Generation” 

Providing a forum for collaboration among participating organizations 

Strengthening participants’ ability to develop 

and implement comprehensive youth and secondhand smoke policy initiatives 

Expanding resource networks among participants 

Providing resource tools for use “back home” 

Providing proactive strategies for dealing with 

Sharing Massachusetts’s and participating organizations’ programs and interventions 

Providing information on national tobacco prevention efforts 

114 
M o n o g r a p h 1 6. A S S I S T 

No. 

Date Place Participants	 Training Content 

Oct. 1995 197 ■ Identifying methods for durability and institutionalization 

■ 

coalitions 

■ 

Information Exchange Conference: “Tobacco Prevention: Connecting for the Future” 

Washington, DC 

Enhancing skills for effectively working with 

Learning from the experiences of women’s and 

other organizations to build allegiances to develop a sustainable tobacco prevention movement 

National Tobacco Control Conference:


“Communities for Tobacco-Free Kids: Drawing the Line”


May 1996 Chicago, IL 712 ■	 Providing a forum for the sharing of information 

and tobacco prevention and control methods 

among conference participants 

Oct. 1996 228 ■ 

tems for durability to prepare for project transition 

■ 

230 ■ 

■ 

issues in tobacco control 

■ 

strengthen federal, state, and local partnerships 

Information Exchange Conference: 

“Building Momentum for Tobacco Prevention: Planning for the Future” 

Arlington, VA Identifying, exploring, and starting to build sysSharing strategies for building and maintaining 

strong partnerships between ASSIST partners 

and allied organizations on state and local levels 

Information Exchange Conference: “Step by Step: Advancing Toward a Tobacco-Free Nation” 

Apr. 1997 Washington, DC Providing a forum for the exchange of 

information among ASSIST sites 

Providing learning opportunities on emerging 

Providing opportunities to develop and 

National Tobacco Control Conference:


“A National Conference on Tobacco and Health: Entering a New Dimension”


Sept. 1997 Houston, TX 736 ■	 Providing a collaborative forum for conference 

participants to strengthen partnerships and to 

share strategies, technology resources, and information to advance and mobilize communities to 

reduce tobacco use. Program objectives include 

the following: 

– To provide current and accurate information 

on tobacco issues 

– To showcase program outcomes 

– To foster communication and collaboration 

across various programs and organizations 

– To provide sessions designed to increase in-depth 

knowledge and skill-building opportunities. 

115 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

Appendix 4.I (continued) 

No. 

Date Place Participants Training Content 

Detroit, MI 246 ■ 

gies, resources, and information to further reedge and skills 

project 

Information Exchange Conference: 

“Affirming Our Commitment to Tobacco-Free Communities” 

Apr. 1998 Providing a collaborative forum for conference 

participants to develop skills and to share strateduce tobacco use. Program objectives include 

the following: 

– To provide opportunities to increase knowl­

– To provide current information on national 

and international tobacco control efforts 

– To acknowledge the success of the ASSIST 

– To reaffirm the commitment to tobacco control to prepare for a new era 

National Conference on Tobacco and Health:


“No More Lies—Truth and the Consequences for Tobacco”


Oct. 1998 St. Paul, MN 972 ■ Providing a collaborative forum to strengthen 

partnerships and share strategies, technology resources, and information to advance and mobilize communities to reduce tobacco use. 

Program objectives include the following: 

– To provide current and accurate information 

on tobacco control issues 

– To showcase program outcomes and best practices 

– To foster communication and collaboration 

across various programs, communities, and 

cultural groups 

– To provide sessions to increase in-depth 

knowledge and develop and enhance skillbuilding opportunities to prepare for new and 

emerging challenges 

Bethesda, MD 231 ■ 

Information Exchange Conference: “ASSIST Success: A Foundation for the Future” 

Mar. 1999 Providing a collaborative forum for the conference participants to develop skills; to share strategies, resources, and information to further 

reduce tobacco use; and to acknowledge the success of the ASSIST project. 

116 
M o n o g r a p h 1 6. A S S I S T 

No.


Date Place Participants Training Content


National Conference on Tobacco and Health: “Tobacco-Free Future: Shining the Light” 

Aug. 1999 Orlando, FL 1,040 ■	 Providing current and accurate information on tobacco control issues 

■	 Showcasing program outcomes and best practices 

■	 Fostering communication and collaboration across 

various programs, communities, and cultural groups 

■	 Providing sessions to increase in-depth knowledge 

and develop and enhance skill-building opportunities to prepare for new and emerging challenges 

Note: Shading indicates training events that were information exchange conferences. 

117 
4. B u i l d i n g N a t i o n a l, S t a t e, a n d L o c a l C a p a c i t y a n d C a p a b i l i t y 

References 

1. Butterfoss, F. D., R. M. Goodman, and 

A. Wandersman. 1993. Community 

coalitions for prevention and health 

promotion. Health Education Research 

83:315–30. 

2. Kaye, G., and T. Wolff, eds. 1997. From 

the ground up: A workbook on coalition 

building and community development. 

2nd ed. Amherst: Univ. of Massachusetts, AHEC/Community Partners. 

3. ASSIST Coordinating Center. 1991.


ASSIST program guidelines for


tobacco-free communities. Internal


document, ASSIST Coordinating


Center, Rockville, MD.


4. VC&A. 1995. ASSIST coalition 

assessment pilot project: Final report. 

Internal document, VC&A, Poolesville, 

MD. 

5. Sofaer, S. 1992. Summary of


preliminary results of assessment of


coalition training needs. Internal


document, ASSIST Coordinating 

Center, Rockville, MD. 

6. Colorado Department of Health. 1999. 

Final report. Colorado ASSIST Project. 

Denver: Colorado Department of 

Health. 

7. Minnesota Department of Health. 1999. 

Quarterly report. Fourth quarter, year 

eight, phase II: Final report. Minneapolis: Minnesota Department of Health. 

8. Rhode Island Department of Health. 

1999. Final report. Providence: Rhode 

Island Department of Health. 

9. Washington State Department of Health. 

1999. Final report. ASSIST quarterly 

report content for fourth quarter. 

Olympia: Washington State Department 

of Health. 

10. Manley, M., W. Lynn, R. P. Epps, D. 

Grande, T. Glynn, and D. Shopland. 

1997. The American Stop Smoking 

Intervention Study for Cancer 

Prevention: An overview. Tobacco 

Control 6, Suppl. no. 2: S5–S11. 

118 
M o n o g r a p h 1 6. A S S I S T 

5. Media Interventions to Promote

Tobacco Control Policies 

Patrick L. Remington, C. Ann Houston, and Lynn C. Cook 

Contributors: Germaine Dennaker, Brenda Grant, Carol Hall-Walker, 

Thomas J. Kean, Johnny Kincaid, Helen Matheny, Sally Herndon Malek, 

Dianne May, Anne Marie O’Keefe, Harriet Robbins, Margaret Thomas, 

and Marge White 

Contents 

The Power of the Media ............................................................................................. 121


Preparing for Media Interventions ............................................................................. 122


System Prerequisites ......................................................................................................... 123


Media Relations ................................................................................................................ 125


Training Spokespersons ..................................................................................................... 126


Media Strategies and Tactics .................................................................................... 127


Media Advocacy ................................................................................................................. 127


Planning for Media Advocacy ..................................................................................... 129


Training for Media Advocacy ...................................................................................... 130


Acting Locally: The ASSIST Media Network ................................................................. 132


National Backup for Media Advocacy ......................................................................... 133


News Coverage of Tobacco Issues ..................................................................................... 135


Special Events ........................................................................................................... 140


Tobacco News ............................................................................................................. 142


Research Results ....................................................................................................... 142


Mass Media and Countermarketing Campaigns ................................................................ 142


“Let’s Make Smoking History” .................................................................................... 147


Campaigns in ASSIST States ...................................................................................... 149


Monitoring Newspaper Coverage ............................................................................... 149


Newspaper Clippings Database ........................................................................................ 149


Reports to the States on Their Newspaper Coverage ......................................................... 151


From Media to Policy Change .................................................................................... 152


References ................................................................................................................ 164


119 
5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

Case Studies 

Case Study 5.1. Tobacco State Turns Opinion Around ............................................................ 134


Case Study 5.6. The Tobacco Master Settlement Agreement—A National Event


Case Study 5.8. ASSIST–Wisconsin State Medical Society Partnership for Publishing


Case Study 5.9. Todo a Pulmón (“With Full Breath”): A Rhode Island Radio Campaign


Case Study 5.2. Strengthening Youth Access to Tobacco Laws: North Carolina ...................... 136


Case Study 5.3. The Media Network of the Tobacco-Free Michigan Action Coalition .............. 137


Case Study 5.4. Winston Additive-Free Media Advocacy Campaign ....................................... 138


Case Study 5.5. Charleston, West Virginia, Bids So Long to the Marlboro Man ...................... 143


Covered Locally ...................................................................................................................... 144


Case Study 5.7. The Indiana Countercampaign—A Local Event Covered Nationally ............. 144


Tobacco Research .................................................................................................................. 145


for Hispanic Youths ................................................................................................................ 150


Tables and Figures 

Table 5.1. Number of Newspaper Editorials in North Carolina, 1993–98 ............................... 135


Figure 5.1. Number of Policy-Related Tobacco Articles: Michigan October 1, 1993,


Figure 5.2. Percentage of Articles by Policy Type


Table 5.2. Media Analysis Quarterly Report for Michigan: October 1, 1993,


to March 31, 1994 ................................................................................................................. 153


Michigan, January 1 to March 31, 1994 ................................................................................. 153


to March 31, 1994 ................................................................................................................. 154


Appendix 

Appendix 5.A. ASSIST Bibliography ........................................................................................ 155


120 
M o n o g r a p h 1 6. A S S I S T 

5. Media Interventions to Promote Tobacco Control Policies 

The overall strategy of the American Stop Smoking Intervention Study (ASSIST) 

was to reduce the prevalence and effects of tobacco use by promoting a tobacco-free 

social norm and environment. State health departments, voluntary health agencies, 

and other partners came together in coalitions to advocate for state and local 

tobacco prevention and control policies, such as cigarette excise tax increases, 

restrictions on tobacco advertising and promotion, youth access laws, and clean 

indoor air ordinances. Getting these policies accepted and enacted required a broad 

base of support from the public and from policymakers. This chapter describes a 

strategic approach to using a variety of media interventions to promote public health 

policies and illustrates how media advocacy was used in ASSIST to promote policies 

for a tobacco-free environment. In particular, a principal strategy was to leverage 

earned media coverage to advance policy issues. The strategies described in this 

chapter are especially relevant to states and communities with small mass media 

budgets. Several case studies are presented to illustrate the processes and 

effectiveness of the interventions. While ASSIST’s comprehensive approach used 

several types of media interventions, it was the strategic application of the 

interventions to effect policy change that made them powerful and that distinguished 

ASSIST in the tobacco control movement. 

The Power of the Media 

T

he power of the media is widely acknowledged. Broadcast media—television and 

radio—reach nearly every person in this country at home and at work. Print media— 

newspapers and magazines—also have a wide reach, especially among adults, decision 

makers, and highly educated individuals. The Internet is an electronic medium of mass 

communication rapidly increasing in reach worldwide. The tobacco industry gives testimony to the influence and reach of the media by the billions of dollars that this industry 

has invested in advertising campaigns to promote tobacco use, specific brands, and protobacco social norms. At the end of the 1980s, U.S. cigarette manufacturers were 

spending almost $4 billion annually on advertising and promotion; in 2002, the six largest cigarette manufacturers spent $12.5 billion, an 11% increase from 2001, while the 

total number of cigarettes sold or given away decreased by nearly 4% from the previous year.1

 In 1998, the tobacco industry spent $40 million on a television advertising 

campaign to defeat the proposed McCain bill to control tobacco products.2(p223) This bill 

would have given the Food and Drug Administration authority to regulate the sale, 

manufacturing, labeling, and marketing of tobacco products and to use a tobacco tax to 

fund antismoking campaigns, research, and health-related activities. 

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5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

Billboard featuring R. J. Reynolds, a private citizen, of 

Washington State 

Decades of advertisements positioned 

cigarette images, such as the Marlboro 

Man, as central figures in American 

life and promoted the perception of 

smoking as an acceptable, even desirable, social behavior, associated with 

healthy, vibrant lifestyles. A study of 

formerly confidential tobacco industry 

documents has revealed that the industry, despite voluntary restrictions on 

such practices, continues to use the power of film to promote social acceptability 

of tobacco use, particularly among 

young people.3 In addition, the tobacco 

industry was able to influence the kind 

and amount of coverage of tobacco and 

health issues in other types of media because they depended on the substantial 

revenue from tobacco advertising.4,5 

At the time that ASSIST started, research had begun to establish the effectiveness of mass media interventions in 

influencing health behaviors, including 

tobacco use.6–8 (Also see chapter 1.) 

Tobacco control activities had used 

media interventions to accomplish two 

objectives: 

1. To increase the public’s exposure 

to prohealth, antitobacco 

messages 

2. To limit the public’s exposure to 

protobacco messages 

Media coverage of the tobacco 

and health issue was credited with 

improving public awareness of the 

health hazards of smoking, with 

changing attitudes about smoking, 

and with contributing to declines in 

the prevalence of smoking in the general 

population.7 For tobacco control programs, five specific functions of mass 

media interventions had been identified. 

Mass media interventions 

1. provided information to the public 

about health facts and issues related to 

tobacco use, 

2. alerted citizens and policymakers to 

injurious public policies that 

promoted tobacco use, 

3. motivated people to stop or to refrain 

from initiating tobacco use, 

4. recruited smokers into treatment 

programs, and 

5. offered smoking cessation advice and 

programs.9 

ASSIST contributed to the state of the 

art an important sixth function: the strategic use of the media on a large scale to 

advocate for tobacco prevention and 

control policies. 

Preparing for Media 

Interventions 

Effective use of media interventions is critical to advocacy efforts. The media can reach large numbers of people 

122 
M o n o g r a p h 1 6. A S S I S T 

ASSIST-produced video, Up in Smoke: The Transformation of America’s Billboards 

with persuasive messages and can play a 

powerful role in establishing the legitimacy of tobacco prevention and control 

interventions. Conversely, if criticisms in 

the media of tobacco prevention and 

control efforts are not skillfully countered, these criticisms can drastically undermine support among the public and 

key decision makers. The tobacco industry has been very effective in using the 

media to sell its products and to undermine the major messages of the tobacco 

prevention and control movement.10,11 

Early in ASSIST, it became apparent that 

there was a need to quickly build the capabilities of ASSIST partners at the national, state, and local levels not only to 

implement media interventions, but also 

to react effectively to media coverage 

and advocacy opportunities. 

System Prerequisites 

For ASSIST to conduct media interventions successfully, three elements 

had to be in place: 

1. An infrastructure of organizational 

units clearly responsible for the 

interventions 

2. A system of communication 

throughout the infrastructure that 

would enable timely implementation 

of media interventions 

3. Technical assistance to equip ASSIST 

personnel and coalition volunteers 

with needed skills and to provide 

them continued support in planning 

and implementing media interventions 

These three elements were developed 

and established during ASSIST’s 2-year 

planning phase. Each ASSIST state was 

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5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

service to a paid campaign. If a media channel or personality becomes interested in the topic, 

■ 

■ 

■ 

■ 

■ 

In 

Tips on Media Relations from Virginia ASSIST 

The media can bring many resources to a small campaign and can cause it to become prominent in the 

community. The media can offer public service time or space to a project or can give value-added 

additional coverage may be provided in the form of news features or commentary. In planning for 

media relations, consider the following strategies: 

Make the best connection. When looking for a contact at a media channel, first review the staff 

structure. The easiest person to approach is a public service director, but he or she may not be the 

best contact for your purposes. Think strategically. Determine who would be the most valuable 

connection, and approach that person directly, whether it be the editor of a publication, a public 

service director, a journalist, an account executive (for paid campaigns) who can assist with added 

value, a radio personality, a television anchor or reporter, or a community relations director. 

Explore existing connections. Look at existing relationships with organizations, and identify their 

media connections. Get these organizations involved in an activity, and let them reach the media. 

Show the media channel how the media will benefit. Find a way to link your message to something 

that the channel values. For example, look at the channel’s past community relations efforts, staff 

make-up, or editorial policy statement to find common ground. 

Get a commitment from the media channel. Getting a commitment from the newspaper or the radio 

or television station, not just from an individual, is critical. For example, after the second year of 

Virginia’s Sack the Pack campaign, the sportscaster left the station’s employment. Although many 

of the station’s staff members were involved in the campaign, the station had not committed itself 

to the project. The station’s lack of commitment meant that the coalition had to approach the new 

sports anchor and the station director to regain involvement. 

Get media buy-in. Media channels that “buy in” to a project will focus on it to ensure its success. 

They can offer valuable public service time and space, known personalities who will commit 

themselves to the cause, and matching funds for project materials. 

Source: Adapted from M. White. 1998. Institutionalizing tobacco use control into the media’s agenda. 

No more lies: Truth and the consequences for tobacco (Case Studies of the Fourth Annual National 

Conference on Tobacco and Health, October 26–28, 1998). Rockville, MD: ASSIST Coordinating 

Center. 

required to include a staff position dedicated to media interventions by the end 

of the planning phase. This requirement 

emphasized the critical importance of 

media activities to the success of 

ASSIST interventions. By mid-1993, the 

17 states were ready to implement media 

intervention strategies described in their 

annual action plans. (These are described in chapters 3 and 4.) 

Nevertheless, while the advantages of 

using mass media interventions were 

clear, the states faced a major challenge— 

the high cost of paid mass media—at the 

outset and throughout the project. Recognizing that purchasing only a few media spots could exhaust a state’s budget, 

ASSIST contracts limited the use of 

funds to purchase mass media to no 

more than 15% of the states’ total budgets. In practice, the states spent even 

less than the amount allowed. The 

ASSIST guidelines directed the states to 

use media advocacy techniques to generate “earned” media coverage of tobacco 

and health issues, that is, coverage that 

is not purchased but is achieved through 

124 
M o n o g r a p h 1 6. A S S I S T 

■ 

which require simple, short, and straightpublic. ■ 

partners at the national, state, and local 

■ 

time to prepare. If there is no response 

■ 

ground. ■ Stay focused. 

media-related distractions during the 

Success Factors behind 

ASSIST’s Effective Communications 

Over the course of the project, several key 

success factors emerged concerning 

effectively engaging the media. 

Develop hard-hitting, clear messages to 

explain ASSIST. ASSIST was a complex 

project, difficult to describe for the media, 

forward messages, readily grasped by the 

Identify and prepare all spokespersons to 

deliver the same messages. The 17 ASSIST 

states had numerous coalitions with many 

levels, and all spokespersons had to 

describe the project in a consistent way. 

Be ready to respond to the media quickly 

when asked. The media require a response 

on a very short deadline with virtually no 

within a single news cycle, the 

opportunity is very likely lost. Being 

ready and effective requires having a 

strategic communication plan in place. 

Be ready to counter tobacco industry 

arguments. ASSIST staff members, aware 

that the tobacco industry would oppose 

their efforts, were trained to stand their 

ASSIST staff members and 

partners were confronted with many 

project. When crises arose, they 

responded quickly to the issues raised, but 

they also knew how to determine which 

issues would advance their goals and 

which would deter them. 

the strategic efforts of advocates.12 

Thus, media advocacy became the principal media intervention. 

Media Relations 

Before implementing any media interventions, ASSIST staff had to underQuestion: 

Answer: 

starting. 

Question: 

Answer: 

run through their kitchens, whether or not 

them well enough to dramatically reduce the 

potential health and safety risks. 

Answer Quickly, and 

Get Back to Your Point 

Won’t increasing the price of 

tobacco products drive people out of state and 

hurt our convenience stores and gas stations? 

There’s a good reason tobacco 

companies make this argument: They know 

that raising prices prevents children 7, 8, and 

9 years old from smoking. The industry fights 

price increases across the board because they 

know that higher prices will encourage 

smokers to quit and will discourage kids from 

Restaurants are private businesses. 

Shouldn’t the government stay out and let 

these private business people accommodate 

customers as they see fit? 

We wouldn’t dream of letting these 

private businesses determine how many rats 

they should have sneeze guards over the salad 

bar, or whether they can serve meat that has 

been sitting on the counter for 2 days. These 

businesses thrive only because the public has 

confidence that the government has regulated 

Source: ASSIST Coordinating Center. 1998. 

Advanced media advocacy module trainer’s 

manual. Training manual, ASSIST 

Coordinating Center, Rockville, MD. 

stand the importance of cultivating positive relationships with members of the 

media. To succeed in dealing with the 

media, individuals had to establish their 

credibility and the credibility of the 

project with media gatekeepers. Advocates had to be trusted as sources of 

truthful and useful information, and they 

had to be known as reliable and responsive contacts for the media. To begin 

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5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

©1997, 

Collage of headlines from 

January 22, 1997. Reprinted with permission. 

proaches: 

■ 

community—who reports on the 

whole story or certain parts of the 

story? 

■ 

interested in the issue for later contact. 

■ Build relationships with those 

information about tobacco issues or 

when the tobacco industry challenges 

some aspect of the program or opposes a 

public requires preparation, coaching, 

pared to speak to their media contacts. 

been trained to function in highly 

The Washington Post. Reprinted with permission. 

The Charlotte Observer, 

establishing media relations, ASSIST 

personnel were taught the following apWatch how the media work in the 

tobacco issue, and how frequently? 

How do the media cover it—the 

Develop a list of media professionals 

professionals by providing useful 

by commenting on stories that they 

have already done. 

policy intervention. When the momentum builds around tobacco news and 

events, the right individual, or spokesperson, must be available to keep decision makers and the public clear about 

the real issue at hand. Speaking effectively to members of the media or to the 

and practice. While celebrities or content experts, such as the former 

tobacco industry researcher Victor DeNoble or the president of a local oncology 

medical society, are often desired spokespersons, ASSIST staff also had to be prePeople in the tobacco control movement generally have backgrounds in the 

health professions and may not have 

charged or adversarial circumstances. 

Therefore, spokesperson training workshops were provided to ASSIST staff 

members. Participants in the training 

workshops were taught skills around 

four techniques to use for an interview 

with a representative of the media: 

1. Establish rapport and a conversational 

approach in the interview; this 

■ Be proactive about 

making media contacts. 

The media need timely, 

relevant, newsworthy 

ideas as much as 

advocates need the 

coverage. 

Training Spokespersons 

Tobacco control can be 

adversarial, most notably 

126 
M o n o g r a p h 1 6. A S S I S T 

technique will enable the spokesperson to bring up important 

information that might not be asked 

for in a question-and-answer format. 

2. Find out as much as possible about 

the story beforehand, and provide the 

interviewer with materials on the 

topic for use as background 

information. 

3. Develop three or four key messages 

relevant to the topic. Stay on track by 

returning quickly and authoritatively 

to the key messages when tobacco 

industry spokespersons or reporters 

frame the debate away from the policy 

issues. 

4. Suggest visuals for television 

appearances. Provide photo 

opportunities. 

Media Strategies and Tactics 

Media Advocacy 

“Media advocacy is the strategic use 

of mass media as a resource for advancing 

a social or public policy initiative.”13(p8) 

Media advocacy stimulates community 

involvement in defining policy initiatives that influence the social environment in which individuals make 

choices—for example, choices about tobacco use. Media advocates react to unexpected events and breaking news and 

create events to draw media attention 

and coverage to an issue.14 When traditional media relations and interventions—for example, publicizing special 

events, marking health observances, and 

publicizing research results—are used 

strategically, not just informatively, they 

are tactics in the approach of media advocacy. In all the ASSIST states, ASSIST 

staff and volunteers were trained to use 

all media interventions in ways that 

were strategic and community based. In 

this way, ASSIST advanced the state of 

the art in media advocacy for tobacco 

control. 

Media advocates must know the relevant policy issues, know how to frame 

an issue for public debate, and know 

how the media function—what types of 

stories are deemed newsworthy, how editors decide what stories get covered, 

and what deadlines and logistic issues 

might influence coverage. Therefore, 

ASSIST conducted media advocacy 

training to impart knowledge and skills 

to advocates and to encourage and empower their involvement in tobacco control. A communication network among 

advocates for sharing information on local and national activities helped ASSIST 

advocates implement media advocacy 

efforts. Newsletters, listservs, and 

Dorfman, and I. Diaz. 1999. 

the media. Thousand Oaks, CA: Sage 

Publications (p. ix). 

A Definition of Media Advocacy 

“Strategic media approaches can help 

deliver the visibility necessary to 

enhance power in this media-driven age. 

Media advocacy is one such strategy: It 

is the strategic use of news media and, 

when appropriate, paid advertising, to 

support community organizing to 

advance a public policy initiative. It 

gives visibility to and ‘certifies’ the 

existence of those demanding change. It 

adds an exclamation point to the 

demand.” 

Source: Wallack, L., K. Woodruff, L. 

News for a 

change: An advocate’s guide to working with 

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5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

Looking Outward 

Message: 

Messengers: 

in a winning mix. 

Looking Inward 

Strategy Development: Nine Key Questions to Consider 

in the Development of an Advocacy Strategy 

Objectives: What do you want? 

Any advocacy effort must begin with a sense of its goals. Among these goals some distinctions are 

important. What are the long-term goals and what are the short-term goals? What are the content goals 

(e.g., policy change) and what are the process goals (e.g., building community among participants)? 

These goals need to be defined at the start, in a way that can launch an effort, draw people to it, and 

sustain it over time. 

Audiences: Who can give it to you? 

Who are the people and institutions you need to move? This includes those who have the actual formal 

authority to deliver the goods (i.e., legislators). This also includes those who have the capacity to 

influence those with formal authority (i.e., the media and key constituencies, both allied and opposed). 

In both cases, an effective advocacy effort requires a clear sense of who these audiences are and what 

access or pressure points are available to move them. 

What do they need to hear? 

Reaching these different audiences requires crafting and framing a set of messages that will be 

persuasive. Although these messages must always be rooted in the same basic truth, they also need to 

be tailored differently to different audiences depending on what they are ready to hear. In most cases, 

advocacy messages will have two basic components: an appeal to what is right and an appeal to the 

audience’s self-interest. 

Whom do they need to hear it from? 

The same message has a very different impact depending on who communicates it. Who are the most 

credible messengers for different audiences? In some cases, these messengers are “experts” whose 

credibility is largely technical. In other cases, we need to engage the “authentic voices” who can speak 

from personal experience. What do we need to do to equip these messengers, both in terms of 

information and to increase their comfort level as advocates? 

Delivery: How can we get them to hear it? 

There is a wide continuum of ways to deliver an advocacy message. These range from the genteel 

(e.g., lobbying) to the in-your-face (e.g., direct action). Which means is most effective varies from 

situation to situation. The key is to evaluate them and apply them appropriately, weaving them together 

Resources: What have we got? 

An effective advocacy effort takes careful stock of the advocacy resources that are already there to be 

built on. This includes past advocacy work that is related, alliances already in place, staff and other 

people’s capacity, information and political intelligence. In short, you don’t start from scratch, you 

start from building on what you’ve got. 

128 
M o n o g r a p h 1 6. A S S I S T 

computer newsgroups supported timely 

communication and creativity among the 

national, state, and local advocates. 

When ASSIST became an object of 

scrutiny in hearings of the House Committee on Appropriations Subcommittee 

on Labor, Health and Human Services, 

Education, and Related Agencies, funding for ASSIST was threatened. Tobacco 

control advocates mounted an intensive 

media advocacy effort about ASSIST 

with a reporter from the Washington 

Post. This effort paid off in a front-page 

Post story on April 19, 1997, by J. 

Mintz, with the lead sentence, “Finally, 

a federal program that works.” 

Planning for Media Advocacy 

Planning for media advocacy typically occurs in two stages: the broad, strategic stage of preparing for readiness and 

the focused, tactical stage of responding 

Gaps: 

Shultz, J. 1995. 

What do we need to develop? 

After taking stock of the advocacy resources you have, the next step is to identify the advocacy 

resources you need that aren’t there yet. This means looking at alliances that need to be built and 

capacities such as outreach, media, and research, which are crucial to any effort. 

First efforts: How do we begin? 

What would be an effective way to begin to move the strategy forward? What are some potential shortterm goals or projects that would bring the right people together, symbolize the larger work ahead and 

create something achievable that lays the groundwork for the next step? 

Evaluation: How do we tell if it’s working? 

As with any long journey, the course needs to be checked along the way. Strategy needs to be 

evaluated revisiting each of the questions above (i.e., are we aiming at the right audiences, are we 

reaching them, etc.). It is important to be able to make midcourse corrections and to discard those 

elements of a strategy that don’t work once they are actually put into practice. 

Source: Strategy development: Key questions for developing an advocacy strategy. 

Washington, DC: Advocacy Institute. http://www.democracyctr.org/resources/strategy.html. 

to or creating a specific opportunity. A 

good strategic plan identifies the policy 

issue to be promoted through the media 

and the methods for obtaining favorable 

media coverage—in other words, the 

plan assesses where the advocate wants 

to go and how to get there. A good strategic plan also puts in place the tools 

and skills that the advocate will need 

when the moment comes for specific 

media advocacy activities. The plan must 

include “damage control” strategies; that 

is, advocates need to anticipate and prepare for challenges to their messages and 

credibility. (Chapter 3 describes the fundamentals of strategic communication 

that should be considered.) 

In brief, planning for media advocacy 

should include deciding which policy 

objectives will be advanced; gathering 

accurate information on the relevant issues; making contacts with journalists to 

win or support their interest in the 

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5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

ASSIST training materials for media advocacy 

issues; defining the audience to reach 

with the media intervention and tailoring 

a clear message for that audience; 

choosing appropriate media channels for 

the message (e.g., newspaper, television, 

radio); and anticipating how to deal with 

negative responses. After the plan has 

been implemented, it is important to determine which elements of the plan succeeded and which elements did not. 

Feedback from the field to improve the 

plan should indicate whether the message should change, whether the priority 

audience has shifted, and whether the 

media contacts list is still appropriate.15 

For example, instead of a message originally designed for women, the strategy 

might require a more specific focus on 

teenage women, and this focus would 

require media contacts who relate to that 

audience. 

ASSIST media advocacy kit 

Training for Media Advocacy 

As ASSIST was moving from the 

planning phase to the implementation 

phase, two of the early national meetings were dedicated to media advocacy 

training. On March 17–19, 1993, a 

workshop entitled “Media Advocacy: A 

Strategic Tool for Change” was held in 

Washington, DC. This training event, 

attended by staff from all the ASSIST 

sites, laid the groundwork for doing 

media advocacy at the state and local 

levels. The training event launched a 

new media document created jointly by 

the American Cancer Society (ACS) and 

the National Cancer Institute (NCI): 

ASSIST: A Guide to Working with the 

Media.15 

A second media advocacy training 

event—“From Phase One to Page One: 

Refining Our Media Skills”—was held 

on July 22–23, 1993. This training event 

included nationally recognized media 

advocacy speakers, a panel of media 

professionals, and on-camera spokesperson training. 

Together, these two training events 

helped prepare ASSIST staffs and coalitions to use media advocacy as an effec130 
M o n o g r a p h 1 6. A S S I S T 

A Strategy Checklist 

need to assess your use of media in 

relation to and in support of, rather than 

instead of or isolated from, other 

change? 

for change? 

Dorfman, and I. Diaz. 1999. 

the media. Thousand Oaks, CA: Sage 

Publications (pp. 9, 13). 

“The critical element of an effective 

media advocacy effort is that it is 

strategic. This means that you always 

approaches.” 

Questions for Strategy Development 

1. What is the problem? 

2. What is the solution? 

3. Who has the power to make the necessary 

4. Who must be mobilized to apply pressure 

5. What message would convince those with 

the power to act for change? 

Source: Wallack, L., K. Woodruff, L. 

News for a 

change: An advocate’s guide to working with 

tive approach in the ASSIST model. The 

strategic focus on framing policy initiatives to obtain earned media coverage 

became a hallmark of the overall strategies in ASSIST states. Media advocates 

also met in ancillary meetings at each 

ASSIST information exchange conference and at national conferences. The 

ASSIST Coordinating Center typically 

arranged for a guest speaker at those 

meetings—a member of the media or a 

representative of the advertising industry—who provided insights on an aspect 

of media advocacy. Toward the end of 

the project, in 1998, the ASSIST Coordinating Center developed and presented 

the train-the-trainer module Advanced 

Media Advocacy. The focus was on how 

to meet the new challenges brought 

about by success—in some cases, intencitizens to write letters supporting an issue. 

editorial board and community support 

may already be concerned about the 

real community problem—not as a 

tobacco control. 

readers’ interest. 

the rationale behind a bill under 

during the debate about a proposed bill. 

Benefits of the Newspaper Channel 

in North Carolina 

1. Newspapers have the space to give indepth explanations of complicated issues. 

2. Because they have editorial pages, newspapers can offer policy issue support by 

printing positive editorials and editorial 

cartoons and can provide a forum for 

3. Newspaper articles can be “recycled”— 

they can be copied and circulated to 

inform decision makers and to show 

for a policy change. 

4. It is important to allow a reporter to 

maintain objectivity. Though the reporter 

problem, the media advocate should treat 

the reporter as an objective observer of a 

tobacco control advocate. 

5. Awards and appreciation should be 

expressed for thorough and fair 

coverage—not for advocacy work in 

6. It is the man biting a dog that makes the 

news, not the dog biting a man; shocking, 

extreme stories draw reporters’ and 

7. The timing of articles or a series of 

articles is important. Coverage that gives 

consideration, for example, is critical 

sified opposition by the tobacco industry; in other cases, a waning interest by 

the media. Spokesperson training was an 

important component of the workshop. 

Following these national workshops, 

most of the ASSIST states held media 

advocacy training events with presentations and on-site technical assistance 

from NCI and ASSIST Coordinating 

Center staff and from other national media advocacy experts. 

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5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

Acting Locally: The ASSIST Media Network 

306[e][B]. 

Evolving Limitations on the Right to Lobby 

Although the use of federal money to lobby the U.S. Congress has long been restricted, when the 

ASSIST interventions began in the early 1990s, federal money could be used to advocate for policies 

to state governments and local policymaking bodies. However, the laws and regulations changed 

during the course of the 8-year ASSIST project. 

The Federal Acquisition Streamlining Act (FASA) also was enacted during the course of ASSIST. The 

final rules implementing FASA were published on August 16, 1995, and the law became effective on 

October 1, 1995. Under FASA, “Costs incurred to influence (directly or indirectly) legislative action 

on any matter pending before Congress, a State legislature, or a legislative body of a political 

subdivision of a State” were deemed unallowable under federal contracts P.L.103-355, section 

By its own terms, FASA applied only to government contracts based on solicitations issued after 

October 1, 1995. Since the original ASSIST contracts preceded that date, they were not affected by it. 

Later, FASA’s total prohibition against using federal money to lobby at any level of government did 

apply to the 1-year extension contracts issued to ASSIST states beginning on October 1, 1998, because 

these contracts were considered new contracts. The law that appropriated fiscal year 1997 money for 

the Department of Health and Human Services—the Omnibus Consolidated Appropriations Act— 

broadened the ban on using that money for lobbying and prohibited lobbying to state legislatures. 

—Anne Marie O’Keefe, former Policy 

and Media Advocacy Manager, 

ASSIST Coordinating Center 

composed of one or more individuals 

Because the policy changes at the 

core of ASSIST were designed to occur 

at the local level for the greatest effect, 

most media advocacy activities also 

were conducted at the local level. Local 

media are likely to cover an issue or policy when it has a local angle and is represented by a community spokesperson. 

To support effective local media advocacy interventions, ASSIST staff established the ASSIST Media Network, a 

network of trained media advocates who 

would receive information and manage 

media advocacy activities in their 

ASSIST sites. 

The ASSIST Media Network, which 

became the basic infrastructure for communications on media advocacy, was 

from each state whose primary responsibility was to work with the media. The 

network was a critical element of the 

media advocacy strategy. ASSIST’s media and policy achievements would not 

have been possible without empowering 

the field staffs with time, resources, and 

skills sufficient to conduct effective media advocacy. For example, in North 

Carolina, the Philip Morris “Think. 

Don’t Smoke” campaign was covered by 

two different newspapers, each of which 

framed the story very differently. A contact person of the North Carolina 

ASSIST Media Network worked with 

the reporter of the Charlotte Observer 

story, which presented the Philip Morris 

campaign as a disingenuous attempt by 

the tobacco company to gain credibility 

132 
M o n o g r a p h 1 6. A S S I S T 

by funding what was in fact a weak and 

ineffective youth antismoking message. 

She quoted local spokespersons. The Associated Press, on the other hand, wrote 

a story that was carried in the WinstonSalem Journal. The Associated Press reporter, who had not been contacted by a 

tobacco control staff member, presented 

the Philip Morris campaign as the company’s effort to turn over a new leaf and 

prevent underage smoking. 

As the ASSIST project matured, so 

did the network. Early in the implementation phase, the ASSIST Media Network served as a resource for staff 

members who were developing media 

capabilities and media relations—they 

shared information on and experience in 

gaining the media’s attention through 

special events, research results, and other 

means. In the later years of the project, 

as local tobacco policy initiatives gained 

prominence, the ASSIST Media Network responded through increasingly sophisticated applications of media 

advocacy. Many ASSIST Media Network representatives established their 

own intrastate networks of community 

media advocates who could adapt information and frame messages for community newspapers and local television 

stations in ways that would succeed locally. These networks fostered creativity 

as a result of the information sharing and 

group brainstorming. For example, in tobacco-producing states, the media and 

the public were not always open to stories criticizing the tobacco industry. Understanding this predisposition, local 

advocates found alternative spokespersons 

or framed messages as prohealth. In this 

way, they made messages more acceptable 

to the media. (See case study 5.1.) 

In some situations, it was not possible 

for state or local health department staffs 

to disseminate a particular tobacco control story. Some events and stories were 

considered too controversial within the 

state’s political environment. In these 

cases, the advantage of the partnership 

model became evident: the nongovernmental partners, such as ACS and other 

voluntary health groups, took the lead as 

media spokespersons. 

National Backup for Media Advocacy 

ASSIST staff members monitored 

trends and activities at the national level 

and disseminated information to the 

ASSIST Media Network with suggestions on how to frame the information 

for the local media. The information was 

provided in a rapid manner that facilitated quick action by the local sites. Many 

suggestions focused on how to piggyback local coverage on national stories 

and events. The media materials distributed by ASSIST staff made the practice 

of media advocacy easier for state-level 

personnel and provided consistent messages across ASSIST states. 

Project staff members at NCI and the 

ASSIST Coordinating Center provided 

ongoing technical assistance to the 

ASSIST Media Network 

■	 at monthly teleconferences; 

■	 by telephone and e-mail on an asneeded basis; and 

■	 in the form of mailings of materials 

(including sample press releases, 

sample letters to the editor, detailed 

information on topics for op-eds, and 

updates on tobacco issues and 

research) and recommendations for 

media activities. 

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5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

Case Study 5.1 

Situation: 

Strategy: 

Media Intervention: 

ties and threats in the media 

using the data collected to plan a successful editorial board visit, op-ed piece, or 

letter to the editor 

Results: 

Tobacco State Turns Opinion Around 

When ASSIST first started in North Carolina, key informant interviews with 

journalists and analyses of newspaper coverage revealed that the North Carolina 

press usually covered tobacco as a business issue, not as a health issue. 

ASSIST leaders planned to change the type of coverage by training advocates in communities around the state to create news stories, coordinate news coverage, and orchestrate opinion writing on tobacco as a health issue. The project tracked 

progress through the news analyses of print coverage of tobacco provided by the 

ASSIST Coordinating Center, which tracked and analyzed tobacco coverage in every 

daily newspaper in the United States. ASSIST staff looked particularly at newspaper 

editorials, which not only reflect the opinions of a community, but also often change 

policy opinions and lie at the cutting edge of social norm changes. 

North Carolina ASSIST worked to change the editorial slant about 

tobacco and to make it a health issue. It focused on building the capabilities of local 

communities in the following four areas: 

1. Strategic communication, which means being prepared to respond to opportuni2. Spokesperson preparation, which involves ensuring that staff, key leaders, youths, 

adult volunteers, and community activists know how to frame tobacco issues for 

the news media and how to prepare for news interviews 

3. Media advocacy, which entails planning for changes in policy and social norms 

by embedding media communication as part of the overall plan 

4. Editorial board advocacy, which involves monitoring local editorial boards and 

While no attempt has been made to assess a specific outcome relationship 

between ASSIST’s media advocacy efforts from 1994 to 1997, North Carolina 

newspaper editorials on tobacco policy issues did become more supportive of the 

health issue. Prohealth editorials increased and even exceeded the number of 

protobacco editorials. (See table 5.1.) 

—Sally Herndon Malek, former ASSIST Project Manager, 

North Carolina Department of Health and 

Human Services and current Head, North Carolina 

Tobacco Prevention and Control Branch 

134 
M o n o g r a p h 1 6. A S S I S T 

Table 5.1. Number of Newspaper Editorials in 

North Carolina, 1993–98 

Year Prohealth Protobacco Neutral 

1993 16 38 28 

1994 51 73 31 

1995 49 35 13 

1996 53 42 16 

1997 97 42 8 

1998 52 63 9 

Source: ASSIST newspaper clippings database. 

The monthly teleconferences and the biannual meetings provided opportunities 

for ASSIST Media Network members to 

learn from one another. Peer-to-peer 

sharing of strategies, materials, and messages was one of the most valuable resources of the ASSIST Media Network. 

ASSIST relied on national experts for 

advice to provide the ASSIST Media 

Network with the most up-to-date and 

accurate information with which to 

frame stories in the local media. For example, when a U.S. District Court judge 

in North Carolina ruled on July 17, 

1998, that the assessment of relevant scientific studies for the Environmental 

Protection Agency’s 1992 report, Respiratory Health Effects of Passive Smoking, 16 was selective, misrepresentative, 

and procedurally faulty,17 the national 

project staff convened an emergency 

ASSIST Media Network conference call 

with legal experts, media advocacy experts, and an author of the report to explain the situation from all perspectives. 

The tobacco industry’s allegations about 

the report were effectively countered by 

the experts, who explained them to the 

ASSIST Media Network representatives, 

who, in turn, framed stories in their local 

media with a favorable tobacco control 

perspective. 

Among the types of materials that the 

ASSIST Coordinating Center sent to 

network members to support their efforts 

were “swiss cheese” press releases. 

These press releases were referred to as 

swiss cheese because they had “holes” 

for inserting local information. These releases became a staple that local media 

advocates relied on to do their jobs. 

From 1997 to 1999, a release was included in a packet of materials sent 

monthly to network members. 

ASSIST states used several types of 

media tactics in their media advocacy 

strategies, such as news coverage of activities, events, and antitobacco educational campaigns. Ensuring that the 

news was covered strategically set the 

context for additional media tactics that 

would promote specific public policies. 

The combination of media interventions 

raised the public’s consciousness of the 

problem and supported a tobacco-free 

social norm. Case studies 5.2–5.4 illustrate how media networks identified an 

advocacy opportunity, planned a strategy 

and tactics, and mobilized the necessary 

individuals to conduct activities and to 

influence the media in framing and covering the stories. 

News Coverage of Tobacco Issues 

Straightforward news coverage of tobacco-related events adds importance to 

those events, helps keep tobacco issues 

in the public’s mind, and reinforces a tobacco-free social norm. In particular, 

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5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

Case Study 5.2 

Situation: 

knowingly

Strategy: 

minors in North Carolina. 

weeklong series of articles in the 

on teen tobacco use. 

Results: 

series, which ran January 12–15, 1997, included sidebars, photographs, graphics, an 

attention to the problems of underage smoking. 

Strengthening Youth Access to Tobacco Laws: North Carolina 

The North Carolina ASSIST media contact person received a call from a 

general assignment reporter regarding an expected bill that would strengthen the 

state law on youth access to tobacco by increasing penalties to violators. The bill 

would require a photo identification check, signage, and removal of the word 

 from the law’s text (which had made the law difficult to enforce). The reporter 

planned to do a brief background story. 

The media contact person saw this situation as an opportunity to do more 

and pitched to the reporter the idea of an investigative series on tobacco use by 

Media Intervention: The ASSIST media contact person orchestrated an exclusive 

Charlotte Observer regarding underage tobacco use 

across the state. A state-level media contact person worked behind the scenes with 

the reporter and helped to shape a comprehensive story. 

In a telephone background interview, the media contact person made a list of documents to copy for the reporter and provided statistics, stories, and names of local and 

state contacts. After more than an hour on the phone, the reporter decided that a visit 

to the tobacco control office was in order. At the meeting, the media contact person 

provided documents, fact sheets, names of more contacts, and stories. 

Months later, the reporter was asked what about this story compelled her to pursue it 

as an investigative series and not just as a single news story. She noted that the media 

contact person had told her how health educators in mountain counties learned that 

smokeless tobacco use was being encouraged for very young boys—as young as 3 or 

4—by parents who believed that chewing tobacco is harmless. Health educators also 

knew of parents and grandparents rubbing snuff onto the gums of infants to ease 

teething pain. The thought of educating the public about such shocking practices 

compelled the reporter to talk to more sources; the result was a comprehensive series 

A four-part series, “Carolina’s Youth: Sold on Smoking,” was published. The 

series covered the history of the youth access to tobacco law, smoking in schools, 

smokeless tobacco use, health effects of smoking, and reasons that teens smoke. The 

editorial supporting the proposed law change, and an editorial cartoon drawing 

While the series was running, the media contact person asked the reporter whether 

the series could be offered as a reprint, with all the related articles, editorial, cartoon, 

and letters to the editor printed together for distribution to interested citizens. The 

136 
M o n o g r a p h 1 6. A S S I S T 

Charlotte Observer

of Health and Human Services 

Case Study 5.3 

Situation:

Strategy: 

Media Intervention: 

newspaper publisher not only agreed to do so, but also offered to send a copy of the 

reprint, along with a cover letter, to each member of the North Carolina General 

Assembly. 

When debate began on the bill in the spring, multiple copies of the 

 series were circulated at the legislative building. Although the efforts of many 

groups and individuals contributed to the eventual passing of Senate Bill 143, which 

strengthened the state law and made it enforceable, the Charlotte Observer series and 

reprint had a significant effect. The new law went into effect on December 1, 1997. 

—C. Ann Houston, Director of Public Education 

and Communication, Tobacco Prevention and 

Control Branch, North Carolina Department 

The Media Network of the Tobacco-Free Michigan Action Coalition 

 On Christmas Eve 1993, during final negotiations on a tobacco tax bill, the 

legislative leadership in Michigan added a local preemption clause and pushed it 

through without public notification or debate. This preemption issue raised awareness of the need to increase tobacco control media efforts. 

The Tobacco-Free Michigan Action Coalition established a network of 

media advocates at the community level who could conduct effective media advocacy with local media on tobacco control issues. Local tobacco control coalition 

coordinators were responsible for media advocacy in their areas. They established 

relationships with local reporters, forwarded background information, pitched 

stories, and either acted as the tobacco expert or as a referral source to another local 

expert. Michigan Department of Health staff members summarized events and information and communicated summaries to the network by telephone, mail, and fax. 

State health department staff members organized formal training sessions to enhance 

the skills of media network members. In an initial full-day training event, national 

media experts, a panel of local reporters, and a media consultant addressed media 

relations and media advocacy. The network meetings included training on how to 

convey messages effectively at meetings with editorial boards. Communication was 

an essential part of the program and included a summary of events relevant to the 

policy issue; suggestions for framing the issues; media bites; and sample materials, 

such as swiss cheese press releases, op-ed pieces, and sample letters to the editor. 

In 1994, during a legislative battle seeking to repeal local preemption, media network members spoke on radio and appeared on television in their 

137

5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

change his position, he clearly felt the pressure. 

natorial candidates. 

Results: 

Case Study 5.4 

Winston Additive-Free Media Advocacy Campaign 

Situation:

Case Study 5.3 (continued) 

local areas. In each interview, outlining the issues and keeping the repeal before their 

audience, they turned the discussion to preemption. When a legislator emerged as the 

primary roadblock to repeal, the media network coordinator in the legislator’s district 

mobilized coalition members and launched a local media strategy primarily using the 

print media, but also including television and radio. Although the legislator did not 

The chief medical officer for the county wrote several letters to the editor and op-ed 

pieces. The network coordinator organized individuals to write letters to the editor, 

resulting in even more letters from the general public. The network coordinator 

provided information to a local newspaper, which then, in an editorial in the Sunday 

edition, criticized the legislator for his role in blocking repeal. The coordinator then 

provided questions about preemption to reporters covering a debate between guberAlthough the repeal effort failed (the lame-duck legislature did not act on the 

bill), Michigan’s media network members gained experience and confidence. They 

successfully gained access to the media and engaged the community and editorial 

staff in their efforts. Time and again, they reported that it was easy for them to do 

media advocacy when tools were provided. Had staff members been required to do 

the research and draft their own press materials, they would have been less likely to 

do it, but they almost always followed through when they received everything that 

they needed to do the job. 

The training for and the experience with the repeal laid the groundwork for future 

successful media advocacy efforts in Michigan. 

Source: Adapted from D. May. 1995. Care and feeding of the media network. In Tobacco prevention: 

The next generation (New approaches to youth policies, secondhand smoke, and institutionalization, 

June 4–6, 1995). Rockville, MD: ASSIST Coordinating Center. 

 In 1997, R.J. Reynolds Tobacco Company (RJR) repositioned its Winston 

brand as an additive-free cigarette with the theme “No additives. 100% tobacco. No 

bull.” The ASSIST Coordinating Center recognized the campaign as an effort to 

convince smokers that an additive-free cigarette is less hazardous than other cigarettes. This effort might discourage smokers from quitting or might convince nonsmokers to initiate smoking. 

138 
M o n o g r a p h 1 6. A S S I S T 

Strategy: By piggybacking on national events, three voluntary organizations mobilized a local grassroots countercampaign to terminate the misleading and deceptive 

nature of the ad campaign for RJR’s new additive-free Winston cigarette. 

At the national level, the American Cancer Society, the American Lung Association, 

and the American Heart Association filed a joint petition with the Federal Trade 

Commission (FTC), the federal agency charged with enforcing fair and truthful 

advertising. The petition urged an investigation of the campaign, especially the 

implied health claim contained in the no-additive assertion. The petition asked the 

FTC to enjoin the campaign based on the deception inherent in this implied health 

claim and on the lack of scientific evidence to substantiate it. 

For local media advocacy activities, the ASSIST Coordinating Center produced and 

disseminated a packet containing media advocacy materials and provided networking 

opportunities and technical assistance on how to use the materials most effectively. 

Media Intervention: At the national level, the three voluntary health associations 

decided to provide exclusive breaking stories to CNN and the Wall Street Journal, 

which ran the story of the FTC petition on the front page of the business section. 

Further national broadcast and print coverage followed, including feature stories, 

editorials, and letters to the editor. 

At the local level, numerous activities kept the story alive. For example, in Rhode 

Island, at a news conference in front of a Winston billboard near a school, a group of 

high school students held a sign that read “100% bull.” The story was carried on the 

front page of the Pawtucket Times and was the lead news story on two local television network affiliates. One of the television reporters contacted the billboard 

company from the site and informed the company that the billboard was in violation 

of an ordinance restricting tobacco advertisements near schools. Within 30 minutes 

of that phone call, the Winston additive-free billboard was removed. 

Results: There was broad and well-placed national and local coverage of the opposition to the Winston campaign and of the resulting action taken by the FTC. In 1999, 

the FTC ruled that RJR’s campaign deceptively implied a health claim and that RJR 

had to run corrective advertising to the effect that not putting additives in the cigarettes did not mean that the cigarettes were safe or less harmful. It was the first time 

that the FTC required such a disclosure in an ongoing ad campaign. The Washington 

Post reported that the petition filed by the health groups spurred the action by the 

agency.a 

Source: Adapted from C. Hall-Walker and M. Thomas. 1998. Taking advantage of an opportunity: The 

Winston Billboard Youth Demonstration. In No more lies: Truth and the consequences for 

tobacco (Case studies of the Fourth Annual National Conference on Tobacco and Health, October 26– 

28, 1998), 83–6. Rockville, MD: ASSIST Coordinating Center. 

a

Schwartz, J. “FTC has a beef with ‘no bull’ ads.” Washington Post, March 4, 1999. 

139 
5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

three types of news coverage brought attention to the need for tobacco control: 

special events, breaking tobacco news, 

and publication of research results. 

Special Events 

Events that are of interest to large 

segments of the population are opportunities for earned media coverage of tobacco control issues. The ASSIST 

Coordinating Center alerted ASSIST 

Media Network members about nonASSIST events on which they could piggyback media messages. For example, 

the best-known national smoking cessation event is ACS’s Great American 

Smokeout (GASO), which has been held 

annually since 1977. The Smokeout is a 

multimedia event occurring each November throughout the United States. In 

some communities it includes an 8-day 

media blitz leading up to Smokeout day, 

when smokers are urged to stop smoking 

for at least 24 hours. Public awareness 

of and participation in the Smokeout 

have been high for years.9 In 1998, an 

estimated 9 million persons (nearly 20% 

of all U.S. smokers) participated in the 

GASO community activities either by 

smoking less or by not smoking at all 

for 24 hours. Of those participants, 10% 

reported smoking less or not smoking at 

all for 1–5 days after the event.6,18 

In 1987, the American Lung Association began sponsoring Non-Dependence 

Day on the 5th of July to focus attention 

on the problem of nicotine addiction and 

to offer assistance to smokers wanting to 

quit smoking. National events, such as 

the Smokeout and Non-Dependence 

Day, can be used to trigger media events, 

such as television and radio cessation clinics,6 newspaper stories profiling former 

smokers,19 and community-wide stopsmoking contests.20–22 

News coverage also is generated 

when government agencies designate 

specific times of the year to highlight 

specific prevention initiatives (e.g., High 

Blood Pressure Control Week). The state 

of New York designated the first week of 

January 1990 as Tobacco Awareness 

Piggybacking on Special Events 

Missouri local coalitions conducted mediaworthy events to publicize ACS’s Great 

American Smokeout, including radio station 

interviews, Dixieland funerals, cessation 

programs, “screamouts,” and Teens Against 

Tobacco Use training events. These activities 

generated 11 newspaper, radio, and television 

stories. 

New Jersey held a statewide rally of 750 

students for the Great American Smokeout. 

The students—from all parts of the state— 

marched from a park to the New Jersey State 

House, where they delivered pledges from 

friends and family members promising not to 

smoke. The students listened to motivational 

speeches by the commissioner of health, 

physicians, and peers. The event received 

public television and local newspaper 

coverage. 

North Carolina worked with partners, 

including ACS, to promote a U.S. Women’s 

Soccer game in Davidson, North Carolina, on 

March 16, 1996. Two commercials with 

tobacco use prevention messages for youths 

aired in the Charlotte area during the days 

surrounding the game. About 3,000 people 

attended the game and received a poster of 

the team with a no-smoking message. 

Source: Adapted from ASSIST site quarterly 

reports, 1996–99. Internal documents, 

ASSIST Coordinating Center, Rockville, MD. 

140 
M o n o g r a p h 1 6. A S S I S T 

Week and provided $5,000 to each county health department across the state to 

create local tobacco control events. The 

events varied from poster contests to 

smoking policy workshops for businesses 

to training programs for healthcare providers. Because the local events were 

conducted as part of a statewide initiaMore Piggybacking 

To reach African Americans in Milwaukee, 

Wisconsin’s ACS conducted an educational 

outreach campaign to kick off a cessation 

program and the Great American Smokeout 

in late 1997. A T-shirt exchange was also a 

component of the program. A news story and 

an ad promoting the event appeared in the 

local newspaper. 

Rhode Island made a special effort to involve 

Hispanic/Latino youths in planning and 

coordinating a variety of tobacco control 

activities; these activities included Kick Butts 

Day in 1998, presentations on smoking 

policies at schools, participation in the World 

No Tobacco Day collaborative event with 

other youths, a spring health fair, attendance 

at a state forum to learn about a pending 

smoke-free restaurant policy, and 

participation in a peer-counseling retreat. 

Seven of South Carolina’s local coalitions 

conducted educational and awareness 

activities to piggyback on Kick Butts Day 

and World No Tobacco Day. A few of these 

activities drew media attention. Activities 

included an event for youths featuring a jazz 

band, student presentations, and door prizes; 

sending out a press release recognizing 

smoke-free restaurants in the area; letters to 

the editor to publicize the day; events at a 

baseball stadium; and airing 25 tobacco facts 

during the course of the day. 

Source: Adapted from ASSIST site quarterly 

reports, 1996–99. Internal documents, 

ASSIST Coordinating Center, Rockville, MD. 

tive, local media coverage of the events 

was heightened. 

In addition to the training and technical assistance provided to the states for 

local media advocacy activities, ASSIST 

staff arranged media events for the 

project at the national level. The national 

tobacco control conferences usually 

Approximately 300 youths participated in 

kicking soccer balls through the collage to 

presentations on tobacco-related topics at 

local middle schools reaching 1,500 students. 

Also in 1999, in recognition of Kick Butts 

reports, 1996–99. Internal documents, 

And More Piggybacking 

In April 1999, four local Colorado coalitions 

planned and conducted prevention activities 

and media activities for Kick Butts Day. 

events in Denver, 100 in Boulder, 1,500 in 

Larimer, and 150 in La Plata; the total was 

2,050 youths. Youths from local schools 

delivered speeches, and other youths created 

a large collage of tobacco advertisements and 

arranged a media event featuring youths 

demonstrate eliminating tobacco advertising. 

Media coverage was strong and enhanced the 

reach of these activities. 

In a sixth county in Colorado, working with 

key community groups, including the State 

University’s Men’s Soccer Team, coalition 

volunteers and student interns delivered 

A local newspaper featured the Kick Butts 

Day events with a lead story, and a local 

affiliate of a national network covered the 

event in its evening news. 

Day, students from a New York school went 

on a scavenger hunt for smoking messages in 

their community. They subsequently wrote 

letters to newspapers and community leaders 

about their findings. Participating youths and 

local organizations were quoted on local 

television and in newspapers. 

Source: Adapted from ASSIST site quarterly 

ASSIST Coordinating Center, Rockville, MD. 

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5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

generated considerable local coverage in 

the city where the conference was being 

held and several stories in the national 

media. To prepare for these annual conferences, ASSIST project staff at NCI 

convened a media task force composed 

of members of each partner organization. 

The task force determined the main media messages and managed the media advocacy activities at all five National 

Conferences on Tobacco or Health held 

during ASSIST. 

Case study 5.5 about West Virginia illustrates how strategic thinking can create 

a tobacco news event at an already 

scheduled event likely to receive coverage. 

Tobacco News 

Tailoring information for the local 

news media can effectively extend the 

life of a national news story or create a 

new media hook. For example, after a 

news release on the medical costs associated with treating smoking-related diseases in the United States, several state 

health departments released cost information specific to their individual states. 

A new wave of media coverage on the 

local burdens of smoking ensued.13,23 

Case studies 5.6 and 5.7 show how to 

bring local attention to a national event 

and national attention to a local issue. 

Research Results 

The release of research results also can 

be newsworthy. The public’s interest in 

health stories is so strong that even familiar health information can be presented in new ways to capture attention. A 

good example is the release of the U.S. 

surgeon general’s reports on smoking 

and health. Even though the reports 

summarize previously released scientific 

information, presentation by the surgeon 

general in a high-profile news conference 

generates extensive media coverage. For 

state and local programs to prepare for 

this media opportunity and localize 

health news, it is important for the sponsoring national agency to work with 

them, for example, to send embargoed 

publications and press releases far 

enough in advance to enable the states to 

plan for the official release of a document 

or other event. Having a highly visible 

and credible spokesperson or group deliver the information will often generate 

media coverage, even when the message 

is familiar—such as health consequences of smoking during pregnancy.13,24,25 

(For a bibliography of articles written 

about ASSIST, see appendix 5.A; for a 

discussion of dissemination of research 

results in Wisconsin, see case study 5.8.) 

Mass Media and Countermarketing 

Campaigns 

Mass media educational and antitobacco campaigns work by creating 

awareness and support in the community, but the process can be complex— 

advocates must work to address competing interests (including official constraints) and must learn to apportion 

competing resources. Considerable effort typically is spent achieving consensus about the messages of a campaign, 

and considerably more effort is required 

to implement a campaign that will 

achieve the desired outcome. 

A review of 56 evaluated antitobacco 

campaigns concluded that a key element 

142 
M o n o g r a p h 1 6. A S S I S T 

Case Study 5.5 

Charleston, West Virginia, Bids So Long to the Marlboro Man 

Situation: In the fall of 1996, the Charleston City Council adopted a resolution 

prohibiting tobacco product advertising on city property. One council member 

thought the 20-foot sign advertising cigarettes in the outfield of a minor league 

ballpark sent the wrong message to children. Members of the local tobacco control 

coalition agreed. 

Strategy: Complementing the city council members, the coalition reached out to 

establish a partnership between the local coalition’s smoking workgroup and the 

Charleston Alley Cats baseball team to promote a tobacco-free message at the 

baseball park. 

Media Intervention: A coalition representative approached the baseball team’s community relations director to discuss partnering on tobacco prevention activities. To draw 

media attention, a news conference was planned around the removal of the tobacco 

advertising sign and the announcement that members of Teens Against Tobacco 

would raise funds to replace the Marlboro Man sign. 

Next, the coalition sponsored a contest for high school students to design a tobaccofree sign. The design contest drew more than 30 entries. A pregame ceremony for 

Teens Against Tobacco Day was planned to unveil the winning sign; the ceremony 

featured the mayor, a council member, teens, and a representative from the coalition. 

A photo session was held at the end of the pregame ceremony with the teen who 

designed the winning sign, elected officials, and a representative of the minor league 

baseball team. 

Results: The events received excellent media coverage, including a positive slant in a 

column of the morning newspaper. The Charleston City Government became interested in working with the coalition on other tobacco prevention initiatives. 

Tips from West Virginia 

■	 Acknowledge community leaders. Elected officials appreciate the public 

recognition and positive media coverage. 

■	 Seek to develop partnerships with nontraditional allies within the community, 

such as a minor league baseball team. 

■	 Look for win-win situations. All partners should benefit from the events. 

■	 Maintain the momentum. After a positive experience, continue to build a 

working relationship with the new partners. 

—Brenda Grant, Charleston Area Medical Center, and Helen Matheny, 

formerly with the Kanawha Coalition for Community Health 

Improvement and current Director of Communications and 

Health Programs,West Virginia State Medical Association 

143 
5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

Case Study 5.6 

Situation: 

Intervention: 

Results: 

Case Study 5.7 

The Indiana Countercampaign—A Local Event Covered Nationally 

Situation: 

Intervention: 

Results: 

The Tobacco Master Settlement Agreement—A National Event Covered Locally 

The removal of tobacco billboards nationwide is an example of a national event used 

by ASSIST to generate earned media coverage at the local level. 

As part of the November 1998 Tobacco Master Settlement Agreement, the 

tobacco companies agreed to remove all billboard advertising by April 23, 1999, and 

to turn over remaining leases for this space to the state attorneys general. 

The National Cancer Institute, the Centers for Disease Control and 

Prevention, the Food and Drug Administration, and Arnold Communications (an 

advertising agency) collaborated to provide information to the ASSIST Media 

Network on how to work with outdoor advertising companies to replace the tobacco 

billboards with prohealth messages. In addition, the ASSIST Coordinating Center 

directed an effective earned media campaign. In teleconferences and mailings, the 

ASSIST Media Network received suggestions for holding and promoting media 

events at the billboard sites, obtaining video coverage of the Marlboro Man coming 

down, and developing talking points that framed the issue not as a gift from the 

tobacco industry but as a chance to rid the landscape of deceptive, antihealth messages. 

The effort paid off in an abundance of local television and print coverage 

featuring several state attorneys general and other high-profile spokespersons. The 

ASSIST Coordinating Center created a videotape documenting this historic event. 

—Lynn C. Cook, former Media Relations Specialist, ASSIST 

Coordinating Center, and current Prevention 

Project Director, Danya International, Inc. 

A media countercampaign in Indiana is an example of a local story that resulted in 

national coverage. 

A local convenience store chain began advertising discount cigarette prices 

in direct violation of the Master Settlement Agreement. 

The Indiana ASSIST Media Network representative mounted a local 

countercampaign on television and radio. 

These broadcast countermarketing spots caught the attention of an ABC 

evening news producer and became the subject of an Eye on America segment. Some 

local stations pulled the cigarette advertisements. The chain revised the ads, but they 

soon disappeared completely. 

—Johnny Kincaid, Smokefree Indiana 

144 
M o n o g r a p h 1 6. A S S I S T 

Case Study 5.8 

Situation:

limited health information through its vital and health statistics reports and its 

Media Intervention:

the tobacco topic. 

Results: 

for the health department to disseminate information about tobacco use and enASSIST–Wisconsin State Medical Society Partnership for Publishing Tobacco Research 

 In the early 1990s, the Wisconsin Division of Public Health published 

periodic special reports. However, these reports rarely contained policy-oriented 

health information. The production of a tobacco-specific report was costly and 

required substantial resources for staff and distribution. The State Medical Society of 

Wisconsin published a monthly medical journal for its nearly 7,000 physician 

members and health policymakers throughout the state; hence, an opportunity 

existed to partner with that organization. 

 Staff members from the Wisconsin Division of Public Health 

approached the medical society to discuss their interest in finding a better way to 

disseminate tobacco and health information. The medical society was interested in 

gaining positive recognition and in increasing its stature among its members and in 

the community. The public health staff proposed publishing reports periodically on 

tobacco, an arrangement that seemed beneficial to all. Subsequently, ASSIST staff 

coauthored 25 articles in the Wisconsin Medical Journal on a variety of tobacco 

control issues, including the health and economic burdens of smoking, the prevalence of tobacco use, youth access to tobacco products, environmental tobacco 

smoke, and smoking cessation. In addition, several journal covers were dedicated to 

This public health series of articles provided a low-cost and credible method 

hanced the medical society’s ability to improve health and to increase its visibility in 

the community and among policymakers. (Appendix 5.A includes tobacco-related 

articles published in the Wisconsin Medical Journal, 1992–97.) These articles led to 

numerous newspaper and media stories and were frequently cited by policymakers 

throughout the duration of ASSIST. These articles were used in conjunction with 

state-driven data that enhanced and expanded media coverage on numerous tobacco 

control issues. These efforts also furthered the new approach of community and 

social environment change. 

—Patrick L. Remington, former Wisconsin ASSIST Department of 

Health Project Director and current Professor of Population 

Health Sciences, University of Wisconsin Medical School 

in the success or failure of a campaign is 

its intensity.6 The more intensive the 

campaign—that is, the greater its reach, 

frequency, and duration—the greater is 

its effect on behavior. The success of interventions depends on the intended audience receiving an adequate “dose” of 

the message.6,26 The disappointing results 

of many health promotion campaigns delivered through the mass media can be 

145 
5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

traced directly to inadequate exposure to 

campaign messages, especially in campaigns relying solely on public service 

announcements that are infrequent and 

aired during times of low viewership.6

 In 

an evaluation of a 6-month antismoking 

television campaign conducted in media 

markets in New York and Pennsylvania 

from August 1988 to January 1999, only 

two of the television stations kept 

records of when the messages were 

aired, and those two reported that half of 

the donated airtime was between 12 midnight and 7 a.m. Purchasing time to air 

the same messages in better time slots 

significantly improved response, as measured in calls to a hotline.27 Nevertheless, 

because of budget constraints, ASSIST 

used very little paid airtime and instead 

focused on earned media coverage. 

Perhaps the most visible mass media 

intervention for tobacco control prior to 

ASSIST was the tobacco counteradvertising campaign that aired between 1967 

and 1970 and that was sponsored primarily by the major voluntary health organizations and government agencies.6–8 

For the most part, the campaign relied 

on donated airtime and advertising space 

for public service announcements. When 

the Federal Communications Commission ruled that, under the Fairness Doctrine, television and radio broadcasters 

were required to donate airtime for countertobacco messages as a balance to cigarette commercials, a significant amount 

of antismoking advertising aired. The 

free time provided for the counteradvertising spots was valued at approximately 

$75 million (in 1970 dollars) per year 

from 1968 through 1970.28 Several studies support the conclusion that the antiimplemented a hard-hitting antitobacco 

tobacco industry: 

communities. 

tobacco, nicotine addiction, secondhand 

medium featured a toll-free number for 

public questions, comments, and information 

quarterly reports. Internal documents, 

(Also see case study 5.4.) 

South Carolina Takes on 

the Tobacco Industry 

In 1998, South Carolina ASSIST created and 

media campaign. The 6-month, sequential, 

multimedia counteradvertising campaign 

targeted four messages disseminated by the 

1. Nicotine is not addictive. 

2. Secondhand smoke is not dangerous. 

3. The industry does not market to youths. 

4. Preemption is in the best interest of 

Aptly launched on April Fool’s Day and 

designed to reach South Carolina’s registered 

voters in three media markets, the series of 

informative billboards and radio and print ads 

was designed to create outrage and to raise 

the public’s awareness about youths and 

smoke, and the repeal of preemption of local 

clean indoor air ordinances. Each advertising 

about participation in the Partners Working 

for a Smoke-free South Carolina group. 

Source: Adapted from ASSIST Coordinating 

Center. 1998. South Carolina ASSIST 

ASSIST Coordinating Center, Rockville, MD. 

smoking messages aired during the Fairness Doctrine era were very effective.8,29 

Cigarette consumption declined each 

year during the campaign and rose again 

when cigarette advertising and antismoking messages were removed from 

the air in 1970. 

By 1990, Minnesota, Michigan, and 

California had funded countertobacco 

media campaigns with revenue earmarked 

from cigarette excise tax increases. Minnesota and Michigan had limited funds 

146 
M o n o g r a p h 1 6. A S S I S T 

■ 

children. 

■ 

■ 

support for restricting smoking in public 

on smoking in restaurants. (More than 

half prefer a complete ban.) 

11 Suppl. no. 2: ii4–ii7. 

Selected Results from the 1999 

Massachusetts Adult Tobacco Survey 

96% of nonsmokers and 92% of smokers 

believe that secondhand smoke can harm 

89% of nonsmokers and 79% of smokers 

believe that secondhand smoke can cause 

lung cancer. 

98% of the adults surveyed expressed 

buildings and for some form of restriction 

Source: Robbins, H., M. Krakow, and D. 

Warner. 2002. Adult smoking intervention 

programmes in Massachusetts: A comprehensive approach with promising results. 

Tobacco Control

for this purpose, but in California, excise 

taxes funded a $28.6-million, 18-month 

antismoking advertisement campaign 

launched in April 1990 as part of a larger comprehensive tobacco control program that spent $1.3 billion over 10 

years. The campaign included paid advertisements in newspapers and magazines, on billboards, and during prime 

time on television and radio. A 14% decrease in lung and bronchus cancers between 1988 and 1997 is attributed in 

part to the comprehensive program.30 

“Let’s Make Smoking History” 

Massachusetts was an ASSIST state 

but also had other sources of funding for 

major tobacco control efforts. Independent of ASSIST funding, but simultaneous with the project, Massachusetts 

began a $14-million media campaign in 

October 1993 designed to reduce the acceptability of smoking, to personalize 

health risk, and to expose the behavior 

of the tobacco industry. The Massachusetts Tobacco Media Education Campaign produced television, radio, 

newspaper, and billboard advertising 

and conducted public relations events 

throughout the state.31 Partnering with 

its advertising agency, Arnold Communications, a full-service marketing communications agency, the Massachusetts 

Tobacco Control Program (MTCP) media campaign has garnered significant 

national and international attention and 

numerous awards. The MTCP was a 

leader in developing campaigns that 

were unique, creative, and powerful and 

served as a model for other states. 

Therefore, NCI made arrangements with 

Massachusetts and Arnold Communications to air some of their advertisements 

in other states at no cost to Massachusetts or the other states. 

The Massachusetts media campaign 

used a three-segment approach of youth 

prevention, adult cessation, and public 

education and public opinion. Each segment was directed to a particular audience 

and was aimed at achieving a designated 

outcome, with the general goal being to 

raise awareness and influence behavior. 

For example, youth prevention messages 

were designed to decrease the demand 

for cigarettes among minors. Adult cessation messages focused on populations 

over 18 years of age and were designed 

to motivate and support a quit attempt. 

Public education and public opinion 

campaigns were aimed at the entire population and raised awareness about the 

hazards of secondhand smoke and the 

tobacco industry’s practice of targeting 

advertising to children. 

147 
5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

Massachusetts is well known for its 

tag line “Let’s make smoking history,” 

which accompanied numerous strong 

media messages. Massachusetts 

launched the first of three tobacco control campaigns called Truth; the other 

notable Truth campaigns were developed by Florida and the American Legacy Foundation. These were among the 

first ads aimed at changing public opinion toward the tobacco industry, without 

a specific behavioral change goal (e.g., 

cessation or prevention). 

The Massachusetts Truth Campaign 

utilized spokespersons such as Janet 

Sackman, who began smoking when she 

was modeling for cigarette ads in the 

1950s and was later diagnosed with 

throat cancer. In her advertisement, she 

talks about how sorry she is that she 

helped persuade young people to smoke. 

In another advertisement, Victor De Noble, who was a tobacco industry scientist, talks about what he refers to as the 

tobacco industry’s deception. The Truth 

Campaign presents people on camera 

who talk about the unglamorous health 

consequences of smoking from their experiences. Pam Laffin—a young mother, 

a lung transplant recipient, and a victim 

of smoking—tells about the physical 

and emotional pain that she and her children have experienced. Rick Stoddard 

shares the experience of watching his 

beloved wife die at age 46 of lung cancer. Ronaldo Martinez, who has had a 

laryngectomy due to throat cancer, talks 

about how “cigarettes take everything.” 

Another notable Massachusetts media 

campaign is the Get Outraged campaign 

(www.getoutraged.com); this campaign 

educates the public with compelling 

smoking history” remained high and 

estimates of the proportion of adults who 

and 80% from 1995 to 1998. 

6 (3): 40–4. 

Massachusetts Campaign Visibility 

Recognition of the tag line “Let’s make 

consistent throughout the campaign. Annual 

recognized the tag line varied between 76% 

Source: Biener, L. 2000. Adult and youth 

response to the Massachusetts Anti-Tobacco 

Television Campaign. Journal of Public 

Health Management and Practice 

facts that should outrage them about the 

hazards of cigarettes, the tobacco industry’s lack of accountability, and deaths 

related to smoking. 

The MTCP was very successful in 

reaching Massachusetts youths with 

more than 40 separate youth-oriented 

television spots between 1993 and 1999, 

designed for many different segments of 

the youth audience in Massachusetts. 

Many youths also saw the approximately 

70 MTCP ads that were part of the general audience campaign. The ads used 

various approaches to deliver the messages, including graphic depiction of 

health consequences, dramatic presentation of personal histories, explanations 

of tobacco industry strategies, frequent 

use of humor and sarcasm, and the power of celebrity. One recent television 

spot features former Boston Red Sox 

star pitcher Pedro Martinez teaching 

hopeful teenagers how to throw a curveball. Noticing that one boy has cigarettes, Martinez looks at him with 

surprise and says, “You can’t pitch with 

these. You gotta throw them away!” The 

advertisement ends with the pack of cig148 
M o n o g r a p h 1 6. A S S I S T 

arettes, pitched as a fastball, bursting 

into flame in the catcher’s mitt. Related 

images of Martinez have appeared in 

print and outdoor advertising, much of it 

in Spanish.32 A scientific study found 

that adolescents aged 12 to 13 who were 

exposed to the media campaign were 

significantly less likely to become established smokers than those who had not 

been exposed to the media campaign.33 

Campaigns in ASSIST States 

Case study 5.9 illustrates the effectiveness of an integrated, multimedia approach during an intense campaign 

period in one ASSIST state. In Rhode Island, community-based organizations 

worked with the Spanish-language radio 

station to reach teenagers through a multiple-format radio campaign conducted 

by youths. 

Monitoring Newspaper Coverage 

T

he ASSIST states worked strategically and with great determination to increase media coverage of the health issues related to tobacco use and of the 

policies that would promote a tobaccofree environment. Some measurement of 

their progress toward this objective was 

important to ASSIST staff members and 

coalitions. Knowing that their efforts 

were making a difference motivated the 

staff and coalitions. 

Newspaper Clippings Database 

The ASSIST Coordinating Center 

conducted ongoing tracking and periodic 

assessments of newspaper coverage of 

tobacco issues. Beginning October 1, 

1993, and continuing through March 

analysis of the cost and morbidity associated 

with tobacco use and released the results to 

the media early in 1999. 

conducted a merchant education assessment 

Maine released data collected from conducting Operation Storefront in 1997, in which 

community groups assessed the amount of 

Displays and data from the program were reMonth. Local press conferences for media 

outlets were conducted throughout the state. 

Rockville, MD. 

Media Coverage of 

Published Research Results 

West Virginia conducted a county-by-county 

In Virginia on November 7, 1996, the 

Shenandoah Coalition Against Tobacco 

of 70 merchants in 2 counties, Winchester 

and Frederick. The results were released at a 

press conference on November 21, the Great 

American Smokeout day. The story received 

favorable media coverage and amplified the 

educational effort through a wider audience. 

storefront advertising for tobacco products. 

leased in a media event featuring the governor declaring May to be Tobacco Awareness 

Sources: Adapted from ASSIST Coordinating 

Center. various dates. West Virginia, Virginia, 

and Maine ASSIST quarterly reports. Internal 

documents, ASSIST Coordinating Center. 

2001, a database was maintained of 

newspaper clippings on tobacco topics 

from more than 1,800 domestic daily 

newspapers from all 50 states and the 

District of Columbia. The clippings included news and feature articles, letters 

to the editor, and editorials about tobacco control policies. Trained staff at the 

ASSIST Coordinating Center coded the 

clippings and added them to the 

newspaper clippings database. The four 

ASSIST policy areas were tracked and 

then coded according to whether they 

149 
5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

Case Study 5.9 

Situation: 

challenge. 

Strategy: 

WRIB broadcasts , a program for teens airing from 

met with 

wrote and prerecorded their public service announcements to be played between 

week of the campaign. 

. By the third Saturday broadcast, Latino youths had 

videos. During the 2 months of broadcasting 

their campaign. 

Todo a Pulmón (“With Full Breath”): A Rhode Island Radio Campaign for Hispanic Youths 

Tobacco companies have successfully used advertising and promotional 

techniques to sell their products to minority members of their market, particularly 

youths. Reaching culturally diverse youths with a culturally sensitive message is a 

Two Rhode Island community-based organizations, Progreso Latino and 

Channel One, worked collaboratively with Latino youths and the personnel of the 

Spanish-language radio station WRIB to reach 12- to 17-year-old Hispanics/Latinos 

through a radio campaign. Youths from the two organizations were trained in countertobacco advocacy at workshops. Through ASSIST, they conducted a survey of 

racial/ethnic neighborhood billboard advertising. 

Media Intervention: Generación X

4 p.m. to 6 p.m. each Saturday. Between mid-December 1997 and mid-January 1998, 

youth tobacco control advocates and staff from Progreso Latino and Channel One 

Generación X personnel to work intensively on designing a statewide 

campaign. The campaign ran January–February 1998. The youths developed ideas, 

music cuts, and created antismoking messages to be broadcast live from the studio. 

The youths determined that both English and Spanish would be used on the program 

in an effort to reach a wider audience and to allow bilingual youths to use the language with which they were most comfortable. 

Youth participants rotated responsibilities for recording messages and going to the 

radio studio for broadcasts. Their prerecorded messages were broadcast 40 times 

during the week. The youths wrote and developed new messages, which aired every 

With the support of the radio station staff, Latino youths assumed ownership of the 

first half-hour of Generación X

renamed their segment of the program Todo a Pulmón. Youth-created don’t-smoke 

messages were delivered live from the studio. These antismoking messages were 

interspersed with tobacco facts contests; notices of local school and community 

events; calls from the youth audience; and talk about current music, movies, and 

Todo a Pulmón, the participating youths 

became more proficient, and the program improved in quality and popularity. This 

experience provided young Hispanic tobacco control advocates in Rhode Island with 

a bilingual radio forum to reach other youths in the state and gave them ownership of 

150 
M o n o g r a p h 1 6. A S S I S T 

Results: 

ish-language ads in their radio campaigns. 

youth. In 

In addition to the airtime devoted to the program, an unanticipated payoff of 

the campaign occurred: Other tobacco control coalition partners began using SpanSource: Adapted from G. S. Dennaker. 1998. Todo a Pulmón: A radio campaign targeting Hispanic 

No More Lies: Truth and the Consequences for Tobacco (Case Studies of the Fourth Annual 

National Conference on Tobacco and Health, October 26–28, 1998). Rockville, MD: ASSIST Coordinating Center. 

were in favor of, against, or neutral with 

respect to tobacco control.34 (To simplify 

discussion, the terms used in this section 

to describe the type of slant are prohealth, protobacco, and neutral.) 

To get a broad picture of whether 

there were changes in the general newspaper environment, the ASSIST 

Coordinating Center conducted a study 

to determine whether newspaper coverage of tobacco issues increased during 

several years of ASSIST. The study analyzed 95,911 articles collected in the 

newspaper clippings database during 

calendar years 1994 through 1998 to determine the rate of print media coverage 

on local tobacco control issues and to 

compare the amount of coverage in 

newspapers in ASSIST states with nonASSIST states. The analysis showed that 

the amount of tobacco coverage in newspapers was greater in ASSIST states 

than in non-ASSIST states in analyses 

that controlled for differences in states’ 

initial tobacco control conditions. Because ASSIST states had lower baseline 

scores on these conditions, it was predicted that fewer articles would be found 

in ASSIST states. Just the opposite was 

observed; thus, focusing on media interventions and media advocacy may have 

influenced the amount of coverage.34 

Reports to the States on Their 

Newspaper Coverage 

Media analysis quarterly reports derived from the database served to compare ASSIST state newspaper coverage 

with non-ASSIST state coverage of tobacco in the four ASSIST policy areas. 

On a quarterly basis, the ASSIST Coordinating Center sent to each state reports 

summarizing the data on newspaper articles specific to that state. Clipping tallies and percentages of coverage were 

calculated for each state and compared 

with national and ASSIST state percentages. States also received tables illustrating the number of articles clipped over 

the course of the quarter and a pie chart 

denoting the percentage of articles by 

policy type for that quarter. For example, a report to Michigan covering January 1 to March 31, 1994, highlighted the 

following two observations: 

1. There was a 2.6-fold increase in the 

number of clips between February 

and March of 1994, in part as a 

result of the Day One report on 

tobacco and the tobacco workers’ 

march on Washington. . . .

2. Press attention to Michigan’s Prop 

A and the tobacco workers’ march 

on Washington resulted in ASSIST 

sites having a higher percentage of 

articles focusing on economic 

151 
5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

disincentives than the national 

average. 35 

The data presented in figures 5.1 and 5.2 

are from the ASSIST newspaper clippings database. 

Time segment reports on newspaper 

coverage, such as those illustrated in table 5.2, can further be compared with significant events, legislation, and media 

interventions stimulated by either the tobacco companies or tobacco control advocates. The case study about North Carolina 

(case study 5.1) describes media intervention efforts by ASSIST from 1994 to 1997 

to move tobacco coverage from the business page to the news and editorial pages. 

In this tobacco-growing state, it was important for public health professionals to 

bring attention to tobacco use as a health 

issue, not only as an economic issue. During those years, the number of editorials 

supporting tobacco control measures increased. During three of those years 

(1995–97), the number of editorials supporting tobacco control exceeded the number of editorials that were opposed to 

tobacco control measures. This kind of 

feedback to the tobacco control practitioners reinforced their motivation and confidence in the effectiveness of their media 

intervention efforts. 

From Media to Policy Change 

T

hrough media advocacy and other 

media interventions, ASSIST brought 

public attention to tobacco policy issues. 

Although no single strategy worked in 

every state, the following important elements were in place throughout the 

project and contributed to the success of 

the media interventions: 

■	 Technical assistance and training in 

media communications 

■	 Strategic communication plans 

■	 Mechanisms for sharing information, 

ideas, and successes 

■	 Communications with the ASSIST 

Coordinating Center, which provided 

a national perspective on tobacco 

issues 

■	 A dedicated media staff person at the 

state level 

■	 Access to national experts 

■	 Access to materials that could be 

adapted locally for news stories, 

editorials, press releases, and other 

formats 

■	 A clear understanding of the 

audiences to be reached 

■	 Familiarity with the media markets 

■	 Well-established media relations 

■	 Skills in media advocacy 

The interventions of the 17 ASSIST 

states made tobacco and health an issue 

of public priority. The media interventions described in this chapter were applied to, and brought media attention to, 

the four policy areas described in chapter 6: clean indoor air, youth access to 

tobacco, cigarette excise tax increases, 

and tobacco advertising and promotion. 

152 
M o n o g r a p h 1 6. A S S I S T 

Michigan, January 1 to March 31, 1994 

Miscellaneous 

5% 

Clean Indoor 

Air 

45% 

Promotion 

7% 

Economic 

40% 

Access to 

Minors 

3% 

Michigan, October 1, 1993, to March 31, 1994 

0 

50 

100 

150 

200 

250 

300 

October December January February March

Month 

Number of articles 

Figure 5.2. Percentage of Articles by Policy Type: 

Advertising and 

Disincentives 

Source: ASSIST newspaper clippings database. 

Figure 5.1. Number of Policy-Related Tobacco Articles: 

Source: ASSIST newspaper clippings database. 

November 

153

5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

Table 5.2. Media Analysis Quarterly Report for Michigan: October 1, 1993, to March 31, 1994 

Michigan National ASSIST States 

N % % % 

By month 

October 

November 

December 

January 

February 

March 

Total 

By policy type 

Clean indoor air 

Youth access to tobacco 

Economic disincentives 

Advertising and promotion 

Miscellaneous 

Total 

By type of article 

Cartoon 

Editorial 

Hard news 

Letter to the editor 

Total 

By point of view 

Protobacco 

Neutral 

Prohealth 

Total 

By circulation 

< 10,000 

10,000–49,999 

50,000–99,999 

> 100,000 

Total 

By number of front-page articles 

130 17 14 18 

101 13 12 

54 7 

78 10 

116 15 

290 38 

13 

9 8 

13 12 

17 16 

36 33 

769 100 100 100 

220 45 

12 2 

194 40 

35 7 

23 5 

64 59 

7 6 

6 6 

6 6 

18 23 

484 100 100 100 

8 2 

94 19 

259 54 

123 25 

1 1 

17 17 

62 61 

20 21 

484 100 100 100 

77 16 

251 52 

156 32 

16 16 

58 55 

27 29 

484 100 100 100 

47 10 

198 41 

115 24 

124 26 

14 12 

43 41 

16 21 

26 26 

484 100 100 100 

59 12 11 12 

Source: ASSIST Coordinating Center, Rockville, MD. 

154 
M o n o g r a p h 1 6. A S S I S T 

Appendix 5.A. ASSIST Bibliography 

Bibliography Criteria 

These criteria were determined by the ASSIST Research and Publications Subcommittee. 

To be included in the ASSIST bibliography, 

• articles should relate to ASSIST and be authored after 10/91, 

• author/coauthor should be ASSIST staff or persons funded by ASSIST, and 

• articles should have appeared in peer-reviewed publications and/or should be official 

DOH publications that are available upon request. 

Asterisks indicate titles that were added since July 2003. 

Aakko, E., P. Remington, J. Calamon, S. Brazin, and L. Ford. 1997. Smoke-free 

workplaces, Wisconsin municipal and county government buildings, 1996. 

Wisconsin Medical Journal 96 (11): 34–6. 

Aakko, E., T. M. Piasecki, P. Remington, and M. C. Fiore. 1999. Smoking cessation 

services offered by health insurance plans for Wisconsin state employees 

(editorial). Wisconsin Medical Journal 98 (1): 14–8. 

Abt Associates. 1995. Independent evaluation of the Massachusetts Tobacco Control 

Program, executive summary, fiscal year 1994. Cambridge, MA: Abt Associates. 

Abt Associates. 1995. Independent evaluation of the Massachusetts Tobacco Control 

Program, first annual report, fiscal year 1994. Cambridge, MA: Abt Associates. 

Abt Associates. 1995. Independent evaluation of the Massachusetts Tobacco Control 

Program, interim summary, July 1993–December 1994. Cambridge, MA: Abt 

Associates. 

Abt Associates. 1996. Independent evaluation of the Massachusetts Tobacco Control 

Program, second annual report, January 1994–June 1995. Cambridge, MA: Abt 

Associates. 

Abt Associates. 1996. Independent evaluation of the Massachusetts Tobacco Control 

Program, second annual report, summary, January 1994–June 1995. Cambridge, 

MA: Abt Associates. 

Anderson, R. H., and M. C. Kegler. 1998. An assessment of local coalitions funded by 

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14. Wallack, L., K. Woodruff, L. Dorfman, 

and I. Diaz. 1999. News for a change: 

An advocate’s guide to working with the 

media. Thousand Oaks, CA: Sage. 

15. American Cancer Society and National 

Cancer Institute. 1993. ASSIST: A guide 

to working with the media. Atlanta: 

American Cancer Society. 

16. Environmental Protection Agency. 1992. 

Respiratory health effects of passive 

smoking: Lung cancer and other 

disorders (Publication no. EPA/600/6-

90/006F). Washington, DC: U.S. 

Environmental Protection Agency. 

17. U.S. District Court for the Middle 

District of North Carolina. 1998. The 

Osteen decision (6:93CV00370). 

www.tobacco.org/resources/documents/ 

980717osteen.html. 

18. Centers for Disease Control and 

Prevention. 1999. Great American 

Smokeout—November 18, 1999. 

Morbidity and Mortality Weekly Report 

164 
M o n o g r a p h 1 6. A S S I S T 

48 (43): 985. www.cdc.gov/tobacco/ 

research_data/mmwr1199.pdf. 

19. Cummings, K. M., R. Sciandra, and S. 

Markello. 1987. Impact of a newspaper 

mediated quit smoking program. 

American Journal of Public Health 77 

(11): 1452–3. 

20. Cummings, K. M., J. Kelly, R. Sciandra, 

T. DeLoughry, and F. Francois. 1990. 

Impact of a community-wide stop 

smoking contest. American Journal of 

Health Promotion 4 (6): 429–34. 

21. King, A. C., J. A. Flora, S. P. Fortmann, 

and C. B. Taylor. 1987. Smokers’ 

challenge: Immediate and long-term 

findings of a community smoking 

cessation contest. American Journal of 

Public Health 77 (10): 1340–1. 

22. Lando, H. A., B. Loken, B. HowardPitney, and T. Pechacek. 1990. 

Community impact of a localized 

smoking cessation contest. American 

Journal of Public Health 80 (5): 601–3. 

23. American Cancer Society. 1987. Smoke 

signals: The smoking control media 

handbook. New York: American Cancer 

Society. 

24. Davis, R. M. 1988. Health education on 

the six-o’clock news: Motivating 

television coverage of news in medicine. 

Journal of the American Medical 

Association 259 (7): 1036–8. 

25. Remington, P. L. 1998. Communicating 

epidemiologic information. In Applied 

epidemiology: Theory to practice, ed. R. 

C. Brownson and D. B. Petitti, 323–48. 

New York: Oxford Univ. Press. 

26. Warnecke, R. B., P. Langenberg, C. L. 

Gruder, B. R. Flay, and L. A. Jason. 

1989. Factors in smoking cessation 

among participants in a televised 

intervention. Preventive Medicine 18 

(6): 833–46. 

27. Cummings, K. M., R. Sciandra, S. 

Davis, and B. Rimer. 1989. Response to 

anti-smoking campaign aimed at 

mothers with young children. Health 

Education Research 4 (4): 429–37. 

28. Lydon, C. 1970. “Ban on TV cigarette 

ads could halt free spots against 

smoking.” New York Times, August 16, 

1970. Cited in U.S. Department of 

Health and Human Services. 1989. 

Reducing the health consequences of 

smoking: 25 years of progress, 496. A 

report of the Surgeon General (CDC 

publication no. 89-8411). Atlanta: U.S. 

Department of Health and Human 

Services. 

29. O’Keefe, M. T. 1971. The anti-smoking 

commercials: A study of television’s 

impact on behavior. Public Opinion 

Quarterly 35:242–8. 

30. Cowling, D. W., S. L. Kwong, R. 

Schlag, J. C. Lloyd, and D. G. Bal. 

2000. Declines in lung cancer rates— 

California, 1988–1997. Morbidity and 

Mortality Weekly Report 49 (47): 1066– 

9. www.cdc.gov/tobacco/research_data/ 

health_consequences/ccmm4947.pdf. 

31. Robbins, H., M. Krakow, and D. Warner. 

2002. Adult smoking intervention 

programmes in Massachusetts: A 

comprehensive approach with promising 

results. Tobacco Control 11 Suppl. no. 

2: ii4–ii7.

32. Abt Associates Inc., G. D. Norton, and 

W. L. Hamilton. 1999. Independent 

evaluation of the Massachusetts 

Tobacco Control Program. Sixth annual 

report, January 1994 to June 1999. 

Cambridge, MA: Abt Associates, Inc. 

33. Siegel, M., and L. Biener. 2000. The 

impact of an antismoking media 

campaign on progression to established 

smoking: Results of a longitudinal youth 

study. American Journal of Public 

Health 90 (3): 380–6. 

165 
5. M e d i a I n t e r v e n t i o n s t o P r o m o t e T o b a c c o C o n t r o l P o l i c i e s 

34. Stillman, F. A., K. A. Cronin, W. D. 

Evans, and A. Ulasevich. 2001. Can 

media advocacy influence newspaper 

coverage of tobacco: Measuring the 

effectiveness of the American Stop 

Smoking Intervention Study’s (ASSIST) 

media advocacy strategies. Tobacco 

Control 10:137–44. 

35. ASSIST Newspaper Clippings 

Database. Internal document, ASSIST 

Coordinating Center, Rockville, MD. 

166 
M o n o g r a p h 1 6. A S S I S T 

6. Public and Private Policy Interventions

Sally Herndon Malek, Robert E. Vollinger Jr., Stephen Babb, 

Karla S. Sneegas, and Donald R. Shopland 

Contributors: Kenneth Adami, Patrick Cobb, Lori Fresina, Jim Harrington, 

C. Ann Houston, Anne Landman, Patricia Lindsey, Jim D. Martin, 

Tim Nichols, Krista V. Schaafsma, Russell Sciandra, Sue Vermeulen, 

Gregory White, and Marge White 

Contents 

Policy as an Intervention ........................................................................................... 169


Interventions in Four Policy Areas ............................................................................. 170


Eliminating Exposure to Environmental Tobacco Smoke .................................................... 171


Promoting Higher Taxes for Tobacco .................................................................................. 174


Limiting Tobacco Advertising and Promotions ................................................................... 179


Reducing Minors’ Access to Tobacco Products .................................................................. 182


Challenges to Public Policy Interventions .................................................................. 183


Discrediting the Science .................................................................................................... 185


Ineffective Alternatives ..................................................................................................... 185


Preemption ........................................................................................................................ 186


Insights from Policy Advocacy Experiences ............................................................... 187


Insight 1: Most Policymakers Want to Do the Right Thing for the Public’s Health, but


the Right Thing Must Be Explained and Promoted to Them by Their Constituents ............. 187


Insight 2: The Process of Laying the Groundwork for Policy Change Can Be as

Important as the Policy Itself ............................................................................................ 189


Insight 3: Policy Change Is Political; Therefore, Boundaries Must Be Defined and Redefined .. 191


Insight 4: United, We Succeed ........................................................................................... 194


Insight 5: Develop the Necessary Skills among Various Leaders to Advance a Winning


Combination of Activism, Advocacy, and Diplomacy .......................................................... 196


Insight 6: Shining Light on the Tobacco Industry’s Tactics Can Help Advocates Achieve


Policy Goals ....................................................................................................................... 198


Insight 7: Effective Social Movements Engage Many Segments of the Community ........... 198


Insight 8: Youth Are Effective Change Agents ................................................................... 200


Insight 9: Framing the Issue and Using the Science Help to Put You in Control ................ 203


167 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Insight 10: Policy Change Requires a Flexible Strategy and the Ability to Respond

Rapidly to Opportunity ....................................................................................................... 212


Insight 11: Make Gains Where Possible—Small Changes Add Up .................................... 213


Insight 12: Keep Policy Advocacy Local and Loud .............................................................. 213


Insight 13: It’s Not Over ’Til It’s Over, or Never Give Up, Never Give Up, NEVER GIVE UP! ... 216


Insight 14: It’s Never Over!: The Importance of Vigilance after a Policy Takes Effect ......... 218


The Influence of Policy .............................................................................................. 218


References ................................................................................................................ 278


Additional Resources ................................................................................................ 282


Case Studies 

Case Study 6.1. Kids Make Crucial Appeal to Policymakers in St. Louis County ..................... 190


Case Study 6.2. Tobacco and Sports Don’t Mix in Virginia! .................................................... 192


Case Study 6.3. ASSIST Unites with Faith Leaders to Ban Tobacco Advertising in St. Louis ... 195


Case Study 6.4. Filling the Roles in Las Cruces, New Mexico ................................................. 197


Case Study 6.5. Shining the Light on Tobacco Advertising and Promotions ........................... 199


Case Study 6.6. Massachusetts Increases Tobacco Tax to Fund Healthcare for Children ....... 201


Case Study 6.7. Youth Advocates Make Michigan Arena Tobacco Free ................................... 204


Case Study 6.8. Teens Lead the Way in Silver City, New Mexico .............................................. 206


Case Study 6.9. New York Counters Tobacco Industry Claims with Data ................................ 208


Case Study 6.10. Collecting Local Numbers in North Carolina ............................................... 209


Case Study 6.11. Point of Purchase: Operation Storefront ..................................................... 210


Case Study 6.12. An Historic Opportunity: South Carolina Bans Smoking in Its State House ...... 214


Case Study 6.13. Twice North Carolina Makes Gains for a Smoke-free School Environment ..... 215


Case Study 6.14. Indiana’s Battle against Preemption .......................................................... 217


Case Study 6.15. Persistence Pays Off in Mesilla, New Mexico .............................................. 219


Case Study 6.16. Changing Policy on Public Transportation: Smoke-free Washington


State Ferries .......................................................................................................................... 220


Case Study 6.17. Protecting the Gain in Las Cruces, New Mexico .......................................... 222


Tables 

Table 6.1. Number of Municipalities per State with Clean Indoor Air Ordinances,


as of August 25, 2003 ........................................................................................................... 175


Table 6.3. Number of Municipalities per State with Advertising Ordinances,


Table 6.4. Number of Municipalities per State with Youth Access Ordinances,


Table 6.2. State Tax Rates for 2000 and Rate Increases, 1991–99 (per pack) ....................... 177


as of August 25, 2003 ........................................................................................................... 181


as of August 25, 2003 ........................................................................................................... 184


Appendices 

Appendix 6.A. Excerpts from Youth Access to Tobacco: A Guide to Developing Policy ............. 224


Appendix 6.B. Excerpts from Clean Indoor Air: A Guide to Developing Policy .......................... 235


Appendix 6.C. Excerpts from Tobacco Advertising and Promotion: A Guide to Developing Policy .. 253


168 
M o n o g r a p h 1 6. A S S I S T 

6. Public and Private Policy Interventions

At the center of the American Stop Smoking Intervention Study (ASSIST) model is 

the use of policy to alter the environment in which people live and change the social 

norm from one that tolerates smoking to one that actively discourages the use of 

tobacco in any form. This chapter presents the ASSIST states’ intervention strategies 

to achieve policies that advance objectives in four tobacco control areas: eliminating 

exposure to environmental tobacco smoke, increasing the price of tobacco products, 

restricting tobacco advertising and promotions, and reducing youth access to 

tobacco products. All 17 ASSIST states made progress in these four areas, but not 

without overcoming formidable challenges. Through policy advocacy interventions, 

ASSIST educated policymakers, organizations, businesses, and individuals about the 

benefits of mandatory and voluntary tobacco control policies. In this chapter, case 

studies of interventions and insights of staff and coalition members illustrate the 

process of mobilizing ordinary citizens to effect major policy change despite 

opposition from a powerful, determined tobacco industry. 

Policy as an Intervention 

Changes in public and private policies are formal reflections of changes in community norms and as such, predictors of behavioral change. Providing leadership for 

policy development is a core function of governmental public health agencies.1,2(pp6–7),3 

State and local health departments have a long history of using policy interventions (requiring immunizations and restaurant inspections, etc.) to prevent and control infectious 

diseases. However, using a policy advocacy approach to prevent chronic disease caused 

by tobacco use was a major change in the public health approach to tobacco prevention 

and control at the time ASSIST began. 

Shaping community norms about tobacco use and building support for public and 

private policies through the mass media and social networks are at the heart of the 

ASSIST model. Policy interventions must convince decision makers that the public 

perceives a proposed policy to be in the best interest of the community as a whole. 

Media advocacy helps bring about public and private policy changes, which in turn increase the demand for and use of program services. The three types of intervention— 

mass media, policy, and program services—can be likened to a three-legged stool: all 

three support behavioral change and without any one of the legs, the stool will not 

stand. 

As all ASSIST contractors and subcontractors knew, federal money carries a variety 

of contractual, regulatory, and legislative restrictions. In 1991, at the start of the 

project, these restrictions were identified, explained, and widely disseminated in the 

169 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

White Paper entitled Restrictions on 

Lobbying and Public Policy Advocacy 

by Government Contractors: The 

ASSIST Contract.4 It was revised, updated, and redistributed to all ASSIST 

project directors, project managers, and 

the ASSIST Coordinating Center by the 

National Cancer Institute (NCI) ASSIST 

contracting officer on July 23, 1997.5 

The restrictions were also the subject of 

numerous trainings.6 Throughout the 

ASSIST intervention phase, additional 

restrictions in regard to lobbying were 

attached to federal funding, especially 

through the annual appropriations process. Beginning October 1, 1998, none 

of the federal funding for ASSIST could 

be used by any partners for lobbying at 

any level, including the local level. The 

provisions of the Federal Acquisition 

Streamlining Act of 19947

 applied to the 

ASSIST contract extensions for the last 

year of ASSIST, in 1998, because they 

were considered “new contracts.” Encumbrances on the use of federal and 

foundation funding were one of the important reasons that ASSIST coalitions 

included different partners. Charitable 

organizations—called 501(c)(3)s in the 

Internal Revenue Code—including the 

American Cancer Society (ACS), are allowed to make substantial expenditures 

on lobbying.8,9 Most of the public education that precedes policy and all of the 

enforcement that follows policy do not 

constitute lobbying. Partners like ACS 

and the many volunteers who participated in ASSIST coalitions could lobby and 

perform other functions that could not 

be financed with federal funds. (See section on Understanding the Regulations 

on Lobbying, chapter 8, part 2). 

Interventions in 

Four Policy Areas 

F

ollowing the ASSIST framework described in chapter 2, the 17 states promoted interventions in four policy areas, 

expressed as objectives in the “ASSIST 

Program Guidelines for Tobacco-free 

Communities”: 

Eliminate environmental tobacco 

smoke in all areas where others may 

face involuntary exposure and the 

serious health risks associated with 

inhalation of other people’s tobacco 

smoke. 

Eliminate all tobacco product advertising and promotion, other than point of 

sale price and objective product 

information advertising. 

Reduce access to and availability of 

tobacco products, particularly to 

persons under the legal age of 

purchase. 

Reduce consumption of cigarettes and 

other tobacco products through price 

increases using increased taxes and 

other costs imposed on tobacco 

products.10(p12) 

tions stimulated the passage of state and local 

and 1999, municipalities enacted local ordiControl Ordinance Database(c), 9/18/03. 

Ordinances Passed during ASSIST Years 

Tobacco control efforts by the ASSIST coalilaws and also private policies. Between 1992 

nances in the ASSIST states in the four policy 

areas: clean indoor air (506), excise taxes (7), 

youth access (688), and advertising (74). 

Source: ANR Foundation Local Tobacco 

Copyright 1998–2003 American Nonsmokers’ 

Rights Foundation. All rights reserved. 

170 
M o n o g r a p h 1 6. A S S I S T 

These objectives guided ASSIST’s tobacco control advocates in developing 

their strategies to reduce tobacco use by 

influencing social norms through policy. 

See appendices 6.A–6.C for excerpts 

from the ASSIST policy guides on youth 

access to tobacco, clean indoor air, and 

tobacco advertising and promotion. 

Eliminating Exposure to 

Environmental Tobacco Smoke 

The purpose of environmental tobacco 

smoke (ETS) policies is to protect people from involuntary exposure to other 

people’s tobacco smoke and from the serious health risks associated with inhaling it. For most people, tobacco smoke 

is the most widespread and harmful indoor pollutant that they will encounter. 

The harmful effects of ETS or secondhand smoke are well documented and 

are described in numerous reports: 

■	 Centers for Disease Control and 

Prevention’s 1986 Health 

Consequences of Involuntary 

Smoking: A Report of the Surgeon 

General11 

■	 U.S. Environmental Protection 

Agency’s (EPA) 1992 Respiratory 

Health Effects of Passive Smoking: 

Lung Cancer and Other Disorders12 

■	 California EPA’s 1997 Health Effects 

of Exposure to Environmental 

Tobacco Smoke: Final Report and 

Appendices13 

■	 National Toxicology Program’s 2000 

Ninth Report on Carcinogens14 

■	 International Agency for Research on 

Cancer’s 2004 monograph, Tobacco 

Smoke and Involuntary Smoking15 

change as it ages and combines with 

Exposure to ETS is also frequently 

a 

clean indoor air

. 

a

National Cancer Institute. 1999. Health ef­

(Smoking and tobacco control monograph no. 10, NIH 

publication no. 99-4645). Bethesda, MD: 

vices, National Institutes of Health (p. ES1). 

Terms for Environmental Tobacco Smoke 

“ETS, or ‘secondhand smoke,’ is the 

complex mixture formed from the 

escaping smoke of a burning tobacco 

product and smoke exhaled by the 

smoker. The characteristics of ETS 

other constituents in the ambient air. 

referred to as ‘passive smoking,’ or 

‘involuntary tobacco smoke’ exposure. 

Although all exposures of the fetus are 

‘passive’ and ‘involuntary,’ . . . in utero 

exposure resulting from maternal 

smoking during pregnancy is not 

considered to be ETS exposure.”

The ASSIST project originally used the term 

 to refer to policies but later 

expanded the concept to include outdoor 

environments as well and used the term 

environmental tobacco smoke

fects of exposure to environmental tobacco 

smoke: The report of the California Environmental Protection Agency

U.S. Department of Health and Human Ser1993.

The U.S. Environmental Protection 

Agency designated ETS as a Class A 

(known human) lung carcinogen in 

12(p1) The National Institutes of 

Health’s National Toxicology Program 

has determined that ETS is a known human carcinogen. NIH’s Ninth Report on 

Carcinogens concluded that ETS exposure is causally related to lung cancer. 

The report notes that secondhand smoke 

contains at least 250 chemicals that are 

known to be toxic or carcinogenic.14 

Each year in the United States, ETS is 

171 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

responsible for at least 3,000 deaths 

from lung cancer and about 47,000 

deaths from ischemic heart disease.16–19 

In addition to causing these diseases in 

adults, ETS has been found to cause a 

number of health problems in children, 

including bronchitis, pneumonia, asthma, middle ear infections, and sudden 

infant death syndrome.16 The Surgeon 

General has concluded that, compared 

with children of nonsmoking parents, 

children of parents who smoke have an 

increased frequency of respiratory infections, increased respiratory symptoms, 

and slightly lower rates of increase in 

lung function.11 The evidence that ETS 

poses serious health risks has become 

even stronger since the end of ASSIST. 

While the primary purpose of smoking restrictions is to protect nonsmokers 

from the carcinogens and toxins found in 

ETS, recent evidence points to a second 

benefit—ETS policies help reduce 

smoking prevalence: 

1999 ASSIST conference materials 

tion purposes. By Mecklenburg County (NC) Health 

Department guide to smoke-free 1991, the adverse 

restaurants health effects of tobacco use and ETS 

Research clearly shows that smokefree public places, especially workplaces, provide a more supportive 

environment for smokers to quit. Even 

the tobacco industry’s own internal 

research has shown this. For example, 

a Philip Morris study that followed 

some 25,000 smokers over time found 

that those working in a smoke-free 

work environment experienced an 84 

percent higher quit rate than those 

facing no or minimal smoking 

restrictions.20(piii) 

A 1990 study of nearly 12,000 California residents found that employees in 

smoke-free workplaces had a lower 

smoking prevalence and, among continuing smokers, lower cigarette consumption than individuals working 

where smoking was permitted.21 A review of 26 studies conducted between 

1984 and 1993 on the effects of smokefree workplaces found that totally 

smoke-free workplaces were associated 

with reductions in smoking prevalence 

of 3.8% and of 3.1 

fewer cigarettes 

smoked per day per 

continuing smoker.22 

When the ASSIST 

project started, a few 

states or localities had 

restrictions on public 

smoking; however, 

many of these had 

been enacted for fire 

prevention or nuisance purposes rather 

than for health protec172 
M o n o g r a p h 1 6. A S S I S T 

exposure were well documented, and a 

mounting body of scientific evidence 

supported the effectiveness of certain 

policies for reducing tobacco use. For 

example, in 1989, Congress prohibited 

smoking on all domestic commercial 

flights up to 6 hours in duration to protect airline workers and passengers from 

health risks associated with ETS. NCI, 

through its systematic research approach 

that led to ASSIST, was ready in 1991 to 

greatly increase the use of policy interventions to reduce and prevent tobacco use. 

The ASSIST program objectives for 

smoke-free environments sought the following four outcomes: 

1. State and municipal regulations 

creating smoke-free environments 

2. Substantial and progressive voluntary 

action by employers, property owners, 

commercial enterprises, university 

and school officials, healthcare providers, municipal and transportation 

authorities, day care centers, media 

gatekeepers, parents, and others to 

support and adopt smoke-free policies 

3. Broader and more intense public and 

policymaker support for implementation of smoke-free policies in worksites, public places, schools, and other 

locations 

4. Increased levels of citizen awareness 

of the harmful nature of ETS 

The primary policy intervention strategy was direct policy advocacy aimed at 

increasing the public’s and policymakers’ awareness of the issues. Coalition members informed public regulatory 

authorities about legislative steps taken 

in other jurisdictions to create smokefree environments; encouraged property 

owners and managers, business owners, 

employers, and healthcare providers to 

voluntarily implement smoke-free policies 

on their premises; and provided media 

contacts with the evidence and rationale 

to support a smoke-free position in articles and editorials. (See chapter 5.) 

ASSIST state and local coalitions recognized the strategic advantages of focusing efforts for smoke-free policies on 

a variety of public settings. In many 

communities, protecting children from 

ETS exposure was the first and most obvious choice. For some indoor commercial settings (e.g., restaurants, hotels, 

and theaters) advocates could present 

clear evidence of financial benefits to 

the businesses in addition to the health 

benefits of smoke-free environments. 

For other settings, such as bars, the evidence became available only in the later 

ASSIST years.23,24 After reviewing all 97 

studies on the economic impact of 

smoke-free policies on the hospitality 

industry, Scollo and colleagues concluded, “All of the best designed studies report no impact or a positive impact of 

smoke-free restaurant and bar laws on 

sales or employment.”25(p13) The tobacco 

industry circulated anecdotal information that led restaurant and bar proprietors to believe that smoking restrictions 

would negatively affect their business.25 

However, the tobacco industry’s internal 

documents make clear that its real concern was the economic impact that these 

policies were having on the industry itself by motivating smokers to quit or reduce their consumption. In the tobacco 

industry’s own words, “Total prohibition 

of smoking in the workplace strongly affects industry volume. Smokers facing 

173 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

these restrictions consume 11%–15% 

less than average and quit at a rate that 

is 84% higher than average.”26 Table 6.1 

contains a breakout of the clean indoor 

air ordinances enacted as of August 25, 

2003. The tables in this chapter include 

data for all states, to put the ASSIST 

states in context. For more current data, 

contact the Americans for Nonsmokers’ 

Rights at www.no-smoke.org. 

As the ASSIST states succeeded in 

securing adoption of clean indoor air 

policies, they also sought to eliminate 

exposure in all public settings in which a 

large number of people could be exposed to environmental tobacco smoke. 

Outdoor settings for sports and entertainment events were also of particular 

concern to ASSIST coalitions because 

children and adolescents tend to be 

present at these settings. 

Promoting Higher Taxes for Tobacco 

An increase in the price of cigarettes 

results in a decrease in cigarette consumption. The substantial evidence for 

the relationship between price (including 

increases by taxation) and consumption 

has been summarized in numerous reports: the 1992 report of the surgeon 

general, Smoking and Health in the 

Americas;

27 a 1993 summary report of a 

National Cancer Institute Expert Panel;28 

the 1994 Institute of Medicine report, 

Growing Up Tobacco Free;

1 the 2000 Institute of Medicine report, State Programs Can Reduce Tobacco Use;

29 and 

the 1999 World Bank report, Curbing 30 the Epidemic. 

Studies show a range of estimates for 

the price elasticity of demand for cigarettes, but most fall in the range from 

–0.25 to –0.50. The range indicates that 

if cigarette prices rise by 10%, overall 

cigarette smoking will fall by between 

2.5% and 5%. The long-term response to 

a permanent change in cigarette prices 

will be larger than the initial short-run 

response.31 Another finding is that young 

smokers are up to three times more sensitive to price than are adult smokers.32 

The relationship between price and consumption is also noted in internal tobacco industry documents: 

In the opinion of PM Inc. and Philip 

Morris International, past increases in 

excise and similar taxes have had an 

adverse impact on sales of cigarettes. 

Any future increases, the extent of 

which cannot be predicted, could result 

in volume declines for the cigarette 

industry, including PM Inc. and Philip 

Morris International.33(p165) 

Many major health and medical organizations in the United States and the 

recognized. In a report on the economics of 

Curbing the 

book/html/chapter4.htm. 

Long-standing Benefits of 

Tobaco Excise Taxes 

The benefits of excise taxes have long been 

tobacco control, the World Bank refers to 

Adam Smith’s reasoning regarding the 

advantages of tobacco taxes. Because tobacco 

taxes would lessen the need for other excise 

taxes, for example, on necessities and other 

manufactured goods, he promoted excise 

taxes as benefiting the poor. Smith argued 

that with tobacco excise taxes, poor people 

would “live better, work cheaper, and . . . 

send their goods cheaper to market.” 

Source: World Bank. 1999. 

epidemic: Governments and the economics of 

tobacco control. Washington, DC: World 

Bank (p. 37). www1.worldbank.org/tobacco/ 

174 
M o n o g r a p h 1 6. A S S I S T 

Table 6.1. Number of Municipalities per State with Clean Indoor Air Ordinances, as of August 25, 2003 

(Shading indicates ASSIST states.) 

State Total Workplaces Restaurants Bars Public Places 

California 332 293 272 22 304 

Massachusetts 227 173 211 76 211 

Missouri 108 95 39 3 

91 39 6 0 52 

105 

New Jersey 

Texas 74 46 61 7 73 

Alabama 68 62 18 1 65 

1 54 

54 53 53 2 

52 48 18 4 

North Carolina 51 43 32 5 

Wisconsin 58 47 23 

West Virginia 54 

New York 47 

50 

Kansas 50 44 7 1 47 

Colorado 47 42 38 6 46 

Georgia 38 33 21 1 35 

Louisiana 38 31 6 0 37 

Mississippi 34 33 1 1 33 

Arizona 30 28 25 2 29 

Illinois 30 20 19 0 28 

Ohio 23 21 20 2 23 

Oregon 21 20 16 3 20 

Virginia 20 9 17 0 20 

Florida 15 5 0 0 6 

South Carolina 15 8 3 0 

14 10 1 0 12 

14 11 8 1 13 

14 

Michigan 

New Mexico 

Maryland 12 10 7 1 11 

Minnesota 4 4 0 6 

Indiana 9 8 3 2 9 

12 

Pennsylvania 9 5 5 0 8 

Rhode Island 9 1 1 0 1 

Tennessee 9 8 3 0 9 

Alaska 7 5 6 0 5 

Washington 7 4 3 0 5 

Hawaii 5 

Montana 5 

Nebraska 5 

North Dakota 5 

Arkansas 4 

3 5 0 5 

5 4 1 5 

4 0 0 4 

4 2 0 5 

3 2 0 4 

Maine 4 3 2 0 3 

New Hampshire 4 0 3 0 0 

Iowa 3 3 0 0 3 

Wyoming 3 3 2 0 3 

Delaware 2 2 2 0 2 

Oklahoma 2 1 0 0 2 

Utah 2 1 0 0 1 

Kentucky 1 1 1 1 1 

District of Columbia 1 1 1 0 1 

Vermont 1 1 1 0 1 

Connecticut 1 1 0 0 1 

South Dakota 1 1 0 0 1 

Idaho 0 0 0 0 0 

Nevada 0 0 0 0 0 

Source: ANR Foundation Local Tobacco Control Ordinance Database©, 9/18/03. Copyright 1998–2003 American 

Nonsmokers’ Rights Foundation. All rights reserved. 

Note: Because some municipalities have coverage in more than one category, the numbers are not mutually exclusive. 

175 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

a number of states to pass tobacco tax 

increases. 

tobacco. Historical compilation,

ASSIST States Increase Tobacco Taxes 

During the ASSIST project, 12 of the 17 

ASSIST states increased tobacco taxes. 

Increases ranged from 1–71¢ and averaged 

14¢. After the ASSIST project ended, the 

capacity built by the project helped facilitate 

Sources: American Lung Association. 2001. 

State legislated actions on tobacco issues, ed. 

E. M. Schilling and C. E. Welch. Washington, 

DC: American Lung Association; The 

Tobacco Institute. 1998. The tax burden on 

 vol. 33. 

Washington, DC: The Tobacco Institute. 

World Health Organization, in its publication Guidelines for Controlling and 

Monitoring the Tobacco Epidemic 34, 

identify increasing tobacco taxes as a 

key strategy for reducing tobacco use.35 

The most common means available to 

the public for raising the price is to increase the excise tax on tobacco products. 

The public tends to support increases 

in tobacco taxes in part because they favor funding tobacco prevention programs.36 Reporting the results of a 1997 

telephone poll paid for by the Abell 

Foundation and the Maryland Teachers 

Association, the Baltimore Sun stated, 

Anti-smoking activists released a poll 

yesterday showing Maryland voters 

favor by nearly 2-to-1 a $1.50-a-pack 

increase in the state’s cigarette tax and 

said teen smoking has become so 

potent a political issue that it can 

outweigh party loyalty.37 

More recently, a 2003 synthesis (by 

the Campaign for Tobacco-Free Kids) of 

polls conducted in 28 states in 2002 and 

2003 shows that there is broad public 

and voter support for cigarette-tax 

increases.36 In most states, voters favor 

the proposed cigarette-tax increase by a 

2-to-1 margin. They prefer cigarette-tax 

increases to other tax increases or to 

budget cuts but also strongly believe that 

at least some tobacco-tax revenues 

should be used for programs to prevent 

and reduce smoking, especially by children and adolescents.36 A second reason 

that the public supports tobacco tax increases may be the exposure of the tobacco industry’s culpability in deceiving 

the public and its diminished credibility 

resulting from the litigation of the 1990s 

and the internal industry documents that 

were consequently made public. 

The ASSIST objective for the tobaccopricing policy area was to reduce consumption of cigarettes and other tobacco 

products through price, and especially 

tax, increases. The objective can be best 

achieved by gaining the support of the 

public and of policymakers; therefore, a 

public-private partnership, such as that 

of NCI with ACS, is fundamental to the 

strategy. To increase the public’s and 

policymakers’ awareness of the need for 

higher taxes on tobacco products, the 

ASSIST coalitions disseminated data on 

the effectiveness of substantial tobaccotax increases in reducing tobacco consumption and on public support for such 

measures. Coalition members met with 

community and business leaders and 

with media contact persons to encourage 

them to write editorials supporting substantial tax increases. Table 6.2 shows 

the state tax excise rate increases during 

the ASSIST years. (See NCI Monograph 

17 for a comparative evaluation of 

176 
M o n o g r a p h 1 6. A S S I S T 

Table 6.2. State Tax Rates for 2000 and Rate Increases, 1991–99 (per pack) 

(Shading indicates ASSIST states.) 

Date of 

State 2000 Rate Rate Change Change 

$1.110 39 to 56¢ 6/1/93 

56¢ to $1.11 3/1/00 

New York 

Alaska $1.000 29¢ to $1.00 1/29/97 

Hawaii $1.000 60¢ 7/1/93 

60 to 80¢ 9/1/97 

80¢ to $1.00 7/1/98 

California $0.870 35 to 37¢ 1/1/94 

37 to 87¢ 1/1/99 

Washington $0.825 43 to 54¢ 7/1/93 

54 to 56.5¢ 7/1/94 

56.5 to 81.5¢ 7/1/95 

81.5 to 82.5¢ 7/1/96 

New Jersey $0.800 40 to 80¢ 1/1/98 

Massachusetts $0.760 26 to 51¢ 1/1/93 

51 to 76¢ 10/1/96 

Michigan $0.750 25 to 75¢ 5/1/94 

Maine $0.740 31 to 33¢ 1/1/91 

33 to 37¢ 7/1/91 

37 to 74¢ 11/1/97 

Rhode Island $0.710 37 to 44¢ 7/1/93 

44 to 56¢ 7/1/94 

56 to 61¢ 7/1/95 

61 to 71¢ 7/1/97 

Oregon $0.680 28 to 33¢ 

33 to 38¢ 

38 to 68¢ 

11/1/93 

1/1/94 

2/1/97 

Maryland $0.660 13 to 16¢ 

16 to 36¢ 

36 to 66¢ 

6/1/91 

5/1/92 

7/99 

District of Columbia $0.650 17 to 30¢ 

30 to 50¢ 

50 to 65¢ 

7/1/91 

6/1/92 

7/1/93 

$0.590 30 to 38¢ 5/1/92 

38 to 44¢ 9/1/95 

44 to 59¢ 11/1/97 

Wisconsin 

Arizona $0.580 

Illinois $0.580 

New Hampshire $0.520 

Utah $0.515 

Connecticut $0.500 

15 to 58¢ 

30 to 44¢ 

44 to 58¢ 

25 to 37¢ 

37 to 52¢ 

23 to 26.5¢ 

26.5 to 51.5¢

40 to 45¢ 

45 to 47¢ 

47 to 50¢ 

1/29/94 

7/14/93 

12/16/97 

7/1/97 

7/6/99 

7/1/91 

7/1/97 

10/1/91 

7/1/93 

7/1/94 

Minnesota $0.480 38 to 43¢ 6/1/91 

43 to 48¢ 7/1/92 

177 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Table 6.2. (continued) 

Date of 

State 2000 Rate Rate Change Change 

North Dakota $0.440 30 to 39¢ 7/1/91 

29 to 44¢ 7/1/93 

Vermont $0.440 17 to 18¢ 7/1/91 

18 to 19¢ 1/1/92 

19 to 20¢ 7/1/92 

20 to 44¢ 7/1/95 

Texas $0.410 No rate change during this period. 

Iowa $0.360 31 to 36¢ 6/1/91 

Nevada $0.350 No rate change during this period. 

Arkansas $0.345 21 to 22¢ 7/1/91 

22 to 34.5¢ 2/1/93 

34.5 to 31.5¢ 7/1/93 

Nebraska $0.340 27 to 34¢ 7/1/93 

South Dakota $0.340 22 to 33¢ 7/1/95 

Florida $0.339 No rate change during this period. 

Pennsylvania $0.310 18 to 31¢ 8/19/91 

Idaho $0.280 18 to 28¢ 7/1/94 

Delaware $0.240 19 to 24¢ 1/1/91 

Kansas $0.240 No rate change during this period. 

Louisiana $0.240 No rate change during this period. 

Ohio $0.240 18 to 24¢ 1/1/93 

Oklahoma $0.230 No rate change during this period. 

Mississippi 

Montana 

$0.180 

$0.180 

No rate change during this period. 

18 to 19.26¢ 

19.26 to 18¢

8/15/92 

8/15/93 

$0.210 15 to 21¢ 7/1/93 

Colorado $0.200 No rate change during this period. 

New Mexico 

Missouri $0.170 13 to 17¢ 10/1/93 

West Virginia $0.170 No rate change during this period.

Alabama $0.165 No rate change during this period. 

Indiana $0.155 No rate change during this period. 

Tennessee $0.130 

Georgia $0.120 

Wyoming $0.120 

No rate change during this period. 

No rate change during this period. 

No rate change during this period. 

South Carolina $0.070 No rate change during this period. 

North Carolina $0.050 2 to 5¢ 8/1/91 

Kentucky $0.030 No rate change during this period. 

Virginia $0.025 No rate change during this period. 

Sources: American Lung Association. 2001. State legislated actions on tobacco issues, ed. E. M. Schilling and C. E. 

Welch. Washington, DC: American Lung Association; The Tobacco Institute. 1998. The tax burden on tobacco. Historical compilation, vol. 33. Washington, DC: The Tobacco Institute. 

178 
M o n o g r a p h 1 6. A S S I S T 

ASSIST and non-ASSIST states.) Some 

municipalities also passed local ordinances 

levying excise taxes on tobacco products. 

During the ASSIST years (1991–99), cigarette excise taxes levied by municipalities in the ASSIST states ranged from 3 

to 36¢ per pack. For cigars, the range 

was 3 to 4¢ per cigar, and for smokeless 

tobacco, it was 4 to 36¢ per smokeless 

tobacco container.38 

Limiting Tobacco Advertising 

and Promotions 

Cigarette advertising and promotions 

by the tobacco industry depict and reinforce social norms that support smoking, 

contribute to the social pressures on 

young people to start smoking, and 

weaken the resolve of smokers to quit. 

Advertising and promotions help create 

the impression, especially among young 

people, that smoking is more pervasive 

than it is and create misleading images 

of social rewards and healthfulness of 

smoking. The tobacco industry has systematically marketed its products to 

youths.39–42 A study of 1,752 adolescents 

in California, from 1993 to 1996, found 

that 34% of teen smoking experimentation was attributable to tobacco advertising and promotional activities.43 The 

tobacco industry spends billions of dollars each year on advertisements and 

promotions. During the ASSIST years 

and directly thereafter, those expenditures increased from $4.6 billion in 1991 

to $8.24 billion in 1999 and $12.5 billion in 2002.44(p1) 

There is strong evidence that advertising targeted at youth influences youth 

attitudes and behavior. In an Advertising 

Age survey conducted in April 1992, 325 

children (8 to 13 years of age) were 

asked to name familiar cigarette brands; 

90% named Camel.45 Having a favorite 

advertisement and having a promotional 

item are each predictive of cigarette experimentation.43 As Fischer and colleagues noted, “Approximately 30% of 

3-year-old children correctly matched 

Old Joe with a picture of a cigarette 

compared with 91.3% of 6-year-old 

children.”46(p3145) (“Old Joe” was a cartoon character featured prominently in a 

Camel cigarette ad campaign.) 

and promotions: 

■ Petition and persuade public authorities 

scope of authority (e.g., on public 

transportation). 

■ 

promotion on their premises. 

■ 

appealing to priority population audiences, 

■ 

and to write editorials in support of 

■ 

appeal to youth; public attitudes and 

Strategies to Limit Tobacco 

Advertising and Promotions 

The states implemented the following types 

of strategies to counter tobacco advertising 

with regulatory powers to restrict or ban 

advertising and promotion within their 

Persuade property and business owners 

and managers to voluntarily reject 

cigarette advertising and tobacco 

Persuade civic, sports, arts, and other event 

sponsors, especially those events 

to reject cigarette advertising and 

promotional sponsorship of such events. 

Persuade media owners and advertising 

managers to refuse cigarette advertising 

advertising and promotion bans. 

Provide the media with evidence about the 

tobacco industry’s advertising and 

promotion strategies, especially as they 

actions supportive of advertising control 

policies; and financial ties and conflicts of 

interest of organizations that accept 

tobacco industry business and support. 

179 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Restrictions on advertising and promotions at the state or local level are difficult to achieve because of First 

Amendment concerns, federal preemption under the 1965 Federal Cigarette 

Labeling and Advertising Act, and the 

economic self-interest of the media in 

preserving advertising revenue. Fear of 

losing those revenues severely inhibits 

publishers from printing articles that 

openly present the hazards of tobacco 

use.47 When ASSIST began, it was not 

entirely clear what policy actions could 

be implemented within the legal limits 

of the Constitution to restrict advertising 

of tobacco products. Case law on cigarette advertising and promotion has 

evolved over time. For some actions the 

states could build on precedent, but for 

others they had to chart new territory. 

For example, states and communities 

could bar certain forms of advertising 

and promotion, such as the distribution 

of free samples, advertising on state or 

municipally owned or operated subways 

and buses, and billboards in municipal 

stadiums. However, no state can ban cigarette advertising in magazines that are 

sold through interstate commerce. The 

authority of states and municipalities to 

bar intrastate forms of advertising, such 

as billboards or tobacco-sponsored music or sports events, had not been adequately tested in the courts. See table 6.3 

for a listing by state of the number of 

municipalities that had enacted ordinances restricting tobacco advertising, 

as of August 25, 2003. 

The ASSIST program objectives for 

restricting tobacco advertising and promotions sought the following four outcomes: 

1. Permissible state and municipal restrictions on cigarette advertising and 

promotion (e.g., bans on advertising 

on mass transit vehicles and in municipal stadiums, billboard restrictions, 

bans on free samples, and action to 

prosecute “unfair or deceptive” cigarette advertising under state laws) 

2. Substantial and progressive voluntary 

action by media owners and advertising managers and by sports, cultural, 

music, and other event managers to 

refuse cigarette advertising and promotion 

3. Broader and more intense public and 

policymaker support for restraints on 

tobacco advertising and promotion 

4. Increased levels of citizen awareness 

of the nature and role of cigarette 

advertising and promotion1,10(p2),40 

ASSIST pursued a number of strategies to limit tobacco industry advertising 

and promotions. The following are some 

examples of direct advocacy efforts: 

■	 Persuading property owners to 

prohibit tobacco advertising on 

billboards in ballparks and on posters 

at convenience stores near schools 

■	 Persuading sponsors of cultural and 

sports events to reject tobacco 

advertising opportunities 

With respect to media advocacy, 

ASSIST staff worked to expose and 

draw attention to factual omissions and 

distortions in tobacco advertising and 

media coverage. Though lacking the resources for an effective paid countermarketing campaign, ASSIST staff did 

respond opportunistically to tobacco media ads by seeking and gaining media 

coverage that highlighted the health 

180 
M o n o g r a p h 1 6. A S S I S T 

Table 6.3. Number of Municipalities per State with Advertising Ordinances, as of August 25, 2003 

(Shading indicates ASSIST states.) 

Location/ Public Retailer Tombstone 

State Total Zoning Transit Restrictions Exemption 

California 48 45 6 36 22 

Massachusetts 29 6 2 0 

20 13 7 4 

6 5 0 5 1 

25 

New York 14 

New Jersey 

Oregon 6 0 0 6 0 

Florida 4 0 1 2 0 

4 3 1 0 1 

4 4 2 1 2 

Colorado 2 2 0 2 0 

Michigan 

Washington 

Connecticut 2 2 1 2 1 

Hawaii 2 2 0 1 0 

Maryland 2 2 0 0 1 

Ohio 

Alaska 

Arkansas 

Illinois 

Oklahoma 

Pennsylvania 

2 

1 

1 

1 

1 

1 

2 

0 

1 

0 

1 

1 

1 

1 

0 

1 

0 

0 

1 

0 

1 

0 

0 

0 

1 

0 

0 

0 

0 

1 

Minnesota 2 2 0 2 2 

Missouri 2 1 1 0 0 

2 2 0 0 0 

2 2 0 1 1 

West Virginia 

Wisconsin 

Indiana 1 1 0 0 0 

Maine 1 0 0 0 0 

Rhode Island 1 1 0 0 0 

Texas 1 1 0 0 0 

Alabama 0 0 0 0 0 

Arizona 0 0 0 0 0 

Delaware 0 0 0 0 0 

District of Columbia 0 0 0 0 0 

Georgia 0 0 0 0 0 

Idaho 0 0 0 0 0 

Iowa 0 0 0 0 0 

Kansas 0 0 0 0 0 

Kentucky 0 0 0 0 0 

Louisiana 0 0 0 0 0 

Mississippi 0 0 0 0 0 

Montana 0 0 0 0 0 

Nebraska 0 0 0 0 0 

Nevada 0 0 0 0 0 

New Hampshire 0 0 0 0 0 

North Dakota 0 0 0 0 0 

South Carolina 0 0 0 0 0 

0 0 0 0 0 

North Carolina 0 0 0 0 0 

New Mexico 

South Dakota 0 

Tennessee 0 

Utah 0 

Vermont 0 

0 0 0 0 

0 0 0 0 

0 0 0 0 

0 0 0 0 

Virginia 0 0 0 0 0 

Wyoming 0 0 0 0 0 

Source: ANR Foundation Local Tobacco Control Ordinance Database©, 9/18/03. Copyright 1998–2003. American 

Nonsmokers’ Rights Foundation. All rights reserved. 

Note: Because some municipalities have coverage in more than one category, the numbers are not mutually exclusive. 

181 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

The terms and 

control. 

Access 

refers to where tobacco products 

can be purchased or acquired in the 

where tobacco products can be obtained. 

A 

Access, Availability, and Restriction 

access, availability, restriction 

are defined as follows for the purposes of this 

discussion of policy interventions for tobacco 

refers to the ease or difficulty with 

which an individual can obtain tobacco 

products. ASSIST sought to make it more 

difficult for individuals, especially minors, to 

purchase tobacco in the community. 

Availability 

community and where they are placed with 

stores. ASSIST sought to limit the locations 

restriction is any public or private policy, 

mandatory or voluntary, that reduces the use, 

possession, promotion, access, or availability 

of tobacco products in a given location. 

consequences of tobacco use. The literature on the effectiveness of mass media 

campaigns suggests that this type of 

countermarketing increases awareness of 

the health consequences of tobacco use 

but does not result in behavior change.48 

The goal of ASSIST staff efforts in this 

context was simply to increase awareness. 

Reducing Minors’ Access 

to Tobacco Products 

The main purpose of establishing and 

effectively enforcing restrictions on minors’ access to tobacco products is to decrease the number of adolescents who 

initiate smoking. Almost 90% of all 

adult smokers started smoking before 

age 18.49 As of 1989, more than 3 million American children under the age of 

18 consumed an estimated 947 million 

packs of cigarettes and 26 million containers of smokeless tobacco yearly.41 

Policies that reduce the access of minors 

to tobacco products, especially the purchase of those products, create barriers 

to early experimentation and reinforce a 

social norm that disapproves of smoking 

by children and adolescents. 

When ASSIST began, 49 states and 

the District of Columbia had laws that 

made it illegal to sell tobacco products 

to minors, but few, if any, of these laws 

were being enforced. A 1990 report of 

the inspector general of the Department 

of Health and Human Services found 

that these laws were ineffective in preventing the sale of tobacco to minors, as confirmed by studies demonstrating the ease 

with which minors obtained tobacco.50 

Restrictions on youth access work 

best when they are introduced as part of 

a multifaceted, comprehensive strategy 

that includes interventions designed to 

address the appeal of tobacco to minors. 

These include interventions addressing 

tobacco advertising and promotion, 

adult modeling of smoking in public 

places, smoking by adult role models, 

and other environmental cues and social 

norms that youths encounter daily in 

adult society. In one study, the authors 

considered the very process of intensive 

community organizing as an important 

context for the effects of local policies 

and their enforcement.51 

The ASSIST program objectives for 

tobacco access and availability policy 

sought the following four outcomes: 

1. State, municipal, and private action 

restricting the access and availability 

of tobacco products, such as 

eliminating the sale of tobacco in 

182 
M o n o g r a p h 1 6. A S S I S T 

smoke-free areas (e.g., hospitals, 

pharmacies) or on municipal property 

and moving all tobacco products 

behind the counter 

2. Substantial and progressive voluntary 

action by retailers to observe existing 

restrictions on the access to and 

availability of tobacco products 

3. Broader and more intense public and 

policymaker support for restrictions 

on, enforcement of, and improvement 

in regulations on the access to and 

availability of tobacco products 

4. Increased levels of citizen awareness 

of the access to and availability of 

tobacco products 

The ASSIST states implemented a 

broad array of strategies to reduce minors’ access to tobacco. The states promoted strengthening access laws, 

adopting laws that require tobacco retailers to obtain licenses, and restricting 

sales—for example, requiring that retailers move tobacco products from selfservice displays to vendor-assisted 

displays, prohibiting the sale of single 

cigarettes, and prohibiting point-ofpurchase displays. (See table 6.4.) The 

strategies included persuading hospitals, 

pharmacies, and public places frequented by minors (e.g., schools, sports arenas, movie theaters) to voluntarily limit 

or eliminate the sale or free distribution 

of tobacco on their premises. Also, as 

with all policy interventions, the coalitions provided the media with information supporting the effectiveness of 

access restrictions. 

More important, the coalitions took 

actions to ensure compliance with these 

laws. For example, in cooperation with 

law enforcement and regulatory agencies, minors participated in compliance 

checks. The coalitions also implemented 

programs to educate vendors about the 

restrictions. The ASSIST states were 

able to intensify their efforts in this policy 

area because of efforts by two other federal agencies—the Food and Drug Administration and the Center for 

Substance Abuse Prevention of the Substance Abuse and Mental Health Services Administration—to reduce youth 

access to tobacco. (See chapter 9.) 

Challenges to Public Policy 

Interventions 

year.”

T

hroughout the process of advocating 

for tobacco control policies, ASSIST 

advocates encountered opposing efforts 

by the tobacco industry, some major and 

some minor. The strength of that opposition reflected the high stakes at risk for 

the tobacco industry. As noted by Tina 

Walls of Philip Morris, “Financial impact of smoking bans will be tremendous. Three to five fewer cigarettes per 

day per smoker will reduce annual manufacturer profits a billion dollars plus per 

52(p4) The chief barriers posed by the 

tobacco industry to the ASSIST efforts, 

as identified in monograph 11 of NCI’s 

monograph series on smoking and tobacco 

control, were discrediting research; enlisting front groups for smokers’ rights; 

and promoting ineffective alternatives, 

legal challenges, and preemptive legislation.20 (See chapter 8 of this monograph 

for a recent analysis of the tobacco industry’s documents and a categorization 

of eight strategies to interfere with the 

ASSIST project.) 

183 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Table 6.4. Number of Municipalities per State with Youth Access Ordinances, as of August 25, 2003 

(Shading indicates ASSIST states.) 

Self- Single Use/ 

Vending Service Cigarette Possession/ 

State Total Machine Sampling Licensing Displays Sales Purchase 

California 197 185 47 34 123 48 5 

Minnesota 192 172 11 161 127 72 105 

Illinois 138 62 59 68 11 11 124 

Florida 42 26 0 0 40 0 2 

Wisconsin 35 14 4 11 1 11 23 

Ohio 23 16 5 6 5 5 15 

Oregon 22 11 0 8 22 1 0 

New York 21 17 5 3 16 1 2 

Pennsylvania 18 14 0 1 2 1 3 

Michigan 15 11 1 4 1 0 5 

Texas 14 10 3 0 3 1 6 

Connecticut 13 11 0 1 3 0 0 

North Dakota 13 13 0 10 7 0 11 

Arizona 11 11 0 1 7 0 1 

North Carolina 11 2 0 0 0 0 0 

Kansas 9 4 2 1 3 3 5 

Maryland 9 9 2 0 7 1 0 

Rhode Island 7 2 0 3 1 1 4 

Utah 7 6 0 0 7 0 0 

Alabama 6 5 0 0 0 0 1 

Maine 6 4 1 1 5 0 0 

Nebraska 6 2 1 1 2 1 4 

Massachusetts 225 218 180 199 174 174 

222 196 2 2 53 

18 

New Jersey 16 87 

Missouri 61 17 12 7 6 8 

Colorado 2 3 6 35 

28 

42 20 13 

6 6 3 4 1 3 2 

4 4 2 0 4 4 3 

Washington 

New Mexico 

Georgia 

West Virginia 

Hawaii 

3 

3 

2 

1 

2 

0 

1 

0 

2 

0 

0 

0 

0 

0 

0 

0 

0 

0 

1 

2 

0 

Indiana 2 0 2 2 0 0 0 

Iowa 2 0 0 1 0 0 0 

Louisiana 2 1 0 0 0 0 0 

Mississippi 2 0 0 0 0 0 1 

Oklahoma 2 0 1 0 0 1 2 

Wyoming 2 1 0 0 0 0 2 

Alaska 1 1 0 1 1 1 1 

Arkansas 1 1 1 0 0 0 1 

District of Columbia 1 1 1 1 0 0 0 

Montana 1 1 1 0 0 0 1 

Vermont 1 1 1 0 1 0 0 

New Hampshire 1 1 0 0 0 0 0 

Delaware 1 0 0 0 0 1 0 

Idaho 0 0 0 0 0 0 0 

Kentucky 0 0 0 0 0 0 0 

Nevada 0 0 0 0 0 0 0 

South Carolina 0 0 0 0 0 0 0 

South Dakota 0 0 0 0 0 0 0 

Tennessee 0 0 0 0 0 0 0 

Virginia 0 0 0 0 0 0 

Source: ANR Foundation Local Tobacco Control Ordinance Database©, 9/18/03. Copyright 1998–2003 American Non­


smokers’ Rights Foundation. All rights reserved.


Note: Because some municipalities have coverage in more than one category, the numbers are not mutually exclusive.


184 

0 
M o n o g r a p h 1 6. A S S I S T 

Discrediting the Science 

The tobacco industry’s efforts to discredit research are evident in its opposition to the U.S. Environmental 

Protection Agency’s (EPA’s) report on 

the respiratory and other health effects 

of passive smoking.53 The EPA report 

presented a meta-analysis of studies on 

the health effects of environmental tobacco smoke. 

The tobacco industry objected to the 

scientific analysis the EPA conducted54 

and referred to the EPA report as “junk 

science.”55,56 Tobacco industry documents 

that became public in the late 1990s during 

litigation indicate the industry’s intent: 

OBJECTIVES 

Our overriding objective is to discredit 

the EPA report and to get the EPA to 

adopt a standard for risk assessment of 

all products. Concurrently, it is our 

objective to prevent states and cities, as 

well as businesses from passing 

smoking bans. And finally, where 

possible we will proactively seek to 

pass accommodation legislation with 

preemption. 

STRATEGIES 

To form local coalitions to help us 

educate the local media, legislators and 

the public at large about the dangers of 

“junk science” and to caution them 

from taking regulatory steps before 

fully understanding the costs in both 

economic and human terms.57(Bates no. 

2021183916) 

—Memo from Ellen Merlo (VP, Philip 

Morris USA Corporate Affairs) to 

William Campbell (Chairman, Philip 

Morris USA) 

During the public comment period on 

the EPA report, 71% of submissions 

claiming the conclusions to be invalid 

were from individuals affiliated with the 

tobacco industry.58 Immediately, after the 

report was released by the EPA, six tobacco-related organizations filed a lawsuit against the EPA59 in the U.S. Court 

of the Middle District of North Carolina 

Winston-Salem Division. The tobacco 

industry groups argued that the EPA had 

exceeded its authority, had violated administrative law procedure, and that the 

risk assessment was flawed and not the 

result of reasoned decision making. The 

lower court ruled in favor of the industry, 

but a federal appeals court reversed the 

decision in December 2002. Nevertheless, 

ASSIST staff found that the publicity 

given to the industry’s claims about the 

science behind tobacco use confused the 

public, making it more difficult to promote 

clean indoor air legislation. 

Ineffective Alternatives 

The tobacco industry continues to 

promote its own alternatives to the public health community’s tobacco prevention and control programs. Past tobacco 

industry alternative programs include 

“Accommodation” and “Red LightGreen Light,” which supported smoking 

in designated public areas; “Helping 

Youth Say No” and “Right Decisions, 

Right Now,” designed for parents and 

schools; and Philip Morris’s 1998 youth 

smoking prevention campaign, “Think. 

Don’t Smoke.” 

These alternatives stimulated research 

into their efficacy. A limited, but growing body of evidence suggests that these 

tobacco industry programs were ineffective. For example, focus group research 

conducted by Teenage Research 

185 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Unlimited,60 a marketing firm that specializes in the teenage market, concluded that the “Think. Don’t Smoke.” 

campaign “does not appear to offer any 

compelling reason for [at-risk] teens not 

to smoke. Therefore, campaigns should 

not be developed with a ‘choice’ theme 

as a key foundation.”60,61 

Preemption 

Preemption is a mechanism by which 

a higher level of government asserts exclusive jurisdiction over an area of policy. 

Preemption clauses remove or limit the 

authority of lower levels of government 

to enact or enforce legislation that is 

stronger than the state law in the policy 

area preempted. Preemptive legislation 

is perhaps the strongest challenge to effective public policy intervention and can lead 

to unanticipated and costly litigation. 

In the mid-1980s, faced with an increasing number of effective local tobacco control ordinances, especially in the 

area of ETS and clean indoor air, the tobacco industry launched a major effort 

to pass preemptive laws aimed at legislatures at the state level.62–64 Later, after 

the 1992 EPA report (Respiratory 

Health Effects of Passive Smoking: Lung 

Cancer and Other Disorders) was released, some boards of health banned 

smoking in public places, and the industry used preemption to challenge the authority of the boards and other local 

governing bodies to enact smoking regulations.65 By 1998, a total of 30 states— 

12 of which were ASSIST states—had 

enacted some form of preemptive legislation, including 14 laws preempting local ordinances on clean indoor air, 22 

laws preempting local ordinances on 

Philip Morris. July 8, 1994. http:// 

no. 2041183751–3790. 

Internal Tobacco Industry Documents 

Confirm the Power of Local Measures 

“By introducing pre-emptive statewide 

legislation we can shift the battle away 

from the community level back to the 

state legislatures where we are on 

stronger ground.” 

—Tina Walls 

Source: Walls, T. CAC presentation #4, draft. 

legacy.library.ucsf.edu/tid/vnf77e00. Bates 

youth access to tobacco, and 17 laws 

preempting some or all types of local restriction on tobacco advertising and promotion. 

The threat of preemption drew varied 

responses from different communities. 

In North Carolina, the threat of preemption in the summer of 1993, when 

ASSIST was to enter its intervention 

phase, prompted 89 communities to hold 

public hearings and fast-track smoking 

control rules passed mostly by local 

boards of health over a 3-month period. 

A legal challenge to the authority of the 

boards of health to regulate smoking in 

public places subsequently invalidated 

the enforcement of 88 of the 89 local 

rules. The issue was that the ordinances 

exceeded the authority of the boards of 

health, which were appointed rather than 

elected. The only rule that withstood the 

challenge was in Durham County. In 

Durham County, not only the board of 

health but also the Durham City Council 

and the Durham County Commissioners 

passed the ordinance during the 3-month 

interval before the preemption law took 

effect.66 The first state to repeal preemp186 
M o n o g r a p h 1 6. A S S I S T 

tion of tobacco control was Maine (an 

ASSIST state), which restored local control over tobacco displays, placement, 

and time of sale provisions in 1996 (the 

preemptive language was included in a 

youth access bill passed a year earlier).67 

In 2002, Delaware became the first state 

to repeal preemption of local clean indoor 

air ordinances, simultaneously adopting a 

comprehensive smoke-free state law. 

Insights from 

Policy Advocacy Experiences 

T

he overall experience of the 17 

ASSIST states was that policy 

change—resulting from community education, grassroots mobilization, and media advocacy—is a powerful tool in 

reducing tobacco use and tobacco-related 

disease. Stillman et al., in their evaluation of ASSIST, concluded that “investment in building state-level tobacco 

control capacity and promoting changes 

in tobacco control policies are effective 

strategies for reducing tobacco use.”35(p1681) 

The enactment of new policies or 

changes in existing policies regarding 

any issue typically result from advocacy 

processes that involve challenges from 

those with opposing views. In the case 

of advancing tobacco control policies, 

these challenges are almost always 

strong and well organized. To be successful in bringing about tobacco control 

policies, advocates must be prepared not 

only to propose the policies, but also to 

endure substantial opposition. Furthermore, as described in chapters 3–5, not 

only the advocates but also the community must be involved and ready to support and defend the policies. Advocates 

must have a clear concept of the specific 

policy desired, the ability to present persuasive reasons for supporting the policy, messages and approaches tailored to 

specific individuals and population 

groups, and a realistic strategic plan that 

pulls together community resources. 

Presented in this chapter are 14 insights that the authors derived from the 

experiences of ASSIST staff and coalition members working in the field to 

promote tobacco control policies. Many 

of those insights are illustrated with case 

studies shared over the ASSIST years 

and from formal presentations at conferences. These insights are told in the 

words of those who were personally involved and reflect their experience. The 

case studies illustrate how, through persistence and with creative strategies, the 

ASSIST staff and coalitions met many 

of the challenges to their policy intervention efforts. As historical experiences, 

the case studies reflect the environment 

at the time, especially the legal environment, which has changed during the past 

several years. The insights are sequenced 

from broad principles of policy advocacy, to specific tactics, to implications for 

the future. 

Insight 1: Most Policymakers Want to 

Do the Right Thing for the Public’s 

Health, but the Right Thing Must Be 

Explained and Promoted to Them by 

Their Constituents 

They don’t see the light until they feel 

the heat. 

—A lobbyist’s insight 

187 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

The 

priorities. 

The 

The 

The Expert 

The Inside Advocate

The 

messages. 

The 

discourse and debate. 

The 

Pertschuk, M. 1999. 

*See Insight #5, page 196. 

A Leadership Taxonomy* 

It takes more than one leader, or one type of leader, for a community to achieve its goals. 

Visionary challenges conventional views of the possible, aims high, takes risks, and rethinks 

Strategist thinks backward from the goals to the means to achieve the goals, sorts out what is 

realistically attainable, and develops the road map to get there. 

Statesperson carries the movement’s flag, is the “bigger than life” public figure who embodies 

authority and respect, lends credibility, and is widely known and respected beyond the movement. 

provides a solid foundation of science and makes it known through peer-reviewed writings 

and authoritative public statements. 

 knows the most effective intervention points: how to open doors, to confront 

decision makers, to feel out the arguments that resonate with them, to press them in ways that cannot 

be dismissed, and to negotiate the tribute that must be paid. 

Strategic Communicator is the public teacher, the master of the sound bite, and translates complex 

scientific data, public policy, or basic concepts of truth and justice, into powerful metaphorical 

Movement Builder successfully resolves conflict, bridges ego and turf, opens up lines of 

communication, and squashes rumor and innuendo. Movement builders are facilitators; they bring 

people, especially the “insiders” and “outsiders,” together, to explore differences through civil 

Outside Sparkplug is an agitator, an unabashed teller of truth, a leader outside the conventional, 

political establishments, free of the ties that bind “inside” players, and capable of holding governments 

and organizations to their own rhetoric of mission and commitment. 

Source: A leadership taxonomy. Washington, DC: Advocacy Institute. 

Reversing the social acceptance of tobacco use requires educating the public 

and policymakers about tobacco’s serious health and economic threats not only 

to the individuals who use tobacco, but 

also to their families, friends, and communities. That educational process must 

be ongoing because new generations must 

also understand the health and economic 

issues associated with tobacco use. 

Educating the public and policymakers about why policies should be enacted 

to protect the public health was a major 

undertaking of the ASSIST coalitions. 

Policymakers, especially at the local level, care about the opinions of their constituents. In numerous communities, ASSIST coalitions presented to their city 

councils the scientific evidence of the 

health consequences of smoking. The 

council members listened, and some 

passed ordinances restricting environmental tobacco smoke. 

One must make some educational efforts in person to be effective with policymakers, but the media can also attract 

policymakers’ attention. Many policymakers regularly rely on the editorial 

pages to take the pulse of the community. 

Editorials can make an appealing case 

188 
M o n o g r a p h 1 6. A S S I S T 

by presenting a solution and by making 

a practical policy appeal. Other types of 

media coverage can also attract attention. For example, in 1995, a social studies teacher introduced her fifth-grade 

class to a fact that she learned from 

ASSIST. As a class project, the class 

took out a classified ad in USA Today 

asking, “Each year, what kills more people than AIDS, alcohol abuse, car accidents, murders, suicides, illegal drugs, 

and fires combined?” The answer—cigarette smoking—drew nationwide media 

coverage about the hazards of tobacco 

use and earned attention for the class 

that conducted this media experiment. 

Case study 6.1 shows how knowledgeable teenagers made a direct appeal to 

policymakers for their own health and 

won over the county council. 

Insight 2: The Process of Laying the 

Groundwork for Policy Change Can 

Be as Important as the Policy Itself 

Critical to success in passing tobacco 

control policies, especially at the local 

level, is laying the groundwork for 

change through a well-planned process 

of community education and mobilization. The elements of the process are 

raising the community’s awareness 

about the issues involved, educating residents about the benefits of the policy, 

changing community norms, and paving 

the way for smooth implementation and 

enforcement of the policy. When community support for a policy is ensured, a 

campaign for policy change can be 

launched, and it can be strengthened 

with media advocacy for the policy. Media coverage of an issue is important 

when advocating for policies that depend on changes in a population’s attitudes and, eventually, in the social norm. 

Media coverage can build community 

support for a policy initiative; it can influence the way that individuals think 

about an issue, which eventually influences social norms. 

Laying this groundwork is time consuming and requires patience; however, 

without the groundwork, the proposed 

policy is not likely to move forward or 

be well received even if it is passed. In 

fact, the groundwork may be even more 

important than the policy outcome. The 

very process of debating a proposed policy 

influences social norms by drawing attention to the issue. Thus, even if the 

proposed policy is defeated, the effort 

put into advocating for it will not have 

been wasted, since community attitudes 

and norms will have been influenced. In 

a way, the adoption of the policy is the 

ratification of an already-occurring 

change in attitude and possibly norms. 

Without community support, if a policy is 

somehow enacted, it may be ignored or 

resisted as well as difficult to enforce. 

A mistake that well-meaning individuals might make is to push prematurely 

for policy change. For example, a legislative sponsor or individual advocate 

might independently introduce a policy, 

anticipating little or no opposition. If opposition arises from the tobacco industry 

and its allies, the sponsor and other policymakers might quickly back off. Without the visible support of the community 

and the media, the policymakers are not 

likely to withstand the opposition. The 

net result is that not only is the policy 

initiative defeated, but it also becomes 

189 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Case Study 6.1 

Kids Make Crucial Appeal to Policymakers in St. Louis County 

Situation: 

selling tobacco products to children younger than 17 and were not asking for proof 

stand on youth access to tobacco. 

Strategy: 

inspectors the authority to collect the license fees and enforce the ordinance throughIntervention: 

tobacco problem in St. Louis County to four members of the St. Louis County 

coalition furnished him with sample ordinances from other cities. From that council 

them to support the youth access ordinance. 

ordinance from retailers and their tobacco industry associates, the coalition leaders 

In 1995, 75% of the tobacco retailers in St. Louis County, Missouri, were 

of age. The St. Louis ASSIST Coalition wanted to curb teen smoking by taking a 

The coalition sought to persuade the county council to pass a countywide 

ordinance covering all 92 municipalities. The only way to avoid a public vote in each 

municipality was to give the St. Louis County Department of Health and its health 

out St. Louis County. 

The first step toward passing this ordinance involved raising the awareness of the legislators and educating them about how tobacco affects the health of 

children. In September 1995, six coalition members explained the magnitude of the 

Council. They reported that the legislators appeared startled by their presentation. 

The coalition members proposed a youth access ordinance that would require 

licensing every retail tobacco vendor in St. Louis County. That week, a council 

member agreed to be the principal sponsor and began writing an ordinance. The 

member, the coalition learned which council members would likely oppose the 

ordinance. The coalition’s allies—the American Cancer Society, American Heart 

Association, American Lung Association, National Council on Alcoholism and Drug 

Dependence, and the St. Louis Clergy Coalition—then conducted a letter-writing and 

telephone campaign in the ZIP-code areas of the resistant council members to urge 

Two public hearings were held in January 1996. Anticipating strong opposition to the 

invited people who were knowledgeable about tobacco issues and could maintain a 

focus on children’s health to testify. Most important, the American Cancer Society 

van picked up students at the various high schools for their “day in court.” 

Testimonies, discussions, and arguments continued for 2 hours before the first youth 

advocate took the podium. He was a 13-year-old who had participated in compliance 

checks and eloquently explained how easy it was for underage youth to purchase 

cigarettes from gas stations, convenience stores, bowling alleys, and, especially, 

vending machines. A healthy-looking 17-year-old smoker who wanted to quit 

smoking was called next. His story of addiction began at age 14 when a friend gave 

him a cigarette. At that time, he wanted only to look cool, but now he was hooked on 

cigarettes. A 16-year-old girl explained how the tobacco industry confused younger 

190 
M o n o g r a p h 1 6. A S S I S T 

Results: 

children through its advertising on the numerous billboards in residential areas, in 

grocery stores, and in gas stations. She said that it seemed to her that children were 

receiving the message “smoking can’t be that bad if it is sold legally in stores 

everywhere.” 

Only these students spoke, but they were supported by the presence of dozens of 

other students in the room. When they spoke, the room was silent. Two months of 

revisions and amendments to the ordinance followed. In the meantime, the nonprofit 

organizations wrote letters and made phone calls to the most resistant council 

member. 

On April 4, 1996, the St. Louis County Council approved the toughest youth 

access ordinance in Missouri. The resistant council member made a 180-degree turn 

and became the cosponsor of the ordinance. That afternoon, the St. Louis county 

executive signed the ordinance into law, which became effective on July 1, 1996. 

After the St. Louis County youth access ordinance was passed, many municipalities 

and school districts strengthened their existing tobacco policies. Tobacco and children’s health had finally become a serious issue worthy of discussion at city council 

meetings throughout the area. Again and again, it was the children who made the 

policymakers understand what was the right thing to do. 

Source: Adapted from P. Lindsey. 1997. Kids are crucial for local ordinances. In Entering a new 

dimension: A national conference on tobacco and health case studies (September 22–24, 1997), 79–82. 

Rockville, MD: ASSIST Coordinating Center. 

much more difficult to revisit it in the 

future. Policymakers may be reluctant to 

get involved again on the same issue 

later on. 

Laying the groundwork by increasing 

awareness is illustrated in case study 

6.2. The purchase of counteradvertising 

opened the doors of the sports stadiums 

to a community and closed them to 

smoking. 

Insight 3: Policy Change Is Political; 

Therefore, Boundaries Must Be 

Defined and Redefined 

You don’t need a weatherman to know 

which way the wind blows. 

—Bob Dylan 

Policy is made within complex social 

and political contexts. Policy advocacates must be aware of the agendas and 

missions of all relevant individuals and 

organizations. In a state tobacco prevention initiative, it is very important to establish a clear division of tasks among 

partner organizations and to obtain consensus among the partners on this arrangement. As part of this process, 

individuals and organizations should be 

assigned roles that are within their competence and legal capacity, including 

any real or perceived restrictions that are 

attached to their sources of funding. One 

should also take care to avoid inadvertently doing anything to restrict these individuals and organizations’ freedom of 

191 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Case Study 6.2 

Situation:

Strategy: 

Interventions and Results:

for ushers; messages for scoreboards, message centers, and announcements; signs for 

sections. 

Tobacco and Sports Don’t Mix in Virginia! 

 In its initial tobacco control plan, Virginia’s ASSIST staff and coalitions set 

an objective to change smoking policies in stadiums. The campaigns were to be 

designed by the state coalition’s media committee with a focus on preventing tobacco 

use by youths. Focusing the message on youths rather than on the total population 

was an acceptable approach in a tobacco-growing and -manufacturing state. 

The approach was to identify partners within existing sports programs and 

organizations through which the coalition could channel tobacco control messages. 

 In 1995, the coalition approached seven minor league 

baseball stadiums in Virginia to discuss advertising within the stadiums as a mechanism to counter tobacco use messages. None of the stadiums was willing to donate 

ad space, but all seven accepted paid counteradvertising; two required that the ads 

focus strictly on prevention of tobacco use by youths. At several stadiums, counteradvertising in event programs and billboards was expanded to include sponsoring 

a youth tobacco prevention day at the ballpark. The community response was 

overwhelmingly positive. 

In 1996, coalitions leveraged their status as advertisers to work on policy change. 

They offered to help the management develop no-smoking policies and presented a 

comprehensive package for implementation. The package included cards and buttons 

seating areas; and a message to be printed on tickets and/or ticket envelopes to 

promote the new policy. 

The managers were receptive to policy change, and by 1997, three stadiums adopted 

100% smoke-free seating polices, and the other four adopted smoke-free family 

The early successes with minor league stadiums led coalitions to focus on developing similar projects in high school stadiums. They worked with students to develop 

advertisements that were placed in sports programs for football and basketball games 

and wrestling matches. Students who had been through advocacy training encouraged their schools to expand smoke-free policies to include athletic stadiums. 

Several groups had success and held celebrations to inform the community of the 

change. One such activity, Sack the Pack, occurred as a partnership with a local 

television sports department. 

Over the next several years, coalitions throughout the state expanded their sports 

initiatives. In one region, a coalition recruited the general manager of a minor league 

baseball team to become active in the coalition’s efforts. His involvement led to a 

decision to remove a lifesize advertisement of the Marlboro Man from the team’s 

192 
M o n o g r a p h 1 6. A S S I S T 

The state coalition created a partnership with the Hampton Roads Mariners, a 

the light

stadium when the contract expired. In another region, the department of parks and 

recreation was instrumental in persuading regional and national youth baseball 

events to be tobacco free. 

semiprofessional soccer franchise. Coalition members worked with the management 

to ensure that the team’s new stadium opened smoke free. The team was pleased with 

the support that they had received and asked for assistance to promote a tobacco-free 

message through its Kids’ Club packets and autograph day. 

Source: Adapted from M. White. 1999. Tobacco and sports don’t mix! In Tobacco free future: Shining 

 (Case studies of the fifth annual national conference on tobacco and health, August 23–25, 

1999), 29–32. Rockville, MD: ASSIST Coordinating Center. 

action. Partners should not accept funds 

that restrict their ability to use a wide 

range of advocacy tools. 

Advocates working for policy change 

are almost invariably called upon to 

make adjustments or compromises to get 

their policies adopted. Advocates must 

determine which concessions are and are 

not acceptable. Tension may arise on 

this point between the perspectives of 

leaders at the state or community level 

and those of experienced national tobacco control advocates. For example, a 

community that lacks any smoking regulations might perceive a proposed clean 

indoor air ordinance that contains numerous exemptions as taking a significant step forward, whereas national 

advocates might view the measure as 

setting a bad precedent for other communities. 

There is no easy resolution to this issue. However, general principles that 

should be followed include advocating 

for the maximum degree of policy 

change possible, never accepting a measure that actually weakens existing policy, 

never accepting preemptive legislation, 

and balancing the lessons learned in other communities against the unique circumstances of the community in 

question and the perception by community members of what is possible. Veteran advocates should help the local 

coalition or advocacy group understand 

the potential implications and pitfalls 

under consideration so that they can 

make an informed decision. This is especially true because provisions in fine 

print that look innocuous on paper can 

severely undermine a policy in practice. 

For this reason, legal expertise early in 

the planning stage is very important. It is 

important that people at the local level 

consider input but make the final decision. When sharing policy case studies 

and model policies, one should take care 

to highlight the local context and potential risks, pitfalls, and loopholes. Perhaps most important, the coalition or an 

advocacy organization should discuss 

and reach consensus from the start about 

which concessions it is and is not willing to accept—in other words, its nonnegotiable bottom line. 

193 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Insight 4: United, We Succeed 

When spider webs unite, they can tie 

up a lion. 

—Ethiopian proverb 

The combined assets of a public-private 

partnership and the ability to activate a 

range of state and local coalitions were 

strengths of the ASSIST model. The public sector partners (state health departments) have the legitimacy and expertise 

associated with government programs. 

Their public policy responsibilities include the presentation of information 

and statistics about the health problem 

being addressed, educating the public 

about evidence-based interventions and 

how public policies affect the public’s 

health, policy analysis and scientific review of various policy options, and policy 

development (in some states and in some 

policy arenas, the authority of policy enforcement). In addition, state agencies 

have organizational or contractual relationships with local educational agencies. 

ASSIST’s formal partner from the 

private, voluntary health sector—the 

ACS—has a compatible mission to recognize and promote cancer prevention 

and control. In 1991, ACS had a local 

volunteer network of approximately 1 

volunteer per 1,000 population.68,69 ACS 

and all public charities—501(c)(3) organizations—are allowed by the Internal 

Revenue Code to expend significant portions of their operating budgets on lobbying.7 

Mobilization of these grassroots networks toward a priority policy goal can 

be a powerful tool. However, this was 

not always easy to achieve. In some 

states, other voluntaries were more committed and better prepared than ACS. 

Moreover, dissension among the voluntaries and between the voluntaries and 

the state health departments sometimes 

inhibited collaboration. Nongovernmental partners became quite frustrated from 

their dealings with the bureaucratic constraints and restrictions on the use of 

federal funds. 

State and local tobacco control coalitions played a crucial role in the policy 

successes of the ASSIST states. In fact, 

community coalitions probably made the 

single most important contribution to policy change in these states. In addition to 

successfully spearheading local policy initiatives, they were also instrumental in mobilizing grassroots support for beneficial 

state legislation (e.g., increases in state cigarette excise taxes, retailer licensing, and 

allocation of Tobacco Master Settlement 

Agreement funds to tobacco control) and 

in opposing harmful state legislation (e.g., 

bills preempting local authority to enact 

clean indoor air, youth access, and advertising ordinances). Working in tandem, 

though not always without tension, these 

diverse partners drew on their complementary strengths to win a series of significant 

policy victories at the local and state levels 

and, in the process, to dramatically influence social norms. 

Case study 6.3 shows how bonds of 

trust among organizations and community members serve all involved when 

the right issue or moment arrives. Involving the African American clergy of St. 

Louis in an effort to eliminate tobacco billboard advertising from all neighborhoods 

especially benefited African Americans, 

194 
M o n o g r a p h 1 6. A S S I S T 

Case Study 6.3 

Situation: 

ing from all residential areas in St. Louis. 

Strategy: 

Intervention: 

white neighborhoods. 

a 

ended in 5 weeks. 

ASSIST Unites with Faith Leaders to Ban Tobacco Advertising in St. Louis 

A strong bond of trust had been established between ASSIST staff in 

Missouri and the St. Louis Clergy Coalition, a network of African American ministers and priests who represent 47,000 congregation members from 13 religious 

denominations in 109 churches in St. Louis. They had worked together successfully 

on tobacco control initiatives. With that trust in mind, the St. Louis ASSIST coalition 

invited the clergy coalition to collaborate on a project to eliminate tobacco advertisThe strategy was for the clergy coalition to add its influence to a proposed 

ordinance to ban tobacco billboard advertising and to draw media attention to the 

initiative. 

A press conference kicked off the campaign to ban tobacco billboards. 

World No Tobacco Day was on a Sunday, so the press conference was held in an 

inner-city African American church at 3 p.m., after church services and before the 5 

p.m. television news deadline. Representatives from the St. Louis Clergy Coalition, 

the Mound City Medical Forum, the American Cancer Society, the St. Louis Catholic Archdiocese, and ASSIST staff, as well as a teenage boy, spoke at the press 

conference. The St. Louis ASSIST media consultant assisted in preparing speeches 

for them, which covered different facts and emphasized how often children are 

exposed to tobacco advertising in neighborhoods. As in other cities, tobacco billboards were far more common in poor African American neighborhoods than in 

The media arrived in full force, and the story of the ministers’ commitment to getting 

an ordinance passed became the lead news story on three major television stations at 

5 p.m. and 10 p.m. The visuals on the television newscasts were the billboards 

located on almost every corner on the streets surrounding the church. The next day, 

the faith leaders’ commitment to ban tobacco billboards in St. Louis City made the 

front page of the St. Louis Post-Dispatch, and the day after that, it was the subject of 

Post-Dispatch column. The story was also covered several times on radio stations 

KMOX-AM and KTRS-AM. 

Without delay, the faith leaders contacted an African American member of the Board 

of Aldermen and asked her to sponsor the ordinance to ban tobacco billboards. She 

willingly agreed, and a meeting was set to discuss the language of the ordinance and 

to plan the strategy for getting the ordinance passed. The proposed ordinance stated 

that tobacco advertising could remain on interstate highways but would be eliminated from all residential areas. The sponsor said that she would introduce the bill in 

committee the following week and get the bill passed before the legislative session 

195

6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Results and Insights: 

ordinance. It passed 24–0. 

control demonstrates what coalition really means—a union for a common purpose. 

and the consequences for tobacco (Case studies of the fourth annual national conference on tobacco and 

Case Study 6.3 (continued) 

On the day that the ordinance was read in the Legislation Committee, members of 

the local coalition showed up at city hall in large numbers to show community support and to testify. Radio and television reporters covered the hearing. The committee approved the bill 7–0. Following the vote, several other committee members 

quickly approached the sponsor of the bill and asked to sign on as cosponsors. 

On Friday, July 17, 1998, the bill was debated before the full 

membership of the Board of Aldermen. On the final day of the legislative session, the 

24 aldermen who were present gave their final vote on the tobacco-advertising 

The faith leaders’ involvement strengthened the St. Louis coalition. The faith leaders 

knew that they had powerful influence in their communities, and they were pleased 

to learn another way they could wield that power. The mutual effort for tobacco 

Much of the success of this project was the result of some excellent advice from a 

credible political consultant and a skilled attorney, the ability of the ASSIST coalition members to do much of the background for the faith leaders, and good timing. 

Source: Adapted from P. Lindsey. 1998. Faith leaders ban tobacco advertising. In No more lies: Truth 

health, October 26–28, 1998), 77–81. Rockville, MD: ASSIST Coordinating Center. 

whose neighborhoods had a disproportionate share of undesired tobacco billboard advertising. 

Insight 5: Develop the Necessary 

Skills among Various Leaders to 

Advance a Winning Combination of 

Activism, Advocacy, and Diplomacy 

Leadership is not one-dimensional or 

static in the ASSIST model. The most 

effective coalitions used a synergistic 

and well-timed combination of activism, 

advocacy, and diplomacy. The Advocacy 

Institute’s A Leadership Taxonomy (see 

sidebar, page 188) reflects the types of 

leaders required by a movement to 

achieve its goals, and these were present 

among the tobacco control practitioners 

working with ASSIST. The organizational affiliations of the individuals who fill 

these roles may vary, as long as the organizations’ restrictions do not prevent 

these individuals from performing the 

functions necessary to their roles. The 

important consideration is whether the 

right person is in the right role at the right 

time. An individual’s role should match 

his or her actual skills (not self-perceived skills) and comfort level. Finally, 

the individuals involved must commit 

adequate time to fulfill the responsibilities 

of their roles. Case study 6.4 illustrates 

how the commitment by the right people 

in the right roles made it possible to lead 

the Las Cruces, New Mexico, community 

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M o n o g r a p h 1 6. A S S I S T 

Case Study 6.4 

Filling the Roles in Las Cruces, New Mexico 

Situation:

Strategy: 

and acceptance within the community to identify and recruit potential allies. 

Intervention: 

Results: 

housing-authority youth program recruited, trained, and mobilized a cadre of youth 

 In 1995, when the first comprehensive clean indoor air ordinance in New 

Mexico—the Las Cruces Clean Indoor Air Ordinance—was under consideration, the 

Las Cruces tobacco control coalition was cochaired by two individuals. One, a health 

educator and member of the regional health department’s health promotion team, 

was a native of Las Cruces who knew the community very well and was respected by 

community residents. The other, a retired pharmacologist and toxicologist whose 

research had focused on tobacco and who had recently moved to Las Cruces, brought 

a different kind of credibility to the table: the credibility that derived from his 

technical expertise. He conveyed this expertise powerfully in his testimony before 

the city council at key junctures in the debate about the ordinance. 

These two individuals complemented each other well. The retired academician was essentially irrefutable in his presentation of the scientific evidence about the 

health risks posed by environmental tobacco smoke and was not afraid to be confrontational when necessary. The health educator, in contrast, was adept at community 

outreach and drew on his community organizing skills, knowledge of the community, 

Both these individuals were fully committed to the cause and were able 

to work full-time on the ordinance campaign for long stretches. The health educator, 

though not in a categorical tobacco control position, recognized the importance of 

this opportunity to protect the public’s health, while the academician, having retired, 

had time available to devote to the effort. 

The contributions of several other key figures further complemented those of 

the retired academician and the health educator. The director of a local publictobacco control advocates who had a major impact on the city council. Several other 

core coalition leaders, working as a team, set the overall strategy for the efforts to 

pass, defend, and strengthen the ordinance. The regional ASSIST field director and 

the New Mexico ASSIST program staff as a whole also played a number of important roles by providing the coalition with staff support and technical assistance that 

linked the coalition to external resources; coordinating its media advocacy efforts; 

providing education and testimony about the health risks posed by exposure to 

secondhand smoke; and overseeing the development, maintenance, and evolution of 

the coalition (including recruiting new members and facilitating leadership transitions). Without capable, appropriate persons to fill these essential, complementary 

roles, the ordinance could not have been adopted and sustained. 

—Stephen Babb, former ASSIST Field Director, New Mexico 

Department of Health in Las Cruces, and current Program 

Consultant at the Office on Smoking and Health, National Center 

for Chronic Disease Prevention and Health Promotion, CDC 

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6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

in successful efforts to pass a clean air 

ordinance. 

Insight 6: Shining Light on the 

Tobacco Industry’s Tactics Can Help 

Advocates Achieve Policy Goals 

Sunlight is the best disinfectant. 

—U.S. Supreme Court Justice 

Louis Brandeis 

Introducing or changing policies, 

whether government regulations or private sector guidelines, is a political process, and stakeholders with opposing 

views are likely to challenge those policies. As detailed in chapter 8, internal 

tobacco industry documents that came to 

light during lawsuits in the 1990s reveal 

a number of political tactics used by the 

industry, including strong lobbying of 

key policymakers, campaign contributions, and support of allies to make its 

case. Shining light on these tactics can 

help to effectively counter or prevent the 

industry’s opposition. 

In countering the tobacco industry’s 

advertising and promotions, the ASSIST 

states had to navigate the legal issues 

imposed by the first amendment and by 

the preemption provision of the Federal 

Cigarette Labeling and Advertising Act 

enacted by Congress in 1965 (as amended in 1970): “No requirement or prohibition based on smoking and health shall 

be imposed under State law with respect 

to the advertising or promotion of any 

cigarettes the packages of which are labeled in conformity with the provisions 

of this chapter. . . .”70 Although preemption laws prevented a number of ASSIST 

states from changing public policies on 

advertising tobacco products, they 

could, and did, develop strategies to influence private policies in an effort to reduce tobacco advertising in their 

communities. Many volunteers rallied to 

oppose advertising that targeted youths 

and other vulnerable populations, as illustrated in case study 6.5. 

Insight 7: Effective Social Movements 

Engage Many Segments of the 

Community 

If there is a problem within a 

community, one must go within that 

community and solve the problem 

from the inside out. 

—Adage 

Social norms reflect the values of a 

community. Thus, to promote and 

strengthen the social norm of a tobaccofree society, the ASSIST model relied on 

community coalitions. The ASSIST coalitions set the priorities for policy interventions in the communities and the 

strategies for conducting policy advocacy. First, however, the coalitions ensured 

that their memberships and outreach 

were comprehensive in involving as 

many segments of the population as possible. The coalition membership represented health organizations, social 

service agencies, community groups, 

and private citizens of diverse ages and 

socioeconomic and ethnic characteristics. In advocating for policy, there is 

strength not only in numbers but also in 

the degree to which the entire community is represented. Case study 6.6 illustrates how 70 organizations worked 

together to achieve mutual goals. 

198 
M o n o g r a p h 1 6. A S S I S T 

Case Study 6.5 

■ 

1999, a 4-month study of 3,031 retail outlets in 163 communities nationwide 

stores.a(p185) 

– 

in neighborhoods with schools and other vulnerable populations. (See insight 

■ 

can Indian communities.b 

■ 

– 

– 

– 

– 

paraphernalia for prizes. 

– 

Shining the Light on Tobacco Advertising and Promotions 

Reducing Point-of-Purchase Advertising. Exposure to point-of-purchase 

advertising influences youths to purchase and experiment with cigarettes. In 

found that some form of tobacco point-of-purchase marketing (interior or exterior 

advertising, self-service pack placement, multipack discounts, tobacco-branded 

functional objects, or vending machines) was observable in 92% of the 

Operation Storefront, developed by the California Tobacco Control Program, 

was adopted by many ASSIST states as an intervention to reduce the amount 

of storefront and in-store tobacco advertising in convenience stores, especially 

9 for examples.) 

Exposing Advertising Targeted to Specific Populations. Advocates in several 

ASSIST states exposed the tobacco marketing technique of targeting youths by 

concentrating advertising in convenience stores and on billboards near middle 

schools and high schools and in African American, Hispanic/Latino, and AmeriExposing Advertising and Giveaways in Family Settings. ASSIST volunteers 

brought attention to the advertising and marketing techniques used in family 

venues, such as tobacco product giveaways at NASCAR races and at sports and 

entertainment events. Some states countered the advertising by introducing an 

alternative, such as entering a tobacco-free car in a NASCAR race, at the event. 

Tobacco industry giveaways such as Marlboro Miles and Camel Cash were 

countered by paid and earned media events. For example, a popular event 

encouraged teens to bring in cigarettes, lighters, or any item with a cigarette 

logo on it and drop them off in exchange for an item with a health message. 

A local coordinator in Minnesota organized a tobacco merchandise “buyback” 

during a lunch hour at a local high school. Teens turned in tobacco merchandise in exchange for antitobacco items. 

Twenty-six New Jersey middle school students attended a workshop on 

tobacco advertising. Their antitobacco advertising designs were reproduced 

on T-shirts and tote bags for fundraising purposes. 

Youths from a Wisconsin antitobacco group monitored outdoor tobacco 

advertising throughout one county. In another county, 1,000 youths from 16 

schools throughout the county collected and exchanged tobacco industry 

Piggybacking on the national Kick Butts Day, a Virginia high school held a 

gear exchange in which more than 50 students exchanged tobacco promotion 

199

6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

items for health promotion materials. More than 200 students who professed 

– - b 

■ 

– 

that traditionally has some tobacco industry sponsorship, reaching potentially 

100,000 participants. 

– 

athletes about the importance of remaining tobacco free and a banner displayb 

■ 

b 

a

Morbidity and Mortality 

51 (9): 184–7. 

b

ASSIST state quarterly reports, 1996–99. 

Case Study 6.5 (continued) 

to have never used tobacco signed a pledge to remain tobacco free for life. 

This event gained local television news coverage. 

Two Indiana middle schools conducted a T-shirt trade-in, where tobacco T

shirts were exchanged for T-shirts with a tobacco-free message.

Placing Tobacco Counteradvertising. New Mexico placed tobacco counterads 

in programs for boys’ and girls’ basketball and soccer championships. For the 

latter event, antitobacco announcements were read over the loudspeaker during 

12 games. 

Indiana produced press releases and counterads for an annual riverfront event 

New Mexico helped sponsor a “Play It Tobacco Free” state championship 

tournament. The tournament featured a number of antitobacco advertising and 

promotion techniques, including statements by high school and university 

ing photos of people who had died from smoking-related diseases. The event 

involved 60 students and was covered by the local public television station.

Protesting Tobacco Advertising. A Ticketmaster/Joe Camel ad protest was held 

by local coalitions in Washington State against the advertising tactics that provided discount tickets with Camel proof of purchase.

Data on reducing point-of-purchase from Terry-McElrath, Y., M. Wakefield, G. Giovino, A. Hyland, D. 

Barker, F. Chaloupka, S. Slater, P. Clark, M. Schooley, L. Pederson, et al. 2002. Point-of-purchase 

tobacco environments and variation by store type—United States, 1999. 

Weekly Report 

Insight 8: Youth Are Effective Change 

Agents 

Youths are the leaders of today! 

—Donna Grande, Director, 

Office of Program Development, 

American Medical Association 

Involving teens in policy interventions in a meaningful way develops their 

skills in the areas of leadership, public 

speaking, policy advocacy, and media 

advocacy; enhances their self-confidence; and puts them on the public 

record as opposing tobacco use. The 

more meaningful the role teens are given 

in planning a policy initiative, the more 

likely it is that they will assume ownership of the intervention, that they will be 

highly motivated to implement the intervention, and that they will do an exceptional job. Furthermore, teens are 

effective advocates. For example, in the 

200 
M o n o g r a p h 1 6. A S S I S T 

Case Study 6.6 

Situation: 

Strategy: 

Intervention:

of members: 

million dollars.a 

Massachusetts Increases Tobacco Tax to Fund Healthcare for Children 

Chapter 47 of the Acts of 1997, An Act Assisting in Making Health Care 

Available to Low Income Uninsured and Underinsured Residents of the Commonwealth (Health Care Access Act) was under consideration in Massachusetts in 1996. 

One part of the bill proposed to expand children’s eligibility for Medicaid and a 

special Massachusetts program that offers health insurance for non-Medicaid eligible 

children. Passing the bill depended partly on a plan to fund the program. Knowing 

that any significant increase in the price of tobacco is an effective tobacco control 

measure, the tobacco control advocacy network saw an opportunity to combine 

forces with children’s health advocates toward complementary goals. 

Tobacco prevention advocates joined forces with supporters of the Health 

Care Access Act to communicate a simple message to the public about raising the 

cigarette tax: Fund children’s healthcare by taxing tobacco. Linking children’s 

healthcare and cigarette taxes was the way to reach congruent public health goals. 

 Seventy organizations joined the coalition to fight for passage of the 

Health Care Access Act, to be funded in part by a 25¢ increase in cigarette taxes. 

Organized by Health Care for All, the coalition included the following five categories 

1. The medical community, including physicians and hospitals 

2. Tobacco control advocate groups 

3. Public health organizations lobbying for children and healthcare reform 

4. Associations representing seniors 

5. Insurance companies and business leaders 

The broad membership of the coalition allowed for both a traditional statewide 

grassroots campaign and insider, relationship-based lobbying. This combination 

created a political will that was impossible to stop despite public opposition by the 

governor and the tobacco industry’s 6-month lobbying expenditures of about half a 

Grassroots lobbying efforts included rallies in communities across the state and 

lobby days at the state house. The American Cancer Society mobilized 1,000 members of its tobacco control advocacy network to phone, write, and meet with legislators. Coalition organizations called their members and asked them to call their 

elected officials and express their support. 

A poll of registered voters in Massachusetts found that 78% favored and 20% 

opposed a bill “that would raise the cigarette tax by 25 cents . . . to buy health insurance for children who don’t have it and help buy prescription drugs for senior 

201

6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

b 

in 1991.c

Results d

 and Insights: 

and control. 

a

b

uncertain. Boston Globe, March 27, 1996, city ed. 

c

d

In 2001, Massachusetts increased the tax another 75¢, for a current total tax of $1.51. 

Case Study 6.6 (continued) 

citizens who can’t afford them.” The coalition took advantage of the popular support 

by integrating an aggressive statewide media campaign into its efforts, including 

hard-hitting radio ads addressing Governor William Weld about his opposition, 

newspaper ads in small local newspapers of swing legislators, and an op-ed column 

by former Senator Paul Tsongas. Equally critical to passing the bill was support from 

the chairs of the House and Senate Health Care Committees, Representative John 

McDonough and Senator Mark Montigny, as sponsors of the bill. 

Opposition to the bill came from retailers who claimed that Massachusetts smokers 

would flock to neighboring states to purchase cigarettes and from the governor, who 

was running for the U.S. Senate and tried to use this bill to underscore his reputation 

as a no-tax governor. Governor Weld had opposed all new taxes since he took office 

 His opponent in the race, Senator John Kerry, held press events and ran 

political ads blasting the governor for his position. 

Before the 4th of July holiday, the tobacco bill passed the Senate 

by a vote of 30 to 2. The governor vetoed the bill shortly afterward. On July 24th, 

both the House and Senate overrode the governor’s veto with more than the twothirds vote necessary, and the bill became law. Massachusetts disproved the notion 

that state legislatures will never pass a tax increase opposed by the tobacco lobby. 

Coalitions that form around expanded access to healthcare are potentially much 

stronger than the public health coalitions that have fought for tobacco use prevention 

Sources: Adapted from K. Adami and L. Fresina. 1997. Funding health care for children through an 

increase in the tobacco tax—The Massachusetts experience. In Entering a new dimension: A national 

conference on tobacco and health case studies (September 22–24, 1997), 1–4. Rockville, MD: ASSIST 

Coordinating Center. 

Massachusetts Lobbyist and Employer Statistics database, Division of Public Records, Massachusetts 

Ethics Commission. http://db.state.ma.us/sec/pre/stat_search.asp. 

Knox, R. A. 1996. Health plan for youths, elders eyed cigarette-tax hike included in state bill; Backing 

Vaillancourt, M., and D. S. Wong. 1996. Weld may try to stall health bill to stop tobacco levy, he risks 

triggering business payroll tax. Boston Globe, July 9, 1996, city ed. 

case of the St. Louis County youth access ordinance that went into effect on 

July 1, 1996, several young people who 

testified at the public hearings made 

more of an impact on the county council 

members than dozens of physicians and 

adult tobacco control experts. Teens who 

had participated in compliance checks 

were able to convince the St. Louis 

County Council that youth access to tobacco and the subsequent increase in 

teen tobacco use are community health 

202 
M o n o g r a p h 1 6. A S S I S T 

problems that must be addressed 

through local legislation. (See insight 1.) 

Case study 6.7 about Grand Rapids, 

Michigan, and case study 6.8 about Silver City, New Mexico, illustrate that, 

with training and adult supervision, 

teens can be entrusted with significant 

responsibility and can have a significant 

influence on policymakers. 

Insight 9: Framing the Issue and Using 

the Science Help to Put You in Control 

If you don’t like the news, go out and 

make some of your own. 

—Scoop Nisker 

Success or failure in advocating for a 

policy may well depend on which side 

does a better job of framing the issue in 

the media and in public debate. A policy 

is more likely to be adopted if public 

health advocates succeed in framing the 

issue as a public health problem. On the 

other hand, a policy may well be defeated if opponents succeed in framing the 

issue in terms of the rights of businesses 

or smokers, or of economic impact. In 

other words, present the issue in a way 

that will appeal to the public at large, 

and keep that message in the forefront of 

the debate. 

An important skill for media advocates to develop is the ability to translate 

research findings and national policy debates into terms that are relevant to local 

residents. This translation can be done 

by using simple, common-sense-language; citing concrete local examples 

and anecdotes; and highlighting the key 

implications for local policy—the bottom line. The new information can be 

used to reinforce the central message— 

the key issue at stake in the ongoing policy debate is public health. This skill is 

especially valuable in media advocacy. 

Advocates must clearly know how they 

wish to frame that information before 

they participate in an interview or some 

other opportunity to speak about the issue. They must be well prepared so that 

when challenged they will not lose the 

framing. (See chapter 5.) 

The ability to frame the issue by using the science is powerful in refuting an 

opponent’s claims. For example, public 

health advocates might rebut opposition 

claims that a proposed clean indoor air 

ordinance violates smokers’ rights by 

making the following points. 

■	 The right to breathe clean air takes 

precedence over the right to smoke. 

■	 Smokers are not barred from patronizing smoke-free restaurants; they just 

may not smoke there. On the other 

hand, persons with respiratory conditions cannot patronize restaurants that 

allow smoking without placing their 

health in immediate jeopardy. 

Similarly, public health advocates may 

refute opponents’ claims that the passage 

of such an ordinance will result in restaurants losing business. For example, 

they could respond to such a claim regarding lost business by asserting, 

“Every independent, scientific study that 

has been done on this issue using sales 

tax data has shown that clean indoor air 

ordinances do not negatively affect restaurant sales.” In both cases, the public 

health advocates should immediately 

link back to their main point, their 

frame: “However, the issue here isn’t 

203 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Case Study 6.7 

Situation: 

Strategy: 

Policy Intervention: 

Results and Follow-Up: 

Youth Advocates Make Michigan Arena Tobacco Free 

The project director of the Smoke-Free Class of 2000: Education, Action, 

and Celebration of Grand Rapids, Michigan, was gathering ideas for writing advocacy letters as an exercise in the smoke-free curriculum of Grand Rapids middle 

schools. She investigated whether the nearly completed Van Andel Arena had a 

smoking policy. This 12,000-seat sports and entertainment facility is the nucleus of 

the downtown revitalization. A conversation with the deputy city manager, also chair 

of the Downtown Development Authority (DDA), revealed that the DDA had not 

even considered smoking an issue. This information became part of a lesson on 

advocacy. 

Eighth graders from six Grand Rapids middle schools involved in the SmokeFree Class of 2000 used their new skills to advocate for a tobacco-free policy for their 

community’s new sports arena. Through a grant, ASSIST supported an integrated 

curriculum built on the materials of the Smoke-Free Class of 2000. 

Seventy students wrote letters requesting a tobacco-free policy for 

the arena to the mayor, to the chair of the DDA, and to the local newspaper (as letters 

to the editor). Subsequently, a teacher and a dozen students met with the chair of the 

DDA. Students read their letters regarding a tobacco-free policy for the arena and 

answered the chair’s question: “Why a tobacco-free arena and not a smoke-free 

arena?” Students explained that the issue covered tobacco sales, advertising, and 

even smokeless tobacco. The chair explained the DDA’s decision-making process: 

after the necessary committee meetings, a policy is recommended to the full committee 

for final determination. 

Near the end of the school year, a group representing the Smoke-Free Class of 2000 

was in the crowd that attended a DDA meeting. During the public comment period, a 

student addressed the mayor and the DDA, urging them to approve the tobacco-free 

policy. A classmate distributed Smoke-Free Class of 2000 bumper stickers and gave 

a logo T-shirt to the deputy city manager in appreciation of his help in their efforts. 

The DDA vote unanimously supported a tobacco-free policy. 

The advocacy effort was successful. 

They celebrated their success. A front-page news story included quotations from members of the Smoke-Free Class of 2000. To draw attention to the new policy and commend 

the DDA for its decision, an ad was placed in the Grand Rapids Press. These three fullpage ads ran prior to the grand opening activities for the sports arena. They read: 

The SMOKE-FREE CLASS OF 2000 Salutes the City of Grand Rapids’ Downtown 

Development Authority for choosing to put the health of West Michigan first by 

making the Van Andel Arena tobacco free! 

204 
M o n o g r a p h 1 6. A S S I S T 

Insights: 

■ 

accusations of using youths to address your agenda. 

■ 

Examples of students’ letters that helped convince the Grand Rapids (MI) Downtown Development Authority to adopt a 

These lines preceded a list of the 400 students in the Smoke-Free Class of 2000 and 

the individuals, agencies, and groups who supported their advocacy efforts. Framed 

ads were presented to the DDA, the Van Andel Arena, the Kent County Board of 

Health, the American Lung Association, and the Grand Rapids Christian High School. 

Members of the ninth-grade class arranged a winter social event at the Van Andel Arena 

during a Harlem Globetrotters basketball game. Students presented the framed ad to the 

arena general manager and then received a surprise of their own. The front patio of the 

arena was being paved with engraved bricks, and the Smoke-Free Air for Everyone 

Coalition purchased a brick honoring the students. Television reporters filmed the event, 

including an interview that appeared as a feature on the evening news. 

Give the students a choice regarding advocacy topics. This helps prevent 

Students love the attention. The media publicity and attention make them feel 

empowered, and this empowerment also works to help bridge the gap into a very 

adult world while it imparts important civic lessons. 

100% tobacco-free policy for the new Van Andel Arena. Letters provided courtesy of Krista Schaafsma. 

205

6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

■ 

■ 

(September 22– 

Case Study 6.7 (continued) 

Prepare the youths. The thought of preparing comments for formal events can 

discourage youth participants, so provide the students with sample statements and 

invite them to reword them. 

Include incentives. Youths appreciate refreshments or food at meetings. In 

addition, T-shirts, articles about the youths in school newspapers or school 

newsletters, and certificates for their school portfolio can all be used to encourage 

and recognize their work. 

Source: Adapted from K. V. Schaafsma. 1997. Youth advocacy in action: Absolutely amazing! In 

Entering a new dimension: A national conference on tobacco and health case studies

24, 1997), 23–8. Rockville, MD: ASSIST Coordinating Center. 

Case Study 6.8 

Teens Lead the Way in Silver City, New Mexico 

Situation: A local contractor in the community of Silver City, New Mexico, recruited 

a team of about 20 peer educators and youth advocates from three local high schools. 

The students were trained in tobacco control, peer education, youth advocacy, media 

advocacy, and policy advocacy. Adult supervisors on the staff of the three schools 

coordinated the training and activities. 

Strategy: The students decided to form a community tobacco control coalition. Their 

initial efforts to recruit adults, including representatives from local public health and 

youth agencies and other community leaders, met resistance. The adults felt that 

existing local coalitions that dealt with broader public health issues were already 

adequately addressing tobacco issues. However, the students persisted and ultimately 

succeeded in recruiting a strong core of committed adult tobacco control activists. 

Working together, the teens and adults formed a coalition, with teens filling several 

of the coalition officer positions and playing an important role in setting the coalition’s priorities. 

Intervention: The coalition set an objective of a strong municipal clean indoor air 

ordinance and laid the groundwork for this ordinance by educating the community 

about the health risks posed by ETS. The coalition’s teen members made presentations to a variety of community organizations. They wrote a weekly teen column in a 

local newspaper that discussed the adverse health effects of ETS, the benefits of 

clean indoor air policies, and other tobacco issues. The coalition also worked with a 

professor of journalism at a local university and the ACS state chapter to conduct a 

poll, which found that an overwhelming majority of Silver City residents supported a 

clean indoor air ordinance. In addition, the coalition conducted a campaign to 

recognize local restaurants that adopted voluntary smoke-free policies. Finally, the 

coalition’s teen members held a series of meetings with Chamber of Commerce 

206 
M o n o g r a p h 1 6. A S S I S T 

members found a majority of them to be open to the idea of an ordinance making 

Results and Insights: 

restaurants. 

officials, other business and community leaders, and city councilors to explore their 

level of support for an ordinance. A survey conducted among Chamber of Commerce 

restaurants smoke free. The teen coalition members considered restaurants a priority 

because many teens worked in or patronized restaurants. 

This careful groundwork ultimately led to an ordinance that 

(1) made Silver City restaurants smoke free, (2) required that bar areas in restaurants 

be either smoke free or separately enclosed and ventilated, and (3) banned or restricted smoking in a number of other public places. The coalition’s teen chairperson 

played a leading role in presenting city officials with a model ordinance, negotiating 

the proposed ordinance’s provisions with the city council, and addressing councilors’ 

concerns. The council viewed her as an expert on clean indoor air policy issues and 

repeatedly deferred to her recommendations. Under her leadership, the coalition was 

successful in mobilizing more than 30 Silver City residents to testify in favor of the 

ordinance, including the mayor’s own teenage daughter. The mayor, who was a 

smoker, publicly stated that he did not believe that smoking was a right when it 

affected other people. The city council adopted the ordinance by a unanimous vote. 

The Silver City story illustrates that, when properly trained and supervised by adults, 

teens can have significant influence on policymakers because the latter are unaccustomed to hearing from teens and are often open to their ideas. Many policymakers 

are becoming aware that teens offer good advice on addressing teen problems, such 

as teen smoking and teen exposure to ETS. A major argument used effectively by the 

teen coalition members was that, in addition to protecting restaurant employees and 

patrons from the health risks posed by ETS, the ordinance would also set a good 

example for youths by removing the environmental cue of seeing adults smoking in 

—Stephen Babb, former ASSIST Field Director, New Mexico 

Department of Health in Las Cruces, and current Program 

Consultant at the Office on Smoking and Health, National Center 

for Chronic Disease Prevention and Health Promotion, CDC 

rights or economics. It’s the serious, documented health risks posed by secondhand smoke, and the right of the public 

and employees to be protected from 

these risks.”25,71 

Case study 6.9 on the cigarette excise 

tax in New York demonstrates that scientific studies can be used to support policy 

decisions. The data showed that a prohealth policy would not have a harmful 

economic impact on most communities. 

Case study 6.10 from North Carolina and 

case study 6.11 on Operation Storefront 

illustrate how local coalitions gathered 

their own observational data on cigarette 

sales to minors and protobacco advertising 

in storefronts in their communities. Although the information was not collected 

207 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Case Study 6.9 

Situation: 

Strategy:

a 

tobacco consumption. 

Insights: 

Applied Research Center; these studies calculate the economic impact of reduced 

ly from a reduction in tobacco product sales.e 

New York Counters Tobacco Industry Claims with Data 

The tobacco industry argued that increasing the cigarette excise tax would 

damage the economy by causing job loss, reduced productivity, and lost profits on 

the part of those involved in the distribution and sale of cigarettes. To address these 

arguments, tobacco control advocates needed scientific evidence that increasing 

cigarette excise taxes would not hurt the economy. 

 In New York, the American Lung Association of New York State commissioned a study (with funding from a Robert Wood Johnson Foundation SmokeLess 

States grant) to determine whether New York would suffer economically from a $1 

increase in the state’s cigarette excise tax. The study showed that a $1 increase in the 

cigarette excise tax would result in economic benefits to New York. The results of 

this study, “Estimating the Economic Impact of Increased Cigarette Excise Taxes: A 

Tool for the State Tax Analyst,” were used to support a tax increase of $1. The 

study—coupled with existing data on medical costs, insurance costs, loss of job 

productivity, and work absenteeism related to tobacco use—provided data needed to 

convince policymakers and businesses that they have a vested interest in reducing 

The tobacco industry has sponsored economic studies by well-known 

consulting groups, including Chase Econometrics, Price Waterhouse, and Wharton 

cigarette consumption.b,c,d However, these studies are critically flawed: they are based 

on the assumption that the resources devoted to tobacco product production and 

distribution would disappear if sales were to decline. In fact, the economic activity 

associated with tobacco sales does not disappear as consumption falls but rather is 

redistributed to other sectors of the economy as consumers use money previously 

spent on tobacco to purchase other goods and services. This alternative spending 

generates economic activity and employment in the same way that spending on 

cigarettes does. 

In 1996, Kenneth E. Warner and his colleagues published a groundbreaking report 

that concluded that most states and regions of the country would benefit economicalWarner and his colleagues found that at 

that time only the tobacco states of the Southeast would suffer economically from 

reduced cigarette consumption. For states outside the Southeast, Warner’s findings 

contradicted the tobacco industry’s long-standing claim that a drop in tobacco sales 

is detrimental to the economy. 

—Russell Sciandra, Director of the Center for a Tobacco Free 

New York, and Tim Nichols, Director of Governmental Affairs

 for the American Lung Association of New York State 

208 
M o n o g r a p h 1 6. A S S I S T 

a

tool for the state tax analyst. In State tax notes (V17#20), 1313–18. 

b

Chase Econometrics. 1985. 

in 1983.

c The economic impact of the tobacco industry on the United States economy: 

d A study 

Columbia.

e

Association 275:1241–6. 

Nauenberg E., and J. Nie. 1999. Estimating the economic impact of increased cigarette excise taxes: A 

The economic impact of the tobacco industry on the United States economy 

 Bala Cynwyd, PA: Chase Econometrics, v–3. 

Price Waterhouse. 1992. 

Update of 1990 study. New York: Price Waterhouse. 

Wharton Applied Research Center and Wharton Econometric Forecasting Associates Inc. 1979. 

of the tobacco industry’s economic contribution to the nation, its fifty states, and the District of 

 Philadelphia: Univ. of Pennsylvania. 

Warner, K. E., G. A. Fulton, P. Nicolas, and D. R. Grimes. 1996. Employment implications of declining 

tobacco products sales for regional economies of the United States. Journal of the American Medical 

Case Study 6.10 

Collecting Local Numbers in North Carolina 

Situation: Since media coverage is mostly local in North Carolina, a clear strategy was 

to build the capacity of local communities to develop messages that they could take 

to the news media. 

Strategy and Intervention: In North Carolina, ASSIST sought to build support for an 

enforceable policy to reduce youth access to tobacco. A policy restricting sales of 

tobacco to minors had been on the books for almost 100 years but was never enforced. Members of the coalition supervised teens who bought Marlboro cigarettes in 

randomly selected stores in each of the state’s media markets. Ten highly successful 

press conferences were held on the same day in 1994 to provide the relevant communities with data on tobacco purchases that the youths had made in the local stores. 

Half of the stores had sold to the teens. The teens told their stories at the press 

conferences, and the coverage was excellent. 

Seeing local people present actual numbers on a local issue on the evening news, 

hearing the issue debated on talk radio, or reading an editorial that supports a policy 

to address the local issue can help the public and policymakers realize that the 

problem is real in their community. This intervention opened the doors to a larger 

public policy debate on youth access to tobacco that resulted in the adoption of an 

enforceable youth access law and the governor’s appointment of the Alcohol Law 

Enforcement Division to enforce the youth access to tobacco law. Buy rates in North 

Carolina dropped from 51% in 1994a

 to 20.8% in 2000b and to 14.8% by 2004.c 

Media coverage of the easy access that youth had to tobacco in 1994 also opened 

209 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

policies such as clean indoor air and 100% tobacco-free schools. 

Department of Health and Human Services 

a

b

Annual Synar Report. Raleigh, NC: North Carolina Department of Health and Human Services, 

c

Annual Synar Report. Raleigh, NC: North Carolina Department of Health and Human Services, 

Case Study 6.10 (continued) 

doors to a broader public discussion of tobacco prevention and control public 

—C. Ann Houston, former North Carolina ASSIST field director 

and current Director for Public Education and Communications, 

Tobacco Prevention and Control Branch, North Carolina Department 

of Health and Human Services, and Jim D. Martin, former North Carolina 

ASSIST field director and current State Advisor on Preventing Teen 

Tobacco Use, Tobacco Prevention and Control Branch, North Carolina 

North Carolina Department of Health and Human Services, Project ASSIST. 1994. Project ASSIST 

bulletin. Raleigh, NC: Division of Adult Health Promotion. 

North Carolina Department of Health and Human Services, Substance Abuse Services Section. 2000. 

Division of Mental Health, Developmental Disabilities and Substance Abuse Services. 

North Carolina Department of Health and Human Services, Substance Abuse Services Section. 2004. 

Division of Mental Health, Developmental Disabilities and Substance Abuse Services. 

Case Study 6.11 

Point of Purchase: Operation Storefront 

Operation Storefront was a two-phase campaign. First, participants documented the 

nature and scope of storefront tobacco advertising. Second, they educated decision 

makers about the effects of advertising on youths and promoted private and public 

policy changes. They documented the changes that resulted. This intervention was 

conducted from 1996 to the end of ASSIST in Maine, Massachusetts, Michigan, 

Missouri, New Jersey, New York, Rhode Island, Washington State, West Virginia, 

and Wisconsin. Below are a few excerpts from states’ experiences described in their 

quarterly reports. 

■	 Maine developed and distributed a working manual on Operation Storefront. This 

manual was distributed to participants in a skills-building train-the-trainer workshop. Displays and data from Operation Storefront were released in a media 

event, which featured the governor declaring May as Tobacco Awareness Month. 

Local press conferences for local media outlets were conducted throughout the 

state. 

■	 Maine conducted 248 tobacco advertisement assessments statewide with 102 

youths and adult volunteers. 

■	 Massachusetts’s local providers completed phase 1 of Operation Storefront. 

Phase 1 entailed assessing tobacco advertising visible from the outside of 3,000 

210 
M o n o g r a p h 1 6. A S S I S T 

tobacco merchandisers in 125 cities and towns (whose combined population was 

greater than 3.5 million) throughout the state. Tobacco advertisements made up 

52% of more than 2,000 advertisements visible to youths on storefronts. Phase 2 

involved educating decision makers and advocating for policy change. 

■	 One of Michigan’s local coalitions trained 200 students via teleconference on the 

tobacco industry’s advertising tactics and on how to advocate for the removal of 

tobacco advertising and replacement with countertobacco messages. This event 

was covered by the local media. 

■	 Missouri coalitions conducted Operation Storefront activities, including training 

and press events. One coalition held a press conference to report the results of its 

assessment. As a result, the city prosecutor considered strengthening a policy 

regarding signage for smoking and advertising. Missouri developed a database for 

community groups participating in the Operation Storefront project, for which 

more than 60 groups signed up. 

■	 One of Missouri’s local coalitions held a news conference to release the results of 

Operation Storefront and the billboard assessment. The coalition also kicked off their 

countertobacco billboard campaign, which entailed posting prohealth messages on 12 

billboards in the Kansas City area. This event was covered by two print and two 

broadcast media outlets and was also picked up by the Associated Press. 

■	 A New Jersey local coalition conducted training on tobacco control issues and 

Operation Storefront for Eagle Scout candidates. 

■	 Twelve New York students conducted Operation Storefront throughout one region 

of the state. They found an average of 128 tobacco ads in the stores that they 

visited; this average was significantly higher than for the preceding years. The 

biggest increase was for cigar products. The students presented their findings on a 

local radio station talk show. 

■	 New York sponsored several activities to raise awareness of tobacco advertising. 

The activities included a conference on women and tobacco for 70 participants, a 

conference for 1,200 sixth graders, and a news conference and protest rally on 

Marlboro Man’s induction to the Advertising Hall of Fame. 

■	 Rhode Island local coalitions and youths conducted outdoor and point-of-purchase tobacco advertising assessments. Rhode Island students assessed tobacco 

billboard advertisements, took photographs, and documented six sites. Youths 

also approached an advertising firm to donate billboard space for their posting of 

antitobacco messages. 

■	 In Washington State, a county health department—in collaboration with the local 

coalition, the Korean Women’s Association, and the local Girl Scouts—conducted 

Operation Storefront. They surveyed 177 stores and awarded certificates of 

compliance to those retailers who had complied with the tobacco outdoor ad 

limitation, the yellow warning stickers, and the year-of-birth signs. 

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6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

■ Nineteen of 39 

which youths visited tobacco retail outlets in their communities to assess the 

■ Local coalition members in 

■ 

Case Study 6.11 (continued) 

Washington counties completed Operation Storefront activities in 

amount and placement of tobacco advertising. 

West Virginia took photos of tobacco advertising 

displays in storefronts for media advocacy efforts of the state coalition regarding 

the effects of advertising on youths. 

Wisconsin local coalitions worked with ACS to recruit youth for Operation 

Storefront activities. 

Source: ASSIST state quarterly reports, 1996–99. 

with a scientific study design, it did document what was happening in the communities and was useful in media 

advocacy efforts. 

Insight 10: Policy Change Requires a 

Flexible Strategy and the Ability to 

Respond Rapidly to Opportunity 

Opportunity is missed by most people 

because it is dressed in overalls and 

looks like work. 

—Thomas A. Edison 

Strategies and tactics used in ASSIST 

were defined as planned or opportunistic. Planned strategies were based on the 

body of scientific evidence supporting 

tobacco control, and ASSIST guidelines 

called for focusing on the policies that 

would have the greatest effect on the 

population. Planned strategies were described at the outset of each fiscal year 

and were implemented as a part of an 

annual action plan. As states entered the 

intervention phase, staff realized that the 

action plans had to be flexible to respond to opportunities that were not 

known when the plans were written, especially when those opportunities were 

related to a development in the political 

climate favorable to achieving policy 

changes. 

Opportunistic strategies are quick responses to breaking news, media events, 

or other unanticipated opportunities for 

policy advocacy—a member of a local 

governing body agrees to sponsor a 

tobacco control ordinance, a political 

shift occurs in a governing body that 

suddenly makes possible the adoption of 

a proposed ordinance that previously had 

been stymied, or there is a local hook to 

a breaking national news story. In ASSIST, 

opportunistic strategies arose from the 

resourcefulness of staff and coalitions. 

For example, when billboards advertising tobacco products were brought down 

in compliance with a provision in the 

Tobacco Master Settlement Agreement, 

the coalitions promoted media events 

around the dismantling to bring attention 

to the health issues of tobacco use. The 

Tobacco Master Settlement Agreement of 

1998 was an opportunity for states to seek 

funding for tobacco control programs. 

212 
M o n o g r a p h 1 6. A S S I S T 

Key informant interviews were used 

to examine the worth of responding to 

opportunities because action might require a redirection of resources, time, 

and energy. Coalitions were challenged 

to show that these strategies would lead 

them to their policy goals more rapidly 

and with fewer negative repercussions than 

the previously planned activities. For example, as described in case study 6.12, 

when the South Carolina state house was 

declared a historic site, the ASSIST coalition seized the opportunity and advocated successfully to pass a policy that 

prohibited smoking in the building. 

Insight 11: Make Gains Where 

Possible—Small Changes Add Up 

If you can’t do A, then do B, C, and D, 

but never lose track of A because it 

may come around again. 

—John M. Garcia, former Project 

Director, ASSIST Coordinating Center 

Changing social norms requires taking incremental steps that over time add 

up to arriving at a larger, long-term policy goal. Changing tobacco control policies requires an investment of time. For 

example, increasing state tobacco taxes 

may take 6 years from the time a wellthought-out strategy is designed. Numerous smaller victories will be needed on 

the way to the ultimate goal of increasing tobacco taxes, for example, increasing public awareness in the geographical 

areas of key legislators who have leadership positions. Advocates should never 

underestimate the significance of these 

smaller victories and should never lose 

track of strategies that may not have 

been effective at a particular time—because an opportunity to apply the strategies may occur later. 

A measure that ASSIST program 

managers often used to help decide if an 

activity was worth the effort was to ask 

“What is it going to get us?” If the answer 

did not reveal that the activity would lay 

groundwork or build support for evidence-based policy change, the activity 

was reconsidered. On the other hand, an 

activity that could help build community 

support for an evidence-based policy 

change in one of the four policy areas 

would be well worth the effort. 

Case study 6.13 illustrates how helping North Carolina public schools solve 

a school-based problem was a step toward building support for an important 

tobacco control initiative later. 

Insight 12: Keep Policy Advocacy 

Local and Loud 

Never doubt that a small group of 

thoughtful, committed citizens can 

change the world. Indeed, it’s the only 

thing that ever has. 

—Margaret Mead 

We could never win at the local level. 

The reason is, all the health advocates 

... they’re all local activists who run 

the little political organizations. They 

may live next door to the mayor, or the 

city councilman may be his or her 

brother-in-law, and they say “Who’s 

this big-time lobbyist coming here to 

tell us what to do?” When they’ve got 

their friends and neighbors out there in 

the audience who want this bill, we get 

killed. So the Tobacco Institute and 

tobacco companies’ first priority has 

always been to preempt the field, 

preferably to put it all on the federal 

213 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Case Study 6.12 

An Historic Opportunity: South Carolina Bans Smoking in Its State House 

Situation: 

Strategy: 

■ 

and carpet. 

■ 

■ The taxpayers of South Carolina are spending $68 million on the historical 

Intervention: A 40-member coalition of traditional and nontraditional partners, 

sion and radio outlets from all parts of the state. 

South Carolina’s 1991 Clean Air Act required that government buildings 

become smoke-free environments, but legislators exempted the state house from the 

law. During the next 7 years, health advocates attempted three times to make this 

historic building smoke free. Finally, in 1998, a 3-year, $68 million historical renovation project provided an opportunity to revive the issue. 

A grassroots advocacy plan that included the media and the distribution of a 

postcard was quickly developed to bring the following three key messages to the 

attention of the House-Senate Oversight Committee: 

The historical significance of the State House makes it appropriate to make the 

building smoke free. Tobacco smoke would harm historical artifacts, furnishings, 

Visitors to the State Capitol are exposed to harmful chemicals in secondhand 

smoke. Specifically, hundreds of South Carolina school students visit the state 

house daily. 

renovation of the State House. If tobacco use continues, taxpayers will incur 

additional costs for cleaning and maintaining the building. 

including ASSIST, collaborated on an initiative for a smoke-free state house. Three 

of the partners—the American Cancer Society, the American Lung Association, and 

the American Heart Association—had a working relationship with South Carolina 

state senator Darrell Jackson and sought his support. He agreed to join this effort (for 

the third time). Also during this time (June–July 1998), a reporter from the state’s 

largest daily newspaper began to follow the oversight committee’s agenda. The 

oversight committee was charged with developing rules and regulations regarding 

special events and food consumption inside the state house. The reporter, and a 

representative of the American Cancer Society, contacted Senator Jackson for 

comments regarding tobacco use and smoking in the state house. The story, which 

became the official kickoff of the campaign, was published on July 8, 1998, and 

became a front-page issue. The Associated Press picked up the story, as did televiThe grassroots movement also distributed 15,000 postcards with the simple message 

that smoking does not belong in the House or Senate. Within 2 weeks, all 15,000 

postcards were distributed and mailed to the clerk of the senate. Editorials and news 

articles supporting the smoking ban began to appear in newspapers. 

Senator Jackson placed the item on the oversight committee’s agenda before the 

August committee meeting. At the meeting, the senator, along with health advocates 

214 
M o n o g r a p h 1 6. A S S I S T 

state house. 

Results: 

Case Study 6.13 

a 

State Board of Education adopting a resolution endorsing 100%-tobacco-free schools. 

and 75 members of the Young People’s Division of the African Methodist Episcopal 

Church, a community-funded partner of ASSIST, presented the case for a smoke-free 

After 45 minutes of discussion, with media representatives present from 

around the state, the committee voted unanimously to make all public areas of the 

state house smoke free. The same afternoon, the governor and lieutenant governor 

banned tobacco use in their offices. The total cost of this campaign was less than 

$300, which covered printing the postcards. 

What had been an issue in South Carolina for many years was now legislative policy 

in just 22 days. This successful effort to ban smoking in the state house was the lead 

story that night on television stations across the state and was covered extensively in 

print the next morning. 

Source: Adapted from P. Cobb and G. White. 1999. It’s a state house, not a smoke house! In Tobacco 

free future: Shining the light (Case studies of the fifth annual national conference on tobacco and health, 

August 23–25, 1999), 135–8. Rockville, MD: ASSIST Coordinating Center. 

Twice North Carolina Makes Gains for a Smoke-free School Environment 

In 1994, the U.S. Congress passed the Pro-Children Act, which required that all 

education, health, and library institutions that receive federal funds become smoke 

free. Therefore, the school buildings in North Carolina had to become smoke free; 

however, the schools were not interested in tobacco prevention and control—the 

curricula were overburdened already, and North Carolina produces tobacco. Tobacco 

control advocates learned that schools were under pressure to improve their standardized test scores, but scores do not improve if students are repeatedly suspended for 

smoking. Thus, an alternative-to-suspension program was created jointly to address 

the related needs. This alternative program provided a win-win approach and a 

means to recruit support from school leaders for a tobacco and health initiative. 

Three years later, concerned by the data on tobacco use by North Carolina school 

children, North Carolina’s governor, James B. Hunt, called a governor’s “Summit to 

Prevent Teen Tobacco Use” and listened to what the teens had to say. They asked the 

governor to help make schools in North Carolina 100% tobacco free, not just for 

students, but also for teachers and visitors campus-wide. The governor responded; he 

understood that to have good schools, teachers and staff had to be good role models, 

and he asked every school board in the state to adopt such a policy. 

Advocacy continued for 100%-tobacco-free schools in 2001–02 with the North Carolina 

215

6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

a

Case Study 6.13 (continued) 

The Tobacco Prevention and Control Branch (staffed with former ASSIST personnel) 

wrote grants to the American Legacy Foundation and secured a staff person to be 

dedicated to this policy change. Intensive training events and earned media have resulted 

in a new surge in school districts adopting 100%-tobacco-free school policies, including 

districts that have strong historic ties to the tobacco industry. 

—Sally Herndon Malek, former ASSIST Project Manager, 

and current Head, Tobacco Prevention and Control Branch, 

North Carolina Department of Health and Human Services 

Pro-Children Act. U.S. Code 20 (1994), § 6083. Available at http://www.unf.edu/dept/fie/sdfs/ 

legislation/pca.pdf and at http://thomas.loc.gov. 

level, but if they can’t do that, at least 

on the state level, because the health 

advocates can’t compete with me on a 

state level.72 

—Victor Crawford, former 

Tobacco Institute lobbyist who 

shared insights before his death 

from tobacco-induced cancer 

All 17 ASSIST states found that most 

effective tobacco control policy change 

took place or was initiated at the local 

level. Policymaking is generally more 

transparent and responsive to citizen input at the local level than at the state or 

national level. During the ASSIST era, 

as illustrated in the Victor Crawford 

quotation, the tobacco industry was far 

less effective at fighting a series of local 

efforts than state and national efforts, 

where their money and resources invariably outweigh the resources of tobacco 

control advocates. Moreover, the process 

of advocating for local policies educates 

the community about the rationales, benefits, and requirements of these policies 

and thereby reinforces changes in social 

norms and facilitates policy implementation and enforcement. Tobacco control 

policies that are effective at the local 

level can become the experience and evidence that advocates can point to when 

promoting state-level policies. The tobacco industry’s intensive lobbying for 

state preemption laws—a goal that, for 

much of the 1990s, was at the forefront 

of the industry’s state-level legislative 

agenda57,58—seems to be an acknowledgment of the effectiveness of local policy 

change (see case study 6.14). In some 

states, the lack of local policies was a 

key factor in unsuccessful fights against 

preemption. 

Insight 13: It’s Not Over ’Til It’s Over, 

or Never Give Up, Never Give Up, 

NEVER GIVE UP! 

If you are building a house and the nail 

breaks, do you stop building or do you 

change the nail? 

—Zimbabwean proverb 

Sometimes it takes years for a community or a state to adopt sweeping policy 

change. Even when strong public support 

exists for such change, powerful interests may resist it and create an impasse. 

216 
M o n o g r a p h 1 6. A S S I S T 

Case Study 6.14 

Situation: 

Strategy: 

Intervention: Indianapolis Star

Star

Star 

Results: 

Epilogue and Insight:

 (September 22– 

Indiana’s Battle against Preemption 

The Indiana General Assembly passed a bill that preempted all local 

jurisdictions on the sale, distribution, and promotion of tobacco products. 

The Indiana Campaign for Tobacco Free Communities spearheaded a 

campaign to bring about a veto of the bill by the governor. The campaign was funded 

by the National Center for Tobacco-Free Kids and received technical assistance from 

the Center, the American Cancer Society, and Americans for Nonsmokers’ Rights. 

News coverage of the issue in the was excellent, with 

almost daily coverage. The , which had previously shown little editorial support 

for tobacco control, published two editorials supporting a veto by the governor; one 

of the editorials ran on the day of the crucial vote. After the General Assembly 

overrode the governor’s veto of the original bill that had been passed by the General 

Assembly in 1995, the ran an in-depth article on the tobacco industry’s influence in the state house. The article was a culmination of a year of work by coalition 

members with reporters who had covered a “state house sellout” series published in 

1996. The result was a front-page story outlining the tobacco industry’s ties with 

retailers’ groups and the subsequent impact on the vote to overturn the governor’s 

veto. 

Indiana’s governor vetoed the bill in March 1996. As part of his veto message, he pointed to the lack of local tobacco ordinances as a weakness in Indiana’s 

ability to effectively fight preemption. The governor noted: 

Supporters argue this legislation is necessary to preempt local ordinances that, at present, 

are virtually nonexistent in Indiana; opponents defend the right of localities to enact 

measures which, to date, they have shown little or no inclination to enact. 

 In 1997, the Indiana legislature removed the right of local 

communities to regulate youth access to tobacco by a single vote, thereby overturning a veto by Governor Evan Bayh. Though the veto failed, key victories were scored 

in this hard battle. Tobacco advocates were successful in limiting the preemption 

coverage to the sale, display, and promotion of tobacco products; thus, clean indoor 

air laws were excluded from the exemption. Also, the battle became a litmus test for 

commitment to tobacco control and laid the groundwork for future policy battles. 

Source: Adapted from K. Sneegas. 1997. Lessons from Indiana: The battle against preemption. In 

Entering a new dimension: A national conference on tobacco and health case studies

24, 1997), 159–65. Rockville, MD: ASSIST Coordinating Center. 

217

6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

However, by refusing to become discouraged and by continuing to lay the 

groundwork for change through ongoing 

community education and mobilization, 

advocates can prepare themselves for 

opportunities that suddenly create an 

opening for the long-sought change to 

occur. (See case studies 6.15 and 6.16.) 

Insight 14: It’s Never Over!: 

The Importance of Vigilance 

after a Policy Takes Effect 

Often, getting a policy adopted is 

only the start of the battle. Advocates 

cannot afford to relax once they have 

achieved that goal. In many cases, opponents of the policy will not give up once 

the policy is passed. Instead, they may 

seek to reverse it through various means. 

Advocates must publicize the positive 

impact of policy change through data 

and testimonials as well as anticipate 

and prepare to respond to opposition 

tactics. One helpful approach is for advocates to “put themselves in their opponents’ shoes” and then ask what they 

would do and what options are open to 

them. (See case study 6.17.) 

The Influence of Policy 

Public policy affects everyone and 

reflects and reinforces social norms 

and behaviors. Some policies provide 

guidance; others mandate adherence to 

regulations. The role of public health 

policy is to protect the population from 

unnecessary health risks and dangers, to 

promote public knowledge about healthful and preventive behaviors, and to provide opportunities and access to health 

care. As evidence unfolds about benefichange the practice within a chain of stores. 

Educating Local Store Owners about 

Tobacco Displays and Placement Fees 

The smaller the town, the greater the effect. 

Many operators of stores in smaller towns 

and cities live in the same area as their stores. 

These owners are known by the community 

and feel more responsibility toward their 

neighbors than the big-city chains with large, 

absentee corporate owners. Most small-town 

retailers are not aware of the tobacco 

industry’s true agenda behind contracts for 

placement of tobacco products and ads. They 

simply do what the tobacco representatives 

tell them to do and take the money. The act of 

simply educating a retailer about how tobacco 

displays facilitate shoplifting by children and 

explaining that the community is aware that 

he takes placement fees to perpetuate the 

situation can be quite powerful with some 

individuals. Several concerned citizens 

making this point to a storeowner in person is 

an effective approach and might be enough to 

—Anne Landman, former Regional 

Program Coordinator for the American 

Lung Association of Colorado 

cial and harmful environmental factors, 

scientists and the public health community have a responsibility to disseminate 

that information to the public. When 

challenges deter dissemination and application, public health policy is an effective recourse, but it is not an easy 

process. Enacting new policies requires 

(1) the support of the community for a

policymaker who has introduced a policy 

or (2) advocacy by the community to introduce a policy. 

Policy advocacy was the very core of 

the ASSIST project, and its focus on interventions in four policy areas proven 

to be effective in promoting health and 

218 
M o n o g r a p h 1 6. A S S I S T 

Case Study 6.15 

Persistence Pays Off in Mesilla, New Mexico 

Situation: In 1995, the small, traditional, predominantly Hispanic/Latino community 

member of the board of trustees shifted his stance on the ordinance from opposition 

(which included a number of Mesilla residents), as well as by personal and political 

Insight: At each of the three stages of this process, and in the interim between them, 

the Las Cruces coalition consistently educated Mesilla residents and leaders, as well 

of Mesilla in south central New Mexico considered adopting a comprehensive clean 

indoor air ordinance covering all workplaces, including restaurants, along the lines 

of an ordinance passed earlier in neighboring Las Cruces. However, the board of 

trustees (the town’s governing body) lacked the votes to pass a strong ordinance and 

settled for a weaker ordinance that allowed smoking in up to 40% of the seating in 

restaurants. The main obstacle to the ordinance was vigorous opposition by two local 

restaurants that were among the town’s largest employers; the owners were concerned about potential loss of revenues, especially from tourists. 

In 1998, Mesilla revisited its ordinance but again was unable to muster a majority for 

an ordinance requiring restaurants to go 100% smoke free. Finally, in 2000, a key 

to support. This trustee’s change of position was influenced by information on health 

and economic issues provided to him by the Las Cruces tobacco control coalition 

factors. This shift made it possible to amend the original ordinance to ban smoking 

in restaurants and to require bar areas of restaurants to be either smoke free or 

separately enclosed and ventilated. 

as the members of the board of trustees, and advocated for smoke-free restaurants. 

However, the coalition was careful to take a low-key approach that avoided burning 

bridges with opponents and that was respectful of the tight-knit community’s norms 

of civility and consensus decision making. This steady perseverance ultimately paid 

off, with the two previous “failures” laying the foundation for the final victory. 

—Stephen Babb, former ASSIST Field Director, New Mexico 

Department of Health in Las Cruces, and current Program 

Consultant at the Office on Smoking and Health, National Center 

for Chronic Disease Prevention and Health Promotion, CDC 

in decreasing premature death and disease related to tobacco use: clean indoor 

air, restricted tobacco advertising and 

promotion, reduced youth access to 

tobacco products, and price increases on 

tobacco products. The ASSIST staff and 

coalitions met a variety of challenges in 

promoting policies in those areas. They 

met the challenge of developing the personal skills necessary to conduct policy 

advocacy successfully, of mobilizing 

community support for policy campaigns, 

and of responding to tobacco industry 

opposition. Their strategies and tactics 

were varied and met the particular needs 

of their communities, but the coalitions 

219 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Case Study 6.16 

Situation: 

wheels of change were put in motion. 

Strategy: 

Intervention: 

Response:

Response: 

September 1997: 

Response:

October 1997: 

Response:

December 1997: 

Changing Policy on Public Transportation: Smoke-free Washington State Ferries 

The Washington State Ferry System serves daily commuters and thousands 

of tourists. Because smoking was allowed on the ferries, virtually all 23 million 

passengers and 1,500 employees were exposed to secondhand smoke. A member of 

the Tobacco Free Coalition of Sno-King was embarrassed that her visitor had to walk 

through tobacco smoke to enjoy the scenic beauty and breathe in the fresh sea air. 

The visitor asked, “So what are you going to do about it?” With that question, the 

The Sno-King coalition led multiple efforts to achieve a policy banning 

smoking on the ferries: volume postcard mailings, peaceful protests, public education events, and persistent contact with state authorities. 

A series of interventions from June 1997 through July 1998 were 

necessary to achieve results. First, the Sno-King coalition wrote 15 letters to the 

chief executive officer of the Washington State Ferry System asking for 100%-

smoke-free ferries and wrote several letters to the editors of local newspapers. 

 No policy change. 

Next, the Sno-King coalition collaborated with the Tobacco-Free Kitsap County 

Coalition and conducted a smoke-free rally at the ferry terminal. This hour-long rally 

received coverage from two local television stations and the daily newspaper, and 

positive comments from ferry passengers. 

No policy change. 

The Tobacco-Free Washington Coalition became involved. Hundreds of postcards urging the Washington State Transportation Commission to 

change its smoking policy were sent to the commission. 

 No policy change. 

A smoke-free walking tour was coordinated with a regional youth 

tobacco conference, “Tobacco in 3-D.” Participants held “We want smoke-free 

ferries” signs or handed out flyers about the smoke-free ferry issue. About 30 

participants chanting “secondhand smoke makes us choke” walked all over downtown Seattle, through the Washington State ferry terminal, and past the CEO’s office. 

National Public Radio interviewed participants. 

 No policy change. 

It was time to get on the agenda of the Washington State Transportation Commission’s meeting. The Department of Transportation’s ombudsman was 

a critical element in this process. Letters and postcards, many from youths, were sent 

220 
M o n o g r a p h 1 6. A S S I S T 

Response: 

Results and Insights: 

sometime in the future. 

(Case studies of 

the fourth annual national conference on tobacco and health, October 26–28, 1998), 113–6. Rockville, 

to the State Transportation Commission, and at the commission’s meeting, seven 

volunteers provided public comment on the smoke-free ferry issue. 

The commission decided that because a 1988 law prohibited smoking in 

state facilities, there was a need to reopen discussion regarding the State Ferry 

System’s smoking policy. The Transportation Commission charged the State Ferry 

System to evaluate its smoking policy. 

January 1998: Representatives from the various coalitions attended six regional 

meetings of the Ferry Advisory Committee. 

On June 21, 1998, the State Ferry System announced a policy 

change: smoking would be permitted only in designated areas at the back section of 

the ferries. Although the policy change was not a 100% ban, it was a step in the right 

direction, and the Transportation Commission has stated that a total ban will occur 

It is important to determine who has the authority to make policy change in a large 

state system and to anticipate who might pose barriers. For example, there are 13 

unions representing 1,500 ferry employees. Smoking breaks were written into the 

collective bargaining contracts between the ferry system and the ferry system 

employees. 

Source: Adapted from S. Vermeulen. 1998. Campaign to change policy on public transportation: Smoke 

free Washington State ferries. In No more lies: Truth and the consequences for tobacco 

MD: ASSIST Coordinating Center. 

all used media interventions and media 

advocacy to bring attention to the health 

issues inherent in tobacco use and to the 

proposed policies. 

Once in effect, policies have an impact on the daily lives of many people. 

Policies protecting workers from environmental tobacco smoke impose rules 

in the workplace but also liberate those 

workers from exposure to thousands of 

secondhand smoke chemicals and poisons. Cigarette taxes raise the price of a 

pack of cigarettes but also decrease the 

prevalence of smoking and of the resulting diseases and premature deaths. Advertising restrictions limit the placement 

of billboard ads and other signage but 

thereby remove unwanted protobacco 

messages from the view of children. Restrictions on selling to minors increase 

the responsibility and culpability of retailers but thereby decrease the ease with 

which children could have access to cigarettes leading to addiction. 

In short, tobacco control policies are 

experienced in some form by everyone 

in society and reinforce a tobacco-free 

way of life. As policies take effect, positive 

outcomes occur—people quit smoking, 

employers implement smoke-free work 

environments, and retailers learn how to 

refuse to sell tobacco products to minors. 

221 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Case Study 6.17 

Protecting the Gain in Las Cruces, New Mexico 

Situation:

forced the Las Cruces City Council to either repeal the ordinance or place it on a 

Las Cruces a

 the 

ordinance 

Strategy: 

these challenges. 

Intervention: 

coordinated tactics: numerous letters to the editor and op-ed columns (which includ­

 In 1995, Las Cruces became the first community in New Mexico to enact a 

comprehensive clean indoor air ordinance. Before the ordinance had even taken 

effect, opponents launched a referendum drive. If successful, the drive would have 

ballot for a public vote. Although the Las Cruces tobacco control coalition was 

confident that the ordinance would have prevailed in a referendum (a poll conducted 

by the New Mexico State University Journalism Department and the 

Sun-News found that 73% of the residents surveyed supported the ordinance),

campaign would have consumed enormous energy and resources and would have 

opened the door to further tobacco industry interference. The drive failed when the 

opposition gathered fewer than half of the signatures required. 

However, the referendum drive was succeeded by a series of other opposition tactics, 

including the following six tactics: 

1. Two lawsuits by local restaurants seeking to block enforcement of the ordinance 

and to have it struck down 

2. The formation of a regional restaurant association created in response to the 

3. A media and public relations offensive against the ordinance by a new restaurant 

that was refusing to comply with the ordinance in coordination with a local radio 

talk show host 

4. Personal attacks in the media on members of the local tobacco control coalition 

and, in some cases, legal harassment of these advocates 

5. An effort to unseat a mayor who had come to support the ordinance by channeling $10,000 in campaign contributions to his opponent in an election 

6. An attempt to invalidate the ordinance through the passage of a preemptive law at 

the state level 

Through prompt responses, sound strategic thinking, and effective community mobilization and media advocacy, the Las Cruces coalition, working closely 

with partners at the local, state, and national levels, was able to turn back each of 

The coalition countered the opposition through a series of its own 

ed scientific findings, presented in nontechnical language, with explanations of their 

policy implications), press conferences, sponsorship of community forums and 

candidate debates, broad community outreach and cultivation of allies (including 

proprietors of restaurants that had adopted voluntary smoke-free policies), petition 

222 
M o n o g r a p h 1 6. A S S I S T 

Results: 

In October 2002, the Las Cruces City Council, at the request of the Las Cruces 

a , May 7, 1995. 

drives in support of the ordinance, delegation visits to newly elected and incumbent 

city council members, and ongoing consultation with the ordinance sponsor. 

The coalition was able to defeat each of the opposition’s attempts to roll back 

the ordinance. In addition, the coalition was able to achieve passage of several 

amendments progressively strengthening the ordinance. The Las Cruces experience 

also helped inspire several other communities in the region (including the New 

Mexico communities of Carlsbad, Mesilla, and Silver City and the nearby Texas city 

of El Paso) to adopt ordinances similar to that in Las Cruces. In January 2002, Doña 

Ana County (the county in which Las Cruces sits) adopted an ordinance that was even 

more comprehensive than the Las Cruces one. 

coalition, rescinded the original ordinance and replaced it with a new one that 

contained almost no exemptions. Opponents once more launched a petition drive to 

force a referendum on the new ordinance, and this time succeeded in collecting 

enough signatures to do so. The opposition, led by the local Chamber of Commerce, 

conducted a well-funded, well-organized campaign against the ordinance; the 

coalition once more waged a vigorous campaign in its defense. The vote was held in 

March 2003, and the new ordinance lost, 56% to 44%. Technically, the vote was on 

just the new provisions in this ordinance, which extended the ordinance’s coverage to 

free-standing bars, truck stops, private clubs, parks, and areas within 50 feet of the 

entrances of buildings where smoking is banned. With the defeat of the new ordinance, Las Cruces reverted to the previous ordinance, which still required most 

enclosed workplaces and public places to be smoke free, including restaurants. 

Throughout the series of events that followed the passage of the original ordinance, 

the coalition was forced to expend effort on defending the ordinance that could have 

otherwise been devoted to other policy interventions. The coalition had not anticipated the amount of energy that it would have to spend on sustaining its initial policy 

victory. 

—Stephen Babb, former ASSIST Field Director, New Mexico 

Department of Health in Las Cruces, and current Program 

Consultant at the Office on Smoking and Health, National Center 

for Chronic Disease Prevention and Health Promotion, CDC 

Giles, M. 1997. Poll shows most residents support smoking ban. Las Cruces Sun-News

Program services are needed to respond 

to the increased demand that are created 

by these outcomes, whether smoking 

cessation clinics, management training 

events, or retailer education programs. 

Chapter 7 describes how ASSIST staff 

worked with their coalition partners to 

encourage them to offer the services, 

congruent with their organizations’ missions, that would help individuals and 

communities embrace a tobacco-free 

norm in daily life. 

223 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Appendix 6.A. Excerpts fr om Youth Access to Tobacco: 

A Guide to Developing Policy 

Youth Access


To Tobacco


A Guide To Developing Policy


Number one in a series of four policy guides 

ASSIST 

The American Stop Smoking Intervention Study 

National Cancer Institute 

National Institutes of Health 

US DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Prepared by: 

Americans for Nonsmokers’ Rights 

Berkeley, California 

with 

Prospect Associates 

Rockville, Maryland 

224 
M o n o g r a p h 1 6. A S S I S T 

Contents* 

Acknowledgments ................................................................................................................... i


Background ............................................................................................................................. 1


Overview: Policy Options To Reduce Youth Access to Tobacco ......................................... 2


Policy Options ........................................................................................................................ 4


Minimum Age of Purchase for Tobacco Products ...................................................... 4


Tobacco Retailer Licensing ......................................................................................... 4


Tobacco Vending Machines ......................................................................................... 6


Self-Service Displays ................................................................................................... 8


Distribution of Free Tobacco Product Samples ........................................................... 8


Single Cigarette Sales .................................................................................................. 9


Point-of-Purchase Warning Signs ................................................................................ 9


Enforcement and Compliance .............................................................................................. 11


State and Local Enforcement ..................................................................................... 11


Designating an Enforcement Agency ........................................................................ 12


Activities To Achieve Compliance ............................................................................ 12


Penalties for Violation ................................................................................................ 14


Voluntary Youth Access Programs ....................................................................................... 16


General Components .................................................................................................. 16


Effectiveness .............................................................................................................. 16


Resources To Design a Voluntary Youth Access Program ........................................ 17


Special Issue: Preemption ................................................................................................... 18


The Synar Amendment ......................................................................................................... 21


Tobacco Industry Youth Access Programs ........................................................................... 23


Youth Access Programs ............................................................................................. 23


Education Programs ................................................................................................... 24


Analysis ...................................................................................................................... 25


References ............................................................................................................................. 27


Appendix A. Lists of Youth Access Ordinances 

Licensing Tobacco Retailers 

Completely Eliminating Cigarette Vending Machines 

Severely Restricting Cigarette Vending Machines 

Banning Tobacco Samples 

Appendix B. Sample Laws 

King County, WA: Tobacco Retailer License 

Radnor Township, PA: Ban on Tobacco Vending Machines 

City of Cupertino, CA: Partial Ban on Tobacco Vending Machines 

State of Minnesota: Ban on Distribution of Free Tobacco Products 

Williamstown, MA: Ban on Self-Service Displays, Distribution of 

Free Tobacco Products, and Single Cigarette Sales (Section 11) 

*Page numbers in this Table of Contents are from the original document and do not correspond to page 

numbers in this monograph. 

225 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Background 

Tobacco use is the leading cause of preventable disease and death in the United 

States (US DHHS, 1989). Primary smoking claims an estimated 419,000 lives per year 

(CDC, 1993a), secondary smoking another 53,000 (Glantz and Parmley, 1991). Tobacco addiction typically begins during childhood or adolescence. Approximately 75 percent of cigarette smokers tried their first cigarette before their 18th birthday (CDC, 

1991a). Initiation of daily smoking generally occurs during sixth through ninth grade 

(Johnston et al., 1992). 

Surveys conducted throughout the U.S. show increasingly high rates of smokeless 

tobacco use, concentrated among young males. Estimates of use range from 10 to 39 

percent (US DHHS, 1992). 

These young tobacco users underestimate the addictive nature of nicotine. According to a 1986 survey, only five percent of high school smokers believed they would be 

smoking five years later; in fact, an estimated 75 percent continued to smoke seven to 

nine years later (Johnston et al., 1992). 

Tobacco use among youth has failed to show a significant decline over the past ten 

years. Although the daily smoking rate for high school seniors decreased from 29 percent to 

20 percent between 1977 and 1981, the smoking rate decreased only an additional 1.8 

percent through 1991 (Johnston et al., 1992). This trend is in sharp contrast to the 

greater declines observed for other drug use among youth during the same time period. 

Despite the fact that almost all states prohibit the sale and distribution of tobacco 

products to minors, tobacco is easily accessible to youth. Studies indicate that underage youth can purchase tobacco products 70 to 100 percent of the time from merchants 

and through vending machines (Altman et al., 1989). Youth themselves report that it is 

easy for them to purchase tobacco; the majority buy their own cigarettes (Cummings et 

al., 1992). 

The tobacco industry, including manufacturers and retailers, profit from these illegal 

sales. Researchers estimate that 947 million packs of cigarettes are sold annually to underage youth in the United States, representing total sales worth $1.23 billion and a net 

profit of $221 million (DiFranza and Tye, 1990). 

Overview: Policy Options To Reduce Youth Access to Tobacco 

Strategies to reduce youth consumption of tobacco products focus on either the demand or the supply side of the problem. Counter-advertising campaigns and schoolbased tobacco prevention curricula seek to reduce youth demand for tobacco products. 

Policy options regarding the advertising and promotion of tobacco products will be explored in a future paper in this series. Youth access policies are designed to reduce the 

supply of tobacco products available to youth. 

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M o n o g r a p h 1 6. A S S I S T 

Youth access policies are based on the premise that reducing access will lead to a reduction in youth consumption and addiction. The effectiveness of these policies cannot 

be measured simply in terms of achieved reduction in tobacco sales to minors. The ultimate goals of all of these policies are to reduce youth consumption of tobacco products and reduce childhood addiction, ultimately reducing adult consumption. 

Preliminary results from three studies indicate that youth access legislation may reduce youth consumption. Following enactment and enforcement of a youth access ordinance in Woodridge, Illinois, student surveys showed over a 50 percent reduction in 

rates of cigarette experimentation and regular use of cigarettes (Jason et al., 1991). A 

youth access ordinance in Everett, Washington, reduced tobacco use among girls from 

26.4 percent to 11.5 percent (Hinds, 1992). In Leominster, Massachusetts, active local 

enforcement of a state sales to minors law was followed by a significant decrease in 

the number of youth identifying themselves as cigarette smokers (DiFranza et al., 

1992). 

Policies to reduce youth access to tobacco can be enacted at the Federal, state and 

local levels. A recent Federal initiative, the Synar Amendment, requires states to adopt 

and enforce laws prohibiting tobacco sales and distribution to youth less than 18 years 

of age. States which fail to achieve specified reductions in the rate of youth sales risk 

losing a percentage of their Federal funding for drug and alcohol prevention and treatment. 

The majority of existing state laws focus on establishing a minimum age for purchase of tobacco products; some states have restricted placement of vending machines, 

banned free distribution of tobacco product samples, or licensed tobacco retailers (US 

DHHS, 1993b). State legislation has been largely unenforced and ineffective in reducing youth access (US OIG, 1992). Florida and Vermont are the only two states which 

currently provide for statewide enforcement of their youth access laws (US OIG, 

1992). This situation may change, as the Synar Amendment offers significant incentives for states to achieve reduction in rates of tobacco sales to minors. 

Although it is not strictly speaking a youth access policy, increasing state tobacco 

excise taxes does reduce youth access by placing the product out of financial reach of 

many youth. An increase in the excise tax will lead to a reduction in tobacco consumption among youth (US GAO, 1989). The issue of excise taxes will be explored in greater depth in a future paper in this series. 

To date, the greatest successes in reducing youth access have been achieved at the 

local level (US DHHS, 1993b). Provisions that have been enacted at the local level include: 

•	 Licensing tobacco retailers, providing for suspension/revocation for repeated sales to 

minors. 

•	 Banning or restricting tobacco vending machines. 

•	 Banning self-service displays of tobacco products. 

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6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

•	 Banning distribution of free samples or coupons for free samples of tobacco 

products. 

•	 Banning sale of single cigarettes. 

•	 Requiring point-of-purchase warning signs. 

The provisions listed above are also appropriate for adoption at the state level. Several of the options (vending machines, licensure, point-of-purchase signs) are included 

in the Model Sale of Tobacco Products to Minors Control Act for States developed by 

the Department of Health and Human Services (US DHHS, 1990). 

Studies consistently show strong public support for stronger laws and better enforcement to reduce youth access (CDC, 1991b; US OIG, 1992; Burns and Pierce, 

1992). The only substantial opposition to reducing youth access comes from the tobacco industry and merchants, both of whom profit from sales to minors. 

Policy Options 

MINIMUM AGE OF PURCHASE FOR TOBACCO PRODUCTS 

Forty-nine states have established a minimum age of purchase for tobacco products; 

the majority set the minimum age at 18 years of age (US DHHS, 1993b; US OIG, 

1992). Under the Synar Amendment, states are required to prohibit the sale or distribution of tobacco products to persons under the age of 18 (US DHHS, 1993a). 

Legislation should avoid vague language stating that it is a violation to “knowingly 

sell tobacco products to minors.” This provides a loophole for merchants, who can 

claim they were not aware the customer was underage (US OIG, 1992). Stronger language requires merchants to request photographic identification if a customer appears 

to be under a specified age, before concluding the sale. 

Options 

•	 Prohibit the sale or distribution of tobacco products to persons under 18 

years of age. 

•	 Require merchants to request photographic proof of age for customers 

who appear to be under 21 years of age. 

Passing a law which simply prohibits the sale and distribution of tobacco products 

to minors will not automatically decrease youth access to tobacco. In order to achieve a 

true reduction in access, policies must also address the locations and manner in which 

tobacco is sold or otherwise made available (Reynolds and Woodward, 1993). Policies 

must also include clear enforcement mechanisms and be actively enforced if they are 

to achieve their potential to reduce youth access. Policy provisions and enforcement 

228 
M o n o g r a p h 1 6. A S S I S T 

mechanisms to achieve compliance with minimum age requirements are discussed in 

this paper. 

TOBACCO RETAILER LICENSING 

Tobacco retailer licensing legislation requires merchants to obtain a license to sell 

tobacco products and provides for the suspension or revocation of the license if the 

merchant sells tobacco to a minor. This scheme, similar to that used to control alcoholic beverage sales to minors, creates a significant financial incentive for retailers to 

avoid illegal sales to minors. The profits lost by forfeiting the right to sell tobacco to 

adults exceed the typical $100 to $500 fine exacted for violations under most youth access legislation. License fees can be earmarked to fund enforcement activities. 

Licensing ordinances are a relatively new development, and there is only preliminary research documenting their effects. Researchers report that a licensing ordinance 

in Woodridge, Illinois, has reduced the rate of illegal sales to minors, from 70 percent 

at baseline to less than five percent 18 months after initiating enforcement (Jason et al., 

1991). King County, Washington, reduced sales to minors to 27 percent following enactment of a licensing ordinance (Spokane County Health District, 1992). 

These licensing ordinances include strong enforcement provisions. Both Woodridge 

and King County have used underage “inspectors” who, under adult supervision, spot 

check retailer compliance. The license fee is set at a level sufficient to cover the cost of 

enforcement efforts. The King County ordinance was recently superceded by preemptive state legislation passed to satisfy the Synar Amendment, and the local enforcment 

activities have been dismantled. (See sections on Preemption and the Synar Amendment.) 

Most licensing ordinances contain a graduated schedule of fines and penalties; suspension or revocation of a license is the last resort, after the retailer has shown a consistent pattern of illegal sales to minors. Under some ordinances, the retailer may 

appeal suspension or revocation of the license at a public hearing. To avoid frivolous 

appeals, the retailer may be required to bear the costs of the appeal process. 

Options 

•	 Require a license for the retail sale of tobacco products. Earmark fees to 

fund enforcement efforts. 

•	 Establish a graduated penalty system which culminates in suspension or 

revocation of the tobacco retail license for repeated sales to minors. 

•	 Establish a public appeal process for suspension or revocation of license. 

The retailer may be required to pay the costs of the appeals process. 

•	 Enforcement: Systematic, unannounced spot checks of all retailers by 

underage “inspectors.” 

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6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

TOBACCO VENDING MACHINES 

A study commissioned by the vending machine industry found that 23 percent of 

youth that smoke use vending machines “often” or “occasionally” (NAMA, 1989). A 

recent study found an even higher percentage (37.8 percent) of youth that smoke who 

reported using vending machines “often” or “sometimes” (Cummings et al., 1992). 

Younger children rely more heavily on vending machines as a source of cigarettes (US 

DHHS, 1989). The NAMA study found that 13-year-olds reported using a vending machine “often” 11 times more frequently than did 17-year-olds (NAMA, 1989). 

Option One: A Complete Ban on the Sale of Tobacco Products Through Vending Machines 

Former Secretary of Health and Human Services Louis Sullivan and former Surgeon 

General C. Everett Koop both have called for a total ban on cigarette vending machines. Unlike over-the-counter sales, vending machine sales to minors don’t respond 

to merchant education programs (Altman et al., 1989) or to increased penalties and 

fines for sales to minors (Forster et al., 1992b). 

Complete bans are relatively easy to enforce; the simple presence of a tobacco vending machine indicates a violation. A study of two cities with tobacco vending machines 

bans found complete compliance two years after the bans were enacted (Forster et al., 

1992a). 

Options 

•	 Ban the sale of tobacco products through vending machines in all locations. 

•	 Enforcement: If a tobacco vending machine is present, the owner is in 

violation of the law. 

Option Two: A Partial Ban on the Sale of Tobacco Products Through Vending Machines, 

Restricting Their Placement to Adult Locations 

A partial ban provides an exemption for tobacco vending machines placed in bars or 

other “adult-only” locations, such as employee cafeterias or adult social clubs. These 

policies are less effective than total bans in preventing illegal sales to minors. Researchers from the University of Minnesota have demonstrated that underage youth experience high rates of success (78 percent) in purchasing cigarettes from vending 

machines placed in establishments characterized as adult locations (Forster et al., 

1992b). 

The effectiveness of a partial ban may increase if machines are required to be placed 

at least 25 feet from any entrance. This prevents placement of the machines in unattended lobbies and entrances. Defining adult-only locations should be done carefully. 

230 
M o n o g r a p h 1 6. A S S I S T 

For instance, exempting the bar area of a restaurant may fail to prevent sales to minors; 

47 percent of youth using tobacco vending machines report that the machine was 

placed in a restaurant (NAMA, 1989). 

Options 

•	 Ban the sale of tobacco products through vending machines, providing 

an exemption for adult-only locations. 

•	 Require that tobacco vending machines be placed at least 25 feet away 

from any entrance in an exempted location. 

•	 Enforcement: If a tobacco vending machine is present, verify that it is in 

an exempted location. Verify that the machine is 25 feet from any entrance. Periodic purchase attempts by underage “inspectors.” 

Option Three: Require Installation of Locking Devices on all Tobacco Vending Machines 

This option is often promoted by vending machine trade associations and the tobacco industry as an alternative to full or partial bans. This is the least effective means of 

curtailing illegal sales to minors through vending machines. 

The state of Utah, which required their use until 1988, found that locking devices 

were rarely installed, and, where installed, seldom operating. In St. Paul, Minnesota, 

one year after a locking device ordinance was passed, 30 percent of the machines were 

not equipped with a locking device. Of those machines with a locking device, compliance deteriorated during the first year after the law was passed, from 30 percent sales 

to minors at three months to 48 percent at one year (Forster et al., 1992a). 

Locking device requirements entail a greater enforcement burden than complete 

bans (Forster et al., 1992a). Even when installed and operating, attendants may continue to sell cigarettes to underage youth. However, in areas where a full or partial tobacco vending machine ban is politically infeasible, some researchers feel that a locking 

device requirement accompanied by strong enforcement to ensure installation and operation is better than nothing. 

Options 

•	 Require installation of a locking device on all tobacco vending machines. 

•	 Enforcement: Site visits to verify locking device installation and operation. Periodic purchase attempts by underage “inspectors.” 

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6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

SELF-SERVICE DISPLAYS 

Self-service displays allow customers to acquire tobacco products without the intervention of a store employee. Tobacco companies offer retailers “slotting fees” for favorable placement of their products in the store, including placement of self-service 

displays. 

Banning self-service displays may reduce youth access in two ways: (1) youth may 

be less likely to attempt purchase when they must request tobacco from a store employee, rather than handing the product to a sales clerk for checkout, and (2) the absence of displays makes it more difficult to steal tobacco products. This is a relatively 

new policy development; there is no research to date which indicates whether banning 

self-service displays reduces youth access to tobacco. 

Options 

•	 Prohibit open displays of tobacco products which can be reached without 

the intervention of a store employee. 

DISTRIBUTION OF FREE TOBACCO PRODUCT SAMPLES 

Distribution of free tobacco samples is a popular form of promotion for both cigarette and chewing tobacco manufacturers. Free tobacco samples frequently are distributed in locations where underage youth are likely to congregate: music festivals, rock 

concerts, sports events, zoos, and fairs (Davis and Jason, 1988; Chudy et al., 1993). 

Most states prohibit the distribution of tobacco samples to underage youth. In addition, the tobacco industry has a voluntary code addressing product sampling which 

prohibits the distribution of tobacco products to “any person whom they know to be 

under 21 years of age or who, without reasonable identification to the contrary, appears 

to be less than 21 years of age” (Tobacco Institute). 

Despite these state laws, and the industry’s voluntary code, free sampling of tobacco 

products in public areas and through the mail is a source of tobacco products for underage youth. A survey of underage youth found that 50 percent reported witnessing 

other people their age receiving free samples (Davis and Jason, 1988). The same study 

found that 20 percent of high school students and four percent of elementary students 

surveyed reported that they themselves had received free samples of tobacco products. 

232 
M o n o g r a p h 1 6. A S S I S T 

Options 

•	 Ban distribution of free tobacco samples or coupons for free samples in 

publicly and privately owned property accessible to the general public. 

•	 Ban the distribution of free tobacco samples through the mail. 

SINGLE CIGARETTE SALES 

Although the Federal Cigarette Labeling and Advertising Act prohibits the sale or 

distribution of cigarettes without the mandated warning label, some stores sell single 

cigarettes which are taken out of their packages and stored in cups and trays. This 

practice is illegal, unless the cigarettes are removed from their packages by the customer or in the presence of the customer (Manfreda, 1989). A study of stores in a 

southern California community found that almost half sold single cigarettes and that 

youth were able to purchase them almost twice as often as adults (Leary, 1993). This 

despite the fact that California prohibits all sales of single cigarettes. 

Options 

•	 Prohibit the sale or distribution of one or more cigarettes, other than in a 

sealed package which conforms to the Federal labeling requirements, including the Federal warning label. 

POINT-OF-PURCHASE WARNING SIGNS 

Requiring warning signs stating that sales to minors are illegal does not lead to a reduction in sales to minors. A merchant education project in New York found that posting signs had no effect on the rate of sales. Although the intervention led to an increase 

in the number of stores posting warning signs (40 percent), those stores showed no significant reduction in sales to minors when compared to control stores which did not receive the intervention (Skretny et al., 1990). Posting of signs is the major component in 

the Tobacco Institute’s program “It’s the Law.” Researchers have shown that this program does not reduce merchants’ illegal sales to minors (DiFranza and Brown, 1992). 

Studies conducted in Missouri and Texas also found that the likelihood of success was 

not significantly different for stores with and without warning signs (CDC, 1993b). 

233 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

A study of stores in Massachusetts found that stores which posted signs were less 

likely to sell to minors; however, the majority (32 of 36) of the signs were not visible 

to the customers (DiFranza et al., 1987). The warning signs may have served as a cue 

to the clerks, reminding them to avoid selling tobacco products to minors. 

Some tobacco control professionals are concerned that posting warning signs where 

they are visible to minors presents tobacco as a “forbidden fruit” reserved for adults 

and may encourage teen rebellion against adult rules (Carol, 1992; DuMelle, 1991). A 

study of youth susceptibility to smoking found that rebellious attitudes were associated 

with an increased susceptibility to smoking among adolescents (Pierce et al., 1993). 

This dilemma may be solved by posting a warning sign so as to be visible to the clerk, 

but not to underage youth. 

Options 

•	 Require warning signs to be posted at point-of-purchase in view of the 

sales clerk. 

234 
M o n o g r a p h 1 6. A S S I S T 

Appendix 6.B. Excerpts from Clean Indoor Air: 

A Guide to Developing Policy 

Clean


Indoor Air


A Guide to Developing Policy


Number two in a series of four policy guides 

ASSIST 

The American Stop Smoking Intervention Study 

National Cancer Institute 

National Institutes of Health 

US DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Prepared by: 

Americans for Nonsmokers’ Rights 

Berkeley, California 

with 

Prospect Associates 

Rockville, Maryland 

June 1994 

235 
6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Contents* 

Acknowledgments ..................................................................................................................................... i


Background ............................................................................................................................................... 1


Overview: Clean Indoor Air Policy Options ........................................................................................... 4


Voluntary Clean Indoor Air Policies ............................................................................................. 4

Clean Indoor Air Legislation ......................................................................................................... 5


Policy Options .......................................................................................................................................... 8


Workplaces ..................................................................................................................................... 8


Enclosed Public Places ................................................................................................................ 10


Restaurants and Bars .................................................................................................................... 10


Schools ......................................................................................................................................... 11


Child Care Centers ....................................................................................................................... 12


Health Care Settings .................................................................................................................... 12


Public Transportation ................................................................................................................... 13


Prisons .......................................................................................................................................... 14


Recreational Facilities .................................................................................................................. 14


Enforcement Issues ...................................................................................................................... 16


Common Exemptions ............................................................................................................................. 18


Routine Exemptions ..................................................................................................................... 18


Separately Ventilated Smoking Rooms ....................................................................................... 19


Phase-In Period ............................................................................................................................ 20


Size Exemptions ........................................................................................................................... 20


Hardship Clauses ......................................................................................................................... 20


Economic Impact .................................................................................................................................... 22


Enacted Legislation ...................................................................................................................... 22


General Principles for Analyzing Economic Impact Reports ..................................................... 25


Voluntary Policies ........................................................................................................................ 26


Legal Issues ............................................................................................................................................. 27


Legal Challenges to Clean Indoor Air Legislation ...................................................................... 27


Legal Issues Regarding Smoking in Workplaces and Other Environments .............................. 27


Opposition to Clean Indoor Air Policy .................................................................................................. 31


Preemption ................................................................................................................................... 31


Campaign Contributions .............................................................................................................. 32


Tobacco Industry Front Groups ................................................................................................... 33 


Smokers’ Rights Groups .............................................................................................................. 35


Disputing the Science .................................................................................................................. 35


Voluntary Clean Indoor Air Programs ................................................................................................... 37


Components to Adopting Successful Voluntary Policies ............................................................ 37


Tobacco Industry Programs .................................................................................................................... 39


References ............................................................................................................................................... 41


Appendix A: Lists of Clean Indoor Air Ordinances


100% Smokefree Ordinances


Smokefree Ordinances Which Regulate Bars


Appendix B: Sample Legislation


Larkspur, CA: 100% Smokefree public places, workplaces, and restaurants


Vermont: 100% Smokefree public places including restaurants


Dothan, AL: Partial restrictions on public places, workplaces, and restaurants


*Page numbers in this Table of Contents are from the original document and do not correspond to page 

numbers in this monograph. 

236 
M o n o g r a p h 1 6. A S S I S T 

Background 

THE HEALTH EFFECTS OF ENVIRONMENTAL TOBACCO SMOKE 

Environmental tobacco smoke (ETS), also called secondhand smoke, is a combination of smoke exhaled by the smoker and sidestream smoke emitted from a burning 

cigarette. Exposure to ETS is often referred to as involuntary smoking. The adverse 

health effects of ETS on the nonsmoker are no longer in question. Environmental tobacco smoke is a cause of respiratory disease, including lung cancer, and may also 

cause heart disease in nonsmokers (US DHHS, 1986; US EPA, 1992; Glantz & Parmley, 1991; Taylor et al., 1992). 

The 1986 Surgeon General’s Report was devoted to the health effects of involuntary 

smoking on the nonsmoker. Based on a comprehensive review of the scientific research, the report reached three major conclusions (US DHHS, 1986): 

1.	 Involuntary smoking is a cause of disease, including lung cancer, in healthy


nonsmokers.


2.	 Children of parents who smoke, compared with children of nonsmoking parents, 

have an increased frequency of respiratory infections, increased respiratory 

symptoms and slightly smaller rates of increase in lung function as the lung 

matures. 

3.	 Simple separation of smokers and nonsmokers within the same air space may 

reduce, but does not eliminate, exposure of nonsmokers to environmental tobacco 

smoke. 

The findings of the Surgeon General’s Report were seconded by the National Academy of Sciences, which also reviewed the scientific evidence regarding secondhand 

smoke in 1986 (NAS, 1986). 

In 1990, the Environmental Protection Agency convened a scientific advisory board 

to review research on the respiratory effects of ETS on nonsmokers. The final report, 

Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders, 

was released in 1992 and included the following conclusions (US EPA, 1992): 

In adults: 

1.	 ETS is a Group A (known human) carcinogen. 

In children, ETS exposure is causally associated with: 

1.	 Increased prevalence of lower respiratory tract infections; 

2.	 Increased prevalence of middle-ear effusion, symptoms of upper respiratory tract 

irritation, and a small but statistically significant reduction in lung function; 

3.	 Additional episodes and increased severity of symptoms in children with asthma; 

and, 

4.	 Exposure to ETS is a risk factor for new cases of asthma in children who have 

not previously displayed symptoms. 

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6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

The EPA did not issue any findings regarding the link between heart disease and 

ETS exposure. However, the American Heart Association’s Scientific Council has concluded that ETS increases the risk of heart disease (Taylor, et al., 1992). Some research indicated that the public health burden caused by ETS may be greater for heart 

disease than lung cancer (Steenland, 1992; Taylor, et al., 1992; Glantz & Parmley, 

1991). Researchers have estimated that in addition to the cancer deaths attributable to 

ETS exposure (up to 3,700 to lung cancer and up to 12,000 to other cancers), up to an 

additional 37,000 nonsmokers die from heart disease caused by ETS exposure (Glantz 

& Parmley, 1991). 

In addition to the EPA’s classification of ETS as a Group A carcinogen, the National 

Institute for Occupational Safety and Health (NIOSH) has determined that ETS meets 

OSHA’s criteria for classifying substances as potential occupational carcinogens 

(NIOSH, 1991). NIOSH also concludes that exposure to ETS poses an increased risk 

of heart disease among occupationally exposed workers (NIOSH, 1991). 

CONSTITUENTS OF ENVIRONMENTAL TOBACCO SMOKE 

Environmental tobacco smoke is a combination of mainstream smoke exhaled by 

the smoker and sidestream smoke emitted by the burning tip of a cigarette. The major 

source of ETS is sidestream smoke. Because of a lower burning temperature, sidestream smoke actually contains higher amounts of toxins and carcinogenic agents per 

gram of tobacco burned than mainstream smoke (US DHHS, 1986). 

Nonsmokers’ exposure to ETS can be measured by cotinine levels in body fluids. 

Cotinine, a metabolic by-product of nicotine, is an accurate marker for ETS exposure 

because of nicotine’s specificity to tobacco smoke (US DHHS 1986). Many people 

who report no exposure to ETS have measurable levels of cotinine in their body fluids 

(NIOSH, 1991). The tobacco industry has claimed that cotinine levels in nonsmokers 

are caused by eating vegetables from the solanecae family (e.g., eggplant). However, a 

nonsmoker would have to eat several pounds daily to produce measurable levels of cotinine (Perez-Stable, et al., 1992; Repace, 1994). Although a metabolized by-product 

of nicotine is the biological marker of ETS exposure, nonsmokers are exposed to far 

more than just nicotine when they are exposed to ETS. 

Four thousand seven hundred (4,700) chemical compounds have been identified in 

ETS, including carbon monoxide, nicotine, carcinogenic tars, ammonia, hydrogen cyanide, formaldehyde, benzene, and arsenic (US EPA, 1989). Many of these compounds 

are treated as hazardous when released into outdoor air by industrial plants (US EPA, 

1989). Forty-three chemicals in tobacco smoke are identified carcinogenic compounds 

(US DHHS, 1989). 

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M o n o g r a p h 1 6. A S S I S T 

EFFECTS ON INDOOR AIR QUALITY 

The EPA considers ETS the most widespread and harmful indoor air pollutant and a 

major contributor to indoor air pollution (US EPA, 1990). A 1980 study found that every indoor environment where smoking was permitted had air pollution levels of respirable suspended particles above the standards for outdoor air, while all smokefree areas 

met Federal standards for outdoor air (Repace & Lowrey, 1980). Exposure to ETS is 

high because most people spend approximately 90 pecent of their time indoors (US 

EPA, 1993). 

RECOMMENDATIONS TO ELIMINATE EXPOSURE TO ETS 

Both the Environmental Protection Agency and the National Institute for Occupational Safety and Health (NIOSH) recommend that nonsmokers should not be exposed 

to ETS (US EPA, 1989; NIOSH, 1991). Both agencies recommend two methods by 

which nonsmokers’ ETS exposure can be eliminated (US EPA, 1989; NIOSH, 1991): 

1. Complete elimination of smoking in the building; or 

2. Establishment of separate, enclosed smoking areas that are separately


ventilated and directly exhausted to the outside.


Overview: Clean Indoor Air Policy Options 

Clean indoor air policies to reduce nonsmokers’ exposure to environmental tobacco 

smoke (ETS) have historically treated public places, workplaces, restaurants, and bars 

as separate entities (Hanauer, et al., 1986; Pertschuk & Shopland, 1989; US DHHS, 

1993). At a minimum, these policies set nonsmoking as the norm and restrict smoking 

to designated areas. A more recent trend is to prohibit smoking altogether (US DHHS, 

1993). 

Clean indoor air policies have been adopted in both the private and the public sectors. In the private sector, voluntary clean indoor air policies generally have been 

adopted by private employers, although public venues such as hospitals, hotels/motels, 

airports, and shopping malls have also adopted voluntary policies. 

In the public sector, clean indoor air policies take either the form of legislation 

passed by elected legislative bodies or regulations adopted by public agencies. State 

laws are often referred to as clean indoor air laws, while local laws are called smoking 

ordinances (Pertschuk & Shopland, 1989). 

Although the chief purpose of clean indoor air policy is to protect nonsmokers from 

the hazards of ETS exposure, restrictions on smoking have been shown to reduce both 

smoking prevalence and, among continuing smokers, cigarette consumption (Woodruff, et al., 1993; Emont, et al., 1992; Borland, et al., 1990; Stillman et al., 1990, 

Brigham, et al., 1994). 

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6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

VOLUNTARY CLEAN INDOOR AIR POLICIES 

Voluntary smoking policies have generally been the purview of private workplaces. 

The earliest workplace smoking policies were developed as safety measures to prevent 

fires, protect machinery, avoid product contamination, and improve workplace safety 

and were more commonly found among blue-collar (i.e., manufacturing) workplaces 

(US DHHS, 1986). Not until the 1970s did the nature and scope of voluntary workplace policies begin to change (US DHHS, 1986). 

During the 1980s, smoking restrictions began shifting from workplace safety to employee health, and more nonmanufacturing workplaces began adopting policies (US 

DHHS, 1986). The policies themselves became more stringent, restricting smoking to 

even smaller designated areas. 

Since the late 1980s, a growing trend to eliminate smoking in the workplace has 

emerged. A 1991 survey by the Bureau of National Affairs found that 34 percent of 

companies had eliminated smoking in the workplace, compared with 7 percent in 

1987 and 2 percent in 1986 (BNA, 1991). In 1992, 52 percent of facilities managers 

surveyed reported that their facility had a smokefree workplace policy (Ward, 1992). 

CLEAN INDOOR AIR LEGISLATION 

Clean indoor air legislation has shown a bottom-up trend, with the strongest and 

most comprehensive policies concentrated at the local level, followed by state legislation, and, lastly policy established at the Federal level. 

FEDERAL CLEAN INDOOR AIR POLICY 

Federal clean indoor air policy focuses on smoking in Federal facilities and on public transportation (US DHHS, 1989). Both the U.S. Department of Health and Human 

Services and the U.S. Postal Service have adopted policies eliminating smoking in all 

of their facilities. Other Federal agencies have implemented policies that prohibit 

smoking except in designated smoking areas. 

Amtrak, a quasi-governmental agency, has adopted a policy that eliminates smoking 

completely on trains traveling less than 41/2 hours such as the metroliner between 

Washington and New York. The ban also covers all trains in California and other selected trains. To date, congressional action on clean indoor air has been limited to the 

airline smoking ban. Smoking is banned on all airline flights within the continental 

United States and overseas domestic flights of 6 hours or less. 

STATE CLEAN INDOOR AIR POLICY 

Early state legislation restricting smoking was intended to reduce fire and other 

safety hazards or treated tobacco use as a moral wrong (US DHHS, 1986). This trend 

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M o n o g r a p h 1 6. A S S I S T 

continued until the 1970s. With the first reports that smoking’s ill effects were not limited to the smoker, state legislation began to shift its concern from fire safety to protecting nonsmokers (US DHHS, 1986). 

In 1975, Minnesota passed its Clean Indoor Air Act, the first comprehensive state 

legislation to set nonsmoking as the norm. This landmark legislation restricted smoking except in designated areas in many public places, including restaurants and public 

and private worksites. In 1993, Vermont passed the most restrictive state clean indoor 

air legislation. Vermont is the first state to completely ban smoking in public places, 

restaurants, and all government buildings. 

As of 1993, 46 states and the District of Columbia had passed some form of clean 

indoor air legislation dealing with public places. Forty-two restrict smoking in the 

public workplace and 22 include restrictions in private workplaces (Nobel, 1994). 

LOCAL CLEAN INDOOR AIR POLICY 

As with state legislation, the first local clean indoor ordinances were passed in the 

1970s (US DHHS, 1993). As of September 1992, 543 local smoking ordinances were 

on the books (US DHHS, 1993). 

Local ordinances are almost always stronger and more comprehensive than their 

corresponding state laws (US DHHS, 1989). The recent trend to completely eliminate 

smoking in public places, workplaces, and restaurants began and continues to flourish 

at the local level. In 1985, Aspen, Colorado was the first municipality to ban smoking 

in restaurants. Following the release of the draft EPA risk assessment in 1990, an increasing number of local 100 percent smokefree ordinances were enacted. As of May 

1994, 87 smokefree ordinances completely eliminate smoking in public places, workplaces, and restaurants; 35 eliminate smoking in public places and restaurants; and 16 

eliminate smoking in public places and workplaces (ANR, 1994). 

Local ordinances have been adopted at a much faster rate than state legislation. A 

1993 status report for the Tobacco Institute tracked a total of 388 local clean indoor air 

ordinances. Of these, 215 had been adopted, 147 were pending, and only 26 had been 

defeated (Tobacco Institute, 1993a). In contrast, of the clean indoor air bills introduced in 43 state legislatures in 1993, 20 were defeated (including an attempt to repeal 

preemption in Iowa) and only 16 were adopted (at least two of which include preemption of local ordinances) (Tobacco Institute, 1993b). 

The tobacco industry has been largely unsuccessful in defeating clean indoor air 

policy at the local level. For this reason, preemption of local ordinances by state legislation has emerged as the tobacco industry’s primary strategy to prevent the passage of 

clean indoor air legislation. (See section on Opposition to Clean Indoor Air Policy for 

more information on preemption.) 

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6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

LOCATIONS COVERED BY CLEAN INDOOR AIR LEGISLATION 

Locations that are generally covered by clean indoor air policies (legislative or regulatory), at both the local and the state level include: 

•	 Workplaces, both public and private 

•	 Enclosed public places, which include most areas open to the general public or to 

which the public is invited (e.g., retail stores, banks, theatres, museums, and public 

transit) 

•	 Restaurants, and in some instances, bars (particularly those attached to restaurants) 

•	 Schools 

•	 Child care centers 

•	 Health care settings 

•	 Public transportation 

•	 Prisons 

•	 Recreation facilities such as sports stadiums, bowling centers, and bingo parlors 

PUBLIC SUPPORT FOR CLEAN INDOOR AIR POLICIES 

As early as 1964, a majority (52 percent) of adults thought smoking should be allowed in fewer places than it was at the time (US DHHS, 1989). Years before the 1986 

Surgeon General’s report on involuntary smoking, nonsmokers believed that exposure 

to secondhand smoke was harmful. A 1978 survey completed for the tobacco industry 

found that 58 percent of Americans believed that being exposed to other’s cigarette 

smoke was hazardous to their health (The Roper Organization, 1978). 

A 1988 Gallup survey found that the percentage favoring a total ban on smoking in 

public places was 60 percent (75 percent of nonsmokers) (Gallup, 1988). In 1994, that 

percentage had increased to 67 percent (78 percent of nonsmokers), according to a 

New York Times/CBS NEWS poll (Janofsky, 1994). The public has also shown a consistent trend in support of restrictions on smoking in the workplace (US DHHS, 1989). 

Adoption of smokefree policies may actually lead to an increase in support for 

smoking bans in certain environments. In 1984, a Field poll in California found that 

only 38 percent of the state’s residents favored a complete ban on smoking in airplanes. In 1993, a few years after the congressional ban of smoking on domestic 

flights, that number had more than doubled to 81 percent (The Field Poll, 1993). 

Policy Options 

Given the serious health risks associated with secondhand smoke exposure, it is imperative that nonsmokers be provided with smokefree public places and workplaces to 

the greatest extent possible. In some instances, it is not judged to be politically possible to immediately enact smokefree legislation; this may be particularly true in jurisdictions that are adopting restrictions on smoking for the first time. To be effective, it 

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M o n o g r a p h 1 6. A S S I S T 

is essential that the legislation be supported by the community. Policy development 

should always begin with community education, including media advocacy, before any 

legislation is introduced. 

The options listed below contain several provisions that can be incorporated into a 

piece of clean indoor air legislation. Each list begins with the total elimination of 

smoking; recommendations for partial restrictions are located at the end of each options list. Although these options specifically focus on enacted legislation, many of the 

options are appropriate guidelines to develop voluntary policies. 

WORKPLACES 

Approximately 80 percent of the average nonsmoker’s exposure to secondhand 

smoke occurs at work (Repace & Lowrey, 1985). In addition to reducing secondhand 

smoke exposure, worksite restrictions and bans help some smokers reduce or quit 

smoking (Borland, et al., 1990; Stillman, et al., 1990). A recent study estimates that if 

every California workplace went smokefree, consumption among employees would 

drop 41 percent below that if there were no workplace smoking policies (Woodruff, et 

al., 1993). The effect of a workplace policy on smoker behavior is reduced when the 

workplace is only partially smokefree (Woodruff, et al., 1993). 

Many workplaces voluntarily restrict or eliminate smoking. A 1991 survey by the 

Bureau of National Affairs found that 85 percent of responding firms adopted policies 

restricting smoking, with 34 percent completely eliminating smoking at work. Although many of these were adopted voluntarily, 36 percent of the respondents reported 

that their policies were adopted as a result of state or local legislation (BNA, 1991). 

(See section on Voluntary Worksite Programs for more information.) 

Many local jurisdictions and state legislatures first adopt policies that cover only 

governmental workplaces, restricting or eliminating smoking in all government facilities. These restrictions are often adopted through administrative policies or resolutions, although some are put in place through enacted legislation. The next phase is to 

extend these restrictions to private workplaces. The majority of state and local laws 

partially restrict smoking in public and private workplaces, although a growing number 

of local ordinances completely eliminate smoking in all workplaces. 

Smokefree workplace legislation prohibits smoking in all enclosed areas of the 

workplace. Some legislation has allowed the construction of smoking areas, which are 

enclosed and separately ventilated from the rest of the building. (See section on Common Exemptions for more information.) 

Partial bans on smoking in the workplace generally prohibit smoking in all common 

areas, particularly restrooms, hallways, common work areas, and meeting rooms. In 

addition, many allow employees to designate their own immediate work areas as nonsmoking (Pertschuk & Shopland, 1989; US DHHS, 1993). Partial restrictions often include a “nonsmoker’s preference” clause, specifying that in the event of a dispute over 

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a smoking policy, the right of the nonsmoker to a smokefree workplace prevails (US 

DHHS, 1993). Partial restrictions almost always specify that the proprietor of any regulated area has the right to designate the entire facility smokefree (US DHHS, 1993). 

Most workplace legislation, smokefree or partial restrictions, includes a “nonretaliation clause” protecting employees and job applicants who seek their rights under the 

law (US DHHS, 1993). Many clean indoor air laws also require employers to develop 

a written policy for the workplace, which conforms with the requirements of the law 

(US DHHS, 1993). 

Options 

*	 Prohibit smoking in all enclosed workplaces. 

*	 Prohibit smoking in all enclosed workplaces, except for a designated 

smoking area that is enclosed, separately ventilated, and directly exhausted to the outside. 

*	 Include a nonretaliation clause protecting nonsmokers who assert their 

rights under the law from retaliation by an employer. 

*	 Require the employer to develop a written workplace policy whose provisions comply with requirements established by the law. Copies shall 

be provided on request. 

*	 If smoking is allowed in designated areas, prohibit smoking in all commonly used areas of the workplace, allow employees to designate their 

immediate work area as nonsmoking, specify that the nonsmoking employee’s rights prevail when disputes arise over smoking in the workplace, and specify that any regulated area may designate the entire 

facility as smokefree. 

ENCLOSED PUBLIC PLACES 

Legislation restricting smoking in public places typically prohibits smoking completely rather than mandating separate smoking and nonsmoking areas. “Public places” includes any enclosed area open to the public such as retail stores, businesses open 

to the public, theatres, museums, and reception areas (Pertschuk & Shopland, 1989; 

US DHHS, 1993). Some of the newest local ordinances regulate smoking in the common areas of apartment buildings such as lobbies, stairways, common laundry facilities, and hallways between apartments (ANR, 1994). 

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M o n o g r a p h 1 6. A S S I S T 

Most clean indoor air legislation lists various venues covered under the law to clarify the intent and coverage of the law. When such lists are present, it is important to include language stating that the list “includes, but is not limited to” the listed areas. 

Options 

*	 Prohibit smoking in all enclosed public places, specifying that all enclosed public places, unless specifically exempt, are included. 

*	 List specific environments (e.g., elevators and restrooms, service lines, 

retail stores, office areas where the public is allowed, and theatres) that 

are covered by the ban. 

RESTAURANTS AND BARS 

Although restaurants and bars serve as both public places and workplaces, they have 

historically been treated separately in clean indoor air legislation (Pertschuk & Shopland, 1989; US DHHS, 1993; Hanauer, et al., 1986). However, the debate has begun to 

focus on restaurants and bars as workplaces. This is important, as secondhand smoke 

levels in both restaurants and bars are higher than those found in most other workplaces. 

The level of environmental tobacco smoke in restaurants is about 1.6 to 2 times 

higher than that found in an office. In bars, exposure to ETS is 3.9 to 6.1 times higher 

than office exposure. This increased exposure to secondhand smoke results in a 50 

percent greater risk of contracting lung cancer for restaurant and bar workers (Siegel, 

1993b). 

Many clean indoor air laws require restaurants to establish smoking and nonsmoking sections. A move to completely eliminate smoking in restaurants began in the mid1980s and has accelerated in the 1990s with the release of the Environmental 

Protection Agency’s risk assessment classifying secondhand smoke as a Group A carcinogen (US DHHS, 1993; US EPA, 1992). A report released by an Attorneys General 

Working Group on Tobacco, recommending that fast food restaurants go smokefree, 

has provided additional impetus to the restaurant industry to adopt voluntary smokefree policies (Attorneys General, 1993). 

Policymakers have been reluctant to restrict smoking in free-standing bars and taverns. A handful of local laws require separate smoking sections in bars, but by early 

1994, only 10 local ordinances completely banned smoking in all bars (ANR, 1994). 

Smoking is more commonly regulated in bars that are attached to restaurants. Thirtysix local ordinances that prohibit smoking in restaurants have also covered smoking in 

bars attached to restaurants (ANR, 1994). Generally, these laws either prohibit smoking in 

restaurant cocktail lounges and bars or allow smoking only if the bar area is separately 

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6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

enclosed and ventilated in a manner that prevents secondhand smoke from recirculating into the rest of the restaurant. 

Options 

*	 Eliminate smoking completely in all restaurants and bars. 

*	 Permit smoking in free-standing bars, but eliminate smoking in bars attached to restaurants unless the bar: (1) is in a separate room from the 

dining room; (2) has a separate ventilation system; (3) is not the sole entrance or waiting area for dining; and (4) prohibits minors from entering. 

*	 If smoking sections are established, set the maximum allowable size of 

the smoking area at a percentage that is no larger than the percentage of 

smokers in the community. 

SCHOOLS 

A growing number of public schools completely prohibit tobacco use on school 

grounds, by students, faculty, staff, and visitors. Some of these restrictions follow state 

or local law, others have been adopted by the local school district. By the end of 1992, 

nine states and the District of Columbia prohibited smoking on school grounds. A survey by the National School Board Association found that in the 1991-92 school year, 

40 percent of school districts totally prohibited tobacco use by both students and adults 

(NSBA, 1992). 

Fourteen states ban tobacco use by students on school grounds (O’Connor, 1992). 

Because these policies still allow smoking by faculty, staff, and visitors, they may fail 

to adequately protect nonsmokers. Smokefree policies that include faculty and staff receive greater support among students (Phillips & McCoy-Simandle, 1993). A policy 

that applies to both students and adults promotes “a consistent message — tobacco use 

is hazardous for adults as well as students and therefore unacceptable in the school setting” (Griffin, et al., 1988). 

Options 

* Prohibit the use of tobacco products by students, faculty, staff, and visitors within all public school buildings and on school grounds during and 

after school hours. 

* Prohibit tobacco use at all off-campus school functions by students, faculty, staff, and visitors. 

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M o n o g r a p h 1 6. A S S I S T 

CHILD CARE CENTERS 

Child care centers have begun prohibiting smoking as a result of their own voluntary 

policies or state or local laws. These policies are the result of increased awareness of 

the health risks of secondhand smoke, especially for children. 

By the end of 1993, 14 states prohibited smoking in child care centers, while many 

others restricted smoking (Nobel, 1994; ANR, 1994). Many local ordinances ban 

smoking in all day care centers, covering facilities serving both children and adults 

(ANR, 1994). 

Options 

*	 Prohibit smoking in all child care centers. 

*	 In child care centers that are operated in private homes, allow smoking 

only after hours in areas where clients are not permitted. 

HEALTH CARE SETTINGS 

Smoking restrictions in hospitals are fairly common. A 1987 survey by the American College of Healthcare Executives found that 96 percent of responding hospitals 

had some type of restrictions on smoking (American Medical News, 1991). As a result 

of standards established by the Joint Commission on Accreditation of Healthcare Organizations, hospitals, including long-term care and mental health care programs housed 

within a hospital, must be virtually smokefree. The standards permit smoking only for 

patients with a physician’s prescription that permits smoking based on criteria developed by medical staff. Hospitals that were not already smokefree must at least have a 

plan for going smokefree by December 31, 1993 (JCAHO, 1991). 

Under revisions of the JCAHO standards, hospitals may also designate certain 

smoking areas for patients who do not have patient-specific permission to smoke, providing that the smoking areas are designed in a way to protect nonsmokers and providing that the areas are only for the use of chronically mentally ill patients, long-term/ 

intermediate care and skilled nursing patients, forensic psychiatry patients, and postacute head trauma (social rehabilitation) patients (Sachs, 1993). 

There is little information about smoking policies in non-hospital health care settings. An area that generates controversy is long-term care facilities. Because patients 

reside in these types of facilities for long periods of time, staff are reluctant to adopt 

complete bans on smoking. In some states, only the state can regulate smoking in 

these facilities. In California, for example, the Department of Health Services, rather 

than counties or municipalities, has regulatory jurisdiction over skilled nursing facilities and intermediate care facilities (Cal DHS, 1992). 

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6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Options 

* Prohibit smoking completely in hospitals and other health care facilities, 

including private homes when used as a health care facility. 

* Allow exemptions for chronically mentally ill patients, long-term/intermediate care and skilled nursing patients, forensic psychiatry patients, 

and post-acute head trauma (social rehabilitation) patients, if they have 

written, patient-specific permission from their attending physician based 

on standards established by the medical staff and smoking is allowed 

only in areas that are enclosed, separately ventilated, and directly exhausted to the outside. 

PUBLIC TRANSPORTATION 

Today, smoking is rarely permitted on public transportation vehicles. Numerous 

Federal, state, and local laws eliminate smoking on public transportation vehicles and 

transit depots (US DHHS, 1993). In 1989, Congress banned smoking on all airline 

flights within the continental United States. The airline smoking ban also extends to 

overseas domestic flights of 6 hours or less (e.g., California to Hawaii). 

Smoking policies covering local public transportation systems, such as buses or 

light rail, are typically adopted in one of two ways. The first is through inclusion in a 

local smoking ordinance. The second is adoption of a smoking policy by the local policymaking body with jurisdiction over the system. A total of 391 local ordinances regulate smoking on public transportation. In addition, 39 state clean indoor air laws ban 

smoking on public transportation (US DHHS, 1993). 

Options 

•	 Prohibit smoking in all vehicles of public transportation, including buses 

and taxicabs. 

•	 Prohibit smoking in all transit depots such as airports and train platforms. 

PRISONS 

Although prisoners smoke at rates significantly higher than the general population 

(Duggan, 1990), an increasing number of prisons and jails are eliminating smoking. 

The American Jailers Association adopted a resolution in May 1990 urging jails to ban 

smoking (Skolnick, 1990), and about 10 million prison inmates are currently covered 

by some sort of smoking restrictions (CDC, 1992a). 

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M o n o g r a p h 1 6. A S S I S T 

Some prison policies prohibit smoking in jail cells but permit it in prison yards, 

while others prohibit smoking by inmates entirely, and the strongest do so for prison 

staff as well. Some of these policies are put in place by administrators, while others 

are the result of state or local legislation and regulation. 

A recent court case has increased the incentives for prisons and jails to establish 

smoking policies. In Helling v. McKinney, the U.S. Supreme Court opened the door to 

potential lawsuits brought by nonsmoking prison inmates on the theory that exposure 

to secondhand smoke constitutes cruel and unusual punishment, prohibited by the 8th 

Amendment to the U.S. Constitution. 

Although many jails are adopting smokefree policies, larger prisons are responding 

more slowly (Skolnick, 1990). Nearly two-thirds of inmates are housed in prisons 

rather than jails (CDC, 1992a), leaving a substantial number of inmates and prison 

staff exposed to secondhand smoke. 

Options 

* Prohibit smoking in enclosed areas of jails and prisons by both inmates 

and staff. 

* Establish a nonsmoking area in prison yards. 

RECREA TIONAL F ACILITIES 

Although recreational facilities are considered public places, they are often treated 

separately in clean indoor air legislation. Recreational facilities, including sports arenas, bingo parlors, bowling alleys, and card rooms often seek exemptions from restrictions covering public places. 

SPORTS ARENAS AND STADIUMS 

Many sports arenas and stadiums, including open-air stadiums, have voluntarily implemented smokefree policies. By mid-1993, 12 open air stadiums and the two enclosed stadiums for Major League baseball teams eliminated smoking in seating areas, 

compared with 12 open-air stadiums that permitted smoking. Of the 12 that permitted 

smoking, 6 had nonsmoking seating sections (SES, 1993). 

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Options 

* Prohibit smoking in all seating sections, concourses, and restrooms. If 

the facility is open air, permit smoking only in a designated area away 

from the seating sections and restrooms. 

* Prohibit smoking in all concourses and restrooms. Establish nonsmoking and smoking seating sections. 

BINGO PARLORS 

Many lawmakers are reluctant to confront churches, schools, and other non-profit 

organizations that operate bingo parlors as fundraisers. As a result, bingo parlors are 

often exempt from provisions regulating smoking in public places. Exemptions for 

bingo parlors are particularly troubling because some of the highest levels of indoor air 

pollution ever measured were in bingo parlors (Repace & Lowrey, 1980; Repace & 

Lowrey, 1982). More recent clean indoor air legislation is beginning to drop the exemption for bingo parlors. The state of Vermont and numerous local ordinances prohibit smoking at bingo games, while others require the establishment of smoking and 

nonsmoking sections or rooms (Rau, 1993; ALA, 1993b; ANR, 1994; Sullivan, 1992). 

Options 

* Prohibit smoking at all bingo games. 

* Require separate rooms for nonsmoking and smoking patrons. 

BOWLING CENTERS 

Although bowling centers market themselves as “family entertainment” and are frequented by children, bowling centers have historically been exempted from clean indoor air legislation. As with bingo parlors, new legislation is beginning to drop this 

exemption. The state of Vermont and numerous local ordinances now include bowling 

centers under provisions regulating smoking in public places (Rau, 1993; ANR, 1994; 

ALA, 1993a). 

Many bowling centers have restaurants or bars located on the premises. These restaurants and bars must comply with whatever requirements have been established for 

these venues under state or local legislation. 

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M o n o g r a p h 1 6. A S S I S T 

Options 

* Prohibit smoking in bowling centers.


* Prohibit smoking except for a designated area on the concourse.


ENFORCEMENT ISSUES 

Clean indoor air legislation has historically required relatively little enforcement activity. Most laws are “self-enforcing;” enforcement is activated by complaint, rather 

than through active surveillence. 

DESIGNATING AN ENFORCEMENT AGENCY 

At the state level, the state health department is the most commonly designated enforcement agency (US DHHS, 1989). Most local ordinances designate either the city 

manager or local health department as the primary enforcement agency (US DHHS, 

1993; Hanauer, et al., 1986). Fewer jurisdictions have designated the police department as the enforcement agency (US DHHS, 1989). As a supplement to enforcement 

activities by the primary agency, environmental health officers and fire officials may be 

required to inspect facilities for compliance with clean indoor air legislation during the 

course of other mandated inspections. 

VIOLATIONS AND PENALTIES 

Compliance with clean indoor air legislation is required of smokers, employers, and 

proprietors of public places covered by the legislation. Language should be included 

specifying that each of these parties must comply with the provisions of the law. 

Violations should be civil rather than criminal. Many laws classify violations as an 

infraction. As has been observed in the youth access to tobacco arena, the criminal 

justice system is already overburdened, and violations of clean indoor air legislation 

are not likely to be a high priority with law enforcement officials or the courts. 

Most legislation establishes a graduated fine structure that increases with multiple 

violations. 

IMPLEMENTATION 

One of the chief means of achieving compliance is the posting of “No Smoking” 

signs and the removal of ashtrays and other smoking paraphernalia from areas in which 

smoking is prohibited (Hanauer, et al., 1986). Posting of signs informs the public 

about the law and provides a mechanism for employers and proprietors to request compliance. A study examining the compliance level of retail stores under a local ordinance 

found that employees and patrons in stores that posted signs were more likely to comply with the prohibition against smoking (Rigotti, 1993). 

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Because the majority of clean indoor air legislation is “self enforcing,” it is important to inform the general public and the business community about the requirements 

of the law (Rigotti, 1993). Some legislation includes a public education component, 

requiring the health department or other enforcing agency to develop a program or 

mechanism to educate the community. 

Enforcing laws protecting nonsmokers does not require vast amounts of resources. 

In Minnesota, the Department of Health spent about $4,600 per year for the first 3 

years in which their statewide Clean Indoor Air Act was in effect (Kahn, 1983). San 

Luis Obispo, California, spent $3,000 on educational materials to help implement their 

ordinance (Reiss, 1992). Several local jurisdictions have found that enforcement activities required a decreasing amount of attention over time, with the majority of complaints received during the first few months after enactment (Martin, 1988). 

Although enforcement activities largely rely on community education and adequate 

signage to achieve compliance, resources should be available to follow up on complaints and, if necessary, issue citations. 

Options 

*	 Designate an enforcement agency. 

*	 Require proprietors and employers to post “No Smoking” signs and remove all ashtrays and smoking paraphernalia in all areas where smoking 

is prohibited. 

*	 Define violations by smokers, proprietors, and employers who are out of 

compliance. 

* Create a graduated civil fine structure for violations. 

*	 Require the enforcement agency to engage in a public education program to inform the public and the business community about the law. 

*	 Require Health and Fire Department officials to inspect an establishment 

for compliance during the course of any other mandated inspections. 

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M o n o g r a p h 1 6. A S S I S T 

Appendix 6.C. Excerpts fr om Tobacco Advertising and Promotion: 

A Guide to Developing Policy 

Tobacco Advertising


and Promotion


A Guide to Developing Policy


Number three in a series of four policy guides 

ASSIST 

The American Stop Smoking Intervention Study 

National Cancer Institute 

National Institutes of Health 

US DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Prepared by: 

Americans for Nonsmokers’ Rights 

Berkeley, California 

with 

Prospect Associates 

Rockville, Maryland 

November 1994 

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Contents*


Acknowledgments .................................................................................................................................. i


Background ........................................................................................................................................... 1


Overview of Policy Options .................................................................................................................. 8


Legal Issues ......................................................................................................................................... 11


The First Amendment ............................................................................................................ 11


Can State and Local Governments Act on Advertising? ....................................................... 12


Policy Options ..................................................................................................................................... 14


Restrictions on Tobacco Advertising ................................................................................................... 14


Tobacco Billboards ................................................................................................................ 14


Public Transportation ............................................................................................................ 15


Public Facilities ..................................................................................................................... 16


Athletic Facilities ................................................................................................................... 16


Tobacco Advertising Deductability ....................................................................................... 17


Cartoon Characters ................................................................................................................ 18


Restrictions on Promotional Activities ................................................................................................ 18


Tobacco Industry Sponsorship .............................................................................................. 19


Free Sampling.. ...................................................................................................................... 19


Point-of-Purchase Displays ................................................................................................... 20


Counteradvertising .............................................................................................................................. 21


Paid Counteradvertising ........................................................................................................ 21


Mandatory Counteradvertising .............................................................................................. 21


Public Service Announcements (PSA’s) ................................................................................ 22


Counterpromotions .............................................................................................................................. 23


Alternative Sponsorship ........................................................................................................ 23


Countersponsorship ............................................................................................................... 24


Other Counterpromotions ...................................................................................................... 25


Voluntary Approaches ......................................................................................................................... 25


Community Advertising Surveys ........................................................................................... 25


Poster Contests ...................................................................................................................... 26


Voluntary Tobacco Advertising Restrictions ......................................................................... 27


Voluntary Point-of-Purchase Advertising Bans ................................................................................... 28


Media Advocacy .................................................................................................................................. 28


References.. ......................................................................................................................................... 30


Appendix A. Advertising and Promotion Restrictions-lists


Policies Banning Transit Advertising


Policies Banning Tobacco Advertising in Stadiums


Ordinances Which Ban Self-Service Tobacco Displays


Ordinances Banning Free Tobacco Sampling


Appendix B. Sample Laws and Policies 

Statewide Tobacco Billboard Ban: Utah 

Ordinances Prohibiting Tobacco Billboards: Cincinnati, Ohio; Baltimore, Maryland 

Policy Eliminating Tobacco Ads on a Public Transit System: San Francisco Municipal Railway 

Advertising Prohibition on Public Property: King County, Washington 

Ordinance Restricting Point-of-Purchase Advertising: Preston, Minnesota 

Ordinance Banning Self-Service Merchandising: Roseville, Minnesota 

*Page numbers in this Table of Contents are from the original document and do not correspond to page 

numbers in this monograph. 

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Background 

INTRODUCTION 

“Advertising, in the hands of manufacturers of tobacco products, has become a 

powerful tool for the construction of the massive edifice of this industry.” 

“There is no obstacle to large-scale sales of tobacco products that cannot be surmounted by aggressive selling.” 

Although these statements from the United States Tobacco Journal were made in 

1953 and 1955, respectively, they document the tobacco industry’s early recognition of 

the impact and value of advertising and promotion to increase and maintain the consumption of cigarettes and other tobacco products (US DHHS, 1994). The magnitude 

and scope of tobacco advertising and promotion have increased to such a great extent 

that many localities, states, and the Federal Government have enacted or are considering policy remedies to curb tobacco advertising and promotion as a complement to other tobacco control activities such as the adoption of smoking ordinances and 

restrictions on youth access to tobacco products. 

ADVERTISING VS. PROMOTION 

With approximately 400,000 people dying each year from tobacco-related diseases 

as well as smokers who die of other causes and 1.5 million Americans who quit smoking, the tobacco industry must attract more than 2 million new smokers each year to 

maintain its market (Myers & Hollar, 1989). 

Two major forms of tobacco marketing exist: advertising and promotion. “Advertising” is the use of advertisements in the paid media, which is comprised of newspapers, 

magazines, billboards and other outdoor venues, and transit system vehicles. Advertising entails direct targeting of current or prospective consumers of tobacco products to 

initiate or maintain cigarette consumption. The tobacco industry argues that advertising 

functions strictly as a means to encourage brand switching or maintain brand loyalty. 

Other evidence indicates that advertising serves to foster new and expanded consumption. 

“Promotion” encompasses efforts to influence consumers beyond advertising. One 

prominent form of promotion is sponsorship of artistic, athletic, and cultural events. 

Other promotions include point-of-purchase displays that publicize the location of tobacco products and increase brand recognition. Retail stores are filled with clocks, grocery cart signs, in/out decals on doors, and banners (Cummings, 1991). Other 

promotions include coupons, retail value-added items (such as free cigarette lighters 

and T-shirts), and free samples. Another promotional device that has been extremely 

successful, but expensive, is the distribution of merchandise that displays tobacco logos (US DHHS, 1994; Warner et at, 1992). The names and addresses of those requesting 

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merchandise, often along with survey data, are entered into databases that are used for 

additional marketing efforts as well as political organizing efforts. 

TOBACCO INDUSTRY EXPENDITURES 

In 1992, according to the Federal Trade Commission, tobacco advertising and promotion expenditures had reached $5.23 billion (FTC, 1994). These expenditures have 

been increasing dramatically, with the industry spending $361 million in 1970 and $1.2 

billion in 1980 (US DHHS, 1994). 

By the mid-1980’s, advertising expenditures had decreased relative to promotional 

activities, primarily as a result of decreased reliance on print advertisements in newspapers and magazines (US DHHS, 1994). In addition, the number of newspapers and 

magazines that have voluntarily instituted policies banning tobacco advertising continues to grow, although many are more narrowly read journals rather than major publications such as Time and People magazines. Use of outdoor advertising (billboards) and 

transit posters remains high (US DHHS, 1994). 

In 1992, promotional activities such as coupons, merchandise, and sponsored events 

accounted for approximately 80 percent of overall advertising and promotion expenditures, up from 12 percent in 1970 (Butler, 1993; FTC, 1994). The largest category of 

promotional spending includes coupons and retail value-added promotions such as free 

shirts and lighters, totaling $2.17 billion in 1992, or more than 40 percent of all cigarette advertising and promotional expenditures (FTC, 1994). This is a stunning figure, 

up from $960 million in 1988 (FTC, 1994). 

Promotional allowances are another growth area for tobacco promotion. Promotional allowances are designed to provide incentives to wholesalers and retailers to promote a company’s products and include free goods or price reductions, slotting 

allowances, contests, and training programs. Cigarette companies spent $1.5 billion on 

promotional allowances in 1992, accounting for nearly 29 percent of the total spent on 

advertising and promotion (FTC, 1994). 

THE IMPACT OF ADVERTISING AND PROMOTION ON TOBACCO CONSUMPTION 

Research has demonstrated that a connection exists between advertising, promotion, 

and tobacco consumption. The tie between tobacco marketing and consumption is confirmed by the following findings: 

• Advertising and promotion may encourage children or young adults to experiment 

with tobacco, and regular use may be initiated with repeated exposure to positive 

images associated with tobacco use (US DHHS, 1989). 

• Advertising and promotion may influence former smokers to resume smoking. 

• The paid media’s dependence on revenue from tobacco advertising decreases 

coverage of the risks and consequences of tobacco use (Warner & Goldenhar, 

1989; Warner, 1992). 

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• Organizations such as professional sports teams, cultural and charitable 

organizations, and groups that serve populations targeted by the tobacco industry 

(e.g., communities of color and women) have become dependent on tobacco 

company resources. These groups may be less likely to publicize the negative 

impact of tobacco use and possibly mute opposition to the tobacco industry’s 

political agenda (Robinson et al., 1992). 

• Tobacco advertising and promotion encourages the social acceptability of tobacco 

products, sometimes diminishing the smokers’ perception of the danger of 

tobacco use (US DHHS, 1989; Myers & Hollar, 1989). 

THE IMPACT OF ADVERTISING ON CHILDREN 

The Surgeon General’s Report on Preventing Tobacco Use Among Young People, released in February 1994, documents the problem of underage smoking. Although the 

report acknowledges that many factors contribute to the initiation and maintenance of 

tobacco use by children and adolescents, considerable attention is given to the strong 

influence of advertising and promotion (US DHHS, 1994). 

Tobacco industry marketing researchers have successfully produced tobacco-related 

themes and images that appeal to teenagers. Youth of both genders are enticed with images that associate tobacco use with independence, popularity, and relaxation. Boys are 

influenced by the ties between smoking and masculinity, athleticism, and adventure, 

but girls are conditioned to associate tobacco use with thinness, romance, and liberation (US DHHS, 1994). 

More than 90 percent of all new smokers are under age 20. During the past decade, 

the smoking rate for adults has steadily declined, but the teenage rate has remained virtually constant (McKenna & Williams, 1993). 

Evidence of the association between tobacco advertising, promotion, and underage 

smoking is found in a number of studies: 

• Approximately 86 percent of adolescent smokers prefer either Marlboro,


Newport, or Camel, which are the brands that spend the most on advertising


(CDC, 1994).


• In an analysis of tobacco advertising, a study showed that as tobacco expenditures 

targeting women rapidly increased from 1967 to 1974, a corresponding rise in the 

annual rates of initiation for 11- to 17-year-old girls was found (Pierce et al., 1994). 

•	 One-half of the adolescents in a Gallup survey could associate brand names with 

cigarette slogans (US DHHS, 1994). 

To counter concerns about tobacco advertising’s appeal to children, the tobacco industry adopted a voluntary code of advertising ethics (CigaretAdvertising Code, 1964). 

The industry’s code, for example, purports to prohibit tobacco advertisements in publications intended for persons under age 21 and admonishes against the use of models 

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6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

who are or appear to be under age 25. The existence of the code has resulted in little, if 

any, reduction in tobacco advertising’s impact on children. In some cases, the guidelines are insignificantly weak. In other cases, the guidelines are apparently ignored, as 

in the case of the rule against young-looking models. Indeed, the most egregious example of advertising that targets children, the Joe Camel campaign, appeared long after 

the code had been adopted. 

The Joe Camel Campaign 

In 1988, R.J. Reynolds began one of the most successful advertising campaigns in 

history with its “Smooth Character” campaign, featuring a cartoon character named 

Joe Camel. The mischievous Joe Camel appears in numerous daring, adventurous, and 

of course, cool situations. The campaign was also among the first to offer products 

with brand logos in exchange for proofs-of-purchase. 

Critics charge that this campaign targets children. Not only is the Joe Camel character well recognized by children, but Camel cigarettes have improved Reynolds’ market 

share among underage smokers (Pierce et al., 1991). 

Several indicators substantiate the campaign’s youth appeal: 

•	 Camel’s share of the under age 18 market increased from 0.5 percent in 1988, 

when Joe Camel was introduced, to 32.8 percent in 1991 (DiFranza et al., 1991). 

•	 Camel was identified as the most advertised brand of cigarettes by 28.5 percent of 

teenagers. This brand was preferred by 24.5 percent of males age 12 to 17 and 

21.7 percent of females in the same age group (Pierce et al., 1991).

•	 Approximately 30 percent of 3-year-olds could match the Old Joe character with 

a cigarette, and 6-year-olds could accomplish this task 91 percent of the time. In 

addition, the 6-year-old children identified Joe Camel as often as the Mickey 

Mouse ears of the Disney channel (Fischer et al., 1991). 

TARGETED ADVERTISING AND PROMOTION BY RACE AND SEX 

Particular attention has been paid to advertising and promotion that targets ethnic 

groups and women (US DHHS, 1989). The tobacco industry has a long history of 

courting ethnic populations. The most obvious example of this is a history of extensive 

financial contributions to political, social, and artistic organizations. Examples include 

the Congressional Black Caucus, the National Women’s Political Caucus, the Kool 

Jazz Festival, and various Cinco de Mayo celebrations. 

The introduction of population-specific brands of cigarettes is one of the more recent avenues that the tobacco industry has taken to target its marketing efforts to particular groups. One of the most notorious examples was the “Uptown” cigarette brand, 

targeted at African Americans. After a community coalition in Philadelphia mobilized 

opposition to this marketing strategy by R.J. Reynolds, Uptown was not introduced as 

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part of a planned test market (US DHHS, 1994; Advertising Age, 1990). In another 

case, the tobacco industry enraged women’s groups with the introduction of the “Dakota” brand, which targeted young “virile” females (Cotton, 1990). 

There are numerous examples of tobacco industry targeting, and the best can often 

be found in one’s own backyard. However, some examples follow: 

•	 Targeting of African Americans includes sponsorship of cultural activities such as 

the Kool Jazz Festival and the Alvin Ailey Dance Theater. Other activities include 

the Kool Achiever Awards and image advertisements featuring Martin Luther 

King. African-American newspapers and magazines receive about $6 million per 

year in tobacco advertising revenues (Williams, 1986). 

•	 Targeting of the Latino/Hispanic community includes sponsorship of cultural 

events such as Cinco de Mayo celebrations. Philip Morris is the largest advertiser 

in Latino magazines, and 20 percent of all Latino newspaper advertising revenue 

comes from alcohol and tobacco companies (Maxwell & Jacobson, 1992). 

•	 There is growing evidence of targeting of Asian/Pacific Islanders. Several 

California surveys indicate that Asian/Pacific Islander neighborhoods suffer the 

highest concentrations of tobacco billboards (Le, 1994). One survey indicated that 

Asian-American neighborhoods have 17 times more cigarette billboards than 

white neighborhoods (McLaughlin, 1993). 

•	 One notorious example of a promotion targeting women is Philip Morris’ Virginia 

Slims tennis sponsorship. Virginia Slims has sponsored the women’s tennis tour 

since 1971 (Robinson et al., 1992). 

•	 Native Americans, a group with high use of cigarettes and smokeless tobacco in 

adults and youth, are also targeted by the tobacco industry, although little if any 

research on tobacco advertising and promotion has been conducted around this 

population. 

•	 There is growing evidence that the tobacco industry may be targeting lesbians and 

gays. Philip Morris ran advertisements for Benson and Hedges’ Special Kings in 

the gay fashion magazine Genre and other magazines with a high gay readership 

as well as for Parliament cigarettes in OUT magazine, the largest circulation gay 

magazine in the United States (Lipman, 1992; CLASH, 1994). Recent 

advertisements for Virginia Slims may target lesbians, and advertisements for 

American Brand’s Montclair cigarettes feature stereotypically effeminate gay men 

(Goebel, 1994). 

The argument that tobacco industry advertising targets people of color has been validated by numerous surveys of billboard placement. Tobacco billboards are predominantly found in neighborhoods where African Americans and other people of color are 

more highly concentrated. Some survey results, reported by the Center for Science in 

the Public Interest (1990), include: 

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•	 Seventy percent of the 2,015 billboards in Baltimore advertised alcohol and 

tobacco; three-quarters of billboards were in predominately African-American 

neighborhoods. 

•	 In low-income neighborhoods in Detroit, 55 to 58 percent of billboards advertised 

alcohol or tobacco. 

•	 More than one-third of New Orleans’ billboards are located within one-half mile 

of the city’s low-income Federal housing projects. 

•	 Sixty-two percent of billboards in black neighborhoods in St. Louis advertised 

alcohol and tobacco, compared with 36 percent in white neighborhoods; three 

times as many billboards were found in black neighborhoods as white. 

PUBLIC OPINION ON ADVERTISING RESTRICTIONS 

Recent public opinion polls suggest that there is growing support for restrictions on 

tobacco advertising and promotion. A sample of some of the most recent polls include: 

•	 In a Gallup survey conducted in February 1994, 68 percent of Americans believe 

that cigarette advertisements influence children and teens to smoke; 66 percent 

believe that some cigarette advertisements are specially designed to appeal to 

young people; 53 percent want a total ban on tobacco advertising (Colford, 1994). 

•	 In a 1993 Gallup survey, 53 percent favored a complete ban on tobacco 

advertising, 76 percent of adults favor restrictions on cigarette advertising that 

appeals to children, 66 percent favor restrictions on advertising that encourages 

people to smoke, 64 percent favor restrictions on advertisements that make 

smoking appear glamorous, and a majority of people in the largest tobaccogrowing states also favor the restrictions listed above (Coalition on Smoking OR 

Health, 1993). 

•	 Ten communities participating in NCI’s Community Intervention Trial for 

Smoking Cessation (COMMIT Program) were surveyed, and 60.5 percent agreed 

that all tobacco advertising should be banned (CDC, 1991). 

•	 A 1990 survey in California found that 54 percent support a ban on billboard 

tobacco advertisements, 49 percent support a ban on tobacco advertisements in 

newspapers and magazines, 67 percent supported a ban on the distribution of free 

tobacco samples or coupons to obtain free samples by mail, and 75 percent 

support a ban on the distribution of free tobacco samples on public property. 

For a detailed discussion of answers to tobacco industry arguments against regulating tobacco advertising, see the ASSIST Key Required Resource Truth and the Consequences of Cigarette Advertising: An Advocate’s Guide to Arguments in Support of 

Banning Cigarette Advertising and Promotions. 

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Overview of Policy Options 

Tobacco advertising and promotion constitute one of the greatest obstacles to tobacco control in the United States. Advertising and promotion encourage children and 

young people to use tobacco, reduce smokers’ motivation to quit, and legitimize the tobacco industry (US DHHS, 1989). 

Numerous options are available to the public health community to counter tobacco 

industry advertising and promotion, ranging from a total ban on advertising and promotion to various voluntary approaches. 

Before considering how to approach the problem of tobacco advertising and promotion, public health professionals should first understand the role of tobacco advertising 

in their specific community. The tobacco industry’s activities in each community are 

different, and it is vital to identify those activities of greatest concern in a specific 

community before crafting a response. 

Pro-health interests must also understand the acceptable limits of policy change in a 

given community. Although some regions may support a complete ban on advertising 

and promotion, others such as those in tobacco-producing states may be more limited 

in what the community is prepared to accept. 

The following issues should be considered in assessing a particular community: 

•	 How receptive is the community to tobacco control policy? For example, have 

ordinances that limit smoking or reduce youth access to tobacco products already 

been adopted? How strong are those policies? 

•	 To what extent does the tobacco industry target particular populations with their 

advertising and promotion? 

•	 How are tobacco billboards distributed in the community? 

•	 To what extent does the tobacco industry sponsor cultural, artistic, or athletic 

events? 

•	 Does tobacco advertising appear on public transportation vehicles or transit depots? 

•	 Do tobacco billboards appear in sports facilities such as stadiums? 

•	 What types of point-of-purchase advertising and promotion are found in the 

community? Promotional displays? Sales or free distribution of logo-branded 

gear? 

•	 Does the tobacco industry engage in free sampling of tobacco products? 

By answering these questions, public health professionals can develop a sense of 

both the needs of the community and any practical limits on policy change. 

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After assessing the needs of the community, the next step is considering options. Although many of these policy options may be implemented at the Federal level through 

either legislative or regulatory mechanisms, this discussion is intended to provide practical information to those working at the local and state levels. 

The following are options available to state and local public health professionals and 

policymakers. It should be noted that the first two categories represent options for policy change, but the latter four categories provide other options for countering the effects 

of tobacco advertising and promotion and supporting policy change. 

Restrictions on Tobacco Advertising 

— Banning or limiting tobacco billboards 

— Banning or limiting tobacco advertising on public transportation 

— Banning or limiting advertising in public facilities 

— Banning or limiting advertising in athletic facilities 

— Eliminating the tax deductibility of tobacco advertising expenses 

— Barring the use of cartoon characters in tobacco advertising 

Restrictions on Promotional Activities 

— Prohibiting tobacco industry sponsorship of events 

— Prohibiting free sampling of tobacco products 

— Banning or limiting point-of-purchase displays 

Counteradvertising 

— Paid counteradvertising 

— Mandatory counteradvertising 

— Public service announcements (PSA’s) 

Counterpromotions 

— Alternative sponsorship 

— Countersponsorship 

— Other counterpromotions 

Voluntary Approaches 

— Community advertising surveys 

— Poster contests 

— Voluntary advertising restrictions 

— Voluntary point-of-purchase advertising bans 

Media Advocacy 

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M o n o g r a p h 1 6. A S S I S T 

Policy Options 

RESTRICTIONS ON TOBACCO ADVERTISING 

The most direct and comprehensive solution to the problem of tobacco advertising is 

to ban it. In spite of significant legal issues, there are a number of actions that State 

and local governments and public health professionals can undertake to eliminate or 

limit tobacco advertising. 

Federal law prohibits television and radio advertisement of tobacco products, effective January 1,1972. Under current Federal law, however, billboard, magazine, and 

newspaper advertising of tobacco products is permitted. Numerous bills have been introduced in Congress to ban or limit tobacco advertisement and promotion, but to date 

none have passed. 

Tobacco Billboards 

The Federal Cigarette Labeling and Advertising Act contains a preemption clause 

that limits the authority of State and local governments to ban tobacco advertising (see 

Legal Issues). However, the state of Utah banned tobacco billboards in 1929 (Utah 

Criminal Code). The Utah law bans all types of billboards, public transportation displays, and point-of-purchase advertisements for tobacco products, including in/out 

signs, clocks, and merchandise racks (Van Dam, 1989). 

The tobacco industry has determined that the Utah ban is either legally valid or that 

a legal challenge would result in undesirable public relations or political consequences. 

In either case, the Utah approach should be considered an option. Other states have 

considered adopting laws banning tobacco billboards, including California, Oregon, 

Massachusetts, Minnesota, and New Jersey. 

The potential for local restrictions on tobacco billboards has generated a significant 

amount of interest. In 1990, Richmond, California considered an ordinance banning tobacco (and alcohol) advertising within 500 feet of any school. Although this approach 

is not ideal, a large percentage of the billboards in a given community are affected, especially if the distance is increased to 1,000 feet or even 1 mile. This approach may 

also have a greater chance of surviving a tobacco industry legal challenge than a complete ban because it is so closely tied to protecting children, which is acknowledged as 

a legitimate function of State and local government (see Legal Issues). 

On February 24, 1994, the city of Baltimore adopted a ban on tobacco and alcohol 

billboards (City of Baltimore, 1993). In June 1994, Cincinnati, Ohio adopted a law 

prohibiting all tobacco billboards effective June 1, 1996. Signs within 500 feet of 

schools or other facilities frequented by children are banned immediately. Cincinnati’s 

law also extends to tobacco advertisements on public transportation vehicles. Another 

city that has considered, but not adopted, tobacco billboard bans is Philadelphia (Bird, 

1994). 

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Options 

•	 Prohibit all tobacco billboards and other outdoor tobacco advertising 

signs. 

•	 Prohibit all tobacco billboards within 1 mile of schools and other facilities (such as churches or parks), which are frequented by children. 

Public Transportation 

The most common type of restriction on tobacco advertising affects public transportation. Transportation depots, such as bus shelters and airports, and public transit vehicles, such as buses and subway cars, have traditionally played host to tobacco (and 

alcohol) advertisements. These advertisements are of special concern because they are 

observed by children, often in transit to school. 

Bans on public transportation tobacco advertisements are also a sound option because they have not been challenged on the Federal preemption issue. They do not appear to be preempted by the Federal Cigarette Labeling Act (see Federal preemption 

discussion, Legal Issues). Their legal basis is strong because transportation systems are 

usually public or quasi-public, and their policies are not treated as broad regulations of 

advertising in the private sector. Indeed, such policies are often adopted as administrative measures or crafted merely as “preferences” for hiring advertising agencies that 

refuse tobacco advertising. 

Transportation systems that have eliminated tobacco advertising include New York 

City’s MTA, San Francisco’s BART and AC Transit bus system, the Minnesota Valley’s Transit Authority, Portland’s bus system, Denver, Boston, Syracuse, and Madison (WI) (Scenic America, 1993). Utah’s ban on all tobacco billboards extends to 

public transportation. The New York and New Jersey Port Authority has banned all tobacco advertising in facilities under its jurisdiction, including LaGuardia, Kennedy, 

and Newark airports, the World Trade Center bus terminal, and marine terminals 

(Weigum, 1993). 

The primary argument made against transportation-based policies is the potential 

loss of advertising revenues. None of the systems or facilities that have implemented 

such bans have reported any net loss of revenues, however, and other advertisers appear to replace the tobacco companies. 

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M o n o g r a p h 1 6. A S S I S T 

Options 

•	 Ban tobacco advertising on all public transit vehicles, shelters, and in 

transit depots. 

•	 Ban tobacco advertising in airports. 

•	 Ban tobacco advertising in and on public transit shelters such as train 

stations and bus shelters. 

Public Facilities 

In addition to eliminating tobacco advertisements on public transportation, some local governments have banned such advertisements in all publicly owned facilities. 

In July 1992, King County, Washington adopted the broadest local policy on advertising to date. King County’s ordinance covers all county-owned facilities, including 

the King Dome, Seattle’s stadium (King County, 1992). 

Option 

•	 Eliminate tobacco advertising in all facilities owned by a given county or 

city, including sports facilities, fairgrounds, and public transportation vehicles and depots. 

Athletic Facilities 

Perhaps the single most important local action that can be taken to reduce tobacco 

advertising is eliminating billboards and other advertisements in stadiums and other 

athletic facilities. This includes both professional sports facilities and college stadiums. 

Addressing this advertising is important for two reasons. First, children are present in 

large numbers at many athletic events. Second, major sporting events are often televised. Tobacco advertisements in stadiums are usually positioned to be picked up on 

television cameras (Smokefree Educational Services, Inc., 1991). 

Tobacco advertising bans in athletic facilities may be adopted by various governing 

agencies, including a stadium authority, county board of supervisors, or university. In 

some cases, sports facilities are privately owned and may be approached to voluntarily 

eliminate tobacco advertisements (see Voluntary Approaches). In some cases, more 

than one agency will have the jurisdiction to limit tobacco advertisements in an athletic 

facility. King County, Washington’s ordinance banning all tobacco advertisements in 

county facilities covers athletic facilities (King County Ordinance, 1992). 

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Many advertisement bans have been adopted voluntarily by stadium management. 

Sports facilities that prohibit tobacco advertisements include the Minnesota Metrodome, Dodger Stadium (Los Angeles), Wrigley Field (Chicago), Jack Murphy Stadium 

(San Diego), and the Oakland Coliseum (Hwang, 1992; Smokefree Educational Services, Inc., 1991). 

Option 

•	 Prohibit tobacco advertising in all athletic facilities under the jurisdiction 

of a public agency. 

Tobacco Advertising Deductibility 

One approach to tobacco advertising that has recently received a great deal of attention relates to the tax deductibility of such advertising. Proposals have been introduced 

at both the Federal and State levels to remove tobacco advertising from the class of 

business expenses that are tax deductible (Colford, 1993; Stark, 1986). 

Proponents of eliminating the deductibility of tobacco advertisements point out that 

such deductions amount to a subsidy for cigarette advertisements, a so-called tax subsidy. It should be noted that indirect restrictions on tobacco advertising face the same 

first amendment challenges as direct bans. In some cases, partial restrictions may be 

harder to defend legally than a complete on all tobacco advertising (see Legal Issues). 

Connecticut and California have both considered legislation. 

The same arguments in favor of eliminating the tax deductibility of tobacco advertising apply to promotions as well. However, no specific proposal has yet been propounded on the deductibility of tobacco promotional expenses. 

Options 

•	 Eliminate the deductibility of tobacco industry advertising expenses under State corporate income tax laws. 

•	 Eliminate the deductibility of tobacco industry promotional expenses under State corporate income tax laws. 

Cartoon Characters 

Some states have considered prohibiting the use of cartoon figures in tobacco advertising. These proposals represent a reaction not only to Joe Camel but other cartoon 

figures as well such as the Kool penguin. 

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The public health impact of the Joe Camel cartoon advertising campaign for Camel 

cigarettes is well documented (Pierce et al., 1991; DiFranza et al., 1991; Fischer et al., 

1991). The campaign clearly targets children and has been extremely successful in attracting them to Camel cigarettes. Therefore, eliminating the use of cartoons in tobacco 

advertising can be easily justified. 

Although the Federal Government would have the authority to prohibit cartoon 

characters in all tobacco advertisements, states’ jurisdiction is probably limited to advertising signs such as billboards. States are not permitted to place significant burdens 

on interstate commerce, and magazines normally fall into this category. This is also 

true of newspapers if at any time even a single copy enters interstate commerce. 

As in the case of advertising deductibility, selective bans on particular types of tobacco advertising may raise more serious constitutional issues than a complete ban 

(see Legal Issues). 

Although proposals to date have focused on advertising, it would also be possible to 

eliminate the use of cartoon figures in promotional activities and materials. This could 

be accomplished by defining advertising broadly in any proposed legislation. The 

phrase “other display advertising” is an example of such language. 

Option 

•	 Prohibit the use of cartoon characters in tobacco billboards and other 

display advertising. 

RESTRICTIONS ON PROMOTIONAL ACTIVITIES 

Although tobacco advertising remains the most obvious marketing tool for cigarettes and other tobacco products, other promotional activities are playing an increasingly important role. During the past 25 years, expenditures on promotional activities 

other than advertising have increased dramatically relative to advertising expenditures 

themselves (Butler, 1993). Therefore, an effective strategy to counter tobacco marketing must address promotional activities as well as advertising. The most direct approach to tobacco industry promotional activities is to simply prohibit them by law or 

by voluntary policy. 

Tobacco Industry Sponsorship 

A number of organizations and governing bodies have adopted bans on tobacco (and 

alcohol) promotions at community events such as county fairs, college gatherings, Cinco de Mayo celebrations, and rodeos. Much of this activity has occurred in California 

under Proposition 99, the state’s tobacco tax/tobacco education program. Although no 

State or local government has yet taken this action, it is within their authority to do so. 

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Options 

•	 Prohibit tobacco industry sponsorship of all athletic, artistic, cultural, or 

musical events. 

•	 Prohibit tobacco sponsorship of a specific athletic, artistic, cultural, or 

musical event. 

Free Sampling 

Distribution of free tobacco product samples is a popular form of promotion of tobacco products (Hobart & Goebel, 1994). Of greatest concern is the fact that free samples are often distributed at events and locations popular with children such as rock 

concerts, music festivals, sports events, and fairs (Davis & Jason, 1988). 

Although most states prohibit the distribution of free tobacco samples to underage 

youth, free samples are a source of tobacco products for children (Davis & Jason, 

1988). Only the elimination of free tobacco sampling will ensure that samples do not 

end up in the hands of underage youth. The States of Utah, Minnesota, and California 

ban or significantly restrict the free sampling of tobacco products. These bans may also 

prohibit free sampling by mail. More than 103 cities and counties prohibit free sampling as well (ANR, 1994). 

Options 

•	 Prohibit the distribution of free tobacco samples in all private and publicly owned facilities and grounds accessible to the public. 

•	 Prohibit the distribution of free tobacco samples through the mail. 

Point-of-Purchase Displays 

In-store advertising is among the most prevalent forms of tobacco promotion. One 

study of tobacco advertising in stores found that 87 percent of retail stores carry some 

promotional items advertising tobacco products (Cummings et al., 1991). Two-thirds 

of stores displayed tobacco posters, and 80 percent of all tobacco displays were for 

cigarettes. 

Point-of-purchase advertising can be especially damaging to public health efforts. 

This type of advertising encourages impulse shopping and can undermine the resolve 

of those who are attempting to quit (Weigum, 1993). Such advertising is also perfectly 

situated to impact children in stores and gives the impression that cigarettes and other 

tobacco products are merely ordinary consumer goods like candy or food, rather than 

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deadly and addictive drugs. Additionally, countertop displays make it easier to shoplift 

cigarettes. Because the tobacco companies provide financial incentives for retailers to 

use these displays, shoplifting is less of a financial burden. 

The past 5 years have seen a flurry of activity addressing various forms of point-ofpurchase tobacco promotion (Weigum, 1993; ANSR PA, 1991). Several communities 

have campaigned successfully against cigarette advertisements on handbaskets in grocery stores, including New York City and North Carolina (ANSR PA, 1991). More recently, an effort was undertaken in Minnesota to promote ordinances that prohibit all 

point-of-purchase tobacco promotions. 

In Minnesota, the city of Preston adopted a law banning point-of-purchase advertising (see Appendix B). Brooklyn Center (MN) adopted an ordinance on first reading 

that limits in-store advertising to “tombstone” listings of cigarette brands and prices. 

Tombstone advertisements consist exclusively of black-on-white lettering listing the 

brands and their prices. The threat of tobacco industry legal challenge, however, held 

up the final passage of this ordinance on second reading. 

Options 

•	 Prohibit all in-store advertising and promotion of tobacco products, including banners and signs, basket or cart advertisements, in/out decals, 

separator bars, clocks, and logo merchandise. 

•	 Prohibit all point-of-purchase advertising except tombstone advertisements listing the brands and their prices, which may not be disguised advertisements for particular brands. 

•	 Prohibit self-service displays for tobacco products, requiring all tobacco 

products to be kept behind the counter (thereby eliminating counter displays). 

COUNTERADVERTISING 

One way to counter tobacco industry advertising is to purchase anti-tobacco advertisements. Three types of counteradvertising exist: paid counteradvertising, mandatory 

counteradvertising, and public service announcements (PSA’s). 

Paid Counteradvertising 

One strategy for countering the tobacco industry and promoting an anti-tobacco 

message is the use of paid media campaigns. Although traditional PSA’s tend to focus 

on individual behavior (i.e., “you should quit”), counteradvertisements tend to focus on 

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6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

social and political issues as well as environmental change (Dorfman & Wallack, 

1993). 

Until recently, the use of paid media to counter the tobacco industry in the United 

States has been limited. Since 1989, California has implemented a massive anti-tobacco campaign under Proposition 99, the tobacco tax initiative passed by the voters in 

1988. California’s campaign is funded by a tobacco excise tax. There is strong evidence that Proposition 99’s media campaign has been successful, at last in promoting 

cessation among smokers (Popham et al., 1993). California’s advertisements have 

ranged from strong messages about the health effects of passive smoking to direct attacks on the tobacco industry. Minnesota and Massachusetts have also undertaken antitobacco media campaigns. 

Options 

•	 Conduct a sophisticated, well-funded anti-tobacco media campaign, 

which is funded by a tobacco excise tax increase. 

•	 Conduct limited anti-tobacco media campaigns, focusing on one media 

market and/or one particular issue. 

Mandatory Counteradvertising 

Another approach to counteradvertising is requiring broadcasters, billboard companies, and others who carry tobacco advertisements to run a certain number of anti-tobacco advertisements, thereby balancing their pro-tobacco promotions. This strategy 

was effective on a wide scale in the late 1960’s, before the congressional ban on television and radio advertising that took effect in 1972. 

During the late 1960’s, the Federal Communications Commission (FCC) required 

broadcasters to run free anti-tobacco advertisements to balance the tobacco advertisements that then appeared on television and radio. The FCC did so by applying the socalled Fairness Doctrine, which has since been abandoned. Many of the most effective 

television advertisements that ran under the Fairness Doctrine were produced by the 

acclaimed public interest media consultant, Tony Schwartz (Bird, 1991). The advertisements were so effective that the tobacco industry ultimately embraced the 1972 ban on 

radio and television advertisements, which eliminated both the tobacco industry’s own 

advertisements and the effective counteradvertisements. 

More recently, the New York City Council adopted an ordinance in 1992 requiring 

billboard companies to post one anti-tobacco advertisement for every four tobacco advertisements on city property. The law applies to advertisements on ferries, baseball 

stadiums, telephone kiosks, taxis, bus shelters, and some billboards (McKinley, 1992). 

The New York ordinance is currently in litigation. 

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M o n o g r a p h 1 6. A S S I S T 

Options 

•	 Require free counteradvertisements to balance tobacco advertising on 

public property, including public transportation, sports facilities, and taxis. 

•	 Require free counteradvertisements on billboards. 

•	 Advertisements should be produced by pro-health organizations rather 

than the tobacco industry. 

Public Service Announcements 

Traditional PSA’s are another option for countering tobacco advertising and promotion. PSA’s, however, have several disadvantages relative to paid or mandatory counteradvertisements. PSA’s are most often carried for free, and television and radio 

stations rarely show or play them during the most popular times. PSA’s may also not 

be placed on the air enough to have a major impact. In addition, PSA’s tend to be general in scope rather than targeted to specific groups. Some researchers have even suggested that some PSA’s may actually cause harm by focusing the media’s attention on 

individual behavior and away from “more effective socially based health promotion 

strategies” (Dorfman & Wallack, 1993). 

PSA’s may have more promise when they are associated with a paid media campaign. Under California’s Proposition 99, the state negotiated with media outlets for 

additional free placement of advertisements beyond the substantial paid media buy. 

Also, these hard-hitting television and radio advertisements will be made available as 

PSA’s after their use as paid advertisements. 

Options 

•	 Extend the impact of paid counteradvertising campaigns by negotiating 

for free additional time for PSA’s. 

•	 Fund high quality production of PSA’s, equivalent to tobacco industry 

efforts. 

•	 Focus PSA’s on social, political, and environmental change rather than 

personal behavior. 

COUNTERPROMOTIONS 

As the tobacco industry invests more of its resources in sophisticated promotional 

activities rather than advertising, it is important for the public health community to 

counter such activities. Although the most effective policy alternative is the elimination 

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6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

of tobacco promotional activities, there are other strategies available for countering 

such promotions. 

Alternative Sponsorship 

Perhaps the most insidious form of tobacco promotion is the sponsorship of athletic, 

cultural, and artistic events. The identification of alternative sponsors for events, which 

are currently sponsored by tobacco firms, is a relatively new strategy that shows great 

promise. 

In one early example of alternative sponsorship, Doctors Ought to Care (DOC) arranged an alternative sponsor for the “U.S. Boomerang Team.” The team was heading 

for the Boomerang championships in Australia, with sponsorship and funding from 

Philip Morris. As part of the deal, the team was required to wear Marlboro shirts and 

hats and promote Marlboro cigarettes in media interviews. After being contacted by a 

member of the team, DOC contributed funds, solicited additional funds from the antitobacco community, and the team rejected Philip Morris’ sponsorship in favor of 

DOC’s (Raeburn, 1988; Wolinsky, 1988). 

In Victoria, Australia, the government instituted a broad alternative sponsorship program (Powles & Gifford, 1993; Scollo, 1991). In 1987, the Victorian parliament passed 

legislation that, among other things, raised the tobacco excise tax by 5 percent and allocated the proceeds to a new Victorian Health Promotion Foundation. The Foundation’s mission includes buying out tobacco sponsorship and initiating public health 

sponsorship of artistic, sports, and community organizations. During 1990-91, the 

Foundation sponsored 128 athletic and 134 cultural organizations (Powles & Gifford, 

1993). 

Under California’s Proposition 99 anti-tobacco program, a program was funded to 

investigate and promote alternative sponsorship (Alternative Sponsorship Project, 

1993). The project provided assistance to groups seeking alternatives to tobacco and 

alcohol sponsorship for events, with a focus on ethnic events such as Cinco de Mayo. 

The project also sought to educate those in the business community such as banks 

about the advantages of marketing to particular ethnic groups with growing economic 

resources (a lesson that the tobacco industry learned long ago). The project also 

brought together event organizers and public health professionals to share their perspectives on tobacco industry sponsorship. 

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M o n o g r a p h 1 6. A S S I S T 

Options 

•	 Encourage organizations receiving tobacco funding to reject that funding 

and seek alternative donors. 

•	 Provide alternative funding to organizations that conduct athletic, cultural, and artistic events. 

•	 Educate event organizers about the availability of alternatives to tobacco 

sponsorship. Educate them on marketing the benefits of event sponsorship to alternative sponsors. 

•	 Educate potential nontobacco providers of funds about the benefits of 

sponsoring sports, cultural, and artistic events. 

Countersponsorship 

A number of activities are available to counter tobacco industry sponsorship of 

events and organizations. For many years, DOC, the national health advocacy group 

for medical care practitioners, has pioneered this endeavor. DOC’s activities range 

from protests of tobacco- and alcohol-funded events such as Virginia Slims tournaments to sponsorship of their own events (e.g., “Emphysema Slims”) (Providence 

Journal-Bulletin, 1990). At a minimum, these activities appear to decrease the promotional value of tobacco industry sponsorships. 

California’s Proposition 99 has funded several pro-health athletic programs or 

events. Among these are a Tobacco Free Challenge racing car and a ski racing program 

for children. Such activities often draw attention because they place pro-health messages in events traditionally dominated by the tobacco and alcohol industries. 

Option 

•	 Fund and organize artistic, cultural, and athletic events with a pro-health 

message. 

Other Counterpromotions 

Other examples of counterpromotions include a T-shirt exchange organized by the 

National Association of African Americans for Positive Imagery (NAAAPI). The 

project encouraged smokers (and others) to turn in tobacco- and alcohol-branded items 

in exchange for a T-shirt or cap bearing a pro-health message. In another example, 

youth in New Jersey surrounded a tobacco van that was giving away promotional 

items. The youth-led protest cut short the van’s promotional mission. 

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6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Options 

•	 Organize a tobacco-branded merchandise exchange project. 

•	 Implement a protest, preferably organized by and for young people, 

against a specific tobacco industry promotional event. 

VOLUNTARY APPROACHES TO TOBACCO ADVERTISING AND PROMOTION 

A number of voluntary approaches can be developed to counter tobacco advertising 

and promotion. In some cases, advertising and promotion can be limited by the voluntary action of businesses such as billboard companies. 

Community Advertising Surveys 

One strategy that effectively combines youth education with efforts to counter tobacco advertising is tobacco advertising surveys. In a community advertising survey, a 

group of school-age youth would organize to survey the type and location of tobacco 

advertisements in a given community. Such a survey has several positive outcomes: 

• Young people learn about tobacco industry targeting and other advertising-related 

issues by studying them directly. 

•	 Public health professionals gain knowledge of the quantity and placement of 

tobacco advertisements in their own community. 

• The information gained in the survey can assist young people and activists in 

achieving limits on tobacco advertising in the community. 

Of course, tobacco advertising surveys may also be conducted by adults. In some 

cases, such surveys have also been conducted by college students or public health 

graduate students as part of their course work. 

Options 

•	 Organize a project to survey the quantity, type, and location of tobacco 

advertisements in the community. Involve young people in your survey 

project. 

•	 Publicize the results of your tobacco advertising survey to increase public knowledge of the impact of tobacco advertising in the community. 

•	 Use the results of your advertising survey to urge businesses such as billboard companies to voluntarily ban or limit tobacco advertisements. 

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M o n o g r a p h 1 6. A S S I S T 

Poster Contests 

Another common community response to tobacco advertising is a poster contest for children. In these contests, young participants create their own anti-tobacco posters. Often, the 

most powerful of these posters satirize the tobacco industry’s own advertisements. 

Many such contests have been conducted around the country, but the most well 

known has been organized in New York City by Smoke-Free Educational Services 

(Bird, 1991). The winners of the contest receive substantial prizes, their posters appear 

in a nationally distributed book and are prominently displayed in 6,000 New York subway cars (Coalition for a Smoke-Free City, 1993; Tobias, 1991). 

Option 

•	 Conduct an anti-tobacco poster contest among children in your community. Provide significant awards for participants and winners. Encourage 

business owners to donate awards. Display winning posters prominently 

in the community. 

Voluntary Tobacco Advertising Restrictions 

One successful approach to limiting advertising involves encouraging business to 

voluntarily limit tobacco advertising. This strategy has been particularly successful in 

the case of newspaper and billboard companies (Guy, 1993; Horovitz, 1991). 

Unlike many magazines, newspapers typically receive a very small percentage of 

their advertising revenues from tobacco advertising. At least 12 U.S. daily newspapers 

have eliminated tobacco advertisements, including the Seattle Times (Bischoff, 1993; 

Guy, 1993). 

Billboard companies are concerned about the negative publicity associated with tobacco advertising, especially the accusation that tobacco billboards target poor neighborhoods and communities of color. Community activists, in many cases local clergy, 

have succeeded in limiting tobacco billboards in some communities (Horovitz, 1991). 

Recently, pressure has been increased on magazine publishers to remove tobacco 

advertising. Many magazines receive a large percentage of their advertising revenue 

from tobacco and represent a particularly insidious form of targeted advertising. Of 

greatest concern are magazines with a large audience of young people such as Spin and 

Rolling Stone. More responsible publications such as Sassy have never accepted tobacco advertising. Groups ranging from the Women and Girls Against Tobacco (WAGAT) 

project and the Interfaith Center on Corporate Responsibility have called on magazines 

to drop tobacco advertisements (Teinowitz & Kelly, 1994). 

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6. P u b l i c a n d P r i v a t e P o l i c y I n t e r v e n t i o n s 

Options 

•	 Call on local billboard companies to voluntarily eliminate or limit tobacco 

advertisements. 

•	 Encourage local, privately owned athletic facilities to eliminate tobacco 

advertising. 

•	 Organize a meeting with your local newspaper to encourage them to 

drop tobacco advertising. 

•	 Urge magazine publishers to stop accepting tobacco advertising. This is 

especially important for those publications such as Vogue, which have a 

large audience of young people. 

Voluntary Point-of-Purchase Advertising Bans 

Although legislation that prohibits point-of-purchase advertising is one response to 

this form of promotion, another is to encourage businesses to eliminate such promotions voluntarily. Because point-of-purchase advertising is so lucrative, voluntary actions by businesses may not be practical unless there is a groundswell of opposition 

from the community. 

Options 

•	 Encourage businesses to stop all in-store advertising and promotion of 

tobacco products, including banners and signs, basket or cart advertisements, in/out decals, separator bars, clocks, and logo merchandise. 

•	 Encourage businesses to stop particular types of point-of-purchase promotions such as grocery cart advertisements. 

MEDIA ADVOCACY 

Anti-tobacco activists have successfully countered tobacco industry promotional activities through the strategic use of the media, known as media advocacy. Media advocacy not only can support the other categories of advertising and promotion policy but 

also can serve as a freestanding educational strategy. 

One successful example of media advocacy in tobacco control was a campaign initiated by DOC to counter a national Philip Morris Bill of Rights tour that began in 1990. 

The national tour marked the 200th anniversary of the Bill of Rights and featured Virginia’s 

original copy of the Bill of Rights as well as an elaborate museum-like presentation. 

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M o n o g r a p h 1 6. A S S I S T 

Anti-tobacco activists feared that Philip Morris’ association with the Bill of Rights 

would foster a positive image of tobacco manufacturers and thus promote smoking. In 

addition, Philip Morris clearly sought to promote the false notion that tobacco advertising is a protected form of speech under the first amendment. In response, the Washington State chapter of DOC constructed a 15-foot replica of the Statue of Liberty called 

“Nicotina,” featuring a cigarette in place of the torch of freedom and a chain representing addiction. 

The protest against Philip Morris was spectacularly successful. As the tour moved 

from state to state, activists set up Nicotina and protested with such slogans as “Bill of 

Rights—YES; Philip Morris—NO.” Rather than the positive publicity they had anticipated, Philip Morris was dogged by negative coverage, with headlines such as “Bill of 

Rights Display Opens to Protests,” and “Tobacco Firm Blasted on Bill of Rights Link” 

(Pool, 1991; Krebs, 1990). Ultimately, the tour was shortened and Philip Morris ceased 

publicizing it altogether. 

Other examples of media advocacy to counter tobacco promotion include use of the 

media to end tobacco sponsorship of a specific event. A good example of this occurred 

in 1993 in San Luis Obispo County, California. The huge California Mid-State Fair, 

held in the county each year, had planned to include a major Marlboro Adventure Team 

promotion in exchange for sponsorship funding. The county tobacco control coalition 

pressured the fair organizers to drop Philip Morris as a sponsor. After the issue was 

widely covered in the media, the fair’s board prohibited Marlboro’s promotional activities, and Philip Morris pulled out as a sponsor (San Luis Obispo County TelegramTribune, 1993). 

Another example of media advocacy is Los Angeles’ “death clock,” an electronic 

billboard that continuously updates the number of smoking-related deaths in the United States. Built by billboard owner William E. Bloomfield, the death clock has received extensive media coverage both nationally and internationally. In the process, 

millions have been impacted by a pro-health, anti-tobacco message. 

Options 

•	 Contact the media to express concerns about specific tobacco industrysponsored events. 

•	 Conduct protests or counter events to draw attention to the negative public health consequences of tobacco sponsorship and promotion. 

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Youth access to cigarettes (OEI-0290-

02310). Washington, DC: U.S. Department of Health and Human Services. 

51. Forster, J. L., D. M. Murray, M. 

Wolfson, T. M. Blaine, A. C. Wagenaar, 

and D. J. Hennrikus. 1998. The effects 

of community policies to reduce youth 

access to tobacco. American Journal of 

Public Health 88 (8): 1193–8. 

52. Walls, T. 1993. A smokers’ alliance 

[draft]. July 1, 1993. http:// 

legacy.library.ucsf.edu/tid/pfo14e00. 

Bates no. 2025771934–1995. 

53. Environmental Protection Agency. 1994. 

Setting the record straight: Secondhand 

smoke is a preventable health risk 

(Document no. 402-F-94-005).


www.epa.gov/smokefree/pubs/


strsfs.html.


54. Muggli, M. E., J. L. Forster, R. D. Hurt, 

and J. L. Repace. 2001. The smoke you 

don’t see: Uncovering tobacco industry 

scientific strategies aimed against 

environmental tobacco smoke policies. 

American Journal of Public Health 91 

(9): 1419–23. 

55. Ong, E. K., and S. A. Glantz. 2001. 

Constructing “sound science” and “good 

epidemiology”: Tobacco, lawyers, and 

public relations firms. American Journal 

of Public Health 91 (11): 1749–57. 

56. Muggli, M. E., R. D. Hurt, and J. 

Repace. 2004. The tobacco industry’s 

political efforts to derail the EPA report 

on ETS. American Journal of Preventive 

Medicine 26 (2): 167–77. 

57. Merlo, E. 1993. [Memo to W. Campbell]. 

Philip Morris. February 17. http:// 

legacy.library.ucsf.edu/tid/qdf02a00. 

Bates no. 2021183916–3930. 

58. Bero, L. A., and S. A. Glantz. 1993. 

Tobacco industry response to a risk 

assessment of environmental tobacco 

smoke. Tobacco Control 2:103–13. 

59.	 Flue-cured Tobacco Cooperative 

Stabilization Corp. et al. v. U.S. 

Environmental Protection Agency, and 

Carol Browner. 1998. The Osteen 

decision. www.tobacco.org/Documents/ 

980717osteen.html. 

60. Teenage Research Unlimited. 1999. 

Youth focus groups to assess tobaccouse-prevention ads. Northbrook, IL: 

Teenage Research Unlimited. 

61. Farrelly, M. C., C. G. Healton, K. C. 

Davis, P. Messeri, J. C. Hersey, and M. 

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L. Haviland. 2002. Getting to the truth: 

Evaluating national tobacco countermarketing campaigns. American Journal of 

Public Health 92:901–7. 

62. National Cancer Institute. 1993. Major 

local tobacco control ordinances in the 

United States (Smoking and tobacco 

control monograph no. 3, NIH publication no. 93-3532). Bethesda, MD: National Cancer Institute. 

63. Hobart, R. 2002. Preemption: Taking the 

local out of tobacco control. Chicago: 

American Medical Association. 

64. Siegel, M., J. Carol, J. Jordan, R. 

Hobart, S. Schoenmarklin, F. DuMelle, 

and P. Fisher. 1997. Preemption in 

tobacco control. Review of an emerging 

public health problem. Journal of the 

American Medical Association 278 (10): 

858–63. 

65. Dearlove, J. V., and S. A. Glantz. 2002. 

Boards of health as venues for clean 

indoor air policy making. American 

Journal of Public Health 92 (2): 257–65. 

66. Fellers, T. 1993. Durham public 

smoking ordinance to force puffing in 

private. Herald-Sun. October 10, 1993. 

67. Centers for Disease Control and 

Prevention. 1999. Preemptive state 

tobacco-control laws—United States, 

1982–1998. Morbidity and Mortality 

Weekly Report 47 (51): 1112–4. 

68. National Cancer Institute, American 

Cancer Society. 1990. Memo of 

understanding between the National 

Cancer Institute and the American 

Cancer Society. Internal document, 

National Cancer Institute, Bethesda, MD. 

69. United States Bureau of the Census. 

1993. Selected historical decennial 

census population and housing counts: 

Table 2. Population, housing units, area 

measurements, and density: 1790 to 

1990. www.census.gov/population/ 

censusdata/table-2.pdf. 

70.	 Preemption Cigarette Act. U.S. Code 15, 

1970. § 1334b. www4.law.cornell.edu/ 

uscode/15/1334.html. 

71. Glantz, S. A. 2002. Tobacco Scam: How 

big tobacco uses and abuses the 

restaurant industry. www.tobaccoscam 

.ucsf.edu. 

72. Skolnick, A. 1995. Cancer converts 

tobacco lobbyist: Victor L. Crawford 

goes on the record. Journal of the 

American Medical Association 274 (3): 

199–202. 

Additional Resources 

1. Kelder, G., and P. Davidson. 1999. The 

Multistate Master Settlement Agreement 

and the future of state and local tobacco 

control: An analysis of selected topics 

and provisions of the Multistate Master 

Settlement Agreement of November 23, 

1998. www.tobacco.neu.edu/ 

tobacco_control/resources/msa. 

2. Web site for the Tobacco Control 

Resource Center, Inc. & The Tobacco 

Products Liability Project: 

www.tobacco.neu.edu. 

282 
M o n o g r a p h 1 6. A S S I S T 

7. Program Services: Reaching the Individual

Jane Pritzl and Walter ‘Snip’Young 

Contributors: Melissa Albuquerque, John K. Beasley, G. Lea Bryant, 

Sandra Colt, Lynn C. Cook, Glenna Davenport-Cook, Linda Gamble, 

Kitty Jerome, Jim D. Martin, Gael A. O’Sullivan, Tracy Enright Patterson, 

and Mikelle Robinson 

Contents 

The Challenge of Services Delivery: Setting Priorities ................................................ 286


Support for Individual Change .......................................................................................... 286


The Contract ...................................................................................................................... 289


The Role of ASSIST in Service Provision ..................................................................... 289


Types of Program Services ................................................................................................. 289


Identification of Existing Program Services ....................................................................... 291


Increase in Capacity for Services Delivery ......................................................................... 291


Identification and Marketing of Evidence-based Program Services ................................... 294


Smoking Education for the General Public ........................................................................ 299


Interaction between Policy and Program Services ..................................................... 300


Strength in Comprehensiveness ................................................................................ 305


References ................................................................................................................ 306


Additional Resources ................................................................................................ 307


Case Studies 

Case Study 7.1. Helping Schools Shift to a Tobacco-Free Norm in North Carolina .................. 293


Case Study 7.2. Diapers, Dishes, and Deep Breathing: Stress Management and


Case Study 7.4. Colorado Tobacco-Free Schools Law Creates Demand


Smoking Cessation for Low-income Mothers in Massachusetts ............................................. 295


Case Study 7.3. Smoking Cessation Quitline for Michigan Medicaid Recipients .................... 296


for Cessation and Prevention Programs ................................................................................. 297


Case Study 7.5. Employers: “Anybody Going to Tell Us What’s Going On?” ............................. 301


Case Study 7.6. Clearing the Smoke at the University of Maine ............................................. 302


Case Study 7.7. Strengthening the Enforcement of the Youth Access Law in North Carolina ..... 304


283 
284

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M o n o g r a p h 1 6. A S S I S T 

7. Program Services: Reaching the Individual

The three critical components of the American Stop Smoking Intervention Study 

(ASSIST)—mass media, policy, and program services—were highly interrelated. 

However, the approach to the delivery of program services was very different from 

the ways in which mass media and policy interventions were provided. The role of 

program services, as defined in ASSIST, was to guide and support individuals in 

making changes consistent with tobacco-free norms. Program services are usually 

considered individual-level interventions, whereas policy, environmental, and, at 

times, strategic use of the media are systems-level strategies. These latter 

interventions are directed at changing organizations, communities, and the society in 

which people live. 

Considerable research and dissemination of evidence-based, individual-level 

interventions had occurred, and various organizations and health-care providers 

were providing services by the late 1980s. However, research findings indicated that 

without supportive social and physical environments, individual behavior changes 

and their benefits were often short-lived. Research at that time had demonstrated the 

effectiveness of applying policy and environmentally focused strategies to tobacco 

prevention and control as well as combining individual- and systems-level change 

interventions. Limited work had been done on disseminating evidence-based policy 

and environmental interventions. Work also remained to be done on building the 

state- and local-level capacity to deliver these interventions. 

ASSIST planners focused on strengthening state and community capacity to 

implement the policy and environmental interventions needed to support individual 

behavior change. They determined that promoting policy change and media 

advocacy would have the greatest long-term impact on behavior change and that the 

funding of program services would be a low priority for ASSIST. The National 

Cancer Institute’s (NCI) contracts with the states prohibited them from spending 

substantial funds directly on program services, but those prohibitions were not 

intended to diminish the importance of, or the need for, program services. The 

strategy was to build states’ capacity to offer program services without using public 

funds to pay for them. Anticipating that the strategic use of media and media 

advocacy would result in policy development and that the implementation of policies 

would stimulate the need for improved and expanded individual-level services, 

ASSIST contractors were required to encourage, advise, and partner with 

appropriate community organizations to ensure that program services were 

provided. 

285 
7. P r o g r a m S e r v i c e s : R e a c h i n g t h e I n d i v i d u a l 

The Challenge of Services 

Delivery: Setting Priorities 

Support for Individual Change 

In addition to mass media and policy, 

the ASSIST model incorporates interventions that concentrate on individual 

behavior change as an essential element 

of a comprehensive tobacco control program. Called program services in 

ASSIST, these individual-level interventions (cessation, prevention of tobacco 

use initiation, and education of the general public) were defined as “smoking 

control activities involved directly in 

assisting individuals to make behavioral 

changes.”1(p4) 

NCI’s Standards for Comprehensive 

Smoking Prevention and Control, which 

informed the design and planning of the 

ASSIST project, represented the composite of what had been learned from 

NCI’s smoking research initiative and 

from other related research studies. 

These Standards define the interactions 

and interrelationships of the three types 

of interventions that are included in the 

ASSIST model—mass media, policy, 

and program services—as follows: 

The mass media and policy components of a comprehensive smoking and 

prevention intervention raise awareness of the smoking issue and motivate 

people to make changes in their behavior relative to smoking. Such efforts 

must be accompanied by a wide range 

of program services that guide and 

support individuals in making those 

changes. Most program services are 

delivered via the identified channels 

for smoking prevention and control, 

that is, through the health care system, 

worksites, schools, and community 

networks.2(p27) 

ASSIST was innovative in its approach to providing program services. 

Whereas ASSIST staff engaged directly 

in media and policy intervention activities, they used indirect methods to stimulate and expand the capacity of others 

to do the direct delivery of the individually focused program services. This indirect approach to providing program 

services was supported by several 

factors. After years of research on individually focused tobacco control interventions, the evidence was there to 

guide the application of these findings. 

When ASSIST was conceptualized, 

the effectiveness of various program services had been established, and these 

findings were being disseminated and 

implemented. As research from NCI, the 

National Institute on Drug Abuse 

(NIDA), and other researchers provided 

a scientific foundation for these individually focused efforts, a proliferation of 

programs and services developed to help 

people avoid tobacco use.3–7 Tobacco 

cessation programs and school prevention programs were abundant. However, 

these interventions were resource intensive, and their benefits, when achieved, 

were often short-lived.8–11 Avoiding tobacco use or maintaining a quit attempt 

often required a Herculean personal effort in a climate where tobacco use was 

glamorized in the media, championed by 

friends, and practiced at worksites and 

public places. 

Studies demonstrated the effectiveness of policy and environmental-level 

changes and of combining this approach 

286 
M o n o g r a p h 1 6. A S S I S T 

with the individual approach.12 This was 

documented in NCI monograph number 

1, Strategies to Control Tobacco Use in 

the United States: A Blueprint for Public 

Health Action in the 1990’s, on strategies to control tobacco use: “The current 

state of the art in combating tobacco use 

combines multiple environmental changes with multiple programs directed to individuals in different stages of the 

smoking initiation and cessation 

process.”9(px) 

Program services were an integral 

part of ASSIST’s policy-based approach 

to tobacco prevention and control, but 

the emphasis had shifted from individual-level to policy- and environment-level 

interventions to complement the already 

existing capacity to deliver program services. When they received their contracts, 

the ASSIST awardees were instructed 

about the prohibition on direct funding 

of program services. The intent of this 

restriction was not to diminish the imStudents participate in a tobacco use prevention activity 

portance of program services. The goal 

was to increase the number of program 

services, monitor and ensure the quality 

of existing program services, and enhance their reach and effectiveness. The 

ASSIST objectives for program services 

are listed below: 

By 1998, major community groups and 

organizations that represent the priority 

populations and have broad-based 

statewide reach should be involved in 

ASSIST activities. 

By 1998, worksites reaching major 

target populations will adopt and 

maintain a tobacco use cessation focus. 

By 1998, 100 percent of all schools 

serving grades K through 12 will use a 

tested, efficacious tobacco use 

prevention curricula. 

By 1998, at least 75 percent of primary 

medical and dental care providers will 

routinely advise cessation and provide 

assistance and followup for all of their 

tobacco-using patients.13(p3) 

Self-directed tobacco use prevention program 

booklet used in Colorado 

287 
7. P r o g r a m S e r v i c e s : R e a c h i n g t h e I n d i v i d u a l 

(See table 2.1 in chapter 2 for a list of all 

of the ASSIST program objectives.) 

As ASSIST progressed from the planning phase to the implementation phase 

in 1993, the need for a transition from 

direct to indirect provision of program 

services was reiterated. Financial restrictions for program services were spelled 

out in detail in ASSIST training materials, including the following prohibitions: 

■	 No funds will be provided to develop 

new smoking prevention, cessation, 

and education materials. 

■	 No funds will be provided for labor to 

support the delivery of smoking 

prevention, cessation, or education 

programs.14 

The director of the NCI ASSIST 

project stressed that program services 

were an essential component of a comprehensive tobacco control program, but 

he reminded state staff of the spending 

restrictions. He cited a checklist of imprudent use of funds on program servicA student studies material on the consequences of smoking 

es that included (1) duplication of services, (2) services with negligible effect, 

(3) services that were not the primary responsibility of ASSIST state or local 

staff, (4) services that were part of an 

unsustainable effort, and (5) updating of 

materials. He described specific examples of misuse of funds: (1) a media 

campaign encouraging smoking cessation that exceeded the cap on media 

spending or was not coordinated with 

other ASSIST activities, (2) delivery of 

curriculum training for large numbers of 

teachers that could be better accomplished by departments of education, 

and (3) paying for labor to staff a cessation hotline.14 

The ASSIST funding itself, $140 million, seemed enormous at that time but 

would have been quickly depleted if the 

17 ASSIST states were unconstrained in 

their use of the funds to develop and directly provide program services. The indirect approach to providing program 

services freed ASSIST funds to address 

Materials and activities for 

tobacco-free schools in Colorado 

288 
M o n o g r a p h 1 6. A S S I S T 

the gaps in policy, media, and environmental interventions that were needed 

for a comprehensive tobacco prevention 

and control program. 

The Contract 

NCI’s use of a contract mechanism, 

rather than a grant or cooperative agreement, ensured that expenditures for program services remained focused on 

ASSIST program goals. Instead of statelevel agencies proposing their plan of 

action to NCI, NCI specified what was 

to be done, how it was to be done, and 

how much could be spent. States developed annual action plans within the confines of the requirements. The contract 

mechanism helped state program managers limit program service expenditures 

of their local contractors. 

One reason that NCI used a contract 

mechanism to fund ASSIST was to help 

insulate program managers and other 

state staff from political pressures within 

their health departments and states. Early on, NCI staff acknowledged the politically sensitive nature of bold tobacco 

control interventions and the potential 

influence of the tobacco industry. Therefore, NCI elected to use contracts and 

require specific deliverables to help ensure that precious resources were not diverted to ineffective or inconsequential 

interventions. Once state staff became 

comfortable with the intent of the contract 

approach, they embraced this model. 

This directive approach from NCI 

was critical to maintaining the integrity 

of ASSIST. The challenge was to filter 

these funding restrictions down to the 

local level. When ASSIST funds arrived 

in the states, there was an expectation at 

the local level that cessation program efforts could be expanded to draw in more 

smokers and pay for more staff time. 

That was not allowed under the contract. 

The contractual restrictions for program services meant that health department staff had to partner with service 

providers within the communities. The 

ASSIST staff collaborated with organizations to promote and support existing 

services so that they would be prepared 

to meet the anticipated increase in demand for services stimulated by policy 

interventions and an environment where 

nonsmoking was becoming the norm. 

This was a challenge for many of the local staff and volunteers, health department contractors, and the American 

Cancer Society (ACS); with time and 

continued monitoring and support, however, the transition from direct to indirect provision of program services was 

realized. 

The Role of ASSIST 

in Service Provision 

Types of Program Services 

Program services in the ASSIST 

project were grouped into the following 

three categories: 

1. Smoking Education of the General 

Public: Education of the general 

public to raise individuals’ awareness 

and shape attitudes on tobacco issues 

2. Cessation: Support for smoking cessation, such as physician counseling, 

group cessation classes, and self-help 

materials 

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7. P r o g r a m S e r v i c e s : R e a c h i n g t h e I n d i v i d u a l 

3. Prevention of Tobacco Use Initiation: 

Education to prevent tobacco use, 

such as school-based prevention 

curricula and parent-based 

interventions1 

The “ASSIST Program Guidelines” 

specified that these three types of program services would be offered in a 

variety of settings, for example, in physicians’ offices, outpatient clinics, workplaces, schools, and community 

facilities.1 Organizations such as ACS, 

the American Lung Association (ALA), 

and the American Heart Association 

(AHA) each had programs designed to 

educate the general public about the 

health effects of tobacco and to provide 

smoking cessation classes. Smoking cessation programs were also available 

through hospitals, health maintenance 

organizations, worksite wellness programs, and many private entrepreneurs. 

To reduce early adoption of tobacco use, 

schools were enjoined to provide coordinated school health education, which included drug, alcohol, and tobacco use 

prevention. 

For guidance on allowable activities 

and how ASSIST was to ensure that program services would be provided, program managers could refer to the 

“ASSIST Program Guidelines,”1 which 

offered examples in each program service area of activities that could provide 

self-help materials and referral guidelines for smokers: 

■	 Identify current resources that 

provide smoking cessation 

resources and encourage them to 

target priority worksites with their 

marketing efforts . . . 

■	 Identify model worksites in which 

intensive smoking cessation 

activities are occurring, and 

promote them through business 

media targeted to business owners 

in priority industry areas.15(pp4–5) 

Of the three types of program services, one—smoking education for the general public—could be provided directly 

by ASSIST staff. In addition, to ensure 

the provision of all program services, 

staff were to (1) identify existing program services, (2) increase capacity for 

The Public Health 

Service guideline 

Use and Dependence presents stratappropriate treatments for current 

and former tobacco 

lines were designed 

to assist clinicians 

and smoking cessation specialists, as 

well as health-care administrators, insurers, 

and purchasers in identifying and assessing 

from 1975 to 1999 and included more than 50 

meta-analyses. 

Rockville, MD: U.S. 

Department of Health and Human Services, 

Treating Tobacco Use and Dependence 

Treating Tobacco 

egies for providing 

users. The guidetobacco users and in delivering effective tobacco dependence interventions. The guidelines were based on an exhaustive systematic 

review and analysis of the scientific literature 

Source: Fiore, M. C., W. C. Bailey, S. J. 

Cohen, S. F. Dorfman, M. G. Goldstein, E. R. 

Gritz, R. B. Heyman, et al. 2000. Treating 

tobacco use and dependence. A clinical 

practice guideline. 

Public Health Service. www.surgeongeneral 

.gov/tobacco/treating_tobacco_use.pdf 

290 
M o n o g r a p h 1 6. A S S I S T 

services delivery, and (3) identify and 

market science-based program services.16 

Each activity is elaborated on below. 

Identification of Existing Program 

Services 

All states conducted a site analysis. 

The 1991 “ASSIST Program Guidelines” directed staff to analyze the target 

populations, identify channels for reaching those populations, ascertain existing 

tobacco control resources (including 

policy and media initiatives and existing 

program services), and identify the site’s 

potential resource capability.16 

These site analyses yielded specific 

quantitative information on the availability of program services. Those data 

proved very useful for the ASSIST planners and also formed the basis for community resource guides that were 

developed in most states. Excerpts from 

South Carolina and Wisconsin’s site 

analyses are presented in a sidebar on 

page 292. 

Increase in Capacity for 

Services Delivery 

The passage below from the “ASSIST 

Program Guidelines” illustrates the intent of the ASSIST planners to stimulate 

increased program services capacity: 

The intent of ASSIST is not to create a 

new institution devoted to smoking 

control but rather to increase the 

capacity for existing groups and 

organizations to sustain and enhance 

their role as smoking control agents 

beyond the life of ASSIST.17(p2) 

ASSIST staff were to identify groups 

whose memberships and constituencies 

were likely to contain smokers targeted 

by ASSIST and to help those groups become smoking cessation agents.18 The 

ASSIST states used a variety of strategies to support the development of prevention and cessation program services, 

such as train-the-trainer programs, the development of materials, and awareness 

days to attract attention to cessation programs. Illustrative activities in Virginia 

and Missouri are described below: 

■	 Virginia. Seven training workshops 

were held in Virginia for health-care 

providers and substance abuse 

treatment counselors. Topics ranged 

from nicotine addiction to developing 

and implementing a smoke-free 

policy for treatment facilities. The 

state certification board for substance 

abuse counselors adopted a policy 

requiring that anyone applying for 

recertification undergo 6 hours of 

training on the theory and treatment 

of nicotine addiction. In addition, 35 

coordinators of a mentoring program 

for pregnant and parenting teens were 

trained in a smoking-cessation protocol. 

■	 Missouri. Presentations on prevention 

of tobacco use, delivered in Missouri 

schools, focused on the health hazards 

of tobacco use. More than 1,108 sixth 

graders were reached. In addition, 

more than 80 teachers and counselors 

received training from two local 

coalitions concerning instruction on 

prevention of tobacco use.19 

Case study 7.1 illustrates the benefits 

of an assessment of the North Carolina 

Safe and Drug-Free Schools Program. 

The assessment data revealed significant 

shortcomings, and dissemination of 

291 
7. P r o g r a m S e r v i c e s : R e a c h i n g t h e I n d i v i d u a l 

Control. 

Report.

■ 

program. In 1991, participants in the 

program included 1,500 people in 120 

■ 

smoking cessation module that includes 

the Calling It Quits kit. During 1991– 

students in 41 schools in the state 

■ During 1991, 68% of the 421 

participating elementary schools were 

with 51,180 students participating. 

■ 

Medicine. 

■ 

■ Programs related to tobacco or smoking 

agencies. Counseling about the health 

these agencies, group smoking cessation 

by 70%. 

■ 

smoking cessation programs. In 1990, 

ALA helped 300 companies with 30,000 

smoking policies and cessation programs. 

■ 

■ 

smoking cessation programs, 7,840 

Sources: Center for Health Promotion, South Carolina Department of Health and Environmental 

South Carolina Project ASSIST. Site Analysis. Contract Number N01-CN-15382. October 1, 

1992. Columbia: South Carolina Department of Health and Environmental Control; Wisconsin 

Department of Health, Tobacco-Free Wisconsin Coalition. ASSIST Wisconsin Project: Site Analysis 

 October 1, 1992. Milwaukee: Wisconsin Department of Health. 

Program Services Identified through Site Analysis Data 

South Carolina 

ALA has 72 trained facilitators 

working in the Freedom From Smoking 

worksites. 

AHA’s Heart at Work program has a 

92, this kit was used by 9,000 

employees from 36 companies. AHA 

also has a peer-oriented smoking 

intervention program for middle and 

high school students, called Save a 

Sweet Heart, which served 6,894 

during the 1991–92 school year. 

involved in the Smoke-Free Class of 

2000 tobacco use prevention program, 

NCI offers a train-the-trainer program 

to provide smoking cessation training 

for physicians. This program is used 

only for training residents in Preventive 

and Family Medicine programs at the 

University of South Carolina School of 

Wisconsin 

Most cessation programs offered are 

modules that were developed by ACS, 

ALA, or AHA. Eighty-one percent of 

hospitals offer tobacco cessation 

programs at their facilities. 

are offered by 85% of local public health 

risks of smoking is offered by 82% of 

is offered by 21%, and referrals to 

smoking cessation programs are offered 

Both ACS and ALA offer worksite 

employees develop and implement 

According to a survey of 541 schools that 

was conducted in April 1990, 93% of those 

surveyed offered smoking prevention or 

cessation programs during the previous 

year. 

During ACS’s 1989–90 Fresh Start 

smokers participated and 37% remained 

smoke-free 1 year later. 

those results led to increased demand for 

more effective tobacco-free school policies and increased capacity for delivering direct program services. 

The focus of tobacco control efforts 

on groups likely to contain targeted 

smokers is illustrated by case study 7.2. 

The Mother’s Stress Management Task 

Force in Massachusetts involved a number of groups that work with low-income 

women in workshops that offered stress 

management techniques as an alternative 

to smoking. Those groups had little previous involvement in tobacco control, 

and this initiative is a case in which new 

capacity was created in program services. 

292 
M o n o g r a p h 1 6. A S S I S T 

Case Study 7.1 

Situation: 

all districts restricted tobacco use by students and that 95% of them restricted 

this disclosure resulted in (1) an increased demand for technical assistance with 

Program Services Provided: 

Instruction. 

Helping Schools Shift to a Tobacco-Free Norm in North Carolina 

The 1994 Pro-Children Act (20 USC 6083) included restrictions on smoking inside all school facilities for any school accepting federal funding. Assessment 

of data collected by ASSIST staff and coordinators of the Safe and Drug-Free 

Schools Program in 90 of the 122 North Carolina (NC) school districts showed that 

tobacco use by employees—both requirements of the Pro-Children Act. Most 

policies were not comprehensive, and in a few cases, the policies were not fully in 

compliance with the federal law. Most student policies did not address enforcement 

procedures. Of those that did, most used out-of-school suspension as the penalty. 

Coordinators of the Safe and Drug-Free Schools programs expressed an interest in 

alternatives to suspension programs. Working with the NC Department of Public 

Instruction, ASSIST informed school districts about the results of the assessment; 

developing and enforcing tobacco-free school policies and (2) the opportunity to 

expand program services, as described below. 

A new partner was brought into the effort—the dropout 

prevention and substance abuse prevention staff at the NC Department of Public 

Together, the ASSIST Schools Task Force, ASSIST staff, and NC Department of 

Public Instruction staff proposed a plan that included the following three elements: 

1. A four-session educational alternative to suspension for student violators 

2. A tobacco-cessation program for youths 

3. A variety of promotions to encourage a tobacco-free norm 

As a result of publicizing and implementing this plan, the task force gained new 

volunteers from the schools and expanded tobacco use prevention education and 

tobacco cessation program services. A local coalition piloted activities in one of its 

high schools to learn more about what approaches improve enforcement. 

ASSIST developed Tobacco Free Schools in North Carolina: A Handbook for School 

Administrators. The handbook educated school administrators regarding model 

policies on tobacco use and appropriate implementation of those policies. The North 

Carolina School Boards Administration also distributed to their districts a strong 

model policy on tobacco use. 

Working with a pilot school in Charlotte, North Carolina, ASSIST was able to 

broaden the handbook to include the following three components: 

1. An educational alternative to suspension for students caught violating the school’s 

tobacco use policy 

293

7. P r o g r a m S e r v i c e s : R e a c h i n g t h e I n d i v i d u a l 

enforced tobacco-free school policies, the demand for model policies, enforcement 

tobacco-free norm. In (Case 

2. Sample activities for the prevention and control of tobacco use 

3. A reference to Tobacco-Free Teens, a voluntary cessation class developed by the 

American Lung Association of Minnesota 

When the manual was complete, 10 high schools across North Carolina were recruited to pilot this tobacco-free schools program. As more schools instituted and then 

strategies, tobacco use prevention education, and cessation services grew. Working 

with the NC Department of Public Instruction, ASSIST used the manual on tobaccofree schools that had been pilot-tested and began offering regional training events to 

school districts interested in creating tobacco-free school environments. 

— Melissa Albuquerque, former ASSIST Field Director 

for North Carolina and Program Consultant, 

Office on Smoking and Health, CDC 

Sources: Adapted from T. Enright Patterson and G. Davenport-Cook. 1997. Helping schools shift to a 

Entering a new dimension: A national conference on tobacco and health 

studies, September 22–24, 1997). Rockville, MD: ASSIST Coordinating Center. 209–10; 1994 ProChildren Act. 20 U.S. Code 6083. 

Identification and Marketing of 

Evidence-based Program Services 

Effectively marketing existing prevention and cessation services that had 

been proven to be effective was an important strategy, as cited in the “ASSIST 

Program Guidelines.” In the mass media 

section of the guidelines, one objective 

related to the marketing of cessation services was to “provide critical information to smokers about the effectiveness 

and availability of cessation 

services.”17(p2) 

The “ASSIST Program Guidelines” 

suggested that communities use information gleaned in their site analysis to 

compile a resource guide to cessation 

services. Many such resource guides had 

been developed by the end of ASSIST,16 

and these guides were important for 

marketing program services. 

Successful marketing also occurred in 

Michigan where a smoking cessation 

hotline was set up for Medicaid recipients. Case study 7.3 describes how 

Michigan established and marketed cessation programs that were needed as a 

result of a policy that mandated coverage of cessation services for the Medicaid population. 

As illustrated in case study 7.4, Colorado’s new tobacco-free schools law 

prompted a number of public and private 

organizations to sponsor and promote 

tobacco cessation programs for teens. 

The effectiveness of physician counseling of smokers to quit, coupled with 

structured follow-up, was cited in the 

“ASSIST Program Guidelines”: “When 

advice is coupled with structured follow-up programs and/or pharmacologic 

agents, cessation rates of 18 to 27 percent 

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Case Study 7.2 

Diapers, Dishes, and Deep Breathing: Stress Management and Smoking Cessation 

for Low-income Mothers in Massachusetts 

Situation: 

Program Services Provided: 

from the Massachusetts Department of Public Health, the coalition hired a part-time 

. (Case 

The Tobacco-Free Greater Franklin County Coalition in Massachusetts 

convened the Mother’s Stress Management Task Force in 1995. By using stress 

management techniques taught in pilot workshops, the task force sought to offer lowincome mothers concrete alternatives to smoking. All area providers who served lowincome women and their families were invited to participate in the task force. 

Representatives from Head Start, adult literacy programs, a family planning agency, 

a community college, and other organizations met monthly to plan the intervention. 

Many of these organizations were only peripherally involved in tobacco control 

before the creation of the task force; this intervention helped to institutionalize 

tobacco control as a permanent program component in many agencies. 

A curriculum was made available to agencies working with 

low-income women (including literacy programs, homeless shelters, and other 

tobacco control programs) and to partners with local coalitions. With state funds 

substance abuse counselor for the position of stress management specialist. Based on 

the curriculum “Diapers, Dishes, and Deep Breathing,” 4- and 5-week workshops 

were offered regularly to clients in various settings to teach coping skills, develop 

individual stress management plans, and motivate smoking cessation attempts. The 

workshops used a harm-reduction model, encouraging women to reduce smoking if 

they were not ready to quit. 

A 3-week workshop series was piloted in four areas of the county; thus it was 

accessible to nearly all of the region’s rural residents. Food, childcare, and transportation were offered to participants. The pilot workshops were advertised through 

newspapers, local radio stations, and human service agencies. Each session was 2 

hours long and was facilitated by two task force members. The workshops were 

conducted at local agencies, libraries, and schools—familiar locations in which the 

women would be comfortable. 

Task force members subsequently developed the curriculum “Diapers, Dishes, and 

Deep Breathing.” A fourth week was added to the curriculum to give participants 

more time to support each other and to share experiences. Another session was added 

on creating personal stress-reduction action plans. With a grant from the Massachusetts Department of Public Health, the curriculum was made available to the general 

public and to agencies working with low-income women. The curriculum has been 

distributed to more than 20 literacy programs for use in adult education classes. 

Source: Jerome, K. 1998. Diapers, dishes, and deep breathing: Stress management and smoking 

cessation for low income mothers. In No more lies: Truth and the consequences for tobacco

studies at the Fourth Annual National Conference on Tobacco and Health, October 26–28, 1998.) 

Rockville, MD: ASSIST Coordinating Center. 87–92. 

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Case Study 7.3 

Smoking Cessation Quitline for Michigan Medicaid Recipients 

Situation:

Zyban. 

Program Services Provided: 

by the quitline, and quit rates ranged from 10% to 30%. Six 15-minute counseling 

periodic mailings to Medicaid clients. Quit kits were sent to each participant, and 

 Successful policy advocacy efforts by ASSIST resulted in coverage for all 

Michigan Medicaid patients, beginning in 1997, for nicotine patches, gum, and 

Concern about the availability and promotion of smokingcessation services and information for Medicaid clients led to the development of a 

free smoking cessation counseling service by telephone for Medicaid patients. This 

service was funded by the Michigan State Health Department’s Tobacco Program. 

Partners included Michigan State University and the Michigan Public Health Institute. 

As often happens with these types of programs, it took a couple of years to find a 

contractor, negotiate a contract, and get the quitline up and running; it ran from 

January 2000 through December 2002. During that time, 1,785 clients were served 

sessions and two 5-minute follow-up sessions were offered. The sessions were based 

on modules that follow the Agency for Health Care Policy and Research (now known 

as the Agency for Healthcare Research and Policy) guidelines. Nine health plans in 

Michigan referred Medicaid clients who were smokers to this service. Many were 

self-referred after seeing the quitline number. The quitline was also promoted by 

individual pharmacies and physicians were notified via fax of the participants’ 

enrollment in the program. Although this particular quitline was defunded, another 

statewide quitline that Medicaid clients may access has since been initiated (with 

CDC and American Legacy funds). 

—Mikelle Robinson, former Project Manager, and 

John K. Beasley, former Project Director, Michigan 

Department of Public Health, and currently with the 

Tobacco Section of the Michigan Department of Health 

and the Michigan Public Health Initiative, respectively 

Sources: The Smoking Cessation Clinical Practice Panel and Staff. 1996. The Agency for Health Care 

Policy and Research smoking and cessation clinical practice guideline. Journal of the American 

Medical Association 275 (16): 1270–80; Fiore, M. C., W. C. Bailey, S. J. Cohen, S. F. Dorfman, M. G. 

Goldstein, E. R. Gritz, R. B. Heyman, et al. 2000. Treating tobacco use and dependence. A clinical 

practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health 

Service. www.surgeongeneral.gov/tobaccotreating_tobacco_use.pdf. 

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M o n o g r a p h 1 6. A S S I S T 

Case Study 7.4 

for Cessation and Prevention Programs 

Situation: 

tobacco-free status increased from 51% to 76%, and by 1999, 84% were tobacco 

produced an immediate increase in the demand for youth cessation programs, to 

Program Services Provided: Inquiries about cessation programs were often directed to 

districts that were tobacco free. 

Colorado Tobacco-Free Schools Law Creates Demand 

In 1994, the Colorado State Legislature passed the state’s first tobacco-free 

schools law (Statute 25-14-103.5), prohibiting the use of all tobacco products on 

school property by students, teachers, staff, and visitors, and requiring enforcement 

of the policy. Between 1994 and 1995, the percentage of school districts reporting 

free. The increased number of smoke-free environments in the tobacco-free schools 

which community organizations responded. 

the ALA, which had just launched a new drive to train educators to facilitate a 

program for youth on cessation of tobacco use. The Colorado State Department of 

Education offered additional financial support to any alternative high school willing 

to provide a tobacco use cessation program for its students. In addition to ALA’s 

statewide efforts to provide youths with a tobacco cessation program, Kaiser Permanente in Denver sponsored a drop-in tobacco cessation support group for teens. 

Throughout the state, local administrators and teachers provided imaginative cessation programs (e.g., a 2-day retreat to a mountain camp and a nonsmoker’s running 

group in which members received a new pair of running shoes). 

The demand also rose for information and training on evidence-based programs on 

prevention of tobacco use. A local education training organization, the Rocky 

Mountain Center for Health Promotion and Education, took the opportunity to begin 

delivering teacher training programs on tobacco prevention. New alliances were 

formed. ASSIST staff worked closely with the state’s school nurse consultant to 

provide training to school nurses statewide on teens and tobacco use. Staff also made 

annual appearances at statewide conferences for principals and school board members. Local ASSIST staff actively engaged area school administrators to help with 

implementation. The Colorado State Board of Health requested regular briefings on 

the status of tobacco-free schools in the state and gave certificates of merit to those 

—Jane Pritzl, former ASSIST Field Director, 

Colorado Department of Public Health and 

Environment, and current Intervention Scientist, 

Division of Adolescent and School Health, CDC 

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NCI manual for oral health 

practitioners 

NCI manual for physicians 

Massachusetts Department of 

Health brochure 

have been reported.”20(p1) State ASSIST 

staff were encouraged to identify and 

train other health-care practitioners, 

such as public and occupational health 

nurses, dental hygienists, and pharmacists to conduct such interventions.20 The 

“ASSIST Program Guidelines” also promoted the identification and training of 

individuals not in health-care roles who 

could deliver brief interventions supporting smoking cessation. Cessation 

aids such as print, video, or audio products as well as cessation materials tailored to the needs of a specific priority 

population (e.g., students) could be used 

by existing coalitions, organizations, 

agencies, community groups, and individuals who had access to the education 

community. This referral to cessation 

services through a cessation directory is 

another example of the marketing of 

proven program services during 

ASSIST.21 The North Carolina experience described below is illustrative of 

ASSIST training of health-care practitioners in cessation counseling. 

■	 North Carolina. North Carolina focused cessation efforts on pregnant 

women and developed an award-winning program, “Counseling Women 

Who Smoke,” designed to meet the 

needs of practitioners working with 

pregnant women. Between 1995 and 

1998, 557 North Carolina health-care 

providers were trained in the program, 

and several local communities formed 

Smoke-Free Baby clubs to supplement the program. In 1998, the American College of Obstetricians and 

Gynecologists chose this program as 

one of the best in the nation and disseminated a module based on it. The 

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Women’s Health Branch of the North 

Carolina Division of Public Health 

now requires cessation counseling and 

referral to be implemented in its contracts with 87 local health departments. 

Smoking Education 

for the General Public 

Tobacco use affects everyone. It affects those who do not use tobacco products through exposure to environmental 

tobacco smoke, increased health-care 

costs, and loss of family or friends. It affects tobacco users directly by damaging 

their personal health. Education programs that reach the public with information about tobacco use can help 

individuals make informed decisions 

about quitting or not initiating tobacco 

use. Effective programs reinforce social 

attitudes that support a tobacco-free 

norm. Ideally, a tobacco use prevention 

education program is directed to a defined population and is sensitive to the 

social, economic, and cultural issues affecting that population. ASSIST planners made public education about the 

hazards of tobacco a required component, but the NCI “Standards for Comprehensive Smoking Prevention and 

Control” specified that such public education support “overall smoking prevention and control goals.”2(p32) 

State health department staff conducted 

educational workshops for policymakers. At these workshops, policymakers 

could learn about the negative health effects of environmental tobacco smoke, 

the benefits of policy change in reducing 

tobacco use, and ways to draft and implement effective changes in policy. (See 

chapter 4 for a discussion of ASSIST tobacco use prevention education activities 

that were encouraged for each channel.) 

Examples are presented below: 

■	 West Virginia. West Virginia 

disseminated 270,000 “Through With 

Chew” campaign inserts to all weekly 

newspapers in the state, and 66,000 

inserts were delivered to all 

elementary and middle schools for 

distribution to second, fourth, and 

seventh graders. Print and radio media 

publicized events and information 

regarding the “Through With Chew” 

campaign.19 

■	 Wisconsin. At least five local 

coalitions conducted media advocacy 

to alert the public to the impacts of 

tobacco advertising. Specific media 

activities included running editorials 

in newspapers, sending letters to the 

editor, placing articles on tobacco in 

seven monthly tribal publications, 

providing news releases, and 

developing a counteradvertising 

billboard in cooperation with a 

parents’ program.19 

In 1993, when Denver passed a clean 

indoor air ordinance that affected all 

businesses with more than 5 employees 

and all restaurants with seating for more 

than 25 patrons, there was a need for 

organizations to conduct outreach to 

businesses by offering tobacco use prevention education in the workplace. 

State and local health departments 

worked with local employers’ councils 

to help businesses implement this new 

ordinance, thus creating new capacity 

with these new workplace education 

programs. This aspect of the Colorado 

experience is described in case study 7.5. 

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The experience of the University of 

Maine at Farmington, described in case 

study 7.6, demonstrates that once a policy has been implemented, educating the 

affected individuals about the policy is a 

prerequisite to their accepting it and 

complying with it. At the University of 

Maine, when a policy was implemented 

requiring a smoke-free campus within 5 

years, students provided educational 

services campus-wide to explain the policy and to promote adherence to it. 

ASSIST identified specific high-risk 

populations as priority populations (adolescents, ethnic minorities, blue-collar 

workers, unemployed people, and women), and the states’ partners designed 

many of their activities to serve those 

populations. Examples of such activities 

are described below. 

■	 Massachusetts. Massachusetts 

launched an advertising campaign 

about smoke-free homes to increase 

awareness among the general public 

(especially adults and African Americans) about the harmful effects of 

secondhand smoke. Promotional materials for the campaign were provided to local programs. Newspaper ads, 

“swiss cheese” press releases, and a 

guide for local media outlets were 

also created. 

■	 New Mexico. New Mexico conducted 

focus groups with Vietnamese men to 

ensure that a trainer’s cessation program would be culturally appropriate 

for this population. Workshops, conducted in Vietnamese, were attended 

by six Vietnamese smokers, who were 

recruited via flyers inserted into a regional Vietnamese newspaper. Two 

Vietnamese men interested in becoming smoking cessation facilitators in 

their community completed their 

training. In another effort, train-thetrainer sessions were conducted to 

prepare 23 community members 

throughout the state to offer youth 

smoking cessation programs. 

■	 Washington State. Training for 

smoking-cessation counseling, using 

the NCI “4 A’s” of patient counseling 

about smoking—namely, Ask, Advise, 

Assist, and Arrange—took place in 

Washington State with an emphasis 

on underserved populations, including 

American Indians and farm workers. 

As part of World No Tobacco Day, 

King County purchased a full-page 

no-smoking advertisement in the 

Seattle Times that included a request 

form for a smoking-cessation guide 

and a smoke-free restaurant guide. 

Several hundred requests for the free 

materials were received.19 

Interaction between Policy 

and Program Services 

T

he interaction between policy and 

program services can be selfperpetuating. Program services such as 

smoking education of the general public 

can facilitate policy development, and 

policy implementation can stimulate an 

increase in program services. An example is the federal Synar Amendment, 

which requires states to enact and enforce youth access laws or risk forfeiture 

of block grants for substance abuse prevention and treatment. Efforts to comply 

with the Synar Amendment stimulated 

demand for program services, particularly for educating store owners regarding 

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Case Study 7.5 

Situation: 

additional resources to successfully implement the ordinance. 

Program Services Provided: 

state comply with the ordinance. 

The local and state health departments collaborated on the production of a brochure 

Employers: “Anybody Going to Tell Us What’s Going On?” 

In Denver, Colorado, the 1993 clean indoor air ordinance was passed 

without provisions for communication about or enforcement of the ordinance. 

Advocates hoped that media coverage of the ordinance would help businesses 

understand how the new law applied to them, but calls to state and local health 

agencies made it clear that the ordinance was not well understood. The city needed 

Colorado ASSIST partnered with the City of Denver’s 

local health department to disseminate the ordinance to businesses, to help provide 

business leaders with technical assistance on implementation, and to develop a 

training workshop to help Denver businesses and other employers throughout the 

to educate Denver businesses about the new law. The brochure was intended to 

provide initial notification about the law and to provide opportunities for follow-up. 

One panel of the flyer was a query/mailer asking employers to describe the policy 

that they intended to implement (100% smoke free or a designated smoking area 

within the limits of the law). It also invited them to request additional information 

and assistance. Initially, more than 5,000 brochures were mailed. The large number 

of employers who returned the tear sheet provided the city with policy information 

and an organized method for dealing with questions. After the first year, the local 

health department took over the printing and distribution of the brochure. The 

brochure became part of the application packet for a business license sent to any 

business new to Denver and was used by both the Metro Chamber of Commerce and 

the Small Business Administration. 

For more intensive assistance, the private Denver-based Mountain States Employers 

Council (MSEC) volunteered a training staff and the use of their training facility to 

present workshops on the new Denver clean indoor air ordinance and associated 

workplace issues. The organization’s legal staff taught a section on the legal implications of not providing a smoke-free workplace, and staff from the Colorado ASSIST 

Tobacco Control Program taught about the health issues and ways to support employees making the transition to a smoke-free workplace. 

Multiple training sessions were held successfully in Denver, and the MSEC decided 

to disseminate the workshop regionally for business members in other parts of the 

state. In subsequent programs, they provided urban and rural employers with discussions on tobacco restrictions in their regions and encouraged them to put policies in 

place. The alliance between the ASSIST state staff, the Denver City and County 

health department staff, and the MSEC proved to be useful beyond these training 

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7. P r o g r a m S e r v i c e s : R e a c h i n g t h e I n d i v i d u a l 

Case Study 7.6 

Clearing the Smoke at the University of Maine 

Situation: 

campus. 

Services Provided: 

campus-wide media campaign: 

2. 

by MSEC for the price of a phone call. 

Case Study 7.5 (continued) 

A 1987 smoke-free policy that prohibited smoking within all institutional 

buildings at the University of Maine at Farmington (UMF) was replaced in the 1998– 

99 academic year by a new policy that outlined a 5-year plan progressing toward an 

entirely smoke-free campus. UMF was awarded an $80,000 grant by the Partnership 

for Tobacco-Free Maine, the state ASSIST coalition, to implement the policy on 

To make a smoke-free policy acceptable, the Tobacco-Free Maine 

project at UMF focused on two goals: 

1. Ensure that information provided by students and faculty about tobacco issues 

would be uniform and accurate 

2. Support student efforts to address their concerns about tobacco use on campus 

To identify opportunities for integrating media presentations on tobacco control 

issues into the undergraduate curriculum, students first conducted a survey of course 

syllabi and content and then distributed information to the faculty. 

In addition, a broad-based media campaign was essential for a successful campus 

dialogue about the effects of tobacco and secondhand smoke. Developed in a seniorlevel course on health education planning, the following five projects served as a 

1. A Second Annual Health Beaver 5K walk/run, with a smoke-free theme—“Catch 

the Fever: Be a Smoke-free Beaver” 

The Art of Being Smoke-Free—an exhibit showing the artist’s idea of how tobacco 

affects the life of the entire community, coupled with a modern dance piece 

workshops. When other issues arose, such as clean indoor air ordinances and workplace smoking policies, pro bono legal guidance was often provided to ASSIST staff 

After the first rush was over, the Denver Department of Public Health took all 

complaints about compliance; conducted all investigations; and provided technical 

assistance to hotels, restaurants, and other employers in making the law a success. 

—Jane Pritzl, former ASSIST Field Director, 

Colorado Department of Public Health and 

Environment, and current Intervention Scientist, 

Division of Adolescent and School Health, CDC 

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M o n o g r a p h 1 6. A S S I S T 

on youths 

acceptance of a tobacco-free culture. 

(Case Studies of the Fifth 

entitled “Death with Smoking,” which portrayed the personal effects of tobacco 

3. Females Against Secondhand Smoke and Tobacco (FASS/T)—a multimedia 

campaign spread broadly across the campus with the message “Tobacco Is Killing 

ME” (Maine), especially focusing on college women and factors that predispose 

them toward smoking 

4. No Butts About It—a community gathering about tobacco use cessation services 

5. Kickin Butts—a dissemination of smoking cessation media materials on the 

availability of local cessation services for smokers in the college population 

The undergraduate curriculum initiative proved practical and timely, as the five 

media projects collectively served as a catalyst in shifting the social climate toward 

One first-year student testified to the effectiveness of the program: 

“A while back, when I finally decided to quit for the sixth and final time, a good 

friend named June gave me a Quit Kit. The kit is put out by the Partnership for a 

Tobacco-Free Maine. In it there are flyers, articles, and reasons for quitting. Surprising enough many of the reasons in the kit were some of the same reasons I have. 

Some are: I want to feel better about myself, I want to quit coughing that sick mucus 

up, and I want to get back into sports. I want to take a second and thank June for all 

her support. She has been my new ‘Saving Grace.’” (Stephen Akeley, May 4, 1999) 

Source: Adapted from G. L. Bryant and L. Gamble. 1999. Clearing the smoke on campus: Policy 

change through grassroots advocacy. In Tobacco-free future: Shining the light 

Annual National Conference on Tobacco and Health, August 23–25, 1999). Rockville, MD: ASSIST 

Coordinating Center, 23–8. 

enforcement strategies. In turn, these efforts motivated additional policy changes 

that would further limit youth access to 

tobacco products. This effect—whereby 

policy change and demand for program 

services stimulate each other—was a 

common phenomenon during ASSIST. 

(See case study 7.7.) 

The relationship between policy and 

program services can be seen readily in 

school settings, particularly in schools 

with tobacco-free policies. In Colorado, 

school districts were governed by the 

state’s Tobacco-Free Schools Law. This 

policy included a loophole, however, 

that allowed school boards to exempt 

any school or school property if “extraordinary circumstances exist” that 

warrant an exception. Hence, the state 

policy essentially allowed for voluntary 

implementation. Because of voluntary 

efforts of schools to implement the 

state’s tobacco-free policy, coupled with 

assistance and materials provided from 

Colorado ASSIST to schools, the demand for prevention and cessation programs grew.22 The wide array of 

program services that were developed to 

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Case Study 7.7 

Situation: 

Program Services Provided:

tobacco sales to minors: 

Strengthening the Enforcement of the Youth Access Law in North Carolina 

The Synar Amendment, a component of the Alcohol, Drug Abuse and 

Mental Health Administration Reorganization Act of 1992, requires each state to 

conduct specific activities to reduce youth access to tobacco products. States were 

required to “enforce the youth access law in a manner that can reasonably be expected 

to reduce the extent to which tobacco products are available to individuals under age 18.” 

 NC ASSIST worked collaboratively with the NC Substance Abuse Services Section and other partners on six major actions to reduce 

1. Educate state and local law enforcement officers on the federal Synar Amendment, state law, and model enforcement strategies. Training programs were 

conducted across the state and were tailored to motivate and strengthen enforcement efforts of the state’s youth access to tobacco law. ASSIST staff conducted 

1-day regional training sessions that reached more than 500 state and local 

officers. Enforcement checks were made by minors attempting to buy cigarettes; 

the results were reported in the media and conveyed how easy it was for the 

minors to buy cigarettes. The initial buy rate was 64%. Voluntary health agencies, 

ASSIST coalition members, and state and local law enforcement officers began a 

2-year process to educate community and state decision makers, including the 

attorney general and the governor, about the importance of enforcing the youth 

access law. 

2. Collaborate with key state and local partners to strengthen the state’s youth access 

to tobacco law. Key voluntary agencies, law enforcement, and youth advocates 

worked with the NC Attorney General and key legislators during the 1997 

legislative session of the NC General Assembly. The efforts resulted in important 

legislation that greatly strengthened the law, effective December 1, 1997. 

3. Work with the governor’s office on an executive order to create a designated 

statewide enforcement agency. In 1997, the governor signed Executive Order 123 

designating the NC Division of Alcohol Law Enforcement (ALE) as the lead state 

agency to implement model merchant education and enforcement of the state’s 

youth access to tobacco law. 

4. Create a Governor’s Interagency Workgroup on Reducing Tobacco Sales to 

Minors. Executive Order 123 also established a Governor’s Interagency Workgroup on Reducing Youth Access to Tobacco Products. 

5. Obtain a contract with the U.S. Food and Drug Administration to enforce the 

federal youth access to tobacco rules. The contract funded ALE to conduct 400 

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M o n o g r a p h 1 6. A S S I S T 

which minors can purchase tobacco products from 50% in 1996 to 19% in 2001. 

Department of Health and Human Services 

compliance checks per month to enforce the federal Food and Drug Administration rules and the state law. 

6. Educate merchants about tobacco and the youth access law. To improve compliance, the governor’s office called a meeting of the retail merchants statewide 

whose compliance with the law was low. Local ASSIST coalitions engaged 

youths and adults in retailer education regarding the new state youth access to 

tobacco law. One model merchant education program was conducted by 

UJIMA—an African American youth leadership initiative created through 

ASSIST. The NC Department of Health and Human Services designed and 

distributed merchant education materials across the state. 

Since 1997, combined enforcement and educational efforts have reduced the rate at 

This reduction in sales to minors exceeded North Carolina’s established Synar 

targets for compliance. Health and Wellness Trust Fund Commission resources from 

the Master Settlement Agreement have been allocated to ALE to enforce the access 

to tobacco laws in 2002–2005. 

—Jim D. Martin, former ASSIST Field Director 

and currently with the North Carolina 

support tobacco-free school policies ultimately contributed to the passage of 

the tobacco-free schools legislation. This 

example illustrates how program services can complete the cycle by stimulating 

demand for policy change. 

Strength in 

Comprehensiveness 

Comprehensive tobacco control programs include a multifaceted approach to the community’s needs. The 

combined media, policy, and program 

services interventions address the critical 

issues of raising consciousness of the 

problem, motivating the community to 

take action, presenting the solutions in 

the strongest light to garner support from 

policymakers, and meeting the needs of 

individuals and communities once policies are in place. The strong focus of 

ASSIST on policy interventions stimulated others to provide program services 

and to develop capacity. Service programs were generated by private vendors, nonprofit organizations, schools, 

and government organizations. Program 

development and delivery often brought 

together these diverse entities as partners. Ultimately, the policy focus helped 

to strengthen community linkages and 

infrastructures that made it possible to 

create a national tobacco prevention and 

control program. Those strengthened 

linkages also made it possible for 

ASSIST state personnel and top federal 

government officials to maintain the integrity of the program. They did this 

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7. P r o g r a m S e r v i c e s : R e a c h i n g t h e I n d i v i d u a l 

while the tobacco industry aggressively 

sought to interfere with ASSIST and the 

public health policies toward which 

ASSIST personnel were working, as described in chapter 8. 

References 

1. ASSIST Coordinating Center. 1991. 

Glossary. In ASSIST program guidelines for tobacco-free communities. Internal document. ASSIST Coordinating 

Center, Rockville, MD. 

2. National Cancer Institute. 1988. Standards for comprehensive smoking prevention and control. Bethesda, MD: 

National Cancer Institute. 

3. Schwartz, J. L. 1987. Review and evaluation of smoking cessation methods: 

The United States and Canada, 1978– 

1985 (NIH publication no. 87-2940). 

Bethesda, MD: National Cancer Institute, Division of Cancer Prevention and 

Control. 

4. Glynn, T. J., and M. W. Manley. 1990. 

How to help your patients stop smoking: 

A National Cancer Institute manual for 

physicians (NIH publication no. 93­

3064). Bethesda, MD: National Cancer 

Institute; Division of Cancer Prevention 

and Control; Smoking, Tobacco, and 

Cancer Program. Revised 1991, reprinted 1993. 

5. Fiore, M. C., J. P. Pierce, P. L. Remington, and B. J. Fiore. 1990. Cigarette 

smoking: The clinician’s role in cessation, prevention, and public health. Disease-a-Month 36 (4): 181–242. 

6. Bell, C. S., and S. M. Levy. 1984. Public policy and smoking prevention: Implications for research. In Behavioral 

health: A handbook of health enhancement and disease prevention, ed. J. D. 

Matarazzo, S. M. Weiss, J. A. Herd, N. 

E. Miller, and S. M. Weiss, 775–785. 

New York: Wiley. 

7. U. S. Department of Health and Human 

Services. 1994. Preventing tobacco use 

among young people: A report of the 

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Prevention and Health Promotion, Office on Smoking and Health. Reprinted, 

with corrections, July 1994. 

8. National Cancer Institute. Minutes of 

the January 30, 1990, ASSIST Proposal 

Conference. Bethesda, MD: National 

Cancer Institute. 

9. National Cancer Institute. 1991. Strategies to control tobacco use in the United States: A blueprint for public health 

action in the 1990’s (Smoking and tobacco control monograph no. 1, NIH 

publication no. 92-3316). Bethesda, 

MD: National Cancer Institute. 

10. Lando, H. A., P. G. McGovern, F. X. 

Barrios, and B. D. Etringer. 1990. Comparative evaluation of American Cancer 

Society and American Lung Association 

smoking cessation clinics. American 

Journal of Public Health 80 (5): 554–9. 

11. Burns, D. M. 1992. Positive evidence 

on effectiveness of selected smoking 

prevention programs in the United 

States. Journal of the National Cancer 

Institute Monograph 12:17–20. 

12. Warner, K. E. 1984. The effects of publicity and policy on smoking and health. 

Business Health 2 (1): 7–13. 

13. ASSIST Coordinating Center. 1992. 

Reference materials section. In ASSIST 

training materials. Vol. III. Site analysis 

and cmomprehensive smoking control 

plan. July 20–21. Internal document, 

ASSIST Coordinating Center, Rockville, MD. 

14. ASSIST Coordinating Center. 1993. 

Program services section, ASSIST 

306 
M o n o g r a p h 1 6. A S S I S T 

training materials. Vol. V: Development 

of the annual action plan. January 25– 

26, 176. Internal document, ASSIST 

Coordinating Center, Rockville, MD. 

15. ASSIST Coordinating Center. 1991. 

Worksite channels section. In ASSIST 

program guidelines for tobacco-free 

communities. Internal document, 

ASSIST Coordinating Center, Rockville, MD. 

16. ASSIST Coordinating Center. 1991. 

Overview of ASSIST. In ASSIST program guidelines for tobacco-free communities. Internal document, ASSIST 

Coordinating Center, Rockville, MD. 

17. ASSIST Coordinating Center. 1991. 

Mass media section. In ASSIST program guidelines for tobacco-free communities. Internal document, ASSIST 

Coordinating Center, Rockville, MD. 

18. ASSIST Coordinating Center. 1991. 

Community group channel section. In 

ASSIST program guidelines for tobacco-free communities. Internal document, ASSIST Coordinating Center, 

Rockville, MD. 

19. ASSIST Coordinating Center. various 

dates. Quarterly reports of ASSIST 

states, January–March and April–June 

1999. ASSIST Coordinating Center, 

Rockville, MD. 

20. ASSIST Coordinating Center. 1991. 

Health care setting section. In ASSIST 

program guidelines for tobacco-free 

communities. Internal document, ASSIST Coordinating Center, Rockville, 

MD. 

21. ASSIST Coordinating Center. 1991. 

School channel section. In ASSIST program guidelines for tobacco-free communities. Internal document, ASSIST 

Coordinating Center, Rockville, MD. 

22. Pritzl, J. 1997. Getting to tobacco-free 

schools in Colorado: The effect of a 

weak law. In A national conference on 

tobacco and health: Entering a new dimension. Case studies. September 22– 

24. Rockville, MD: ASSIST


Coordinating Center.


Additional Resources 

Program Services Case Studies: 

1. Minnesota—Reducing Tobacco Use 

Among Teenagers Through a 

Comprehensive Tobacco Control 

Program. www.healthierus.gov/steps/ 

summit/prevportfolio/programs/ 

tobacco.htm#minnesota. 

2. Nebraska—Implementing a Comprehensive Tobacco Control Program to 

Reduce Tobacco Use. www.healthierus 

.gov/steps/summit/prevportfolio/ 

programs/tobacco.htm#nebraska. 

3. Oregon—Reaching Target Groups With 

High Rates of Tobacco Use Through 

Comprehensive Tobacco Control: A 

Policy-Based Approach. 

www.healthierus.gov/steps/summit/ 

prevportfolio/programs/ 

tobacco.htm#oregon. 

4. Washington State—Identifying and 

Eliminating Disparities in Tobacco Use 

Through a Cross-Cultural Workshop. 

www.healthierus.gov/steps/summit/ 

prevportfolio/programs/ 

tobacco.htm#washington. 

5. Achievements in Tobacco Cessation: 

Case Studies. June 2000. U.S. Public 

Health Service. www.surgeongeneral 

.gov/tobacco/smcasest.htm. 

307 

M o n o g r a p h 1 6. A S S I S T 

8. Tobacco Industry Challenge to ASSIST 

Part 1

Jenny White and Lisa Bero


The authors wish to thank Martha Michel, Bonnie Glaser, Miki Hong, Josh 

Dunsby, Stanton Glantz, Ruth Malone, and Jennifer Ibrahim for valuable 

comments and assistance. This research was funded by the California Tobacco 

Related Disease Research Program, Grant #9RT-0193. 

Part 2

Anne Marie O’Keefe, Timothy W. Filler, Jerie Jordan, and


Walter ‘Snip’ Young


Contributors: Russell Sciandra, Jeanne Weigum, and Randy H. Schwartz 

Contents 

Part 1. The Tobacco Industry’s Response to ASSIST:


An Analysis of Tobacco Industry Internal Documents ................................................ 312


Methods for Researching the Tobacco Industry Documents ....................................... 312


Results of the Research ............................................................................................ 315


The Tobacco Industry’s Perception of ASSIST as a Major Threat ....................................... 315


The Biggest Threat: The Community Environment Channel ........................................ 317


Tobacco Industry Plans for Countering ASSIST ................................................................. 318


The Strategies .................................................................................................................. 320


Strategy 1: Gather Information on ASSIST and Monitor Its Activities at the State

and Local Levels ........................................................................................................ 321


Strategy 2: Enlist Congressional Allies....................................................................... 328


Strategy 3: Enlist Business and Consumer Allies....................................................... 333


Strategy 4: Discredit ASSIST—File Legal and Regulatory Actions.............................. 336


Strategy 5: Infiltrate ASSIST....................................................................................... 342


Strategy 6: Divert Funds from the Community Environment Channel

and Promote Alternative Programs ............................................................................. 343


Strategy 7: Discredit ASSIST through Public Relations Tactics ................................... 345


Strategy 8: Promote Preemption Laws and Ballot Initiatives...................................... 347


309 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

Discussion ................................................................................................................ 349


Part 2. ASSIST’s Response to the Tobacco Companies: Facing the Opposition .......... 350


Understanding the Obligation to Respond to FOIA Requests ..................................... 350


Understanding the Regulations on Lobbying ............................................................. 352


Case Studies ............................................................................................................. 354


Onward after the Opposition ..................................................................................... 354


References ................................................................................................................ 372


Additional Resources ................................................................................................ 383


Case Studies 

Case Study 8.1. Full-Scale Challenge in Colorado ................................................................. 355


Case Study 8.2. Work Disruptions in Washington State .......................................................... 361


Case Study 8.3. In Minnesota: Multiple Strategies, Multiple Defeats—Ultimate Victory ....... 362


Case Study 8.4. On Alert in Maine .......................................................................................... 367


Case Study 8.5. New York State Defeats Tobacco Industry’s Attempt to Impose Preemption .... 369


Table 

Table 8.1. Search Terms Used with Tobacco Industry Document Sites .................................... 313


310 
M o n o g r a p h 1 6. A S S I S T 

8. Tobacco Industry Challenge to ASSIST


If successful in bringing about policies that would help create a tobacco-free 

norm, the American Stop Smoking Intervention Study (ASSIST) would have the dual 

effect of decreasing tobacco use and decreasing the adverse health effects resulting 

from tobacco use. The tobacco companies were aware of this potential, even before 

ASSIST started. Because of ASSIST’s potential impact, the tobacco companies 

undertook efforts to counter the project. The two parts of this chapter present the 

tobacco industry’s challenge to ASSIST, first from the perspective gleaned from 

industry documents that became available as a result of litigation and second from 

the perspective of ASSIST personnel who experienced the challenges first-hand. 

The tobacco companies burdened the states with requests for documents through 

processes allowed by the federal Freedom of Information Act (FOIA), accused 

ASSIST staff and local coalition members of using funds for illegal lobbying, and 

brought lawsuits against ASSIST staff members. The results of the systematic 

research of industry documents, presented in part 1 of this chapter, identify eight 

industry strategies to oppose the activities of ASSIST. The search yielded 1,350 

documents relevant to ASSIST. Of these, 166 contained information about the 

tobacco companies’ strategies, which were coded by a standard research method. 

This chapter documents the strategies with quotations from many of the documents. 

Part 2 of this chapter describes the legal and temporal contexts in which ASSIST 

staff members responded to the tobacco industry’s requests and charges. The 

National Cancer Institute (NCI) made continuous efforts to educate the ASSIST staff 

about their responsibilities and limitations regarding advocacy and lobbying 

activities and their obligation to respond to FOIA requests for ASSIST materials. The 

accusations of illegal lobbying that the tobacco companies brought against ASSIST 

staff nevertheless caused confusion about which activities were legitimate, and the 

time burden of responding to FOIA requests diverted the staff members from tobacco 

control activities. As the industry’s challenges repeated themselves and became more 

widespread, the ASSIST states became more effective at responding. The case studies 

in this chapter describe the responses of the state staff to the challenges and, in some 

cases, the unfortunate personal damage experienced by individual staff members. 

311 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

These documents became public in the late 

sites are subject to changes and, because the 

only 10 years, these sites may not be 

documents from the Minnesota depository 

cited in this chapter can be found by 

searching for them by Bates number (unique 

Locations of Tobacco Industry Documents 

For consistency and ease of retrieval, tobacco 

industry documents in this chapter have been 

referenced according to the Legacy Tobacco 

Documents Library Web site of the 

University of California–San Francisco. 

1990s as a result of litigation against the 

tobacco industry. The tobacco industry Web 

Tobacco Master Settlement Agreement 

requires the Web sites to be maintained for 

available in the future. The Legacy Library is 

permanently archiving the tobacco industry 

and elsewhere. Therefore, the documents 

page number) on the Legacy Tobacco 

Documents Library Web site at http:// 

legacy.library.ucsf.edu. 

Part 1. The Tobacco Industry’s Response to ASSIST: 

An Analysis of Tobacco Industry Internal Documents 

Methods for Researching the 

Tobacco Industry Documents 

L

awsuits in the 1990s against the tobacco industry have resulted in the 

release of internal tobacco industry documents as part of the litigation and settlement agreements; these documents are 

now available to the public on the Internet. They provide an unprecedented look 

at tobacco industry motives, strategies, 

and operations—information that is not 

available from any other source. The 

documents describe an industry whose 

actions are directed at, among other 

things, promoting tobacco initiation and 

sustaining its use.1 

To understand the tobacco industry’s 

reaction to ASSIST, the Legacy Tobacco 

Documents Library of the University of 

California–San Francisco (http://legacy 

.library.ucsf.edu), three tobacco industry 

document Web sites (www.pmdocs.com, 

www.tobaccoinstitute.com, 

www.rjrtdocs.com), and Tobacco Documents Online (http://tobaccodocuments 

.org) were searched between June 10, 

2002, and April 28, 2003. The search 

was deliberately broad, the goal being to 

identify all documents that mention 

ASSIST. Exact duplicates were excluded. 

The search terms are listed in table 8.1. 

The authors searched on the name of 

the program, “American Stop Smoking 

Intervention Study for Cancer Prevention.” 

This resulted in a number of documents 

that were official reports belonging to 

the ASSIST program itself, which did 

not provide the information needed to 

analyze the tobacco industry’s strategies 

regarding ASSIST. The authors next 

searched on the term ASSIST, which resulted in over 21,000 hits. Many of these 

documents contained the verb “assist” in 

the title and had nothing to do with the 

ASSIST program. The number of these 

irrelevant documents was significantly 

reduced by combining the search term 

assist with relevant terms such as smoking or NCI. The search was then further 

narrowed to specific document types 

such as memo, confidential, or letter to 

identify the more interesting ones (docu312 
M o n o g r a p h 1 6. A S S I S T 

ALPHA 

ASSIST 

Bennett, JT 

Bonilla 

Cancerscam 

Capitol Research Center 

Chilcote 

DiLorenzo, TJ 

Earhart Cancerscam 

Fish, JH 

HHS 

Istook 

letter 

lobbying 

Mapes 1 

memo 

National Cancer Institute 

NCI 

Shalala 

smoking 

Stuart Cloud 

Sunmark 

Industry Document Sites 

additional documents. But a search on 202401712* resulted in just one document, because all the other 

Bates numbers in the sequence 2024017121 through 2024017129 were either missing or were part of the 

one document. 

American Stop Smoking Intervention Study for 

Cancer Prevention 

attorney client work product 

budget 

confidential 

cost effective 

Earhart Foundation 

Hays and Wilson 

Klausner, R 

Massachusetts ASSIST Summary 

Minnesota Project ASSIST 

New England Convenience 

North Carolina ASSIST Summary 

O’Keefe Project ASSIST 

Project ASSIST in Colorado 

Rhode Island ASSIST Summary 

Slavitt, J 

Tom Huff 

Washington 

Washington Legal Foundation 

West Virginia ASSIST Summary 

work product 

Table 8.1. Search Terms Used with Tobacco 

*For example, a search on 202607951* (with the asterisk substituted for the last number) resulted in three 

ments from the tobacco industry, not reprints of ASSIST program reports, for 

example). Further search terms were developed on the basis of these documents. 

This is called “snowball searching by 

topic.” 

Terms were combined in various 

ways and also limited to specific date 

ranges. Tobacco industry personnel often added prefixes “x” and “xx” to 

names to preserve confidentiality; therefore, the authors also searched most 

names, both as correctly spelled and 

with “x” and “xx” prefixed. Additional 

documents were obtained through snowball searches that identified related documents by examining adjacent Bates 

numbers (unique numerical identifiers 

assigned to documents during litigation).* A document was included if it 

contained a discussion of the ASSIST 

program. In addition, where possible, 

government documents identified in the 

tobacco industry document collections 

were verified with copies from the original source. 

LexisNexis (http://web.lexisnexis.com/ 

congcomp) was searched for legislative 

history on the following terms between 

November 7, 2002, and January 22, 2003: 

■	 House or Senate, 104, SMOKING 

■	 Shalala, House Appropriations, 

2/11/97 

■	 Stop Smoking Intervention, House, 

Appropriations 

■	 SMOKING, Shalala, House, 

Appropriations 

313

8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

■ Shalala, House, appropriations, smok* 

■ National Cancer Institute, smoking 

■ 

1996 

■ 

1995 

■ 

for congressional hearing transcripts, 

and January 29, 2003: 

■ limited to

(OK-5) 

■ Lobbying, 104 

, 

Smoking, House, Appropriations, 

Smoking, House, Appropriations, 

Federal Acquisition Streamlining Act 

The Library of Congress Thomas Web 

site (http://thomas.loc.gov) was searched 

testimony, bills, and laws on the following terms between November 7, 2002, 

Lobby, Istook, Ernest J., Jr. 

Supplemental searches were also performed to find commentary on the history of ASSIST by using the PubMed 

database and various Web sites, including those for the Cato Institute, George 

Mason University, The National Review

and ForceS. 

The tobacco industry Web-site search 

focused on the Tobacco Institute, Philip 

The Tobacco Institute 

The Tobacco Institute was the lobbying and 

trade organization for the American tobacco 

industry. Tobacco companies supported the 

Tobacco Institute financially in return for its 

lobbying, public relations, and other activities 

requiring industry-wide coordination. The 

Tobacco Institute was formed in 1958 and in 

1998 was dissolved as a result of the Tobacco 

Master Settlement Agreement (MSA). 

*These initial categories were information gathering, legislative activities, bring complaint to the 

Department of Health and Human Services (DHHS) inspector general, harassment, diversion, infiltration, 

submit competing proposals, the Schools Channel, media/public relations, “scholarly works,” allies, local 

“astroturf” coalitions, litigation, and “redbaiting.” 

Morris USA, and R.J. Reynolds Tobacco 

Company because, in the searches conducted in the Legacy Library, these three 

entities were the primary and, in most 

cases, the only sources for documents 

relating to ASSIST. Among the companies, Philip Morris appeared to play a 

predominant role in efforts to counter 

ASSIST and, indeed, viewed itself as 

spearheading the effort: “This company 

is viewed as a leader. . . . If this company 

takes the initiative [regarding ASSIST], 

other members of the industry will follow. . . .” 2(Bates no. 2048621158) 

The documents that met the inclusion 

criteria were analyzed inductively using 

a “grounded theory” approach,3(p1) although the authors were guided by their 

previous analyses of tobacco industry 

documents.1,4 Grounded theory entails 

“the discovery of theory from data systematically obtained from social 

research.”3(pp2–3) “In discovering theory, 

one generates conceptual categories or 

their properties from evidence; then the 

evidence from which the category 

emerged is used to illustrate the 

concept.”3(p23) For ASSIST, the first documents examined were preliminarily or 

“openly” coded according to draft conceptual categories.* As the document 

evidence accumulated, the conceptual 

categories were finalized, and documents subsequently found were coded 

according to the final categories (“selective coding”). The final categories, 

which are listed in the Table of Contents, are 

314 
M o n o g r a p h 1 6. A S S I S T 

The tobacco industry will do its best to 

*The initial search strategy resulted in over 21,000 documents mentioning ASSIST. Over 19,000 were 

eliminated because they contained the verb “assist” in their title or other index category but did not concern 

the ASSIST program; because they were redundant copies; because they were standard reports produced 

by ASSIST state programs that did not pertain to the tobacco industry’s interaction with ASSIST; or 

■	 The Tobacco Industry’s Perception of 

ASSIST as a Major Threat 

■	 Tobacco Industry Plans for 

Countering ASSIST 

■	 Strategy 1: Gather Information on 

ASSIST and Monitor Its Activities at 

the State and Local Levels 

■	 Strategy 2: Enlist Congressional 

Allies 

■	 Strategy 3: Enlist Business and 

Consumer Allies 

■	 Strategy 4: Discredit ASSIST—File 

Legal and Regulatory Actions 

■	 Strategy 5: Infiltrate ASSIST 

■	 Strategy 6: Divert Funds from the 

Community Environment Channel 

and Promote Alternative Programs 

■	 Strategy 7: Discredit ASSIST through 

Public Relations Tactics 

■	 Strategy 8: Promote Preemption Laws 

and Ballot Initiatives 

According to Glaser and Strauss, 

Theory . . . must fit the situation being 

researched, and work when put into 

use. By “fit” we mean that the 

categories must be readily (not 

forcibly) applicable to and indicated by 

the data under study; by “work” we 

mean that they must be meaningfully 

relevant to and be able to explain the 

behavior under study.3(p3) 

Another researcher may interpret or code 

the initial data differently and develop a 

different theory from those codes; this is 

only a different interpretation and does 

not invalidate the original researcher’s 

concepts. The only valid criteria are that 

the original researchers’ categories “fit” 

and “work.” On the basis of the evolving 

categories, words, phrases, sentences, or 

whole paragraphs were labeled for purposes of subsequent qualitative data 

analysis. By organizing the data according to these conceptual categories, the 

authors identified the recurring ideas, reactions, and expressions found throughout the documents that referred to ASSIST. 

Approximately 1,350 tobacco industry documents were reviewed by the authors. A number of these documents 

were copies of ASSIST proposals, plans 

of action, meeting minutes, and other 

documents that had been obtained by the 

tobacco industry through the federal 

FOIA and similar state laws. For the results reported in this chapter, all tobacco 

industry documents that pertained to developing and implementing strategies to 

counter ASSIST were analyzed.* These 

166 documents were categorized by type 

of strategy, how strategies were implemented, tobacco companies’ evaluations 

of their own efforts, and date. 

Results of the Research 

The Tobacco Industry’s Perception 

of ASSIST as a Major Threat 

On Friday, October 4, 1991, Louis 

Sullivan, then secretary of DHHS, announced the launching of ASSIST at a 

press conference. After describing the 

program, he commented, “But we are 

fully aware of what we are up against. 

because they did not provide useful information for analysis. 

315 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

undermine our efforts.”5(Bates no. TIMN0019104) 

The tobacco industry did indeed consider ASSIST a major threat because of its 

scope, its emphasis on public and private 

policy change, and its fostering of local 

tobacco control coalitions and infrastructures.6–10 In a speech prepared for a 

meeting of the Tobacco Institute’s Executive Committee in June 1992, Susan 

Stuntz, senior vice president for public 

affairs at the Institute, outlined some of 

the threats: 

In California, our biggest challenge 

has not been the anti-smoking 

advertising created with cigarette 

excise tax dollars. 

Rather, it has been the creation of an 

anti-smoking infrastructure . . . right 

down to the local level. An infrastructure that for the first time has the resources to tap in to the anti-smoking 

network at the national level. . . .

The ASSIST program has the potential 

to replicate our California experience 

in 17 other states. . . .

It [ASSIST] will hit us in our most 

vulnerable areas . . . in the localities 

and in the private workplace. 

It has the potential to peel away from 

the industry many of its historic 

allies.10(Bates no. TI13851814) 

By the mid-1990s, the tobacco control movement presented a challenge to 

the industry nationwide. ASSIST and 

others were involved in a number of major tobacco control initiatives. These initiatives included state excise tax 

increases; efforts to bring nicotine under 

Food and Drug Administration regulation; the Synar Amendment, which required states receiving substance abuse 

block grants to have laws restricting purchase of cigarettes to people aged 18 

and over, and to conduct random unannounced inspections to ensure compliance; and lawsuits by state attorneys 

general to recover from the tobacco 

companies Medicaid costs for tobaccorelated illnesses. A Philip Morris USA 

Five-Year Plan for 1992–96 described an 

“increasingly hostile socio-political 

environment.”11(Bates no. 2024090296) Tobacco 

control advocates appeared to “hold the 

high ground and the momentum.”2(Bates 

no. 2048621164) A Philip Morris executive’s 

draft of a briefing to the company’s marketing branch, dated December 1, 1993, 

described how ASSIST was contributing 

to the tobacco industry’s problems: 

. . . the social battle over smoking has 

escalated into an all-out war. 

Companies that market cigarettes are 

under constant attack at all levels of 

government as well as by an 

increasingly well organized and well 

financed anti-smoking movement that 

wants to tax, restrict, and regulate the 

industry out of business. . . .

Project ASSIST is a windfall to the 

anti-smoking movement. Before 

Project ASSIST, anti-smoking groups 

were constrained like other 

organizations to raise funds for 

overhead and salaries, and what was 

left over could be used to attempt to 

put us out of business. Today, with 

Project ASSIST funds, those groups 

automatically have their overhead/ 

salary nut [sic] paid for, and this means 

that they can use all of their own funds 

to ban all billboards from a town as has 

happened in Massachusetts, or ban 

sampling, couponing, or even in store 

point of purchase displays. . . . 

The way our issues manager Josh 

Slavitt puts it, “for marketing issues, 

316 
M o n o g r a p h 1 6. A S S I S T 

you can look at the Synar law as a 

bullet and ASSIST as the howitzer to 

fire it. Synar is the way to inflict 

damage on us and ASSIST provides 

the shock troops and weaponry to 

inflict the damage. . . .” 

The simple fact is we are at war, and 

we currently face the most critical 

challenges our industry has ever 

met.7(Bates no. 2024017124,7134–7135,7150) 

The Biggest Threat: The Community 

Environment Channel 

The tobacco industry was well aware 

that it would have the most trouble with 

ASSIST’s interventions in community 

environments because of the emphasis 

on local public and private policy 

change, and on use of local media.7,8,12,13 

As stated in the “ASSIST Program 

Guidelines,” the objectives for the Community Environment Channel were the 

following: 

By 1998, cues and messages supporting non-smoking will have increased, 

and pro-smoking cues and messages 

will have decreased. 

By 1998, sites will substantially increase and strengthen public support of 

policies which (a) mandate clean indoor air; (b) restrict access to tobacco 

by minors; (c) increase economic incentives to discourage the use of tobacco 

products; and (d) restrict the advertising and promotion of tobacco.14(Community 

Group Channel, p5) 

Philip Morris consultant Ted Trimpa 

of Hays, Hays & Wilson wrote, “The 

Community Environment Channel . . . 

has the strongest emphasis in ASSIST 

and focuses on goals and activities 

which are the most objectionable.”13(Bates 

no. TNWL0047245) Significantly, a document 

by the Tobacco Institute, dated January 

10, 1995, identified the population of 

smokers who would be most affected by 

the Community Environment Channel 

activities: 

The Community Environment Channel 

is very important in influencing [loweducated] population [sic]. The most 

effective way of reaching low-educated 

populations will be through policy and 

media advocacy.15(Bates no. TI13850331) 

A Philip Morris executive briefing 

document from 1993 spelled out the local challenge as follows: 

. . . the antis—finally having learned 

that it’s tough to win at the state level— . . . have gone local. 

They are focusing their energies on 

town vending bans, stadium advertising bans, county bans on couponing, 

city bans on advertising on city property or public transportation, and so on. 

It is a Pac-Man approach, gobbling up 

our ability to market a small piece at a 

time until suddenly this patchwork of 

marketing regulations coalesces into a 

crazy quilt that is as effective as a national ban.7(Bates no. 202401746–7147) 

Tobacco Institute executive Kurt 

Malmgren described the situation in a 

lengthy memo dated November 30, 

1992, to Executive Director Samuel 

Chilcote: 

The anti-tobacco forces have 

developed a more sophisticated and 

well-funded structure to address local 

government affairs. . . .

ASSIST guarantees that local matters 

will take increasing portions of our 

time and effort. 

Clearly, there is a well-orchestrated 

effort among the anti-tobacco 

317 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

leadership to strike where it perceives 

the tobacco industry to be most 

vulnerable: the local level. . . .

During the 1980’s and until very 

recently . . . the clear priority for the 

industry was in the state capitals; local 

activities always took a back seat. . . .

Today . . . local efforts must be placed 

on a par with state efforts. . . .8(Bates 

no. 2023965875–5877) 

Malmgren illustrates these comments 

with an example from California: 

[In California] it became physically 

impossible to attend all the hearings 

held on certain days, let alone mount 

successful opposition campaigns. . . . 

More troubling still, the industry did 

not have in place a mechanism to make 

it aware of the introduction of some 

local ordinances while opposition was 

still feasible. 

Therefore the industry was, on occasion, forced to address local concerns 

at the ballot box, an extremely expensive undertaking.8(Bates no. 2023965878) 

Malmgren concluded: 

Industry leaders have recognized that 

state laws which preempt local antitobacco ordinances are the most 

effective means to counter local 

challenges. . . .

However state preemption is, at best, 

difficult to achieve. Thus our local plan 

is crucial.8(Bates no. 2023965880,5887) 

Tobacco Industry Plans 

for Countering ASSIST 

By Monday, October 7, 1991, following DHHS Secretary Sullivan’s Friday 

announcement, several tobacco industry 

executives appeared to be communicating about a broad range of strategies to 

“manage the situation.”16 A memo from 

Cathey Yoe of the Tobacco Institute to 

other Institute executives outlined recommended actions: 

■	 Public Affairs Division will obtain 

[ASSIST] technical proposals . . . 

under the Freedom of Information 

Act. . . .

■	 Federal Division will alert key 

Members of Congress to protest use 

of federal taxpayer dollars. . . .

■	 Federal Division will attempt to 

amend National Cancer Institute’s 

[NCI’s] next authorization or 

appropriation bill (a) to prohibit use 

of grant funds for influencing state 

or local legislation, ballot initiatives, 

or other regulatory activities, and 

(b) to require detailed auditing and 

reporting of grant expenditures. . . .

■	 State Activities’ regional staff will 

identify local business and labor 

interests in 17 grant states who could 

gain representation in communitybased ASSIST coalitions. 

■	 State Activities’ regional staff will 

explore possible [ASSIST] grantsponsored local activities educating 

against youth smoking which could 

use industry’s “It’s the Law” and 

similar programs. . . .

■	 Such plans may include limiting 

state health department’s [sic] 

authority to fund community 

coalitions which pursue adoption of 

legislation or regulations.17(Bates no. 

TI13851417–1418) 

The same Monday, R.J. Reynolds executives M. B. Oglesby Jr. and Roger Mozingo wrote a memo stamped “Confidential” 

that described potential courses of action 

regarding ASSIST, including the following: 

318 
M o n o g r a p h 1 6. A S S I S T 

■	 Restrict or limit how the funds are 

used through the state appropriations 

process and contacts with executive 

branch officials. . . .

■	 Work with the tobacco-land


Congressional delegation to


eliminate ASSIST funds in future


appropriations bills; alternatively,


seek restrictions on how the funds


can be used.


■	 In Colorado and Massachusetts, 

where California Proposition 99 type 

initiatives are expected to be on the 

1992 . . . ballot, develop plans to 

make voters aware that ASSIST and 

other federal funds are already used 

in their states for these purposes, and 

additional state funding would be 

duplicative and unnecessary.16(Bates no. 

511073913–3914) 

Two days later, on October 9, 1991, 

executive director Samuel Chilcote 

wrote a memo to the Tobacco Institute 

executive committee that the Institute 

had already taken action to coordinate 

with the state government relations departments of each member company to 

“counter potential state and local legislative action resulting from” ASSIST contracts to the 17 states.18(Bates no. TI13851380) 

According to the memo, activities already under way included the following: 

We have filed a Freedom of Information Act request and will review the 

documents we obtain for “public policy” 

activities which could spark state or local legislation on tobacco issues. 

Members of Congress have been asked 

to protest to the Administration this 

use of federal taxpayer dollars in an 

era of mounting deficits. 

In addition, we are pursuing the 

possibility of including in the 

Department of Health and Human 

Services Appropriations Bill for Fiscal 

1992 language that would prohibit use 

of NCI funds for influencing state or 

local legislation. . . .

At the state level, plans are under development to ensure that the use of ASSIST 

funds is limited to appropriate activities 

and not targeted to anti-smoking lobbying campaigns.18(Bates no. TI13851380) 

Chilcote also wrote that the Tobacco Institute would hold a series of 50 state 

planning sessions with state government 

affairs experts from tobacco companies. 

The goal of the planning sessions was to 

discuss a range of strategies that included the following: 

■	 Work with state administrative and 

legislative leaders to ensure that 

those applying for grants meet 

stringent state guidelines for the use 

of ASSIST funds and face regular 

and rigorous state auditing 

processes. 

■	 Work to limit state health 

departments’ authority to fund 

community coalitions which pursue 

adoption of legislation or regulation; 

and limit state funding of antitobacco programs by amounts 

received under the federal ASSIST 

program. . . .

■	 Massachusetts, New Jersey, North 

Carolina, Virginia, West Virginia, 

and Wisconsin are among the many 

ASSIST states which continue to 

face severe budget shortfalls. Explore the feasibility of introducing 

legislation or specific regulatory language to redirect current state antitobacco education monies to other 

programs. . . .

■	 Identify appropriate local business 

and other groups in the 17 states to 

apprise them of the ASSIST grant 

program so that they might be better 

319 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

*The document did not list an author but was stamped as having been retrieved from Slavitt’s office. 

positioned to join a communitybased ASSIST coalition and apply 

for grants. . . .

■	 Focus special attention on the 

industry’s youth programs in the 17 

ASSIST states. . . .

■	 Focus legislative efforts on passage 

of anti-discrimination and/or indoor 

air quality laws to counter 

encouragement of smoking bans. . . . 

■	 Expand current monitoring of the 

activity of anti-tobacco groups in the 

states to ensure that misuses of 

ASSIST funds are made known in a 

timely fashion to state leaders and 

the public. 

■	 Promote expanded education of 

existing independent scholarly works 

that call into question the motives 

and operating techniques of certain 

voluntary health organizations.18(Bates 

no. TI13851380–1381) 

By July 1992, tobacco industry strategies had begun to be implemented, but a 

document found in the office of Josh 

Slavitt* (who appears to have been the 

primary strategist regarding ASSIST at 

Philip Morris) expressed impatience 

with the tobacco industry’s efforts: 

FACT: . . . 6) ASSIST implementation 

phase commences this fall—coalitions 

have been developed and the program 

has faced no major threat. 

CONCLUSION: . . . 6) The company/ 

industry has taken no action since the 

program’s inception—the longer the 

program goes, the more difficult it is to 

stop.2(Bates no. 2048621155) 

The document also mentioned the costs 

involved in an effective counter-ASSIST 

program, “As this is a time intensive 

project that requires immediate action, 

achieve the objective.”

low financial commitment will not 

2(Bates no. 2048621158) 

Then, after a lengthy section detailing 

“Strengths, Weaknesses, Opportunities, 

and Threats” for both the tobacco industry 

and ASSIST, the document concluded by 

arguing that an effective action plan to 

counter ASSIST will have long-term 

benefits for the tobacco industry overall— 

regardless of the expense involved: 

Use first year of ASSIST program 

implementation as a means for 

launching an investigation to discredit 

NCI, HHS and opponents. . . . Having 

all Anti organizations involved could 

substantially damage the movement if 

ASSIST is brought down. . . . Use

overall investigation to develop a 

public relations program designed to 

erode credibility of opponents over the 

long term. . . . If any lasting impact is 

to occur from an investigation of 

ASSIST, it must be broader in scope 

and have a longer political and public 

lifespan.2(Bates no. 2048621166,1169,1174) 

The documents describing the tobacco 

industry’s early response to ASSIST 

suggest that the industry was prepared to 

launch a coordinated effort to oppose 

ASSIST, even if it was costly. The following sections describe the eight strategies identified from the documents, 

which the tobacco industry used to implement its plans. 

The Strategies 

Numerous strategy papers, memos, 

and briefings on comprehensive plans to 

counter ASSIST appear to have been developed and discussed throughout the 

320 
M o n o g r a p h 1 6. A S S I S T 

tions,

first 4 years of the project by tobacco industry executives, and by public relations firms, legal firms, and others 

with whom they contracted.2,7,8,12,13,16–26 

This section describes the major strategies recommended in these documents 

as well as in other, briefer communica23,27,28 how they were implemented, 

and how the tobacco companies evaluated the results of their efforts. Most of 

these strategies were implemented simultaneously, although gathering information on ASSIST appears to have been a 

priority at the beginning. Below are listed 

the 8 strategies and 10 major messages 

about ASSIST intended to be conveyed 

by those strategies. 

Tobacco Industry Strategies 

to Counter ASSIST 

1. Gather information on ASSIST and 

monitor its activities at the state and 

local levels 

2. Enlist congressional allies 

3. Enlist business and consumer allies 

4. Discredit ASSIST—File legal and 

regulatory actions 

5. Infiltrate ASSIST 

6. Divert funds from the Community 

Environment Channel and promote 

alternative programs 

7. Discredit ASSIST through public 

relations tactics 

8. Promote preemption laws and ballot 

initiatives 

Tobacco Industry Messages 

Regarding ASSIST 

■	 Misuse of taxpayer dollars 

■	 “Illegal lobbying,” “tax grabs,” 

conflict of interest/“cronyism,” 

commingling of funds, use of front 

groups 

■	 Government waste 

■	 Duplication of existing programs, 

unnecessary, diversion from 

legitimate uses (e.g., breast cancer, 

prenatal care), not effective 

■	 Greedy health professionals, 

volunteer charities, academics 

■	 Discrimination 

■	 Unfair tax burden on poor 

■	 Workplace discrimination 

■	 Freedom of choice and “commercial 

free speech” 

■	 Conspiracy of the Left (“an 

instrument of the left designed to 

destroy a legal [tobacco] 

industry”)13(Bates no. TI13850215–0253) 

Strategy 1: Gather Information on ASSIST 

and Monitor Its Activities at the State and 

Local Levels 

Freedom of Information Act Requests. The 

federal FOIA was passed in 1966 to ensure that all citizens have access to 

records and other information generated 

and stored by tax-supported federal 

agencies. The purpose of this law is to 

maximize accountability for the actions 

of government agencies. The records can 

be requested from agencies through an 

established process, and the agencies 

have an obligation to provide the copies 

requested. 

Tobacco industry strategists appeared 

to agree that a crucial first step was to 

gather extensive information about the 

ASSIST programs, primarily through 

“aggressive open records efforts,”24(Bates 

no. TI13850208) using the FOIA and similar 

state legislation, but also using materials 

gathered by private investigators and infiltrators.2,12,13,16–18,24,25 The latter tactics 

are similar to those used over the years 

321 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

by the tobacco industry to learn about a 

variety of public health groups.29 A Philip Morris document categorized as having been found in Josh Slavitt’s office 

described the need for more knowledge: 

Fact: Internal knowledge of workings 

of Anti’s is sporadic. 

Conclusion: Need more information 

about how opponents operate to fight 

them proactively. . . . 

Who/what/where/why/how is 

available and more information is 

coming in—knowing where/how the 

Anti’s will strike is a plus. . . .

Although their frontal assault 

continues, their flank may be 

vulnerable (over-extended and overconfident).2(Bates no. 2048621156) 

The strategists recommended obtaining 

such documents as proposals, “letters, 

correspondence, memoranda, notes, 

plans, proposed plans and agendas. . . .

drafts, working drafts, . . . handwritten 

notes, typewritten notes . . . position papers. . . . Newsletters, handouts, brochures, signs . . . transcripts. . . .”30(Bates no. 

TIMN0044291) “ownership, tax status, etc., of 

vendors, consultants, companies receiving 

ASSIST funds . . . research competitive 

bidding process on ASSIST awarded 

contracts . . . review committee sign-up 

sheets.”25(Bates no. TNWL0020835) 

By June 1992, the Tobacco Institute 

had obtained from NCI, through FOIA 

requests, “the contracting documents for 

the national program, as well as for the 

17 state programs. [Our staff] have completed their review of these documents 

and have begun to identify possible opportunities to raise concerns . . . about 

the manner in which some of these funds 

are being spent.”31(Bates no. 2023608217) Numerous documents show that the tobacco industry, its allies, and paid consultants 

were extremely active throughout the life 

of the ASSIST project in gathering information by a variety of means, primarily 

through FOIA.25,32–42 The documents also 

include copies of responses from the 

NCI contract officer for ASSIST43,44 and 

state health department officials45 promising or enclosing the requested documents.13,15,30,46–59 

Thomas Briant, a lawyer from Minneapolis who reported to the Tobacco Institute during the ASSIST era, pointed 

out in a document that the FOIA requests not only provided valuable information but also had a “chilling” effect 

on ASSIST activities: 

[FOIA requests in Minnesota] have 

been beneficial for several reasons. 

First, and most important, the documents furnished by the Department of 

Health set forth in great detail the local 

activities to be engaged in by the 

ASSIST grantees. That is, the documents are like a road map because they 

indicate what cities are being targeted 

for ordinances, when the ASSIST 

groups will attempt to pass the ordinance and what kind of restrictions 

will be proposed to the city council of 

the targeted locality. The information 

contained in these documents is invaluable and allows retailers to prepare a 

response to take a proactive approach 

when deemed appropriate. 

Second, based on the ASSIST group 

proposals approved by the Dept. of 

Health, the activities of the ASSIST 

groups are tracked by surveying the 

targeted cities via telephone to learn 

what actions are being taken. This 

322 
M o n o g r a p h 1 6. A S S I S T 

provides additional advance notice of 

activities and allows more time in 

which to prepare the necessary 

response. 

Third, the survey results show a reduction in the number of cities actually 

being contacted by the ASSIST groups 

even though the grants require [them] 

.. . to attempt to pass a local ordinance 

in the targeted cities. . . . one reason for

the reduction may be the chilling effect 

the document requests have had and 

the greater sensitivity of the Dept. not 

to allow ASSIST funds to be used for 

lobbying activities. 

Fourth, the retail associations submitted another grant proposal about three 

weeks ago for the 1996–1998 ASSIST 

years. The ASSIST documents obtained through the FOIA requests are 

helpful in drafting the retail ASSIST 

grant proposal.60(Bates no. TI14200702) 

Documents indicate that the Tobacco 

Institute also saw the value of obtaining 

proposals submitted by states that were 

not awarded ASSIST contracts. As 

Karen Fernicola Suhr of the Institute 

wrote in 1992, 

Though these states have not received 

ASSIST funds, they’ll probably be using their proposals as blueprints for at 

least limited anti-smoking activities 

anyway, having gone through the trouble of developing them. So, a review of 

these proposals at some point would 

probably be useful.61(Bates no. 2021253352) 

Thus, not only did these states not receive ASSIST contracts, they exposed 

their plans to the tobacco industry. 

Reasons for Monitoring ASSIST Activities. In 

the tobacco industry documents, the 

most frequently mentioned purpose of 

information gathering was to find evidence of “lobbying,” the label used by 

the tobacco industry to describe ASSIST 

policy initiatives in the Community Environment Channel. In a prepared 

speech to be delivered to the Executive 

Committee on June 11, 1992, Susan 

Stuntz stated, “We think that catching 

the ASSIST coalitions in lobbying activities offers our best shot at working 

through Congress, or in the states to redirect the anti-smokers’ activity.”10(Bates no. 

TI13851818) A Philip Morris document characterized as having been found in Slavitt’s office and dated June 1992 pointed 

out that “Fact: . . . HHS Secretary Shalala 

has gone on record against using HHS 

funds for lobbying activities. Conclusion: . . . The precedent is being established (GAO, Shalala statements) to 

force government agencies to live up to 

their statutory obligations and their rhetoric regarding lobbying.”2(Bates no. 2048621155) 

The definitions and restrictions for 

lobbying with public funds vary widely 

among the states and the federal government. These restrictions on lobbying do 

not preclude public health officials from 

doing policy work but rather direct how 

they can do it.62 People affiliated with 

the tobacco industry used as broad a definition of “lobbying” as possible, in order 

to include most ASSIST policy advocacy activities under that rubric.27,38,63 Field 

reports from the 17 ASSIST states described ASSIST policy advocacy activities; industry public statements also 

misconstrued those activities in a way 

that implied that staff members of publicly funded health departments were 

themselves lobbying.15,49,52–59,64–68 

Throughout ASSIST, no federal funds 

could be used to lobby Congress. Begin323 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

ning in fiscal year 1997 (i.e., starting 

October 1, 1996), lobbying state legislatures with federal funds was also prohibited.69 Beginning with the ASSIST 

contract extension (October 1, 1998), 

the prohibition against using federal 

dollars to lobby was extended to local 

legislative bodies as well. However, nongovernmental entities using unrestricted 

funds were always allowed to lobby, 

subject to restrictions, at every level. 

Although these varied and confusing 

restrictions on lobbying were introduced 

over a period of time, the restrictions had 

a “chilling effect” on ASSIST coalition 

members as early as 1995.39,62 The complex and changing rules were not always 

completely understood by local activists. 

The result was often a decrease in advocacy activities because the activists were 

confused and unsure about the nature of 

their activities.45,70 Some tobacco industry affiliates occasionally became confused about how they should be defining 

the term “lobbying,”39(Bates no. TI14304071) as 

shown in the following memo from tobacco industry advocate Sara Mahler to 

several Philip Morris executives: 

Some of these [documents I am 

sending] may indicate illegal 

lobbying. . . . I don’t have a clear idea 

of how to find the line that separates 

“education” from “lobbying.” . . . Best 

wishes from “the grassroots.”71(Bates no. 

2046641500) 

Tobacco industry affiliates at the state 

level continually provided to tobacco 

companies’ headquarters and to the Tobacco Institute detailed information on 

ASSIST coalition advocacy of local and 

state tobacco control legislation, or 

“lobbying.”15(Bates no. TI13850329) A 1995 

memo from the Tobacco Institute’s Bob 

McAdam in Washington State appears to 

show that these continual requests did 

indeed have an effect on ASSIST’s ability to advocate for policies: 

Our probing for documents has clearly 

caused some internal concern within 

the coalition. They have spent some 

considerable time and discussion on 

developing a “crisis management plan” 

to address the public disclosure request 

that we have initiated. . . .

They now say they will not have any 

direct contact with members of the 

legislature while the legislature is in 

session. . . .

At the same time, they continue to talk 

about influencing local 

ordinances.39(Bates no. TI14304071) 

A second purpose of information 

gathering was to “expos[e] the wasteful 

and inefficient use of ASSIST 

funds.”13(Bates no. TI13850214) A Tobacco Institute report on the Missouri ASSIST 

project provided examples: 

Most ASSIST projects appear to be 

1) duplicating existing programs 2) unnecessary due to already-widespread 

awareness about possible negative 

health effects of smoking 3) opposed 

by many Missouri residents, legislators, teachers, etc. who object to the 

program on financial and/or philosophical grounds. . . .

ASSIST programs are forced on unwilling participants. . . .

Teachers and principals have become 

resistant to calls for additions to already overcrowded curricula. . . .

. . . state legislators ranked funding for 

tobacco control programs last in comparison to other cancer control legislative and budget items. . . .

324 
M o n o g r a p h 1 6. A S S I S T 

*At the time, Arnold Levinson was the executive director of the Fair Share for Health Committee. 

Low-educated populations. . . . cherish

their independence, as reflected in 

their rural lifestyle and purchase of 

trucks, motorcycles, and all-terrain 

vehicles.15(Bates no. TI13850334–0336) 

A third, and equally important, purpose of information gathering was to 

“gain more extensive intelligence concerning current and planned ASSIST activities in order to develop potential 

counter-activities.”13(Bates no. TI13850214) Ted 

Trimpa wrote a thorough report for Tobacco Institute consultants Hays, Hays 

& Wilson in 1994 on Colorado ASSIST.30 

The report described various crucial internal ASSIST documents he had obtained (with substantial portions 

redacted) as well as material that could 

be used to allege that ASSIST was using 

the Coalition for a Tobacco-Free Colorado 

as a “shelter for documents and activities that Colorado ASSIST Project personnel believe to be beyond the purview 

of the taxpaying public.”30(Bates no. TIMN0044290) 

FOIA requests were detailed and exhaustive.72 An example was described in 

a memo from Trimpa, dated July 22, 

1994, in which he announced that he had 

requested 

All letters, correspondence, 

memoranda, notes, plans, proposed 

plans, and agendas that are on 

Coalition for a Tobacco Free Colorado 

stationary [sic] date 1991 to the 

present . . . 

The Colorado ASSIST media plan, . . . 

including all documentation, drafts, 

working drafts, proposed drafts, 

memoranda, handwritten notes, 

typewritten notes, computer-produced 

notes, position papers, plans, proposed 

plans, and letters that were used, are 

being used, or those anticipated to be 

used in the creation . . . of the State 

Media Communication Plan . . . 

All notes, news releases, newsletters, 

handouts, brochures, signs, 

advertisements, transcripts, letters, 

speeches, memoranda, overhead 

display sheets, and statistics used in 

Arnold Levinson’s* presentations on 

tobacco taxes . . . 

All handwritten and typewritten notes, 

memoranda, letters, brochures, and 

correspondence used or distributed by 

Arnold Levinson* in providing 

technical assistance, . . . 

assisting the “Project Director in 

designing implementation of annual 

channel activities . . . of the Community 

Environment Committee . . .”30(Bates no. 

TIMN0044291–4292) 

The Tobacco Industry’s Evaluation of Its 

Efforts. In January 1995, Tobacco 

Institute executive Bob McAdam 

presented an evaluation of progress in 

gathering ASSIST documents: 

The first phase of research on the current usage of ASSIST funds is virtually 

complete. . . . we have learned . . . how 

the[y] intend to spend the funds. . . . 

Only in Colorado have we gone beyond 

phase I research to learn how the money 

is actually being used at the local level. 

We must expand this level of research 

to other ASSIST states.12(Bates no. TI13850204) 

McAdam had commissioned a report 

from Trimpa, of the Colorado consulting 

firm of Hays, Hays & Wilson, titled 

“Analysis and Recommendations Con325 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

cerning Selected State ASSIST Projects” 

and dated January 26, 1995.13 Trimpa 

was to “look at all of the material that 

we currently had on file from the various 

states to determine where our search 

would be most fruitful.”24(Bates no. TI13850208) 

The report’s detailed analysis of ASSIST 

in seven states (Minnesota, Washington, 

Michigan, Wisconsin, Massachusetts, 

Virginia, and West Virginia) included 

sections on “Interesting Facts and Possible Political Opportunities,” such as the 

following concerning Washington: 

Dr. Robert Jaffe, the leader of the 

TFWC [Tobacco Free Washington 

Coalition] . . . is a principal Investigator 

with the Robert Wood Johnson 

Foundation. Which may mean: 

a. Jaffe is probably involved with the 

Washington DOC (Doctors Ought to 

Care) group, which is the recipient of 

RWJF Smokeless States money 

(almost $200K). Washington DOC is 

an ASSIST contractor; 

b. Given Jaffe’s multiple roles and the 

self-proclaimed aggressive legislative 

agenda . . ., there may be some 

exploitable self-dealing/misuse of 

funds opportunities; 

c. Jaffe is probably an “ends justify the 

means” type of person which in turn 

may provide exploitable political 

opportunities.13(Bates no. TI13850235–0236) 

In his cover letter to the Trimpa report, 

McAdam provided names of lawyers 

who might pursue open records requests 

in each state, with additional comments 

such as the following: 

Minnesota 

A sizeable amount of work has already 

been done by Tom Briant, who also 

represents the wholesalers. . . .

Briant has demonstrated an ability to 

use the open records laws in an 

expedited fashion. We can expect to 

reach pay dirt level in a relatively short 

amount of time. 

Washington 

I am more concerned about 

Washington than almost any other state 

in that we have clear indications that 

they plan to launch a tax initiative 

against the industry. If we are able to 

identify the use of ASSIST funds for 

this purpose early on, we could both 

derail the initiative and limit the abuse 

of ASSIST. 

I have identified a law firm that can 

handle the pursuit. Brad Keller has 

represented RJR in a successful Joe 

Camel lawsuit and represented the restaurant association in the Puyallup 

smoking ban case. They appear to have 

an aggressive attitude and have extensive experience in going up against 

government entities.24(Bates no. TI13850209–0210) 

Tobacco Institute executive Patrick 

Donoho appears to have sent the Trimpa 

report and McAdam cover memo on to 

executive director Samuel Chilcote on 

February 2, 1995, with the following 

note: 

I highly recommend that we pursue 

ASSIST research, as outlined in the 

attached memo. The research has a 

projected budget of $135,000. I 

recommend that we use the excess 

funds from the Colorado Initiative, 

which amount to $374,000. 

With your approval, we will move 

forward immediately. 73(Bates no. TI13850207) 

By 1996, the Tobacco Institute had 

prepared comprehensive analyses of 

ASSIST in most ASSIST states,15,30,46–50 

including detailed reports on alleged 

326 
M o n o g r a p h 1 6. A S S I S T 

lobbying activities by all 17 ASSIST 

states. The latter reports were combined 

into a single 95-page document that 

demonstrated the comprehensiveness 

and consistency of analysis the Tobacco 

Institute was able to accomplish. The report included precise examples of alleged lobbying as well as examples from 

ASSIST contracts and planning documents in each state that might be interpreted as intent to lobby, all useful for any 

legal or political action the tobacco industry and its allies might want to initiate.64 

Hays, Hays & Wilson prepared 

lengthier analyses of selected ASSIST 

states for the Tobacco Institute. The 59­

page analysis of Washington 

ASSIST, for example, had a 35-page 

section describing the program, and sections on the responsibilities and background of key individuals in ASSIST, 

the Tobacco Institute’s legislative agenda, and “legal and political 

opportunities.”66(Bates no. TNWL0046638) The report listed a number of “ASSIST Activities 

State Law”

Possibly in Violation of Federal and/or 

66(Bates no. TNWL0046699) but cautioned, “given the loopholes under federal 

law, such as for ‘educational activities,’ 

maintaining a federal claim may be 

difficult.”66(Bates no. TNWL0046698) The solution 

was to exploit politically those activities 

which “lack[ed] specific evidence to 

maintain a federal or state law 

claim.”66(Bates no. TNWL0046700) These “Potential Political Opportunities” included 

items such as the following: 

There are indications that tax dollars . . . 

are being used to build and further the 

grassroots lobbying and coalitionbuilding efforts of the allegedly “independent” Tobacco Free Washington 

Coalition.66(Bates no. TNWL0046700) 

TFW/Washington ASSIST appears to 

be fraught with self-dealing. Many of 

the contractors who have received . . . 

ASSIST funds also sit on the task 

forces which recommended their 

hiring.66(Bates no. TNWL0046700) 

R.J. Reynolds51–56 and Philip Morris57– 

59 also prepared state-based analyses. A 

set of e-mail correspondence within 

Philip Morris in October 1995 indicated 

the tremendous workload tobacco industry affiliates had in keeping track of the 

multidimensional ASSIST program and 

the pressure they were under in implementing the demands of their “Counter 

ASSIST Plan.” Some of the documents, 

quoted in part, suggest that the tobacco 

industry thought that its progress in monitoring ASSIST was slow. 

From Lance Pressl to Tina Walls and 

others (October 4, 1995): “[We need to] 

discuss how to establish a system where 

the Tom Briant’s and Joe C’s of the world 

can send the material for analysis.”74(Bates no. 

2047077445) 

Response from Walls to Pressl and 

Scott Fisher, later on October 4, 1995: 

“. . . quite frankly, the issues group has 

been overwhelmed by other assignments 

and under staffed.”74(Bates no. 2047077445) 

From Pressl to Josh Slavitt, October 

5, 1995: “What do we need to do to get 

this jump-started?”74(Bates no. 2047077445) 

Slavitt to Pressl later on October 5, 

1995: 

I’m not sure what you mean by jump 

starting? . . . We are now going down to 

a lower level in each state to determine 

what local groups are receiving from 

the state agencies—this is a time 

consuming process fraught with delays 

327 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

and snags as the states attempt to 

avoid answering these kinds of 

questions. We’ve also suggested 

repeatedly that all ASSIST states be 

FOIA’d. I’ve prepared questions which 

Scott has used to encourage state 

legislators to inquire specifically 

where funds have gone . . . and what 

audits and controls have been put in 

place to conform with federal 

requirements (specifically the federal 

Single Audit Act, which requires 

states to audit any program receiving 

federal funds that makes expenditures 

of $25K or higher to local groups). 

ASSIST expires in 1997—What else 

CAN we do to jump start this?74(Bates no. 

2047077445) 

Nevertheless, tobacco industry monitoring of ASSIST is impressive in its 

scope, detail, and depth of analysis. The 

documents reflect a well-coordinated 

effort, with consistency in strategies and 

messages.2,24,64 

Strategy 2: Enlist Congressional Allies 

Tobacco industry strategists saw a 

number of ways in which their allies in 

Congress, state houses, and state legislatures could help with the efforts to undermine ASSIST, including holding 

hearings on ASSIST and promoting legislation that would limit ASSIST’s effectiveness in some way.12,25 Tobacco 

industry staff members were available 

to draft testimony for congressional 

hearings, text for questioning ASSIST 

leadership and staff, and even letters for 

legislators to sign.67,75–79 The importance 

tobacco industry executives attached to 

the role of their political allies is reflected 

in the memo Tobacco Institute director 

Chilcote sent out 3 days after ASSIST 

was launched in 1991, announcing that 

Tobacco Institute staff members had 

already contacted “appropriate congressional offices concerning this announcement, and [had] raised concerns about 

the manner in which these funds are being spent.”80 According to one Philip Morris strategist, 

■	 If framed right, it’s a “good


government” story for reform-


minded politicians.


■	 Fiscal watchdogs are interested in 

taking on this issue. 

■	 The Republicans need an issue with 

the Democratic controlled Congress 

and White House—abuse of public 

funds is viewed as a haymaker. . . . 

■	 ASSIST has a “mother-pie”


veneer—whoever takes it on will


have to be prepared for


criticism.2(Bates no. 2048621167) 

At the same time, tobacco industry 

analysts understood the need both to 

protect their political allies and to keep 

them in line: 

We should have our legislative political 

allies make certain that these [ASSIST] 

funds cannot be used . . . to educate the 

community as to the anti-tobacco 

beliefs of a particular public official or 

the pro-tobacco beliefs of a particular 

official. . . .

. . . we should continue to support our 

allies, particularly in the state 

legislatures and in other high political 

posts at every level to help them resist 

the pressure that may come as a result 

of these programs.81(Bates no. TI13850725–0726) 

On August 10, 1992, U.S. Senators 

Malcolm Wallop, Orrin Hatch, and 

Mitch McConnell sent to DHHS Secre328 
M o n o g r a p h 1 6. A S S I S T 

tary Sullivan a letter about ASSIST that 

began as follows: 

We have recently received information 

which indicates that federal funds 

made available through the National 

Cancer Institute will be used to fund 

lobbying activities at the state and 

local level. Given the disturbing 

precedent that this would establish and 

the numerous legal and policy 

problems which could arise when the 

federal government finances one side 

of a debate, we ask that you take 

necessary steps to stop this practice 

immediately.82(Bates no. 2024103356) 

After this initial paragraph, the letter 

contains a number of sentences that are 

remarkably similar to an R.J. Reynolds 

document, undated but with a fax date of 

March 24, 1992 (4.5 months earlier).67 

Selected parts of the texts are placed side 

by side for comparison on the next page. 

Hearings on annual appropriations for 

DHHS also provided opportunities for 

industry advocates to press their cases 

against ASSIST. On February 24, 1994, 

Cathey Yoe of the Tobacco Institute 

wrote to colleagues regarding the upcoming House appropriations hearings 

in which Secretary Donna Shalala would 

testify: “Since ASSIST is a priority for 

Burleigh Leonard at RJR, perhaps we 

should coordinate with him on using 

the appropriations hearings to point 

out abuses of ASSIST funding. I have 

taken a first stab at a draft question for 

Shalala. . . .”75(Bates no. TI13850617) 

Yoe attached two draft versions of 

questions to be asked of Secretary 

Shalala. Excerpts are given below: 

Secretary Shalala, . . . 

when this program first got under way, 

my colleague Mrs. Bentley expressed 

concern that ASSIST funds would be 

used for lobbying state and local 

officials. . . . You assured the 

Committee that federal ASSIST funds 

would not be used for lobbying. . . .

Surely you are aware that in nearly every state receiving ASSIST money, the 

stated goals include passage of legislation. ASSIST funds are being used to 

train “volunteer advocates” or “volunteer activists” in the art of lobbying. . . .

I don’t think any of us quarrel with 

getting greater participation of citizens 

in the legislative process at all levels. 

But when the Federal government 

hands those citizens an agenda and a Tshirt, aren’t those taxpayer dollars 

being used in lobbying? . . . Calling it 

“policy advocacy” or “engaging” state 

legislators doesn’t make it anything 

other than lobbying. . . .

how are you ensuring that those federal 

funds do not get used in “targeting 

legislatures” with lobbying 

efforts?76(Bates no. TI13850618) 

Two years later, R.J. Reynolds staff 

drafted questions to ask Secretary Shalala 

regarding ASSIST at the 1996 hearings 

of the House Appropriations Subcommittee on Labor, Health and Human Services, and Education. A document dated 

March 26, 1996, by John Fish of R.J. 

Reynolds to Eric Fox, staff assistant to 

Congressman Henry Bonilla, who apparently was not familiar with ASSIST at 

the time, contained the following 

questions: 

Attached are a few questions for 

Secretary Shalala—if Mr. Bonilla has 

the opportunity to ask them. They deal 

with a program called ASSIST. . . . 

329 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

million for national coordination and 

“The model program does include a 

form entitled, ‘Disclosure of Lobbying 

. . . 

“Some of the grantees were a bit skittish 

10, 1992. 

“The model program does include a 

form entitled, ‘Disclosure of Lobbying 

. . . 

“The Department of Health and Human 

Department also will spend approximately 

$20 million for national coordination and 

“Some of the grantees were a bit skittish 

: RJR Nabisco. Using Federal Funds to 

Lobby State and Local Leaders. March 24, 

zuu24e00 (accessed June 24, 2002). Bates no. 

2026079534–9535. 

Portions of 

Wallop/Hatch/McConnell Letter 

August 10, 1992 

“Your department will spend approximately 

$115 million over seven years on the 

program, and the American Cancer Society 

will provide an additional $25 to $30 million. 

Your department will also spend roughly $20 

evaluation. . . . 

disclaimer on lobbying, but then includes in 

each of the grants awarded to the states a 

Activities.’

“The Massachusetts ASSIST program will 

use part of its federal funds to finance a 

conference involving legislative and advocacy 

leaders to draft legislation which would be 

submitted simultaneously to all of the New 

England state legislatures. . . . 

about being too directly involved in lobbying. 

For example, the Minnesota ASSIST program 

indicated that it would consider retaining the 

state’s existing tobacco control lobby as a 

subcontractor. . . . 

“. . . once the federal government begins to 

finance one side of a public policy debate, 

there will no longer be a debate. There will 

only be the federal government’s position.” 

Source: Hatch, O., M. McConnell, and M. 

Wallop. Letter to Health and Human Services 

Secretary Louis Sullivan. U.S. Senate. August 

Portions of RJR Nabisco Memorandum 

Faxed March 24, 1992 

disclaimer on lobbying, but then includes in 

each of the grants awarded to the states a 

Activities.’

Services will spend $115 million over seven 

years on the ASSIST program. An additional 

$25 to $30 million will be provided by the 

American Cancer Society. Moreover, the 

evaluation. . . . 

“The Massachusetts ASSIST program will 

use part of its federal funds to finance a 

conference involving legislative and advocacy 

leaders to draft legislation which would be 

submitted simultaneously to all of the New 

England state legislatures. . . . 

about being too directly involved in lobbying. 

For example, the Minnesota ASSIST program 

indicated that it would consider retaining the 

state’s existing tobacco control lobby as a 

subcontractor. . . . 

“Once the federal government begins to 

finance one side of a public policy debate, 

there can be no debate. There will only be the 

federal government’s position.” 

Source

1992. http://legacy.library.ucsf.edu/tid/ 

One concern with asking Shalala about 

this contradiction [regarding lobbying] 

is it gives her the ability to get on her 

soapbox about tobacco. . . . 

One word of warning, Shalala has 

already indicated that the whole FDA 

and tobacco issue is going to be a 

campaign issue—and a winner for the 

Democrats. I say this to warn you that 

any questions asked need to be very 

focused so that the door isn’t opened to 

her. . . .77(Bates no. 522629314–9315) 

330 
M o n o g r a p h 1 6. A S S I S T 

In 1993, my colleague, Helen Bentley, 

raised with you her concern about 

ASSIST funds being used to lobby at 

the state and local levels. Your 

response left no room for 

uncertainty—no funds would be used 

to lobby. . . . Is it still your policy that 

federal funds shall not be used for 

lobbying at the state and local levels? 

. . . I have a copy of a [communication] 

from a contracting officer at NCI to 

ASSIST project directors which 

contradicts your previous statement. 

My question for you is who sets policy 

for HHS—you or the Project Officers? 

What actions are you going to take to 

make sure that federal funds are not 

used to lobby state and local 

officials?77(Bates no. 522629316) 

No evidence is available that Congressman Bonilla used this text to question Secretary Shalala at the 1996 

appropriations hearings. A Tobacco Institute memo dated a month later mentions that “transcripts of Secretary 

Shalala’s testimony before the House 

Appropriations Subcommittee on Labor, 

HHS, and Education will be unavailable 

for some time, due to a technical glitch 

with the transcribing service.”83(Bates no. 

518239758) However, a committee report dated July 8, 1996, from the Committee on 

Appropriations to accompany the appropriations bill (H.R. 3755) for, among 

others, DHHS, included the following 

passage: 

The Committee is concerned that the 

National Cancer Institute may not be 

adequately overseeing the so-called 

ASSIST Program (the American Stop 

Smoking Intervention Study Program). 

Questions have been raised about some 

of the expenditures in this program. 

The Committee strongly urges the 

Inspector General to conduct an audit 

of the contractors in the program to 

determine if the funds are being 

properly spent and that the program is 

meeting its goals.84(p124) 

Transcripts are available for the next 

year’s hearings on the DHHS appropriations, dated February 11, 1997, at which 

Secretary Shalala testified.85 The transcripts provide the full text of Secretary 

Shalala’s response to questioning by Congressman Bonilla as well as by Congressman Ernest Istook. The questions from the 

two congressmen are not available; the 

transcript lists them as “inaudible.” Secretary Shalala’s responses suggest that 

they are questioning her intensively: 

Rep. Bonilla: (Off mike, inaudible.) 

Secretary Shalala: I think we’ve 

provided extensive information to you 

about the activities of the ASIS (?) 

[sic] contracts. We have informed all 

of our contractors and all of our 

grantees that they are not to engage in 

lobbying activities, which is prohibited 

under the Federal Acquisitioning and 

Streamlining Act. 

We have made it very clear that 

violations of the act will not be 

tolerated by the Department. If 

allegations of violations of the act are 

serious enough, we will turn them over 

to the Inspector General. The Inspector 

General is conducting an investigation. 

We have thus far found no lobbying 

violations in the course of our internal 

inquiry and, as you indicated, no one 

on this committee, and I don’t know 

anyone in this country, that’s in favor 

of smoking by children. 

It’s a major public health problem, but 

we intend to obey the law and to make 

sure our contractors obey the law, and 

331 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

thus far we have not found any 

violations, but we have made it very 

clear to the contractors that they are 

not to violate the law.85(p11) 

A few moments later, Congressman Istook 

again raised the subject of lobbying: 

Rep. Istook: (Off mike, inaudible). 

Secretary Shalala: Let me repeat again. 

We have taken the position that once 

the law was passed, any contract after 

the law was passed cannot use federal 

money for lobbying. . . .

We also are taking the position that if 

there is a renewal of any existing 

contract, it ought to be covered by the 

law that was passed so that we would 

catch, as there are any extensions or 

renewals contract [sic], any new people 

coming up. 

As to whether before the law was 

passed, which is October 1st, 1995, 

whether we have actually gone back to 

see whether anyone continues to lobby 

because they have a contract that’s 

before that, I’m not sure I know the 

answer to that question. 

Rep. Istook: (Off mike, inaudible). 

Secretary Shalala: I think that we must 

not have understood the question at the 

time. We’ve been consistent in our 

interpretation of the law, and that is, any 

contract that was awarded after October 

1st and any extension of a contract after 

October 1st, is covered by that law, but 

apparently we have not gone back to 

look whether—and we have sent 

notifications to everyone who is on our 

contracts, or they’ve signed an affidavit 

saying that they understand what the 

rules are, but apparently we have not 

gone back to see whether, even though 

it’s a legal activity under our 

interpretation of the law. 

Rep. Istook: (Off mike, inaudible). 

Secretary Shalala: Well, first of all, a 

year ago was 1996, and a year ago was 

a year after the—I mean, some time 

after the law had been passed. 

Our responsibility is to enforce the 

laws once they’re passed, and what 

I’ve indicated to you is as of October 

1st, 1995, any contracts or any 

renewals of contracts by our lawyers’ 

interpretation are covered by this law, 

and we will enforce that. 

Rep. Istook: (Off mike, inaudible). 

Secretary Shalala: Mr. Istook, I’m 

interpreting the law as passed by the 

Congress. The law, as passed by 

Congress, my understanding of that 

law is it was not retroactive. Now, if 

there is a different interpretation of that 

law, and if— 

Rep. Istook: (Off mike, inaudible). 

Secretary Shalala: I probably couldn’t 

under the law. I’d have to ask my 

counsel. 

Rep. Istook: (Off mike, inaudible). 

Secretary Shalala: You know, all I can 

do is obey the law, as the law is passed. 

I can’t talk to a contract that was a 

contract in the previous Administration 

about a new law that was passed that 

doesn’t apply to them. So I can do my 

best and enforce the new law, and 

that’s what you should hold me 

accountable for.85(pp13–14) 

Congressman Istook had offered an 

amendment to a 1995 Lobby Reform 

Bill86 and another to the March 1996 

Balanced Budget Down Payment Act,87 

requiring all organizations receiving federal grants to provide an annual report of 

expenses for lobbying activities. Organizations and businesses receiving govern332 
M o n o g r a p h 1 6. A S S I S T 

ment contracts or tax exemptions were 

not required to report lobbying expenses.86 The 1996 version of the Lobby Reform Bill passed. In arguing for this 

legislation, Congressman Istook had 

made the following points: 

It is time to end taxpayer-funded 

political advocacy! . . . 

The term “lobbying” is too narrow to 

be useful for this purpose. The broader 

term “political advocacy” should be 

used. . . .

No federal funds should be used for 

political advocacy. 

No grant funds should be used to 

provide support to other organizations 

who, in turn, conduct political 

advocacy. . . . 

Any Federal grantee should be subject 

to an audit. . . .88(pp1–2) 

One tobacco industry document indicated that Congressman Istook worked 

with the tobacco industry to prevent the 

use of federal funds for political advocacy. A Weekly Bullet Report prepared by 

Philip Morris (PM) lobbyists in Washington, DC, dated February 21, 1997 (10 

days after the above hearing), included 

the following passage: 

Labor, HHS [Appropriations Subcommittee]: PM consultants do not think 

we can chop funding for anti-tobacco 

programs, given the obvious sensitivity of the issue and the vote count on 

the Sen. subcomm. We can at least 

work w/ Northup’s office on HHS failure to promptly implement SAMHSA/ 

Synar vs. how quickly FDA put together its rule, and Istook and Bonilla’s office on use of ASSIST funds for 

lobbying.89(Bates no. 2078293672) 

In conclusion, the tobacco companies’ documents indicate that corporate 

executives understood how important it 

was to cultivate political allies and take 

advantage of some allies’ previously defined political positions. The tobacco industry appears to have provided these 

allies with information and drafted language about ASSIST for their legislative 

efforts. 

Strategy 3: Enlist Business 

and Consumer Allies 

While the tobacco companies 

worked closely with their political allies and had extensive sales force networks and other internal resources to 

address the ASSIST situation as well, 

they also recognized the need to recruit and use outside organizations 

linked to the tobacco industry economically or philosophically for their 

efforts to counter ASSIST.2,7,8,10,18–20,90,91 

These potential allies included tobacco 

vendors, restaurateurs, grocers, convenience stores, and hoteliers; organizations and business groups concerned 

with “taxpayer abuse” and “government excess”; conservative and libertarian think tanks; and consumer 

groups (smokers). Josh Slavitt at Philip Morris described several ways in 

which tobacco industry allies could 

contribute to “opportunities to disrupt 

ASSIST funding:”19(Bates no. 2023916866) 

A more thorough investigation should 

be launched . . . particularly in terms of 

the NCI/ACS relationship and the use 

of federal funds for state and local 

lobbying purposes. . . . Various tax and 

fiscally responsible organizations 

could get involved. 

333 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

*The Congressional PIG Book is an annual summary of alleged waste and “Pork in Government” 

expenditures. Citizens Against Government Waste (www.cagw.org) was formed as a nonprofit to continue 

the activities of President Reagan’s Grace Commission. 

Washington Legal Foundation/other 

groups could at the same time launch 

concurrent injunctive challenges in 

ASSIST states to stop dispersal of 

funds while the Congressional 

investigation is going on, as well as to 

determine whether the program 

violates Federal or state ethics/ 

lobbying laws. . . .

Local anti-tax groups could also weigh 

in because the program will affect 

budgets by adding state DoH jobs with 

many ASSIST states looking to reduce 

major deficits.19(Bates no. 2023916866–6867) 

Tobacco industry ally activity appears to 

have begun early in the ASSIST project. 

By June 1992, Slavitt reported, “. . . fiscal 

watchdog groups are examining spending 

at HHS to point out wasteful spending in 

a number of areas, in order to put the department on the defensive. . . . Derek has 

also contacted Citizens Against Government Waste (the former Grace Commission), which has agreed to include 

ASSIST in their “PIG Book.”*,20(Bates no. 

2078755122) 

Kurt Malmgren of the Tobacco Institute developed a lengthy strategy paper 

in November 1992 on how to recruit and 

work with allies at the local level. The 

following strategies were included: 

A. Develop effective monitoring 

systems to ensure that the industry 

learns of the introduction of unfair 

local anti-tobacco proposals in a 

timely fashion. . . . 

Nothing . . . works more effectively 

than a system in which city and 

county clerks are contacted on a 

regular basis to determine if antitobacco activity is scheduled. . . . 

Unlike Massachusetts, where convenience store allies and member 

company sales representatives fill 

the role, in Minnesota, the wholesalers have implemented a similar 

program which has proved effective. 

B. Employ effective local advocates. . . .

Identifying and deploying the local 

person who can “make the sale” 

before local government entities . . . 

accounts for an extremely large 

portion of the reason the industry 

achieves its goals. This is the single 

most important non-managerial 

element of the program. 

C. [Build strong local coalitions.] The 

constant claim on the local front is 

that “It’s only the out-of-state 

tobacco industry that opposes this 

ordinance.” . . . 

[In California], coalition coordinators . . . develop support from individual restaurateurs, retailers, 

hoteliers, local labor leaders and 

others. The coordinators get in the 

door, educate the potential allies, 

form official local groups if necessary, . . . encourage their attendance 

at the hearings, motivate them to 

testify . . . and even encourage them 

to write letters to lawmakers and 

the press. [Coordinators should be 

local too], . . . on the ground every 

day working these potential allies. . . . ”8(Bates no. 2023965881–5883) 

In an early 1995 report to the Tobacco 

Institute, the public relations firm The 

Madison Group recommended aggres334 
M o n o g r a p h 1 6. A S S I S T 

sively mobilizing local coalitions. They 

suggested 

identifying third party allies who share 

a concern with taxpayer abuse and 

government excess. . . .

■	 Cultivate the coalition that will carry 

the attack against Assist [sic]. . . .

■	 Organize coalition indignation and 

uprising against Assist [sic]. . . .

■	 Extend the issue and general indignation for as long as possible.90(Bates 

no. TNWL0047343) 

Allies were also used to send FOIA 

requests, using sample letters provided 

by the tobacco companies;21,41 request 

hearings or file complaints regarding “illegal lobbying” and other allegations;41,92 

file lawsuits;35 write letters to politicians 

at various levels issuing complaints or 

demanding investigations;93 and publish 

articles criticizing ASSIST in their 

newsletters.94 In some cases, allies required “financial assistance to enable the 

organization to improve its capabilities 

in dealing with tobacco issues. . . .”95(Bates 

no. 2023965833) This was the case with the 

American Wholesale Marketers Association, which received contributions from 

the Tobacco Institute in 1993,95 and the 

Minnesota Candy & Tobacco Association, which received $20,000 from the 

Tobacco Institute in 1991.96 

The Tobacco Industry’s Self-evaluation of 

Their Efforts to Recruit Allies. It is difficult to 

assess overall how successful the tobacco industry was in enlisting and using 

these various allies. At the beginning of 

ASSIST, the Tobacco Institute’s Susan 

Stuntz, in a speech to the executive committee, had listed in detail some of the 

diverse coalition members ASSIST 

states had successfully recruited, including major employers, the Urban League 

and NAACP, state newspaper publishers 

associations, Blue Cross, Prudential, and 

state AFL-CIOs. Many of these had also 

been heavily recruited by the tobacco 

industry. Stuntz pointed out that 

those coalitions that involve major 

employers in the state, state or local 

chambers of commerce, or unions and 

other employee organizations are of 

major concern. . . .

In one state, it appears that outdoor 

advertising agencies are working 

quietly with the ASSIST coalition to 

develop anti-smoking messages.10(Bates 

no. TI13851814) 

Malmgren of the Tobacco Institute reported in November 1992 that the industry had been successful in recruiting and 

collaborating with a retail association in 

the northeast: 

. . . the industry established a formal, 

solid working relationship with the 

New England Convenience Store Association to develop better coordination 

of their resources. . . .

For monitoring purposes, we fund our 

allies in the convenience store group to 

regularly report on ordinance introductions and assist in campaigns to stop 

unreasonable measures. . . .

As a result [primarily of this alliance], 

the industry is prepared to deliver direct 

mail, run phone bank operations and 

otherwise attack local proposals with 

our local business allies in a generally 

coordinated and productive fashion. 

The team is beginning to export the 

Massachusetts efforts to other states in 

New England to prepare for the increase in local activity expected from 

ASSIST funding in Maine and Rhode 

335 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

Island, as well as Massachusetts.8(Bates no. 

2023965879) 

In contrast, in a memo dated November 29, 1995, Josh Slavitt of Philip Morris expressed some frustration with the 

lack of a strong key ally in New Jersey: 

. . . as an ASSIST state, NJ is beginning 

to catch fire on the local level where 

communities are attacking our sales 

and marketing practices. It is difficult 

to implement our traditional methods 

of heading off legislative/regulatory 

marketing restrictions at the local level 

in New Jersey due to the lack of a 

strong retail trade association in the 

state.97(Bates no. 2045887287) 

A Philip Morris planning document 

of July 1992 also had expressed doubts 

about the tobacco industry’s ability to 

recruit smokers in their efforts against 

ASSIST: 

Fact: 1) Consumers are diminishing 

resource and have doubts—doubts 

reduce effectiveness. 2) Efforts to 

enlist consumers in fighting the Anti’s 

directly have been generally 

unsuccessful. . . .

Conclusion: 1) Fewer consumers will 

affect the pool of available activists 

who can/will articulate their own 

defense. . . . 2(Bates no. 2048621157) 

Minnesota lawyer Thomas Briant echoed 

this concern in a handwritten note, dated 

August 16, 1994, that accompanied a letter to a Philip Morris executive and complained, “The political environment in 

MN is going further south with ‘stings’ 

at retail all over the place and now the 

state suing PM! Any NY help available 

to fight back? Our people are getting 

overwhelmed.”98(Bates no. 2044135472) Thus, individuals affiliated with the tobacco industry expressed frustration with their 

inability to recruit useful allies. 

Strategy 4: Discredit ASSIST—File Legal 

and Regulatory Actions 

In the tobacco companies’ documents, 

the authors found discussions of a number of tactics to discredit ASSIST and 

those involved with ASSIST. These tactics included injunctions, lawsuits, complaints to the DHHS inspector general, 

audits, changes in federal regulations, 

and complaints before ethical practices 

boards. A 1993 Philip Morris document 

titled “Synar ASSIST Task Force” identified the single overarching objective 

for these activities as eroding the credibility of those involved with ASSIST: 

ASSIST 

Objective 

. . . Launch investigation of ASSIST 

program in Congress and in state 

legislatures. . . .

Use overall investigation to develop a 

public relations program designed to 

erode credibility of opponents over the 

long term.26(Bates no. 2023961348) 

Injunctions and Legal Actions. Tobacco 

company executives planned to use their 

legislative allies to carry out various legal actions. These included Slavitt’s idea 

for filing injunctions against the distribution of ASSIST funds: 

In order to determine whether a 

member of Congress has grounds to 

file an injunction, Legal should review 

the original RFP from HHS and the 

state proposals to determine the 

potential for litigation. . . .

Senator McConnell has previously 

filed a letter to HHS criticizing 

336 
M o n o g r a p h 1 6. A S S I S T 

ASSIST. However, based upon the 

legal analysis, there may be an 

opportunity for other Members of 

Congress to file an injunction against 

distributing these funds. 

Identifying the appropriate MoC 

[member of Congress] must be 

pursued aggressively by the 

Washington Relations Office—in the 

best case, the member should be from 

a non-tobacco state.20(Bates no. 2078755122) 

A lengthy Tobacco Institute document 

reported on the success of one legal action in Colorado: 

On February 13, 1995, a Colorado administrative law judge (“ALJ”) found 

that the Colorado Department of Public Health and Environment (“DPH”) 

violated state election law by using 

public funds and resources, apparently 

including money provided through the 

ASSIST program, to further a pending 

tobacco tax initiative.40(Bates no. TI30519007) 

Federal Acquisition Regulations. In March 

1993, the ASSIST Coordinating Center 

provided a training workshop for state 

ASSIST staff regarding policy advocacy 

limitations on lobbying under current 

law, and the Center prepared a “white 

paper” titled “Restrictions on Lobbying 

and Public Policy Advocacy by Government Contractors: The ASSIST 

Contract.”99(Bates no. TNWL0046714) Among its 

conclusions, the paper found that, under 

current law, 

state public health agencies . . . may 

not use federal Government contract 

funds to lobby Congress. . . . [However, 

no current law] precludes lobbying the 

executive or administrative branch of 

government, at any level. . . . State

public health agencies are likewise free 

to lobby the legislative branch at the 

state or local level, and to attempt to 

influence initiatives or referenda.99(Bates 

no. TNWL0046721–6722) 

The Tobacco Institute obtained a draft 

copy of the ASSIST paper on lobbying. 

From the tobacco industry’s viewpoint, a 

serious weakness in existing laws was 

that lobbying restrictions on federal 

funds did not apply to local legislation 

and ordinances, so the Tobacco Institute 

strongly advocated for amending the 

Federal Acquisition Streamlining Act 

(FASA). As described in a Tobacco Institute document dated December 15, 1994, 

. . . this fall we were able to attach an 

amendment to the Federal Acquisition 

Streamlining Act (“Act”) legislation . . . 

which—for the first time—would 

prohibit federal funds from being used 

to lobby a local legislative body. . . . 

The Act will result in a revision of the 

Federal Acquisition Regulations 

(“FAR”), which govern all federal 

contracts, including the ASSIST 

program. . . . the new lobbying 

prohibition will not be enforceable 

until final regulations are promulgated, 

probably some time in the fall of 

1995.23(Bates no. TI13850309–0310) 

The amended FASA stated that “Costs 

incurred to influence (directly or indirectly) legislative action on any manner 

pending before Congress, a State legislature, or a legislative body of a political 

subdivision of a State” were not allowed 

in federal contracts.100(§§1587–68) 

The new law took effect on October 1, 

1995, and it applied only to government 

contracts based on solicitations issued 

after that date. Because the original 

ASSIST contracts had been awarded prior to that date, they were not governed 

337 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

by FASA—as the Tobacco Institute discovered when it attempted to use the 

new regulations to restrict ASSIST activities. Nevertheless, tobacco companies used this amendment as a basis for 

requesting official government audits of 

ASSIST contract activities. 

HHS Inspector General Audits. The December 15, 1994, Tobacco Institute document cited above also pointed out that, 

even with the FASA amendment, certain 

clauses in the Federal Acquisition Regulations (FAR) would make it difficult to 

challenge ASSIST: 

. . . complaints involving the ASSIST 

program may not fit under the Federal 

Acquisition Regulations framework for 

several reasons. . . .

the regulations envision an interested 

party to be . . . a company that may have 

submitted a contract bid and lost. . . . 

Second, . . . the probable remedy is 

very mild. . . . the contractor . . . would 

be expected simply to reimburse the 

government for the cost of its lobbying 

efforts.23(Bates no. TI13850310–0311) 

The author of the document mentions 

the role played by two U.S. Senators in 

attempting to fit the legislation to the tobacco industry’s needs, then introduces 

a new strategy involving not only congressional allies but also allies at the 

state and local levels: 

As you know, Senators Hatch and Ford 

were unsuccessful in their attempt to 

amend the Act to make sure that 

individual ASSIST grantees could be 

sued by any interested party under the 

Federal Acquisition Regulations. 

Consequently, the best way to use the 

new lobbying prohibition may be to 

bring a complaint to the Inspector General of the Department of Health and 

Human Services. . . . [This] has three 

distinct advantages over the FAR. First 

the Inspector General has a great deal 

of discretion over the scope of his investigations and has a wide spectrum 

of remedies from which to choose if 

he determines that federal funds are 

being used to lobby. . . . Consequently, 

even if the complaints would not be actionable under the FAR on procedural 

grounds, the complaints coupled with 

political pressure from the Hill eventually might be more effective than a 

FAR complaint to the GAO [General 

Accounting Office] or the GSBCA 

[General Services Admin-istration 

Board of Contracts Appeals]. 

Second, unlike the FAR framework, 

there are no procedural technicalities 

that hinder outside third parties from 

bringing complaints before the Inspector General. In fact, by sending the 

complaints to the Inspector General, 

we could coordinate a grassroots effort 

that would send dozens of complaints 

to the Inspector General’s office, forcing the Inspector General to address 

the problem. 

Finally, if the Inspector General dismisses the complaints, or if he chooses 

to engage in a less than vigorous investigation, his actions will be of interest to the appropriate congressional 

oversight committees. And, given 

recent political changes, the Department of Health and Human Services 

may be more sensitive to Congressional pressure. 

Procedurally, filing a complaint with 

the Inspector General is very straightforward. . . . The letter should . . . request 

that the Inspector General investigate 

and audit ASSIST to determine whether such violations are indeed 

occurring.23(Bates no. TI13850311–0313) 

338 
M o n o g r a p h 1 6. A S S I S T 

The author finishes by suggesting that 

the complainant “request that the Inspector General recommend that the ASSIST 

program be eliminated and that the federal government be reimbursed for federal 

funds that were illegally spent.”23(Bates no. 

TI13850313) 

In 1996, the House Appropriations 

Subcommittee on Labor, Health and Human Services, and Education requested 

that the inspector general of the DHHS 

perform an audit of ASSIST.101 A year 

later, R.J. Reynolds’s John Fish again 

wrote Congressman Henry Bonilla’s 

office, this time with a set of questions 

for the inspector general, including the 

following: 

Does your office conduct periodical 

[sic] reviews of all contracts to ensure 

that the money is used in appropriate 

ways? . . . 

You are currently conducting an audit 

of the ASSIST program. Can you tell 

me when your audit will be 

completed?78(Bates no. 522524229) 

In June 1997, the deputy inspector general for audit services at DHHS wrote 

the following to Congressman Bonilla, 

with a copy to Congressman Istook: 

This is to provide you the status of our 

review, made at your request, of the . . . 

(ASSIST) program. . . . Your staff 

expressed particular concern about 

(1) whether ASSIST funds were used 

for lobbying activities, (2) whether 

the program was effective, and 

(3) the relationship of ASSIST to 

other initiatives to reduce smoking. 

The Committee on Appropriations 

also requested the Office of Inspector General (OIG) to conduct an audit of the program. . . .

To determine whether the activities 

were reimbursable under the provisions of Federal cost principles and 

laws which prohibit use of Federal 

funds for lobbying elected officials, we: 

■	 interviewed NCI ASSIST officials 

and officials of one ASSIST 

contractor [NJ], . . . 

■	 reviewed progress reports, . . . [and] 

■	 engaged the Office of Counsel to 

the Inspector General (OCIG). . . . 

Our review of the list of eight reported 

activities and progress reports submitted by ASSIST contractors disclosed 

(1) one instance where nonreimbursable lobbying activities occurred, and 

(2) six instances had not violated applicable Federal lobbying laws. We are 

continuing to review one instance to 

ensure that no Federal funds were used 

for lobbying activities.102(Bates no. 522524692– 

4693) 

The single case found involved a journal 

advertisement in New Jersey regarding 

banning of smoking in casinos. The advertisement’s cost was $1,470.102 NCI 

auditors followed up with an audit of the 

New Jersey contract and found that the 

$1,470 expense was appropriate. The 

deputy inspector general also “concur[red] 

with the observation of NCI ASSIST officials that more analysis is needed in order to determine the effectiveness of the 

ASSIST program.”102(Bates no. 522524696) 

State Audits. Demands for audits were 

also used at the state level.21,25,28,93 In 

Michigan, Philip Morris’s Scott Fisher 

wrote a memo (April 25, 1994) to executives at the Tobacco Institute, Philip 

Morris, and R.J. Reynolds detailing how 

the tobacco industry could use a local 

politician to force an audit of the state 

ASSIST program: 

339 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

Michigan’s Co-Speaker of the House 

has taken a keen interest in uncovering 

more information regarding the state’s 

seven-year involvement in the ASSIST 

program. Attached you will find a copy 

of a letter Speaker Hertel sent to . . . 

Director of the Michigan Department 

of Public Health . . . seeking detailed 

information on the ASSIST program. . . . 

Please note . . . [three counties] have received over $25,000 each year. . . . The

Single Audit Act of 1984 requires any 

sub-recipient which received over 

$25,000 in federal grant monies to be 

audited. No such audit of these agencies has been done by [Fiscal Year] FY 

’91, ’92, or ’93.21(Bates no. 2041190064) 

Fisher then made several recommendations, among them, 

1. What specific follow-up questions 

should the Speaker send back to the 

Director of the [Department of 

Public Health]? . . . 

5. Can a letter be sent by Speaker 

Hertel to federal officials such as 

Michigan’s Congressional 

representatives or HHS and/or its 

auditor regarding the lack of 

enforcement of the Single Audit Act 

of 1984 which could jeopardize 

future funding for Michigan’s 

ASSIST?21(Bates no. 2041190065) 

On October 18, 1995—less than 2 

weeks after the new legislation took effect—a tobacco ally, the Minnesota Grocers Association,28,103 wrote a letter to 

Governor Arne Carlson and the state auditor, with copies to the Minnesota congressional delegation. Portions of the 

letter follow: 

Information has been brought to the 

attention of the Minnesota Grocers 

Association which indicates that 

taxpayer dollars dispensed under the 

direction of the Minnesota Department 

of Health’s ASSIST Project have been 

used unlawfully and improperly to 

fund lobbying activities. . . . Using the

more than 500 pages of documents 

provided to us, . . . we are asking the 

Governor’s Office and the State 

Auditor to launch an immediate 

investigation. . . .93(Bates no. 513967722) 

Four months later, the Minnesota Grocers Association received a letter from 

the Minnesota ASSIST project director 

pointing out that, according to the NCI, 

the Federal Acquisition Streamlining Act 

of 1994 only affects contracts awarded 

on or after October 1, 1995. Since the 

ASSIST contracts were awarded in September of 1991, the new cost principles 

do not apply to Minnesota’s ASSIST 

contract. Further, the Office of General 

Counsel, Department of Health and Human Services, has advised NCI that in 

its opinion the ASSIST subcontractors 

are also not covered by the changes of 

October 1, 1995 because ASSIST contractors are not expected to pass on the 

new cost principles to their 

subcontractors.104(Bates no. 2046957021) 

A similar effort to use the new FASA 

regulations in New York also failed, as 

shown by an undated Tobacco Institute 

document from around 1996, which includes a letter from New York’s ASSIST 

program manager to his coalition project 

directors and contacts, with the following announcement: 

I am happy to tell you that a final interpretation of the regulations by the Department of Health and Human 

Services has determined that contracts 

awarded prior to October 1, 1995, are 

not subject to the FASA, and, there340 
M o n o g r a p h 1 6. A S S I S T 

fore, these regulations do not apply to 

contractors or subcontractors participating in the ASSIST program. . . . 

This news should encourage all coalitions to redouble their policy advocacy 

efforts. All coalitions may use contract 

funds to appropriately advocate for tobacco control at the local level, and 

most may do so at the state level. Local legislation, regulation, and voluntary policies are the cornerstone of our 

effort to eradicate tobacco-caused disease. Your vigorous advocacy for tobacco control is the key to our 

success.105(Bates no. TI16270186) 

In Washington State, tobacco industry 

operatives drafted letters for state Representative Tom Huff. Representative Huff 

appears to have been recruited to request 

an audit of ASSIST, as described in a 

memo (March 15, 1996) from Bill Fritz 

of Public Affairs Associates, a public relations firm working with the Tobacco 

Institute: 

Here is the State Auditor’s reply to 

Rep. Tom Huff’s request for an audit 

of the ASSIST program. 

The audit appears to have been “a 

once over lightly” effort that either 

avoided some questions poised [sic] 

by Rep. Huff or provided inadequate 

answers. . . . 

we should draft another letter for Rep. 

Huff’s signature pointing out and 

reasking the questions that were not 

answered. . . .79(Bates no. TNWL0046478) 

In Maine, an attorney from the law 

firm Doyle & Nelson met with and then 

wrote to Maine’s attorney general on 

April 23, 1997, regarding “possible failure to follow the law and inappropriate 

conduct” by ASSIST. The attorney requested that the attorney general “launch 

an immediate investigation in conjunction with the State Auditor’s Office.” 106 

(Bates no. 518270712) The attorney cited “lobbying activities” and “lack of bidding procedures,” but he was most indignant that 

the local program had sent to the 

ASSIST Coordinating Center a list of 

Maine tobacco lobbyist lawyers and selected clients and then encouraged health 

care clients to switch to other lawyers: 

Carol Allen clearly was told that she 

lost the Maine Teachers Association . . . 

because of her representation of 

tobacco clients; I personally was told 

that there were attempts to remove me 

as head of the United Way campaign . . . 

because of my representation of 

tobacco clients; My partner Craig 

Nelson, who serves on one of the 

affiliated boards of the Kennebec 

Health System, was told by several 

persons that he should resign, and 

there was some pressure to do that 

until I intervened. (I spoke with the 

President of the Maine Lung 

Association . . . who heads up this 

years [sic] anti-smoking effort and told 

him that if his organization or any 

unknown members of that organization 

persisted that we would sue them both 

collectively and individually.) . . . I am 

absolutely outraged that state tax 

dollars can be used to attempt to 

deprive attorneys engaged in private 

practice of their clients.106(Bates no. 518270715) 

Investigation by Ethical Practices Board. In 

addition to demanding an audit, as mentioned earlier in this chapter, the Minnesota Grocers Association, a tobacco 

industry ally, sent a letter on October 18, 

1995, to the State Ethical Practices 

Board requesting that “the Governor’s 

Office and the State Auditor . . . conduct a 

341 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

formal investigation of the Minnesota . . . 

ASSIST Project . . . [regarding] lobbying 

activities. . . . the vast majority of these 

groups that have engaged in lobbying activities have not registered with the Ethical Practices Board as lobbyists and have 

failed to file lobbyist reports.”107(Bates no. 

513967726) On February 4, 1996, lawyer 

Thomas Briant, writing on Minnesota 

Wholesale Marketers Association letterhead, wrote to Tobacco Institute, Philip 

Morris, R.J. Reynolds, and U.S. Tobacco 

executives that the Ethical Practices 

Board had dismissed 15 of the 16 complaints brought by the Minnesota Grocers Association because the amount of 

money and time spent lobbying had not 

exceeded the threshold.28 Undeterred, 

Briant went on to say that he would be 

“sending a letter to the Minnesota Department of Health informing them 

which ASSIST grantees intended to engage in local and/or state lobbying activities and request that the Department of 

Health take all necessary to steps to prevent such lobbying.”28(Bates no. 517759156) 

The above examples demonstrate the 

industry’s perseverance in bringing federal 

and state complaints against ASSIST; 

adverse rulings did not deter the tobacco 

industry from repeated attempts to stop 

ASSIST’s policy advocacy efforts. In 

Washington, public relations consultant 

Fritz described “our objective” in a memo 

to the Tobacco Institute as follows: 

turning the public spotlight on the 

improper and illegal use of public 

funds for anti-tobacco lobbying, 

producing a “chilling effect” on the 

zeal and cavalier manner in which the 

anti-tobacco activists conduct their 

programs, leading to the diminishment 

and eventual curtailment of some of 

these programs funded with public 

money.108(Bates no. TNWL0020096) 

Strategy 5: Infiltrate ASSIST 

The tobacco companies’ documents 

reveal that they planned to infiltrate 

ASSIST as they have infiltrated other 

public health groups, such as Stop Teenage Addiction to Tobacco (STAT) and 

Infant Formula Action Coalition (INFACT).29 Proposed strategies included 

joining and reporting on ASSIST coalitions as well as applying for ASSIST 

grants and contracts.109 One of the Tobacco Institute’s initial action plans, in 

October 1991, included the following: 

“State Activities’ regional staff will 

identify local business and labor interests in 17 grant states who could gain 

representation in community-based 

ASSIST coalitions.”17(Bates no. 518143180) 

The tobacco industry took advantage 

of the openness with which ASSIST coalitions welcomed new members. Briant, 

a Minneapolis attorney who, as noted 

above, worked for both the Tobacco Institute and the Minnesota Wholesale 

Marketers Association, included the following recommendation in his analysis 

of the Minnesota ASSIST proposal: 

As indicated in the Best and Final 

Offer Proposal, . . . “any organization 

desiring to join [the ASSIST Coalition] 

will be welcomed.” Given this open 

membership, I would recommend that 

business groups which would be 

effected [sic] by the ASSIST study as a 

result of reduced smoking rates 

become members of the Minnesota 

ASSIST Coalition.91(Bates no. TI14021167) 

The Minnesota Wholesale Marketers Association then applied for funding from 

342 
M o n o g r a p h 1 6. A S S I S T 

the ASSIST program. In a letter dated 

February 4, 1996, however, Briant reported that the Minnesota Grocers Association had applied for but had not been 

awarded a grant from ASSIST.28 The tobacco industry, through its “retail association” allies, tried again in May with 

another grant proposal for 1996–98.60 

Research documented a single example of outright infiltration by a tobacco 

industry operative; this instance occurred in Colorado in 1992. An individual, apparently working for the Denver 

public relations firm Karsh & Hagan, reported on attending a meeting of an 

ASSIST coalition in Fort Collins: 

I arrived after the meeting commenced 

and, despite my effort to remain 

invisible, ended up seated at the head 

of the table. I signed in as a student 

and hoped that my baggy clothes and 

backpack would make this credible. . . . 

One attendee said that tobacco 

companies often worked through . . . 

rights groups to make their efforts 

seem “local.” This person believed that 

informational breakfasts were already 

being conducted along these lines in 

Denver. She suggested sending a spy to 

these events, as well as to a smoker’s 

rights group that meets at Gabby’s . . . 

restaurant in Ft. Collins. 

At this point, I felt extremely 

conspicuous and decided it would be a 

good time to leave. I waited until the 

group moved on to a more benign 

topic so as not to seem abrupt, looked 

conspicuously at my watch and left. 

Would advise future “plants” to arrive 

late and leave early, avoiding the 

awkward small talk with other 

attendees that might create 

suspicion.110(Bates no. 2023667420,7422)) 

Strategy 6: Divert Funds from the 

Community Environment Channel 

and Promote Alternative Programs 

The sixth strategy identified in the review of the tobacco industry’s documents was to diminish the effectiveness 

of ASSIST by diverting funding from 

the strongest part of ASSIST to alternative programs that would either weaken 

ASSIST’s effectiveness or strengthen the 

tobacco industry’s image. Specifically, 

the tobacco industry wanted to move resources away from the Community Environment Channel, which had “the 

strongest emphasis in ASSIST . . . and 

focuses on goals and activities which are 

the most objectionable.”13(Bates no. TI13850215) 

Within 3 days of the announcement of 

ASSIST, Tobacco Institute executives 

were discussing how to involve their political allies in ways to divert ASSIST 

funding from activities to mobilize the 

community around tobacco control: 

We should have our legislative political 

allies make certain that these 

[ASSIST] funds cannot be used for 

any anti-tobacco strategy which is 

political in nature. . . .

We could also work to assure that the 

money is so widely disbursed that its 

impact is lessened. . . .81(Bates no. TI13850725) 

One way to lessen the impact could 

be to restrict ASSIST funding to specific 

populations: 

Restrict or limit how the funds are 

used through the state appropriations 

process and contacts with executive 

branch officials. 

Make reasonable grants for programs 

directed at pregnant women and youth 

a priority; secondary priorities to be 

343 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

developed, but may include smoking 

cessation programs for people who 

have decided to quit.16(Bates no. 511073913) 

Tobacco Institute executive Bob 

McAdam recommended that the tobacco 

industry attempt to “restrict ASSIST 

funding to school-based anti-tobacco 

eduction [sic].”12(Bates no. TI13850205) Consultant Ted Trimpa agreed, recommending 

that the Institute “provide a basis to advocate shifting all ASSIST funds to the 

Schools Channel. . . .”13(Bates no. TI13850215) 

Nevertheless, he warned that this strategy might inadvertently fund activities in 

the Community Environment Channel: 

The Community Environment Channel 

. . . has a number of youth access objectives which may overlap with the 

Schools Channel. By shifting funds to 

Schools, the Community Environment 

Channel activities may be inadvertently supported/funded.13(Bates no. TI13850215) 

grams.

One reason that the tobacco industry 

might have preferred the schools channel 

to the Community Environment Channel 

is because school interventions alone are 

not as effective as those combined with 

community-based or comprehensive pro- 111–114 In addition, as Slavitt, of 

Phillip Morris, pointed out, “The tobacco 

industry could also offer our own youth 

initiatives . . . and suggest that further 

Federal or state funding is not needed for 

youth anti-smoking campaigns.”19(Bates no. 

2023916867) (Philip Morris had its own youth 

initiative, titled “It’s the Law,” which 

emphasized smoking as an adult pastime.) In other words, the tobacco industry could argue for a shift in funding to 

the Schools Channel followed by an argument to eliminate school programs. 

While one Philip Morris executive 

wrote that “the industry’s ‘Youth Initiamer of 1992,

tives’ have ground to a halt” in the sum2(Bates no. 2048621164) by 1993, the 

company had distributed a total of 1.9 

million “It’s the Law” kits nationally.115 

(Bates no. 2023916805) A report prepared for 

Philip Morris’s Task Force on Smoking 

by Minors announced that the company 

had a database of more than 50,000 subscribers to “It’s the Law,” with a budget 

of $1,199,000.116 

The tobacco industry strategists also 

suggested diverting funding entirely 

from ASSIST to nontobacco programs. 

One of Philip Morris’s strategies involved taking advantage of the needs of 

groups not normally considered allies of 

the tobacco industry: 

Use of Health Advocacy Groups: 

At both the state and Federal levels a 

number of Health Advocacy groups 

could attack Sullivan for failing to 

address major health care issues— 

AIDS, pre-natal, teen pregnancy, 

affordable health care, child 

immunization—instead of wasting 

more Federal dollars on anti-smoking 

programs.19(Bates no. 2023916867) 

In a later memo (June 1992), ACT-UP 

and expanded low-income health services were added as “other health constituencies” which “can criticize waste in 

state [Department of Health] 

DoH’s.”20(Bates no. 2078755123) The Corporate 

Affairs section of the Philip Morris 

1992–96 marketing plan listed as a longterm goal: “Work with grass roots organizations to divert state health 

department funds, equivalent to the 

amount of ASSIST funding, to support 

other health programs (pre-natal care, 

half-way houses, etc.).”11,117(Bates no. 

2046454338) 

344 
M o n o g r a p h 1 6. A S S I S T 

Strategy 7: Discredit ASSIST 

through Public Relations Tactics 

reporters;

Proposed tobacco industry public relations tactics identified in this research 

were coded into four categories: identify 

and assist tobacco-friendly investigative 

12,20,25,90 work with local grassroots coalitions;90 sponsor “scholarly 

works” that criticize voluntary health organizations, particularly ASSIST partner 

the American Cancer Society;18,118 and 

publicize the tobacco industry’s youth 

programs (for example, Philip Morris’s 

“It’s the Law”).17,18 

The Tobacco Institute and tobacco 

companies planned to make the most of 

FOIA requests by organizing media coverage regarding the information gathered. In 1995, the Tobacco Institute 

commissioned The Madison Group, a 

public relations firm, to develop a public 

relations/public affairs plan for FOIA requests. The proposed plan outlined a 

number of activities including the following: 

Prepare for FOIA request, identify 

spokesperson and provide adequate 

media training. . . .

Counter efforts by project Assist [sic] 

to stir up animosity in the media and 

among elected officials . . . 

Identify investigative reporter(s) likely 

to independently pursue Assist [sic] 

abuse . . . 

If an interested reporter has been


identified, brief and provide with


information that will support the


reporter. . . .


Provide targeted contact on the results 

to key office holders.90(Bates no. TNWL0047342– 

7343) 

The Madison Group proposed a budget 

of $40,000 for these and other activities. 

This analysis did not uncover documentation about whether the activities were 

funded. 

A number of documents reveal the tobacco industry’s activities of writing 

press releases,118 providing information 

to friendly reporters,40,119 and developing 

messages about ASSIST,120 which they 

often shared with each other to prevent 

duplicating efforts. For example, a Tobacco Institute publication about 

ASSIST, titled, “Federal Tax Funding to 

‘ASSIST’ State Tobacco Control Lobbying,” appeared 19 times in the Philip 

Morris, Lorillard, and Tobacco Institute 

document collections.121 (See page 323 

of this chapter for additional messages 

that were to be conveyed in public relations materials about ASSIST.) 

The Tobacco Institute appears to have 

been consulted on a comprehensive media plan to publicize a complaint filed 

with the Washington Public Disclosure 

Commission in 1995 against ASSIST 

and alleging “taxpayer-funded 

lobbying.”92(Bates no. TI14303912) The complaint 

was brought by Stuart Cloud, proprietor 

of a small chain of Seattle-area tobacco 

shops. Public relations consultant Bob 

Kahn stayed in touch with the Tobacco 

Institute while developing a press release,92 writing a backgrounder,68 arranging for interviews with Cloud and his 

attorney,68 and sending information to reporters.122 On October 13, 1995, Kahn 

sent a list of questions and answers to 

the Tobacco Institute’s Bob McAdam to 

review120 in preparation for the upcoming press conference regarding Cloud’s 

345 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

filing. The purpose was to “be sure that 

I’m positioning this properly. My intent 

is to suggest abuse without actually 

claiming it. I assume that’s the best we 

can do at this point.”120(Bates no. TI14303899) 

Kahn’s comments included a recommendation that the attorney general investigate ASSIST. McAdam wrote back with 

additions that included a number of the 

main messages the tobacco industry 

wanted to convey to the press: 

[Handwritten note] Using taxpayer 

money to lobby is not right. . . .

We hope there will be a healthy public 

debate. . . .

If they confined the use of ASSIST 

funds to education, no one would 

quarrel. However they have pursued an 

overtly political agenda. . . .123(Bates no. 

TI14303898) 

Many of the grants went to advocacy 

groups that are part of the Democratic 

party coalition (e.g., Planned Parenthood, Gay and Lesbian groups). . . . 

Audits . . . have never been performed. 

. . . There is no accountability in this 

program. . . .124(Bates no. TI14303897) 

The tobacco industry also publicized 

its criticism of ASSIST on the Smokers’ 

Rights ForceS Web site, www.forces.org. 

At least fifty-one different articles attacking ASSIST appeared on the Web 

site during the lifetime of ASSIST.125,126 

A major public relations tool for the 

counter-ASSIST effort was the 1998 

book, CancerScam: The Diversion of 

Federal Cancer Funds to Politics, by 

James T. Bennett and Thomas J. 

DiLorenzo, established critics of tobacco control researchers and private health 

charities.127–136 CancerScam, a 170-page 

criticism of the American Cancer Society, presents the ASSIST project as a 

prime example of “blatantly illegal taxfunded politics”127(p13) involving “front 

groups, illegal lobbying, and other improper uses of federal funds.”127(p13) Although no documents were found that 

showed Drs. Bennett and DiLorenzo had 

been recruited to write the book, a review of documents found three copies of 

early drafts—one was apparently of the 

entire book, and the others were of different sections—on the Philip Morris 

Web site, www.pmdocs.com. The drafts 

came from the office of Lance Pressl, 

who was director of government affairs 

at Philip Morris, and all were dated 

1994 by Philip Morris—4 years before 

the book was published.118,137,138 

The tobacco companies’ documents 

also provide evidence that Philip Morris 

surreptitiously gave Bennett materials 

on ASSIST coalition member organizations. An e-mail, dated May 27, 1993, to 

John Ostronic from Slavitt of Philip 

Morris (PM) concerning the Coalition 

for a Smoke-Free Colorado, states the 

following: 

I talked with Lindsay Steyer at Russell, 

Karsh & Hagan [a Denver public 

relations firm]. . . . She will collect all

of the state agencies, universities, and 

organizations involved in anti-tobacco 

activities in CO and forward them to 

you. . . .

Please also forward a copy to Jim 

Bennett, be careful to ensure that 

nothing on Lindsay’s materials 

references her firm, or contains any 

other references to PM—if there is a 

cover note, shred it. Please remember 

not to use a PM return address, or any 

346 
M o n o g r a p h 1 6. A S S I S T 

thing [sic] which indicates that the info 

eminated [sic] from us—PM postal 

stamp, etc.139(Bates no. 2073248267A) 

The information was forwarded in a 

letter to Dr. Bennett at his office at 

George Mason University.140 Philip Morris then began working on public relations for the book. A handwritten memo 

faxed on August 13, 1993, and found in 

Philip Morris executive Victor Han’s office, reads: 

I got all the 411 on Jim Bennett. We 

need first to get this guy media-trained. 

We then need to identify key markets 

across the US to publicize his book 

and information. . . . Why not cultivate 

the very talented Grace Martin 

(formerly of Burson Marsteller, a 

public relations firm/D.C. and now 

newly-married, living in Roanoke, Va 

and unemployed) to do the publicity 

for Bennett. . . . She could . . . be very 

effective for us, without having any 

ties to us!141(Bates no. 2046527199–7200) 

A proposed 1994 Philip Morris budget 

for communications, found in the company’s documents, listed $50,000 for 

“Assist [sic] Book Publicity.”142 Philip 

Morris was also a “benefactor” for 

George Mason University in 1994–95, 

donating in the $10,000 to $99,999 category.143 

Strategy 8: Promote Preemption Laws 

and Ballot Initiatives 

The tobacco industry appears to have 

launched several legislative efforts in response to ASSIST, and it worked hard to 

undermine initiatives sponsored by 

ASSIST coalitions. A document describing Philip Morris’s 1992–96 Marketing 

Plan announced as one of its long-term 

goals a “Rollback Program” to do as follows: “Particularly in localities, introduce legislation to reinstate sales 

practices, such as free-standing displays, 

that have been banned or restricted” and 

“Pass state preemption.”117(Bates no. 2046454338) 

Philip Morris executive Tina Walls, in a 

draft speech dated July 8, 1994, noted 

the importance of preempting local initiatives with weaker state laws as a key 

strategy for dealing with the tobacco 

control advocates’ “PAC-man” approach: 

Our goal, simply stated, is to see some 

form of accommodation/pre-emption 

legislation passed in all 50 states. . . .

. . . the anti-smoking movement has 

become more sophisticated in its 

efforts to enact bans and restrictions on 

smoking. . . .

they can be in more places than we can 

and, thanks to Project ASSIST in 17 

states, Proposition 99 in California, 

and Question 1 in Massachusetts, the 

“antis” now have the deep pockets 

necessary to intensify their local 

efforts. 

The solution to “PAC-man” is 

statewide pre-emption. . . .

we’re dead serious about achieving 

pre-emption in all 50 states.144(Bates no. 

2041183752–3753,3756) 

Tobacco industry efforts to promote 

statewide preemption are illustrated by a 

letter, dated December 13, 1994, from 

Geoffrey C. Bible, President and Chief 

Executive Officer of Philip Morris, addressed to then Governor-Elect George 

Pataki of New York. Bible wrote this letter to follow up on a visit with the governor-elect the previous evening. In it, 

347 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

Bible described what he perceived to be 

the negative implications of the Vallone 

Bill, which would restrict tobacco use in 

workplaces; restaurants, bars, and hotels; 

recreational areas; public buildings; and 

transit facilities in New York City. Bible 

asserted that Philip Morris would support an amendment to the Vallone Bill 

that would reduce the permitted smoking 

area from 50% to 25%, and he also 

raised the option of statewide preemption. The following excerpt from that letter highlights Philip Morris’s view on 

preemption: 

I trust that this will only be the 

beginning of what I know can be a 

mutually beneficial dialogue. . . .

Another option to consider, and one on 

which we would be pleased to work 

with you, is statewide pre-emption, 

something that 17 other states have on 

their books with regard to smoking restrictions. Reasonable statewide preemption would provide a uniform 

standard for all localities throughout 

New York. One county would not be 

placed in competition with another for 

business and tourism, and New York 

would not be forced to compete with 

more hospitable climates in surrounding states such as New Jersey and 

Connecticut.145(Bates no. 2046988148–8149) 

Bible closed the letter by listing his 

views on the many ways that Philip Morris has contributed to the economies of 

New York State and New York City. (See 

case study 8.5). 

During the early 1990s, the number of 

local tobacco control initiatives across 

the country increased dramatically, in 

part because of ASSIST. By the end of 

1995, 1,006 communities had adopted 

local tobacco control measures. However, at the same time, 29 states had enacted laws that preempted local tobacco 

control ordinances. Twenty-six state preemption bills were introduced in 19 

states during the 1996 legislative session 

alone; 17 states defeated these laws, and 

2 states passed them.146 Attempts to repeal preemptive tobacco control laws 

were initiated in six states.146 As of late 

1998, Maine, an ASSIST state, was the 

only state that had succeeded in repealing a youth-access preemptive tobacco 

control law.147 In 2002, Delaware was the 

first state to repeal preemption of local 

clean indoor air regulations.148 

The considerable costs of the many 

local battles generated by ASSIST activities were an issue of concern, as shown 

by this 1995 memo from McAdam of 

the Tobacco Institute: 

. . . many of the activities and 

organizations of the ASSIST coalitions 

in the states have used the funds to 

influence state and local legislators. . . .

[This] clearly raises the level of 

activities the industry must respond to. 

In Minnesota, for example, ASSIST 

documents . . . indicate there will be at 

least 90 local ordinance battles during 

1995. Several groups receiving ASSIST 

money are part of the statewide 

coalition attempting to pass a large 

tobacco tax increase in the legislature. 

Documents in other states indicate a 

variety of local and state battles that 

the industry will be compelled to 

address. These battles will significantly 

add to the projected costs of our 

operation.12(Bates no. TI13850203) 

348 
M o n o g r a p h 1 6. A S S I S T 

Discussion 

During the 1990s, the U.S. tobacco industry had tremendous resources 

with which to counter tobacco control 

efforts in the nation. This analysis of the 

internal documents of the Tobacco Institute, Philip Morris USA, and R.J. Reynolds Tobacco Company shows that the 

industry moved quickly and relentlessly 

against ASSIST. The tobacco companies 

appear to have used their resources in a 

coordinated way to aggressively monitor, 

audit, and attempt to infiltrate ASSIST 

coalitions; pursue legal actions; preempt 

local tobacco control initiatives; generate 

negative publicity about ASSIST; and 

use their political and other allies to confront ASSIST at every level of government. These tactics were not new to the 

tobacco industry.1

 Furthermore, the documents strongly suggest that the tobacco 

industry attempted to hide its efforts by, 

for example, working through third parties such as public relations firms and 

legislators in nontobacco states, providing information but not disclosing that 

the Tobacco Institute or a tobacco company was the source, and secretly infiltrating public health groups. 

This analysis of tobacco industry documents has several limitations related to 

using internal tobacco industry documents as a data source. Because of the 

enormous volume of tobacco industry 

documents available, and the variable indexing of these documents, there is no 

way to determine if all key documents 

related to the tobacco industry and 

ASSIST were retrieved. Furthermore, 

time and financial resources presented a 

limitation because the documents are 

spread across depositories worldwide 

and are on multiple Web sites. The purpose of this research was to document 

and highlight the tobacco industry’s 

plans related to ASSIST and their implementation, not to establish causality between the industry’s efforts and the 

outcomes of ASSIST. This analysis suggests that tobacco control advocates 

should expect a vigorous, sophisticated, 

and well-coordinated response from the 

tobacco industry to any efforts to implement major policy change at the local, 

state, and national levels. The tobacco 

industry’s response to ASSIST also 

shows that mobilizing local coalitions— 

the “grass roots”—in a policy-focused 

approach presents the greatest challenge 

for the tobacco industry in its efforts to 

keep Americans smoking. 

349 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

Facing the Opposition 

Part 1 of this chapter analyzes tobacco industry documents to reveal and categorize the strategies that the tobacco industry planned to counter the effects and 

the very existence of ASSIST. Part 2 presents the experiences of ASSIST staff 

members as they encountered those 

strategies over the life of the ASSIST 

project. The case studies, which depict 

both the programmatic and the personal 

effects of tobacco industry activities, are 

preceded by an explanation of the legal 

and temporal contexts in which these 

events occurred. In particular, as government employees, ASSIST staff members 

had an obligation to respond to FOIA requests and to spend funds in compliance 

with state and federal regulations. Therefore, background information is presented about FOIA and about what 

constituted legitimate lobbying and advocacy practices by ASSIST personnel 

and coalition members. 

When ASSIST staff members were 

experiencing the tobacco industry’s 

charges of misuse of funds and illegal 

lobbying, they did not know that the tobacco industry was very determined to 

disrupt the project. The tobacco industry 

documents were only beginning to become available near the end of the 

ASSIST project. The case studies presented in this chapter describe events 

that occurred from 1993 through 1997. 

Although ASSIST staff members anticipated that the industry would oppose 

their efforts, they did not anticipate the 

types of strategies or the amount of time 

Part 2. ASSIST’s Response to the Tobacco Companies: 

that would be required to respond. Complying with the multiple FOIA requests 

reduced the time that ASSIST staff 

members could spend on their tobacco 

control work. When the tactics took the 

form of accusations of wrongdoing—of 

illegal lobbying—some advocates were 

intimidated, and some coalitions struggled to keep their partners involved. 

When the tobacco industry leveled accusations against ASSIST at the state level, 

program intervention activities sometimes slowed down or became less effective. Not all advocates in the movement 

were intimidated, however, and some 

became stronger and more committed in 

the face of attacks. 

Understanding the Obligation 

to Respond to FOIA Requests 

As explained in part 1, strategy 1, of this chapter, the federal FOIA was 

passed in 1966 to ensure that all citizens 

have access to records and other information generated and stored by tax-supported federal agencies.149 

Eventually, through conversations 

with one another, ASSIST project managers and directors realized that many of 

them were receiving FOIA requests for 

documents. The FOIA requests made the 

material in the ASSIST files accessible 

to the tobacco industry and its allies. 

When served with FOIA requests, the 

public health staffs at the state and local 

levels interrupted their activities to comply with the relevant laws and to provide 

350 
M o n o g r a p h 1 6. A S S I S T 

the requested documents. These documents included ASSIST plans for future 

activities that the departments of health 

and coalition partners would have preferred not to release at that time. 

To assist the states with understanding the extent of these requests and to 

respond to them, the ASSIST Coordinating Center contracted with a consultant 

to assess the experience of the ASSIST 

programs receiving FOIA requests. The 

consultant conducted telephone conversations during February 1996 with most 

ASSIST project directors and other individuals who were knowledgeable about 

FOIA activity. These conversations revealed that all 17 states had received at 

least 1 written request from Fiscal Planning Services Inc. (a private firm in Bethesda, Maryland, that was contracted 

by Philip Morris to coordinate this20,150) 

for a listing of all recipients and awards 

made in fiscal year 1995.151 Additional 

FOIA requests varied in number and 

scope. They included (1) what appeared 

to be requests from interested individuals following the instructions in ASA 

News, a publication of the American 

Smokers Alliance;152 (2) follow-up requests from Fiscal Planning Services for 

more detailed information; (3) formal 

requests filed by trade associations in 

which tobacco companies were overt or 

covert participants (Walter ‘Snip’ Young, 

e-mail message to E. Bruce, April 5, 

2004);153 and (4) requests filed by law 

firms that typically did not (and did not 

have to) reveal the client whose interests 

they were representing. 

An obvious pattern of using information from previous FOIAs to construct 

the next FOIA was discerned in the insota,

formation derived from the telephone interviews—building on information from 

previous FOIAs. Some ASSIST states, 

such as Massachusetts, received very 

burdensome FOIA requests that required 

increasingly greater specificity and detail from local health departments and 

ASSIST subcontractors. These continuing requests seemed, in a well-coordinated way, to build on information 

obtained through prior FOIA requests. 

The internal tobacco industry documents 

quoted in part 1, strategy 1, of this chapter subsequently provided a clear picture 

of the extent of the tobacco industry’s 

FOIA strategy. Described also is the extensive public relations/public affairs 

plans to use information extracted from 

ASSIST documents to erode public and 

legislative support for the program. Typically, the tobacco companies, their trade 

associations, and other allies garnered 

voluminous documents from which they 

culled small parts that they later used as 

part of their legal and ethical challenges 

in Colorado, Washington State, Minne- 154–157 and Maine.158 

The tobacco industry’s use of FOIA 

did have a disruptive effect on the operation of ASSIST. In some cases, fulfilling 

FOIA requests disturbed communication 

and cooperation among coalition members who felt that their confidences had 

been betrayed. Responding to the 

requests diverted resources and staff 

from tobacco control work and was burdensome. Washington State staff members reported spending hundreds of 

hours to respond with extensive information about coalition members statewide. Massachusetts hired an attorney 

half-time to coordinate and oversee re351 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

sponses to the almost constant flow of 

FOIA requests. Many ASSIST staffs, 

however, related that they had received 

little legal assistance in complying with 

the requests. Over time, the ASSIST 

states learned to share information about 

their FOIA experiences, to coordinate 

responses to the tobacco industry’s use 

of FOIA, and to reduce the disruption of 

their programs. 

Understanding the 

Regulations on Lobbying 

Policy advocacy is distinct from lobbying, and that distinction became an 

important legal issue during ASSIST. 

Lobbying refers to promoting or fighting 

a bill that is actually under consideration 

by a legislative body. Policy advocacy 

refers to expressing support for a position on an issue or on a policy before it 

is under consideration for passage into 

law. Policy advocacy is a legitimate activity for federal and state government 

agencies and their employees and has 

never been prohibited. However, some 

ASSIST staff and coalition members 

tended to overinterpret restrictions on 

lobbying and believed that they could 

not do advocacy work. When ASSIST 

interventions began in the early 1990s, 

federal money could not be used to lobby at the federal level, but could be used 

to lobby state governments and local 

policy-making bodies in regard to policies. The laws and regulations changed 

during the course of the 8-year ASSIST 

project. Beginning with federal fiscal 

year 1997, the law that appropriated 

money for DHHS broadened the ban on 

using federal funds for lobbying and prohibited the lobbying of state legislatures.159 

FASA also was enacted during the 

course of ASSIST.160 The final rules implementing FASA were published on 

August 16, 1995, and the law became 

effective on October 1, 1995. Under 

FASA, “Costs incurred to influence (directly or indirectly) legislative action on 

any manner pending before Congress, a 

State legislature, or a legislative body of 

a political subdivision of a State”160 were 

deemed unallowable under federal contracts. By its own terms, FASA applied 

only to government contracts based on 

solicitations issued after October 1, 

1995. Because the original ASSIST contracts preceded that date, they were not 

affected by it. FASA’s total prohibition 

against using federal money to lobby at 

any level of government did apply to the 

1-year extension contracts issued to 

ASSIST states beginning October 1, 

1998, because these were considered 

new contracts. 

From the beginning and throughout 

ASSIST, the principal planners at NCI, 

the American Cancer Society (ACS), the 

ASSIST Coordinating Center, and state 

departments of health were highly sensitive to the myriad restrictions on how 

federal contract money could be spent. 

They were especially careful, because 

these numerous restrictions were occasionally contradictory, and often confusing, and they changed during the 

ASSIST era. The Internal Revenue Code 

(IRC) definition of lobbying is complex 

and in itself could be confusing. The 

IRC definition of lobbying excludes 

many kinds of activities (e.g., advocating for regulations and administrative 

352 
M o n o g r a p h 1 6. A S S I S T 

■ 

■ 

■ 

■ 

■ 

■ 

■ 

■ 

■ 

■ 

■ 

etc.); 

■ 

smoking policies, bans on smoking in restaurants, etc.; 

■ 

■ 

■ 

■ 

Example of Instructions to the States Regarding Lobbying 

“In the absence of an explicit definition, government specialists in cost principles urge reliance 

on the ‘customary’ definition of lobbying. . . . The best articulation of the customary definition of 

lobbying would be exactly what is contained in the Internal Revenue Code [IRC]. Therefore, for 

purposes of ASSIST, the IRC definition should guide contractors in determining what would be 

allowable costs under the contract. 

“Specific examples of likely activities that can and cannot be reimbursed under FAR and OMB 

Circular A–122 may help to clarify these rules. Under this regulatory scheme, for-profit and 

501(c)(3) awardees may not use federal contract money to: 

participate in electoral activities; 

work for or against passage of referenda or initiatives; 

lobby Congress to introduce or to pass legislation; 

lobby state legislators to introduce or to pass legislation; 

conduct grassroots lobbying on state or federal legislation; 

lobby members of the executive branch to urge the signing or vetoing of legislation; 

advocate that state or local officials should lobby Congress or state legislatures; 

conduct legislative liaison activities in ‘knowing preparation for,’ i.e., in support of 

unallowable activities. 

“It is equally clear that, until FASA applies to the ASSIST contract (i.e., beginning October 1, 

1998), for-profit and 501(c)(3) contractors may use federal contract money to: 

lobby legislative or policy-making bodies at the local level; 

lobby the executive branch (except to sign or veto a bill); 

lobby regulatory agencies at all levels (e.g., OSHA, EPA, FDA, state health departments, 

advocate the enactment or enforcement of ‘private’ or voluntary policies, e.g., workplace 

advocate the enforcement of existing laws, e.g., those that control tobacco sales to minors; 

conduct educational activities that help people understand issues and supporting evidence . . . ; 

conduct public education campaigns to affect the opinions of the general public . . . ; 

respond to documented requests by providing technical and factual presentations on topics 

directly related to your contract performance.” 

Source: ASSIST Contracting Officer. 1997. Restrictions on lobbying and public policy advocacy by 

government contractors: The ASSIST contract. July 18. Internal document, ASSIST Coordinating 

Center, Rockville, MD (pp. 11–12). 

actions, enforcement activities, and public education activities).161 In addition, 

activities that would constitute lobbying 

under some circumstances would not 

under others. For example, if the chair 

of a congressional committee asks an individual or organization to testify about 

an issue, nothing done in preparation for 

or delivery of that testimony constitutes 

lobbying. 

Throughout the life of ASSIST, much 

effort was invested in tracking, analyzing, and explaining to ASSIST contractors and subcontractors the laws and 

regulations that applied to their federal 

contract money and the different rules 

353 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

that applied to state governmental and 

nongovernmental partners. Assistance 

was provided through written guidelines,162 numerous training events,163 individual consultations, and other forms of 

technical assistance.164 For example, a 

1993 “White Paper,” which covered the 

limitations on lobbying, was updated 

and circulated by NCI to all ASSIST 

project directors and managers in 

1997.99,164 

Because the effectiveness of tobacco 

control efforts depends on various types 

of organizations fulfilling different roles, 

it was important that ASSIST coalitions 

include nongovernmental partners. Nonprofit organizations (including ACS)— 

sometimes known as 501(c)(3) groups or 

public charities—are legally allowed to 

lobby up to certain limits.165 In fact, the 

1976 Tax Reform Act specifically encourages nonprofit organizations to participate in public policy making. Although 

the ASSIST partners could and did use 

unrestricted nonfederal funds to lobby, 

the tobacco industry repeatedly made 

accusations of illegal lobbying, as described in the experiences of five states 

later in this chapter. 

Case Studies 

T

he tobacco companies continuously 

challenged ASSIST activities and 

staff. Case studies 8.1–8.5 describe the 

reactions of tobacco control advocates in 

Colorado, Washington State, Minnesota, 

Maine, and New York to the opposition 

their programs encountered. In Colorado, the tobacco industry filed five legal 

actions; although only minor infractions 

were upheld, the legal actions seriously 

impaired tobacco control initiatives in 

the state and had grave and serious repercussions for the Colorado ASSIST 

codirector. Similar complaints of illegal 

lobbying were filed against ASSIST in 

Washington State. Although minor infractions had occurred in reporting 

spending, the ruling indicated that they 

had not improperly used public funds for 

lobbying. In Minnesota, the tobacco industry’s strategy significantly deterred 

the implementation of local tobacco control ordinances but was unsuccessful in 

defeating comprehensive youth access 

legislation. Maine, on the other hand, 

having learned of the strategies used in 

other states, was ready when the tobacco 

industry brought charges there and attempted to discredit ASSIST publicly. In 

New York, when Philip Morris tried to 

implement a preemption strategy, tobacco control advocates turned the tables on 

the company, made charges of illegal 

lobbying, and won. The accusations that 

the tobacco industry had made against 

health advocates were actually used 

against the industry. 

Onward after the Opposition 

T

he ASSIST project was based on solid 

research, which had clearly indicated 

that public and private policy advocacy—in local, state, and federal legislatures, businesses, schools, and local 

communities—is an effective way to reduce smoking initiation and prevalence. 

This policy focus was a major problem 

for the tobacco industry. The documents 

demonstrate that tobacco industry executives were under a great deal of pressure 

in dealing with ASSIST’s local, commu354 
M o n o g r a p h 1 6. A S S I S T 

Case Study 8.1 

Full-Scale Challenge in Colorado 

Colorado, industry opposition in the 

other states seems piecemeal. In 

Colorado, the tobacco industry took 

complaints to the Colorado secretary 

tobacco industry to defeat a statewide grassroots question for the 

to support a political campaign issue. 

public health side of the tobacco tax 

ASSIST application process. 

” 

setting public policy been faulty? Is this my 

” 

without your help.

“But I’m still worried about the outcome of these 

in public health? . . .

” 

In relation to the tobacco industry’s 

full-scale challenge to ASSIST in 

a comprehensive approach through 

five legal actions: a lawsuit in 

Colorado’s district court, three 

of state, and a lawsuit in Federal 

District Court. These legal actions 

were a principal strategy of the 

November 1994 ballot that would 

raise the tax on cigarettes from 20¢ 

to 70¢. Through legal actions, the 

tobacco industry built a case in the 

popular press that ASSIST had 

violated Colorado’s Campaign 

Reform Act by spending state dollars 

Supporting the Tax Initiative 

Two principal entities worked on the 

initiative: the Coalition for a TobaccoFree Colorado (CTFC), a nonprofit 

501(c)(3) public health organization 

with experience in policy advocacy 

acitivities, and the Fair Share for 

Health Committee, a tax-exempt 

501(c)(4) political organization, 

which, by law, was permitted to 

lobby. CTFC had helped position 

Colorado to be competitive in the 

An All-Too-Personal Experience 

With my forehead in my palms and elbows 

perched on the edge of a long, dark mahogany 

conference table, I heard my attorney say, “Don’t 

worry, everything will be all right. I’ll be back in 

a few minutes. I have an urgent call to take.

Then, alone in the empty and unfamiliar room in 

a high-rent office building, I suddenly felt lonely 

and besieged. I gazed out the window over the 

16th Street pedestrian mall in downtown Denver 

and became frightened, thinking, . . . If the 

attorney general’s office doesn’t represent me, 

where will I get $50,000 for my legal defense? . . . 

Mortgage my house? . . . Borrow from family? 

Had my careful research into the legal 

parameters for state employee participation in 

reward for trying to prevent tobacco-caused 

death and disability? What will my family think? 

Are my children hearing negative comments 

about me at school? Will the media ever let up? . . . 

The door swung open and my attorney exclaimed, 

“Let’s make that call now to the attorney general.

In this call, my attorney implied that he might 

bring a suit against the state if the attorney 

general did not represent me. 

Replacing the phone receiver in its console, I said 

to my lawyer, “Thanks for your help. I don’t think 

I would have convinced them to represent me 

” They believed that I had 

willfully broken the law and therefore they would 

not have been obligated to represent me. 

lawsuits. What will it mean for me? . . . my career 

” I asked with great pause. 

In a commanding tone, my attorney said, “Don’t 

worry, just tell the truth, and the truth will set you 

free.

Never before had such a trivial statement meant 

so much. I felt immense relief. Finally, there was 

someone in my corner, someone with credibility 

who believed I had not broken the law. 

—Walter ‘Snip’Young 

355

8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

Case Study 8.1 (continued) 

Walter ‘Snip’ Young, the director of the Colorado Department of Health Division of 

Prevention Programs, was a long-time active member of CTFC and was the Colorado ASSIST project director. He was appointed to chair an ad hoc committee 

formed to plan a February 1993 community meeting where a proposed increase in 

the tobacco tax would be discussed. 

Through his research of Colorado statutes and consultation with an attorney knowledgeable in these matters, Young was aware that Colorado law permitted state 

employee involvement in matters of policy that could lead to voter initiatives, as long 

as he was not involved in his official capacity after the matter was before the electorate. In this case, that date was December 15, 1993. After the ballot petition language 

was filed, government employees could participate in voter-initiated actions only on 

their own time, as citizen advocates. 

This understanding of the law and his compliance with it provided Young with a 

false sense of security. He did not anticipate that his strict adherence to the law 

would not protect him from litigation and criticism in the press. 

T obacco Industry Groups 

The tobacco industry used many law firms and various organizations and individuals 

to oppose the tax initiative.a,b The Colorado Executive Committee—the political 

action committee formed to oppose the proposed tobacco tax increase—was organized by Colorado lobbyists at Hays, Hays & Wilsonc

 for the Tobacco Institute and 

other tobacco industry interests. The Colorado Executive Committee spent $5.5 

million, mostly for television and radio air time, on the political and public relations 

campaigns to defeat the tax initiative. The Colorado Executive Committee also 

formed a 501(c)(4) tax-exempt political organization called Citizens Against Tax 

Abuse and Government Waste. This organization’s name was attached to political 

ads run by the tobacco industry during the campaign. Groups supported by the 

tobacco industry (such as the American Constitutional Law Foundation, Smoker 

Friendly Stores, and a few individual owners of smoke shops and discount cigarette 

stores) filed the lawsuits described in the following paragraphs. Most of the openrecords research that went into building the cases for the American Constitutional 

Law Foundation was conducted by an attorney employed by Hays, Hays & Wilson. 

According to a 1996 Tobacco Institute budget document, disclosed during the 

Minnesota tobacco consumer fraud lawsuit, the American Constitutional Law 

Foundation was paid $60,000 in 1995 after the defeat of the Colorado tobacco tax 

initiative.c 

After acquiring more than 6,000 pages of documents from the Colorado Department 

of Health, the tobacco industry groups filed a second open-records request, which 

produced about 5,000 pages of documents that were never claimed. This action 

356 
M o n o g r a p h 1 6. A S S I S T 

reflected a tactical strategy used by the tobacco industry affiliates to divert Colorado 

Department of Health resources and ASSIST staff and volunteers from matters 

related to tobacco control. 

Legal and Regulatory Actions 

Action #1. The first lawsuit was triggered by a series of requests for documents that 

were filed under Colorado’s public records law by a local lobbying firm known to 

represent the Tobacco Institute.c Although the request in February 1994 came from a 

Colorado state representative on the Legislative Audit Committee, staff suspected 

that the letter was written by tobacco industry attorneys, because it sought specific 

documents by names generally known only to those close to the program and the 

tobacco industry (e.g., ASSIST annual action plan, comprehensive tobacco use 

reduction plan). The letter signaled the start of a year-long legal and public relations 

struggle for Colorado ASSIST. 

At the time, files and records for CTFC were stored in the ASSIST office of the 

Colorado Department of Health and had been kept in these offices for many years 

before the start of ASSIST because the Colorado Department of Health provided 

administrative and clerical assistance to CTFC. When the open-records request for 

CTFC files was received, Young told the president of the coalition about the request, 

and CTFC removed the files the next day. The Tobacco Institute’s local attorneys 

then filed a lawsuit in Colorado’s district court to obtain the CTFC records. According to Young, the state attorney general did not vigorously defend this suit, because it 

was determined that since the Colorado Department of Health employees had access 

to these records, they were deemed public records under Colorado statute. 

Tobacco Institute attorneys were interested primarily in obtaining a copy of the 

recently completed application for funds submitted to The Robert Wood Johnson 

Foundation’s (RWJF’s) SmokeLess States Project. This application proposed to run a 

prevention and public education campaign about tobacco use during the fall of 1994. 

The tobacco industry prevailed in district court, and CTFC records (including the 

RJWF application for funds) that had been on site at the Colorado Department of 

Health were turned over to tobacco industry attorneys. 

On July 12, 1994, a Washington, D.C., law firm sent a letter to the RWJF staff 

member managing the SmokeLess States competition, complaining that the planned 

timing of the CTFC public education campaign was “no coincidence.” It stated that 

“this [public education campaign] obviously could have adverse tax consequences 

for the foundation” and that “our clients and we would strenuously object to any use 

of the private foundation funds to support . . . a lobbying effort.”d The tobacco 

industry was trying to intimidate the RWJF Board into not funding the Colorado 

application, claiming that it was an illegal contribution to the tax initiative campaign. 

357 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

Case Study 8.1 (continued) 

A few days later, a letter from a Colorado attorney was sent to the major media 

outlets and advertising firms in Colorado “warning” them that they might not recover 

money that they might spend to purchase television, radio, and newspaper ads under 

contract with CTFC or RWJF. The letter stated, “We will pursue this matter vigorously and, if necessary, file complaints against the Robert Wood Johnson Foundation 

and CTFC with the Internal Revenue Service as well as seek injunctive relief in 

Federal Court.”e 

Action #2. The second legal action was a complaint filed with the Colorado Secretary 

of State by the Citizens Against Tax Abuse and Government Waste. In a promotional 

campaign, a Denver radio station gave away baseball tickets to smokers who would 

toss their cigarettes into a coffin that was set up at a bus station where American 

Cancer Society volunteers were seeking signatures to qualify the excise tax initiative 

for the November state ballot. The complaint charged that the activity constituted 

“bribery.” The radio station publicized the complaint, which was then dropped. 

Action #3. The third legal action, a complaint by the American Constitutional Law 

Foundation, charged that the Colorado Department of Health and Young himself had 

violated Colorado’s Campaign Reform Act by helping to plan the state initiative to 

raise tobacco taxes. The secretary of state ultimately exonerated the Colorado 

Department of Health and Young of any illegal activity and rejected the complaint, 

except for three minor violations: 

1. Mentioning the tax initiative in an ASSIST newsletter 

2. Preparing a presentation (which was never delivered) about the Colorado tax 

initiative for an international lung cancer conference in Colorado Springs 

3. Contributing to the Fair Share for Health Committee (FSHC) through its annual 

dues to CTFCf 

Action #4. The American Constitutional Law Foundation also filed a complaint 

against the Fair Share for Health Committee. The complaint alleged that the Fair 

Share for Health Committee had failed to disclose in-kind contributions (totaling less 

than $100) to the campaign made by the Colorado Department of Health. The 

secretary of state subsequently determined that three items should have been reported that were not, and the Fair Share for Health Committee amended its campaign 

contribution reports to reflect the items. 

Action #5. In an apparently frivolous lawsuit brought in Federal District Court, the 

American Constitutional Law Foundation charged the Boulder County Health 

Department, the Colorado Department of Health, and specific staff members with 

violating the First, Fifth, Ninth, Tenth, and Fourteenth Amendments and Article IV, 

Section 4, of the U.S. Constitution by using public funds to support a voter-initiated 

358 
M o n o g r a p h 1 6. A S S I S T 

action. The court dismissed this lawsuit in 1995 for lack of evidence. It was appealed 

and dismissed again later the same year. 

A Lost Opportunity 

Ultimate exoneration from these various charges was a hollow victory. These public 

health groups and individuals all operated within the confines of the laws that 

chartered and governed them (with the exception of the minor violations mentioned 

in Action #3), yet the tobacco industry was successful in spinning the public health 

involvement as illegal. By casting the collaborative activities of these entities as an 

improper and perhaps illegal entanglement of the government and private sector, the 

tobacco industry diverted attention away from the public health message and toward 

the message of big government acting improperly or illegally. 

Specifically, Young’s involvement in the early planning stages for the tax initiative, 

although prior to placement of the ballot question before the electorate and, therefore, within the confines of the law, was eventually characterized in the popular press 

as “improper,” if not illegal. Tobacco industry attorneys provided to the local press 

excerpts that they had drawn from their open-records requests—with the tobacco 

industry’s spin on the information and supporting documentation. Simply by raising 

questions about the propriety of ASSIST actions, the tobacco industry put the 

Colorado Department of Health, ASSIST, and Young on trial in the court of public 

opinion. 

Eventually, the Colorado attorney general agreed to represent Young and the other 

state employees who were named personally as defendants (after Young’s attorney 

threatened her office with a lawsuit), but the social and psychological stresses 

imposed on these people were severe. 

The costs to Colorado’s tobacco control effort were also large. A poll conducted in 

spring 1993 had documented that 72% of Colorado voters supported the proposed 

50¢ per pack increase in Colorado’s cigarette tax. Nevertheless, the tax initiative 

campaign, hampered by insufficient funding and mired in the legal challenges, was 

overwhelmed by the tobacco industry, which spent more than $5 million to oppose 

the referendum. In November of that year, the initiative (Amendment 1/CO Tobacco 

Tax Initiative) was defeated at the polls by a margin of 20% (60% against, 40% for).g 

Insights 

Being named as a defendant in a legal action is traumatic; however, such experience 

offers valuable insights that might benefit other state tobacco control programs and 

their community partners. 

First, a state health agency tobacco control program should establish a working 

relationship with the state attorney general’s office. In this way, trust and understanding 

359 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

to tobacco industry challenges (see chapter 3). Each should monitor the actions of 

a

possession. 

b

c

2216. 

d

e

f

2004). Bates no. 522525513–5541. 

g . 

Case Study 8.1 (continued) 

between attorney and client will be established prior to any tobacco industry legal 

actions. It is particularly important that this be done now that state attorneys general 

are responsible for monitoring compliance with the Master Settlement Agreement. 

State tobacco control program staff should be aware of violations of the Master 

Settlement Agreement, learn of complaints filed by others, and/or bring their own 

complaints to the attorney general’s office. 

Second, each state tobacco control program should develop a strategic communication plan that guides responses of the health agency and nongovernmental agencies 

the tobacco industry, examine potentially vulnerable areas of the state program, and 

anticipate the tobacco industry’s opposition to public health advocacy actions. 

Third, engaging state and local public health leaders in planning tobacco control 

efforts has never been more important. High-level state government officials tend to 

be more involved now because of the need for executive management of Master 

Settlement Agreement funds, yet this involvement could be more broadly based and 

involve communities. Involvement of high-level leadership and management will 

help to deflect assaults on government agencies and criticism of policy actions. 

—Walter ‘Snip’Young, former Colorado ASSIST Project Director 

and Director of the Division of Prevention Programs of the 

Colorado Department of Health (CDH) and currently 

Scientist, The Cooper Institute, Golden, Colorado 

Flora, M. E. Letter to Betsy Zakely. June 9, 1994. Kelley, T. B. Letter to Julie Merrick. June 22, 1994. 

Hays, F. L. III. Letter to select Colorado advertising firms. July 15, 1994. Perlman, B. A. Letter to Joyce 

Herr. September 30, 1994. O’Toole, N. D. Letter to Joyce Herr. December 1, 1994. In the author’s 

U.S. District Court for the District of Colorado. Civil Action 94-2239. September 29, 1994. 

Adams, W. A. 1995. Memorandum re: 1996 Tobacco Institute budget. October 27. The Tobacco 

Institute. http://legacy.library.ucsf.edu/tid/rju28d00 (accessed May 18, 2004). Bates no. 2041212088– 

Temko, S. L. 1994. Letter to Edward H. Robbins, proposal manager, The Robert Wood Johnson 

Foundation, July 12. Internal document, Covington & Burling, Washington, DC. 

Hayes, F. L. III. 1994. Letter to select Colorado advertising firms. July 15, 1994. 

Hopf, N. A. Before the Secretary of State, State of Colorado. Case no. OS 94-02. Initial decision, 

American Constitutional Law Foundation and Lonnie Hayes v. Colorado Department of Public Health 

and Environment and Pueblo CI, 25. http://legacy.library.ucsf.edu/tid/ygo60d00 (accessed May 18, 

Schrader, A. “Smoke tax goes down in flames. Tobacco lobby fends off Amend. 1” The Denver Post

November 9, 1994. 

360 
M o n o g r a p h 1 6. A S S I S T 

Case Study 8.2 

Work Disruptions in Washington State 

requests under FOIA in SeptemDepartment of Health had 

more than 5,000 pages of 

records; supplying these records 

consumed 360 person-hours of a

 Subsewith the State Public Disclosure 

public funds improperly for 

almost identical to those made 

(described in case study 8.1). It 

the complaint against Colorado 

ASSIST also helped prepare the 

State ASSISTb

 and (2) that the 

c–e 

1. 

funds. 

2. 

3. 

4. 

consultants. 

5. 

accounts. 

6. 

7. 

8. 

1. 

2. 

3. 

4. 

The ASSIST project in Washington State began to receive 

ber 1994; over time, the requests 

grew in size, scope, and specificity. Soon the Washington 

supplied to tobacco lawyers 

state employees’ time.

quently, attorneys purporting to 

represent an individual tobacconist filed a 425-page complaint 

Commission against ASSIST, 

the Washington Department of 

Health, the Washington State 

Division of ACS, and the 

Tobacco-Free Washington 

Coalition. The complaint 

charged, among other things, 

violations of state law by using 

lobbying. These charges were 

against Colorado ASSIST 

was discovered and eventually 

reported in the news media 

(1) that the attorney who filed 

complaint against Washington 

Tobacco Institute, not the 

individual tobacconist, had paid 

the legal fees involved. 

Tobacco Institute Strategy for Investigating and 

Impeding the Washington State ASSIST Project 

“We would recommend that you hire a private 

investigator to pursue the following: 

Research ownership, tax status, etc., of vendors, 

consultants, companies receiving ASSIST 

Compile aggregate totals of all expenditures 

made by state employees and reimbursed 

expenses received. 

Total all entertainment, catering, hotel, travel 

expenses. 

Determine connection, if any, between 

temporary services provided and campaign 

Cross match Prop. 43 expenditures, 

contributions, etc. with TFW and ASSIST 

Research actual expense vouchers presented by 

ASSIST employees. 

Research competitive bidding process on 

ASSIST awarded contracts to determine any 

violations of state law. 

Review committee sign-up sheets for names 

that match with ASSIST payments in order to 

determine if any of the witnesses received 

payment for appearing before the Legislature. 

Potential Actions: 

State Auditor Review: The State Auditor could 

audit the ASSIST program upon a request of a 

legislator. 

Media: We could turn information over to an 

investigative reporter or to a tax ‘watch dog’ 

group for public distribution. 

Legislative: We could request a standing 

committee of the Legislature to hold hearings & 

investigate. 

Legal Action: Depending on what we find . . . ?” 

Source: Fritz, B., T. K. Bentler, J. Daniels, and S. Halsan. 

1995. ASSIST information. Memorandum to B. McAdam 

of the Tobacco Institute, May 23, 1995. http:// 

legacy.library.ucsf.edu/tid/txt07d00 (accessed May 18, 

2004). Bates no. TNWL0020835. 

361

8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

f

 Substantial tobacco 

—

a

article.) 

b Seattle 

c . October 24. 

d . 

e

f

of Health

Disclosure Commission. 

Case Study 8.2 (continued) 

The Washington State Public Disclosure Commission issued its final order in this 

case in December 1999. In the final order, the department of health conceded that it 

had inadvertently failed to disclose the funding of four programs that it was required 

to report. The department paid a $2,500 penalty and implemented a training program 

about compliance with Washington State’s lobbying laws.

industry resources were spent, with minimal identification of program misconduct. 

Anne Marie O’Keefe, 

former Policy and Media Advocacy 

Manager, ASSIST Coordinating Center 

Levin, M. 1996. Legal weapon. Los Angeles Times. April 21. (Kim Dalthorp, a former Washington 

Department of Health tobacco control official and ASSIST Co-Project Manager, is quoted in this 

Murakami, K. 1995. Tobacco Institute backs complaint against state anti-smoking program. 

Times. November 10. 

Paulson, T. 1995. Cough up documents, agency told. Seattle Post-Intelligencer

Paulson, T. 1995. Smokers’ rights advocate files complaint against state. Seattle Post-Intelligencer

November 10. 

Mapes, L. V. 1995. Smokers’ rights advocate says foes aren’t fighting fair. The Spokesman-Review.com. 

November 10. 

Washington Public Disclosure Commission. 1999. Enforcement Action v. Washington State Department 

 (PDC case no. 97-192). Final order, December 21, 1999. Olympia: Washington Public 

Case Study 8.3 

In Minnesota: Multiple Strategies, Multiple Defeats—Ultimate Victory 

In June 1991, Minnesota was awarded an ASSIST contract of $6.3 million over a 7­

year period. (It was later extended for 1 year as all the state contracts were.) Within 

months, the tobacco industry began a coordinated effort of multiple tactics to interfere with the plans and interventions of ASSIST local coalitions. The extent of the 

industry’s tactics and the degree to which they were coordinated were not apparent to 

ASSIST staff and volunteers. Only after the tobacco industry documents became 

public, as a result of the lawsuit State of Minnesota and Blue Cross/Blue Shield of 

Minnesota v. Philip Morris, Inc., et al., did they understand what they had been 

working against. Tobacco industry tactics to counter ASSIST in Minnesota included 

threats of lawsuits, FOIA requests, confrontational face-to-face meetings with health 

department staff, and even an application for an ASSIST grant. The industry filed 

complaints against ASSIST grantees with elected officials and filed a formal complaint with the state Ethical Practices Board. Tobacco lobbyists attended at least one 

ASSIST quarterly meeting. As illustrated and documented in this case study, the 

362 
M o n o g r a p h 1 6. A S S I S T 

industry’s strategy in Minnesota resulted in repeated defeats of comprehensive youth 

access legislation and delays in implementing local tobacco control ordinances. The 

industry’s tactics intimidated the tobacco control practitioners. 

FOIA Requests 

The tobacco industry used FOIA requests to learn the plans that ASSIST had for 

tobacco prevention and control interventions. Between September 7, 1993, and 

February 8, 1996, tobacco-related interests filed 11 FOIA requests with the Minnesota Department of Health (MDH). Through a FOIA request, the Minnesota ASSIST 

comprehensive tobacco control plan became available to the industry. 

Minnesota attorney Tom Briant was retained as a consultant by individual tobacco 

companies and the Tobacco Institute to coordinate the Minnesota Local Response 

Project, the purpose of which is clear from the following memorandum from Thomas 

A. Briant to Minnesota Sales Representatives/Sales Managers/Sales Directors of 

Philip Morris, July 20, 1994: 

The Project involves coordinating the response of the tobacco retailers to local ordinances and state legislation that seeks to regulate tobacco products. . . . A significant 

part of the Project is the development of a communications network between you and 

myself. I need your assistance to inform me of any proposed local ordinances or other 

local restrictions on tobacco products or the sale of tobacco products.a 

As an example of his involvement, Briant noted, in a letter to tobacco retailers in 

Litchfield before a City Council meeting on a proposed ordinance, “I represent the 

Minnesota Coalition of Responsible Retailers. The Coalition is comprised of five 

state trade associations that have an interest in the retail issues.”b 

Threats of Lawsuits 

On September 23, 1993, Briant filed a FOIA request for materials related to the 

ASSIST contract, but his activities were not limited to opposing ASSIST initiatives. 

For example, in December 1993 and January 1994, he spoke against an ordinance 

that would restrict point-of-sale advertising in the Minnesota city of Brooklyn 

Center. He attended the public hearing on the ordinance and wrote a letter to the city 

council suggesting that the city would face litigation with the tobacco industry if the 

ordinance were to become law. 

Lawsuits 

In May 1994, Preston, a town of 1,500 residents in southern Minnesota, passed an 

ordinance restricting point-of-sale advertising. In December, Jim Larkin, a founding 

partner at one of Minnesota’s largest law firms that was representing the owner of a 

Preston convenience store, filed a lawsuit against the city. Larkin claimed not to 

know who was paying his fees to represent Binh Chiglo,c

 but Peggy Carter of R.J. 

363 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

Case Study 8.3 (continued) 

Reynolds was quoted in a newspaper article as saying that R.J. Reynolds is “helping 

with some of her [Ms. Chiglo’s] legal fees.”d While the Preston case was pending, the 

Stillwater city council tabled a proposal to ban in-store advertising of tobacco 

products; the ban was proposed by the ASSIST coalition, Tobacco-Free Future. e 

Briant, representing the Minnesota Coalition of Responsible Retailers, then wrote 

letters to Stillwater tobacco retailers, urging them to oppose the proposal.f The court 

overturned the ordinance, ruling that the Preston ordinance was preempted by federal 

law. Preston did not appeal, and Stillwater did not go ahead with its ordinance. 

The FOIA requests for the Preston case had other reverberations. On June 30, 1995, 

Larkin wrote a letter to the MDH ASSIST project director stating that in the 

discovery process for the Preston case they had learned of activities by ASSIST that 

they believed violated the Federal Acquisition Streamlining Act: 

See for example, the attached materials from your records of the application of Brian 

Bates for ASSIST funds. No applications for ASSIST funds should be approved which 

contemplate the use of ASSIST funds to lobby state or local legislative bodies. I believe 

that this would include use of such funds to defend these ordinances. In discovery in 

the above case, the City of Preston admitted that its ordinance was prompted by direct 

solicitation from Mr. Bates’ organization.g 

The letter concludes, 

Thus I believe it is clear that the department should not approve any ASSIST subcontracts or subgrants that contemplate use of federal funds for such purposes.g 

As a result of the letter, even though ASSIST staff believed they were acting properly 

and legally, they began devoting increasing amounts of their time to documentation 

due to concerns about potential lawsuits. 

Formal Complaints 

Another large FOIA request was submitted to MDH in August 1995; four pages 

detailed documents beginning with the first quarterly reports of ASSIST. These 

documents became the basis for a complaint filed by the Minnesota Grocers Association, Inc. The complaint, “RE: Unlawful Use of Federal Taxpayer Dollars by Minnesota Department of Health and Violations of State Lobbyist Registration and Reporting Laws” was filed with Minnesota Governor Arne Carlson and State Auditor Judy 

Dutcher, with a copy sent to the Ethical Practices Board. Two months later, the 

Minnesota Grocers Association filed ethical practices complaints against 17 ASSIST 

subcontractors. The complaint received newspaper and television coverage. The 

outcome of the filing was described by Briant in a confidential memo to five persons 

at the Tobacco Institute, two at Philip Morris, one at RJR, and one at U.S. Tobacco: 

The entire Minnesota ASSIST Project has been placed on indefinite hold until the 

outcome of the pending investigation by the Minnesota Department of Health and the 

Ethical Practices Board. This includes 1995–1996 ASSIST grants which have been 

364 
M o n o g r a p h 1 6. A S S I S T 

approved, but the contracts between the Department of Health and the ASSIST groups 

have not been executed nor have the 1995–1996 ASSIST funds been disbursed. These 

revelations come directly from Barbara Nerness, the Assistant Commissioner of the 

Minnesota Department of Health, in a telephone conversation I had with her earlier today.h 

The memo continued, 

Barbara [Nerness] also stated that if the Department’s investigation demonstrates that 

the ASSIST groups did indeed use federal funds for lobbying, then the Department of 

Health will take all necessary corrective action. She also stated that the Department will 

not protect anti-smoking zealot groups (her words) if they used federal funds for 

lobbying purposes.h 

In a September 1995 activity report to Philip Morris, Media Services Incorporated 

reported having “launched a major effort to interest local editors and reporters in an 

investigative story on the anti-tobacco lobby illegally using federal ASSIST monies 

to lobby local and state officials contrary to federal rules and regulations.”i 

In February 1996, however, the Ethical Practices Board dismissed the Minnesota 

Grocers Association complaint against 15 of 16 ASSIST groups and found only that 

the Minnesota Coalition for a Smoke-Free Society 2000 did not disclose $40.00 

spent for producing and distributing an action alert that urged others to communicate 

with legislators about a retail tobacco licensing bill. 

Countering Legislation 

The First Youth Access Bill. In 1995, a bill was introduced in the Minnesota state 

legislature that would have required mandatory licensing of retail cigarette sales and 

would have supported compliance checks and fines for selling to minors. The 

tobacco industry opposed the bill and instead promoted bills to limit the licensing 

authority of local governments and to preempt local ordinances in favor of the 

industry. The industry-backed bills called for (1) a statewide mandatory training 

standard for retail clerks engaged in retail sales of tobacco and (2) a system for 

j compliance checks.

On February 25, 1996, 2 days before the Minnesota House of Representatives vote 

on the industry-promoted bill, the Association for Nonsmokers–Minnesota staff 

found an envelope under their office door. The document in the envelope appeared to 

be a status report that Briant had sent to individuals at the Tobacco Institute, Minnesota Wholesale Marketers Association, Licensed Beverage Association, Minnesota 

Retail Merchants, Minnesota Petroleum Marketers, RJR Grassroots Consulting, 

Philip Morris, Lorillard, U.S. Tobacco, Brown and Williamson Tobacco Company, 

R.J. Reynolds, and the Smokeless Tobacco Council. The document showed the deep 

reach of the tobacco industry into local communities, with monitoring and reporting 

to the highest level of the tobacco industry activities of towns as small as 2,000 

residents. State representative Matt Entenza read the memo on the floor of the House 

365 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

Case Study 8.3 (continued) 

of Representatives, effectively taking the mask off the Coalition for Responsible 

Retailers, which had argued that they were merely a group of local retailers, with no 

connection to the tobacco industry. “After rather lengthy and heated debate” the 

House voted to delete preemption from the bill and the bill was pulled.k 

The Second Youth Access Bill. A renewed effort was made to pass a comprehensive 

youth access law when the legislature reconvened in 1997. Both sides were fully 

mobilized. Preemption was the issue. The health campaign fighting preemption 

included the Smoke-Free Coalition, ASSIST coalitions, the Children’s Defense 

Fund, health maintenance organizations, medical associations, voluntary health 

organizations, and the state’s attorney general. The League of Minnesota Cities 

weighed in heavily against preemption. On the other side were the tobacco industry 

and their retail allies. 

At a critical point in the legislative battle, a member of the health coalition thought 

that compromise could be worked out with the retailers, but the other members 

disagreed. One person overheard a tobacco lobbyist say, “Don’t worry about the 

coalition; when they start to go down, they eat their own.” Subsequently, “Don’t eat 

our own” became a rallying cry for the coalition, and the coalition members pulled 

together and won passage of one of the strongest youth access bills in the country— 

with no preemption. 

Tobacco Industry Tactics 

To achieve “desired results of putting the antis on the defensive regarding ASSIST 

funding”l

 the tobacco industry called editorial board meetings and wrote guest 

editorials. In addition, the tobacco industry sponsored media fly-arounds (airplane 

tours from town to town to meet with media representatives) and phone banking 

(contacts with a list of supporters to request that they call their legislators to oppose 

the bill). The media fly-arounds were planned and managed for Philip Morris by 

Media Services Incorporated.m The telephone bank operation was proposed by Briant 

on letterhead of the Minnesota Coalition of Responsible Retailers.n,o In the end, the 

tobacco industry succeeded in intimidating tobacco control practitioners and delayed 

tobacco control interventions, but ASSIST continued to function, and the coalitions 

passed and implemented numerous local and state initiatives while developing a 

formidable grassroots network in response. 

—Jeanne Weigum, Association for Nonsmokers–Minnesota 

a

Briant, T. A. Confidential memorandum to Minnesota sales representatives, sales managers, and sales 

directors of Philip Morris. July 20, 1994, 1. http://legacy.library.ucsf.edu/tid/rin38c00 (accessed May 

25, 2004). Bates no. 2061902465. 

b

Briant, T. A. Letter to Litchfield tobacco retailers. February 16, 1995. http://legacy.library.ucsf.edu/tid/ 

rbj61d00 (accessed May 25, 2004). Bates no. 51512003-2005.


c

Franklin, R. 1994. Preston, Minn., sued for banning tobacco ads where products sold. Minneapolis Star


Tribune. December 13.


366 
M o n o g r a p h 1 6. A S S I S T 

d

. December 13. 

e . June 12. 

f

tid/rms13c00 (accessed May 25, 2004). Bates no. 94040084. 

g

h

qyx83e00 (accessed May 25, 2004). Bates no. 2047077566–7567. 

i

j

k

l

(accessed May 25, 2004). Bates no. 2047062557. 

m

thu28d00 (accessed May 25, 2004). Bates no. 20478700052. 

n

pzt28d00 (accessed May 25, 2004). Bates no. 2062976202. 

o

rzt28d00 (accessed May 25, 2004). Bates no. 2062976204–6205. 

Dougherty, M. 1994. Cigarette ad ordinance pits tiny Preston against tobacco giant. Rochester (MN) 

Post Bulletin

Broede, J. 1995. Town #2 may ban in-store tobacco ads. St. Paul (MN) Pioneer Press

Briant, T. A. Letter to the Stillwater Tobacco Retailer, January 12, 1996. http://legacy.library.ucsf.edu/ 

Larkin, J. P. Letter to Richard Welch. June 30, 1995. http://legacy.library.ucsf.edu/tid/kze30d00 

(accessed November 9, 2004). Bates no. 518239682–9684. 

Briant, T. A. 1995. Update on Minnesota Project ASSIST investigation. Confidential memorandum to 

five persons at the Tobacco Institute, two at Philip Morris, one at R.J. Reynolds, and one at U.S. 

Tobacco. Minnesota Wholesale Marketers Association. November 21. http://legacy.library.ucsf.edu/tid/ 

Media Services Inc. 1995. Activity report to Philip Morris. September. http://tobaccodocuments.org/ 

pm/2044420610.html (accessed April 28, 2005). Bates no. 2044420610. 

Lenzi, J. 1996. MN-3A game plan. Memorandum to T. Walls, D. Crawford. January 10. http:// 

legacy.library.ucsf.edu/tid/ugt28d00 (accessed May 25, 2004). Bates no. 2062985025–5027. Note: 

Master document ID range 2062985024–5027 contains T. Walls document. 

Lenzi, J. Memorandum to T. Walls re: Minnesota retailer bill. February 29, 1996. http:// 

legacy.library.ucsf.edu/tid/clo52d00 (accessed May 25, 2004). Bates no. 2047216418A-6419. Note: 

6418A also contains memo from Walls to Lenzi. 

ASSIST conference call agenda. February 29, 1996. http://legacy.library.ucsf.edu/tid/bgu28d00 

Media Services Inc. 1995. Plan for media fly-arounds. June 25. http://legacy.library.ucsf.edu/tid/ 

Briant, T. A. 1996. Telephone bank operation proposal. February 2. http://legacy.library.ucsf.edu/tid/ 

Briant, T. A. 1996. Telephone bank operation proposal. February 5. http:legacy.library.ucsf.edu/tid/ 

Case Study 8.4 

On Alert in Maine 

By the time the tobacco industry brought its strategy of FOIA requests and legal 

accusations to Maine, ASSIST personnel had discerned the pattern in other states and 

were prepared. The Maine Department of Human Services (DHS) received a FOIA 

request, dated November 21, 1996, for all ASSIST documents. The request, filed by 

an Augusta attorney who stated that he was acting on his own initiative, reflected 

almost verbatim requests made in other ASSIST states. In responding to the request, 

the department’s staff invited local television stations to film the staff members 

hunting through boxes and filing cabinets of documents. This coverage exposed the 

tobacco industry’s tactics as burdensome harassment and presented opportunities for 

media advocates to frame tobacco use as the chief preventable cause of death in 

Maine. Rather than presuming her staff had done something wrong, Dr. Dora Mills, 

director of Maine’s Bureau of Public Health, went on the offensive, declaring, “The 

public has a right to know this is happening and it will tie up our staff for quite a few 

367 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

Case Study 8.4 (continued) 

days.”a A newspaper headline asked, “The smoking gun? Some Mainers think 

cigarette makers’ request for hundreds of documents is an attempt to stall 

legislation.”a An editorial announced, “Tobacco industry bungles use of right-toknow law.”b 

The documents obtained from the FOIA requests later appeared in a notebook 

labeled “Survey of DHS ASSIST Files,” distributed by a Maine tobacco lobbyist to 

every member of the legislative committee then considering an increase in the 

cigarette excise tax. The notebook organized its accusations into five sections, the 

last of which included the familiar false charge of illegal lobbying. The “survey” 

included details such as copies of travel and expense account vouchers for ASSIST 

staff seeking reimbursement for attending meetings. The notebook featured a graph 

labeled “Maine Adult Smoking (Age 18+) and Cumulative ASSIST Dollars Spent to 

9/30/96,” cited as compiled from Maine DHS ASSIST files. The graph plotted 

Maine’s annual smoking prevalence from a high of 27.8% in 1986 to 25% in 1995 

against the steep upward curve of cumulative annual ASSIST spending—making 

tobacco control look like a bad investment. 

An April 23, 1997, letter from another Maine lawyer to Maine’s attorney general 

advised him that a review of the ASSIST files revealed illegal activities. Among 

other demands, the letter said that the attorney general “should launch an immediate 

investigation in conjunction with the State Auditor’s Office to determine the responsibility of state officials who knew of, condoned or encouraged illegal lobbying 

practices and determine what steps the State of Maine should take to put an immediate end to these activities.”c 

Tobacco control leaders in Maine immediately responded to the charges in the survey 

notebook and in the letter to the attorney general. With speed and accuracy resulting 

from its nationwide information sharing and readiness, the national ASSIST program 

staff prepared and distributed its own notebook, titled “Tobacco Industry Campaign 

of Harassment Against State Public Health Agencies: Latest Target—Maine.” The 

notebook exposed the false allegations and distortions and the similarities between 

the FOIA requests and charges made in Maine and those made in other ASSIST 

states. It also accurately described the goals and activities of ASSIST. 

On May 22, 1997, the assistant attorney general for health responded to all charges 

made in the letter, corrected the misstatements of law and fact, pointed out the “lack 

of any evidence that any state laws have been violated,” and concluded that “a closer 

look at federal law reveals that these allegations do not violate any specific provisions of federal law and certainly do not warrant investigation by the Attorney 

General’s Office.”d 

—Anne Marie O’Keefe, former Policy and Media 

Advocacy Manager, ASSIST Coordinating Center 

368 
M o n o g r a p h 1 6. A S S I S T 

a

. December 17. 

b . December 17. 

c

d

The smoking gun? Some Mainers think cigarette makers’ request of hundreds of documents is attempt 

to stall legislation. 1996. Lewiston (ME) Sun Journal

Tobacco industry bungles uses of right-to-know law. 1996. Kennebec (ME) Journal

Doyle, J. R. Letter to Andrew Ketterer, Esq., Maine attorney general. April 23, 1997. http:// 

legacy.library.ucsf.edu/tid/pce30d00 (accessed October 1, 2004). Bates no. 518270712–0716. 

Leighton, C. C. (assistant attorney general; director, health and instructional services unit). Letter to 

Jon R. Doyle. May 22, 1997. 

Case Study 8.5 

New York State Defeats Tobacco Industry’s Attempt to Impose Preemption 

In 1994, the New York City Council, led by Speaker Peter Vallone, enacted smoking 

restrictions that were far more comprehensive than existing state law. The new 

legislation prohibited smoking in the indoor dining areas of restaurants with more 

than 35 seats. Smoking was still permitted in smaller restaurants, bar areas of 

restaurants, and stand-alone bars and taverns.a Internal industry documents show that 

the tobacco companies battled the proposed restrictions fiercely, spending hundreds 

of thousands of dollars and deploying a team of corporate and contracted lobbyists in 

a vain effort to defeat the measure.b At the time, the New York tobacco control 

coalition did not know the extent of specific tobacco industry funding and other 

resources expended to obstruct the coalition’s efforts. 

Shortly after the bill was passed by the New York City Council in November 1994, 

George Pataki was elected governor of New York. On December 13, Philip Morris 

chief executive officer Geoffrey Bible sent a letter to governor-elect Pataki.c

 Bible 

wrote, “It was a pleasure visiting with you last night.”c

 His letter laid out the company’s objections to the “Vallone Bill” and argued that the bill should be weakened to 

protect the “City’s economy from sudden economic fallout” that would result from 

the regulations on smoking in restaurants and other public places. In fact, no such 

“fallout” occurred; rather, New York City’s hospitality industry enjoyed an unprecedented boom in the following years.d

 On December 15, 1994, a check from Philip 

Morris in the amount of $25,000 was deposited to the governor’s then-undisclosed 

inaugural account.e (See part 1 of this chapter, strategy 8.) 

On December 19, 1994, Philip Morris corporate lobbyist Sharon Portnoy distributed 

the “NY SWOT and preemption plan” to advocacy and communication staff within 

the company and scheduled a meeting to discuss it.f A Lorillard memo (dated 

February 27, 1995) reported that the tobacco companies had developed a “New” 

New York City Plan. The memo said, “The United Restaurant and Tavern Associa369 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

Case Study 8.5 (continued) 

tion of New York State was a tremendous ally during the legislative battle [in New 

York City]. They have agreed to spearhead continuing efforts. . . .”g 

On April 25, Scott Wexler, executive director of the New York Tavern & Restaurant 

Association (the group operated under several names), sent a nine-page proposal to 

the Tobacco Institute’s New York lobbyist requesting between $307,400 and 

$419,900 to “seek enactment of state legislation that establishes uniform standards 

for the regulation of smoking which preempts any local action in this area.”h The 

Tobacco Institute’s 1996 budget shows that in 1995 its special projects account 

center allocated $279,700 to a “New York State Preemption Plan.”i 

On May 11, 1994, New York State senate majority leader Joseph Bruno met with 

chief executive officer Geoffrey Bible, Sharon Portnoy, and Ellen Merlo at Philip 

Morris’s Manhattan headquarters. Merlo followed up with a letter that said, “We all 

j took great comfort in the message that you had to deliver.” On June 12, the state 

senate rules committee, controlled by State Senator Bruno, introduced legislation 

preempting all local laws and regulations “concerning the sale, distribution, use or 

display of tobacco products.”k 

Alerted to the preemptive legislation by the ASSIST program director, New York’s 

commissioner of health, Dr. Barbara DeBuono, criticized the legislation to a newspaper reporter, even though State Senator Bruno was quoted in newspapers as saying 

that the governor’s office had asked him to introduce the measure—something the governor’s office denied. The storm of controversy created by the commissioner and 

health advocates ensured that no action was taken on the bill. A second attempt to 

pass preemptive legislation in 1996 failed when the state assembly refused to consider the legislation. 

In 1998, advocates gained access to the Tobacco Institute’s 1996 budget and filed a 

complaint with the New York Temporary Commission on Lobbying alleging that the 

Tobacco Institute’s spending on the “Preemption Plan” had not been appropriately 

reported as legally required. After an investigation by the commission, the Tobacco 

Institute acknowledged that it had failed to report $443,072 spent in 1995 on lobbying and that those funds had been transferred to the New York State Tavern & 

Restaurant Association to lobby the state government on its behalf. The Association 

similarly admitted that it had failed to report the expenditures.l

 In July 1999, after 

reviewing materials in the online Philip Morris archive, the New York Times reported 

that between 1995 and 1997, Philip Morris lobbyist Sharon Portnoy had spent tens of 

thousands of dollars on entertainment, as well as on gifts for state legislators and 

executive staff—expenditures that she failed to report to the Lobby Commission as 

required by law.m 

370 
M o n o g r a p h 1 6. A S S I S T 

a

b

c

d

e

f

tid/coo52d00 (accessed October 1, 2004). Bates no. 2044716234–6240. 

g

kcl00e00 (accessed October 1, 2004). Bates no. 93766255–6261. 

h

(accessed October 1, 2004). Bates no. 92104063–4071. 

i

j

k

l , December 12. 

m , July 27. 

After a second investigation by that commission, Philip Morris amended its reports 

to reflect the spending and paid a $75,000 fine. Portnoy was fined $15,000 and was 

banned from lobbying in New York State for 3 years. 

The Philip Morris preemption plan was dead. 

—Russell Sciandra, former New York ASSIST Department 

of Health Project Manager and current Director, 

Center for a Tobacco-Free New York 

Smoke-Free Air Act. Local Law 5 of 1995. Int. No. 232-A. New York City code §§17-501–17-514. 

www.nycosh.org/NYC_Smoke-Free_Air_Act.htm. 

Philip Morris. 1994. A chronology of the tobacco lobby’s efforts to repeal smoking laws. http:// 

legacy.library.ucsf.edu/tid/oey97d00 (accessed October 1, 2004). Bates no. 2073535531–5535. 

Bible, G. 1994. [Letter to Governor-elect George Pataki]. Philip Morris. December 13. http:// 

legacy.library.ucsf.edu/tid/wjg45d00 (accessed October 1, 2004). Bates no. 2046988148–8149. 

Hyland, A., K. M. Cummings, and E. Nauenberg. 1999. Analysis of taxable sales receipts: Was New 

York City’s smoke-free air act bad for restaurant business? Journal of Public Health Management 

Practice 5 (1): 14–21. 

Governor-elect Pataki’s Inaugural Fund, 12/15/94. 

Portnoy, S. 1994. New York SWOT and preemption plan. December 19. http://legacy.library.ucsf.edu/ 

Lorillard memo on “New” New York City plan. February, 1995. http://legacy.library.ucsf.edu/tid/ 

New York Tavern and Restaurant Association. 1995. Hospitality coalition proposal to establish a 

statewide standard for the regulation of smoking. April 26. http://legacy.library.ucsf.edu/tid/wnn00e00 

The Tobacco Institute. 1996. The Tobacco Institute 1996 proposed budget. Revised October 26, 1995. 

http://legacy.library.ucsf.edu/tid/bfr90d00 (accessed October 1, 2004). Bates no. 518257876–7999. 

Merlo, E. 1995. [Letter to New York State Senate Majority Leader Joseph Bruno]. May 16. http:// 

legacy.library.ucsf.edu/tid/ivm38d00 (accessed October 1, 2004). Bates no. 2044313530. 

Tobacco Industry Relief Act, New York State bill 5414, 104th Cong., 2nd session. 1995. 

Levy, C. J. 1998. Lobby admits to higher spending in smoking-law fight. New York Times

Levy, C. J. 1999. Tobacco giant spends heavily around Albany. New York Times

nity-based approach to policy advocacy 

and other activities.10 From the number 

of planning memoranda, meeting minutes, e-mails, contacts with legislators 

and other allies, and other communications available in the tobacco industry 

documents, it is clear that the industry 

invested an enormous amount of time, 

money, thought, and energy into undermining ASSIST. 

There is no question that the continual FOIA requests, lawsuits, complaints, 

and negative publicity brought against 

ASSIST had a dampening effect on the 

program. A lawyer affiliated with the tobacco industry, Thomas Briant, saw this 

371 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

very clearly in Minnesota when he 

spoke of the reduction in the number of 

cities actually being contacted by 

ASSIST groups to pass local ordinances, 

and the “chilling effect” the document 

requests had had in that state.166 As public health staff became better versed in 

FOIA and other requirements, the requests became less disruptive and local 

public health associations and state 

agencies maintained their resolve to initiate policy actions to prevent and control tobacco use. 

At the end of ASSIST, the tobacco 

control movement was at the threshold 

of a new opportunity—an opportunity 

for all agencies, organizations, and individuals supporting tobacco control to 

unite nationally around common goals. 

Chapter 9 describes how ASSIST leaders worked with other stakeholders in 

the tobacco control movement to plan 

and act strategically to bring about a national tobacco prevention and control 

program. 

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42. Ault, C. 1996. ASSIST executive 

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56. R.J. Reynolds. 1995. Project ASSIST in 

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57. Philip Morris. 1991 [estimate]. New 

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81. O’Connor, J., and D. D’Errico. 1991. 

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82. Hatch, O., M. McConnell, and M. 

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83. Walker, R. 1996. ASSIST. Tobacco 

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84. Porter, J. E. (R-IL). 1996. Departments 

of Labor, Health and Human Services, 

and Education, and Related Agencies 

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85. Congressional hearing transcript, 

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Services, 1–24. 1997. U.S. House of 

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93. Christensen, N. 1995. Unlawful use of 

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94. Emord, J. 1992. Project “ASSIST”: 

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378 
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98. Briant, T. 1994. Osseo area schools 

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379 
8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

110. Karsh & Hagan. 1992. Report on 

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R. Elay, and C. A. Johnson. 1989. 

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113. Perry, C. L., S. H. Kelder, D. M. 

Murray, and K. I. Klepp. 1992. 

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Health 82 (9): 1210–6. 

114. Peterson, A.V., Jr., K. A. Kealey, S. L. 

Mann, P. M. Marek, and I. G. Sarason. 

2000. Hutchinson smoking prevention 

project: Long-term randomized trial in 

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115. Philip Morris. 1993 [estimate]. [Note 

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kits]. http://legacy.library.ucsf.edu/tid/ 

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tid/vbu72e00 (accessed December 17, 

2002). Bates no. 2044725481–5513. 

117. Philip Morris. 1992. Corporate Affairs. 

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118. Bennett, J., and T. DiLorenzo. 1994 

[estimate]. [CancerScam—complete 

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119. Scott, T., K. Daragan, V. Han, M. York, 

C. Wall, D. Colby, G. Little, and J. 

Mulderig. 1995. [Four e-mails 

regarding media planning]. Philip 

Morris. September 22. http:// 

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(accessed December 23, 2002). Bates 

no. 2048857603–7604. 

120. Kahn, R. 1995. Q & A. Robert D. Kahn 

& Company. October 13. http:// 

legacy.library.ucsf.edu/tid/pek86d00 

(accessed December 10, 2002). Bates 

no. TI14303899. 

121. Tobacco Institute. 1991. Federal tax 

funding to “ASSIST” state tobacco 

control lobbying. October. http:// 

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(accessed December 23, 2002). Bates 

nos. TIMO0005923–5924; also 

91798371–8373, TIMO0002582–2584, 

TIMO0001015–1017, 2041211627– 

1629, TICT0002489–2491, 88028909– 

8911, 2062980721–0723, 

2048353752–3754, TI16640144–0146, 

TI16161667–1669, TI13850197–0199, 

TI16660282–0284, TI16640155–0156, 

TI16640151–0153, TI16640163–0164, 

2047077492–7494, and 2048254541– 

4543. 

122. Kahn, R. 1995. [Letter describing Stuart 

Cloud requests and ASSIST documents]. 

Robert D. Kahn & Company. October 

16. http://legacy.library.ucsf.edu/tid/ 

jvj86d00 (accessed December 10, 

2002). Bates no. TI14304151–4155. 

380 
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123. Kahn, R. 1995. Questions & answers. 

Robert D. Kahn & Co. October 13. 

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oek86d00 (accessed December 10, 

2002). Bates no. TI14303898. 

124. McAdam, B. 1995. Q’s and A’s. 

Tobacco Institute. October 16. http:// 

legacy.library.ucsf.edu/tid/nek86d00 

(accessed December 10, 2002). Bates 

no. TI14303897. 

125. ForceS. 1996 [estimate]. Why is 

ASSIST covering up their lobbying (if 

what they are doing is so right?). 

www.forces.org. http://legacy.library 

.ucsf.edu/tid/ags50d00 (accessed 

December 23, 2002). Bates no. 

522912075–2076. 

126. ForceS. 1996 [estimate]. Continued 

lobbying with federal funds by the 

National Cancer Institute’s ASSIST 

program. www.forces.org. http:// 

legacy.library.ucsf.edu/tid/yfs50d00 

(accessed December 23, 2002). Bates 

no. 522912072–2073. 

127. Bennett, J., and T. DiLorenzo. 1998. 

CancerScam: Diversion of federal 

cancer funds to politics. New 

Brunswick, NJ: Transaction Publishers. 

128. Bennett, J. T. 1992 [estimate]. 

American Cancer Society—Colorado 

division: Health or wealth? George 

Mason University. October. http:// 

legacy.library.ucsf.edu/tid/ccs88e00 

(accessed January 27, 2003). Bates no. 

2023667374–7393. 

129. Bennett, J. 1994. Regulate to eliminate: 

The real goal of the neo-prohibitionist 

movement. Washington Legal 

Foundation. February 25. http:// 

legacy.library.ucsf.edu/tid/emi86e00 

(accessed January 27, 2003). Bates no. 

2046942410–2413. 

130. Bennett, J. 1995. The American Cancer 

Society; Project ASSIST: Image and 

reality. Capital Research Center. July. 

http://legacy.library.ucsf.edu/tid/ 

kaf97d00 (accessed January 27, 2003). 

Bates no. 2046304000–4007. 

131. Bennett, J. 1996. The American Cancer 

Society: Feeding at the taxpayer’s 

trough. George Mason University. http:// 

legacy.library.ucsf.edu/tid/rgz01d00 

(accessed January 10, 2003). Bates no. 

517118284–8300. 

132. Bennett, J., and T. DiLorenzo. 1994. 

Unhealthy charities: Hazardous to your 

health and wealth. New York: Basic 

Books. 

133. Bennett, J., and T. DiLorenzo. 1985. 

Destroying democracy: How 

government funds partisan politics. 

Washington, DC: Cato Institute. 

134. DiLorenzo, T. 1995. The crusade for 

politically correct consumption. The 

Freeman (publication of Foundation for 

Economic Education). September. 

135. DiLorenzo, T. 1995. Policing PC: How 

the government is stacking the deck in 

the debate over smoking. National 

Review August 28. 

136. DiLorenzo, T. 1995. Tax-funded politics 

at NCI. Loyola College (Maryland). 

May 22. http://legacy.library.ucsf.edu/ 

tid/ygw87d00 (accessed September 17, 

2002. Bates no. 2046557119–7122. 

137. Bennett, J., and T. DiLorenzo. 1994 

[estimate]. [CancerScam—chapters 3–6 

draft]. George Mason University and 

Loyola College of Maryland. http:// 

legacy.library.ucsf.edu/tid/jph48d00 

(accessed July 24, 2002). Bates no. 

2047053325–3420. 

138. Bennett, J., and T. DiLorenzo. 1994 

[estimate]. [CancerScam—chapters 6, 

7, and 8 draft]. George Mason 

University and Loyola College of 

Maryland. http://legacy.library.ucsf.edu/ 

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8. T o b a c c o I n d u s t r y C h a l l e n g e t o A S S I S T 

tid/kph48d00 (accessed July 24, 2002). 

Bates no. 2047053421–3524. 

139. Slavitt, J. 1993. Coalition for a Smoke 

Free Colorado. Philip Morris. May 27. 

http://legacy.library.ucsf.edu/tid/ 

bdk95c00 (accessed September 17, 

2002). Bates no. 2073248267A. 

140. Ostronic, J. 1993. [Letter to James 

Bennett]. Philip Morris. June 10. http:// 

legacy.library.ucsf.edu/tid/gdk95c00 

(accessed September 17, 2002) and 

http://legacy.library.ucsf.edu/tid/ 

hdk95c00 (accessed March 30, 2004). 

Bates nos. 2073248271 and 

2073248272–8274. 

141. Philip Morris. 1993. Event marketing. 

August 13. http://legacy.library.ucsf 

.edu/tid/uvt72e00 (accessed September 

30, 2002). Bates no. 2046527193–7201. 

142. Philip Morris. 1994 [estimate]. 

Proposed 1994 budget: Communications. 

http://legacy.library .ucsf.edu/tid/ 

vkl47d00 and http://legacy.library.ucsf 

.edu/tid/wk147d00 (accessed 

September 10, 2002). Bates nos. 

2070055613 and 2070055614–5617. 

143. George Mason University. Honor Roll; 

1994–1995 Fairfax, VA: George Mason 

University (accessed July 2002). 

144. Walls, T. 1994. Tina Walls— 

Introduction. CAC presentation no. 4. 

Philip Morris. July 8. http://legacy 

.library.ucsf.edu/tid/vnf77e00 (accessed 

November 11, 2003). Bates no. 

2041183751–3790. 

145. Bible, G. C. 1994. [Letter to New York 

Governor Pataki re: preemption]. Philip 

Morris. December 13. http://legacy 

.library.ucsf.edu/tid/wjg45d00 

(accessed April 9, 2003). Bates no. 

2046988148–8149. 

146. Siegel, M., J. Carol, J. Jordan, R. 

Hobart, S. Schoenmarklin, F. DuMelle, 

and P. Fisher. 1997. Preemption in 

tobacco control. Review of an emerging 

public health problem. Journal of the 

American Medical Association 278 

(10): 858–63. 

147. Preemptive state tobacco-control 

laws—United States, 1982–1998. 1999. 

MMWR Morbidity and Mortality 

Weekly Report 47 (51–52): 1112–4. 

148. Henson, R., L. Medina, S. St. Clair, D. 

Blanke, L. Downs, and J. Jordan. 2002. 

Clean indoor air: Where, why, and how. 

Journal of Law, Medicine, and Ethics 

30 Suppl. no. 3: 75–82. 

149. Freedom of Information Act of 1966. 

U.S. Code 5 (1960), § 552. 

150. Ostronic, J. F. 1993. [Letter to Stuart 

Rabinowitz, President and CEO of 

Financial Planning Services, Inc.] June 

9. http://legacy.library.ucsf.edu/tid/ 

hdk95c00 (accessed October 18, 2004). 

Bates no. 2073248272–8274. 

151. Clark, M. A. 1995. Letter to Stuart 

Ravinowitz. Indiana State Department 

of Health. October 10. http://legacy 

.library.ucsf.edu/tid/sxh48d00 (accessed 

December 10, 2003). Bates no. 

2063420964. 

152. ASA accomplishes! ASA wants more 

researchers. 1995. ASA News: An 

American Smokers Alliance Publication 

6 (Summer): 1–3. 

153. Adams, W. A. 1995. [Memorandum re: 

1996 Tobacco Institute budget.] The 

Tobacco Institute. December 15. http:// 

legacy.library.ucsf.edu/tid/rju28d00 

(accessed October 18, 2004). Bates no. 

2041212088–2216. 

154. Byrnes and Keller, form letter to Kim 

Dalthorp, Project ASSIST Manager, 

February 14, 1995. Department of 

Health, Olympia, WA. http:// 

legacy.library.ucsf.edu/tid/waq40c00 

(accessed October 18, 2004). Bates no. 

TI14311099–1101. 

382 
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155. Hopf, N. A. 1995. Violations of 

Colorado law and findings of fact: 

American Constitutional Law 

Foundation v. Colorado Department of 

Health. http://legacy.library.ucsf.edu/ 

tid/qbq85c00 (accessed October 18, 

2004). Bates no. 2073865788–5792. 

156. Hays, Hays & Wilson. n.d. Preliminary 

report of the Washington ASSIST 

project’s record review. http:// 

legacy.library.ucsf.edu/tid/wpg07d00 

(accessed October 18, 2004). Bates no. 

TNWL0047380–7383. 

157. 1994–1995 Minnesota ASSIST 

analysis. October 18, 1995. http:// 

legacy.library.ucsf.edu/tid/jek61d00 

(accessed October 18, 2004). Bates no. 

513967727–7743. 

158. Dawson, P. T. Letter to Honorable 

Kevin Concannon, Commissioner. 

November 21, 1996. 

159. Omnibus Consolidated Appropriations 

Act of 1997. Public Law 104-208. U.S. 

Code (1997), §§ 503(a) and (b). 

160. U.S. Congress. Federal Acquisition 

Streamlining Act of 1994, Public Law 

103-355. U.S. Code 31 (1994), § 1352. 

161. U.S. Department of the Treasury. 

Treasury regulations, § 56.4911. 

162. O’Keefe, A. M. 1992. Advocating 

tobacco control policies: Tax guidelines 

for nonprofit organizations. Prepared 

for divisions of the American Cancer 

Society. 

163. ASSIST Coordinating Center. 1994. 

Implementing policy advocacy: Steps to 

success—Part one. Training module 

prepared for the Site Trainers’ Network 

of ASSIST. Internal document, ASSIST 

Coordinating Center, Rockville, MD. 

164. Shroff, T. H. 1997. Memorandum dated 

July 23, White paper on policy (rev. 

July 18, 1997) to all ASSIST project 

directors, ASSIST project managers, 

and ASSIST Coordinating Center from 

ASSIST contracting officers. Bethesda, 

MD: National Institutes of Health, 

National Cancer Institute. 

165. Berry, J. M. 2003. The lobbying law is 

more charitable than they think. 

Washington Post, November 30, 2003. 

166. Briant, T. A. 1996. Memorandum RE: 

ASSIST. (faxed to McAdam, B., 

Walker, R.) Effect of FOIA requests in 

Minnesota. June 17. http://legacy. 

library.ucsf.edu/tid/eck86d00 (accessed 

October 18, 2004). Bates no. 

TI14200702. 

Additional Resources 

1. Chapman, S., R. Borland, D. Hill, N. 

Owen, and S. Woodward. 1990. Why 

the tobacco industry fears the passive 

smoking issue. International Journal of 

Health Services 20:417–27. 

2. Legacy Tobacco Documents Library: 

http://legacy.library.ucsf.edu. 

3. MacKenzie, R., J. Collin, and K. Lee. 

2003. The tobacco industry documents: 

An introductory handbook and resource 

guide for researchers. London: Centre 

on Global Change and Health, London 

School of Hygiene & Tropical 

Medicine. www.repositories.cdlib.org/ 

context/tc/article/1075/type/pdf/ 

viewcontent. 

4. Philip Morris USA Inc.:


www.pmdocs.com.


5. R.J. Reynolds Tobacco Company 

Online Litigation Document Archive: 

www.rjrtdocs.com. 

6. Tobacco Documents Online:


www.tobaccodocuments.org.


7. Tobacco Institute:


www.tobaccoinstitute.com.


383 

M o n o g r a p h 1 6. A S S I S T 

9. Planning Strategically for the Future

Nancy Salas, Brenda McAdams Motsinger, and Kelly Alley 

Contributors: Deborah Borbely, Neil Bracht, Joy Epstein, John M. Garcia, 

David Harrelson, Gloria Latimer, Dearell R. Niemeyer, Marianne Ronan, 

André G. Stanley, Gael A. O’Sullivan, and Carol A. Winner 

Contents 

At the Turning Point .................................................................................................. 387


The States Work to Sustain Their Programs ............................................................... 388


Technical Assistance to the States .................................................................................. 389


Activities by the States .................................................................................................... 390


Fulfillment of Sustainability Conditions ........................................................................... 390


Developing Strategic Plans for a Sustained National Program .................................. 391


The ASSIST Strategic Planning Subcommittee Plans for the Future ................................. 391


Concept Papers for a National Strategy and Program ...................................................... 392


Taking Action to Get Commitment ............................................................................. 398


Joining Forces .................................................................................................................. 400


Encouraging DHHS to Extend ASSIST ............................................................................... 403


An Early Expression of DHHS’s Commitment .............................................................. 403


Funding Approved for the Temporary Continuation of ASSIST ..................................... 403


Encouraging DHHS to Establish a National Program ....................................................... 404


Resolution to DHHS from the ASSIST Coordinating Committee ................................... 406


Report from the Advance Groups: Realizing America’s Vision for


Healthy People: Advancing a Federal Commitment to Effective Tobacco Control ....... 408


Affirming the Commitment ....................................................................................... 409


Turning to Transition ................................................................................................. 410


References ................................................................................................................ 441


Additional Resource .................................................................................................. 442


385 
9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

Figures 

Figure 9.1. ASSIST Strategic Planning Subcommittee Long-term Planning


Products, 1995–98 ................................................................................................................ 392


Figure 9.2. Tobacco Settlement Negotiation Milestones ......................................................... 400


Appendices 

Appendix 9.A. Executive Summary from “Planning for a Durable Tobacco Prevention


Movement: Sustaining Tobacco Prevention beyond the American Stop Smoking


Intervention Study” ................................................................................................................ 411


Appendix 9.B. Executive Summary from “Turning Point for Tobacco Control: Toward a


Appendix 9.D. Realizing America’s Vision for Healthy People: Advancing a Federal


National Strategy to Prevent and Control Tobacco Use” ......................................................... 414


Appendix 9.C. Helene Brown Testimony .................................................................................. 418


Commitment to Fund Effective Tobacco Control ..................................................................... 421


386 
M o n o g r a p h 1 6. A S S I S T 

9. Planning Strategically for the Future

Through the work of its various committees, subcommittees, and working groups, 

the American Stop Smoking Intervention Study (ASSIST) took a leadership position 

and became a nationally respected voice for the tobacco prevention and control 

movement. ASSIST leaders conducted or participated in major national activities 

designed to ensure that the essential components of the ASSIST model would be 

incorporated into the next generation of comprehensive tobacco prevention and 

control programs. ASSIST leaders met with tobacco control leaders from many 

states, the District of Columbia, and the U.S. territories; broadened the annual 

ASSIST training conferences to include non-ASSIST states; and advocated for 

funding for all states to continue and expand their programs after the ASSIST 

contracts ended. 

This chapter describes the strategic planning approaches used from 1994 through 

1998 at the state, local, and national levels to ensure that tobacco prevention and 

control programs would be incorporated into state and national infrastructures and 

would have sufficient funding to sustain the programs permanently. The National 

Cancer Institute (NCI) extended the ASSIST project for an additional year (through 

September 1999) while a decision about a national program was finalized and 

transition issues were resolved. The ASSIST Strategic Planning Subcommittee 

established working groups with representation from ASSIST and from Initiatives to 

Mobilize for the Prevention and Control of Tobacco Use (IMPACT), the Centers for 

Disease Control and Prevention’s (CDC’s) program. The working groups addressed 

issues specific to the essential elements of a permanent national program: funding; 

technical assistance and training; surveillance, research, and evaluation; and 

advocacy opportunities. As more organizations became involved, their efforts 

catalyzed and strengthened an emerging tobacco control movement. Though the 

efforts are described separately in this chapter, many occurred simultaneously over 

the 4-year period, and all were highly interrelated. 

At the Turning Point 

T

wenty-eight years after clearly establishing that cigarette smoking was a hazard of 

sufficient importance to warrant remedial action,1 the U.S. surgeon general, in the 

1992 report Smoking and Health in the Americas, acknowledged that a critical element 

to address this major health problem was missing—the federal government lacked a coordinated tobacco control program.2

 Since then, a number of reports have specifically 

recommended that the federal government support a national tobacco prevention and 

control effort. In 1994, the Institute of Medicine (IOM), whose mission is “to advance 

and disseminate scientific knowledge to improve human health,”3 published a report, 

387 
9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

Growing Up Tobacco Free, which recognized that ASSIST was a major turning 

point for tobacco control. It described 

ASSIST as a time-limited “demonstration program, a culmination of a research approach,” whose emphasis in 

time “should shift from demonstration to 

permanent program operation and 

support.”4(p260) The report recommended 

that funding for all states be commensurate with funding for the ASSIST states.4 

A 1998 IOM report reaffirmed the concept, stating, “It is time to apply the lessons of ASSIST nationwide.”5(p10) 

Early on, ASSIST leaders realized 

that the ideal outcome of ASSIST would 

be to permanently sustain the infrastructure built by ASSIST and to maintain 

public-private partnerships similar to the 

partnership between NCI and the American Cancer Society (ACS). As ASSIST 

came into its own and took a leadership 

role in advancing tobacco prevention 

and control, leaders evolved from state 

health departments, volunteer organizations, and local coalitions. From the outset, NCI’s goal was that ASSIST, as a 

phase V demonstration project, would 

move from the institute’s research cycle 

to full application and dissemination in 

community-based tobacco prevention 

and control programs. (See chapter 1.) 

Upon completion, a logical next step 

would be a national public health program positioned to administer long-term 

state-based programs. 

Achieving a commitment from the 

federal government to fund a sustained 

national tobacco control program required a series of actions by ASSIST 

leaders and others (1) to build support 

and collaboration among the many segments of the growing tobacco control 

movement and (2) to present a wellfounded, convincing appeal to the Secretary of Health and Human Services. The 

process led to a series of meetings with 

representatives from a variety of tobacco 

control programs and related organizations, who engaged in strategic planning. They developed concept papers 

that expressed the vision of a national 

program and the science base to justify 

the socioecological approach demonstrated by ASSIST. Those papers were 

shared with individuals and organizations that could engender support for the 

concept. As the concept became accepted within the tobacco control community, organizations collaborated and joined 

forces to approach essential policy makers, including Secretary of Health and 

Human Services Donna E. Shalala. 

The States Work to 

Sustain Their Programs 

I

nnovation and adoption of new practices require leadership. From the 

ASSIST project, leaders emerged to 

build a network of 17 tobacco control 

programs, collaborating and interacting 

as a recognized, effective national project. 

Initially, the ASSIST state tobacco control leaders worked with their coalitions 

to create a shared vision and a strategic 

plan of action for their state programs. 

Their overarching goal for the ASSIST 

state programs was institutionalization, 

which refers to “the process of integration and maintenance of programmatic 

activities within organizations.”6(p7) Later, 

they defined their goal more broadly and 

referred to it as durability, that is, “the 

388 
M o n o g r a p h 1 6. A S S I S T 

maintenance and growth of the overall, 

broadly based tobacco prevention movement at the state and local level, with 

Federal/national support.”6(p7) This broader goal included permanently incorporating practices, policies, relationships, and 

norms into the thinking and actions of 

individuals, groups, communities, and 

the nation. 

Many factors affect this dynamic process—the complexity of the program, 

the characteristics of agencies and organizations, the availability of resources, 

the core elements of a sustained program 

■ Data are needed to demonstrate the 

continuing programs. 

■ 

groups are essential elements for longterm success of a program and commitment to the program by community groups 

and coalition members. 

■ 

communities of the issues of tobacco 

essential to engendering the support for 

permanent public health approach in a 

Examples of Insights from States on 

Building Support for Sustained Programs 

Over the years, as the states worked with 

their partners and the communities, they 

encountered barriers. From this experience, 

became apparent. The following are some of 

the elements that ASSIST staff members 

identified as important to making programs 

permanent in a state’s infrastructure: 

effectiveness of interventions and program 

activities and thereby to build support for 

A dedicated budget, well-trained staff, and 

distribution of dollars to community 

Establishing a basic awareness in 

control and building community support 

for changing policy and social norms are 

making tobacco prevention and control a 

state’s infrastructure. 

—Kelly Alley, Managing Director, 

Smokefree Indiana 

and the sociopolitical environment.7

 A 

five-country study by the U.S. Agency 

for International Development identified 

five conditions that are considered to be 

essential for sustaining a program: 

1. Achievement of clear goals and 

objectives 

2. Integration of activities into 

established administrative structures, 

3. Significant levels of funding 

4. A mutually respectful process of giveand-take in program design 

5. A strong training component8 

Similar characteristics for sustaining 

community interventions have been 

identified from cardiovascular disease 

prevention projects.9 

Technical Assistance to the States 

At the onset of the ASSIST project, 

the 17 participating states were at various stages of incorporating tobacco control programs into their infrastructures. 

Some states, such as Massachusetts, 

Minnesota, and Michigan, had already 

built capacity, as was evident by their effective collaborations with diverse partners and recognized leaders. These 

states secured high-level support for preventing tobacco use within their health 

departments and the tobacco control 

community and capitalized on their relationships with NCI to support the 

growth and development of their infrastructures. 

States that were in earlier phases of 

building capacity benefited greatly from 

the technical assistance and training 

support that they received from NCI. 

Beginning in 1994, at the suggestion of 

389 
9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

state project managers, training sessions 

and information exchanges were tailored 

to focus on the process of sustaining tobacco control programs beyond the life 

of ASSIST. The information shared at 

these exchanges enabled the ASSIST 

Strategic Planning Subcommittee to 

identify trends and anticipate problems 

and opportunities that were critical to the 

future of tobacco control. Training was 

offered to state staff and coalition members on how to develop strategies to survive beyond the ASSIST funding, to 

build allies for funding, and to design interventions to foster institutionalization. 

Skill-building sessions were conducted 

for advanced participants. 

In mid-1996, a training module, 

“Planning for Durability: Keeping the 

Vision Alive,” was developed, and in 

October 1996, a training session was 

conducted for ASSIST staff.10 The planning module was designed to help the 

states determine how best to mobilize 

resources, establish new and support existing partnerships, and recognize various agendas among partners. The 

individuals selected to participate in the 

training were state tobacco control leaders. These trained participants took the 

module back to their states to develop a 

state strategic plan for institutionalization, and the ASSIST Coordinating Center provided further technical assistance 

to the states for developing plans and for 

training representatives of the state and 

local coalitions. The ASSIST Coordinating Center also created a video, The Tobacco Challenge: Communities at Work, 

for use by the states to engage state and 

local policy makers in the public and 

private sectors in a dialogue about the 

need to support tobacco control and the 

necessary commitments of program staff 

and other resources. 

Activities by the States 

Key organizations needed to reach out 

to other partners to establish relationships 

and obtain commitments to continue to 

work together on tobacco control. As the 

ASSIST project ended, sustaining the 

momentum required reaching out to a 

wide variety of allies. By doing that, the 

ASSIST partners would be able to protect the investments that had been made. 

Even as they were making progress at 

obtaining commitments for collaboration, many partners were concerned that 

they would lose their trained staff who 

had become increasingly effective 

through their experience with ASSIST. 

Fulfillment of Sustainability 

Conditions 

As the ASSIST project approached 

the end of its original contract time, it 

had met all but one of the five conditions 

for program sustainability mentioned 

above. The goals and objectives of 

ASSIST had been clearly defined, and 

progress had been made in achieving 

these goals. Activities had been integrated at the national level through the NCIACS partnership and at the state level 

through the sharing of responsibilities 

by the health departments and ACS in 

the implementation and management of 

the project. Several planning groups, 

along with state and local coalitions, 

promoted communication among key 

project participants to support a giveand-take process in program design and 

390 
M o n o g r a p h 1 6. A S S I S T 

delivery. Training of staff and of trainers 

had been conducted to continue increasing 

capabilities. The condition that remained 

to be fulfilled was to acquire funding 

sufficient to support a solid infrastructure (1) for delivering effective tobacco 

control interventions after ASSIST ended and (2) for incorporating the essential 

elements of the ASSIST model into a 

national tobacco control program. 

Developing Strategic Plans for 

a Sustained National Program 

T

hrough the contracts, NCI had 

provided a significant level of funding 

directly to the states and had established 

the ASSIST Coordinating Center to provide training, technical assistance, and 

support, but that funding would end in 

1999. ACS supported one full-time staff 

person per state dedicated to tobacco 

control and was committed to continuing 

its support. It was apparent to many that, 

without federal funding, the ability to 

continue adequate tobacco control efforts beyond the life of ASSIST would 

be a problem in most participating states. 

At the end of the project, a few ASSIST 

states had state funding matching or exceeding the amount provided by ASSIST, 

but several states had no funding for 

continuing tobacco control in their state 

health departments. Continuation of tobacco prevention and control programs 

in the states, therefore, was seen as dependent on a federal commitment to 

funding for all states. States generally 

are reluctant to appropriate state monies 

for tobacco prevention and control despite the enormous health and economic 

burden. Federal support seemed to be in 

the nation’s best interest because without 

organized state tobacco control efforts to 

create a constituency for tobacco control, 

national efforts would lack momentum. 

The ASSIST Strategic Planning 

Subcommittee Plans for the Future 

The ASSIST Strategic Planning Subcommittee’s mission was to advance nationwide goals and institutionalize the 

practice of tobacco prevention and control in the United States. (See chapter 3.) 

From 1995 through the end of the 

project, four sets of issues emerged in 

the ASSIST Strategic Planning Subcommittee as critical to the continuation of 

the tobacco control programs and networks that had been developed through 

the ASSIST project: 

1. Achieve a federal commitment to 

maintain and expand tobacco 

prevention and control efforts; 

2. Determine which organizational 

entities would be responsible for a 

large-scale program that would 

include population-based applied 

research and public health 

interventions based on research and 

best practices; 

3. Get public health professionals, 

opinion leaders, and responsible 

policy makers to understand and 

approve the level of resources 

required to achieve significant 

reductions in tobacco use; and 

4. Build in time and resources to plan 

for a smooth transition from ASSIST 

to the next phase of federal involvement in tobacco control efforts. 

The ASSIST Strategic Planning Subcommittee itself, and in collaboration 

391 
9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

with other groups, developed concept 

papers and took steps to advance a 

strategic plan for ensuring long-term 

continuation of a national tobacco prevention and control program and movement. (See figure 9.1.) The concept 

papers, described below, were milestones 

that stimulated the desired combination 

of dialogue, research, analysis, and coordination to achieve two substantial goals: 

1. To ensure the level of commitment 

and action required to fund effective 

tobacco prevention and control 

programs over the long term 

2. To help catalyze a stronger, nationwide tobacco prevention and control 

movement 

Concept Papers for a 

National Strategy and Program 

“Planning for a Durable Tobacco 

Prevention Movement” 

—Developed by the 

Institutionalization Working Group 

With a vision for the future, in 1995 

the ASSIST Strategic Planning Subcommittee created the Institutionalization 

Working Group to present the case for a 

comprehensive policy-oriented approach 

to tobacco prevention and control at the 

national, state, and local levels, through 

public-private partnerships. The working 

group presented a discussion paper titled 

“Planning for a Durable Tobacco Prevention Movement”6 at the June 1995 

meeting of the ASSIST Coordinating 

Committee. (See appendix 9.A for the 

executive summary of the paper.) The 

purposes of the paper were to contribute 

to planning for tobacco prevention within and beyond the ASSIST project and 

Figure 9.1. ASSIST Strategic Planning 

Subcommittee Long-term Planning 

Products, 1995–98 

Planning Subcommittee produced a paper 

May 1995: 

May 1996: 

Durability 

Planning Subcommittee issued a resolution 

the future needs of state and local tobacco 

control programs. 

Planning Subcommittee established 

Opportunities. 

December 1997: 

Funding submitted recommendations to the 

deputy assistant secretary for DHHS. 

recommendations to the deputy assistant 

secretary for DHHS. 

March 1996: The ASSIST Strategic 

titled “Advice to NCI About Their Future 

Role in Tobacco Control.” 

The Institutionalization 

Working Group produced a paper titled 

“Planning for a Durable Tobacco Prevention 

Movement.” 

The Working Group on 

produced a paper titled “Turning 

Point for Tobacco Control: Toward a 

National Strategy to Prevent and Control 

Tobacco Use.” 

April 1997: The ASSIST Strategic 

to the ASSIST Coordinating Committee on 

August 1997: The ASSIST Strategic 

Advance Groups on Funding; Technical 

Assistance and Training; Surveillance, 

Research, and Evaluation; and Advocacy 

The Advance Group on 

February 1998: The Advance Groups on 

Technical Assistance and Training; 

Surveillance, Research, and Evaluation; and 

Advocacy Opportunities submitted 

392 
M o n o g r a p h 1 6. A S S I S T 

to stimulate discussion and offer proposals for next steps to be undertaken by 

state projects, NCI, ACS, and the 

ASSIST Coordinating Center. In the paper, the working group identified relevant issues and barriers to continuing 

effective tobacco control programs beyond the life of ASSIST and suggested 

methods for surmounting those barriers.6 

Important Factors. The working group 

identified eight interdependent factors 

that could affect the institutionalization 

and durability of future tobacco prevention and control efforts and assessed the 

status of each factor. Within each of 

these factors, cultural diversity and 

cross-cultural competence were included as important topics. The factors are 

described in the following excerpts from 

the report: 

CONTEXTUAL FACTORS: 

Contextual factors . . . include the 

nature and extent of social and 

political support for tobacco 

prevention, economics . . . , history of 

involvement with tobacco . . . , and 

history of involvement in community 

and state broad-based health, social, or 

environmental movements. 

POLICY COMMITMENTS: Public 

policy commitments are reflected in . . . 

increases in tobacco taxation, . . . [and] 

may also be encoded in state legislation or local ordinances to curtail 

youth access to tobacco products, 

eliminate or greatly reduce secondhand 

smoke, or ban or restrict tobacco advertisements and promotions. 

FUNDING: Durability concerns most 

often arise from the realization that 

NCI contracting for the ASSIST 

demonstration is for a fixed period. . . . 

The tobacco prevention movement 

Institutionalization and Durability 

progress 

Interdependent Factors That Affect 

1. Contextual factors 

2. Policy commitments 

3. Funding 

4. Organizational capacity and infrastructure 

5. Support (enabling) system 

6. Diffusion of innovation factors 

7. Engagement of multiple channels, settings, 

systems, and organizations 

8. System of monitoring and feedback on 

Source: Institutionalization Working Group, 

Strategic Planning Subcommittee. 1995. 

Planning for a durable tobacco prevention 

movement. Discussion paper, ASSIST 

Coordinating Center, Rockville, MD. 

began [before] and will continue, at 

some level, after ASSIST. 

ORGANIZATIONAL CAPACITY 

AND INFRASTRUCTURE: The 

literature on the diffusion and 

institutionalization of health promotion 

programs within organizations shows 

that it is facilitated by change agents 

and program champions. 

SUPPORT (ENABLING) SYSTEM: 

Beyond ASSIST, the Centers for Disease Control and Prevention via the 

Office on Smoking and Health, have 

begun to create a support system for 

IMPACT state programs and national 

organizations. CDC is also supporting 

via a grant to the University of North 

Carolina a Summer Institute on Tobacco Control. The Robert Wood Johnson 

Foundation is supporting tobacco prevention in states via the American 

Medical Association and the SmokeLess States Initiative. 

DIFFUSION OF INNOVATION FACTORS: Given the constraints on tobacco 

393 
9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

tobacco control and are pleased that 

DHHS agencies can collaborate in a 

the attached document, we identify 

ASSIST Coordinating Committee letter to 

CHANNELS, SETTINGS, SYSTEMS, 

ple channels—community groups, health 

April 14, 1994. 

stability for tobacco control by incorporating 

the function as a primary component of its 

National Center for Chronic Disease 

limited program structures. 

purposes of ensuring continuing 

progress and durability of the 

6(pp8–14) 

Recommendations: In “Planning for a 

Excerpt from the Committee’s 

Transmittal Letter 

“We recognize NCI’s leadership role in 

NCI is exploring how it and other 

national tobacco control strategy. . . . In 

major elements of a national strategy 

and suggest specific roles that NCI 

might play in implementing the strategy.” 

Source: Maldavir, J., and B. Motsinger. 1996. 

E. J. Sondik, March 27, 1996. 

prevention . . . , change agents are both 

essential and critical to the movement. 

. . . The broad-based nature of the tobacco prevention movement leads to 

unevenness in knowledge, skills, and 

commitments to the movement. 

ENGAGEMENT OF MULTIPLE 

AND ORGANIZATIONS: The ASSIST 

model explicitly recognizes the need to 

implement tobacco prevention in multicare settings, schools, and worksites. 

Source: Adapted from the Campaign for Tobacco-Free Kids Web Site, July 8, 2001. Photo courtesy of AP/ 

Wide World Photos. Used by permission. Photo of tobacco industry executives from Hearings on Regulation 

of Tobacco Products before the U.S. House of Representatives Subcommittee on Health and the Environment, 

IMPACT 

In 1993, CDC, through the Office on 

Smoking and Health (OSH), began funding 

IMPACT, a state-based tobacco control 

program. Initially, CDC funded 32 states plus 

the District of Columbia with a budget of $5 

million. Although CDC-funded states 

received only a fraction of the resources 

dedicated to ASSIST states, CDC provided 

Prevention and Health Promotion. With low 

funding levels, IMPACT states had developed 

SYSTEM OF MONITORING AND 

FEEDBACK ON PROGRESS: For 

interagency tobacco prevention 

movement, there is a need for a system 

of monitoring, feedback, evaluation, 

and strategic redirection.

Durable Tobacco Prevention Movement,” the working group suggested numerous follow-up activities for each of 

Campaign for Tobacco-Free Kids Web banner 

394 
M o n o g r a p h 1 6. A S S I S T 

the eight factors. They addressed a number of recommendations for action within a broader strategic plan to the state 

ASSIST coalitions and the ASSIST Coordinating Committee. For example, the 

following was a recommendation to the 

coalitions: 

Starting with the factors and questions 

identified in this discussion paper, 

(a) explore the constraints and supports 

that will contribute to the durability of 

tobacco prevention in the state, and 

(b) develop a plan for the institutionalization and durability of tobacco 

prevention.6(p22) 

Similarly, the working group recommended that the ASSIST Coordinating 

Committee involve more entities in developing a national strategy for tobacco 

control: 

Develop a concept paper on the vision, 

general strategy, and roles and responsibilities of major players in a national 

strategy to prevent tobacco use in 

America. Consideration should be given to how to further extend partnerships with CDC, RWJ, ASTHO, the 

Coalition on Smoking OR Health, and 

other agencies to build a national strategy that supports state strategies.6(p22) 

“Advice to NCI About Their Future 

Role in Tobacco Control” 

—Developed by the ASSIST 

Strategic Planning Subcommittee 

The next concept paper defined NCI’s 

future role in tobacco control. The 

ASSIST Coordinating Committee requested that the ASSIST Strategic Planning Subcommittee prepare this paper in 

response to a presentation by Dr. Edward 

J. Sondik, deputy director of NCI’s Division of Cancer Prevention and Control, 

partners include health, education, medical, 

zations that are dedicated to reducing tobacco 

Free Kids are to: 

■ 

use and countering tobacco industry 

practices. 

■ Change public policies at federal, 

children from tobacco. 

■ Increase the number of 

National Center for Tobacco-Free Kids 

In 1996, the National Center for TobaccoFree Kids evolved from the Campaign for Tobacco-Free Kids, a program funded largely 

by The Robert Wood Johnson Foundation 

(RWJF). The center has established a collaboration of member organizations with an interest in preventing tobacco use. The 130-plus 

civic, corporate, youth, and religious organiuse among children and adults. The three primary goals of the Campaign for Tobacco-

“Alter the public’s acceptance of 

tobacco by deglamorizing tobacco 

marketing to youth and other 

state, and local levels to protect 

organizations and individuals 

fighting against tobacco.” 

The Web site of the National Center for 

Tobacco-Free Kids (www.tobaccofreekids.org) 

offers a wealth of information for reporters 

and the media on events and issues in tobacco 

control. This information includes state-bystate comparisons, reports on industry marketing, and fact sheets about tobacco. The 

center is an excellent source of technical 

assistance and media strategies. 

Source: Campaign for Tobacco-Free Kids. 

Who we are. www.tobaccofreekids.org. 

and a follow-up letter from Dr. Peter 

Greenwald, the division’s director. 

Sondik had explained that NCI would be 

developing a strategic plan in the near 

future and forming a new Behavioral 

Sciences Working Group, which would 

advise NCI in this process. Sondik and 

Greenwald welcomed advice from the 

395 
9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

ASSIST Coordinating Committee, both 

through the working group and directly 

to NCI staff. In the following excerpt of 

his follow-up letter to Jerry Maldavir, 

Greenwald explained his views in favor 

of a national strategy: 

I am in favor of a national tobacco use 

prevention strategy. A coordinated 

effort is essential if we are to continue 

to reduce this major cause of death and 

disease. A national strategy will 

require the participation of many 

organizations and agencies. NCI staff 

are currently working to determine the 

interest of other DHHS agencies in the 

planning process. 

In the paper “Advice to NCI About 

Their Future Role in Tobacco Control,” 

submitted on March 27, 1996, to Sondik, 

the ASSIST Coordinating Committee 

presented four issues with related recommendations regarding NCI’s involvement in tobacco control.11 In its 

transmittal letter (written by J. Maldavir 

and B. Motsinger), the committee outlined a national strategy and specified 

NCI’s role in implementing that strategy; recommended that NCI increase its 

investment in tobacco control; supported 

continued development of the tobacco 

control infrastructure based on the 

ASSIST model, with related funding for 

technical assistance, training, and communication; and recommended that policybased interventions be emphasized 

within the context of a balanced approach to research and development in 

the tobacco control program. 

“Turning Point for Tobacco Control: 

Toward a National Strategy to 

Prevent and Control Tobacco Use” 

—Developed by the 

Working Group on Durability 

To move forward on the basic concepts and recommendations that the Institutionalization Working Group had 

presented, the ASSIST Strategic Planning Subcommittee established a Working Group on Durability in late 1995 and 

charged the members with the task of 

developing a concept for a national strategy for tobacco control. The working 

group researched the types of support— 

organizational, monetary, and theoretical—that already existed and could be 

drawn into the strategic process. The 

working group’s May 1996 working paper, titled “Turning Point for Tobacco 

Control: Toward a National Strategy to 

Prevent and Control Tobacco Use,”12 

presented a framework and general description of elements that should be included in a comprehensive national, 

state, and local strategy. (See appendix 

9.B for the executive summary of the 

report.) The report described several 

policy studies, reports from consensus 

conferences, and comprehensive tobacco 

control interventions that delineated future directions for tobacco control and 

prevention in the United States. The report suggested that these documents 

provide a basis for the development of a 

national strategy. . . . Nevertheless, a 

single unified statement of vision for a 

national comprehensive tobacco control 

and prevention strategy does not exist. 

These documents could provide the 

basis for such a vision and plan.12(p21) 

(The reports referred to are listed in the 

sidebar.) 

The “Turning Point” paper emphasized the need to bring together the 

many players in tobacco control to create a new level of influence and effec396 
M o n o g r a p h 1 6. A S S I S T 

recommendations and a vision for the future of 

tobacco control. Based on the contents of these 

for tobacco control could be written. 

■ 

Smoking and Health, including the recent 

report on 

[1994]; ■ Report of the Institute of Medicine, 

[1994]; ■ 

(ASSIST), as articulated in 

[1991]; ■ Healthy 

[1992]; ■ Program descriptions for the Centers for 

■ 

■ 

print for Success: 

[1990]; 

■ 

; 

■ Conference Report and 

American Crisis [1993]; 

■ 

Reports: A Starting Point 

“The following is a list of reports that articulate 

reports and documents, using the framework 

presented in this paper, a national strategic plan 

“Reports from the Surgeon General on 

Preventing Tobacco Use Among 

Young People 

Growing Up Tobacco Free: Preventing 

Nicotine Addiction in Children and 

Youths 

National Cancer Institute’s American 

Stop Smoking Intervention Study 

Strategies to 

Control Tobacco Use in the United 

States: A Blueprint for Public Health 

Action in the 1990’s

Tobacco Control Objectives for 

People 2000

Disease Control and Prevention’s 

IMPACT program; 

Program descriptions of the Robert Wood 

Johnson Foundation’s SmokeLess States 

Initiative; 

Coalition on Smoking OR Health’s BlueCountdown 2000—Ten 

Years to a Tobacco-Free America 

Association of State and Territorial 

Health Officials’ Policy Statement on 

Tobacco Use Prevention and Control

Recommendations from America’s 

Health Community, Tobacco Use: An 

And various plans for tobacco control 

and prevention developed at the state 

level (e.g., Comprehensive State Smoking 

Control Plans developed by ASSIST 

states) [1993].” 

Source: Working Group on Durability, 

Strategic Planning Subcommittee. 1996. 

Turning point for tobacco control: Toward a 

national strategy to prevent and control 

tobacco use. Discussion paper, ASSIST 

Coordinating Center, Rockville, MD (p. 29). 

tiveness. The paper presented a table 

that suggested roles and responsibilities 

for nearly 40 organizations and agencies, including federal and state agencies, private and governmental scientific 

research organizations, national health 

advocacy groups, foundations, and voluntary organizations.4,12 The working 

group emphasized the need for flexibility in implementing an effective strategy 

for tobacco control.12 

The paper also identified seven elements that the working group considered 

important in a national, state, and local 

strategy: 

Public health objectives, 

Health promoting tobacco-control 

policies, 

Movement infrastructure and 

programmatic interventions, 

Social marketing and mass media 

interventions, 

Intervention research, development, 

and dissemination,


Monitoring and evaluation, and


Management and coordination


mechanisms.12(p21) 

Again, the working group acknowledged that there would be differences of 

opinion but expressed confidence that 

there was agreement about a broad, integrated approach: 

It must be acknowledged that there are 

various opinions within the tobacco 

control movement about the relative 

value of different intervention options 

and where resources should be 

invested in the short term. However, 

there is apparent agreement that a 

comprehensive, multifaceted, and 

integrated approach is necessary to 

address the problem.12(p21) 

397 
9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

a 

■ 

■ 

■ 

■ 

■ 

reducing the use of tobacco; and 

■ Educate the public about the need for stronger tobacco control policies. 

b 

a

b

Initiative. 

The Robert Wood Johnson Foundation’s SmokeLess States National Tobacco Policy Initiative 

“Founded in 1993, the SmokeLess States National Tobacco Policy Initiative is a private-sector effort that supports activities of statewide coalitions working to improve the tobacco policy environment with the goal of reducing tobacco use. The initiative is a collaborative effort among 

RWJF, the American Medical Association, and statewide coalitions receiving the grants.”

“During the first seven years of the program, RWJF provided approximately $40 million for educational and policy efforts undertaken by statewide coalitions in 36 states and the District of Columbia. 

In 2001, RWJF committed an additional $52 million to the initiative, funding 42 statewide coalitions. Policy efforts undertaken by these coalitions, which receive additional funding from their 

member organizations, including the American Cancer Society, the American Heart Association, the 

American Lung Association, and state medical societies, focus on three areas: 

“Promoting ordinances to reduce public exposure to environmental tobacco smoke, including 

smoke-free work places and public places; 

Increasing state tobacco excise taxes in order to reduce the demand for tobacco products; and 

Fostering changes in Medicaid and state employee health insurance coverage and 

encouraging private health insurers to cover tobacco dependence treatment as part of routine 

coverage. 

“Some of the coalitions are also working to secure tobacco settlement funds for comprehensive 

tobacco control programs in their states. . . . 

“The coalition structure that is at the heart of SmokeLess States grants has been crucial to the 

program’s effectiveness. This is because each coalition member-organization brings to the table 

different strengths and resources which, when taken together, make many victories possible. 

Specifically, the grantees and the partnerships they create under the program should: 

“Strengthen statewide coalitions and diversify their active membership base; 

Develop a plan to improve the tobacco policy environment within their state with the goal of 

“To help underwrite these policy campaigns, coalition member organizations contribute matching 

funds as a condition to receiving the SmokeLess States grant. No SmokeLess States grant money 

is used for lobbying-related activities.”

American Medical Association. n.d. SmokeLess States National Tobacco Policy Initiative. www.amaassn.org/go/smokelessstates. 

American Medical Association. n.d. More on the initiative: SmokeLess States National Tobacco Policy 

With the completion of the “Turning 

Point” paper, the conceptual foundation 

and strategic approach for garnering support for a national tobacco prevention and 

control program were sufficiently described. It was time to implement the approach in a calculated, persistent manner. 

Taking Action to 

Get Commitment 

T

he national context in which ASSIST 

leaders were moving their agenda forward was particularly opportune for 

growing a tobacco control movement 

398 
M o n o g r a p h 1 6. A S S I S T 

among local, state, and federal agencies in order to promote and strengthen public health. 

■ 

■ 

■ 

■ 

of local boards of health and assists them in assuring the health of their communities. 

ASTHO, NACCHO, and NALBOH 

Association of State and Territorial Health Officials 

“The Association of State and Territorial Health Officials (ASTHO) is the national non-profit 

organization representing the state and territorial public health agencies of the United States, the U.S. 

Territories, and the District of Columbia. ASTHO’s members, the chief health officials of these 

jurisdictions, are dedicated to formulating and influencing sound public health policy, and to assuring 

excellence in state-based public health practice.” 

ASTHO’s origins go back to the late 19th century, and the current form of the organization, with 

membership limited to executive officers of the departments of health of any state, territory, or 

possession of the United States, was founded on March 23, 1942. 

National Association of County and City Health Officials 

“NACCHO was formed in July 1994 when the National Association of County Health Officials and 

the U.S. Conference of Local Health Officers combined to form a unified organization representing 

local public health. The two predecessor organizations were formed separately in the 1960s. 

“NACCHO is a nonprofit membership organization serving all of the nearly 3,000 local health 

departments nationwide—in cities, counties, townships, and districts. NACCHO provides education, 

information, research, and technical assistance to local health departments and facilitates partnerships 

“NACCHO aims to promote the concerns of local public health in the nation’s capital by: 

Educating Members of Congress and other policymakers about local public health issues; 

Analyzing the impact on local public health of legislative and regulatory actions; 

Disseminating legislative alerts and legislative reports to all local public health departments; and 

Providing the latest updates on key public health issues.” 

National Association of Local Boards of Health 

“MISSION: The National Association of Local Boards of Health (NALBOH) represents the interests 

“NALBOH has been engaged in establishing a significant voice for local boards of health on matters 

of national public health policy.” 

Sources: Association of State and Territorial Health Officials. About ASTHO: ASTHO history. 

www.astho.org; National Association of County and City Health Officials. About NACCHO. 

www.naccho.org; National Association of Local Boards of Health. About NALBOH. www.nalboh.org. 

and for establishing and sustaining a national program. At their May 31, 1996, 

meetings, the ASSIST Coordinating 

Committee and its Strategic Planning 

Subcommittee discussed the need to 

unite all of the principal tobacco control 

organizations in the country and to effect 

a dialogue about how to build a national 

cohesive movement that would be successful over time. The “Turning Point” 

paper was reviewed and placed on the 

ASSIST Coordinating Committee conference call agenda to discuss ways for 

using the paper to initiate multiple outreach efforts on a national strategy for 

institutionalization. ASSIST leaders 

399 
9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

planned to use the paper to initiate multiple outreach efforts with state and 

national organizations to begin collaboration on a national strategy for institutionalization. 

During the early and mid-1990s while 

the ASSIST states brought intensive 

attention to tobacco prevention and control as a public health issue, the socialenvironmental climate became more 

favorable for tobacco prevention and 

control interventions throughout the nation, and more programs and organizations supported initiatives to decrease 

tobacco use. A number of non-ASSIST 

tobacco control programs and unanticipated political events brought tobacco 

issues and the tobacco industry to the 

forefront of media attention and further 

strengthened the social and political climate. These events, briefly summarized 

in sidebars in this chapter and in figure 9.2, 

provided the context in which ASSIST 

leaders took action to involve other entities supportive of tobacco control and to 

approach the Department of Health and 

Human Services (DHHS). It was in this 

context that the deputy secretary of 

DHHS represented DHHS at an October 

1996 ASSIST conference, described in 

the subsequent section, and that Secretary of DHHS Donna E. Shalala recognized ASSIST. 

Joining Forces 

The ASSIST Strategic Planning Subcommittee faced an extraordinary challenge: integrating national tobacco 

control ideas and visions with state-level 

tobacco control ideas and realities. 

Therefore, to strategically plan for maintaining tobacco prevention and control at 

sible and as quickly as possible, especially from entities that already had a 

Negotiation Milestones 

the global settlement. 

May 1998: Minnesota settlement results in 

disclosure of numerous industry documents. 

a national level, it was paramount to 

have diverse representation from as 

many state and national agencies as postrack record in working for tobacco control on a national or multistate scale. At 

the national level, NCI and ACS provided 

strong leadership and strategic guidance 

to the ASSIST project and recognized 

Figure 9.2. Tobacco Settlement 

April 1997: Negotiations began for 

November 1997: McCain bill was introduced. 

June 1998: McCain bill was defeated. 

November 1998: Tobacco Master Settlement 

Agreement was signed. 

June 1997: Global settlement was proposed. 

400 
M o n o g r a p h 1 6. A S S I S T 

Administration 

■ 

■ 

■ 

■ 

■ Prohibit tobacco brand names from appearing on clothing, bags, and other promotional items. 

■ Require the tobacco industry to fund an annual public education campaign to reduce youth 

smoking. 

Food and Drug 

Because nicotine is an addictive drug and cigarettes are drug-delivery devices that contain more than 

40 cancer-causing agents, FDA Commissioner Dr. David A. Kessler attempted to assert jurisdiction for 

FDA to regulate tobacco products. A consideration was that if FDA were to regulate tobacco product 

ingredients like other products, the agency would have to ban them, which would not be feasible. 

Instead, FDA attempted to regulate the sale, access, and advertising of tobacco to minors as a child 

protection rule. In August 1996, FDA issued a rule with the following requirements: 

Restrict tobacco advertising in magazines with high teen readership. 

Prohibit tobacco brand-name sponsorship of sporting and entertainment events. 

Ban outdoor tobacco advertising near schools and playgrounds. 

Require age verification and face-to-face sales, and eliminate free samples, self-service displays, 

and most cigarette vending machines. 

The FDA effort was mired in court battles until March 21, 2000, when the U.S. Supreme Court ruled 

5–4 that FDA does not have, and has never had, the authority to regulate tobacco products. However, 

while the legal battles were being waged, the provisions for identification checks remained in effect. 

FDA granted funds to state enforcement agencies to train enforcers to conduct compliance checks. The 

attention to the FDA issues and legal battles helped keep tobacco control a major political issue, 

especially during the 2 critical years (1996–97) of ASSIST activity to promote support for a national 

tobacco prevention and control program. 

Source: U.S. Department of Health and Human Services. 2000. Reducing tobacco use: A report of the 

surgeon general. Atlanta: National Center for Chronic Disease Prevention and Health Promotion, 

Office on Smoking and Health. www.cdc.gov/tobacco/sgr/sgr_2000/chapter5.pdf. 

the potential strength of a collaboration 

with CDC’s Office on Smoking and 

Health, the U.S. Food and Drug Administration (FDA), the Association of State 

and Territorial Health Officials (ASTHO), 

the American Lung Association, the 

American Heart Association, the National Center for Tobacco-Free Kids, RWJF, 

and other partnering agencies and organizations. The combined leadership from 

all these entities would not only empower 

the ASSIST states to reach their potential but also motivate others to support tobacco prevention and control efforts over 

the long term. 

During this early phase, several entities were important collaborators. The 

Tobacco Control Network of State 

Health Agency Program Managers for 

Tobacco Prevention and Control had 

been conducting efforts that paralleled 

those of the ASSIST Strategic Planning 

Subcommittee. The network was formed 

by ASTHO at its 1994 annual meeting in 

San Antonio, Texas. (The ASTHO network at that time was supported by a cooperative agreement between OSH and 

NCI.) The initial purpose of the network 

was to bring together all states to plan 

collectively for national strategies that 

would advance tobacco control. The network rotated the duties of the chair between ASSIST and IMPACT states 

annually. 

401 
9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

in 

January 1996. 

The Substance Abuse and Mental Health Services Administration and the Synar Amendment 

A major federal effort to reduce tobacco sales to minors resulted from a 1992 amendment to the 

Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act by the late Congressman 

Mike Synar. The new law created the Substance Abuse and Mental Health Services Administration and 

required states to take steps to reduce tobacco sales to minors or risk losing federal block grant funds 

for substance abuse prevention and treatment. Each state was required to establish a minimum sale age 

of 18 and to conduct random, unannounced inspections of tobacco outlets and report these findings to 

the DHHS. The goal of the inspections was to reduce illegal sales to minors to less than 20%. 

Regulations for implementing the Synar Amendment were published in the Federal Register

Implementation of the Synar Amendment affected states across the nation and prompted media 

coverage at the national and local levels. Not only public attention in all states, but also political 

pressure was brought to the problem of tobacco sales to minors by the Synar Amendment. An 

important effect of implementing the requirements of the Synar Amendment was the need to bring in 

more substance abuse professionals to tobacco control activities. Tobacco control claimed a legitimate 

place among their many responsibilities because of the Synar requirements and created a need for 

permanent staff and programs within departments of health. 

Source: U.S. Department of Health and Human Services. 2000. Reducing tobacco use: A report of the 

surgeon general. Atlanta: National Center for Chronic Disease Prevention and Health Promotion, 

Office on Smoking and Health. www.cdc.gov/tobacco/sgr/sgr_2000/chapter5.pdf. 

At the May 1996 ASSIST Strategic 

Planning Subcommittee meeting mentioned earlier, the subcommittee developed a motion for consideration by the 

ASSIST Coordinating Committee at its 

May 1996 meeting to facilitate the implementation of a national strategy that 

would reinforce ASSIST goals. After 

considerable discussion, the committee 

voted to amend the motion to reflect a 

proposal drawn up by ASTHO and the 

National Association of County and City 

Health Officials (NACCHO). The following motion was adopted by the committee: 

A copy of the paper titled “Turning 

Point for Tobacco Control” will be sent 

to Philip R. Lee, M.D., Assistant Secretary for Health. The accompanying 

cover letter should state: (a) the importance of state and community based 

comprehensive tobacco control interventions beyond ASSIST; (b) the need 

for continuing support in ASSIST 

states while a national strategy is developed (i.e., extension to 2005); 

(c) the need to increase the IMPACT 

funding equivalent to the levels of 

Project ASSIST, using the ASSIST 

model; (d) assure funding for national 

training and technical assistance for all 

states based on the ASSIST model; 

(e) the ASSIST Coordinating Committee wishes to offer assistance to Dr. 

Lee in his new endeavor to lead the development of a national strategy; and 

(f) that the cochairs will contact 

Mr. Ripley Forbes to determine how 

the ASSIST project may assist him to 

formulate the DHHS plan.13(p6) 

A few months later, in September 

1996, ASTHO and NACCHO published 

their formal policy statement, “Tobacco 

Use Prevention and Control.” One tenet 

of the policy covered institutionalization: 

402 
M o n o g r a p h 1 6. A S S I S T 

Tobacco use prevention and control 

programs must be institutionalized 

within state and local health agencies 

to ensure that activities supported by 

this policy statement are completed.14(p4) 

In the meantime, the cochairs of the 

ASSIST Coordinating Committee were 

approaching DHHS Secretary Donna 

Shalala and her senior staff through 

telephone conversations and letters. The 

series of communications described the 

essential elements and goals of ASSIST, 

emphasized the effectiveness of the 

project’s community-based approach, 

and expressed the need for states to be 

assured of long-term funding in order to 

build state infrastructure for permanent 

programs. 

Encouraging DHHS to Extend ASSIST 

Simultaneously with efforts to 

strengthen the tobacco control movement, ASSIST leaders had to articulate 

the need for extending the funding of 

ASSIST. An extension would require a 

commitment of additional funds from 

NCI and a renewed commitment from 

ACS as a partner. A critical step toward 

ensuring both the immediate future of 

ASSIST and a national tobacco prevention program that would incorporate the 

essential elements of ASSIST was a 

commitment from DHHS to support 

long-term, state-based programs to prevent and reduce tobacco use. 

An Early Expression 

of DHHS’s Commitment 

At an ASSIST information exchange 

conference in October 1996 in Crystal 

City (Arlington), Virginia, Kevin Thurm, 

the deputy secretary of DHHS, first expressed the commitment of DHHS to the 

Synar Amendment and to the FDA tobacco regulations. He then conveyed the 

department’s commitment to continue 

the type of community-based tobacco 

control efforts exemplified in ASSIST: 

I can’t tell you at this time whether our 

support for your activities will come 

from the existing ASSIST program or 

from another HHS program or agency. 

But what I can tell you is this: This 

Department, and this Administration, 

are 100% committed to continuing 

your work.15(p3) 

In a follow-up to the conference, at an 

ASSIST Coordinating Committee meeting in October 1996, a senior advisor at 

DHHS commended the group for the 

significant achievements attained 

through the work of the ASSIST project. 

He underscored the deputy secretary’s 

comments delivered at the conference 

regarding the department’s commitment 

to the continuation of tobacco control 

activities throughout the United States.16 

Funding Approved for the 

Temporary Continuation of ASSIST 

To maintain the infrastructure and capacity for sustaining the work of ASSIST 

while providing adequate time for planning the future program, in January 1997 

NCI approved funding to extend the 

ASSIST contracts for one year. In a 1997 

letter to ASSIST project managers written by R. Klausner and P. Greenwald, 

NCI announced the extension: 

NCI will extend the current ASSIST 

contracts, with full funding, for one 

full year. From now until September of 

1999, we all will be working together 

to determine the most effective way to 

403 
9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

support and manage future tobacco 

prevention efforts as we move beyond 

the research phase of ASSIST and 

make the transition to the essential task 

of supporting disseminated programs 

in public health. 

Encouraging DHHS to 

Establish a National Program 

With the 1-year extension of ASSIST 

confirmed, the informal consortium of 

organizations and their leaders could refocus their efforts on promoting a national program that would endure 

beyond the ASSIST project. The activities in 1997 were numerous. 

On March 5, 1997, representatives of 

ASTHO, NACCHO, and NALBOH 

(J. Dillenberg, M. Vignes-Kendrick, and 

J. Saccenti) wrote a letter to Secretary 

Shalala thanking her for the department’s commitment to tobacco control 

reflected in the extension of ASSIST and 

increased funds for CDC programs and 

requesting a meeting with her. 

Meanwhile, on March 31, 1997, to 

make the case to NCI for the expansion 

of the ASSIST model to all 50 states, a 

senior advisor to ASSIST presented testimony to NCI’s National Cancer Policy 

Board that suggested that the 17-state 

ASSIST project continue and serve as a 

research arm of NCI’s tobacco control 

program; that NCI be designated the 

lead agency in establishing ASSIST in 

the other 33 states; and that, once implemented, the project be transferred to 

CDC for continued implementation and 

evaluation.17 (See appendix 9.A.) 

The 1-year extension of ASSIST had 

implications for ACS in terms of commitment and funding; therefore, ACS organized a meeting in Atlanta in April 

1997 to bring together key stakeholders 

to discuss the ASSIST public-private 

partnership as well as NCI’s and ACS’s 

future roles in a sustained, federally funded, national tobacco control program. 

Given the complexity of the issues, the 

meeting was the first of many discussions 

among many stakeholders for articulating a position regarding recommendations for DHHS. In addition, ACS was 

undergoing tremendous organizational 

change and needed to evaluate current 

tobacco control efforts and operations 

and the training needs of state health departments and regional ACS staffs. An 

evaluation was being designed to aid 

ACS staff in future planning and budget 

allocations.18 

In June 1997, in preparation for a 

meeting with Secretary Shalala, 

ASTHO, NACCHO, NALBOH, and 

ACS formalized a proposal to DHHS regarding federal involvement with state 

and local programs for tobacco use, with 

the following recommendations to DHHS 

(according to a memo and excerpt from 

the ASTHO-ACS proposal, sent by J. 

Moore and D. Magleby to S. Malek on 

June 4, 1997): 

1. CDC would fund all 50 states at


ASSIST levels by FY 1999 to be


■	 coalition/partner based in order to 

leverage new resources; 

■	 policy oriented. 

2. The NCI will fund applied research 

on statewide programs. This research 

will test new or expanded interventions and will guide and inform state 

programs funded by the CDC. 

3. Safeguards must be developed so 

that no gaps or reductions in funding 

404 
M o n o g r a p h 1 6. A S S I S T 

for state tobacco prevention and 

control programs occur while 

funding is in transition. 

4. A training and technical assistance 

center and plan will be developed 

with input from the states and national 

partners and will be funded collaboratively by NCI and CDC in order 

to bridge research and practice. 

The next activity was a meeting on 

July 25, 1997, between Secretary Shalala and a small group of ASSIST statelevel tobacco control practitioners. In a 

follow-up letter to the secretary, R. 

Schwartz, the cochair of the ASSIST 

Coordinating Committee, summarized 

the committee’s requests and concerns: 

State and local tobacco control programs such as those funded through 

ASSIST must continue and must be 

extended to all states. To ensure the 

continuity of ASSIST projects and 

coalitions, the DHHS needs to make a 

commitment to these programs in the 

immediate future. Without a commitment now, not only will continuity and 

momentum of programs be lost, but 

experienced and trained staff will also 

be lost to other, more certain 

endeavors. . . . We look to your strong 

leadership to give state tobacco control 

programs the commitment they need 

for long term support. 

The meeting that ASTHO requested 

on behalf of the key stakeholders took 

place shortly after, on August 4, 1997. 

Representatives from ASTHO, NACCHO, 

NALBOH, ASSIST, and ACS attended 

that meeting. A follow-up letter to the 

secretary, on August 7, 1997, signed by 

M. Caldwell, B. Motsinger, J. Rice, 

J. Saccenti, and R. Todd, after the meeting reiterated the major themes that the 

group had presented: 

The McCain Bill 

introduced “a bill to reform and restructure 

the processes by which tobacco products are 

defeated by the U.S. Senate in June 1998, it 

tion to the need for a sustained tobacco control program. Features of the proposed bill inbacco industry if youth smoking rates did not 

fund antismoking campaigns, research, and 

280:1279–84. 

On November 7, 1997, Senator John McCain 

manufactured, marketed, and distributed, to 

prevent the use of tobacco products by minors, to redress the adverse health effects of 

tobacco use, and for other purposes.” If 

passed, the law would have had a profound 

effect on the tobacco industry and tobacco 

control. Although this comprehensive bill was 

represented a high-water mark for conceptualizing national tobacco control legislation 

and was yet another event that brought attencluded the following: a $1.10 (per pack) increase in cigarette taxes; penalties on the todrop significantly; the delegation of complete 

authority to FDA to regulate sale, manufacturing, labeling, and marketing of tobacco 

products; and the use of collected money to 

health-related activities. 

Sources: National Cancer Institute. 1998. 

NCI legislative update for September 15, 

1998—Tobacco page. www3.cancer.gov/legis/ 

sept98/tobacco.html; Blendon, R. J., and J. T. 

Young. 1998. The public and the comprehensive tobacco bill. Journal of the American 

Medical Association 

It was very reassuring to hear again 

that the Administration is fully committed to a vision of statewide, community-based tobacco prevention and 

control programs throughout the country. It is our intent that this includes: 

Increasing federal funding to assure all 

states an ASSIST-level minimum; 

Maintaining continuity in existing 

programs to avoid loss of personnel 

and infrastructure; 

405 
9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

Informational brochure accompanying 

tact for tobacco 

control issues. 

ASSIST leaders 

shaped the concept of an interorganizational team, 

which took 

the form of four 

advance groups. 

The ASSIST Strategic Planning 

Subcommittee 

took the lead in 

establishing the 

advance groups to 

address the issues 

of funding; techni- ASSIST manual for training session on durability	 ASSIST-produced video The T obacco cal assistance and Challenge: Communities at W ork training; surveillance, research, 

Forging an NCI/CDC collaboration and evaluation; and advocacy opportunito link applied research and ties. Representatives from ASSIST and 

increase interdependent program IMPACT states, California, and ACS 

planning and implementation; formed the membership of the advance Expanding the training and technical groups, whose charge was to develop assistance resources that assure recommendations to submit to the depu­ skilled leadership at the national, ty assistant secretary of DHHS. state and local levels.


The outcomes of the meeting with
 Resolution to DHHS from the 

Secretary Shalala were far-reaching. The ASSIST Coordinating Committee 

department’s commitment invigorated While the advance groups were busy the efforts of the lead organizations in preparing a report with a detailed plan, the movement for a national program. At ASSIST and other organizations main- the meeting on August 4, 1997, Secre­ tained the momentum. The ASSIST Co­ tary Shalala proposed the formation of ordinating Committee met with Jim an interorganizational team to work with O’Hara, the deputy assistant secretary the department on the strategy for a fed- for health of DHHS, in September 1997 erally supported national tobacco pre- in Houston.19 The committee thoroughly vention and control program, which the briefed him about four matters: group endorsed. Also attending the 

meeting was the deputy assistant secre­ 1. The issues and concerns of ASSIST 

tary of DHHS, James O’Hara, who was regarding the durability of state and 

appointed to be the DHHS primary con- local tobacco control 

406 
M o n o g r a p h 1 6. A S S I S T 

global settlement agreement. 

community meets the global settlement. Public Health Reports 

The Tobacco Master Settlement Agreement and the Minnesota Lawsuit 

In April 1997, the tobacco industry began negotiations with the state attorneys general. The global 

tobacco settlement was proposed June 20, 1997, but was only finalized after months of debate and 

negotiation. The negotiations generated considerable media attention: Nationwide, nearly 1,000 

articles ran in newspapers around the country during June 1997, following the announcement of the 

The plaintiffs had sued the tobacco industry to recoup Medicaid costs for the care of persons injured 

by tobacco use. The suit alleged that the companies had violated antitrust and consumer protection 

laws, had conspired to withhold information about adverse health effects of tobacco, had manipulated 

nicotine levels to maintain smoking addiction, and had conspired to withhold lower-risk products from 

the market. 

During settlement negotiations, there were divisions among the ranks of public health advocates. Some 

in the public health community were skeptical of any federal initiative, and others argued that 

compromise was unnecessary. Critical issues surfaced during these negotiations, but the participants 

ultimately failed to reach agreement. 

The cohesiveness of the tobacco control movement was seriously at risk over the issue of either halting 

the settlement or incorporating provisions that would give the tobacco industry immunity from future 

lawsuits and other advantages. Tobacco control advocates were bitterly divided. Although advocates 

agreed that the millions of dollars to be given to states annually should be spent on health causes, 

specifically tobacco use prevention and control, ASSIST was strongly opposed to providing immunity 

to the tobacco industry under any foreseeable circumstances, and the ASSIST Coordinating Committee 

passed a resolution to express its objections to the concept of immunity. 

On November 23, 1998, 46 attorneys general signed the Tobacco Master Settlement Agreement (MSA) 

with four tobacco companies to settle state suits to recover costs associated with treating smokingrelated illnesses. Tobacco companies were projected to pay in excess of $206 billion over the next 25 

years. In addition, the settlement agreement contained a number of important public health provisions. 

Similar to the experience with the global settlement agreement, settlement of the state lawsuits 

generated intense media attention, with numerous articles running in newspapers around the country. 

Meanwhile, individual states were pursuing separate negotiations. Minnesota was conducting a trial of 

its state lawsuit against the tobacco industry, which was eventually settled on May 8, 1998, for $6.1 

billion. The disclosure of numerous industry documents that resulted from the Minnesota case exposed 

the tobacco industry’s deceptive behavior and formed the basis for future lawsuits. The case generated 

front-page coverage in the Minneapolis Star Tribune and frequent television coverage in the state. The 

media attention to tobacco issues made public, on a wide scale, the industry’s deception about tobacco 

use and health. The discovery process in the Minnesota trial generated millions of industry documents, 

which became accessible to the media, tobacco control advocates, and the public. 

Sources: Akhter, M. N., M. L. Myers, and J. Seffrin. 1998. Comment: The past and future national 

comprehensive tobacco control legislation. American Journal of Public Health 88 (11): 1606–7; 

Bloch, M., R. Daynard, and R. Roemer. 1998. A year of living dangerously: The tobacco control 

113:488–97; National Association of 

Attorneys General. NAAG projects: Tobacco page. www.naag.org/issues/issue-tobacco.php; U.S. 

Department of Health and Human Services. 2000. Reducing tobacco use: A report of the surgeon 

general. Atlanta: National Center for Chronic Disease Prevention and Health Promotion, Office on 

Smoking and Health. www.cdc.gov/tobacco/sgr/sgr_2000/chapter5.pdf; ASSIST Coordinating 

Committee. 1997. ASSIST Coordinating Committee meeting summary, April 17, 1997, meeting, 

Rockville, MD: ASSIST Coordinating Center; Pertschuk, M. 2001. Smoke in their eyes: Lessons in 

movement leadership from the tobacco wars. Nashville, TN: Vanderbilt Univ. Press. 

407

9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

2. A resolution of the ASSIST Coordinating Committee, which is discussed 

below 

3. The creation of the advance groups— 

composed of representatives from 

ASSIST and IMPACT states and NCI, 

CDC, and ACS—to formulate 

recommendations about funding of 

programs, research and development, 

technical assistance and training, and 

other issues 

4. The interest of all concerned to work 

with and support DHHS in advancing 

a multilevel strategy of tobacco 

control based on the experience of the 

state and local movement 

The ASSIST Coordinating Committee 

resolution included the following requests: 

1. Federal funding for tobacco control 

should be reflected in the President’s 

FY99 Budget through multiple 

funding streams, with no reductions 

or gaps in the funding for state and 

community-based tobacco control; 

and, request that the Department’s 

commitment to continuous and expanded program funding be communicated to state and territorial 

tobacco control programs by January 1998. 

2. Federal funding for comprehensive, 

culturally diverse, policy-oriented 

tobacco control should be provided 

to all 50 states, the District of 

Columbia, and the territories 

regardless of state levels of funding, 

at a level consistent with the activity 

levels in California and 

Massachusetts as soon as possible. 

3. Additional federal funding should 

be available for applied research on 

statewide tobacco control strategies. 

4. Federal support should include more 

than provision of funds and should 

include an organized system of 

consultation, technical assistance, 

and training available to state and 

territorial tobacco programs.19(p3) 

At the meeting, the deputy assistant secretary for health of DHHS reaffirmed the administration’s commitment to programs 

like ASSIST and communicated President 

William J. Clinton’s intention to continue 

state and local programs. He recognized 

the legitimate concern about the uncertainty of funding for tobacco prevention and 

said that the budget for fiscal year 1999 

would likely not be finalized until January 

1998. In closing, he commented that the 

advance groups signify the advance of the 

ASSIST program to all 50 states. He expressed interest in actively communicating 

with the advance teams and invited their 

recommendations about the future of state 

and local tobacco control, including the 

role of the federal government in supporting initiatives such as ASSIST.19 

Report from the Advance Groups: 

Realizing America’s Vision for 

Healthy People: Advancing a Federal 

Commitment to Effective Tobacco Control 

The advance groups prepared their report, titled Realizing America’s Vision 

for Healthy People: Advancing a Federal Commitment to Effective Tobacco 

Control, in two parts. (See appendix 

9.D.) Part 1 was prepared by the Advance Group on Funding and was sent to 

the deputy assistant secretary of DHHS 

on December 12, 1997. Part 2 was prepared by the other three groups and was 

made available in February 1998.20,21 

In the advance groups’ report, the 

ASSIST Coordinating Committee rec408 
M o n o g r a p h 1 6. A S S I S T 

ommended that DHHS commit to fund 

the following: 

■	 A $2.5 billion per year program


capable of reducing the tobacco


epidemic, with the following


components:


–	 Public health programs at the national, state, and local levels to 

build community support for policies and programs that prevent tobacco use 

– Tobacco-free schools or interventions by youth service organizations and programs 

– Mass media-based public health 

education campaigns 

– National program of technical assistance, training, and communication throughout the tobacco control 

network 

–	 Surveillance, evaluation, and applications research conducted through 

the NCI and the CDC and national 

and state partners 

■	 A minimum program of state and lo­


cal tobacco control at a rate of $70


million per year


■	 A $50 million per year program of


research, development, and dissemi­


nation of effective tobacco control


innovations19(pp1–2)


Affirming the Commitment 

n a January 1998 letter to state tobacco 

control leaders, Secretary Shalala affirmed an intensified commitment to 

state-based programs. She stated that, in 

the president’s fiscal year 1999 budget, 

DHHS had proposed to expand support 

for state and community programs from 

$34 million in fiscal year 1998 to $51 

million in fiscal year 1999. This 50% increase would enable CDC to 

fund all states and the District of Columbia to implement innovative tobacco prevention programs as a core 

component of public health practice. 

Federal support for state tobacco prevention programs will be maintained 

or expanded in all 50 states. This is a 

model of government working at its 

best: We are moving the proven research findings generated from the National Cancer Institute’s (NCI) 

successful ASSIST program into widespread public health practice. 

State-based programs are a critical part 

of the Administration’s overall national 

effort to prevent tobacco use among 

our youth. Local input allows programs to be tailored to local needs and 

benefit from local innovation. Multiple 

agencies at HHS have a part to play in 

this effort. CDC, the Food and Drug 

Administration, the Substance Abuse 

and Mental Health Services Administration and several of the Institutes at 

the National Institutes of Health, will 

continue to work together to ensure 

that our strategies remain state-of-theart and responsive to changes in our 

dynamic environment. The NCI, in 

particular, will continue to support a 

broad range of research that will help 

support these community and state tobacco control programs.22(p1) 

Secretary Shalala’s statements that 

the future program would be state based 

and would include local input embraced 

the essential ASSIST element of community involvement and provided the 

opportunity to incorporate media interventions and policy development into 

the nationwide program that would be 

planned and administered by CDC. Under CDC’s leadership, the capacity built 

409 

I
9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

by the ASSIST states during 8 years 

would benefit the future program. With 

funding of $51 million, which was made 

available for fiscal year 1999 in the federal budget, the planning process would 

begin to move toward a funding level 

equivalent to that of ASSIST. 

Turning to Transition 

Public health practitioners across the 

nation applauded Secretary Shalala’s 

announcement. Many had worked for 

nearly a decade toward such an outcome. 

The national commitment was the outcome of two forces. First, the leaders of 

the ASSIST project and of numerous organizations had formulated the concept 

and funding requisites of an enduring 

state-based national tobacco prevention 

and control program. Through discussions and negotiations that over time involved more and more stakeholders, they 

anticipated the fundamental needs of and 

potential barriers to a national program. 

In working sessions, they focused their 

thoughts on strategies designed to articulate a credible proposal and build support for the concept. They produced 

documents to use in reaching out to other entities and in refining the concept. 

Consequently, they were able to approach the leaders of the funding agencies with a unified voice. 

Second, all the planning and strategies 

would have been fruitless had there not 

been the success story of the in-thetrenches work of the state health department staff, of ACS volunteers, and of 

coalitions composed of other organizations and individuals committed to public health through tobacco control. The 

work of the communities made it clear 

that the preferred social norm is to be 

tobacco-free and that a tobacco-free 

norm can be achieved through persistent 

efforts to adopt and enforce appropriate 

policies. The ASSIST demonstration 

study successfully involved communities in media interventions and policy 

advocacy to enact measures to protect 

the public’s health. ASSIST’s achievements were evidence of the need for a 

long-term commitment from DHHS and 

Congress to support a national program 

that would help states build their permanent tobacco control infrastructures. 

The leaders of ASSIST, the staffs of 

the state departments of health, and the 

coalitions underwent a remarkable process of professional and organizational 

development in learning how to implement a community-based program of 

policy interventions achieved through 

advocacy. For them, Secretary Shalala’s 

announcement represented the highest 

form of congratulations for a job well 

done. 

It also represented a turning point for 

them. The transition from a demonstration study to a national public health 

program administered by CDC would 

require a transition not merely of contractual locus, but also of operational adjustments and conceptual broadening. 

As the ASSIST staff participated in 

planning the transition, they encountered 

new developmental challenges, professionally and institutionally. Chapter 10 

recounts the transitional activities in the 

context of what it means to implement a 

public health program for the long term. 

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M o n o g r a p h 1 6. A S S I S T 

Appendices 9.A through 9.D are reproduced faithful to the originals, including minor errors. 

Appendix 9.A. Executive Summary from “Planning for a Durable 

Tobacco Prevention Movement: Sustaining Tobacco Prevention 

beyond the American Stop Smoking Intervention Study” 

Executive Summary 

Purpose: 

The Strategic Planning Subcommittee was requested by the ASSIST Coordinating 

Committee to consider the issue of the institutionalization of tobacco prevention. The 

Strategic Planning Committee created a Working Group to explore this issue, to prepare a brief discussion paper, and present this to the June 1995 meeting of the Coordinating Committee. 

This paper is intended to contribute to planning for tobacco prevention within and 

beyond the ASSIST project by identifying relevant issues and possible methods to resolve these. It is intended to stimulate discussion and offer proposals for next steps to 

be undertaken by state projects, NCI, ACS, and the Coordinating Center. 

Institutionalization and the durability of tobacco prevention is seen as a priority for 

the ASSIST project. 

Terms: 

The term institutionalize is used to refer to the process of integration and maintenance of programmatic activities within organizations. The term durability of tobacco 

prevention is used to refer to the maintenance and growth of the overall, broadly based 

tobacco prevention movement at the local and state level, with federal/national support. 

Factors affecting durability of tobacco prevention: 

Several interdependent factors that affect the durability of tobacco prevention are 

identified and discussed. These are: 

•	 contextual factors (including the degree of public support and willingness to pay for 

prevention activities), 

•	 policy commitments (including non-partisan commitments to public health), 

•	 funding commitments (including special tobacco taxation revenues earmarked for 

tobacco prevention), 

•	 organizational capacity and infrastructure (including change agents/champions, and 

staffing), 

•	 support (enabling) systems (technical assistance, training, funding, etc.), 

•	 diffusion of innovation factors (complexity, etc.), 

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9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

•	 engagement of multiple channels, settings, systems, and organizations, and, 

•	 system of monitoring and feedback on progress (e.g. tracking progress toward state 

defined strategic goals, objectives and implementation of interventions). 

The critical role for state health agencies as linkage agents in the national, state, 

and community-based tobacco prevention movement is highlighted; as is the essential 

role of voluntary networks to mobilize citizen action for policy advocacy. 

Support (enabling) systems—that deliver training, technical assistance, resource 

materials, funding, and facilitate networking—are seen as important to the continued 

growth of the tobacco prevention movement. Change agents (champions) to affect 

policy and funding commitments may prove to be the most critical of all. 

The factors identified in this paper should be explored and a plan developed to support institutionalization in each state. Support should be provided by the National 

Cancer Institute and the ASSIST Coordinating Center. 

Major developments affecting durability: 

Major developments affecting the durability of tobacco prevention are identified 

and discussed briefly, including: 

•	 progress within the ASSIST states; 

•	 Robert Wood Johnson Foundation funding of the SmokeLess States initiative; 

•	 Centers for Disease Prevention and Control IMPACT program; 

•	 Institute of Medicine Reports; 

•	 Association of State and Territorial Health Officials’ policy developments; 

•	 initiatives of the Center for Substance Abuse Prevention; 

•	 National Cancer Institute’s model for and stated interests in cancer control research; 

and, 

•	 American Cancer Society commitments to tobacco prevention. 

Recommendations: 

Recommendations are made for consideration by State ASSIST and the Coordinating Committee as follows: 

Recommendations for State ASSIST Coalitions 

1.	 Make institutionalization of tobacco prevention within state health departments, 

American Cancer Society, and other tobacco prevention organizations a priority 

for ASSIST. Pursue institutionalization by: (a) continuing to position tobacco 

prevention as a priority in the media and through policy advocacy initiatives, 

(b) working with key organizations within the state tobacco movement to seek 

reaffirmation of commitments to tobacco prevention and exploring specific strategies to ensure institutionalization of tobacco prevention within these organiza412 
M o n o g r a p h 1 6. A S S I S T 

tions, (c) integrating tobacco prevention into chronic disease prevention, health 

promotion and alcohol, tobacco and other drug initiatives, (d) ensuring a prominent and unique role for tobacco prevention in each state and local health agency, and (e) further developing the voluntary networks to mobilize citizen action 

for policy advocacy at local, state, and national levels. 

2.	 Starting with the factors and questions identified in this discussion paper, (a) explore the constraints and supports that will contribute to the durability of tobacco prevention in the state and (b) develop a plan for the institutionalization and 

durability of tobacco prevention. (Note: This recommendation is linked to recommendation number 4 below.) 

3.	 In ASSIST states with SmokeLess State initiatives, further develop working relationships with SmokeLess State initiatives in order to explore issues related to 

long term funding of and fund raising for tobacco prevention, including raising 

taxes on tobacco products. 

Recommendations for the Coordinating Committee 

1.	 Develop a strategy to support CDC initiatives to establish performance partnerships between CDC and state health departments for tobacco prevention. Watch 

for language in federal legislative proposals that would support mandatory, comprehensive, policy based tobacco prevention via federal grants. Refer this item 

to the Strategic Planning Subcommittee. 

2.	 Develop a concept paper on the vision, general strategy and roles and responsibilities of major players in a national strategy to prevent tobacco use in America. 

Consideration should be given to how to further extend partnerships with CDC, 

RWJ, ASTHO, the Coalition on Smoking OR Health and other agencies to build 

a national strategy that supports state strategies. Refer this item to the Strategic 

Planning Subcommittee and request them to report on their work to the fall 1995 

meeting of the Coordinating Committee. 

3.	 Work with NCI on future tobacco prevention research projects giving consideration to durability issues; and, ask NCI to consider extending ASSIST to at 

least the year 2000 in order to further contribute to the attainment of the Healthy 

People 2000 objectives. Refer action on this item to the Strategic Planning Subcommittee and Chair of the Coordinating Committee. 

4.	 Advise NCI about technical assistance and training needs with respect to the exploration of constraints/opportunities for and the development of state plans to 

ensure the durability of tobacco prevention in the states beyond the year 2000. 

Refer these issues to the Project Managers’ and Training Subcommittees. 

5.	 Encourage ACS to continue its support of NCI and state and local health agencies to advance tobacco prevention efforts and advocate for policy and funding 

commitments for tobacco prevention. 

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9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

Appendix 9.B. Executive Summary from “Turning Point for Tobacco 

Control: Toward a National Strategy to Prevent and Control 

Tobacco Use” 

Executive Summary 

1. Introduction (pp. 3-5) 

Despite 30 years of progress, today: 

•	 Tobacco remains the leading cause of preventable death; 

•	 About one-quarter of adults still use tobacco products; 

•	 Tobacco use continues to rise among adolescents; 

•	 Tobacco is responsible for more preventable deaths than are alcohol, car crashes, 

AIDS, murder, suicide, fires, and illegal drugs combined. 

The tobacco control movement is at a turning point. A renewed effort by public, private, 

and voluntary sectors is needed to move the country toward the goal of a smokefree society. This paper is written for the ASSIST (American Stop Smoking Intervention 

Study) project and suggests that participants in ASSIST now work to communicate a 

vision of a smokefree society, to reaffirm commitments and reunite efforts that are ongoing, and to seek greater coordination and planning within a comprehensive, policyoriented approach to preventing and controlling tobacco use. This paper makes the case 

for continued widespread application of the ASSIST model of tobacco control. 

2. Public Health Burden (pp. 5-7) 

The toll of tobacco-related morbidity and mortality remains high. Tobacco: 

•	 Causes more than 400,000 premature deaths annually; 

•	 Causes 87% of lung cancer deaths; 

•	 Causes 30% of all cancer deaths; 

•	 Is responsible for $68 billion per year in health care expenditures and lost 

productivity due to premature death and disability. 

Environmental tobacco smoke: 

•	 Causes about 3,000 lung cancer deaths in non-smokers annually; 

•	 Increases risk of respiratory tract infections such as bronchitis and pneumonia, 

including 150,000 to 300,000 cases in infants and children under 18 months; 

•	 Causes additional episodes and increased severity of symptoms of asthma in 

children. 

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M o n o g r a p h 1 6. A S S I S T 

3. Making The Case for Comprehensive Tobacco Control (pp. 7-15) 

Nicotine Addiction in Children Is a Pediatric Disease Requiring a Comprehensive Approach. 

Federal institutes and leaders have acknowledged that nicotine is addictive and that 

mass addiction to tobacco products is a public health problem resulting from child and 

adolescent use. 

•	 More than 3 million adolescents smoke cigarettes; 

•	 3,000 children and adolescents become smokers each day; 

•	 If a person smokes, the younger the person begins, the more likely that he or she will 

become a heavy smoker; 

•	 Tobacco products are heavily advertised; the ads are pervasive and reach children; 

children buy the most heavily advertised tobacco products. 

Why a Multigoal Orientation to Tobacco Control Is Needed 

Tobacco control efforts must seek to prevent mass addiction in children, to reduce environmental tobacco smoke, and motivate and support tobacco users to stop. This multigoal approach has been attempted and supported by the ASSIST program and others. 

Multiple public health goals are accomplished by policy interventions. 

Why a Comprehensive, Integrated, Policy-Focused Tobacco Control Strategy Is Needed 

A multilevel approach to community health promotion views health behavior as a social 

behavior developed and shaped in part by social context. A combination of policy and 

programmatic interventions can work together to promote health through synergistic interaction. The ASSIST program emphasizes policy-based interventions—in particular, 

policies in these areas: reducing youth access, increasing clean indoor air, restricting tobacco advertising and promotion, and increasing the price of tobacco products. The rationale for the ASSIST strategy is as follows: 

•	 Smoking is a public health problem and a social epidemic. It affects everyone in a 

community, not only smokers. Community empowerment is required to address this 

issue. 

•	 Significant and enduring changes in smoking behavior require a change in social 

norms. Broad participation is required to effect environmental changes supportive of 

non-smoking. 

•	 Each minute of every day the tobacco industry invests tremendous resources to 

encourage young people to begin smoking and to portray smoking as normal 

acceptable behavior. Resources for tobacco control need to be mobilized from 

private, public, and voluntary organizations. 

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9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

The Need to Further Develop Multicultural Competence 

As a comprehensive and inclusive approach to tobacco control, ASSIST embraces and 

values cultural differences and is able to draw strength from the diversity and breadth of 

communities concerned about tobacco use. Further efforts are necessary to gain cultural 

proficiency within the tobacco control movement. 

Why a Coordinated National/State/Community Tobacco Control Strategy Is Needed 

The tobacco industry has developed a coordinated, comprehensive, and multilevel approach to countering the tobacco control movement. For example, the industry: 

•	 Frames tobacco as a non-health issue in the media and other communications; 

•	 Organizes national campaigns to convince state and local legislators that legislative 

interventions are unneccessary because the industry is addressing the problem; 

•	 Harasses state governments with freedom-of-information requests; 

•	 Has developed a broad base of support from constituencies with a financial 

dependence on tobacco. 

The national, state, and local strategy needs to consider and address these and many 

other industry tactics. Also, state health agencies and other public and private sector 

agencies can play a pivotal role in the process of research translation and application in 

communities. 

4. Overview of Tobacco Control Efforts in ASSIST States (pp. 15-20) 

Coalitions. The ASSIST experience has shown that leadership is essential; that focusing 

on policy reforms can mobilize broad support; that coalitions can be of strategic value 

in facilitating access to and making changes in communities, and can be organized effectively in many different ways. 

Planning. Site analyses can be valuable for planning interventions. Long-range planning helps to develop and communicate a vision for tobacco control. A heavy focus on 

planning to the exclusion of action early in a project can result in attrition of participants. 

Capacity Building. The ASSIST model has led successfully to capacity building. The 

role of the national partners has changed from “top down” to “interactive.” Planning 

and support for training and technical assistance have become based on interests, needs, 

and capacities at state and local levels. 

The Intervention. It has been found that public education and tobacco control policy interventions are complementary; that persistence is essential; that providing small resources to local community groups can stimulate substantial efforts. 

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M o n o g r a p h 1 6. A S S I S T 

5. The Future for Comprehensive Tobacco Control: A Framework (pp. 20-28) 

Following from lessons gained from the ASSIST project, we propose that it will be productive to articulate a vision and set guidelines for comprehensive tobacco control. 

These can be used as points of reference for planning implementations. 

A vision for a comprehensive strategy should be drawn from a variety of policy studies, 

reports from consensus conferences, and descriptions of interventions (Appendix 1). 

Elements of a national strategy should include the following: 

• Public health objectives 

• Health-promoting tobacco-control policies 

• Movement infrastructure and programmatic interventions 

• Social marketing and mass media interventions 

• Intervention research, development, and dissemination 

• Monitoring and evaluation 

• Management and coordination mechanisms. 

Finally, the Institute of Medicine has described possible roles and responsibilities of 

partners in a national tobacco prevention and control strategy (Table 6). 

It is suggested that the vision articulated in various reports, elements of a national strategy, and the IOM report’s analysis of roles and responsibilities could be used as a starting point for the further development of a national strategy to prevent and control 

tobacco use. 

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Appendix 9.C. Helene Brown Testimony 

TESTIMONY FOR NATIONAL CANCER POLICY BOARD 

RE: ASSIST, March 31, 1997 

By Helene Brown 

Senior Advisor 

Director, Community Applications of Research 

UCLA Jonsson Comprehensive Cancer Center 

1100 Glendon Ave., Suite 711 

Los Angeles, California 90024 

310-794-8583 

Please allow me to express my views about your service as a National Cancer Policy 

Board. All of us hunger for the day when cancer will no longer be a threat to our lives. 

There are those of us who believe that Dr. Klausner, in bringing a torrent of change to 

the National Cancer Institute, has shown that he is clearly willing to take some risks to 

ease that hunger. Establishing this policy board is a neat idea, and one that deserves 

applause. The objective manner in which you will seek to establish policy related to 

cancer issues is an absolute necessity. We are not engaged in idle conversation today. 

This is truly a matter of life and death. I cannot possibly tell you what a pleasurable 

experience this is for us. We have a critical issue to put before you. I hope you are as 

pleased to see and to hear what we have to offer as we are to be here. 

The American Stop Smoking Intervention Study for Cancer Prevention (ASSIST) is 

only midway through its intervention phase. ASSIST is implemented in 17 states 

(Slide 1) with a control group of the rest of the United States. These states do not exist 

in a vacuum. There are other forces both for and against the use of tobacco active in 

both sets of states for the playing field is level. Excellent cigarette consumption information is derived from tax data. The ASSIST states are now consuming 10 percent 

fewer cigarettes than the non-ASSIST states (Slide 2). We are just half-way through 

the clinical trial. This is an astounding trend. This difference in consumption equals 

70 MILLION packs of cigarettes not smoked each month (Slide 3). ASSIST has actually managed to suppress the market for the tobacco companies by 10 percent . . . In 

anyone’s language, that is a “market share” of enormous proportions. 

ASSIST is a clinical trial of a protocol developed by the National Cancer Institute 

(NCI) to reduce mortality from cancer caused by the use of tobacco. It is a dynamic 

human laboratory of phenomenal proportions. There are over 200 coalitions with more 

than 6,200 organizations and individuals offering the intervention protocol. Please 

think of this in the same manner that you would any other clinical trial. If this were a 

drug or a vaccine and had this level of success in a clinical trial, the pharmaceutical 

manufacturers in the private sector would be vying with each other to further develop 

the “drug” or “vaccine,” and then to profitably market the product. This is the wonder 

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M o n o g r a p h 1 6. A S S I S T 

of our public/private partnership that uses the NCI well to develop the knowledge that 

makes possible the private sector development of products. 

However, the ASSIST clinical trial is different. There is no profit to be made in the 

market place by selling “do not smoke or chew.” Thus, it clearly becomes the responsibility of government (that’s us . . . of the people, by the people, for the people) to see 

that the 400,000 premature deaths (slide 4) due to the use of tobacco continue to be reduced. Please take a good look at this slide. Alcohol, motor vehicle accidents, suicides, AIDS, homicides, illegal drug use and fires taken all together do not offer the 

reduction in mortality that is possible by ridding ourselves of the use of tobacco. 

Looking at it in another sense, it is the underlying cause of death (Slide 5) in heart disease, cancer, stroke and chronic obstructive lung disease . . . the top four killing agents 

in our society. 

The ASSIST model has established the proper minimum dose. Like a drug or vaccine the ASSIST model is dose-related. In California and Massachusetts, consumption 

is further reduced simply because they have tobacco tax revenues that offer the 

ASSIST protocol in larger doses. 

The rates of cancer mortality in the USA have begun to decline. The turn-around 

started in 1990, and the trend is continuing (Slide 6). It is equally clear that the cancers caused by the use of tobacco are responsible for a goodly portion of this decline 

(Slide 7). Lung cancer is down 5.6 percent in the under-65 group, bladder cancer 

down 9.3 percent and oral cancer down 14.1 percent. We are on a roll, and we dare not 

lose the advantage. 

The problem that must become the policy interest of this Board is this. Government 

has the true responsibility to continue using the ASSIST model for all the 400,000+ of 

its citizens who are in need. Government is meant to offer to the people that which the 

private sector cannot offer – highways, public parklands, defense, flood control, etc. 

The list is long and delivery of the ASSIST model for the reduction of mortality is top 

priority on this list. To date, the federal expenditures in this arena are pitifully minuscule (Slide 8). 

With all of this in mind, we respectfully make these suggestions. 

A) That this Board does what it must do to assure that the policy of this Administration is one that delivers the ASSIST model to all 50 states. 

B) That ASSIST I (17 model states and the coordinating center) remain fully funded 

at this point in time. That it also be the vanguard group and serve as the research arm 

of the NCI in tobacco control. There are still new research questions to be asked. Retaining such a human laboratory with the experience and record of accomplishment of 

ASSIST I makes good sense. 

C) That the NCI be designated the lead agency in establishing ASSIST II with the 

monetary cooperation of the various public agencies and members of the NIH that 

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9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

have a stake in this problem such as CDC, HCFA, Medicare, Medicaid, NHLBI, NIAID, NIDA, the VA and others, including the private sector agencies like the ACS, 

AHA, and ALA. This plan would emulate the successful funding of the AIDS research 

program where one agency was the “lead” agency and was funded for the work in a 

great part with contributions from the other Institutes. 

D) That the staff, budget, training, reporting and evaluation mechanisms needed to 

support this complex initiative be established and put into place for the other 31 states 

(Massachusetts and California excepted) under the ASSIST I model by the NCI, thus 

becoming ASSIST II. 

E) That after the ASSIST II model is experienced, up and running well, the lead 

agency responsibility could be transferred to the CDC for continued implementation 

and evaluation. 

It is imperative that this nation not have such remarkable returns as reduced mortality interrupted or delayed. If the reduction of mortality from cancer is truly the mission 

of the NCI, then it must truly be the mission of this Policy Board to carefully consider 

the consequences if the NCI declares that further implementation and delivery of this 

life-saving methodology is “not my job,” and walks away from the task without setting 

in place that which will ultimately preserve 400,000 premature deaths. 

I don’t know many things for sure, but I do know this. If we do not shoulder this responsibility and make it happen, no one else will. If we do not shoulder this responsibility, it will likely become one more of America’s dirty little secrets. 

I pledge to you my full concern and effort to help and guide this project until the 

day that I can no longer do it. I hope we – all those involved in ASSIST – can join 

with you to forward these plans and to see that this becomes the tobacco policy of the 

Administration. 

Thank you and may I now introduce Sally Malek, who is the Manager of the 

ASSIST Project in North Carolina, and is the Chair of the Association of State and Territorial Health Officers Tobacco Prevention Network. Sally, please make whatever remarks you wish to make and then we can try to reply to your questions. 

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M o n o g r a p h 1 6. A S S I S T 

Appendix 9.D. Realizing America’s Vision for Healthy People: 

Advancing a Federal Commitment to Fund Effective Tobacco 

Control 

Report of the Advance Group on Funding 

With Membership from State Health Agencies and 

American Cancer Society 

December 31, 1997 

Executive Summary 

The Funding Advance Group prepared this report in response to the Department of 

Health and Human Services (DHHS) request for advice about how the Federal Government should support tobacco control. The Funding Advance Group is a group of tobacco control leaders and experts from many states, including public health professionals 

from states engaged in the American Stop Smoking Intervention Study (ASSIST) and 

Initiatives to Mobilize for the Prevention and Control of Tobacco Use (IMPACT), 

American Cancer Society (ACS), and the ASSIST Multicultural Subcommittee. 

It is time for Federal Government leadership in funding an effective nationwide stateand community-based program to control the epidemic of tobacco-caused disease. 

Our vision for the nationwide federal program is one that is based on the great American traditions of participatory democracy and free speech, in which diverse communities are empowered to oppose the tobacco industry and create their own futures free 

from tobacco addiction and disease, and public health professionals are free to play 

their important role of informing the public and policymakers about the implications of 

tobacco control policies. 

Recommendations 

After giving careful consideration to the massive public health concern presented by 

tobacco use and the requirements to reduce the epidemic, the Advance Group makes 

the following three recommendations. It is recommended that: 

1. DHHS fund a program capable of reducing the epidemic that includes: 

•	 Public health programs at the national, state, and local levels to build community 

support for policies and programs that prevent tobacco use, motivate and support 

efforts to stop tobacco use, and control secondhand smoke 

•	 Tobacco-free schools or interventions by youth service organizations and 

programs, including tobacco prevention education curriculum, tobacco-free policy 

implementation, and school and community collaborative activities with an 

emphasis on policy reforms that promote the nonuse of tobacco (limited but 

important role) 

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9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

•	 Mass media-based public health education campaigns, including a focus on 

tobacco industry practices, information about tobacco products, the public health 

benefits of tobacco control policies, in addition to some programming aimed to 

prevent tobacco use and motivate and support attempts to quit tobacco use 

•	 National program of technical assistance, training, and communication throughout 

the tobacco control network 

•	 Surveillance, evaluation, and applications research conducted through the 

National Cancer Institute (NCI) and Centers for Disease Control and Prevention 

(CDC) and national and state partners. 

Such a program would cost at least $2.5 billion per year, which is substantially less 

than current federal spending on other important public health problems of lesser 

magnitude. Funding for such a program should be in place by the year 2000. 

2. DHHS fund, in Fiscal Year 1999, a minimum program of state and local tobacco 

control at a rate of $70 million per year. 

3. This program would be commensurate with current ASSIST funding levels and 

would immediately support a base level of state and local tobacco control in all 

states, territories, and the District of Columbia. Such a program would ensure 

cultural inclusiveness and sensitivity, an emphasis on policy development that 

supports the nonuse of tobacco and minimizes protobacco messages, and be 

comprehensive in terms of interventions, settings and locations, and priority 

populations engaged. 

4. DHHS fund, in Fiscal Year 1999, a $50 million per year program of research, 

development, and dissemination of effective tobacco control innovations. 

This research program would include funding for innovation by national, state and 

community tobacco control organizations and research institutions in several states. 

Knowledge gained from this program would be used to guide the implementation of 

future programs. This immediate funding should be augmented annually to reach 

approximately $100 million annually. 

Rationale 

The rationale for this request is as follows. 

Tobacco-related addiction, disease, disability, and death make up the nation’s largest 

public health epidemic. 

The Administration has publicly committed to address the problem. However, lack of 

a strong federal commitment to funding perpetuates the epidemic. 

The Administration spends more money on other public health problems of lesser magnitude. 

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M o n o g r a p h 1 6. A S S I S T 

Evidence from the evaluations of the Massachusetts, California, IMPACT, and 

ASSIST programs demonstrates that state and local tobacco control can be effective. 

Larger investments yield greater success. This knowledge should be used to guide the 

next generation of tobacco control. 

Research investments by the NCI and CDC have made a substantial contribution to 

the field of tobacco control. These investments must continue in order to ensure the 

continuing development of tobacco control innovations and the translation of scientific 

knowledge into effective public health practices. 

Background 

A. Introduction 

In this paper, the Advance Group on Funding1 2 identifies the funding requirements for 

federal support of a national tobacco control program that works. We discuss the rationale and assumptions that were used in preparing recommendations for consideration 

by the DHHS. First, we provide a brief summary of the context and general values 

that have guided the development of this paper. Then, we estimate the requirements 

for a federally funded nationwide tobacco control intervention capable of reducing the 

epidemic of avoidable tobacco-caused disease, disability, and death. Finally, we identify the immediate minimum funding requirements that are required to protect recent 

initial accomplishments, and provide a platform from which to launch an effective national effort. 

B. Context

Planning for the long-term continuation of tobacco control efforts has proceeded within the ASSIST project since the first year of the intervention (cf. Planning for a Durable Tobacco Prevention Movement–Sustaining Tobacco Prevention Beyond the 

American Stop Smoking Intervention Study, May 1995; Turning Point for Tobacco 

Control: Toward a National Strategy to Prevent and Control Tobacco Use, December 

1996). Since the ASSIST Coordinating Committee initiated this planning, much dialogue has occurred within the tobacco control movement about the need for an en1 Advance Groups were created to plan for the future of tobacco control. There are five funding groups 

addressing funding requirements; technical assistance and training; surveillance, evaluation, and 

applications research; advocacy opportunities; and liaison/communication issues. These groups are 

comprised of representatives from state health departments (IMPACT and ASSIST states) and the 

American Cancer Society. In convening these groups, care was given to ensure cultural sensitivity through 

inclusion of members of the ASSIST Multicultural Subcommittee. CDC and NCI staff were consulted on 

matters of fact. 

2

 Members of the Advance Group on Funding are as follows: John Beasley – MI (Cochair), David Bourne – 

AR, Pam Eidson – GA, Julie Harvill – IL, Jennie Hefelfinger – FL, Jerie Jordan – ACS/National, Sally 

Herndon Malek – NC, Bob Moon – MT (Cochair), William S. Robinson – SC, Nancy Salas – CO, Carter 

Steger – VA, Joan Stine – MD, and Ron Todd – ACS/National. 

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hanced federal role in supporting tobacco control interventions and research. CDC has 

made a long-term commitment to fund states not receiving funding from NCI. 

A broad consensus now exists within the tobacco control community (e.g., ASSIST, 

ACS, ASTHO, AMA, NCTFK, ANR, CDC, NCI, and others) that DHHS should fund 

comprehensive, culturally inclusive, policy-focused, state and local tobacco control initiatives in all states (cf. ASSIST Coordinating Committee resolutions, AMA resolution, 

ASTHO decisions, joint statement by ASTHO and ACS, CDC’s IMPACT Program, 

etc.). It is also widely acknowledged that technical assistance, training, and network 

support should be provided to all states. Furthermore, the tobacco control community 

has reached a broad consensus that an effective tobacco control effort must continue to 

include public health applications research on tobacco control within NCI, as well as 

surveillance and evaluation efforts within CDC and other federal agencies. 

At the October 1996 ASSIST Information Exchange Meeting, Mr. Kevin Thurm, Deputy Secretary for DHHS, indicated that the Department and the Administration are 

“100 percent committed to continuing” the work of tobacco control. Mr. Thurm also 

acknowledged that an overall coordinated strategy—built on state and community efforts—is necessary to achieve the Administration’s policy objectives. However, no decision had been made at that time about which agency within DHHS would take 

responsibility for the continuation of Project ASSIST. The National Cancer Institute 

has agreed to extend ASSIST state contracts for an additional year until September 1999. 

Secretary Shalala met on at least two occasions with leaders in state and local tobacco 

control during the summer of 1997. During these meetings, the Secretary reiterated 

the Administration’s commitment to continuing support for state and local tobacco 

control. 

The President’s 1998 budget proposed funds for tobacco control programs and research to be implemented by the CDC, FDA, SAMHSA, and the NCI. The Administration is committed to reducing tobacco use by 50 percent within the next 5 years (FDA 

objective). CDC is committed to implementing tobacco control in all 50 states, funded 

at levels commensurate with the problem. CDC also wishes to work with the NCI to 

ensure the integration of public health research and practice. The President’s 1998 budget proposal included a $15 million increase for the CDC to support tobacco control 

initiatives. Congress appropriated $7 million. 

Mr. Jim O’Hara, Assistant Deputy Secretary of Health and Human Services, has been 

designated by the Secretary as the departmental coordinator of tobacco control interventions. At its recent meeting in Houston, the ASSIST Coordinating Committee met 

with Mr. O’Hara and gave him a thorough briefing about (a) the issues and concerns of 

the ASSIST project about the durability of state and local tobacco control; (b) a resolution of the ASSIST Coordinating Committee (see attached); (c) the creation of “transition task forces”–composed of representatives from ASSIST and IMPACT states–to 

formulate recommendations about funding of programs, research and development, 

technical assistance and training, and other issues; and, (d) the interest of all concerned 

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M o n o g r a p h 1 6. A S S I S T 

to work with and support the Department in advancing a multilevel strategy of tobacco 

control based on the experience of the state and local movement. 

Mr. O’Hara communicated his clear understanding of the issues, as well as his personal commitment and the department’s commitment to advance tobacco control at the 

state and local level. He demonstrated his understanding of the need for an urgent resolution of the issues presented. He also expressed an interest in the “transition task 

forces” and suggested the use of a more positive term such as “advance groups,” that 

is, planning to advance tobacco control, not just transition it. At the meeting, Mr. 

O’Hara indicated that he would follow-up within two weeks with the chairpersons of 

the Coordinating Committee about receiving input from the Advance Groups. He followed through on this commitment by further communication with Mr. Randy Schwartz, 

cochair of the ASSIST Coordinating Committee, expressing interest in input as soon as 

possible. This report is prepared in response to Mr. O’Hara’s request for advice. 

C. Values Guiding This Exercise 

The Advance Group discussed several values that served to guide this exercise. These 

considerations are as follows: 

1. Resolve to address the epidemic. Tobacco-caused disease, disability, and death 

are of enormous proportions that demand resolute government intervention to address 

the public health crisis caused by the tobacco industry. In fiscal year 1997, the Federal 

Government allocated about $15 billion for substance abuse control, $8 billion for 

HIV/AIDS, and about $0.046 billion for tobacco control. The leading cause of preventable death is currently at the bottom of the funding pyramid of major public health 

problems. 

The failure to meet the Healthy People 2000 Goals for tobacco use is directly attributable to lack of resources applied to the problem. The goal of 15 percent smoking prevalence may be realized in only one state. The states that had the most success in 

reducing tobacco use have applied resources commensurate with the problem. The 

FDA objective to reduce tobacco use by 50 percent will meet a similarly disappointing 

fate unless a commitment is made to fund programs at a level that works. 

2. Cultural diversity and inclusive participation. The tobacco control movement is 

defined by and draws its strength from its breadth of participation. We believe that our 

current and future strength emanates from our cultural diversity and our commitment 

to the inclusion and active participation of individuals and organizations of many cultures, including, but not limited to, those defined by ethnicity, race, language, geographic, sexual preference, and age. 

Tobacco use has caused unnecessary and avoidable morbidity and mortality among African Americans, Native Americans, Asian Americans, and Hispanic-Latinos. Furthermore, high tobacco use continues in other cultures such as the physically disabled, the 

gay and lesbian community, and illegal drug users. The tobacco industry has spent disproportionate dollars targeting many of those communities in promoting tobacco prod425 
9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

ucts. We believe that a share of any funds available should be allocated for programs, 

research, advocacy, training, media and all other elements of the national tobacco control program, commensurate with the impact of tobacco use in those communities. We 

believe that only through a sustained commitment to cultural inclusiveness will we begin to reduce tobacco use and its impact on all the cultures cited above. 

3. Building on experience. During the 1990’s tobacco control has gained momentum 

through programs and actions of the federal and state governments, voluntary and philanthropic agencies, and activists. We believe that the national commitment should 

build on and extend this experience by increasing the capacity of organizations and 

programs already active. Through this mechanism we can reach and enable action 

through a growing tobacco control network. 

4. Implementing what works. Evidence is available from the evaluations of the California, Massachusetts, IMPACT, and ASSIST interventions. Comprehensive, policyoriented, culturally inclusive state and local tobacco control is effective, and 

effectiveness is dose related. Greater investments in tobacco control are associated 

with larger impacts on tobacco use at the population level. Puny investments by the 

Federal Government will only serve to perpetuate the epidemic and ensure that generations will continue to suffer more unnecessary, avoidable deaths. 

5. Comprehensiveness and integration, with a focus on policy. A key defining characteristic of effective tobacco control is comprehensiveness with a focus on policy. Policy reform is the first priority for tobacco control at all levels. Creating environments that 

denormalize tobacco use and establish nonuse as the norm represents the best method 

to influence tobacco use. Such interventions should be implemented through multiple 

settings (health care, school, workplace, community organizations, etc.), address the 

needs of multiple priority populations (e.g., minority, blue collar, children, etc.), and 

through multiple approaches (e.g., programmatic, policy, and media advocacy). 

6. Continuity. Federal funding should ensure that current programs at the state and 

local level are not disrupted by reductions or gaps in funding. A broad-based movement has been mobilized against the epidemic with federal funding and support. It is 

essential that this work not be discontinued in the short or long term. 

The current ASSIST program funding commitment extends to September 1999 (the 

end of the fiscal year). IMPACT state funding cycles are from December through November. Funding for all states should be extended and there should not be discontinuity of the programs. 

7. Nationwide intervention. The benefits of effective tobacco control should be 

available to all Americans. DHHS funding is needed for interventions in all states, territories, and the District of Columbia. 

8. Minimum federal program in all states. A minimum federal program contribution is necessary for all states, even those that have earmarked state taxes or legal settlement funds for significant tobacco control program investments. It is necessary that 

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the Federal Government fund staff positions in all states, foster innovation and the 

transfer of effective tobacco control interventions among states, and ensure participation of all states in national events such as national meetings, planning activities, and 

trainings. 

9. Federal flexibility to support state and local changes. Federal funding for a nationwide, state, and locally based tobacco control program would be an important expression of federal leadership. We respect the Federal Government’s role in supporting 

change at the state and local level. We believe that federal support for state and local 

changes can best be achieved through the establishment of a base budget for all states 

and a grants program that can be awarded on the basis of changing need and strategic 

opportunities. Successful programs can be incorporated into base budgets. Moreover, through such a mechanism the Federal Government can ensure that all states have 

a minimum program, respond to opportunities for strategic development as these occur 

at the state level, and build programs over time. Some flexibility should be preserved. 

10. National program infrastructure. The creation of an adequately funded nationwide state- and community-based program requires a central infrastructure. Federal 

Government staff and budget, as well as training, technical assistance, planning, and 

communication networks, must be expanded to ensure the expanded state/local program is appropriately supported, monitored, and managed. 

11. Multiple complementary federal funding sources. Given the breadth of the tobacco problem and the need for the involvement of multiple federal agencies, we believe that it is important for DHHS to employ multiple complementary funding 

streams. CDC, NCI, SAMHSA, and FDA all play important complementary roles. 

D. Controlling the Tobacco Epidemic: Funding Requirements for an Effective 

Nationwide Tobacco Control Program 

While funding at current ASSIST levels for a nationwide intervention would protect 

gains and strengthen the tobacco control efforts in many states, it is insufficient to substantially reduce the tobacco epidemic within the foreseeable future. Rather, funding 

levels based on the California and Massachusetts experiences can effectively reduce tobacco use within a decade. Funding at higher than current ASSIST levels could be expected to have an increased effect on public health in a similar period of time. 

The Advance Group gave consideration to the elements of the program and based its 

cost estimates on these components. Elements of the program that have proven to be effective are as follows: 

•	 Public health programs at the national, state, and local levels to build community 

support for policies and programs that prevent tobacco use, motivate and support 

efforts to stop tobacco use, and control secondhand smoke 

•	 Tobacco-free schools or interventions by youth service organizations and programs, 

including tobacco prevention education curriculum, tobacco-free policy 

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9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

implementation, and school and community collaborative activities with an emphasis 

on policy reforms that promote the nonuse of tobacco 

•	 Mass media-based public health education campaigns, including a focus on tobacco 

industry practices to provide information about tobacco products, the public health 

benefits of tobacco control policies, in addition to some programming aimed to 

prevent tobacco use and motivate and support attempts to quit tobacco use 

•	 National program of technical assistance, training, and communication throughout 

the tobacco control network 

•	 Surveillance, evaluation, and applications research conducted through the National 

Cancer Institute (NCI) and Centers for Disease Control and Prevention (CDC) and 

national and state partners. 

School-based programs are an important element of the national program. However, 

we should not expect the educational system to fully address the problem. We strongly 

recommend that funding to this sector be focused to those endeavors shown to have a 

significant impact at a reasonable cost. 

We estimate that the cost of a truly effective national program would be $2.487 billion. 

We advise that these funds be allocated and the program be fully operating by the year 

2000. We believe that the tobacco crisis demands such a commitment as soon as possible. 

This funding commitment should not be contingent on the outcome of any arrangement, deal, or “settlement” with the tobacco industry. The responsibility to deal with 

the national epidemic is that of the Federal Government, regardless of what the tobacco industry may or may not agree to. Government should not stand in line waiting for 

a donation from the industry that caused the problem. 

While we do not believe that funding for the national program should be contingent on 

a tax increase, we agree with the Administration that a tax increase would have clear 

public health benefits, particularly in reducing tobacco addiction among youth. We 

note that an increase of 75 cents per pack would generate about $11 billion per year in 

new revenue (Congressional Joint Committee on Taxation, 1995). Nevertheless we do 

not believe that funding for the tobacco control program should be contingent on a tobacco tax increase. 

E. 	Immediate Requirements for a Nationwide Tobacco Control Program 

1. Funding for all states, territories, and the District of Columbia based on 

ASSIST funding levels 

The Advance Group believes that DHHS should address the public health epidemic of 

tobacco through an aggressively led national program implemented in all states, territories and the District of Columbia. We believe that the California and Massachusetts 

tobacco control interventions—based on the ASSIST model—present the best examples of what should be implemented across the country. 

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M o n o g r a p h 1 6. A S S I S T 

However, given the evidence that the ASSIST project has been effective, we believe 

that the Federal Government should immediately fund a nationwide program at 

ASSIST levels. NCI currently funds the ASSIST project at a rate of about $25 million 

per year for funding to state health departments, technical assistance, and training and 

evaluation. Given that ASSIST states represent about 95.7 million people or 36 percent of the U.S. population, the rate of spending is about 26 cents per person. Applying this rate of spending to the total U.S. population (about 265.3 million) suggests a 

requirement of about $69.31 million to implement an immediate minimum nationwide 

program based on the ASSIST model. 

The Advance Group suggests that these funds, at minimum, need to be made available 

and the funding mechanism communicated to all concerned immediately. Such a program would make a significant contribution to the public’s health. However, the 

amount of funding is insufficient to reduce smoking prevalence to 15 percent of the 

adult population which is the Healthy People 2000 objective. Therefore, we believe it 

is critical that greater funding be pursued to implement a program with the scale necessary to control the tobacco epidemic. 

2. Funding for research, development, and dissemination 

Scientific innovation and collaboration are needed between the scientific/academic and 

public health communities. This goal can be accomplished only through an expanded 

program of research, development, and dissemination with leadership from NCI and 

should be given priority by DHHS as the Department proceeds toward the implementation of a fully funded, effective, national tobacco control program. 

We believe that NCI should implement a research program in 15 to 20 states to study 

the impact of innovative tobacco prevention and control interventions at the community, state, and multistate level. This research program would simultaneously provide resources to research institutions and established state tobacco control coalitions to 

undertake multiple studies collaboratively. The results of this research would guide tobacco control programs in the remaining states and provide knowledge that would focus the larger national program on effective, state-of-science interventions. 

The goal of this program would be to incorporate rigorous research as an ingrained 

feature of state and local tobacco control programs by expanding existing tobacco control coalitions to include research institutions. This would be accomplished by the development and expansion of collaborative relationships in 15 to 20 states between 

research institutions, state health departments, voluntary health organizations, and tobacco prevention and control coalitions at the state and local levels. The collaborative 

nature of this relationship would be defined in a written document from each state, 

clearly defining the roles of the research institution, the state health department, and 

the named voluntary health organization and how they would make collaborative decisions regarding all aspects of the research. 

Research institutions for each of the states or for groups of states should be funded directly by NCI to conduct multiple studies of interventions at the community, state, and 

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9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

multistate level. The research institution would have experience and expertise in multidisciplinary tobacco control studies at the community and state level. Appropriate areas of expertise would include psychology, preventive oncology, economics, 

pharmacology, medicine, nursing, communications, sociology, and political science. 

The research institution in each state would manage all aspects of state and local study 

design, data collection, and data analysis with members of the partnership. An important objective for this research would be to create in these institutions a cadre of cancer 

control researchers with experience in community and state public health research (including being sensitive to the collaborative requirements of such research). These institutions would also support the training of new professionals and serve as a locus for 

continuing professional education about tobacco control. 

NCI would also make competitive awards to state health departments to implement innovative interventions. These interventions would be conducted through state and local coalitions and with the active participation of a named voluntary health 

organization that would contribute resources to the project. All states would include a 

paid counter-advertising campaign as one of their interventions. Policy interventions 

at the state and local level would also be required. State coalitions must have experience at implementing comprehensive tobacco control programs with an emphasis on 

policy interventions and at reaching diverse population groups with culturally appropriate interventions, and be willing to participate in collaborative research. 

Many different aspects of the interventions are appropriate subjects of research. Examples of research questions that may be addressed through this project are as follows: 

In the context of a statewide program, what is the impact of a large counteradvertising 

campaign on (1) attitudes toward tobacco advertising, tobacco use, and the tobacco industry, and (2) tobacco use behaviors? What themes of counteradvertising campaigns 

are most effective in achieving the goals of the campaign? How do state laws that preempt local tobacco control legislation influence the public’s knowledge, attitudes, and 

behavior related to tobacco? How should tobacco control programs be modified to be 

most effective in tobacco-growing states? How should tobacco control programs be 

modified to meet the needs of special population groups? How can new funds be used 

to reduce tobacco use as rapidly as possible? What is the optimal level of per capita 

spending on tobacco control programs? What public policies are most strongly predictive of reductions in tobacco use? 

A more detailed listing of research questions is being developed by the Surveillance, 

Evaluation, and Applied Research Advance Group. 

Attachment #1 – ASSIST Coordinating Committee Resolution (9/26/97) 

WHEREAS there is evidence from the evaluation of the California, Massachusetts, and 

ASSIST interventions that comprehensive, policy-oriented, culturally inclusive tobacco 

control is effective and effectiveness is dose-related; and, 

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WHEREAS there is broad consensus within the tobacco control movement that the 

Federal Government should support effective tobacco control in all states and this 

should include funding for state and local tobacco control, as well as technical assistance, training and network support based on the ASSIST model; and, 

WHEREAS the Secretary of Health and Human Services has communicated her Department’s commitment to support effective tobacco control in all states; and, 

WHEREAS beyond the current funding commitment, a specific funding plan does not 

exist to ensure that the momentum for tobacco control is not lost; and, 

WHEREAS if momentum for tobacco control is lost at the state and local level, this 

would be a public health disaster; and, 

WHEREAS the National Cancer Institute, Centers for Disease Control and Prevention, 

American Cancer Society, Association of State and Territorial Health Officers, and other state and local health organizations share a commitment to ensure that effective tobacco control continues and expands, without gaps in funding to impede these 

developments; and, 

WHEREAS lives depend on NCI advancing the science of tobacco control through 

vanguard state tobacco control initiatives; and, 

WHEREAS the current media and public policy attention on tobacco control policy 

has raised the public health priority of effective tobacco control programs to the President’s agenda and there are national expectations that the Administration would implement an effective national tobacco control policy regardless of any outcome of the 

proposed settlement; 

THEREFORE, BE IT RESOLVED that the ASSIST Coordinating Committee requests 

the following of the Department of Health and Human Services. 

1. Federal funding for tobacco control should be reflected in the President’s FY99 

Budget through multiple funding streams, with no reductions or gaps in the funding 

for state and community-based tobacco control; and, request that the Department’s 

commitment to continuous and expanded program funding be communicated to state 

and territorial tobacco control programs by January 1998. 

2. Federal funding for comprehensive, culturally diverse, policy-oriented tobacco 

control should be provided to all 50 states, the District of Columbia, and the 

territories, regardless of state levels of funding, at a level consistent with the activity 

levels in California and Massachusetts as soon as possible. 

3. Additional federal funding should be available for applied research on statewide 

tobacco control strategies. 

4. Federal support should include more than provision of funds and include an 

organized system of consultation, technical assistance, and training available to state 

and territorial tobacco programs. 

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9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

Realizing America’s Vision for Healthy People: Advancing a 

Federal Commitment to Effective Tobacco Control. Part II. 

Report of the Advance Groups on 

Training and Technical Assistance 

Surveillance, Evaluation, and Applications Research 

Advocacy Opportunities 

With Membership from State Health Agencies and 

American Cancer Society 

February 4, 1998 

OVERVIEW 

Tobacco control leaders and experts from many states, including public health professionals from the American Stop Smoking Intervention Study (ASSIST) and Initiatives 

to Mobilize for the Prevention and Control of Tobacco Use (IMPACT), along with the 

American Cancer Society (ACS), and the ASSIST Multicultural Subcommittee, 

formed four Advance Groups to provide direction and input into the design of a nationwide comprehensive tobacco prevention and control program and to respond to a request from the Department of Health and Human Services (DHHS) for advice about 

how the Federal Government should support such a program. The issues addressed by 

the four Advance Groups are: 

• Funding 

• Training and Technical Assistance 

• Surveillance, Evaluation, and Applications Research 

• Advocacy Opportunities.


The Funding Advance Group has submitted separately its recommendations for the fi­


nancial resources needed to adequately address the epidemic of tobacco use in this


country. This document combines the reports of the other three groups.


TRAINING AND TECHNICAL ASSISTANCE ADVANCE TEAM REPORT 

Introduction 

The Training and Technical Assistance (TAT) Advance Team includes members from 

16 states,1 from both the IMPACT and ASSIST programs, and the American Cancer 

Society. 

1

 Jeanne Prom, ND; Deborah Borbely, NM; Wendy Boblitt, IN; Chuck Bridger, NC; C. Ann Houston, NC; 

Bob Leischow, AZ; Jane Moore, OR; Rebecca Murphy, UT; Jane Pritzl, CO; Deborah Quinones, NY; April 

Roessler, CA; Judy Schmidtke, WA; Ron Sherwood, OH; Shannon Spurlock, MA; Kerry Whipple, IL; 

Mikelle Whitt, MI; Gary Wilson, MO. CDC and NCI staff provided technical and editorial assistance. 

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M o n o g r a p h 1 6. A S S I S T 

Training and technical assistance is a critical element of any successful tobacco prevention and control program. Training delivers information and develops skills that 

are needed to prepare effective plans and turn them into a reality. Technical assistance 

is the ongoing support needed to respond to the ever changing environment of tobacco 

control. Both training and technical assistance should provide content information on 

best practices in tobacco control and build skills to enable grantees to plan, implement, 

and evaluate tobacco control interventions and policies appropriate to their setting. 

Additionally, training and technical assistance should be provided which strengthens 

the ability of the funding recipient to receive and utilize government funds and implement programs nationally. Currently, training and technical assistance is provided at 

different levels to the 17 ASSIST states and the 33 IMPACT states, the District of Columbia, and California. Consistency is needed in designated funding for technical assistance and training for all states. 

The members of the team analyzed six components of technical assistance and training, and from that preliminary analysis developed the following recommendations. 

Recommendations 

Funding:

Funding for technical assistance and training in each state must be at an adequate level 

to provide information and skills necessary to reduce the prevalence and adoption of 

tobacco use. 

Therefore, states recommend that federal government funders: 

1. Designate funds to ensure 	that each state receives adequate and consistent technical 

assistance and training and that national training sessions are conducted. 

2. Raise funding in Fiscal Year 1999 for all states to the level of the ASSIST Program 

for training and technical assistance. Future funding for all states should be 

increased in proportion to total resources allocated for tobacco control. 

3. Support and strengthen training and technical assistance 	at the federal level by 

contracting services to facilitate conference arrangements and increase response time 

to states’ needs. 

Location and Schedule:

Training opportunities must be available to all states, with technical assistance provided that is consistent, both proactive and reactive to national, state, and local needs. 

Therefore, states recommend that federal government funders: 

1. Assure that state tobacco control plans include goals for training and technical 

assistance to facilitate effective strategies. 

2. Conduct national training and coordinated regional trainings. 

3. Provide training schedules and locations which permit accessibility and affordability 

to the largest number of state representatives. 

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9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

4. Seek and use 	substantial state input in planning and in the accountability of the 

contracted services. 

Information and Dissemination/Rapid Response System/Transfer of Technology 

Information dissemination occurs through many channels, such as conferences, train 

the trainer workshops, the Internet, conference calls, overnight mail, video conferences 

and fax. Coordinated linkages from the designated agency to all states is necessary for 

fast and efficient information dissemination. 

Therefore, states recommend that federal government funders: 

1. Establish a central repository, possibly through a contractor, 	to gather and 

disseminate information to all state program contracts and grantees. 

2. Establish and fund, at the federal, state, and local levels, minimum hardware and 

software compatibility recommendations to promote compatibility among users and 

facilitate information exchanges and the transfer of technological advances. 

Consultation 

Consultation and visits to states by federal funders are necessary to provide on-going 

intensive, tailored training and technical assistance addressing each state’s specialized 

needs. State tobacco prevention and control programs have training and technical assistance needs unique to their own environments. These specialized needs require that 

federal funders adapt the content and delivery of the technical assistance and training 

they provide to help individual states operate more effectively in these environments. 

Therefore, states recommend that federal government funders: 

1. Maintain at their agency a point of contact 	for each state to provide ongoing 

consultation and technical assistance. 

2. Establish formal teams from the federal funding agency that visit each state at least 

once per year to provide on-site program review and technical assistance. 

3. Build teams of experts on specialized subjects who can serve as traveling technical 

assistance and training units. These teams will be available to provide on-site 

consultation and training to all states as needed, and will be available to all states for 

ongoing technical assistance. Federal funders would fund these teams as part of 

their training and technical assistance budgets. 

Multicultural Considerations 

It is critical to structure program expectations so that individual multicultural groups 

can develop strategies that are tailored to the needs and unique cultural characteristics 

of their communities. At the same time, multicultural training and programs should focus on shared objectives and activities to foster unity, trust, and strength among all 

groups. This approach recognizes individual differences while acknowledging that we 

live in a diverse society. 

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M o n o g r a p h 1 6. A S S I S T 

Therefore, states recommend that federal government funders: 

1. Establish and maintain a process for “start to finish” multicultural input and review 

in all tobacco control programs. 

2. Increase the awareness and skills, via a range of training opportunities, of state site 

staff to work more effectively with all multicultural groups (including newly arrived 

immigrants) in developing long term commitments to tobacco control. 

3. Encourage the states, via technical assistance and training opportunities, to partner 

with national and community-based multicultural organizations to implement their 

own specific realistic community norm changes. 

Overcoming Barriers to Out-of-State Travel 

Overcoming barriers to traveling out-of-state is necessary for federal programs in order 

to develop competent state staff and share information and implement programs nationally. In addition, overcoming barriers to out-of-state travel is necessary for staff to 

meet training requirements imposed by federal funding agencies. 

Therefore, states recommend that federal government funders: 

1. Add language to all contracts and cooperative agreements that 1) require certain 

personnel to attend specified regional and national trainings, and 2) include 

dedicated funding solely for this purpose. 

2. Establish a national point-of-contact, e.g. a grants management or contract office or a 

designated officer, to manage all issues relating to overcoming barriers to out-ofstate travel. This office or officer would enforce the cooperative agreement and 

contract requirements concerning required participation in regional and national 

trainings. 

SURVEILLANCE, EVALUATION & APPLICATIONS RESEARCH ADVANCE TEAM 

RECOMMENDATIONS FOR ADVANCING TOBACCO CONTROL ACTIVITY REPORT 

Introduction 

The purpose of the Surveillance, Evaluation and Applications Research Advance team2 

was to produce a list of recommendations regarding surveillance, evaluation and applications research that states believe will address their priority needs to move ahead tobacco control activities. 

Recommendations for surveillance, evaluation and applications research were generated from state level tobacco control staff representing a range of programs from those 

with extensive experience and funding to those with limited experience and very low 

2

 Ellen Capwell, OH; Marianne Ronan, MO; Neal Graham, VA; David Fleming, OR; Phil Huang, TX; 

Lodie Lambright, RI; Michael Johnson, CA; Jesse Nodora, AZ; Tracy Enright Patterson, NC; Deborah 

Quinones, NY; Lois Suchomski, IL. CDC, ACS and NCI staff provided technical and editorial assistance. 

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9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

levels of funding. The recommendations listed below resulted from generation and prioritization of ideas by members of this Advance Team, followed by review and comment from members of the Tobacco Control Network Coordinating Committee 

(representing ASTHO, ASTHO Affiliates, NACCHO, NALBoH, regional tobacco control coalitions, representatives from IMPACT, ASSIST and Smokeless states). 

Recommendations fall into three broad categories, presented in priority order: evaluation 

guidance, tobacco control strategies, and surveillance/monitoring. Specific recommendations within each category are also presented in priority order. Recommendations are 

made with the expectation that needs will be addressed through communication with 

those working at state and local levels and that guidance and resources will be disseminated to those working at all levels. 

Recommendations to be Addressed by the U.S. Department of Health and 

Human Services 

Evaluation Guidance 

1. (Primary priority) 	Identify common indicators/measures of environmental/systems 

changes in tobacco control that lead to reduced initiation and use of tobacco. 

Common indicators should include both quantitative and qualitative measures to be 

taken as part of process, impact and outcome evaluation at the local, state, and 

national levels. Systems changes to be measured include: 

•	 Legislation and policy formation (effectiveness of policies and tracking and 

monitoring of policies) in the areas of:


Youth Access


Second Hand Smoke


Advertising


Economic Disincentives


•	 Coalition development and management 

2. (Primary priority) 	Make available exemplary or recommended evaluation models, 

protocol, and instruments for assessing comprehensive and diverse state and local 

tobacco control initiatives. These tools and resources should facilitate mid-course 

modifications to programs, as well as evaluation of impact and outcome of programs 

operating under different conditions. 

Tobacco Control Strategies 

3. (Primary priority) Identify the current best practices and most effective combinations 

of strategies for tobacco control over broad areas of interest including promotion of 

clean indoor air policies and prevention of tobacco use, particularly among youth. 

All areas need to be addressed, including: 

•	 Why and how are strategies effective in diverse and complex settings (community 

and state programs); best approaches with low SES groups, racial/ethnic and 

other cultures? 

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M o n o g r a p h 1 6. A S S I S T 

•	 Youth access; relationship between reduced sales to minors and youth tobacco use 

initiation and prevalence rates; social acceptability of selling to youth; primary 

source of tobacco for youth; the significantly lower initiation and use rate among 

African American youth. 

•	 Youth tobacco use cessation; best motivation strategies. 

•	 Restrictions (voluntary policies or local ordinances) on advertising; how to 

initiate; effectiveness, relationship of youth tobacco use rates to ad campaigns and 

tobacco use in movies. 

•	 What training techniques are most effective in disseminating skills for tobacco 

control? 

4. (Secondary priority) Answer research questions related to tobacco product and 

promotion that impact tobacco control, e.g.: 

•	 Youth perceptions of Tobacco Industry 

•	 Status of tobacco promotion in media, movies, TV, and effect 

•	 Effect of cigar trend 

•	 Changes in tobacco products; addictiveness, harmful chemicals 

•	 Social and political acceptability of accepting money or being an ally of the


Tobacco Industry


Surveillance & Monitoring 

5. (Primary Priority) Surveillance to address research and monitoring needs including: 

•	 Population-based studies of patterns of tobacco use behaviors including initiation, 

cessation, and nicotine dependence, brand preference, product selection, and 

ethnic and gender variations. 

•	 Population-based studies of environmental tobacco smoke exposure, its


prevalence, implementation and enforcement of policies and legislation


•	 Evaluation of current and future tobacco products, added ingredients and product 

design 

•	 Environmental factors which either promote or discourage tobacco use 

6. (Primary priority) Determine the type, quantity, quality, and location of tobacco 

control initiatives currently being implemented and establish a system to monitor 

application of best practices, such as local ordinances and voluntary policies to 

restrict tobacco advertising, extent and impact of counseling by health care 

providers, etc. 

7. (Secondary priority) Determine current status and establish systems to identify and 

monitor emerging trends in tobacco industry tactics, by location, related to: 

•	 Advertising and promotional spending 

•	 Point of purchase ads, billboards, print ads, special offers 

•	 Political influence through lobbying, contributions and ads 

•	 Pricing patterns 

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9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

Recommendations for Addressing Identified Needs 

It is recommended that the needs identified above be addressed through a shared and 

collaborative role by CDC, NCI, FDA, SAMHSA, and other federal agencies. 

Evaluation guidance may be provided through guidelines, training, and technical assistance. Policies need to be established regarding inclusion of standard index items in 

state and national surveillance instruments. Materials from states that have had significant funds to devote to evaluation should be compiled and distributed to all states. Following gathering of baseline information regarding program evaluation activities for 

tobacco control programs, surveillance systems need to be developed and maintained. 

It is strongly recommended that the “Tobacco Control Research Framework,” developed by ASSIST states, and the Proposed Plan for a Tobacco Surveillance System, prepared by the DHHS Tobacco Data Workgroup, be reviewed by all states and involved 

federal agencies, and considered for use as models for evaluation and surveillance. 

Information about current best practices should be compiled and disseminated by federal agencies. Identification and testing of tobacco control practices may be accomplished through linkages with CDC Task Force on Community Preventive Services 

and/or through extension of ASSIST like demonstration trials. Additional tobacco control research funds will be necessary for those activities as well as applied research into 

new and emerging strategies. 

It is estimated that approximately 10% of the amount of funds allocated for program 

will be necessary for evaluation, surveillance and monitoring, and an additional 

amount should be directed to research. Additionally, of the FY99 funds appropriated 

to NIH for research, the percent directed toward applied research should be increased. 

Research should be driven by needs identified in the field of tobacco control practice. 

ADVOCACY OPPORTUNITIES ADVANCE GROUP REPORT 

Introduction 

The Advocacy Opportunities Advance Group3 included members from 14 states. 

Recent advances in tobacco control are based on the results of research showing that 

policy and media advocacy help state and local communities achieve lasting changes 

and that coalitions are important agents of the change. 

Tobacco control started as a grassroots movement. Those involved in carrying forward 

the environmental changes initiated by small groups of activists fully realize change is 

more successful and permanent when the people it impacts are involved in initiating 

and promoting the change. We recommend state and local health departments be 

2

 Ellen Capwell, OH; Marianne Ronan, MO; Neal Graham, VA; David Fleming, OR; Phil Huang, TX; 

Lodie Lambright, RI; Michael Johnson, CA; Jesse Nodora, AZ; Tracy Enright Patterson, NC; Deborah 

Quinones, NY; Lois Suchomski, IL. CDC, ACS and NCI staff provided technical and editorial assistance. 

438 
M o n o g r a p h 1 6. A S S I S T 

authorized to engage fully in the work of communities toward sustaining the changes 

already in place and initiating new policies which will discourage tobacco use. 

In the United States today, state and local health departments are confronted with a tangle of often contradictory restrictions on their activities, placing severe limitations on 

their effectiveness. Even more problematic is finding a clear and consistent definition of 

lobbying and differentiating it from educational activities. Programs funded through 

Department of Health and Human Services appropriations are restricted from lobbying 

for or against tobacco control issues at the state level (See Attachment A). The Federal 

Acquisition Streamlining Act (FASA) restrictions apply to lobbying for tobacco control 

ordinances at the local level (See Attachment B). 

The existing constraints and the implementation of FASA may serve to further diminish 

the participation of communities, particularly communities of color, in tobacco control 

advocacy. Racial/ethnic non-profit organizations, which receive money from the tobacco industry have, at best, remained neutral about tobacco control advocacy. Their lack 

of participation in tobacco control advocacy could result in an even greater disparity in 

health outcomes for members of these groups. 

FASA regulates contracts between for-profit contractors and federal agencies such as 

the Department of Defense and the National Aeronautics and Space Administration 

(NASA). The regulations implementing FASA were made generally applicable to all 

other executive agencies. Thus, FASA was law written to protect the public interest by 

preventing federal profit-making contractors from using federal funds to further their 

own self interest by lobbying state and local governments. It is vital to look at this issue from another perspective: do these restrictions prevent state and local health departments from protecting the health of the public? Tobacco use is the leading 

preventable cause of death in each of the 50 states, the District of Columbia, and the 

territories. Should the Federal government prevent itself and state and local governments from giving its citizens the tools to bring about the environmental changes needed to end the epidemic caused by tobacco? By this enforced silence, public health 

advocates are to some extent forced to abandon the very people we are charged with 

protecting. 

Recommendations 

These restrictions on the use of Federal funds, combined with contradictory regulations 

and ambiguous directives, continue to exert intense political pressures on states’ current tobacco control programs and will impede future advances in tobacco control. 

Therefore, the Advocacy Opportunities Task Force makes the following four recommendations: 

1. Federal funds disbursed to states and local communities for tobacco control activities 

should not be restricted from use for lobbying/advocacy efforts at the state or local 

levels. 

439 
9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

2. Tobacco control programs should be exempt from the FASA law. 

3. The definition of “lobbying” should be that already adopted by the Internal Revenue 

Service and defined in the Treasury Department regulations. 

4. Each state health department should choose a partner of record to serve as an 

advocate for the program and to assure state tobacco control program funds are spent 

wisely and effectively. 

440 
M o n o g r a p h 1 6. A S S I S T 

References 

1. U.S. Department of Health, Education, 

and Welfare, Public Health Service. 

1964. Smoking and health: Report of the 

advisory committee to the surgeon 

general of the Public Health Service 

(PHS publication no. 1103). 

Washington, DC: Public Health Service. 

2. U.S. Department of Health and Human 

Services. 1992. Smoking and health in 

the Americas: A report of the surgeon 

general (CDC publication no. 92-8419). 

Atlanta: Department of Health and 

Human Services, National Center for 

Chronic Disease Prevention and Health 

Promotion, Office on Smoking and 

Health. 

3. Institute of Medicine of the National 

Academies. Home page. www.iom.edu/ 

about.asp. 

4. Lynch, B. S., and R. J. Bonnie, eds. 

1994. Growing up tobacco free. 

Washington, DC: National Academies 

Press. 

5. National Cancer Policy Board, Institute 

of Medicine and Commission on Life 

Sciences, National Research Council. 

1998. Taking action to reduce tobacco 

use. Washington, DC: National 

Academies Press. 

6. Institutionalization Working Group, 

Strategic Planning Subcommittee. 1995. 

Planning for a durable tobacco 

prevention movement. Discussion paper, 

ASSIST Coordinating Center, 

Rockville, MD. 

7. Goodman, R. M., A. Steckler, and M. H. 

Alciati. 1997. A process evaluation of 

the National Cancer Insitute’s DataBased Intervention Research Program: 

A study of organizational capacity 

building. Health Education Research 12 

(2): 181–97. 

8. Haavelmo, T., and S. Hansen. 1991. On 

the strategy of trying to reduce 

economic inequality by expanding the 

scale of human activities (World Bank 

Environmental Work Paper 46). In 

Environmentally sustainable 

development: Building on Brundtland, 

ed. R. Goodland, R. Baly, and S. Serafy, 

41–49. Washington, DC: World Bank. 

9. Schooler, C., J. W. Farquhar, S. P. 

Fortumann, and J. A. Flora. 1997. 

Synthesis of findings and issues from 

community prevention trials. Annals of 

Epidemiology 7 Suppl. no. 7: S54–S68. 

10. Bracht, N., B. Thompson, and C. 

Winner. 1996. Planning for durability: 

Keeping the vision alive. Training 

module, ASSIST Coordinating Center, 

Rockville, MD. 

11. ASSIST Coordinating Committee. 1996. 

Advice to NCI about their future role in 

tobacco control. Discussion paper, 

ASSIST Coordinating Center, 

Rockville, MD. 

12. Working Group on Durability, Strategic 

Planning Subcommittee. 1996. Turning 

point for tobacco control: Toward a 

national strategy to prevent and control 

tobacco use. Discussion paper, ASSIST 

Coordinating Center, Rockville, MD. 

13. ASSIST Coordinating Committee. 1996. 

Summary report of the ASSIST 

Coordinating Committee meeting of 

May 31, 1996. Internal document, 

ASSIST Coordinating Center, 

Rockville, MD. 

14. Association of State and Territorial 

Health Officials and National 

Association of County and City Health 

Officials. 1996. ASTHO/NACCHO 

policy statement: Tobacco use 

prevention and control. Washington, 

DC: ASTHO/NACCHO. 

441 
9. P l a n n i n g S t r a t e g i c a l l y f o r t h e F u t u r e 

15. Thurm, K. L. 1996. Presentation at ASSIST information exchange conference, 

October 22, 1996. Arlington, VA. 

16. ASSIST Coordinating Committee. 1996. 

Summary report of the ASSIST Coordinating Committee meeting of October 

25, 1996. Internal document, ASSIST 

Coordinating Center, Rockville, MD. 

17. Brown, H. 1997. Testimony for National 

Cancer Policy Board re ASSIST, March 

31, 1997. 

18. Bartlett, D., and C. Dilorio. n.d. A 

national evaluation of the America Stop 

Smoking Intervention Study for Cancer 

Prevention (ASSIST)’s impact on 

tobacco control. ASSIST II evaluation. 

Atlanta: American Cancer Society. 

19. ASSIST Coordinating Committee. 1997. 

Summary report of the ASSIST Coordinating Committee meeting of September 

26, 1997. Internal document, ASSIST 

Coordinating Center, Rockville, MD. 

20. ASSIST Advance Groups. 1997. 

Realizing America’s vision for healthy 

people: Advancing a federal 

commitment to effective tobacco 

control, pt. 1. Internal report, ASSIST 

Coordinating Center, Rockville, MD. 

21. ASSIST Advance Groups. 1997. 

Realizing America’s vision for healthy 

people: Advancing a federal 

commitment to effective tobacco 

control, pt. 2. Internal report, ASSIST 

Coordinating Center, Rockville, MD. 

22. Shalala, D. 1998. Letter to state tobacco 

control leaders, January 30, 1998. 

Additional Resource 

1. Pertschuk, M. 2001. Smoke in their 

eyes: Lessons in movement leadership 

from the tobacco wars. Nashville, TN: 

Vanderbilt Univ. Press. 

442 
M o n o g r a p h 1 6. A S S I S T 

10. From Demonstration Project

to Nationwide Program 

Brenda McAdams Motsinger, Dearell R. Niemeyer, Jerie Jordan, and 

William R. Lynn 

Contributors: Gretchen Griffin and R. Neal Graham 

Contents 

The Challenge of Dissemination ................................................................................ 445


Transition from Agency to Agency: Administrative Issues .......................................... 449


Integrating and Maintaining Core Program Elements ............................................... 451


Ad Hoc Workgroup .............................................................................................................. 452


Transition Teams ............................................................................................................... 454


Coordination and Support Team ................................................................................. 455


Technical Teams ......................................................................................................... 455


The National Environment for Tobacco Control: A Consideration ............................... 460


Guidance to States on Acquiring Funding for Their Programs ........................................... 463


Toward the Future ..................................................................................................... 469


References ................................................................................................................ 474


Case Studies 

Case Study 10.1. Transition at the State Level: Minnesota’s Experience ................................ 465


Case Study 10.2. Establishment of the Virginia Tobacco Settlement Foundation ................... 467


Table and Figures 

Figure 10.1. Goals Set for ASSIST in 1988 .............................................................................. 446


Table 10.1. Comparison of the ASSIST and IMPACT Programs ................................................ 448


Figure 10.2. Organizational Structure during the Transition .................................................. 452


Appendix 

Appendix 10.A. Recommended Benchmarks for Multicultural Programs and Activities ......... 470


443 
444

1 0. F r o m D e m o n s t r a t i o n P r o j e c t t o N a t i o n w i d e P r o g r a m
M o n o g r a p h 1 6. A S S I S T 

10. From Demonstration Project to Nationwide Program

The National Cancer Institute (NCI) provided the public health leadership and 

federal funding for the 17 American Stop Smoking Intervention Study (ASSIST) 

states to organize community efforts for the successful delivery of interventions. 

Systematically progressing through the five phases of cancer control research in 

which substantive research precedes wide-scale intervention efforts, ASSIST 

incorporated the essential elements of an effective tobacco prevention and control 

program. However, as a demonstration project, ASSIST was not a national public 

health program with sustained funding and did not have to address all of the core 

functions of governmental public health agencies—policy development, assessment, 

and assurance. A national tobacco prevention and control program for 50 states, the 

District of Columbia, and the U.S. territories under the administration of the Centers 

for Disease Control and Prevention (CDC) would provide the funding and 

leadership to engage both the public and private sectors in preventing tobacco use. 

NCI and the Office on Smoking and Health (OSH) at CDC worked together with key 

stakeholders for more than a year to maintain the capacity built by ASSIST while 

transitioning the program from NCI to CDC and incorporating the core elements of 

ASSIST into the new National Tobacco Control Program (NTCP). The many issues to 

be considered are complex and illustrate the dynamic environment at the time of the 

transition. This chapter describes the processes and challenges of disseminating 

research and demonstration project results as standards and best practices in public 

health programs that the two federal agencies experienced as the demonstration 

project, ASSIST, came to its conclusion. 

The Challenge of Dissemination 

One of the greatest challenges in tobacco control and public health in general continues to 

be overcoming the difficulty in getting advances in prevention and treatment strategies effectively disseminated, adopted, and implemented in their appropriate delivery 

systems.1(p19) 

—U.S. Department of Health and Human Services. 

Reducing Tobacco Use: A Report of the 

Surgeon General—Executive Summary 

T

he transition of ASSIST, as the term implies, was a change, a passage from one form 

to another, not merely a replication or transfer of the program to a different administrative agency. ASSIST as a phase V demonstration and implementation project was 

ending, completing the five phases of cancer control research. The final step in NCI’s 

cancer control model was to expand dissemination from the 17-state demonstration project 

to a nationwide tobacco prevention and control program. (See figure 10.1.) The challenge 

445 
1 0. F r o m D e m o n s t r a t i o n P r o j e c t t o N a t i o n w i d e P r o g r a m 

tained funding for all states and territories. 

In addition, the core elements of the 

2 Such fulltion, and perhaps most challenging, the 

national, state, and local infrastructures to 

done, considerable progress has been 

made in identifying and disseminating 

successful results of clinical research. 

disseminating guidelines for clinical 

practice, such as the recently updated 

. 

3 In the 

tion into Practice Education Kit that included the 

. 

4 

Similar guidance for community preGuide to Community 

Figure 10.1. Goals Set for ASSIST in 1988 

Reached 

goal in 1999 

Cancer 

Control 

Phase 

1989 

Research 

Goal 

Research Process 

III/IV 

Outcome 

Mass application for the 

1990 2000 

V 

Impact 

was to maintain the capacity and capabilities that had been built by ASSIST while 

establishing the national program with susASSIST model were to be incorporated as 

evidence-based practices into all state tobacco prevention and control programs. 

Core elements are the features of an intervention that must be replicated to maintain 

the integrity of the intervention as it is 

transferred to a new setting.

scale dissemination would involve changes 

in funding sources and in administrative 

locus to a different federal agency. In additransition would involve expanding, improving, and integrating already existing 

form the state-based NTCP. 

Although much work remains to be 

The Agency for Healthcare Research 

and Quality (formerly the Agency for 

Health Care Policy and Research) has a 

long history of providing leadership for 

Clinical Practice Guideline: Treating 

Tobacco Use and Dependence

early 1990s, a national preventive services education campaign, Put Prevention into Practice, was initiated. One of 

the first major products was a Put PrevenClinician’s Handbook of 

Preventive Services

ventive services, however, was not 

available to aid in expanding the dissemination of the ASSIST project’s interventions. The 

Source: Adapted from a presentation to the Board of Scientific Advisors, National Cancer Institute, 1988. 

Focus 

Controlled intervention trials to 

develop the most effective 

strategies to reduce cancer 

mortality. 

benefit of public health. 

Disseminate, diffuse, and use 

in target populations the 

strategies proven to be 

effective. 

VI 

446 
M o n o g r a p h 1 6. A S S I S T 

Dissemination 

National Cancer Institute, Center for 

Designing for 

dissemination (Conference summary report, 

September 19–20, 2002). http://cancercontrol 

“Process through which target groups are 

made aware of, receive, accept, and use information and other interventions.” 

Source:

the Advancement of Health, Robert Wood 

Johnson Foundation. 2002. 

.cancer.gov/d4d/d4d_conf_sum_report.pdf. 

Preventive Services was made available 

later through articles in the American 

Journal of Preventive Medicine and 

Morbidity and Mortality Weekly Report 

(MMWR). A report in the latter—“Strategies for Reducing Exposure to Environmental Tobacco Smoke, Increasing 

Tobacco-Use Cessation, and Reducing 

Initiation in Communities and HealthCare Systems: A Report on Recommendations of the Task Force on Community 

Preventive Services”5

—was not released 

until November 10, 2000, in MMWR; 

the full presentation of recommendations and supporting evidence was published in the American Journal of 

Preventive Medicine in 2001.6,7 

Nor were there established procedures for transitioning a federal public 

health demonstration project to a sustained national program or for transferring the administration of a program 

from one federal agency to another. 

ASSIST was transitioning to CDC as a 

sustained, federally funded public health 

program similar to other core public 

health programs such as cancer, cardiovascular disease, diabetes, and sexually 

transmitted diseases/AIDS. The timing 

of the decision to fund a national program created another challenge. The 

planning and implementation of the 

transition had to take place simultaneously, or the capabilities and capacity 

built by ASSIST would be compromised. 

A gap of months between the end of 

ASSIST and the start of the CDC program could have meant a loss of experienced staff at the state and local levels. 

NCI and CDC share a mission that includes tobacco control research and the 

prevention and control of tobacco use. 

Issues in the transition to a national tobacco control program arose from differences in how the agencies pursue that 

mission. NCI’s role is primarily research 

and the application of research results, 

whereas CDC focuses on implementing 

and monitoring effective populationbased interventions, supported by epidemiology and surveillance. 

Demonstration projects tend to be 

different from national public health programs in purpose, design, comprehensiveness, time frame, level of resources, 

degree of intensity and penetration, accountability, and approach to evaluation. 

In 1993, OSH recognized the critical 

need to build states’ capacity for addressing tobacco use as a public health 

problem and began the process with limited funding for Initiatives to Mobilize 

for the Prevention and Control of Tobacco 

Use (IMPACT). (See chapter 9.) It is 

critical to note the considerable differences 

in funding between a demonstration 

project—ASSIST—and a state-based 

public health program—IMPACT. Table 

10.1 illustrates this point.

In her commitment letter, Secretary of 

Health and Human Services Donna E. 

447 
1 0. F r o m D e m o n s t r a t i o n P r o j e c t t o N a t i o n w i d e P r o g r a m 

Table 10.1. Comparison of the ASSIST and IMPACT Programs 

Issue	 NCI: ASSIST CDC: IMPACT 

Funding mechanism and ASSIST states had competitive IMPACT states had cooperative 

flexibility contracts, with NCI-specified agreements with CDC, with prodeliverables. gram deliverables negotiated by 

the states and CDC. 

Funding level	 The 17 ASSIST states received The 32 IMPACT states and the 

approximately $21.5 million per District of Columbia received 

year (an average of $1.26 mil- about $5 million in 1993 (an avlion per award). erage of $156,250 per award) 

and about $12 million annually 

by 1998 (an average of $375,000 

per award). 

Technical assistance and training	 ASSIST Coordinating Center CDC’s training activities and 

provided the states with training, technical assistance to the 

technical assistance, and staff to IMPACT states were provided 

facilitate communication and by CDC staff and one annual 

participation by the states in training. 

planning and decision making. 

Public-private partnerships	 ASSIST had a designated private IMPACT states were encouraged 

partner, the American Cancer to partner broadly. 

Society. 

Evaluation requirements	 ASSIST states could not use The states were expected to 

NCI funds for evaluation of their participate in national 

programs (though the overall surveillance and monitoring 

project was evaluated by a team systems by gathering and 

of scientists who were not a part reporting data to OSH. 

of the intervention itself). 

Notes: NCI indicates National Cancer Institute; ASSIST, American Stop Smoking Intervention Study; CDC, Centers for 

Disease Control and Prevention; IMPACT, Initiatives to Mobilize for the Prevention and Control of Tobacco Use; and 

OSH, Office on Smoking and Health. 

■ Assessment is an understanding of the 

proven research findings generated from 

Shalala stated, “We are moving the 

determinants of health and of the nathe National Cancer Institute’s successful ture and extent of community need; 

ASSIST program into widespread public ■ Policy development is leadership in 

health practice.” 8(p1) The challenge was developing public decisions that 

to maintain the integrity of that approach reflect a full examination of the public 

to tobacco prevention and control inter- interest and sound analysis of 

ventions while adapting it to the core problems and interventions; and 

functions of national public health pro- ■ Assurance is positive action to 

grams: assessment, policy development, encourage other entities to make 

and assurance.9,10 The Institute of Medi­ available the resources necessary to 

cine report characterized those functions achieve goals for the common good, 

as follows: including public health.9(pp140–142) 

448 
M o n o g r a p h 1 6. A S S I S T 

In addition to participating in the CDC-

■ 

■ 

specialize in one major area of cancer 

control 

■ 

The 

ASSIST

American Cancer Society’s Evaluation 

of Its Contributions to ASSIST 

directed transition process of ASSIST, NCI’s 

designated private partner, the American Cancer Society (ACS), conducted an evaluation 

to assess its contributions to ASSIST and to 

identify ways of improving future collaborative initiatives. The evaluation indicated that 

ACS had been an equal partner, with the ACS 

National Home Office contributing nearly 

$4.5 million in direct grants to the ACS divisions in the ASSIST states. The major contributions noted were ACS’s advocacy, strong 

volunteer networks, and strong reputation. As 

ACS staff and volunteers worked with CDC 

to consider ways of involving the large network of individuals and organizations working in tobacco prevention and control, ACS 

also reviewed recommendations from its 

evaluation to do the following: 

Better define and document the roles of 

ACS during the initial planning stages of 

collaborative agreements 

Continue building community-based 

programs where ACS staff could 

Increase resources available at the 

national level to conduct training sessions 

specifically for advocacy and grassroots 

recruitment for staff and volunteers 

Source: Shisler, J., and C. Dilorio. 1999. 

role of the American Cancer Society in 

. Final report. Atlanta: American 

Cancer Society. 

The report also stated that 

the mission of public health is more 

fundamental and more comprehensive 

than the specific activities of particular 

agencies. Organized community effort 

to prevent disease and promote health 

involves private organizations and individuals, working on their own or in 

partnership with the public sector. But 

the governmental public health agency 

has a unique function: to see to it that 

vital elements are in place and that the 

mission is adequately addressed.9(p140) 

An examination of how the expertise 

and capacity built by the ASSIST states 

were integrated into the new NTCP at 

CDC provides useful information for 

disseminating other effective sciencebased programs to public health practice. 

The transition to NTCP occurred in a 

context of at least three challenges: 

1. Addressing funding and management 

issues related to shifting administration 

of a program from one federal agency 

to another 

2. Maintaining the capacity and 

capability of funded programs from 

both agencies while integrating the 

essential core elements of each 

program into a single program 

3. Identifying and addressing those 

forces within the larger tobacco 

prevention and control community 

that might affect program operations 

and effectiveness 

Transition from Agency to 

Agency: Administrative Issues 

Secretary of Health and Human Services Donna E. Shalala charged CDC 

with developing a comprehensive national tobacco prevention and control 

program and with overseeing the administrative transition of the tobacco prevention and control programs of the 17 

ASSIST states. Within CDC, OSH was 

assigned the responsibility for developing and overseeing the program. 

449 
1 0. F r o m D e m o n s t r a t i o n P r o j e c t t o N a t i o n w i d e P r o g r a m 

Mission Statement 

“OSH is responsible for leading and 

promoting smoking cessation among 

youth and adults, protecting 

tobacco-related health disparities. 

“OSH accomplishes these goals by 

■ 

tobacco control. 

■ 

tobacco control programs. 

■ communicating information to 

constituents and the public. 

■ 

Mission statement. 

The Office on Smoking and Health 

coordinating strategic efforts aimed at 

preventing tobacco use among youth, 

nonsmokers from environmental 

tobacco smoke (ETS), and eliminating 

expanding the science base of 

building capacity to conduct 

facilitating concerted action with 

and among partners.” 

Source: Office on Smoking and Health. 2003. 

Atlanta: Centers for 

Disease Control and Prevention. 

www.cdc.gov/tobacco/mission.htm. 

The ASSIST contracts ended on September 30, 1999, and CDC funding for 

NTCP began on October 1, 1999. The 

transition brought new roles and 

responsibilities for the ASSIST states; 

for all the other states; for the American 

Cancer Society (ACS), NCI, and CDC; 

and for non–federally funded programs 

and initiatives. 

Ensuring an orderly transition meant 

delineating the roles and responsibilities 

of NCI and CDC. Certain roles were 

self-evident and would not change. For 

example, NCI would conduct the evaluation of the ASSIST project and publish 

the findings. NCI would maintain the 

newspaper clipping database through 

December 1999 to complete a full 5 

years for evaluation purposes. NCI 

would also continue to support the Tobacco Use Supplement of the U.S. Census Bureau Current Population Survey. 

As the administrative agency for the new 

NTCP, CDC would define program requirements and funding for all the states, 

the District of Columbia, and the U.S. 

territories. CDC would build its capacity 

to provide training, technical assistance, 

and other support for state tobacco prevention and control programs. Both 

agencies would be involved in the continued dissemination of ASSIST and 

other evidence-based tobacco prevention 

and control interventions. They would 

work together to identify strategies and 

elements for an expanded surveillance 

system, which would enable states to 

monitor trends in tobacco use and tobacco-related health problems and to advance methods for evaluating state 

programs. 

In addition, written and unwritten expectations had to be addressed. Different 

stakeholders had various perceptions 

about what was meant by maintaining 

the evidence-based capacity and capabilities built through the ASSIST project. 

For example, although ASSIST states 

had been assured that their funding levels would be maintained for 1 year, 

CDC had made no commitment beyond 

that. NCI had provided considerable 

technical assistance and training support 

for the ASSIST state programs, and the 

states wanted this level of support to 

continue. Building the capacity to implement media and policy interventions 

had been the primary focus of ASSIST, 

and the expectation associated with 

450 
M o n o g r a p h 1 6. A S S I S T 

sored annual conferences on tobacco and 

sachusetts Department of Public Health, and 

Other cosponsors of the conference included 

■ 

■ 

■ 

■ 

■ ASTHO, 

■ 

■ 

Services Administration, 

■ the Indian Health Service, 

■ 

■ 

Kids, and 

■ the National Coalition of Hispanic Health 

breadth and challenge of engaging the full 

and control program. 

Among the Many Stakeholders 

NCI, through ASSIST, collaboratively sponhealth. In June 1995, ACS, CDC, The Robert 

Wood Johnson Foundation (RWJF), the Masthe Association of State and Territorial Health 

Officials (ASTHO) cosponsored the first national conference. Over the 8 years of ASSIST, the tobacco control movement grew. 

the American Heart Association, 

the American Lung Association, 

the American Medical Association, 

the Asian Pacific Partners for 

Empowerment and Leadership, 

the U.S. Environmental Protection Agency, 

the Substance Abuse and Mental Health 

the National Association of African 

Americans for Positive Imagery, 

the National Center for Tobacco-Free 

and Human Services Organizations. 

The number of cosponsors reflects the 

range of public health stakeholders in 

planning a comprehensive tobacco prevention 

maintaining the integrity of these interventions was that these core elements 

would receive high priority in the new 

NTCP. To address these expectations 

and accomplish the work needed for developing and implementing NTCP, CDC 

had to assess the existing capacity of 

OSH. OSH would receive increased 

funding through the Department of 

Health and Human Services (DHHS), 

but neither funding nor staff would be 

transferred from NCI to CDC. OSH 

would quickly need increased numbers 

of experienced staff to successfully fulfill its expanded responsibility, not only 

to administer NTCP, but also to manage 

the transition. 

Maintaining operations of the existing 

state-based programs while planning and 

managing the transition required an unprecedented level of collaboration and 

coordination between NCI and CDC. 

The two agencies had already begun to 

work together through jointly sponsored 

national tobacco prevention and control 

conferences. Also, CDC had participated 

in collaborative decision making at the 

ASSIST Coordinating Committee meetings. The director of CDC’s IMPACT 

program gave updates on the program 

and described what OSH needed from 

the ASSIST Coordinating Committee 

members. CDC was also represented in 

the ASSIST Strategic Planning Subcommittee’s advance groups composed of 

ASSIST and IMPACT program staff.11 

Integrating and Maintaining 

Core Program Elements 

During the 8 years that the ASSIST demonstration project planned and 

delivered media and policy advocacy interventions, its infrastructure, partnerships, networks, capacity, participant 

capabilities, and activities became increasingly complex. As the states made 

the transition to the national program at 

CDC, the value of these elements had to 

be considered. Should they be maintained, 

modified, or replaced with some other 

elements? Likewise, the IMPACT states 

had developed their own networks, 

451 
1 0. F r o m D e m o n s t r a t i o n P r o j e c t t o N a t i o n w i d e P r o g r a m 

cisions about which elements to adapt 

Ad Hoc Workgroup 

Recognizing the importance of prepartners to establish and implement the 

tion for establishing a process to assist 

with the transition that led to the creplications for state health departments 

for NTCP funds 

Notes: DHHS indicates Department of Health and Human Services; CDC, Centers for Disease Control and 

DHHS 

CDC/OSH 

and multicultural groups 

■ 

■ 

■ 

■ 

resources, and methods of implementing 

programs. These also would require deand integrate into the national program. 

serving the capacity built by ASSIST, 

OSH facilitated and coordinated a participatory process engaging all relevant 

next generation of tobacco prevention 

and control programs. To do so, OSH 

developed the organizational structure 

depicted in figure 10.2. In the spring of 

1998, OSH created an ad hoc workgroup 

representing the major stakeholders. The 

workgroup comprised representatives 

from ASSIST, IMPACT, ACS, the RWJF 

SmokeLess States program, ASTHO, 

and national organizations representing a 

variety of racial and ethnic groups. The 

workgroup was asked to provide direcation of the transition teams. The stated 

purpose of the ad hoc workgroup was to 

make recommendations to OSH on the 

following four issues: 

1. The development of a request for apFigure 10.2. Organizational Structure during the Transition 

Prevention; OSH, Office on Smoking and Health; IMPACT, Initiatives to Mobilize for the Prevention and Control 

of Tobacco Use; ASSIST, American Stop Smoking Intervention Study; ACS, American Cancer Society; RWJF, 

The Robert Wood Johnson Foundation; and ASTHO, Association of State and Territorial Health Officials. 

Ad Hoc Workgroup (1998) 

Representatives from IMPACT, 

ASSIST, ACS, RWJF, ASTHO, 

Transition Teams (1999) 

Technical Teams: 

Structural Development Team 

Multicultural Team 

Technical Assistance and 

Training Team 

Evaluation and Outcomes 

Assessment Team 

Coordination and Support Team 

452 
M o n o g r a p h 1 6. A S S I S T 

2. The states’ needs for technical assistance, training, and resource materials 

3. The need for a strong research 

component to ensure evaluation of the 

best strategies and state-of-the-art 

science to advance the most effective 

state-based interventions possible 

4. The roles for future advisory 

committees or workgroups 

To fulfill its charge, the workgroup engaged in a 6-month planning process to 

develop the framework for a CDCadministered NTCP. During that planning process, the insights gained from 

ASSIST, IMPACT, and non-ASSIST 

state programs supported by tobacco excise tax funds (i.e., in California and Arizona) were incorporated into OSH 

program announcement no. 99038 (request for applications)12 for NTCP funds. 

Many ASSIST project directors and 

managers encouraged OSH to put specific requirements into the request for applications to protect the tobacco control 

programs and funds from being diverted 

to less effective programs. This concern 

grew out of the controversy sometimes 

generated by an approach that promotes 

tobacco prevention and control through 

social change, policy, and advocacy. 

Such controversy engenders pressure to 

divert program activities to more traditional public health education approaches. Flexible funding mechanisms, such 

as cooperative agreements, can be vulnerable if spending requirements are not 

in place. The workgroup continued to 

discuss and negotiate the details of the 

program requirements to accommodate 

the needs of the states and CDC. 

The program announcement, issued in 

late 1998, presented the NTCP framework and funding requirements that 

states had to address in their applications. The announcement stated the purpose of the request for applications as 

follows: 

The purpose of this program is to build 

and maintain tobacco control programs 

within State and territorial health departments for a coordinated national 

About NTCP (2002) 

Control Program (NTCP) to encourage 

technical support to State and territorial 

30, 1999, NTCP funds all 50 states, the 

District of Columbia, 7 U.S. territories, 

Best 

. 

“The four goals of NTCP are to 

■ 

■ Promote quitting among adults and 

youth, 

■ 

■ Identify and eliminate disparities 

among population groups. 

“The four components of NTCP are 

■ Population-based community 

■ 

■ 

■ 

Centers for Disease Control and 

/ 

“CDC’s Office on Smoking and Health 

(OSH) created the National Tobacco 

coordinated, national efforts to reduce 

tobacco-related diseases and deaths. 

The program provides funding and 

health departments. As of September 

and 11 national organizations. NTCPfunded programs are working to achieve 

the objectives outlined in OSH’s 

Practices for Comprehensive Tobacco 

Control Programs

Eliminate exposure to 

environmental tobacco smoke, 

Prevent initiation among youth, and 

interventions, 

Counter-marketing, 

Program policy/regulation, and 

Surveillance and evaluation.” 

Source:

Prevention. n.d. About the National Tobacco 

Control Program. http://www.cdc.gov

tobacco/ntcp_exchange/about.htm. 

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1 0. F r o m D e m o n s t r a t i o n P r o j e c t t o N a t i o n w i d e P r o g r a m 

program to reduce the health and economic burden of tobacco use. The focus of the award is population-based 

community interventions, counter marketing, program policy, and surveillance and evaluation. 

These efforts are directed at social and 

environmental changes to reduce the 

prevalence and consumption of tobacco 

use by adults and young people among 

all populations, eliminate exposure to 

second hand smoke, and identify and 

eliminate the disparities experienced 

by population groups relative to tobacco use and its effects.12(pp1–2) 

NCI and CDC worked together to 

fund states so that neither the ASSIST 

nor the IMPACT states would experience a time gap in funding. CDC established two funding levels for the 

proposals from the states: 

The majority of State health departments (SHD) have minimal Federal or 

State funding for tobacco use prevention and control. However, a few States 

have dedicated funding from either tobacco excise tax, or from tobacco industry lawsuit settlements supporting 

implementation of comprehensive programs. Therefore, under this Program 

Announcement, States are classified 

into two groups—core and enhanced. 

1.	 Core States are those needing 

Federal funds to support basic 

SHD infrastructure and program 

components to implement a comprehensive approach and to sustain a national effort. 

2.	 Enhanced States are those needing Federal funds to enhance the 

States’ existing comprehensive 

program, and to sustain a national 

effort.12(p2) 

The distinction in the amount of funding core and enhanced states could receive was to maintain the ASSIST 

capacity. ASSIST states had been assured that their funding would remain 

level for 1 year. CDC awarded a total of 

$49,067,720, ranging from approximately $200,000 to $1,616,151 per award (B. 

Park, e-mail message to Mary Nishioka, 

September 18, 2003), in cooperative 

agreements to all 50 states, the District 

of Columbia, 5 territories, Puerto Rico, 

and the Virgin Islands. 

Transition Teams 

In late 1998, once the program announcement was developed, OSH implemented the ad hoc workgroup’s 

recommendation to establish transition 

teams to address the remaining issues 

for which OSH had requested assistance. 

Figure 10.2 depicts the relationship beASSIST program manager 

Consultants, advisors (1–2, as needed) 

Membership of the Transition Teams* 

IMPACT program coordinator 

IMPACT field staff (2–3) 

ASSIST field staff (2–3) 

CDC-funded national organization (1) 

Representatives from ASTHO 

Tobacco control network (2) 

ASTHO affiliate representative (1) 

ACS 

At-large members (1–4) 

OSH staff 

NCI staff 

*Multicultural representation was ensured on all 

teams. The Multicultural Team also had representatives from the Indian Health Service and from 

federal and state offices on minority health. 

454 
M o n o g r a p h 1 6. A S S I S T 

tween the transition teams and the ad hoc 

workgroup and other organizational structures. From March through November 

1999, these teams worked collaboratively 

with CDC and NCI to develop recommendations concerning the roles of future advisory groups and to ensure that 

the states’ needs would be met when 

NTCP was implemented. 

As recommended by the ad hoc workgroup, the composition of the transition 

teams included critical stakeholders. 

Representation from ASSIST and 

IMPACT state programs was equal to or 

greater than representation from other 

sources. The transition teams included 

individuals from an array of public and 

private sector stakeholders. 

Coordination and Support Team 

The transition teams were composed 

of the Coordination and Support Team 

and four technical teams—the Structural 

Development Team, Multicultural Team, 

Technical Assistance and Training Team, 

and Evaluation and Outcomes Assessment Team. The Coordination and Support Team worked closely with NCI and 

CDC staff to provide leadership and direction. It relied on the four technical 

teams for research and recommendations 

on specific transition issues and was 

composed of the chairs and cochairs of 

those four teams. The transition teams 

addressed specific issues. In addition, a 

broader purpose of the transition teams 

was to ensure a public health approach 

to preventing tobacco use that would involve the many stakeholders, support 

public-private partnerships, and effectively leverage public and private resources. The recommendations and 

critical issues that had been identified by 

the ASSIST/IMPACT advance groups in 

Realizing America’s Vision for Healthy 

People served as a framework for much 

of the transition teams’ work. (See chapter 9.) Because of the positive experiences 

of the ASSIST project with committees 

and subcommittees, the transition teams 

recognized the importance of input from 

states, the need for strategic planning, 

the value of state involvement in planning 

for technical assistance and training, and 

the benefit of communication and interaction among the states. To this end, 

CDC began exploring ways of facilitating collaboration and of strengthening 

the tobacco prevention and control 

movement. 

Technical Teams 

Structural Development Team. The 

Structural Development Team was 

charged with developing a framework 

for coordinating the national program. 

Critical to ASSIST’s success had been 

the participation in decision making and 

planning by all segments of the project’s 

large network of individuals and organizations. Mechanisms had been created to 

facilitate a highly integrated, participatory 

process for implementing, managing, and 

advancing ASSIST. Representatives from 

all 17 state health departments and ACS 

affiliates served on the ASSIST Coordinating Committee and worked collaboratively with NCI to oversee and guide 

ASSIST. (See chapter 3.) For example, 

the ASSIST Coordinating Committee 

over time became the voice of the 

project and played a leadership role in 

the issues of a national strategy for tobacco control and the transition to CDC. 

455 
1 0. F r o m D e m o n s t r a t i o n P r o j e c t t o N a t i o n w i d e P r o g r a m 

Skilled directors, program managers, 

field staff, and volunteers participated in 

information exchanges and served on the 

various subcommittees and work teams. 

The new national program would 

embrace all 50 states, the District of 

Columbia, U.S. territories, and specific 

American Indian tribes. With the transition to this larger program came the 

major challenge of how to use a participatory decision-making and administrative approach to administer a national 

program through state programs that had 

different levels of funding and various 

levels of capabilities and capacities. The 

CDC program would be too large to 

have a committee with representatives 

from each state. Instead, OSH used lessstructured means, such as holding meetings with representatives from all the 

states, to review specific plans and to 

discuss issues. For example, the draft request for applications for NTCP funding 

was reviewed at a meeting of representatives from all the states. Also, OSH 

funded ASTHO to establish a committee 

of the state tobacco control program 

managers. Through this mechanism, the 

states would have a voice and place to 

organize and prioritize their collective 

wants and needs not only from OSH, but 

also from other areas of CDC and 

DHHS. OSH has also reached out to the 

ASTHO affiliates of chronic disease and 

health education directors to seek their 

advice and support. NTCP convenes the 

state program managers twice a year to 

promote communications and feedback 

and to build a collaborative relationship. 

The funding instrument used with the 

states is a cooperative agreement that 

provides flexibility and a participatory 

process in the implementation of the 

state-based NTCP. 

Multicultural Team. The Multicultural 

Team was created to ensure that multicultural representation and issues would 

be woven into all aspects of the transition. It was composed of individuals representing diverse organizations and 

perspectives, including the Indian Health 

Service. The team was charged with 

identifying issues and developing recommendations regarding diversity and 

the elimination of health disparities in 

keeping with the goals of NTCP. (See 

appendix 10.A, Recommended Benchmarks for Multicultural Programs and 

Activities.) 

The team made suggestions to the 

other teams regarding incorporating cultural issues into the mainstream and ensuring adequate funding and resources 

for diverse populations, so that funded 

programs would have the staff, training, 

and other resources necessary to implement effective programs. Prominent 

among the team’s recommendations was 

that CDC establish a group to fulfill the 

role formerly performed by the ASSIST 

Multicultural Subcommittee; the group 

would strive to ensure diversity at all 

levels of NTCP and to eliminate health 

disparities related to tobacco use. The 

team also strongly recommended that 

CDC establish a structure that would 

permit maximum input and participation 

of tobacco control specialists at the state 

and local levels. 

The team endorsed the four program 

areas and program components that 

became the framework for CDC’s request for applications for NTCP fund456 
M o n o g r a p h 1 6. A S S I S T 

ing. The request for applications was 

open not only to the states, but also to 

U.S. territories, which are composed of

multicultural populations. In addition, 

the program announcement included 

funding opportunities for national organizations to form coalitions among their 

multicultural constituencies. The Multicultural Team acknowledged the value 

of NTCP’s goal to eliminate health disparities among population groups. The 

team insisted that diversity and representation from all sectors of the community 

be factors in the planning, implementation, and evaluation of the other three 

NTCP goals. 

To build the capacity of the states to 

address multicultural needs during the 

planning and implementation phases, 

NTCP objectives and activities have emphasized providing opportunities to improve cultural competency, inclusion, 

and diversity in coalitions and staff 

through training, conferences, materials, 

consultation, presentations, and funding 

of special opportunities. 

Technical Assistance and Training Team. 

The Technical Assistance and Training 

Team was charged with identifying the 

immediate and long-range technical assistance and training needs of all NTCP 

participants. The team addressed the following needs: 

■	 Standardization of core competencies 

■	 Assessment of the levels of 

experience of state staff 

■	 Conceptual frameworks for 

organizing training activities 

■	 Outreach to tobacco control 

practitioners at the local level 

■	 Skill building for effective program 

planning and evaluation 

■	 Train-the-trainer models 

■	 Resources scaled to varying need levels 

OSH had supported the Tobacco Use 

Prevention Training Institute’s annual 

training sessions, which were conducted 

in collaboration with the University of 

North Carolina at Chapel Hill School of 

Public Health, and continued to do so 

after NTCP became operational. The institute provided an intensive weeklong 

training on tobacco prevention and control for NTCP state and local staff and 

coalition members. In addition, NTCP 

became one of the primary supporters, 

with other partners including NCI, of the 

National Conference on Tobacco OR 

Health. The following are other types of 

technical assistance and training activities offered through NTCP: 

■	 In the 1st year of the program, two 

technical assistance meetings were 

held with each state health department 

program manager and with the state 

health department media staff. 

■	 Program, media, policy, and 

epidemiology staff served as technical 

assistance liaisons with the state 

health departments. 

■	 Seven tribal technical assistance 

centers were funded to address the 

specific needs of American Indians. 

■	 In the 2nd year of the program, a 5­

year technical assistance and training 

contract was funded to help support 

NTCP’s work with the states. 

■	 Satellite conferences, teleconferences, 

and workshops were offered, and 

training was cosponsored on best 

practices in tobacco control, evidencebased programs, adult and youth 

tobacco surveys, and other tobacco 

control-related topics. 

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1 0. F r o m D e m o n s t r a t i o n P r o j e c t t o N a t i o n w i d e P r o g r a m 

Evaluation and Outcomes Assessment 

Team. The Evaluation and Outcomes 

Assessment Team was charged with 

developing options for evaluation and 

monitoring of state performance and for 

data collection and surveillance. In 

assuming responsibility for NTCP, CDC 

was obligated to put in place at the national and state levels elements of a public health program that ASSIST, as a 

demonstration project, had not required. 

Surveillance, monitoring, and evaluation—particularly increased capacity 

and expertise for these functions within 

the state health departments—had to be 

established. 

As the ASSIST states adapted to requirements of the new NTCP, a significant mismatch became evident: they had 

a strong capacity to deliver effective interventions to prevent tobacco use but 

had little or no capacity for surveillance, 

monitoring, and evaluation. The CDC 

request for applications addressed this 

deficiency by requiring that states spend 

10% of their total funding for surveillance and evaluation and that they hire at 

least one half-time person with expertise 

in epidemiology or evaluation. This 10% 

minimum for evaluation effectively reduced by 10% the funds that were available for interventions. The team 

identified expectations, resources, and 

needs of the states regarding program 

evaluation and outcomes and suggested 

strategies for monitoring program performance. In particular, the team suggested that OSH encourage coordination 

among agencies and organizations that 

conduct school-based surveys that include health behaviors. 

“The settlement requires the tobacco industry each year for ten years to pay 

$25 million to fund a charitable foundation which will support the study of 

programs to reduce teen smoking and 

diseases associated with tobacco use. 

“The foundation will: 

■ Carry out a sustained, nationwide 

to counter youth tobacco use and 

educate consumers about the cause 

associated with tobacco use. 

■ 

campaigns. 

■ Commission studies, fund research 

influence youth smoking and 

■ 

decrease tobacco and substance use 

rates. 

■ Create an industry-funded $1.45 

billion national public education 

is established to carry out a 

and education program to counter 

youth tobacco use and educate 

consumers about tobacco-related 

summary. 

Tobacco Master Settlement Agreement 

Establishes a Foundation 

substance abuse and the prevention of 

advertising and education program 

and prevention of diseases 

Develop, disseminate and test the 

effectiveness of counter advertising 

and publish reports on factors that 

substance abuse. 

Track and monitor youth smoking 

and substance abuse with a focus on 

reasons for increases or failures to 

fund for tobacco control. The fund 

nationwide sustained advertising 

diseases.” 

The foundation today is the American Legacy 

Foundation. Its Web address is 

www.americanlegacy.org. 

Source: National Association of Attorneys 

General. n.d. Tobacco settlement 

www.naag.org/tobac/glance.htm. 

458 
M o n o g r a p h 1 6. A S S I S T 

Building on the work of the Evaluation and Outcomes Assessment Team, 

NTCP has made surveillance and evaluation a priority. It is one of the four major 

NTCP program components, and NTCP 

devotes significant resources to improving 

the states’ capacity to conduct evaluation. 

NTCP-sponsored evaluation activities 

were designed to improve the state of 

the art of evaluation and to provide states 

with data and examples of programs that 

have been evaluated. The following are 

some examples of those activities: 

■	 Extensive technical assistance and 

workshops to help states establish 

state baseline data by implementing 

CDC’s adult and youth tobacco surveys 

■	 A tracking system of state-level 

tobacco control policies and production of State Tobacco Control Highlights for publishing rates of use, 

economic impact, health consequences, expenditures for tobacco control, 

and policy data to facilitate cross-state 

comparisons13 

■	 The State Tobacco Activities Tracking 

and Evaluation System (STATE), 

which collects and electronically 

warehouses state-level data on 

tobacco use prevention and control14 

■	 Publication of Best Practices for 

Comprehensive Tobacco Control 

Programs, which links tobacco 

control expenditures to reduced 

consumption15 

■	 Publication of the Guide to 

Community Preventive Services: 

Tobacco Product Use Prevention and 

Control,

16 which documents the 

effectiveness of evidence-based 

tobacco control programs 

the multi-state settlement opened the 

■ 

and appropriations; 

■ 

funding, such as limiting media 

campaigns; 

■ 

applied to tobacco control 

A 

Challenges Resulting from the 

Tobacco Master Settlement Agreement 

“While tobacco control advocates 

initially heralded the state attorneys 

general lawsuits as opening a powerful 

new front against the tobacco industry, 

door to several threats including: 

“Preemptive language and other 

tobacco industry subversion of the 

state settlement enabling legislation 

Straitjackets on tobacco control 

initiatives to ineffective ‘just say no’ 

Tobacco industry payments under 

the settlement, even when not 

programs, providing politicians an 

excuse for opposing any new 

tobacco excise tax increases.” 

Source: Advocacy Institute. 1999. 

movement rising: A strategic analysis of U.S. 

tobacco control advocacy. Executive 

summary. Washington, DC: Advocacy 

Institute (p. 5). www.advocacy.org/ 

publications/pdf/amovementrising.pdf. 

■	 Publication of the guide for state 

programs, Introduction to Program 

Evaluation for Comprehensive 

Tobacco Control Programs17 

■	 On-site technical assistance and 

workshops to improve the capabilities 

of states to evaluate their programs 

■	 Development of issues of the MMWR 

on the California, Massachusetts, 

Oregon, Arizona, and Florida tobacco 

control programs to document the 

evaluation of the results of these 

statewide programs18–22 

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1 0. F r o m D e m o n s t r a t i o n P r o j e c t t o N a t i o n w i d e P r o g r a m 

CDC/OSH $1,200,000 

SAMHSA $190,000 

State appropriation from $1,620,470 

Other state appropriation 

$175,583 

Centers for Disease Control and 

(TIPS). National Center for Chronic Disease 

/ 

tobacco/statehi/html_2002/South_Carolina.htm. 

Post-ASSIST Funding for South Carolina 

The range of funding for South Carolina’s 

comprehensive tobacco control program that 

was recommended in CDC’s Best Practices 

report was $23,905,000–$62,013,000. In fiscal year 2002, a total investment of 

$3,248,862 was made in South Carolina tobacco control. The breakout of that funding is 

illustrated below: 

settlement revenue 

$62,809 

American Legacy Foundation 

Source:

Prevention. 2002. South Carolina highlights. 

Tobacco Information and Prevention Source 

Prevention and Health Promotion. www.cdc.gov

The National Environment 

for Tobacco Control: 

A Consideration 

T

he transition of the ASSIST project 

took place during a dynamic and volatile period in the history of tobacco prevention and control. The 1990s had been 

an active decade on many fronts—policy, 

legal, and regulatory. During the late 

1990s when the ASSIST states were preparing for transition and when the 

framework of NTCP was being developed, many tobacco-related issues were 

being addressed at the national level and 

were receiving high visibility in the 

media. The outcomes and decisions had 

the potential to strongly influence the 

funding and the scope of NTCP and other federal agencies’ roles. Public health 

staffs at the federal, state, and local levels were very involved, responding to requests for information and serving as 

technical resource staff. Both protobacco 

and antitobacco advocates labored hard 

to ensure that their voices and views 

were heard. 

The Food and Drug Administration’s 

assertion of its authority over the regulation of the marketing of tobacco products was successfully challenged in the 

courts. The Substance Abuse and Mental 

Health Services Administration 

(SAMHSA) enforced a congressional 

mandate (the Synar Amendment) to require states to document that they were 

enforcing state laws to reduce retail sales 

of tobacco to minors. Tobacco control researchers had formed a collaborative organization, the National Organization of 

Tobacco Use Research Funders, to encourage collaboration among funders 

and investigators in tobacco control research. In August 2000, RWJF announced its plan to increase the number 

of grantees and the level of funding for 

its SmokeLess States program, which had 

been initiated in 1993. The National 

Center for Tobacco-Free Kids, founded 

in 1996, continued to position itself as an 

important source for the media on events 

in the tobacco control world and as a resource for state-level advocates and 

grassroots organizations. Senator John 

McCain had introduced a national tobacco control bill that caused a major debate in Congress. Litigation by states 

against the tobacco industry came to a 

resolution in the Tobacco Master Settlement Agreement in 1998 and was a potential source of new funding for 

460 
M o n o g r a p h 1 6. A S S I S T 

tobacco interventions. In addition to 

funding the American Legacy Foundation, 

the Tobacco Master Settlement Agreement provided for about $195.9 billion 

in current dollars to be made available to 

states between 1998 and 2025.23 

Despite these positive developments, 

tobacco prevention and control work 

was by no means over. For example, efforts to raise cigarette and spit tobacco 

tax rates had experienced limited success. Youth access and appeal measures 

were in flux after court rulings against 

the Food and Drug Administration’s authority. Debate over terms of the Tobacco Master Settlement Agreement and the 

McCain bill resulted in some still-lingering divisions among tobacco control advocates. As ASSIST drew to a close, the 

tobacco industry dramatically increased 

its advertising expenditures and promoted a positive image of itself and its philanthropic activities. Tobacco prevention 

and control coalitions challenged those 

new image-changing industry strategies, 

for the industry was still heavily marketing to children.24–26 Tobacco prevention 

and control advocates still had considerable work ahead of them to turn the new 

face of tobacco control into action to 

prevent death and disease resulting from 

tobacco use. 

Availability of funds from the Master 

Settlement Agreement and the ensuing 

state-level campaigns focused tobacco 

control advocates on the problems of acquiring these funds for tobacco prevention and control programs. Interest in 

policy issues, such as increased excise 

taxes or clean indoor air, almost uniformly 

was displaced by more immediate concerns about developing a workable plan 

1999 CDC report on effective tobacco control programs 

and explaining the need for long-term 

sustainable funding. 

In 1999, the Advocacy Institute published a comprehensive analysis of the 

strengths and weaknesses of, threats to, 

and opportunities for the tobacco control 

movement in the United States. The report, A Movement Rising, excerpted in 

the box on page 462, also noted drawbacks that resulted naturally from the 

maturing of a large movement, such as 

bureaucratization and the dimming of 

energies.27 Nevertheless, the report emphasized that the opportunities for tobacco control were robust. For example, 

new litigation to obtain industry documents could lead to further settlements, 

evidence from new documents could 

lead to additional demands for industry 

reform, and groups seeking portions of 

settlement funds could become new 

partners in the tobacco control movement. 

461 
1 0. F r o m D e m o n s t r a t i o n P r o j e c t t o N a t i o n w i d e P r o g r a m 

trol Program under the auspices of CDC. 

include: 

■ 

■ 

throughout the country; 

■ 

■ 

■ 

■ 

■ 

■ 

sic

■ 

■ 

■ 

■ 

■ 

■ 

■ 

Status of the Tobacco Control Movement 

In late 1998, RWJF and ACS funded the Advocacy Institute to conduct a comprehensive strategic analysis of the current tobacco control movement in the United States. The analysis, published in March 

1999, reflects the perspectives of tobacco control advocates across the country. It is a view from inside 

the tobacco control movement. The findings presented below are excerpted from the report. Many represent issues that the states had to consider as they were brought together in the National Tobacco ConExcerpts from A Movement Rising 

“Advantages—Internal Movement Strengths 

While there have been disappointments and conflicts within the tobacco control movement, as well as 

unimagined advances, this movement continues to enjoy potent strengths, as well as the benefit of 

valuable lessons learned in the upheavals of the past several years. These strengths—or advantages— 

Moral authority grounded on a strong scientific base; 

A deep reservoir of dedicated human resources, among them a growing army of veteran advocates 

A solid movement infrastructure of technical support and funding; 

A growing diversity of advocates, both culturally and politically; 

Many mature, experienced state and local coalitions; 

New partnerships forged with public health and education organizations, trial lawyers, the faith 

community, elected policy makers, pharmaceutical companies, and even tobacco growers; and 

Hundreds of advocates adept at media advocacy and a veteran press corps with whom they have 

developed working relationships of trust and confidence. 

“Challenges—Internal Movement Weaknesses 

Many of our challenges are the mirror image of our advantages. Perhaps the most formidable challenges deal with our relationships with each other. . . . 

Among the challenges we face are: 

The growth and bureaucratization of the movement, which has leeched some of the inspiration and 

energy that sprung [ ] from being citizen Davids challenging the industry Goliath; 

Dependence upon public and philanthropic funding, which constrains advocacy, coupled with an 

aversion to political engagement among too many tobacco control professionals, even in their role 

as private citizens; 

The persistent narrowness of the tobacco control movement’s base, despite new outreach efforts to 

minority communities, parents and educators, labor, faith communities, business and tobacco 

farmers; 

Flawed intra-movement strategic communications that leave many state and local advocates feeling 

“out of the loop” in strategic decision making and sometimes lead to inflammatory misinformation; 

A lack of sufficient resources for state and local coalitions to address effectively all tobacco control 

policy objectives; this deficiency is often coupled with a reluctance to set priorities; 

The persistent gap between tobacco control funding and tobacco industry war chests; 

Serious internal divisions among tobacco control advocates over core values and goals, strategies, 

leadership roles, and issues of open communication and information exchange; and 

A residue of lingering resentments, valid or not, including perceived inequities in funding, 

perceived self-promotion, perceived patronizing arrogance of some newcomers toward tobacco 

control veterans, perceived patronizing by some national leaders of state and local leaders, and 

perceived conflicts of interest. 

462 
M o n o g r a p h 1 6. A S S I S T 

them: 

■ 

■ 

been ‘punished enough’; 

■ There are signs of disenchantment with tobacco control programs that do not result in immediate 

and dramatic declines in youth and adult tobacco consumption; 

■ There is increasingly harsh commentary by journalists and others—not industry flacks—who raise 

■ 

“Threats—External Threats to the Movement 

The tobacco control movement’s success has itself engendered a new set of external threats. Among 

High profile media coverage of the state attorneys general lawsuits and the multi-state settlement 

has left many Americans believing that the tobacco ‘problem’ has now been dealt with; 

Years of exposing tobacco industry wrongdoing has left the public numbed to additional 

revelations, and there is even evidence of nascent sympathy for an industry that appears to have 

concerns about the effectiveness, the fairness, the overreaching, and the political expediency of 

tobacco taxes and other tobacco control objectives; 

Some citizens suspect that advocates for new, large tobacco control programs are more motivated 

by self-interest in potential new jobs than in the public health.” 

Source: Advocacy Institute. 1999. A movement rising: A strategic analysis of U.S. tobacco control 

advocacy. Executive summary. Washington, DC: Advocacy Institute (pp. 4–5). www.advocacy.org/ 

publications/pdf/amovementrising.pdf. 

The many issues in the analysis are 

complex and illustrate the dynamic environment at the time of the transition. 

Guidance to States on Acquiring 

Funding for Their Programs 

The president’s budget for fiscal year 

1999 included a $51-million request for 

state-based programs to prevent and reduce tobacco use. But there remained a 

substantial shortfall between the $51 

million that was budgeted and the level 

of funding that would be needed. Therefore, states would need to pursue other 

sources of public and private funding— 

from the Master Settlement Agreement; 

from federal, state, and local government 

funds; and from a variety of other sources, 

such as foundations and organizations. 

Before the $51-million budget for 

NTCP was official, OSH had been preparing a set of recommendations for 

comprehensive tobacco prevention and 

control programs known as best practices. This report, mentioned earlier in this 

chapter, was released by CDC in August 

1999 under the title Best Practices for 

Comprehensive Tobacco Control Programs.15 Best Practices served as a 

guide for the states to plan comprehensive programs and to seek appropriate 

levels of funding through allocations 

from the Master Settlement Agreement 

and by continuing to advocate for financial support from a variety of public and 

private sources. 

Best Practices recommends nine 

components of a comprehensive program, based on existing research and the 

experiences of states with large programs and relatively long-term funding. 

Best Practices provides a useful list of 

the essential elements of a comprehensive tobacco control program. However, 

it does not provide specific guidance on 

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1 0. F r o m D e m o n s t r a t i o n P r o j e c t t o N a t i o n w i d e P r o g r a m 

evidence-based strategies of a comprehensive tobacco control program. That 

guidance was based on the 2000 Surgeon General’s report1 and recommendations of CDC’s Task Force on 

Community Preventive Services.5–7 

Best Practices: 

co use ($850,000–$1.2 million per year 

for state personnel and resources; $0.70– 

($2.8 million–$4.1 million per year) 

($500,000–$750,000 

per year for personnel and resources to 

per student in grades K–12 for annual 

($150,000–$300,000 per 

$0.80 per capita per year for enforcement 

programs) 

$0.40–$1 per capita per year) 

($1–$3 per capita 

per year) 

($1–$3 plus cessation services ranging from $137.50 to 

(10% of total annual program costs) 

(5% of 

total annual program costs) 

Atlanta: Centers for Disease Control and 

research_data/stat_nat_data/bestpracRecommended Funding Levels 

1. Community programs to reduce tobac­

$2.00 per capita per year for local governments and organizations) 

2. Chronic disease programs to reduce the 

burden of tobacco-related diseases 

3. School programs

support individual school districts; $4–$6 

awards to school districts) 

4. Enforcement

year for interagency coordination; $0.43– 

5. Statewide programs (including policy 

and media activities, approximately 

6. Counter-marketing

7. Cessation programs

$275 per smoker served) 

8. Surveillance and evaluation 

9. Administration and management

Source: Adapted from Centers for Disease 

Control and Prevention. 1999. Best practices 

for comprehensive tobacco control 

programs—August 1999. Executive summary. 

Prevention. http://www.cdc.gov/tobacco/ 

execsummay.htm. 

Armed with CDC’s Best Practices for 

Tobacco Prevention and Control Programs and with the National Association 

of County and City Health Officials’ locallevel counterpart, Program and Funding 

Guidelines for Comprehensive Local Tobacco Control Programs,

28 local advocates monitored state legislatures to hold 

them accountable for providing resources 

to counteract the number one preventable cause of death. These documents provide state coalitions, particularly the 

private sector partners in those coalitions, with a much-needed, scientifically 

credible resource for planning their efforts 

and for making a case to acquire settlement funds for tobacco use prevention. 

Case studies 10.1 and 10.2 illustrate 

the states’ experiences in obtaining additional resources for tobacco control interventions while addressing their 

administrative, staffing, and program 

needs. Minnesota is one of the four 

states that did not participate in the 

Tobacco Master Settlement Agreement 

with the tobacco industry because it had 

previously settled its lawsuit against the 

industry, after a lengthy trial, which resulted in substantial additional financial 

resources being devoted to tobacco control efforts beginning in 1999. 

Virginia, a leading tobacco-growing 

and -manufacturing state, along with 45 

other states, participated in the Tobacco 

Master Settlement Agreement. Case 

study 10.2 illustrates how the infrastructure and strong partnerships built by 

ASSIST provided the leadership and 

creativity needed to leverage the relationship with tobacco growers to secure 

a portion of the funds for tobacco prevention and control activities. 

464 
M o n o g r a p h 1 6. A S S I S T 

Case Study 10.1 

Situation: 

Strategy: 

and the Minnesota Department of Health. In addition, with a portion of the funds 

Minnesota: 

■ 

grating these resources. 

■ 

■ 

Transition at the State Level: Minnesota’s Experience 

As the ASSIST project was coming to a close and before the U.S. DHHS 

committed to a national tobacco control program, many states faced challenges in 

obtaining the financial, human, and technical resources needed to continue their 

work in this area. During this period of transition and uncertainty, states were at risk 

of losing talented, experienced staff and program momentum if existing funding 

streams were interrupted and if administrative systems were altered. 

Minnesota was fortunate to have new tobacco control resources available 

from two sources of state funding—the Governor’s Children’s Initiative (1997) and 

the Tobacco-Free Communities for Children Initiative—which together provided 

$1 million per year to support prevention activities of local public health agencies 

from the 1998 Minnesota settlement with the tobacco industry, the 1999 legislature 

established the Tobacco Use Prevention and Local Public Health Endowment, which 

provided unprecedented tobacco control resources for statewide and local activities 

($20.8 million in the first 18 months beginning January 2000, growing to about 

$25 million annually for these two areas when fully funded). Minnesota was well positioned financially to expand existing tobacco control activities, including those previously funded through ASSIST. 

There were, however, challenges related to moving tobacco control forward in 

How could tobacco control activities be more effectively integrated within the 

Minnesota Department of Health? The department’s funding for tobacco control 

efforts came from several different state and federal sources; because of lack of 

coordination among those funding sources, some duplication resulted. When new 

resources became available for statewide and local tobacco prevention initiatives, 

it became imperative that the department develop an internal structure for inteWhat restrictions were associated with the use of tobacco endowment funds? 

Less than 1% of these new funds could be used to support technical assistance activities. This amount was inadequate for the support needed, and the existing staff 

members were unable to meet the demands placed on them. As tobacco control 

activities increased in Minnesota, the need to provide consultation, technical assistance, and training would continue to increase, but the new funds did not allow 

for expansion of staff at the state level. 

How would the state realign program priorities in light of these new sources of 

funds? The state legislature imposed a requirement on the Minnesota Department 

of Health that its tobacco prevention and control focus be limited to 12- to 17-

year-olds. 

465

1 0. F r o m D e m o n s t r a t i o n P r o j e c t t o N a t i o n w i d e P r o g r a m 

Case Study 10.1 (continued) 

■	 How could tobacco control staff and advocates maintain the momentum of ongoing initiatives and scale up their activities while adjusting to new administrative 

and funding mechanisms? Many public and private partners were very involved in 

tobacco control and contributed to maintaining the momentum in Minnesota. 

These included the Minnesota Smoke Free Coalition; the American Cancer Society, Minnesota Division; the Association of Nonsmokers Minnesota; the Minnesota Partnership for Action Against Tobacco; and Blue Cross and Blue Shield of 

Minnesota. All these partners participated in planning processes to determine the 

roles that various organizations would take on as new resources and funding 

mechanisms became available. 

■	 How would the Minnesota Department of Health coordinate its efforts with those 

of other organizations? The Minnesota Department of Health began a process to 

define its role in tobacco control and to examine how the new federal funds could 

be used to support tobacco control activities. 

The state worked at several levels to address these concerns. Beginning in January 

1998, half of the funding for the Tobacco-Free Communities for Children Initiative 

($500,000 per year) was distributed as noncompetitive grants to local public health 

agencies, and half was used to provide staffing at the state Department of Health for 

technical assistance and public education programs. These funds contributed significantly to the ability of state and local health departments to successfully expand and 

incorporate elements of the ASSIST model into their infrastructure. 

Later in 1998, the Minnesota Department of Health began a process that successfully 

defined its role in tobacco control, consolidated tobacco control funds, and provided 

the structure for administering the funds but did not address the lack of administrative staff. Fortuitously, the transition to NTCP provided an opportunity to examine 

how the new federal funds could be used most effectively to support tobacco control 

activities. The new funds from the Centers for Disease Control and Prevention were 

used primarily to support staff at the Minnesota Department of Health in administering tobacco control activities and to provide technical assistance and training to local 

grantees. Because new resources would become available to fund local coalitions and 

other tobacco-related initiatives at the local level, the shift in use of federal funds did 

not diminish local activities. 

Insights: Staff members were not trained to conduct an evaluation of ASSIST, nor 

were evaluation results or resources made available to them; otherwise, they could 

have identified and considered incorporating the most effective program elements 

into the planning process for NTCP. For a community-based demonstration project 

such as ASSIST, evaluation resources should be available, and expertise should be 

466 
M o n o g r a p h 1 6. A S S I S T 

Minnesota Department of Health 

Note: 

Case Study 10.2 

Situation:

to formulate a plan to secure a portion of the funds for tobacco control. 

Strategy: 

built from the beginning of the project to increase the probability that the capacity 

and capabilities of successful tobacco control efforts can be maintained. 

—Gretchen Griffin, Project Manager, 

For further reading on the Minnesota tobacco prevention and control movement, see the 

following source: Wolfson, M. 2001. The fight against big tobacco: The movement, the state, and the 

public’s health. Hawthorne, NY: Aldine de Gruyter. 

Establishment of the Virginia Tobacco Settlement Foundation 

 Before Virginia was awarded an ASSIST contract in 1991, tobacco control 

efforts in the state were sporadic and limited. Between 1992 and 1998, the Virginia 

Department of Health’s Tobacco Use Control Program (VDH-TUCP) established 1 

state-level and 17 local tobacco control coalitions to conduct policy-related activities 

and to counter the long-standing cultural acceptance of tobacco use. These coalitions 

consisted of a wide variety of local nonprofit organizations, hospitals, schools, agencies, and other partners. One partner, the University of Virginia’s Institute for Quality 

Health (IQ Health), was awarded a SmokeLess States grant from RWJF to focus on 

developing a relationship between the tobacco-growing community and tobacco control advocates. 

In 1998, as a result of Virginia’s participation in the Master Settlement Agreement 

(MSA), the state projected revenue of approximately $4 billion over the next 20 

years from the tobacco manufacturers. Anticipating that numerous entities would 

seek funding from the MSA, a group of tobacco control advocates quickly mobilized 

Led by the American Cancer Society (ACS) and the American Lung Association (ALA), this group initially proposed that 20% of Virginia’s MSA fund be used 

for a comprehensive approach to tobacco control. A foundation would be created to 

administer the fund. The foundation would be governed by a board of directors representing a wide variety of health interests related to tobacco use, including medical 

interests, educational interests, treatment, prevention, and enforcement. Acknowledging the legislature’s past opposition to tobacco control legislation, the advocates anticipated a difficult campaign to secure passage of the proposed legislation. 

At the same time, another group representing Virginia’s tobacco-farming interests 

was drafting legislation to target all or a major portion of the MSA funds to compensate growers for loss of tobacco quotas and to provide economic incentives to tobacco-dependent communities. Because IQ Health had sponsored dialogue between the 

advocates and the growers for some time, the two groups met and decided to com467

1 0. F r o m D e m o n s t r a t i o n P r o j e c t t o N a t i o n w i d e P r o g r a m 

Case Study 10.2 (continued) 

funds being used to reduce tobacco use. Both groups were careful not to include the 

accomplishment. 

minor technical changes. 

Summary:

bine forces to secure passage of legislation that would provide funding for both 

interests. They reasoned that the health advocates would offset opposition to funding 

being directed to tobacco farmers and that the growers could offset opposition to 

manufacturers in the discussion or in the drafting of the legislation. 

Negotiations were held, and compromises were made; the result was a combined bill 

to create the Virginia Tobacco Settlement Foundation to administer 10% of the funds 

for tobacco control activities and to create the Virginia Tobacco Indemnification and 

Community Revitalization Commission to administer 50% of the funds for grower 

reimbursement and economic development. The draft plan also included legislative 

members on the foundation’s and commission’s boards of directors to provide legislative oversight. The final sponsors of the bill were prominent supporters of grower 

interests and a known advocate for health. Although the plan reduced the amount of 

funding available and narrowed the scope of the program to focus specifically on 

prevention of youth tobacco use, advocates endorsed the legislation as a significant 

The local tobacco control coalitions were mobilized to promote passage of the legislation during the 1999 Virginia General Assembly session. ACS and ALA developed 

fact sheets. They also developed call logs of selected legislators and promoted their 

use. A letter-writing campaign to the entire General Assembly was initiated. ACS 

and ALA testified before committees in conjunction with representatives from the 

grower community. The end result was that the bill passed both chambers with only 

The next campaign was focused on the governor’s office. Both growers and tobacco 

control advocates were unclear on how the bill would be handled by the administration. Throughout the legislative process, the governor received contradictory advice 

from his staff concerning the content of the bill and the process of dedicating the 

MSA dollars. Letters, phone calls, and e-mails to the governor’s office, as well as 

lobbying by the sponsors, resulted in the governor’s signing the bill with amendments. 

The amendments related to increasing the governor’s oversight of the foundation by 

his appointment of the chair and vice-chair of the board as well as the executive director. The legislation became effective on July 1, 1999, and directed approximately 

$14 million annually to programs to prevent youth initiation of tobacco use. 

 Of all the policy and legislative efforts that the tobacco control coalitions 

engaged in during the years of the ASSIST project, establishing long-term funding 

for tobacco control had the greatest potential for significant long-term impact. 

—R. Neal Graham, former ASSIST Project Manager, 

Virginia Department of Health 

468 
M o n o g r a p h 1 6. A S S I S T 

Toward the Future 

T

he transition to the CDC-administered 

NTCP presented many challenges to 

NCI; CDC; and every participating state, 

territory, district, and American Indian 

tribe. No matter what its existing capacity, each entity had to assess its mission 

and role in relation to the goals and objectives of the national program and to 

realign and shape programs and functions as appropriate. Maintaining their 

capacities was high on the agenda for 

the ASSIST states, but they also had to 

expand their capacity and capabilities 

beyond policy development to undertake 

the additional core functions—assessment/monitoring and assurance of 

necessary services—of a public health 

program. 

Transition between agencies and from 

one type of program to another is challenging. However, NCI and CDC staff 

worked very closely with extensive input 

from state departments of health staff 

and other key partners to ensure that the 

transition process was successful. Many 

issues of mission and role overlap, imbalances of resources and expertise, tradition, ideology, political climate, and 

administrative practicalities had to be 

considered. The transition required a 

highly participatory management process that minimized conflict, maximized 

commitment, and generated enthusiasm. 

Various workgroups and especially 

the transition teams made suggestions to 

OSH about program administrative 

structures and methods of operation that 

would best suit their participation in 

NTCP, essential program elements, and 

training and technical assistance needs. 

Prominent among their suggestions was 

that CDC establish a mechanism for ensuring participatory decision making and 

establish a group to fulfill the role formerly performed by the ASSIST Multicultural Subcommittee; this group would 

strive to ensure diversity at all levels of 

NTCP and to eliminate health disparities 

related to tobacco use. 

Considerable efforts were made to ensure that the essential elements of 

ASSIST became integral components of 

NTCP. Chapter 11 presents the contributions that ASSIST made to the tobacco 

prevention and control movement and 

describes ASSIST’s continuing influence and the challenges ahead. 

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1 0. F r o m D e m o n s t r a t i o n P r o j e c t t o N a t i o n w i d e P r o g r a m 

Appendix 10.A. Recommended Benchmarks for Multicultural 

Programs and Activities 

Developed by the ASSIST Multicultural Subcommittee 

March 1999 

1. 	Recommended Benchmark: 

Provide training in cultural sensitivity and cultural competency for all federal, state and 

local staff working on comprehensive tobacco reduction programs. Incorporate cultural inclusivity as a core value and central principle in all tobacco use reduction programs and practices. Work toward the goal of cultural competency in all programs and 

materials. 

Examples: 

♦	 Provide plenary sessions, break-out presentations, and workshops to develop cultural 

competency during all national tobacco control conferences. 

♦	 Integrate cultural competency principles into local, state, and federal planning, 

coalition building, recruiting, training, implementation, and institutionalization 

processes. 

Rationale: 

♦	 Racial, ethnic, and multicultural communities have unique social, cultural, and historic backgrounds. Culturally specific experiences directly influence the role of tobacco and the tobacco industry and how they are addressed in tobacco use reduction 

messages. People with limited English proficiency, or those who have recently arrived in the United States will have less information about the dangers of tobacco, 

and therefore, different needs than those more acculturated to U.S. customs. 

♦	 Representation from all groups impacted (diversity) is the beginning of this 

integration. Involving impacted groups in decision making (inclusivity) is another 

key step. Building on diversity and inclusivity to better understand and appreciate 

cultural differences leads to culturally competent programs and materials. 

♦	 Media and public education campaigns need to focus on strategies that impact 

populations at highest risk. Public health programs that underscore the importance 

of reaching multicultural populations with effective strategies will reduce tobacco 

use sooner than those that don’t. 

♦	 Including training on cultural competency at national and state level conferences is 

one way to ensure that public health workers and tobacco prevention advocates have 

ready access to the information. 

Accountability: 

♦	 Project Officers and Project Managers are responsible for ensuring cultural inclusivity in planning processes and designing state work plans. 

470 
M o n o g r a p h 1 6. A S S I S T 

♦	 At a minimum, training for staff and volunteers, technical assistance, and training of 

trainers on the topic of cultural competency should be provided. 

♦	 Project Managers review state and local work plans for incorporation of cultural 

competency principles into recruiting strategies, coalition building, and funding for 

community organizations. 

♦	 Establish an [independent] advisory board to monitor multicultural resources, 

funding, and activities that are part of the state health department’s tobacco reduction 

plan. 

2. 	Recommended Benchmark: 

Designate funding and other resources to community based organizations that serve 

multicultural communities as a standard component of the budget for each state’s tobacco reduction program. 

Examples: 

♦	 Make state level and community grants, contracts, and agreements accessible to 

community based programs that serve multicultural communities. Provide training 

in grant writing and comprehensive tobacco prevention strategies to community 

based organizations. 

♦ Require all state and community grants, contracts, and agreements to include 

culturally appropriate and culturally sensitive activities. 

♦ Develop training on alternative funding sources for community based organizations. 

Rationale: 

♦	 The tobacco industry’s targeted advertising, promotion, and philanthropy to multicultural populations may undermine tobacco use prevention and reduction strategies. 

Changes in cultural norms occur best when targeted populations are included in 

planning, funding, implementation, and evaluation stages. 

Accountability: 

♦	 Project Officers, Project Managers, and staff include funding for community based 

organizations, mini-grants, and sponsorship of activities and projects that reach and 

involve each state’s multicultural populations. Provide technical assistance and training in planning and evaluating activities.

 3. 	Recommended Benchmark: 

Collect reliable and valid data on tobacco prevalence and brand use, and review and 

disseminate research on effective tobacco reduction strategies impacting multicultural 

communities. (Note: both process and outcome data are needed.) 

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1 0. F r o m D e m o n s t r a t i o n P r o j e c t t o N a t i o n w i d e P r o g r a m 

Examples: 

♦	 Over sample racial and ethnic populations on the Behavioral Risk Factor Survey and 

the Youth Behavioral Risk Factor Survey to obtain numbers representative of the 

state’s racial and ethnic diversity. 

♦	 Add questions on tobacco use patterns within racial and ethnic populations to the 

Behavioral Risk Factor Survey i.e. brand preferences, menthol or non-menthol, and 

price sensitivity. 

♦ Disseminate research on effective strategies to reduce tobacco use to multicultural 

populations. 

♦ Budget additional resources and funding to data collection for racial and ethnic 

populations. 

Rationale: 

♦	 Qualitative and quantitative reporting allows for a comparison to previous years to 

determine changes in tobacco use patterns, funding, targeted programming and culturally appropriate resource development, within multicultural communities. As 

many community groups serving racial, ethnic, and multicultural communities are in 

early stages of development for community tobacco prevention programming, process measure are equally important with outcome measures. 

Accountability: 

♦ Project Officer and Project Manager review data sources for reliable and valid information. Fund data collection or surveillance activities where inadequacies are found. 

♦ Establish an [independent] advisory board to review, recommend, and monitor this 

benchmark. 

4. 	Recommended Benchmark: 

Promote hiring of staff that represent the state’s ethnic/racial/and cultural diversity in 

leadership and managerial positions in federal, state, and local tobacco reduction programs. Establish a competitive process for selection of contractors, which requires 

cultural inclusivity. Adhere to federal guidelines regarding minority contractors. 

Examples: 

♦	 Contact national minority (multicultural) organizations when publicizing position 

openings and recruiting qualified applicants. 

♦ Publicize position openings in state and local multicultural media. 

♦ Follow affirmative action guidelines. 

472 
M o n o g r a p h 1 6. A S S I S T 

Rationale: 

♦	 Hiring diverse staff increases the ability of the program to reach multicultural populations. The populations that bear the greatest burden of tobacco related disease and 

death should serve as decision-makers in reducing tobacco use within those populations. 

Accountability: 

♦	 Incorporate multicultural outreach into existing hiring guidelines for state health departments. 

♦	 Add training in cultural competency to the list of basic qualifications for all tobacco 

prevention/reduction positions. 

5. 	Recommended Benchmark: 

Develop and distribute resource materials, consultant’s lists, and media messages that 

promote culturally sensitive tobacco reduction strategies in languages understood within the target population. 

Examples: 

♦	 Test market materials within target communities for acceptance and readability within their cultural norms. 

♦	 Provide tobacco prevention materials in languages other than English. 

♦	 Develop materials with guidance and approval from the target group. 

Rationale: 

♦	 Language barriers prevent many people from receiving public information and media 

messages on tobacco prevention that are currently available. State and federal programs will never reach the goal of reducing tobacco use to 15% if the issue is not 

framed in terms that multicultural communities understand. Members of a target 

community are our best sources of accurate and culturally appropriate prevention 

messages. 

Accountability: 

♦	 Federal and state tobacco reduction programs are accountable for producing culturally appropriate materials. 

♦	 New materials must be approved by the [independent] advisory board. 

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1 0. F r o m D e m o n s t r a t i o n P r o j e c t t o N a t i o n w i d e P r o g r a m 

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www.naccho.org/GENERAL185.cfm. 

476 
M o n o g r a p h 1 6. A S S I S T 

11. The Promise of ASSIST

Brenda McAdams Motsinger, Robert E. Vollinger Jr., and 

Dearell Niemeyer 

Contributor: Frances A. Stillman 

Contents 

Beyond ASSIST .......................................................................................................... 480


A Visible Promise: An Evolving Infrastructure ........................................................... 481


The Promise of ASSIST: Shaping the Future ............................................................... 484


Ecological Theory and the ASSIST Conceptual Framework ................................................. 484


Interventions for Systems-Level Change ........................................................................... 484


Media Advocacy ......................................................................................................... 487


Policy ......................................................................................................................... 488


Essential Components ....................................................................................................... 491


Sufficient Funding ..................................................................................................... 491


Competent Workforce ................................................................................................. 492


Effective Strategies for Implementation ............................................................................ 494


Participatory Decision Making .................................................................................... 494


Inclusion .................................................................................................................... 495


Influencing Public Health Initiatives ......................................................................... 496


Tobacco Control ................................................................................................................. 496


Beyond Tobacco Control ..................................................................................................... 499


Heart Health ............................................................................................................... 500


Nutrition, Physical Activity, and Obesity ..................................................................... 500


Future Applications ........................................................................................................... 502


Advancing Evaluation Methodology ........................................................................... 502


Future Interventions and Research Initiatives ........................................................... 504


Onward from ASSIST ................................................................................................. 505


References ................................................................................................................ 508


477 
11. T h e P r o m i s e o f A S S I S T 

Table and Figures 

Figure 11.1. The ASSIST Cube and Subsequent Adaptations to Cardiovascular Disease ........ 485


Figure 11.2. Map of State Cigarette Tax Rates—2004 .......................................................... 489


Table 11.1. State Cigarette Excise Taxes for 1998 and 2003 .................................................. 490


Appendix 

Appendix 11.A. Tobacco Control Professionals Who Shared Their Insights regarding ASSIST ........ 507


478 
M o n o g r a p h 1 6. A S S I S T 

Chapter 11: The Promise of ASSIST


The American Stop Smoking Intervention Study (ASSIST) made significant 

advances in disseminating evidence-based interventions—building an effective 

infrastructure by mobilizing communities; establishing coalitions; and providing 

materials, training, and technical support for using media advocacy and policy 

development. These interventions were not necessarily designed and tested by 

ASSIST. Rather, they were incorporated into ASSIST because they had been proven 

effective by earlier research trials. ASSIST demonstrated on a massive scale how to 

effectively translate and disseminate them. 

For some communities, the funding and technical assistance provided by ASSIST 

made it possible for people and organizations to mobilize around media and policy 

advocacy. For less experienced but nonetheless receptive communities, ASSIST 

provided the conceptual framework on which to build a foundation for tobacco use 

prevention and control efforts. For non-ASSIST states, ASSIST was an example—a 

viable, effective, adaptable, demonstration model—that gave insight and inspiration 

about what communities can accomplish. In brief, ASSIST’s legacy to the field of 

public health is (1) the successful demonstration of the applicability of an ecological 

model to public health initiatives and (2) the development of effective methods for 

building state and community capacity for implementing public health interventions. 

The core elements of a program endure because they have been proven to be 

effective. The core elements of ASSIST provide a process for shifting from a major 

focus on services for individuals to systems-level interventions for large population 

segments. With this systems strategy approach, ASSIST established enduring 

infrastructures in the ASSIST states that facilitate their continuing public health 

efforts over the long term. That infrastructure includes a network of public health 

professionals, local volunteers, and advocates trained by ASSIST in policy and 

media advocacy. ASSIST also demonstrated and brought to the forefront that 

adequate funding and high-quality training are essential for effective tobacco 

prevention and control programs and for developing and maintaining a competent 

workforce. 

This chapter* describes how the effective application of the ASSIST core elements 

contributed to a fundamental shift in the approach to tobacco use prevention and 

control and other behavioral health initiatives. ASSIST’s reliance on ecological 

theory as a basis for its conceptual framework has provided a leading model for 

other systems-level public health programs. The complexity of evaluating ASSIST led 

to the development of new models that could be used for future evaluations of public 

health efforts and other community-based interventions. The complexity of the 

ASSIST evaluation highlighted the importance of a continued commitment to 

rigorous evaluation efforts and broadly disseminating results. 

*In order to develop this chapter, input regarding ASSIST’s legacy was solicited from a wide array of 

public health experts who had integral roles throughout the project. Selected quotations from their input are 

included in this chapter. See appendix 11.A for a list of these tobacco control professionals. 

479 
11. T h e P r o m i s e o f A S S I S T 

Beyond ASSIST 

T

he underlying philosophy and core elements of a project that continue to be 

incorporated into other initiatives constitute its legacy. Those conceptual and 

practical elements become apparent as 

they influence future programs and are 

carried forward in dynamic systems. 

ASSIST incorporated many of the key 

ingredients for successful public health 

efforts—highly credible scientific evidence, passionate advocates, media campaigns, and advocacy in favor of laws 

and regulations.1 The conceptual underpinnings of ASSIST are based on almost 

half a century of public health efforts 

against tobacco use.2 ASSIST borrowed 

from those legacies and built on its predecessors’ successes. Now, 5 years after 

ASSIST has ended, what is its legacy? 

In an unprecedented effort to apply 

the knowledge gained during the preceding decades, the National Cancer Institute (NCI), in partnership with the 

American Cancer Society (ACS) and 17 

state health departments, established 

what was then the largest, most comprehensive public health tobacco control 

project ever initiated in the United 

States. Based on scientific evidence that 

emphasized the importance of community mobilization, community ownership, 

and the creation of structures in the 

community to ensure that successful 

programs are maintained, ASSIST built 

the most visible and promising aspect of 

its legacy—an evolving infrastructure 

for implementing comprehensive tobacco prevention and control initiatives. 

This infrastructure provided the underpinning necessary for conducting media 

I think that ASSIST provided the blueprint to show all of us that it is possible 

to get major policy changes in states and 

communities despite the persistent opposition of the tobacco companies. 

—Erwin Bettinghaus, former ASSIST 

Senior Advisor and current Senior 

Scientist and Associate Vice President 

at the Cooper Institute 

advocacy and policy development—a 

community-based participatory approach to decision making and program 

implementation. 

Another promising legacy of ASSIST 

is its focus on the use of media advocacy 

and policy development to shift the emphasis of public health interventions 

away from just individuals and incorporating systems-level interventions that 

change broad social, cultural, and physical environmental conditions of organizations, communities, and society at 

large. This change in emphasis was referred to as a “paradigm shift” among 

many in the tobacco control community 

because of its broad impact. 

The core elements of the ASSIST 

model (community mobilization and organization, media advocacy, and policy 

development) guided the interventions, 

but other factors were also essential for 

success. Along with adequate program 

funding, public health workers needed 

new skills to effectively deliver these 

types of interventions. ASSIST provided 

an exceptional array of tools, materials, 

training, technical assistance, and other 

support to staff and volunteers and 

thereby increased recognition of the 

need for this level of technical support. 

480 
M o n o g r a p h 1 6. A S S I S T 

These multiple programmatic aspects 

have been incorporated into state-based 

tobacco prevention and control programs 

as well as into other health promotion 

initiatives. This chapter examines the aspects of ASSIST’s legacy that derive 

from (1) its evolving infrastructure and 

(2) the effective applications of its core 

elements. 

A Visible Promise: An Evolving 

Infrastructure 

T

he quotation from Susan Stuntz (see 

sidebar) at the June 11, 1992, Tobacco Institute Executive Committee meeting illustrates the tobacco industry’s 

recognition of the significant potential 

for the ASSIST infrastructure to thwart 

the tobacco industry’s interests. 

“In California, our biggest challenge has 

Stuntz, S. 1992. Comments on joint 

Institute. June 11, 1992. http:// 

2, 2004. 

Tobacco Industry Perspective 

not been the anti-smoking advertising 

created with cigarette excise tax dollars. 

“Rather, it has been the creation of an 

anti-smoking infrastructure . . . right down 

to the local level. An infrastructure that 

for the first time has the resources to tap 

in to the anti-smoking network at the 

national level. . . . 

“The ASSIST program has the potential 

to replicate our California experience in 

17 other states.” 

Source:

NCI/ACS ASSIST program. Tobacco 

legacy.library.ucsf.edu/tid/rjk86d00. Bates 

nos. TI13851813–1818, TI14311813–1818, 

and TIMN404296–4301. Accessed December 

ASSIST left a living legacy that is evident from the current actions of many (if 

not all) of today’s tobacco control organizations. 

—William R. Lynn, former ASSIST 

NCI Project Officer 

NCI, ACS, and state health departments all played key roles in modeling 

what a true public-private partnership 

could accomplish, and the stature of 

these organizations brought legitimacy 

and credibility to ASSIST. As they 

worked together to build a solid infrastructure, there were conflicts and issues that 

had to be resolved. Although ACS was 

the designated partner, discussions and 

negotiations occurred to ensure that other 

organizations critical to the partnership 

such as the American Lung Association 

and the American Heart Association 

were involved in decision making and 

implementation of interventions. With 

ASSIST taught health departments how 

to collaborate with community partners 

and the value and necessity of these partnerships in planning and implementing a 

comprehensive and integrated approach 

to tobacco control. It taught ACS and 

other community organizations how to 

work with the government to get the job 

done. ASSIST also caused local communities to come together as state and local 

coalitions. 

—David Harrelson, former Tobacco 

Control Program Manager, ACS, 

and current Tobacco Prevention 

and Control Specialist, Washington 

State Department of Health 

481 
11. T h e P r o m i s e o f A S S I S T 

Helene G. Brown, former ASSIST Senior Advisor from the 

American Cancer Society, addresses the Fifth Annual 

National Conference on Tobacco and Health in Kissimmee, 

Florida, August 1999. 

continued collaboration and participatory management, all partners came to a 

deeper appreciation of the value that local communities bring to tobacco prevention and control efforts. State health 

departments became more skilled at 

working collaboratively with community 

partners and came to appreciate the critical 

value of those partnerships in planning 

and implementing a comprehensive, integrated approach to tobacco prevention 

and control. ACS and other community 

organizations gained understanding in 

ways to work with and complement the 

efforts of governmental agencies to accomplish their common goals. 

The momentum of the tobacco prevention and control movement increased 

The model of collaboration for coordinated action among the public, for-profit, 

and not-for-profit sectors was proven by 

the ASSIST project to be workable. The 

partners accepted and leveraged funding, 

sought and received in-kind contributions, and used one another’s assets to 

make the project a success. 

—Helene G. Brown, former ASSIST 

Senior Advisor from ACS and 

current Associate Director, 

Community Applications of 

Research, UCLA Jonsson 

Comprehensive Cancer Center 

as ASSIST grew—strengthening existing partnerships and engaging new partners. The strength of the infrastructure 

flowed from the network of tobacco prevention and control public health specialists and community advocates 

trained and tested in the skills essential 

to implementing a socioecological approach to public health problems. A 

communications network and extensive 

training and technical assistance opportunities were critical components developed during ASSIST to support the 

effective functioning of the infrastructure. 

One of the most significant contributions that ASSIST made to public health 

was the empowerment and mobilization 

of local volunteers. Along with professional staff, these volunteers were 

trained at ASSIST conferences known as 

information exchanges, especially in 

media and policy advocacy skills. In 

turn, many of the individuals trained at 

those meetings helped educate and mobilize state and local networks of people 

to influence the adoption of local poli482 
M o n o g r a p h 1 6. A S S I S T 

In 1989, there was no state coalition [in 

West Virginia] and not even one full-time 

state employee devoted to tobacco control. ASSIST created a capacity of 

knowledge and infrastructure at the state 

and local level and laid the foundation for 

the enormous progress that has occurred 

since its inception. This is most evident 

in terms of clean indoor air. In 1989, people could smoke everywhere. Today, 91% 

of the public lives in counties with smoking regulations. 

—Robert H. Anderson, Deputy Director,


Prevention Research Center,


West Virginia University


cies. (See chapter 4.) Without the contributions of local volunteers and the 

grassroots networks established in local 

communities, changes in policies and 

social norms may not have materialized. 

With the development of effective infrastructures in ASSIST states came the 

recognition that every state needed such 

an infrastructure. As the scheduled end 

of the 8-year ASSIST demonstration 

project grew near, this recognition 

strengthened the appeals of ASSIST 

leaders in advocating for the establishment and funding of a national tobacco 

prevention and control program. In part 

because of the effectiveness of ASSIST 

state and local infrastructures, especially 

the work of coalitions, in stimulating 

policy changes, the 1998 Institute of 

Medicine (IOM) report Taking Action to 

Reduce Tobacco Use recommended continued funding of federal, state, and local initiatives, as well as the initiatives 

of nongovernmental organizations, to 

hold policymakers accountable because 

will enable the demonstration project to: 

Furthermore, it is anticipated that by 

National Cancer Institute. 1988. 

Intervention Study (ASSIST). Bethesda, MD: 

National Cancer Institute (p. 3). 

“The coalition model is valuable in that it 

deliver interventions to the community 

that have been tested as effective in 

reducing tobacco use; involve multiple 

organizations and institutions capable of 

addressing tobacco prevention and control 

in a coordinated fashion; encourage 

smoke-free environments; and effect 

public policies regarding tobacco use. 

carrying out this effort through channels 

that are indigenous to our society, 

coalition members will develop a natural 

sense of ownership of the project which 

will strengthen and maintain their efforts.” 

Source: 

Concept: American Stop Smoking 

state and local efforts will “likely remain 

the bulwark of tobacco control.”3(p10) 

This infrastructure is now being 

threatened as states’ antismoking program budgets are being reduced and 

landmark programs such as those in 

Minnesota, Massachusetts, and Florida 

are being dismantled by budget cuts. In 

Florida, those cuts constituted 99% of its 

antitobacco budget.1 The ASSIST infrastructure that remains has left an important legacy of statewide networks of 

citizens, government agencies, private 

organizations, nonprofit agencies, civic 

leaders, and elected officials committed 

to reducing tobacco use. Public health 

specialists were trained with the knowledge and skills needed to mobilize communities, effectively obtain media 

coverage of their issue, and focus the 

public’s attention on the need for policy 

change. Many of these trained individu483 
11. T h e P r o m i s e o f A S S I S T 

als continue to work in the field of public health. As they left ASSIST for other 

opportunities, including staffing the new 

National Tobacco Control Program at 

the Centers for Disease Control and Prevention (CDC), they took with them the 

ASSIST concept, experiences, and 

skills, and had become familiar with its 

tools. This capacity was essential to 

demonstrating the applicability of the 

ecological model to tobacco use prevention and control, as described in the next 

section. 

The Promise of ASSIST: 

Shaping the Future 

Ecological Theory and the 

ASSIST Conceptual Framework 

The ecological model considers a system and all its components—from social 

factors (environmental, economic, political), to interrelationships (coalitions, 

agencies), to individual sectors (education, religion), to individuals. The use of 

ecological models to depict the connections and interrelationships between 

people and their environments—social 

and physical—and to guide interventions is not new. A 2003 IOM report 

Who Will Keep The Public Healthy? 

cites the lessons from community intervention trials that were conducted in the 

late 1970s and early 1980s that reinforced “the emergence of social ecology 

principles for informing public health 

interventions.”4(p86) Ecological theory 

provided the basis for ASSIST’s conceptual framework, and variations on the 

cube used by ASSIST have been adapted 

influenced by intrapersonal, sociocultural, 

Health behavior and health 

“Ecological models of health behavior[:] 

Models proposing that behaviors are 

policy, and physical-environmental 

factors; these variables are likely to 

interact, and multiple levels of 

environmental variables are described that 

are relevant for understanding and 

changing health behaviors.” 

Source: Glanz, K., B. K. Rimer, and F. M. 

Lewis, eds. 2002. 

education: Theory, research, and practice. 

3rd ed. San Francisco: Jossey-Bass (p. 463). 

for use in the application of ecological 

theory to the prevention of other chronic 

diseases, particularly cardiovascular disease (see figure 11.1). 

The magnitude of ASSIST and its 

success brought high visibility to the 

ecological approach, the ASSIST cube, 

and other systems-level approaches to 

preventing chronic diseases. Several 

IOM reports reaffirm the utility of the 

ecological approach in guiding public 

health interventions.5,6,7 A 2000 IOM report, Promoting Health: Intervention 

Strategies from Social and Behavioral 

Research, identifies an “emerging consensus that research and intervention efforts should be based on an ecological 

model,”5(p2) and a subsequent 2003 IOM 

report stresses that the education of public health practitioners should be grounded in ecological theory.4 

Interventions for Systems-Level 

Change 

ASSIST was at the vanguard in shifting the focus of health behavior change 

interventions from primarily program 

484 
M o n o g r a p h 1 6. A S S I S T 

Figure 11.1. The ASSIST Cube and Subsequent 

Adaptations to Cardiovascular Disease 

Source: ASSIST Coordinating Center. 1991. ASSIST program guidelines for tobacco-free communities. Internal document, ASSIST 

Coordinating Center, Rockville, MD. 

The ASSIST Conceptual Framework 

Program Services 

Mass Media 

Policy 

Community 

Environment 

Worksites 

Schools 

Health Care 

Settings 

Community 

Groups 

Axis 2—Channels 

Axis 3—Interventions 

Axis 1—Priority Populations 

Site specific (e.g., adolescents, women, ethnic minorities, bluecollar workers, heavy smokers, and unemployed people) 

Leadership

Scientific & Technical 

High Risk & Clinical Services

Education & Media 

Policy & Environmental 

Larger Populations 

Communities 

Schools 

Organizations 

Healthcare Settings 

Worksites 

A Conceptual Framework for Promoting Heart Health 

Cube from Singapore Declaration 

RISK FACTOR/ 

RISK BEHAVIOR 

SETTINGS 

ESSENTIAL PUBLIC HEALTH 

COMPONENTS 

Source: The Singapore Declaration: Forging the will for heart health in 

the next millennium. Declaration of the Advisory Board of the Third 

International Heart Health Conference. Singapore: Third International 

Heart Health Conference, September 2, 1998. 

Diet 

Sedentary Lifestyle 

Tobacco 

Hyperlipedemia/Hypertension 

Essential Public Health Services 

Source: Pearson, T. A., et al. 2003. American Heart Association guide 

for improving cardiovascular health at the community level. 

Circulation 107 (4): 647. 

Risk Factor/Risk Behavior 

Essential Public Health Services 

Community 

Setting 

Diet

Tobacco

Hyperlipedemia

Hypertension

Sedentary

Lifestyle

Early recognition

of Symptomatic

Disease 

Policy/Legislation 

Surveillance 

Assuring Personal Health Services 

Organizational Partnerships 

Education/media 

Whole communities 

Schools 

Religious Organizations 

Healthcare 

facilities 

Worksites 

A Conceptual Framework for Evidence-Based Public 

Health Practice in CVD Prevention 

Source: Stone, E. J., and T. A. Pearson. 1997. Community trials for 

cardiopulmonary health: Directions for public health practice, policy, 

and research. Executive summary. Annals of Epidemiology 7 (S7): S2. 

Schools & Youth Settings 

Healthcare Settings 

Worksite Settings 

Religious Organizations 

Entire Communities 

Research 

Policy 

Practice 

Smoking 

Nutrition 

Physical 

Activity 

Media 

Social Marketing 

Advocacy 

Policy 

Organizational Policy Change 

Public Policy Change 

Program Services 

Educational 

Clinical 

Community Environment 

Health Care System 

Schools 

Worksites 

Families 

Community Groups Older Adults 

Adults 

Youth 

Children 

CHANNELS POPULATIONS

STRATEGIES 

NC Cardiovascular Health Strategies 

Source: North Carolina Plan to Prevent Heart Disease & Stroke 1999– 

2003. Start with your heart. 1999. Raleigh: North Carolina Heart 

Disease and Stroke Prevention Task Force. 

485

11. T h e P r o m i s e o f A S S I S T 

to community health—the health of the 

U.S. Department of Health and 

Human Services. 2000. 

and Human Services (p. 3). 

Excerpt from Healthy People 2010 

“Over the years, it has become clear 

that individual health is closely linked 

community and environment in which 

individuals live, work, and play. 

Likewise, community health is 

profoundly affected by the collective 

behaviors, attitudes, and beliefs of 

everyone who lives in the community.” 

Source: 

Healthy People 2010. 

Washington, DC: U.S. Department of Health 

services for individuals to a systems-level, 

community-based public health approach. It demonstrated on a large scale 

that the prevention of chronic diseases 

can be effected by mobilizing social, 

family, and community networks to advocate for the enactment of policies that 

will influence social norms and behaviors. 

Before ASSIST, a policy and environmental approach to public health problems was used for preventing and 

controlling infectious diseases but not 

chronic diseases. Founded by an act that 

passed in 1798 during an era when infectious diseases such as yellow fever 

and influenza were often epidemic, the 

U.S. Public Health Service has a long

history of population-wide approaches 

to preventing the spread of infectious 

diseases.8,9,10 Policy interventions, such 

as requirements that children be immunized before attending school, inspection of water supplies, and quarantines 

to prevent the spread of infectious diseases, remain standard practice. 

The ASSIST project’s focus on policyand population-based approaches has 

contributed immensely to a paradigm 

shift in health promotion. Gone are the 

days of T-shirt and button interventions 

or exclusive focus on individual smoking 

cessation. Health promotion has matured 

to recognize that scientifically proven, 

comprehensive, population-based approaches have the greatest potential for 

community health improvement. 

—Walter ‘Snip’Young, former Colorado 

ASSIST Project Director and current 

Scientist at the Cooper Institute 

As chronic disease surpassed infectious disease as the leading cause of 

death, the public health field moved 

away from promoting and protecting the 

public’s health by means of policy or 

population-based interventions toward 

an individual approach. Public health initiatives to prevent chronic diseases, 

such as heart disease and cancer, have 

traditionally reflected an individual approach. Individuals with high cholesterol levels were identified through 

screening and referred for counseling, 

and early tobacco prevention and control 

efforts focused on convincing individuals to stop smoking. While recognizing 

that changing health behavior is more 

complex than requiring immunizations, 

the ASSIST model called for an emphasis on policy interventions, thus contributing to a fundamental shift in the public 

health approach to preventing chronic 

diseases. 

The move to incorporate policy- and 

environmental-level interventions in addition to working directly with individu486 
M o n o g r a p h 1 6. A S S I S T 

als is now recognized as essential to preventing and reducing tobacco use. The 

following description of tobacco control 

initiatives existing in 1998 in a Morbidity and Mortality Weekly Report on state 

tobacco control laws illustrates this 

point: 

Developing and implementing public 

health policies are a central component 

of tobacco-control efforts. Tobacco-control policies cover a range of topics, including minors’ access to tobacco, retail 

tobacco licensing, smoke-free indoor air, 

advertising and promotion, excise taxes, 

warning labels, and product ingredient 

disclosure. Some tobacco-related policies 

are instituted primarily at the federal level; however, most tobacco-related policies are established at the state and local 

level.11(p22) 

This shift in emphasis from the individual to the community is embodied in the 

ASSIST model. 

Media Advocacy 

The use of media advocacy to bring 

about policy change within organizations, communities, and society epitomized the ASSIST approach. The 

concept of media advocacy, although not 

originated by ASSIST, is very closely 

associated with it. Prior to ASSIST, other public health programs, including 

NCI’s Community Intervention Trial for 

Smoking Cessation (COMMIT) project, 

used a media advocacy approach. As is 

reflected in the quotation from Dr. Marc 

Manley, ASSIST advanced the use of 

media advocacy interventions for effective policy development. ASSIST 

brought high visibility to the effective 

use of media advocacy, thereby cataMedia advocacy became a public health 

term. 

—Marc W. Manley, former Chief, 

Tobacco Control Research Branch, 

NCI, and current Executive Director, 

Center for Tobacco Reduction and 

Health Improvement, Blue Cross 

and Blue Shield of Minnesota 

lyzing the dissemination and increasing 

use of this intervention by public health 

programs. 

1982.

products;

One vital area of expertise developed 

during ASSIST was the media advocacy 

skills that were crucial for framing prevention of tobacco use as a major public 

health problem and for countering messages promoted by the tobacco industry. 

ASSIST capitalized on a strategy the tobacco industry had used to its advantage 

for years—the use of the media to influence behavior and to change social 

norms. ASSIST’s cadre of professionals 

were effective at countering many tobacco industry efforts to convince the public 

that the scientific evidence on the health 

consequences of tobacco use is unsound, 

but the challenge persists. Some tobacco 

companies and their allies continue to 

dispute whether secondhand smoke 

causes harm and the magnitude of risk 

associated with new tobacco 

12(p1747) yet, they appear to have 

known about these risks since at least 13–17 Tobacco prevention and control advocates continue to depend on 

media advocacy efforts to shed light on 

the tobacco industry’s invalid claims 

against the relevant science base. To 

maintain credibility, these media advocacy efforts must be based on sound science. 

487 
11. T h e P r o m i s e o f A S S I S T 

The strategic use of media to affect 

social norms and of policies to change 

cultural, economic, and environmental 

factors that influence health behaviors 

has become a vital component of comprehensive programs to change healthrelated behaviors. The use of media 

interventions is increasingly included in 

program standards, requests for proposals, and best practices documents in various public health contexts.2,18,19 

Policy 

Intervening to change policies is typically a lengthy process that often begins 

with a gradual awakening to the awareness of a problem, progressing to analyzing and clarifying the problem, and 

then moving forward to community discussions of potential policy solutions 

that in time lead to building the social 

and political will needed for policy 

change. A hallmark of the ASSIST legacy 

was using policy as an intervention, ensuring that the policy was based on 

sound science.19 ASSIST increased the 

use of policy in chronic disease prevention and demonstrated how to effect policy change.20 (See Monograph 17 on the 

ASSIST evaluation.) 

While ASSIST did not accomplish all 

of its policy goals, it did provide needed 

momentum on a number of policy 

fronts, as evidenced by (1) tobacco prevention and control policies enacted during the project period that endure today 

in their original form, (2) policy interventions that were in process and have 

come to fruition since the end of 

ASSIST, and (3) similar policies that are 

being promoted in other programmatic 

efforts. Three policy interventions are 

particularly noteworthy: (1) increasing 

the price of tobacco products through 

excise taxes, (2) blocking and reversing 

preemption laws supported and promoted 

by the tobacco industry,21 and (3) promoting state and local clean indoor air laws. 

Excise Taxes. ASSIST contributed to 

the increased recognition given to excise 

taxes as a primary tool for discouraging 

tobacco consumption through price increases and to an evolving process that 

led to a more favorable environment for 

these tax increases. In several ASSIST 

states, excise tax increases on cigarettes 

have been enacted since 1999—for example, in New York, Washington State, 

Maine, Rhode Island, Wisconsin,22 and 

Virginia.23 States continue to raise excise 

taxes in an effort to increase revenues as 

well as to provide a disincentive to use 

tobacco. Prior to the ASSIST implementation phase in 1993, the average state’s 

cigarette excise tax was 29¢ per pack.24 

As of August 1, 2004, the average state’s 

excise tax was 79.2¢ per pack and the 

average excise tax for the ASSIST states 

was 95.59¢ per pack.25 Figure 11.2 presents a map with the 2004 cigarette excise tax indicated for each state. 

Table 11.1, which contains a list of 

state excise taxes in 1998 and 2003, illustrates the change in excise taxes since 

ASSIST ended. Thirty-five states and 

the District of Columbia enacted state 

excise tax increases between 1998 and 

2003, and 20 of those increases were in 

excess of 100%. It is noteworthy that 

several tobacco states—Kentucky, North 

Carolina, and South Carolina—have not 

increased their excise taxes in the last 5 

years and that their existing taxes are 

single-digit.26,27(p9) The lack of a tax 

488 
M o n o g r a p h 1 6. A S S I S T 

Figure 11.2. Map of State Cigarette Tax Rates—2004 

MAP OF STATE CIGARETTE TAX RATES 

Average State Cigarette Tax: 79.2 cents per Pack 

Average Cigarette Tax in Major Tobacco States: 15.3 cents per Pack 

Average Cigarette Tax in Non-Tobacco States: 87.7 cents per Pack 

MA: 151 

RI: 246 MI: 200 

NJ: 240 

HI: 140 

OR: 118 

PA: 135 

AZ: 118 

GA: 37 

DE: 55 

AR: 59 

ID: 57 

WY: 60 

MT: 70 

IN: 55.5 

NE: 64 

33.9 

77 

100 

52 

3 

5 

7 

IL: 98 OH: 55 

VT: 119 

NY: 150 

DC: 100 

MD: 100 

CT: 151 

KS: 79 

SD: 53 

WA: 142.5 

TN: 20 

UT: 69.5 

Puerto Rico: 123 

18 

23 

17 

36 

48 

20 

NV: 80 

LA: 36 

AL: 42.5 

WV: 55 

VA: 20 

NM: 91 

AK: 160 

87 

44 

41 

Map shows state cigarette tax rates in effect now or scheduled to be implemented soon. States with increases 

implemented or passed since 1/1/2002 marked in bold. Oregon raised its tax by 60¢ per pack in 2002, but a 

previous temporary 10¢ add-on to the tax rate expired on 1/1/04. The major tobacco states with extensive 

tobacco farming and, often, cigarette manufacturing are NC, KY, VA, SC, TN, & GA. State averages do not 

include Puerto Rico (which has a population larger than those in 20 different states) or U.S. territories (such as 

Guam, which raised its tax from 7¢ to $1.00 on 5/1/03). Including Puerto Rico raises the state average to 80.0 

cents per pack and the non-tobacco state average to 88.5 cents. Federal cigarette tax is 39¢. Some local 

governments also tax cigarettes. For example, New York City increased its cigarette tax from 8¢ to $1.50 per 

pack in 2002, Cook County, IL, which includes Chicago, increased its tax from 18¢ to $1.00 per pack, effective 

4/1/04, and more than 35 localities in VA have taxes ranging from two to 50 cents per pack. The U.S. Centers for 

Disease Control & Prevention estimates that smoking-caused health costs total $7.18 per pack sold. 

National Center for Tobacco-Free Kids, August 1, 2004 / Katie McMahon 

For more information on state cigarette taxes and the benefits from increasing them, see: 

x http://tobaccofreekids.org/reports/prices 

x http://tobaccofreekids.org/research/factsheets/index.php?CategoryID=18 

1400 I Street NW · Suite 1200 · Washington, DC 20005 

Phone (202) 296-5469 · Fax (202) 296-5427 · www.tobaccofreekids.org 

Source: National Center for Tobacco-Free Kids. 2004. Map of state cigarette tax rates—2004 

(August 1, 2004). Compiled by Katie McMahon. http://tobaccofreekids.org/research/ 

factsheets/pdf/0222.pdf. 

489 
11. T h e P r o m i s e o f A S S I S T 

Table 11.1. State Cigarette Excise Taxes for 1998 and 2003 

(Shading indicates ASSIST states.) 

1998 Excise 2003 Excise 

State Tax Rate Tax Rate % Increase 

Alabama $0.165 $0.165 None 

Alaska $1.000 $1.000 None 

Arizona $0.580 $1.180 103 

Arkansas $0.315 $0.590 87 

California $0.370 $0.870 135 

Colorado $0.200 $0.200 None 

Connecticut $0.500 $1.510 202 

Delaware $0.240 $0.550 129 

District of Columbia $0.650 $1.000 54 

Florida $0.339 $0.339 None 

Georgia $0.120 $0.370 208 

Hawaii $1.000 $1.300 30 

Idaho $0.280 $0.570 103 

Illinois $0.580 $0.980 69 

Indiana $0.155 $0.555 258 

Iowa $0.360 

Kansas $0.240 

Kentucky $0.030 

Louisiana $0.200 

$0.360 None 

$0.790 229 

$0.030 None 

$0.360 80 

Maine $0.740 $1.000 35 

Maryland $0.360 $1.000 177 

Massachusetts $0.760 $1.510 99 

$0.750 $1.250 66 

Minnesota $0.480 $0.480 None 

Michigan 

Mississippi $0.180 $0.180 None 

Missouri $0.170 $0.170 None 

Montana $0.180 

Nebraska $0.340 

Nevada $0.350 

New Hampshire $0.370 

$0.700 288 

$0.640 88 

$0.800 128 

$0.520 41 

$0.800 $2.050 156 

$0.210 $0.910 333 

$0.560 $1.500 168 

North Carolina $0.050 $0.050 None 

New Jersey 

New Mexico 

New York 

North Dakota $0.440 $0.440 None 

Ohio $0.240 $0.550 129 

Oklahoma $0.230 $0.230 None 

Oregon $0.680 $1.280 88 

Pennsylvania $0.310 $1.000 223 

South Dakota 

Tennessee 

Texas 

Utah 

Vermont 

$0.330 

$0.130 

$0.410 

$0.515 

$0.440 

$0.530 

$0.200 

$0.410 

$0.695 

$1.190 

61 

54 

None 

35 

170 

Rhode Island $0.710 $1.710 141 

South Carolina $0.070 $0.070 None 

$0.025 $0.025 None 

$0.825 $1.425 73 

$0.170 $0.550 226 

$0.590 $0.770 31 

Virginia 

Washington 

West Virginia 

Wisconsin 

Wyoming $0.120 $0.600 400 

Sources: The Tobacco Institute. The Tax Burden on Tobacco. Historical Compilation 1998. Washington, DC: The Tobacco Institute (p. 9); National Center for Tobacco-Free Kids. Map of State Cigarette Tax Rates—2003 (July 24, 2003) 

compiled by Eric Lindblom. www.tobaccofreekids.org/research/factsheets/pdf/0222.pdf. 

490 
M o n o g r a p h 1 6. A S S I S T 

increase in 14 states is a reminder of the 

formidable challenges that remain. 

Preemption Laws. When the tobacco industry realized the power that ASSIST 

represented because of its local and state 

coalitions and infrastructures,28 the industry successfully promoted the passage of 

laws in many states that restrict local jurisdictions from enacting local excise 

taxes and restrictions on tobacco use. 

ASSIST staff and volunteers brought 

attention to the threat posed by such preemption laws. In some states, local advocates were able to prevent passage of 

preemption laws or were able to repeal 

preexisting laws. (See chapter 6 for a 

more detailed discussion of preemption.) 

At the end of 1998, the tobacco control laws in 30 states contained preemption provisions. The tobacco industry 

continues to use this tactic to constrain 

local tobacco prevention and control efforts. However, because of the successful transition of ASSIST to the National 

Tobacco Control Program and the expansion of effective state-based programs, efforts to prevent or reverse 

preemption laws continue. Recent actions in Maine,11 Massachusetts,29 Delaware,30 North Carolina,31 and West 

Virginia32 successfully countered the tobacco industry’s preemption strategy.33 

Clean Indoor Air. The expectation of a 

smoke-free environment in public places 

has become a social norm. This norm 

was painstakingly achieved through a 

combination of public and private policy 

changes. The efforts of ASSIST and 

many other tobacco control initiatives 

and professionals drew attention to this 

intervention as an important tool for reducing tobacco use. Promoting clean indoor air was a central policy goal of ASSIST from the outset, and it became the 

subject of many activities at the state 

and local levels, as well as numerous 

training events and materials. By maintaining this focus on promoting clean indoor air and by training staff and 

volunteers on this topic, ASSIST was 

able to build momentum for these initiatives that far outlived the project itself. 

California and Delaware led the nation in adopting comprehensive, statewide clean indoor air laws, and five 

other states continued this trend— 

Maine, New York, Massachusetts,34 Connecticut, and Rhode Island.35 Four of 

these were ASSIST states. ASSIST contributed to the supportive environment 

that facilitated the passage of clean indoor air laws and has led to action on 

this front in numerous other states and 

communities across the country. 

Essential Components 

ASSIST contributed to future public 

health interventions its insights about 

which program components are essential 

for success. During ASSIST, sufficient 

funding and a highly competent workforce emerged as two essential ingredients for a successful tobacco prevention 

and control program. 

Sufficient Funding 

With ASSIST came an increased 

awareness of the magnitude of resources 

needed to effectively implement a comprehensive approach to tobacco prevention and control. Considered inadequate 

by today’s standards, the investment of 

federal funds in ASSIST was the largest 

491 
11. T h e P r o m i s e o f A S S I S T 

made in tobacco prevention and control 

programs at that time. That investment 

was accompanied by significant funding 

from ACS, NCI’s designated private-sector partner in ASSIST. Today, the level 

of funding that a comprehensive tobacco 

prevention and control program receives 

is recognized as the single most important determinant of success.36 

wide.”

The IOM report Taking Action to Reduce Tobacco Use cites the evidence of 

a dose-response relationship between the 

level of funding and the effectiveness of 

tobacco prevention and control efforts. 

That evidence has been gleaned from 

experiences with ASSIST, state-supported programs, and CDC’s Initiatives to 

Mobilize for the Prevention and Control 

of Tobacco Use (IMPACT) and was used 

as a basis for IOM’s recommendation to 

“apply the lessons of ASSIST nation3(p10) California and Massachusetts, which had the highest levels of 

state funding during the 1990s, experienced the greatest reductions in tobacco 

consumption. During this time frame, 

per capita cigarette consumption fell by 

57% in California and by 36% in Massachusetts—compared with 27% in the 

rest of the country.37(pI-ii),38(pv) A 2000 

IOM report, State Programs Can Reduce 

Tobacco Use, concludes that the doseresponse observation is “strong evidence 

that state programs have an impact, that 

more tobacco prevention and control 

correlates with less tobacco use and that 

the reduction coincides with the intensification of tobacco control efforts.”7(p4) 

Recognizing that adequate funding is 

essential to effective tobacco prevention 

and control, CDC provided guidance for 

state decision makers regarding funding 

levels necessary for each state to sustain 

an effective, comprehensive state-level 

program.19 Approximate annual costs to 

implement all of the recommended program components were estimated to range 

from $7 to $20 per capita in states with 

smaller populations (< 3 million), from 

$6 to $17 per capita in states with medium populations (3–7 million), and from $5 

to $16 per capita in states with larger 

populations (> 7 million). In addition, a 

base funding of $850,000–$1.2 million 

per year per state was recommended.19 

The commitment to sustainable funding levels by CDC’s Office on Smoking 

and Health (OSH) is even more critical 

today because state budget deficits have 

resulted in deep cuts in some state tobacco prevention and control programs. In 

2002, California’s program was cut by 

$61 million and Massachusetts’s program was cut by $42 million and nearly 

eliminated.39(p12) 

In a special report in the New England Journal of Medicine, “Tobacco 

Control in the Wake of the 1998 Master 

Settlement Agreement,” Steven Schroeder reviews the small amount of funding 

that state tobacco prevention and control 

programs have received from the Master 

Settlement Agreement (MSA) and concludes with a quote from an interview 

with Joseph Califano Jr., the former Secretary of Health, Education and Welfare, 

The results: the money [from the MSA] 

is being spent to close budget deficits 

rather than to stop kids from smoking 

and help adults who are hooked.1(p296) 

Competent Workforce 

The issue of a competent workforce 

has been a growing concern within the 

492 
M o n o g r a p h 1 6. A S S I S T 

field of public health, as was brought to 

the forefront by the 1988 IOM report 

The Future of Public Health40 and reiterated in the 2003 IOM report Who Will 

Keep the Public Healthy? According to 

the more recent report, one of public 

health’s essential services 

is to assure a competent public health and 

personal care workforce. The state health 

department, in cooperation with local and 

federal public health agencies, has a major role to play in facilitating the competency of the public health 

workforce.4(pp162–3) 

ASSIST leaders recognized the new 

set of competencies required for public 

health professionals and developed a 

model for providing training and technical assistance to support individuals and 

organizations in the field. ASSIST acknowledged that because new types of 

interventions were being promoted, staff 

needed new skills in community mobilization, media advocacy, and policy development to be able to carry out those 

new interventions. (See chapter 4.) 

These types of skills are described in 

the recent IOM report on public health 

professionals, Who Will Keep the Public 

Healthy?: 

Public health communication requires 

skills to use mass media strategically in 

combination with community organizing 

to advance public health policies through 

media advocacy, targeting policymakers, 

organizations, and/or legislative bodies. 

Public health professionals should be 

able to frame public health problems as 

social inequities to derive policy solutions, as well as apply news values and 

advertising principles to design stories 

about these public health issues for media outlets.4(p77) 

■ 

relations 

■ 

■ 

■ 

enforcement 

■ Conflict resolution 

■ 

Examples of ASSIST Training Needs 

Media advocacy, social marketing, media 

Community organization (assessment, 

mobilization, creating ownership) 

Leadership development 

Policy analysis, implementation, and 

Legislative analysis 

ASSIST staff and volunteers advanced the understanding of the types 

and levels of skills needed by individuals who implement public health interventions and demonstrated how training 

and technical assistance can be delivered 

to support those individuals—both professional staff and volunteers. 

NCI supported the development of 

the ASSIST Coordinating Center to provide training and technical assistance 

that responded to the needs of the staff 

and coalition members in the 17 states. 

(See chapter 4.) The states found the 

ASSIST training and technical assistance to be so worthwhile that they 

sought to retain this resource after 

ASSIST ended. They used their skills 

and worked through the Technical Assistance and Training Transition Team to 

advocate to CDC and key foundations 

for continued training and technical assistance. CDC sought to provide the 

necessary professional expertise and 

support for the implementation of its 

new National Tobacco Control Program. 

In addition, key partners recognized the 

need for extensive, highly skilled technical assistance, so they advocated for establishing the Tobacco Technical 

493 
11. T h e P r o m i s e o f A S S I S T 

Assistance Consortium (TTAC) to fill 

this critical need. (See chapter 10.) 

This high level of technical assistance 

support is increasingly emphasized in 

public health initiatives and in the literature.4 State health department leaders 

appreciate the importance of comprehensive tobacco prevention and control 

programs and of maintaining a highly 

skilled staff, and are working toward attaining this capacity. The pioneers 

trained during ASSIST constituted a new 

type of public health worker equipped to 

respond to challenges of the 21st century. 

Effective Strategies for 

Implementation 

Throughout this monograph, the design, core elements, strategies, and activities of ASSIST have been described, 

along with insights for their application 

and ASSIST’s continued contributions to 

health behavior change. In addition to 

the infrastructure built, the methods and 

materials developed for effective interventions, and the training and technical 

assistance provided for professional skill 

development, two strategies—participatory decision making and inclusion—are 

especially noteworthy. 

Participatory Decision Making 

Early in ASSIST, the form of program 

management evolved from a hierarchical 

structure to a participatory management 

and decision-making structure. The state 

programs requested an integral role in 

decision making, and they became members of the ASSIST Coordinating Committee and its subcommittees. This 

participatory style of decision making 

was also reflected in the management of 

state programs, as they designated local 

ASSIST coalition members to serve in 

state-level leadership roles. 

In addition to providing training and 

technical assistance to the 17 states, the 

ASSIST Coordinating Center provided 

administrative support and technical assistance to the ASSIST Coordinating 

Committee and its subcommittees. This 

high level of support made possible involvement of state staff in decision making, better feedback for program 

direction, greater retention of volunteers, 

and more efficient resource allocation by 

the coalitions. The Advance Teams and 

Transition Teams discussed in chapters 9 

and 10 considered the ASSIST Coordinating Center and the ASSIST Coordinating Committee to be crucial 

components of the infrastructure for effective collaboration and coordination of 

a national tobacco prevention and control program. The principle has been carried forward into CDC’s National Tobacco 

The ASSIST project located tobacco control at the state and community level, insisting on coalitions in order to include 

members of the community. Participants 

demanded that ASSIST become more diverse and inclusive. I think the 

ASSIST project helped define tobacco 

control as a national movement and 

helped the movement itself become more 

diverse and inclusive. 

—Jerie Jordan, former National 

Manager, ASSIST Project, 

American Cancer Society, and 

current Program Consultant, Office 

on Smoking and Health, CDC 

494 
M o n o g r a p h 1 6. A S S I S T 

The focused nature of ASSIST resulted 

in a clear strategy to reduce tobacco use. 

This evidence-based strategy educated 

health practitioners and community coalition members about best practices in tobacco prevention and control. These 

practices also translate into other public 

health arenas. I continue to use the strategic planning process in the public health 

programs I am involved in by first assessing the community environment through 

community interviews, scientific literature reviews, considering the five channels of delivery: community, community 

environment, health site, worksite, and 

school site. 

—Rebecca Murphy-Hoefer, former 

ASSIST Western New York Field Director, 

former Utah IMPACT Coordinator, Utah 

Department of Health, and current Health 

Communication Specialist, Office on 

Smoking and Health, CDC 

Control Program, although the size of 

the program has necessitated different 

mechanisms for participation. (See chapter 10.) It remains to be seen how extensively this promising ASSIST legacy of a 

national coordinating center and a coordinating committee will be realized. 

Inclusion 

Throughout the life of the project, 

ASSIST promoted the inclusion of and 

representation from diverse cultural 

groups. Progress was made in increasing 

the cultural diversity and competency of 

members of the tobacco control community and the staffs of state health departments, ACS, and NCI. They addressed 

difficult issues and made changes in certain committees to meet diverse needs. 

The creation of the ASSIST Multicultural Subcommittee in 1994 helped ensure 

that all major population subgroups, and 

especially all ethnic population groups, 

would be involved or represented in all 

aspects of the project. (See chapter 3.) 

With the establishment of the Multicultural Subcommittee, state representatives of ASSIST directed efforts to 

educate and involve tobacco control priority populations at high risk for tobacco 

use. The ASSIST Multicultural Subcommittee set the following objectives: 

increasing the awareness and skills of site 

staff to work more effectively with all 

multicultural and diverse groups in developing a long term commitment to tobacco control, 

linking with other national multicultural 

and diverse groups to promote and expand their tobacco control efforts, 

encouraging the dissemination of media 

materials appropriate to multicultural and 

diverse groups, 

The coalitions included people who were 

pro-choice as well as pro-life. They included those who were in favor of the use 

of animals in research and those who had 

opposite views. They included the 

wealthy and the less wealthy and the 

middle class and the poor. The multicultural make-up of the coalition memberships did not constitute ‘unlikely’ partners 

but spoke forcefully to the determination 

of the coalitions to find and exploit their 

common ground. 

—Helene G. Brown, former ASSIST 

Senior Advisor from ACS and current 

Associate Director, Community 

Applications of Research, UCLA Jonsson 

Comprehensive Cancer Center 

495 
11. T h e P r o m i s e o f A S S I S T 

The project focused not only on the inclusion of communities of color, but also 

gays and lesbians, women, and youths. 

This model continues to be the mainstay 

of the National Tobacco Control Program 

and the SmokeLess States National Tobacco Policy Initiative. 

—Victor Medrano, former ASSIST New 

Mexico Field Director, former Program 

consultant, Office on Smoking and Health, 

CDC, and current Health Education 

Specialist, Youth Media Campaign, CDC 

Office of Communications 

promoting and developing alternative 

funding options for minority groups particularly in intervention research and program delivery.41(p2) 

Addressing multicultural issues was 

not restricted to the Multicultural Subcommittee. Two principles—ensuring 

that representation was diverse and that 

health disparities were addressed—were 

integrated into all facets of ASSIST. 

(See recommended benchmarks for multicultural activities in appendix 10.A.) 

ASSIST leaders sought effective means 

for reducing health disparities, and CDC 

built on those efforts. ASSIST staff and 

volunteers wanted to ensure that multicultural issues were represented in all 

aspects of the program. ASSIST’s notion 

of inclusion extended beyond communities of color to other population subgroups such as gays and lesbians, 

women, and youths. 

This principle has persisted in CDC’s 

National Tobacco Control Program. 

CDC’s 1999, as well as its most recent, 

request for applications for the National 

Tobacco Control Program42,43 contained 

a specific goal related to health disparities and how that goal is to be integrated 

into the state programs. The Robert 

Wood Johnson Foundation’s (RWJF’s) 

SmokeLess States National Tobacco 

Policy Initiative and the American Legacy Foundation’s Priority Populations Initiative also exemplify the same principle 

of inclusion. 

Influencing Public Health 

Initiatives 

As researchers increasingly reached consensus on the effectiveness of an 

ecological approach for addressing public health problems and on the strength 

of the evidence supporting policy interventions for preventing tobacco use, 

public health practitioners worked to apply this knowledge and innovative leaders responded. As a result of ASSIST 

and other important tobacco control programs, many new public health initiatives have proliferated. Many of these 

initiatives address health issues beyond 

tobacco control and include elements of 

the earlier successful programs. 

Tobacco Control 

ASSIST was an important early initiative that helped reshape tobacco prevention and control efforts. Frequent 

interactions among all the early leaders 

led to substantial cross-fertilization of 

ideas and information about promising 

approaches to preventing and reducing 

tobacco use. 

Within this climate, states were also 

moving forward. Two innovative leaders, California and Massachusetts, were 

496 
M o n o g r a p h 1 6. A S S I S T 

approach. 

(October 1998), you will see that California adopted the idea of reducing the ‘social acceptability’ of 

California Department of Health Services, 

California’s Connection with ASSIST 

“I can say from direct experience that the strategy that we developed in operationalizing the program 

was strongly influenced by the National Cancer Institute’s ‘Standards for Comprehensive Smoking Prevention and Control’ in ASSIST RFP-56. Especially important was the statement: ‘A smoking prevention 

and control initiative is based on successful worldwide examples that show that a widespread change in 

social acceptability of smoking is required to significantly reduce smoking prevalence’ (p. 3). We often referred to the ‘NCI Standards’ for comprehensive tobacco control to justify and defend our social change 

If you have looked at our A Model for Change: The California Experience in Tobacco Control 

tobacco use as the key for reducing tobacco use among youth as well as adults. 

“The ‘categories of interventions for smoking prevention and control’ in the ASSIST planning model 

helped us justify the heavy emphasis the California program placed on policy development and implementation. Especially helpful to us was the section of the ‘NCI Standards’ titled ‘Smoking Prevention and Control Activities’ (pp. 17–33), which provided us with invaluable ideas on how to 

change the social acceptability of tobacco use. We were particularly influenced by the suggestion that 

achieving and expanding clean indoor air policies could reduce disease and encourage smoking cessation (pp. 21, 22). We focused our program on many of the policies listed on page 24 of this chapter. 

We benefited also from the caution that ‘public support for them [new policies] must be generated 

throughout the community’ to achieve successful policy implementation (p. 25). Our mantra was that 

change happens at the community level. 

“Overall, our program benefited tremendously from the ASSIST ‘Standards for Comprehensive Smoking Prevention and Control.’” 

—Jon Lloyd, Chief, Data Analysis and Evaluation Unit, 

Tobacco Control Section 

conceptualizing and building support for 

state-level funding. In short order, other 

government agencies, organizations, and 

foundations joined the effort. States that 

had not been selected to participate in 

ASSIST also insisted on federal support, 

leading to CDC’s 1993 launch of 

IMPACT. (For more details, see chapter 

9.) Working with coalitions in some 

states, RWJF provided funds for the 

American Medical Association to administer the SmokeLess States National 

Tobacco Policy Initiative. As additional 

agencies and organizations became more 

active, the tobacco control movement 

grew and there were mutual transfers of 

knowledge and information. NCI and 

CDC’s collaboration with Massachusetts 

and California to air their effective public service announcements and paid media advertisements led to the 

establishment of CDC’s Media Campaign Resource Center. 

Rudiments of ASSIST’s legacy are 

evident in the incorporation of core elements of the ASSIST model in a number 

of tobacco prevention and control initiatives that were launched during and following ASSIST. NCI was close to 

releasing its request for proposals when, 

in 1988, California passed a 25¢ tax increase on cigarettes known as Proposition 99. With 20% of the revenue from 

497 
11. T h e P r o m i s e o f A S S I S T 

ASSIST Coordinating Center from 1992 to 1994 and chief of the Program Services Branch at OSH of 

*Note that the third author was chief, Tobacco Control Section, California Department of Health Services, 

from 1990 to 1992 and was with the department for 2 years before that. He was then director of the 

CDC from 1994 to 2000 before becoming director of the Tobacco Technical Assistance Consortium. 

the tax increase dedicated to its tobacco 

prevention and control program, the major design work of the California program began.44 According to the chief of 

California’s program at that time (who is 

an author of this chapter*), NCI’s scientific underpinnings for ASSIST and the 

ASSIST model itself informed the design and strategic direction of California’s 

program and also provided the credibility needed to gain support of California’s 

decision makers. The outcomes from 

California’s program were dramatic: Between December 1989 and December 

1999, per capita cigarette consumption 

in California declined by 57%.37(pI-iv) 

These results demonstrated the effectiveness of a community-based approach to 

reducing tobacco use and provided the 

impetus for other states to adopt it.45 

Massachusetts successfully competed 

for ASSIST funding while implementing 

its own tobacco control program with a 

massive infusion of state funding from 

its 25¢ tobacco excise tax increase. Using those tax funds, of which $116 million were used through June 199646; 

ASSIST funding; and the intensive training programs and technical assistance 

received through ASSIST, Massachusetts built an exemplary tobacco prevention and control program that focused 

very successfully on strategic use of the 

media, one of ASSIST’s core elements. 

The severe budget reductions that the 

California and Massachusetts programs 

have experienced and the resulting loss 

of capacity in these two exemplary state 

programs and in other state programs 

have undermined years of steady progress in preventing tobacco use. Left unchecked, this erosion of funding and 

support for state-based tobacco prevention and control will reverse the important advances that have been made. 

The SmokeLess States National Tobacco Policy Initiative, supported by 

RWJF and administered by the American 

Medical Association, was implemented 

in 1994. Its primary emphasis was on 

policy change—another core element of 

ASSIST. Support from SmokeLess 

States grants provided funding for activities that complemented work that ASSIST, 

with its limited funding and government 

restrictions, could not perform. Many 

key SmokeLess States national staff, including the codirector, had played important roles in ASSIST or had expanded 

their skills at ASSIST trainings, information exchanges, and national conferences. 

In addition, many state project directors 

and state coalition leaders had benefited 

from these same ASSIST trainings and 

had used ASSIST concepts and strategies 

in advancing their own policy goals in 

their respective states. 

The national staff of the SmokeLess 

States Program provided considerable 

technical assistance and support to their 

grantees that was similar to that provided by ASSIST staff. Staff from the 

498 
M o n o g r a p h 1 6. A S S I S T 

SmokeLess States Program also participated in the annual National Conference 

on Tobacco or Health. SmokeLess States 

expanded its national staff to provide 

technical assistance targeted at specific 

resource gaps. For example, the SmokeLess States staff developed resource materials on clean indoor air, preemption, 

and taxation.47 They enhanced their national meetings by focusing on training 

sessions and skill building rather than 

merely sharing coalition strategies. 

These efforts frequently complemented 

and strengthened activities of the 

ASSIST staff. (For more details on the 

SmokeLess States Program, see chapter 

2 in To Improve Health and Health 

Care, vol. viii.)48 

The ASSIST program increased recognition of the importance of high-quality 

technical assistance. SmokeLess States 

and other programs became resources 

that ASSIST coalitions and staff could 

use. The Campaign for Tobacco-Free 

Kids (CTFK) was a valuable resource 

during ASSIST and continues to play a 

critical role in the tobacco control movement. Its state advocacy team gives state 

and local tobacco prevention and control 

coalitions strategic and technical assistance on policy issues, helps them build 

stronger grassroots efforts,49 and provides expert advice on media strategies. 

They also mobilize other CTFK resources, such as public opinion research; strategic communications, including media 

advocacy; and outreach to nontraditional 

partners. 

Another organization that has taken 

on a key technical assistance role is the 

American Legacy Foundation, which 

was established in 1999 to provide 

“grants, technical training and assistance, youth activism, strategic partnerships, counter-marketing and grass roots 

marketing campaigns, public relations, 

and community outreach.”50 

Many national organizations acknowledge the importance of high-quality, 

timely technical assistance, the need for 

coordination, and the need for diffusion 

outlets capable of getting knowledge, 

skills, and abilities to the field in the 

shortest time possible. Beginning in 

2001, ACS, the American Legacy Foundation, and RWJF pooled their resources 

to create the national Tobacco Technical 

Assistance Consortium. The consortium’s mission is to build capacity at the 

state and local levels by providing technical assistance to strengthen the effectiveness of tobacco prevention and 

control programs.51 The consortium has 

been critical in helping to prepare newly 

hired staff at all levels of government 

and has improved the effectiveness of tobacco prevention and control programs. 

This comingling of ideas and information that occurred in tobacco control 

that stimulated the development and expansion of ASSIST-like concepts and incorporated the ASSIST core elements 

also spread to other public health arenas. 

Examples of such adaptations follow. 

Beyond Tobacco Control 

Although ASSIST’s conceptual 

framework was not unique, its high visibility advanced the merits of the 

ASSIST cube that have been affirmed 

through its repeated application in other 

public health contexts. Figure 11.1 presents the ASSIST cube and adaptations 

499 
11. T h e P r o m i s e o f A S S I S T 

of the cube in four planning documents 

for heart health programs. The framework, along with core elements of the 

ASSIST program, can be seen in a number of non-tobacco-related public health 

initiatives, especially heart health, obesity, nutrition, and physical exercise. 

Heart Health 

With the success of ASSIST and state 

tobacco prevention and control efforts in 

California and Massachusetts, other 

public health programs looked to tobacco control for lessons learned and opportunities to achieve similar success. In the 

late 1990s, CDC launched its state-based 

cardiovascular health program. The 

CDC cardiovascular health program 

staff consulted with tobacco control staff 

for help in conceptualizing a framework 

for state-based programs that focus on 

an environmental and policy intervention model to change systemic factors 

within communities. The goals articulated for CDC’s state-based cardiovascular 

health program mirror those of ASSIST: 

To increase state capacity by planning, 

implementing, tracking and sustaining 

population-based interventions that address heart disease, stroke, and related 

risk factors. . . . Strategies should include 

policy and environmental approaches or 

education and awareness supportive of 

the need for policy, environmental, and 

systems changes to support cardiovascular health.52(p2) 

The core elements of the ASSIST 

model are also contained in the American 

Heart Association Guide for Improving 

Cardiovascular Health at the Community Level: “The Community Guide emphasizes the social and environmental 

In many ways, ASSIST was a leap of 

faith for tobacco control. Ten years after 

the state planning phase started, the evidence is clear that the leap was not too 

far off the mark. ASSIST states have 

shown that the model works for tobacco 

control, and other public health programs 

are now trying to emulate tobacco control’s success. 

—Pam Eidson, former Director of 

Health Promotion, Georgia Division 

of Public Health, and current 

Program Manager, Directors of 

Health Promotion & Education, an 

affiliate of the Association of State 

and Territorial Health Officials 

origins of the CVD epidemic.”53(p646) The 

Guide also reproduces an adaptation of 

the ASSIST cube and presents it as a 

“conceptual framework for public health 

practice in CVD prevention.”53(p647) Because tobacco use is a major risk factor 

for CVD, it is especially encouraging to 

observe the diffusion of effective ASSISTlike interventions to other CVD risk factors and to the conceptualization of statebased cardiovascular health programs. 

Nutrition, Physical Activity, and Obesity 

There are obvious parallels between 

overweight individuals and smokers. 

They both grapple with behavioral 

health issues that are reinforced by social influences, environmental factors, 

and advertising. Therefore, efforts have 

been made to learn from the recent successful efforts in tobacco control for 

possible applicability to the obesity 

problem.54 Just as passage and enforcement of clean indoor air laws affect tobacco use and the extent of health 

500 
M o n o g r a p h 1 6. A S S I S T 

The success of the California and Massachuheart health: 

focus of action in California, the recent 

rette smoking has doubled the rate of 

decline of smoking in the entire state 

community for cardiopulmonary health 

S7:S4–S7 (p. S6). 

Exploring Potential Adaptations 

for Heart Health 

setts state tobacco control programs motivated planners of public health initiatives in 

cardiovascular health to consider expanding 

the reach of their public health initiatives to 

“Illustrating the possibility of a larger 

public health campaign to reduce ciga­

(21). Massachusetts likewise has 

mounted a successful statewide campaign against smoking. These experiences suggest enlarging the concept of 

purposes to the state, or even to the national or global level.” 

Source: Breslow, L. 1997. Social origins of 

cardiopulmonary disease: The need for 

population-focused prevention studies. 

Annals of Epidemiology

consequences of secondhand smoke, 

laws or regulations pertaining to school 

lunch programs, vending machine placement in schools, and food labeling have 

important implications for weight control.54 Pricing is another tool that can be 

useful for both applications. Raising cigarette excise taxes reduces the affordability of cigarettes and thereby 

decreases consumption. Similarly, lowering the prices of fruits, vegetables, and 

low-fat snacks may raise consumption of 

healthy foods.54 

The relevance of lessons learned from 

tobacco control initiatives to the prevention of obesity has been noted by numerous researchers and public health 

experts. The goals of CDC’s 12-state 

obesity control program reflect the core 

elements of ASSIST; its goals are to 

prevent and control obesity and related 

chronic diseases by supporting states in 

their development and implementation of 

nutrition and physical activity interventions, particularly through populationbased strategies such as policy level 

change, environmental supports, and the 

social marketing planning process.54(p1078S) 

Mercer and colleagues also point to 

the recent experience in comprehensive 

tobacco control in California and other 

states as evidence of the efficacy of policy-based initiatives and as suggestive of 

promising approaches for obesity.54 

Eating and physical activity patterns 

are addressed in the scope of activities 

described for CDC’s Nutrition and Physical Activity Program, which includes 

“policy and environmental change, communication and social marketing, and 

partnership development.”55(p1) CDC’s 

most recent request for proposals for its 

state nutrition and physical activity programs to prevent obesity and other 

chronic disease instructs prospective 

grantees to use the ecological model to 

guide their program planning: 

(f) Use the social-ecological theoretical 

model to guide State planning to address 

obesity and other chronic diseases in 

these populations; select and implement 

interventions from the list of proven 

strategies . . . so that multiple levels of 

influence in the social-ecological model 

are addressed. Consider using a social 

marketing approach in this 

intervention.42(p15) 

A recent Washington Post article on 

obesity states that “policymakers nation501 
11. T h e P r o m i s e o f A S S I S T 

wide are pursuing legislative solutions 

modeled after the anti-smoking campaigns of the 1990s to attack what many 

in the medical community say is one of 

the gravest threats to the nation’s longterm health.”56 The article reports on 

state legislative efforts to require the 

posting of nutrition information in restaurants and restrictions on the sale of 

candy and soda in schools.56 Public 

health approaches to promoting nutrition 

and physical activity and to controlling 

obesity that incorporate the insights 

gained from the tobacco control experience are proliferating. 

Future Applications 

As more data become available that 

substantiate the efficacy of the ecological model in programs that promote 

heart health, obesity control, physical 

activity, and nutrition, other fields are 

likely to adopt elements of the ASSIST 

model and intervention methods to implement environmental and policy 

changes. A recent IOM report puts forth 

a strategy to reduce and prevent underage drinking that embodies a number of 

elements of ASSIST: limits on youth access to alcohol, community-based coalitions, strategic use of the media, and 

increases in excise taxes. The report recommends restricting glamorous presentations of drinking in movies and music 

that appeal to teenagers, imposing penalties on those who sell alcohol to minors, 

and increasing taxes on beer.57 A Washington Post article points out the link between these recommendations and 

recent antismoking interventions: 

The report marks an important shift in 

strategy that echoes recent antismoking 

efforts. If implemented, the recommendations would be the most dramatic crackdown in decades on alcohol makers, 

retailers and the entertainment media— 

and would put the campaign against underage drinking on the same footing as 

the war against teenage smoking.58 

Given its enormous health toll, the potential benefits of funding a policy-based 

intervention aimed at underage drinking 

are substantial. 

Advancing Evaluation 

Methodology 

Efforts to evaluate the ASSIST project 

brought to the forefront the methodological challenges of evaluating a largescale, community-based program that 

uses multiple interventions to effect systems-level change. The next NCI monograph in this series (Monograph 17) 

addresses in detail the evaluation efforts 

for the ASSIST program, from the development of the evaluation logic model 

and its basic assumptions and methodology, through implementation and results.59 The evaluation model developed 

for the ASSIST project represents an important step, not only for gaining valuable data on tobacco control program 

effectiveness, but also for informing the 

implementation of evidence-based public 

health efforts in general. By developing 

and validating a logic conceptual model 

that reflects the complexity inherent in 

tobacco control and developing measures that correlate with tobacco control 

outcomes, this evaluation effort serves as 

a model for public health interventions 

whose components are diffused throughout an entire population, making ran502 
M o n o g r a p h 1 6. A S S I S T 

Because of their complexity, tobacco 

control programs are very difficult to 

evaluate. We have found how hard it is to 

measure our success in the real world. 

—Marc W. Manley, former Chief, 

Tobacco Control Research Branch, 

NCI, and current Executive 

Director, Center for Tobacco 

Reduction and Health 

Improvement, Blue Cross and 

Blue Shield of Minnesota 

domized controlled trials infeasible or 

inappropriate. 

The ASSIST evaluation defined and 

validated indirect measures of performance and correlated these measures 

with public health outcomes. The following are some of the evaluation methods and measures that evolved from this 

effort: 

■	 The Strength of Tobacco Control 

(SoTC), an indirect measure of statelevel tobacco control efforts based on 

three constructs: resources, capacity, 

and efforts. 

■	 The Initial Outcomes Index (IOI), a 

measure of state tobacco control policy outcomes, which in turn could be 

correlated with subsequent population 

behavior and public health outcomes; 

and 

■	 The ASSIST Print Media Database, a 

demonstration project to quantitatively index newspaper coverage of policy 

issues central to the ASSIST project. 

With ASSIST, the field of evaluation 

advanced. The ASSIST evaluation represents an early step in developing techniques that researchers and policy 

makers need to determine which elements of community-based tobacco control programs are effective. 

The complexity of the ASSIST 

project, the challenges posed in evaluating this type of project, as well as limited evaluation resources necessitated that 

the evaluation focus only on those components of the project that could be 

quantified as part of the evaluation logic 

conceptual framework. While it was not 

possible to fully evaluate all aspects of 

the ASSIST project, this evaluation was 

the first such effort to systematically 

measure the effectiveness of state-level 

tobacco control efforts across all states 

and to assess benefits associated with 

the investment in building infrastructure 

and focusing on policy change. 

The IOM National Research Council 

report Taking Action to Reduce Tobacco 

Use points to the need for adequate 

funding and commitment and also highlights the importance of improved evaluation of tobacco prevention and control 

programs: 

The ASSIST program has shown that a 

more intense intervention produces results, but it does not clearly show which 

elements are most powerful. . . . An expanded commitment to tobacco control 

increases the importance of knowing 

which interventions matter most, requiring demonstrations at sufficient dose and 

duration to enable credible 

evaluation.3(p11) 

In 1999, NCI released a request for 

applications for research in state and 

community tobacco control interventions: 

The scientific evidence supporting some 

of these policies is quite strong; for others it is more limited. Decision-makers 

503 
11. T h e P r o m i s e o f A S S I S T 

frequently must make decisions about the 

details of these policies in the absence of 

strong research.60(p3) 

The ASSIST evaluation highlights the 

need for ongoing, systematic, and coordinated evaluation efforts to be continued. 

New surveillance and methodological 

strategies are still needed to identify the 

environmental factors, such as those 

identified in the ASSIST evaluation, that 

influence tobacco use. These new tobacco 

control evaluation strategies can provide 

much-needed information about programs at the national, state, and local 

levels. 

Future Interventions and 

Research Initiatives 

The ASSIST experience provided insights for planning research initiatives. 

Since the completion of ASSIST and the 

initiation of CDC’s National Tobacco 

Control Program, NCI has sponsored initiatives to address research questions 

that will advance the ecological approach to tobacco prevention and control. NCI established the Tobacco 

Research Implementation Group, which 

brought together 24 leading scientists 

and experts to identify research priorities related to tobacco control. Some of 

those priorities are based on research 

needs gleaned from ASSIST. For example, the group identified the need to refine the media advocacy approach—to 

learn more about “how to tailor messages and materials appropriately for different populations.”61(p2) They also are 

focusing on the need for more research 

on the impact of a range of public poliIt is our hope and intention that the National Cancer Institute, in partnership 

with our many public and private partners, will help to achieve nothing less 

than the complete elimination of tobaccorelated disease. Achieving this lofty goal 

will require that we make strategic decisions to support research that will serve 

as a solid foundation for policy development, will be effectively used by those in 

clinics and communities who are in the 

trenches and working to improve the 

world one person or community at a 

time, and will ensure that our understanding of tobacco use and its health outcomes is peerless. We recognize the 

global threat of tobacco and tobacco-related cancers, and working to provide a 

solid tobacco control evidence base will 

therefore benefit not just those in the 

United States but also children and families around the world—particularly in 

countries with few resources dedicated to 

research. We accept these goals as our 

challenge today, and we remain committed to a comprehensive tobacco control 

research program that will ensure public 

health benefits tomorrow and beyond. 

—Scott J. Leischow, Senior Advisor for 

Tobacco Policy, Office of the Secretary, 

U.S. Department of Health and Human

Services, and previously Chief, Tobacco 

Control Research Branch, and former 

Acting Associate Director, Behavioral 

Research Program, NCI 

cies on tobacco use—for understanding 

“the full impact on tobacco use of clean 

indoor air policies, marketing restrictions, 

and youth access restrictions.”61(p5),62 

NCI is supporting targeted research 

studies that are encouraging partnerships 

between scientists, state tobacco control 

504 
M o n o g r a p h 1 6. A S S I S T 

programs, and tobacco control advocates.60,63 Through a major initiative 

called the Tobacco Research Initiative 

for State and Community Interventions 

(TRISCI), NCI has funded 19 grants that 

will result in a total expenditure exceeding $75 million.64,65 The purpose of the 

TRISCI initiative is to stimulate research 

on new or existing tobacco control interventions relevant to state and community tobacco prevention and control 

programs. This goal will be achieved 

through support of research on innovative tobacco prevention and control interventions at the community, state, or 

multistate level, particularly policy or 

media-based interventions, and by fostering collaboration among tobacco control 

researchers, state-based comprehensive 

tobacco control programs, and community-based coalitions. The results of this 

research will guide and inform existing 

and future tobacco prevention and control programs. 

Onward from ASSIST 

As the field of public health evolves, milestones are achieved through the 

application of a continuing accumulation 

of knowledge until a critical understanding is reached. ASSIST was such a milestone. 

This monograph describes ASSIST’s 

many contributions: the building of effective partnerships; the networks, communications, and other mechanisms 

used to establish community structures 

for participatory decision making and 

collaborative work; the effective application of ecological theory; the strategic 

use of media advocacy to frame policy 

development; an increased understanding of the importance of funding and of 

the critical components of effective programs; and insight into the advancing 

evaluation methodologies for community-based programs with multiple interventions. 

This chapter highlights different ways 

in which ASSIST’s impact can still be 

felt. Through the local infrastructures 

built during ASSIST, networks of public 

health specialists and community advocates with media and policy advocacy 

skills have taken what was learned during ASSIST and are now applying that 

knowledge to other public health initiatives. The tobacco industry viewed these 

local infrastructures as significant threats. 

Policy initiatives that were the focus 

of ASSIST continue to play out at the 

state and local levels. Smoke-free environments in public places are now the 

norm though important progress is still 

required. Excise taxes are universally 

recognized as effective in reducing tobacco use, and states continue to raise 

taxes on tobacco products. Increased understanding of the power of preemption 

bills has given advocates the tools to 

prevent and in some cases reverse this 

particular tobacco industry tactic. 

Key to these accomplishments and 

advances in understanding regarding 

what constitutes an effective tobacco 

prevention and control program was the 

cross-fertilization that occurred between 

ASSIST and other related efforts. Just as 

ASSIST raised awareness of the critical 

importance of a highly trained workforce, others took on this role and 

505 
11. T h e P r o m i s e o f A S S I S T 

informed subsequent ASSIST trainings. 

Similarly, ASSIST’s media advocacy activities inspired others to use similar tactics and to develop resources that were 

then made available to ASSIST and others. 

Researchers and practitioners now 

have a better understanding of the critical components and processes required 

to implement effective communitybased tobacco prevention and control 

programs as well as other health behavior 

change initiatives. Seasoned staff in the 

field continue to apply the insights 

gained during ASSIST. Ultimately, 

ASSIST’s legacy lies in its continuing 

impact on public health: healthier communities through reduced exposure to 

secondhand smoke; lower tobacco prevalence and consumption; reduced death 

and disease from tobacco use; stronger 

community coalitions; and continuing 

collaboration among researchers, state 

health department program staff, and tobacco control advocates. 

506 
M o n o g r a p h 1 6. A S S I S T 

Appendix 11.A. Tobacco Control Professionals 

Who Shared Their Insights regarding ASSIST 

The authors would like to thank the following individuals: 

Robert H. Anderson Jon Lloyd 

John K. Beasley William R. Lynn 

Erwin P. Bettinghaus Sally Herndon Malek 

Michele Bloch Marc W. Manley 

Helene G. Brown Victor Medrano 

Gregory N. Connolly Rebecca Murphy-Hoefer 

Pam Eidson Anne Marie O’Keefe 

Joy Epstein Michael Pertschuk 

John M. Garcia Jane Pritzl 

Donna Grande Patrick Remington 

David Harrelson Nancy Salas 

Jerie Jordan Ron Todd 

Thomas J. Kean Carol Hall-Walker 

Scott J. Leischow Walter ‘Snip’Young 

507 
11. T h e P r o m i s e o f A S S I S T 

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http://2001.cancer.gov/tobacco.htm. 

62. Tobacco Research Implementation 

Group. 1998. Tobacco research implementation plan: Priorities for tobacco 

research beyond the year 2000. Bethesda, MD: National Cancer Institute. http:/ 

/cancercontrol.cancer.gov/tcrb/TRIP. 

511 
11. T h e P r o m i s e o f A S S I S T 

63. National Cancer Institute. 2000. 

Research in state and community 

tobacco control interventions. October 

19, 2000. RFA: CA-01-017. http:// 

grants.nih.gov/grants/guide/rfa-files/ 

RFA-CA-01-017.html. 

64. National Cancer Institute. 2000. 

Tobacco control research. State and 

community research and evaluation. 

Bethesda, MD: National Cancer 

Institute. http://cancercontrol.cancer 

.gov/tcrb/scrfa.html. 

65. Vollinger, R. 2002. NCI’s state & 

community tobacco control 

interventions research. Presentation to 

the annual meeting of the American 

Public Health Association, Philadelphia, 

November 12, 2002. 

512

M o n o g r a p h 1 6. A S S I S T 

Index 

A 

Achievements in Tobacco Cessation: Case Studies 

(Web site), 308


ACS. See American Cancer Society (ACS)


Adami, Kenneth, 202


policy interventions, 167


Advertising Age, 179


advertising from tobacco industry, 121–2


billboards, 143, 144 (See also billboards)


exposing tactics of, 199–200


Operation Storefront, 210–2


point-of-purchase displays, 268–9, 276


policies for limiting, 170, 179–82, 195–6


store owners, educating, 218


Tobacco Advertising and Promotion: A Guide 

to Developing Policy, 253–77 (See also Tobacco Advertising and Promotion: A Guide 

to Developing Policy) 

“Advice to NCI About Their Future Role in Tobacco Control,” 395–6


Advocacy Institute, 65, 462, 463


Advocacy Opportunities Advance Group report,


438–40. See also Realizing America’s Vision 

for Healthy People: Advancing a Federal Commitment to Effective Tobacco Control 

African Americans, 141. See also minority com­


munities


advertising targeted toward, 258, 259


clergy helping to ban tobacco advertising in St.


Louis, MO, 195


Agency for Healthcare Research and Quality, 446


age requirements for tobacco purchasing, 228–9


AHA. See American Heart Association (AHA)


AIR (American Institutes for Research), 54n


Akeley, Stephen, 303


ALA. See American Lung Association (ALA)


Albuquerque, Melissa, 294


program services for interventions, 283


Albuquerque, NM, 84


Alcohol, Drug Abuse, and Mental Health Admin­


istration Reorganization Act (1992), 402


Allen, Carol, 341


Alley, Kelly, 389


strategic planning, 385


American Cancer Society (ACS)


baseball ticket promotion in Denver, CO, 358


CancerScam: The Diversion of Federal Cancer


Funds to Politics (Bennett and DiLorenzo)


criticizing, 346


Coalition on Smoking OR Health, 13


continuing role in ASSIST, 404


contributions to ASSIST, 449


funding affecting durability of tobacco preven­


tion programs, 412


Great American Smokeout (GASO), 140


lobbying rights of, 354


media advocacy workshop, 130


meeting with American Heart Association and


American Lung Association, 14


Missouri, youth appeal to policymakers in,


190–1


National Cancer Institute (NCI) partnership,


43, 68–72, 390


as partner with ASSIST, 11–2


as part of Training and Technical Assistance


Advance Group (TAT), 432


policy advocacy, 52, 170, 194


program services, providing, 289


program services offered in Wisconsin, 292


public health tobacco control project, 480


Shalala, Donna, meeting with, 405


SmokeLess States National Tobacco Policy Ini­


tiative, 398


state health agencies, cooperation with, 482


state health agencies, request for proposals


from, 35–6


in structure of ASSIST, 47–8, 49


Tobacco Technical Assistance Consortium, 499


in transition team, 454


Winston cigarette campaign refuted, 139


American College of Obstetricians and Gynecolo­


gists, 298


American Constitutional Law Foundation, 356,


358


American Heart Association (AHA)


American Cancer Society (ACS) meeting with,


14


cessation of smoking, support for, 290


Coalition on Smoking OR Health, 13, 47


conference sponsorship on tobacco control by,


451


as key organization in selected states, 51


program services in South Carolina and Wis­


consin, 292


SmokeLess States National Tobacco Policy Ini­


tiative, 398


Winston cigarette campaign refuted, 139


513 
I n d e x 

American Heart Association Guide for Improving Cardiovascular Health at the Community 

Level, 500 

American Institutes for Research (AIR), 54n 

American Journal of Preventive Medicine, 447 

American Legacy Foundation, 499 

American Lung Association (ALA) 

cessation of smoking, support for, 290 

Coalition on Smoking OR Health, 13, 47 

conference sponsorship on tobacco control by, 

451 

as key organization in selected states, 51 

meeting with American Cancer Society (ACS), 

14 

New York countering tobacco industry arguments on economy, 208–9 

Non-Dependence Day, 140 

program services in South Carolina and Wisconsin, 292 

SmokeLess States National Tobacco Policy Initiative, 398 

Winston cigarette campaign refuted, 139 

American Medical Association, 53, 451 

American Public Health Association, 53 

Americans for Nonsmokers’ Rights (ANR), 35 

American Smokers’ Alliance, 351 

American Stop Smoking Intervention Study for 

Cancer Prevention (ASSIST), 3. See also 

ASSIST 

American Wholesale Marketers Association, 335 

Anderson, Robert H., 483, 507 

national, state, and local coalitions, 77 

Annual Action Plans, 91–2, 106–7, 109–10 

ANR (Americans for Nonsmokers’ Rights), 35 

antitobacco campaigns, 142, 145–9 

Campaign for Tobacco-Free Kids (CTFK), 498 

(See also Campaign for Tobacco-Free Kids 

(CTFK)) 

counterpromotions, 271–4 

Doctors Ought to Care (DOC) campaign countering Philip Morris’s Bill of Rights tour, 

276–7 

at family events, 200 

Get Outraged campaign, 148 

“Let’s Making Smoking History” campaign, 

147–9 

mandatory counteradvertising, 270–1 

paid media campaigns, 269–70 

public service announcements (PSAs), 271 

radio campaign in Rhode Island, 149, 150 

“Think. Don’t Smoke” campaign, 132–3, 185–6 

“Through With Chew” campaign, 299 

Arnold Communications, 147 

ASA News, 351 

Ashton, Sister Mary Madonna, 56 

Asian Pacific Partners for Empowerment and 

Leadership, 451 

Asians, 259, 300. See also minority communities 

ASSIST 

accomplishments, summary of, 505–6


bibliography for, 155–63


Colorado, tobacco industry opposition in,


355–60 

committees, 55–64 (See also committees of 

ASSIST) 

Community Intervention Trial for Smoking 

Cessation (COMMIT) compared with, 10 

conceptual framework cube, 485f 

conceptual framework for, 19–39 (See also 

conceptual framework for ASSIST) 

conference materials for 1999, 172 

Freedom of Information Act (FOIA), responding to requests, 350–2 

goals for, 388, 446f 

Initiatives to Mobilize for the Prevention and 

Control of Tobacco Use (IMPACT) compared with, 447, 448t 

interventions, 477–510 (See also interventions, 

potential of) 

legacies of, 479–81 

lobbying regulations, understanding, 352–4 

Maine, tobacco industry opposition in, 367–9 

Minnesota, tobacco industry opposition in, 

362–7 

name of, 3 

newspaper clippings database, 35 

New York, tobacco industry opposition in, 

369–71 

policies, focus on, 371–2 

Print Media Database, 503 

response to opposition from tobacco industry, 

350–72 (See also tobacco industry) 

transition from demonstration project to nationwide program, 443–76 (See also transition to 

nationwide program) 

in transition team, 454 

Washington State, tobacco industry opposition 

in, 361–2 

ASSIST: A Guide to Working with the Media, 52, 

130 

ASSIST Coordinating Center, 54–5 

consultant hired by, 95 

514 
M o n o g r a p h 1 6. A S S I S T 

as essential to ASSIST’s success, 494–5 

Freedom of Information Act (FOIA), responding to requests, 351


media advocacy training, 131


newspaper clippings database, 149, 151, 503


resolution for national tobacco control pro­


gram, 408


site trainers network, 98–9


staff, 87


strategic communications, 66


“swiss cheese” press releases, 135


technical assistance from, 93–4, 97, 390


workshop on policy advocacy limitations, 337


ASSIST Coordinating Committee, 44, 55–8 

ASSIST Media Network, 132–3 

Association of State and Territorial Health Officials (ASTHO), 399


conference sponsorship on tobacco control by,


451


meeting with Donna Shalala, 404, 405


Office on Smoking and Health (OSH), working


with, 456


policy developments affecting durability of to­


bacco prevention programs, 412


policy statement from, 402


Tobacco Control Network of State Health


Agency Program Managers for Tobacco Pre­


vention and Control formed by, 401


in transition team, 454


ASTHO. See Association of State and Territorial


Health Officials (ASTHO)


athletic facilities, 265–6. See also recreational fa­


cilities


Australian North Coast Health Lifestyle Program, 9


B

Babb, Stephen 

Las Cruces Clean Indoor Air Ordinance, NM, 

197, 223


Mesilia, NM, smoke-free restaurant policy, 219


policy interventions, 167


tobacco control coalition formed in Silver City,


NM, by teenagers, 207


bars, policies restricting smoking in, 245–6. See


also restaurants


baseball


ban on smoking in stadiums in Virginia, 192–3


Pedro Martinez television spot, 148–9


park in Charleston, WV, 143


Bates, Brian, 364


Bates numbers, 312, 313


Beasley, John K., 507


cochair of Funding Advance Group, 423n2


program services for interventions, 283


smoking cessation hotline in Michigan, 296


structure and communications, 41


Bennett, James T., 346


Bero, Lisa


challenges from tobacco industry, 309


Best Practices for Comprehensive Tobacco Control Programs, 459, 461, 463–4


Bettinghaus, Erwin, 56, 480, 507


Bible, Geoffrey C., 348, 369, 370


bibliography for ASSIST, 155–63. See also re­


sources for ASSIST 

billboards. See also advertising from tobacco industry 

removal of tobacco advertising from baseball 

park in Charleston, WV, 143


restrictions on, 144, 263–4


Tobacco Master Settlement Agreement, 143


voluntary restrictions on tobacco advertising,


275


bingo parlors, 250


Blank, M. J., 80


Bloch, Michele, 507


Bloomfield, William E., 277


Boblitt, Wendy, 432n1


Bonilla, Henry, 330, 331–2, 339


Borbely, Deborah, 432n1


strategic planning, 385


Boston Red Sox, 148


Bourne, David, 423n2


bowling centers, 250–1


Bracht, Neil


strategic planning, 385


Brandeis, Louis, 198


Breslow, L., 501


Briant, Thomas, 322–3, 326


Freedom of Information Act (FOIA) (1966) requests hampering ASSIST program, 372


on membership in ASSIST, 343


memo to tobacco industry representatives, 364–5


Minnesota political environment, 336


representing tobacco industry in Minnesota, 363


Bridger, Chuck, 432n1 

Brown, Helene G., 56, 482


as contributor to ASSIST project, 507


on inclusion of different points of view, 495


testimony before National Cancer Policy


Board, 418–20 

515 
C 

I n d e x 

Bruno, Joseph, 370 

Bryant, G. Lea, 303 

program services for interventions, 283 

businesses as allies to tobacco industry, 333–6, 343 

CA-A Cancer Journal for Clinicians, 6 

Caldwell, M., 405 

Califano, Joseph, Jr., 492–3 

California 

Alternative Sponsorship Program, 272 

antismoking infrastructure in, 482 

countertobacco media campaigns, 146–7, 270 

funding for tobacco prevention programs, 492 

Health Effects of Exposure to Environmental 

Tobacco Smoke: Final Report and Appendices (Environmental Protection Agency of 

CA), 171 

Kurt Malmgren on ASSIST program in, 318 

Marlboro brand sponsoring State Fair in, 277 

reducing social acceptability of tobacco use, 

497 

selection for ASSIST program, 31–2 

smoke-free worksites, study on, 172 

tax increase on cigarettes, 497 

tobacco control as public health initiative, 496–8 

Tobacco Control Program, 97–8 

Camel cigarettes 

“Joe Camel” character, 179, 258, 266–7 

Campaign for Tobacco-Free Kids (CTFK), 498 

banner from, 394 

map of state cigarette tax rates, 489 

National Center for Tobacco-Free Kids evolving from, 395 

cancer control, 3 

environmental tobacco smoke (ETS), 171–2, 

238 (See also environmental tobacco smoke 

(ETS)) 

five phases of, 6–7


mortality rates in decline in U.S., 419


studies linking smoking to cancer, 4–5


The Cancer Letter (newsletter), 58 

CancerScam: The Diversion of Federal Cancer 

Funds to Politics (Bennett and DiLorenzo), 346 

Capwell, Ellen, 435n2, 438n2 

carcinogens, 171–2, 238. See also cancer control 

cardiovascular health/disease, 485f, 500 

Carlson, Arne, 340, 364 

Carter, Peggy, 363–4 

case studies, 100 

achievements in tobacco cessation (Web site), 

308 

Colorado, clean air ordinance passed in Denver, 

301–2 

Colorado, opposition to ASSIST from tobacco 

industry in, 355–60 

Colorado tobacco-free schools law, 297 

Indiana’s battle against preemption of local ordinances, 217 

Maine, opposition to ASSIST from tobacco industry in, 367–9 

Massachusetts, Mother’s Stress Management 

Task Force in, 295 

Massachusetts, regional networks in, 85 

Massachusetts increasing tobacco tax to fund 

healthcare for children, 201–2 

Michigan, smoking cessation hotline in, 296 

Michigan sports arena made smoke-free by 

youth advocates in Grand Rapids, 204–6 

Minnesota, opposition to ASSIST from tobacco 

industry in, 362–7 

Minnesota’s transition from state to national 

program, 465–7 

Missouri, youth appeal to policymakers in, 

190–1 

Missouri clergy helping to ban tobacco advertising in St. Louis, 195–6 

New Mexico, Albuquerque program, 84 

New Mexico, Las Cruces Clean Indoor Air Ordinance, 197, 222–3 

New Mexico, smoke-free restaurant policy in 

Mesilia, 219 

New Mexico, tobacco control coalition formed 

by teenagers in Silver City, 206–7 

New York, countering tobacco industry arguments on economy, 208–9 

New York, opposition to ASSIST from tobacco 

industry in, 369–71 

North Carolina, evaluation of coalitions in, 86 

North Carolina, tobacco prevention program in 

schools, 293–4 

North Carolina advocacy for tobacco-free 

schools, 215–6 

North Carolina reducing youth access to tobacco products, 209–10, 304–5 

Operation Storefront, 210–2 

South Carolina bans smoking in State House, 

214–5 

Virginia baseball stadiums, ban on smoking in, 

192–3 

Virginia Tobacco Settlement Foundation, 467–8 

516 
M o n o g r a p h 1 6. A S S I S T 

Washington State, opposition to ASSIST from


tobacco industry in, 361–2


Washington State’s smoke-free policy on state


ferries, 220–1


CDC. See Centers for Disease Control and Pre­


vention (CDC)


Census Bureau, Current Population Survey (CPS),


34


Centers for Disease Control and Prevention


(CDC), 60


Best Practices for Comprehensive Tobacco 

Control Programs published by, 463


coalitions with states, 89


conceptual framework of ASSIST used to pro­


mote cardiovascular health, 499–500 

conference sponsorship on tobacco control by, 

451


continuing role with ASSIST, 404–5, 409–10


funding affecting durability of tobacco preven­


tion programs, 412


funding for state tobacco prevention programs,


492


Health Consequences of Involuntary Smoking:


A Report of the Surgeon General, 171


Initiatives to Mobilize for the Prevention and


Control of Tobacco Use (IMPACT), 21, 497


(See also Initiatives to Mobilize for the Pre­


vention and Control of Tobacco Use (IM­


PACT))


National Cancer Institute (NCI), mission shared


with, 447


National Tobacco Control Program (NTCP),


445, 484 (See also National Tobacco Control


Program (NTCP))


Nutrition and Physical Activity Program, 501


strategic planning with ASSIST, 387


tobacco control programs, support for, 393


transition, responsibilities during, 450–1, 454


cessation of smoking, support for, 290, 294, 296.


See also program services for individuals


Charleston, WV, 143


The Charlotte Observer (newspaper), 126


Philip Morris’s antismoking campaign, 132–3 

underage tobacco usage, 136–7


chewing tobacco, 136, 299


Chiglo, Binh, 363–4


Chilcote, Samuel, 319, 326, 328


child care centers, policies restricting smoking in,


247


children. See also teenagers


brand identification of tobacco products, 179


child care centers, policies restricting smoking 

in, 247


environmental tobacco smoke, effect on, 237


healthcare for, funded by cigarette tax, 201–2


impact of advertising on, 257–8


chronic diseases, 486


cigarettes


advertising for, 179–82 (See also advertising


from tobacco industry)


California tax increase, 497


Camel cigarettes, 179, 258, 266–7


consumption data, 34


Marlboro brand, 272, 277


Massachusetts tax increase, 498


single sales, 233


smoking linked to lung cancer, 4–5


taxes for, by state, 177–8t, 489f, 490t


taxes on influencing smoking behavior, 27


Uptown brand, 258


Winston brand campaign, 138–9


Citizens Against Government Waste, 334


Citizens Against Tax Abuse and Government


Waste, 356, 358


Clean Indoor Air: A Guide to Developing Policy, 

235–52


air quality, 239


child care centers, policies restricting smoking


in, 247


enforcement issues, 251–2


environmental tobacco smoke (ETS), 237–8


(See also environmental tobacco smoke 

(ETS))


federal policies, 240


health care settings, restrictions on smoking in,


247


local policies, 241


locations covered by policies, 242


policy options, 239–40, 242–51


prisons, restrictions on smoking in, 248–9


public spaces, restrictions on smoking in,


244–5


public support for, 242


public transportation, restrictions on smoking


on, 248


recreational facilities, restrictions on smoking


in, 249–51


restaurants, restrictions on smoking in, 245–6


(See also restaurants)


schools, policies restricting smoking in, 246


state policies, 240–1


voluntary policies, 240


517 
I n d e x 

Clean Indoor Air: A Guide to Developing Policy 

(continued) 

workplaces, 243–4 (See also worksites) 

clean indoor air laws/policies, 171, 175t, 491. See 

also environmental tobacco smoke (ETS) 

clergy against tobacco advertising in St. Louis, 

MO, 195–6 

Clinton, William J., 408 

Cloud, Stuart, 346 

CNN (news network), 139 

coalition-based community interventions, 4. See 

also communities/community interventions 

as backbone of ASSIST, 52 

coalition building, 77–118 (See also coalition 

building)


evaluation of at state level, 33–4


state and local levels, 23–4


coalition building, 77–118, 194–6 

challenges in, 81–3 

guidelines for, 80 

implementation, transitioning to, 96–8 

media, 124, 125–6 

Minnesota, Tobacco Control Plan, 103, 108–10 

national tobacco prevention program, toward, 

400–3 

number of state and local coalitions, 83t 

Rhode Island membership in ASSIST state coalition, 101–2 

site trainers network, 98–9 

SmokeLess States National Tobacco Policy Initiative, 398 (See also SmokeLess States National Tobacco Policy Initiative) 

stages for development, 79–80 

states’ roles in, 83–90 

strategic planning for, 90–3 

training for, 93–5, 113–7 

Washington State, Project Management Plan 

from ASSIST, 111–2 

Wisconsin, Smoking Control Plan, 104–5, 

106–7 

Coalition for a Tobacco-Free Colorado (CTFC), 

355, 357–8 

Coalition for a Tobacco-Free West Virginia newsletter, 51 

Coalition for Responsible Retailers, 366 

Coalition on Smoking OR Health, 13, 47, 48 

Cobb, Patrick, 215 

policy interventions, 167 

Collin, J., 384 

Colorado 

clean air ordinance passed in Denver, 301–2 

coalitions, experience of, 89 

infiltration of ASSIST program by tobacco allies, 343 

Kick Butts Day, 141 

local organizational structures, 50 

number of state and local coalitions, 83t 

opposition to ASSIST from tobacco industry in, 

354, 355–60 

prevention education activities in Denver, 

299–300 

report from tobacco industry on ASSIST in, 

325–6 

tobacco cessation programs for teenagers in, 

294 

tobacco-free schools law, 297, 303 

tobacco-free schools material, 288 

Tobacco Institute’s legal action in, 337 

tobacco use prevention program booklet, 287 

Colt, Sandra 

program services for interventions, 283 

committees of ASSIST, 55–64 

ASSIST Coordinating Committee, 44, 55–8 

Multicultural Subcommittee, 59–62 

Project Managers Subcommittee, 63–4 

Research and Publications Subcommittee, 62–3 

Strategic Planning Subcommittee, 58–9 

Technical Assistance and Training Subcommittee, 62 

communication with ASSIST, 64–7 

electronic communications system (ECS), 65 

media activities, 119–66 (See also media activities)


strategic communication, 65–7


Washington State’s program, 112


communities/community interventions. See also 

interventions 

assessment of needs and assets, 26 

coalition-based as backbone of ASSIST, 52 

coalition building, 77–118 (See also coalition 

building) 

community groups as part of network, 29t, 

30–1 

environment, 25, 28–9 

evaluation of coalition-based model, 33–4 

interventions focusing on, 3–4, 23–4 

local health departments, 50–1 

local policy changes in, 213, 216 

policy changes at local community level, 213 

rationale for commitment to, 10–11 

scientific basis for interventions based on, 7–10 

social movements engaging, 198 

518 
M o n o g r a p h 1 6. A S S I S T 

surveys of tobacco advertisements, 274


Communities for tobacco-free kids: Drawing the 

line (Harris and Herrera), 84


Community Environment Channel, 343–5


Community Guide to Preventive Services, 27


Community Intervention Trial for Smoking Ces­


sation (COMMIT), 4


ASSIST compared with, 10


public opinion on tobacco advertising, 260


relationship to ASSIST, 71


Comprehensive Tobacco Control Plans, 91–2,


104–5, 108


conceptual framework for ASSIST, 19–39 

channels for tobacco prevention, 25–6 

the cube model, 25f 

evaluation of program, 31–5, 33f 

interventions, 26–8 

priority populations, 24–5 

program objectives, 28–31, 29t 

public health model utilization, 21–4 

selection of states, 35–7 

Congress, 328–33


Congressional PIG Book, 334


Connolly, Gregory N., 507


Cook, Lynn C., 144


media interventions, 119


program services for interventions, 283


cotinine, 238


counteradvertising, 269–71. See also antitobacco


campaigns


counterpromotions, 271–4


CPS (Current Population Survey), 34, 72


Crawford, Victor, 216


Croyle, Robert T., viii–xii


CTFC (Coalition for a Tobacco-Free Colorado),


355, 357–8


CTFK. See Campaign for Tobacco-Free Kids


(CTFK)


Cullen, Joseph W., 5


Division of Cancer Prevention and Control


(DCPC), approval of program, 12, 13


five phases of cancer control model, 7f


on partnering with American Cancer Society, 11


on research and interventions, 6


Curbing the epidemic: Governments and the eco­


nomics of tobacco control, 174


Current Population Survey (CPS), 34, 72


D 

Darrity, William, 14


data sources for evaluation of ASSIST program, 

32–3 

Davenport-Cook, Glenna 

program services for interventions, 283


“death clock,” 277


DeBuono, Barbara, 370


decision making, participatory encouraged, 494–5


Delaware, preemption of tobacco restrictions in,


186


Dennaker, Germaine, 151


media interventions, 119


De Noble, Victor, 126, 148


Department of Health and Human Services. See


Health and Human Services Department 

(DHHS)


Diaz, I., 127, 131


Dillenberg, J., 404


DiLorenzo, Thomas J., 346


dissemination, 447


Division of Cancer Prevention and Control


(DCPC)


approval of ASSIST program, 12–4


design and implementation of ASSIST, 45–6


five phases of cancer control, 6–7


Peter Greenwald as head of, 5


Doctors Ought to Care (DOC), 273


campaign countering Philip Morris’s Bill of


Rights tour, 276–7


Robert Jaffe’s involvement with, 326


sponsorship of U.S. Boomerang Team, 272


Donoho, Patrick, 326


Dorfman, L., 127, 131


Doyle & Nelson law firm, 341


Dunsby, Josh, 309


durability of tobacco prevention, 411


Dutcher, Judy, 364


Dylan, Bob, 191


E

ecological theory for systems, 484


Edison, Thomas A., 212


education on tobacco issues, 289. See also training


information dissemination, 145, 434


as part of program services, 299–300


Training and Technical Assistance Advance


Group, recommendations on information dis­


semination, 434


transition to nationwide program, disseminat­


ing information about, 445–6


519 
I n d e x 

Eidson, Pam, 423n2, 500, 507 

electronic communications system (ECS), 65, 112 

e-mail, 65 

Entering a new dimension: A national conference 

on tobacco and health case studies, 206, 217 

Environmental Protection Agency (EPA), 135 

conference sponsorship on tobacco control by, 

451 

recommendation to ban environmental tobacco 

smoke (ETS), 239 

Respiratory Health Effects of Passive Smoking: 

Lung Cancer and Other Disorders, 171, 185, 

186 

environmental tobacco smoke (ETS), 4, 92 

clean air ordinance passed in Denver, CO, 301–2 

Clean Indoor Air: A Guide to Developing Policy, 235–52 (See also Clean Indoor Air: A 

Guide to Developing Policy) 

clean indoor air ordinances enacted, 170 

health effects of, 237–8 

Las Cruces Clean Indoor Air Ordinance, 197, 

222–3 

Mesilia, NM, smoke-free restaurant policy, 219 

policies for the elimination of, 171–4 

Respiratory Health Effects of Passive Smoking 

(Environmental Protection Agency), 135 

South Carolina bans smoking in State House, 

214–5 

tobacco control coalition formed in Silver City, 

NM, by teenagers, 206–7 

Washington State’s smoke-free policy on state 

ferries, 220–1 

Wisconsin’s Comprehensive Smoking Control 

Plan, objectives for worksites in, 104–5, 107 

Environmental Tobacco Smoke (National Academy of Sciences), 4 

environments, social and physical 

in community, 25, 28–9 

pilot study of three state coalitions, 87–8 

in public health model, 22f 

Epstein, Joy, 507 

strategic planning, 385 

Ernster, V. L., 9 

ethnic populations. See minority communities 

evaluation of ASSIST program 

committee for, 46


data sources for, 32–3


methodology, 502–4


model for, 33f


North Carolina, coalitions in, 86


plan for, 31–5


Research and Publications Subcommittee’s role 

in, 63 

team for in transition to nationwide program, 

458–9 

training programs, 96, 98 

excise taxes, 488, 490t. See also taxes 

Eyre, Harmon J., 12, 13 

F

Fairness Doctrine, 146, 270 

Fair Share for Health Committee (FSHC), 358 

faith leaders against tobacco advertising in 

St. Louis, MO, 195–6 

FAR (Federal Acquisition Regulations), 337–8 

farming, tobacco, 467–8 

FASA. See Federal Acquisition Streamlining Act 

(FASA) 

FASS/T (Females Against Secondhand Smoke 

and Tobacco), 303 

FCC (Federal Communications Commission), 

146, 270 

FDA. See Food and Drug Administration (FDA) 

Federal Acquisition Regulations (FAR), 337–8 

Federal Acquisition Streamlining Act (FASA), 

132, 337, 340–1 

enacted during the course of the ASSIST program, 352, 353


lobbying restrictions in, 439


Preston, MN, case, 364


Federal Cigarette Labeling and Advertising Act 

(1965), 198, 233 

Federal Communications Commission (FCC), 

146, 270 

federal government. See also National Cancer Institute (NCI) 

funding from, 391 

goal of commitment for tobacco-control program, 391–2 

nationwide tobacco control program, 443–76 

(See also transition to nationwide program) 

Federal Trade Commission (FTC), 139 

Females Against Secondhand Smoke and Tobacco 

(FASS/T), 303 

Filler, Timothy W. 

challenges from tobacco industry, 309 

Finland, North Karelia Project, 9 

Fiore, M. C., 290 

Fischer, P. M., 179 

Fish, John, 330, 339 

520 
M o n o g r a p h 1 6. A S S I S T 

Fisher, Scott, 327, 340


Fleming, David, 435n2, 438n2


FOIA. See Freedom of Information Act (FOIA)


(1966)


Food and Drug Administration (FDA), 401, 460


Forbes, Ripley, 402


Fox, Eric, 330


Freedom of Information Act (FOIA) (1966), 311,


350–2


Maine, requests from tobacco industry allies in,


367, 368


memo from Samuel Chilcote, 319


Minnesota, requests from tobacco industry al­


lies in, 363


obligation of ASSIST to respond to requests,


350–2


public relations campaigns against ASSIST,


345


requests to ASSIST from tobacco industry,


321–3, 325, 335, 372


Washington State, requests from tobacco indus­


try allies in, 361–2


free tobacco product samples, 232–3, 268


Fresina, Lori, 202


policy interventions, 167


Fritz, Bill, 341, 342


FSHC (Fair Share for Health Committee), 358


FTC (Federal Trade Commission), 139


Funding Advance Group report, 421–31. See also


Realizing America’s Vision for Healthy People:


Advancing a Federal Commitment to Effective


Tobacco Control


funding for tobacco prevention programs, 491–2


from American Cancer Society (ACS), 48,


69–70


ASSIST Coordinating Committee protecting,


56–7


ASSIST’s through contracts with state agen­


cies, 44, 47


California Tobacco Related Disease Research


Program, 309


contracts, not grants for ASSIST program, 14,


289


diverting from Community Environment Chan­


nel, 343–5


durability of tobacco prevention programs af­


fected by, 412


eligibility for contracts, 22


federal, dependence upon, 391


guidance to states on acquiring funding from


national program, 463–4


Health and Human Services Department ex­


tending ASSIST’s, 403–4


levels increasing, 97


lobbying restrictions, 132, 169–70 (See also


lobbying efforts)


in Minnesota after ASSIST, 465–6


National Cancer Institute (NCI), 8f, 69, 285


organizational culture, differences in, 81–2


recommended levels for, 464


in South Carolina, post-ASSIST, 460


to states during transition period, 454


The Future of Public Health (Institute of Medi­


cine), 493


G

Gamble, Linda, 303


program services for interventions, 283


Garcia, John M., 213, 507


conceptual framework, 19


strategic planning, 385


structure and communications, 41


GASO (Great American Smokeout), 140, 141


gays and lesbians, 259


Generación X (radio program), 150


Get Outraged campaign, 148


Girl Scouts of America, 53


Glantz, Stanton, 309


Glanz, K., 484


Glaser, Bonnie, 309, 315


Graham, E. A., 5


Graham, R. Neal, 47, 435n2


member of Advocacy Opportunities Advance


Group report, 438n2


transition to nationwide program, 443


Virginia Tobacco Settlement Foundation, 468


Grande, Donna, 200, 507


structure and communications, 41


Grant, Brenda, 143


media interventions, 119


Great American Smokeout (GASO), 140, 141


Greenwald, Peter, 395–6


Division of Cancer Prevention and Control


(DCPC), director, 5


extension of ASSIST’s funding, 403


five phases of cancer control model, 7f


historical context, 1


on research and interventions, 6


521 
I n d e x 

Griffin, Gretchen, 467


transition to nationwide program, 443


Growing Up Tobacco Free, 174, 388


Guidelines for Controlling and Monitoring the


Tobacco Epidemic, 176


Guide to Community Preventive Service: Tobacco


Product Use Prevention and Control, 446–7,


459


H 

Hall-Walker, Carol, 139, 507


media interventions, 119


Han, Victor, 347


Harrelson, David, 481, 507


strategic planning, 385


Harrington, Jim


policy interventions, 167


Harris, O. S., 84


Harvill, Julie, 423n2


Hatch, Orrin, 329, 330, 338


Havlicek, Darla


conceptual framework, 19


Hays, Hays & Wilson company, 317


analyses of ASSIST activities in various states,


327


report on ASSIST activities in Colorado, 325,


326


representing American Constitutional Law


Foundation, 356


Health and Human Services Department (DHHS),


37


ASSIST, commitment toward, 403–6, 408–9


complaints to Inspector General over lobbying,


338–9


funding and lobbying restrictions, 132, 329


Healthy People 2010, 486


letter from Senator McConnell, 337


National Institutes of Health (NIH), 46


Realizing America’s Vision for Healthy People: 

Advancing a Federal Commitment to Effective Tobacco Control, 408–9 

Reducing Tobacco Use: A Report of the Sur­


geon General—Executive Summary, 445


Shalala, Donna, testifying at a congressional 

hearing, 331–3 (See also Shalala, Donna 

(Secretary, Health and Human Services Department)) 

Treating Tobacco Use and Dependence (Fiore


et al.), 290


health care, 25. See also public health


cessation of smoking counseling, 294, 298


health advocacy groups, 345


objectives of program for facilities, 29t, 30


restrictions on smoking in facilities for, 247


Health Consequences of Involuntary Smoking: A


Report of the Surgeon General, 4, 171


health departments, state. See state health depart­


ments


Health Education Research, 86


Health Effects of Exposure to Environmental To­


bacco Smoke: Final Report and Appendices, 

171


Health Protection Fund (Massachusetts), 85


Healthy People 2010 (Department of Health and


Human Services), 486


Hefelfinger, Jennie, 423n2


Herrera, M. F., 84


Hispanics/Latinos. See also minority communities


advertising targeted toward, 259


Kick Butts Day (Rhode Island), 141


radio campaign in Rhode Island, 149, 150


history of ASSIST, 3–17 

American Cancer Society as partner, 11–2 

creation of Smoking, Tobacco, and Cancer Program (STCP), 5–6


Division of Cancer Prevention and Control


(DCPC), approval of program, 12–4 

five phases of cancer control, 6–7 

individual vs. community approach to interventions, 3–4


scientific basis for community interventions,


7–10


Holbrook, J. H., 9


Hong, Miki, 309


Houston, C. Ann


media interventions, 119


member of Training and Technical Assistance


Advance Group, 432n1 

North Carolina reducing youth access to tobacco, 210


policy interventions, 167


underage tobacco usage in North Carolina, 137


Huang, Phil, 435n2, 438n2


Huff, Tom, 341


I

Ibrahim, Jennifer, 309


522 
M o n o g r a p h 1 6. A S S I S T 

Illinois, enforcement of restrictions in selling to­


bacco to teenagers, 229


Indiana


battle against preemption of local ordinances,


217


campaign against smoking, 144


The Link (newsletter), 58


local organizational structures, 50


number of state and local coalitions, 83t


staff location affecting work in, 52


Tobacco-Free Indiana newsletter, 65


Indian Health Service, 451, 456


individual interventions, 283–308. See also pro­


gram services for individuals


Infant Formula Action Coalition (INFACT), 342


infectious diseases, 486


information dissemination, 434. See also educa­


tion on tobacco issues


transition to nationwide program, 445–6


in Wisconsin, 145


information exchange conferences, 113–7


Initial Outcomes Index (IOI), 503


Initiatives to Mobilize for the Prevention and


Control of Tobacco Use (IMPACT), 451, 497


ASSIST compared with, 447, 448t


conceptual framework for, 21


funding from ASSIST for, 59


funding from Centers for Disease Control and


Prevention (CDC) for, 394


strategic planning with ASSIST, 387


in transition team, 454


Institute of Medicine (IOM), 417


functions of tobacco prevention program, 448–9


Growing Up Tobacco Free, 387–8


on improving evaluation of tobacco control


programs, 503


Taking Action to Reduce Tobacco Use, 483, 492


underage drinking, 502


Who Will Keep The Public Healthy?, 484, 493


on workforce competency, 493


institutionalization, 11


institutionalize, 411


Internal Revenue Code (IRC), 352–3


International Agency for Research on Cancer, 171


International Journal of Health Services, 384


interventions, potential of, 477–510. See also


communities/community interventions 

ASSIST accomplishments, summary of, 505–6 

ASSIST cube conceptual framework, 485f 

in ASSIST’s conceptual framework, 25f, 26–8 

cancer control consisting of, 6


coalition building for, 77–118 (See also coali­


tion building) 

evaluation methodology, 502–4 

funding required for, 491–2 

implementation strategies, 494–6 

individuals, 283–308 (See also program services for individuals)


individual vs. community, 3–4, 23


infrastructures, 481–4


legacies of ASSIST, 480–1


public health initiatives, influencing, 496–502


rationale for community-based, 10–11


research initiatives on, 504–5


scientific basis for community-based, 7–10


state cigarette tax rates, 489f, 490t


systems-level change, 484, 486–8, 491


workforce competency, 493–4


Introduction to Program Evaluation for Compre­


hensive Tobacco Control Programs, 459


involuntary smoking. See environmental tobacco


smoke (ETS)


IOM. See Institute of Medicine (IOM)


Istook, Ernest, 331, 332–3, 339


J

Jaffe, Robert, 326


JCAHO (Joint Commission on Accreditation of


Healthcare Organizations), 247


Jerome, Kitty, 295


program services for interventions, 283


“Joe Camel” character, 179, 258, 266–7


JOFOC. See Justification of Other Than Full and


Open Competition (JOFOC) 

Johnson, Michael, 435n2, 438n2 

Joint Commission on Accreditation of Healthcare 

Organizations (JCAHO), 247


Jordan, Jerie, 47


challenges from tobacco industry, 309


as contributor to ASSIST project, 507


Funding Advance Group member, 423n2


on inclusiveness of ASSIST, 494


structure and communications, 41


transition to nationwide program, 443


Journal of the American Medical Association, 5,


296, 405


Justification of Other Than Full and Open Com­


petition (JOFOC), 70


523 
L 

I n d e x 

K

Kahn, Bob, 346


Kaiser Permanente, 297


Karsh & Hagan public relations firm, 343


Kean, Thomas J., 507


media interventions, 119


structure and communications, 41


Kegler, Michelle, 86


Keller, Brad, 326


Kent County Health Department newsletter


(Michigan), 51


Kerry, John, 202


Kessler, David A., 401


Kick Butts Day, 141, 199–200


Kincaid, Johnny, 144


media interventions, 119


Klausner, R., 403


Koop, C. Everett, v–vii, 3, 230


Krakow, Milly


Massachusetts Adult Tobacco Survey, 147


national, state, and local coalitions, 77


regional networks in Massachusetts, 85


Laffin, Pam, 148


Lambright, Lodie, 435n2, 438n2


Landman, Anne, 218


policy interventions, 167


Larkin, Jim, 363–4


Las Cruces Clean Indoor Air Ordinance, NM,


197, 222–3 

Latimer, Gloria 

strategic planning, 385


leadership styles, 188


League of Women Voters, 53


Lee, K., 384


Lee, Philip R., 402


Legacy Tobacco Documents Library, University


of California, 312, 384


legal actions, 337–42. See also tobacco industry


Colorado, tobacco industry toward ASSIST in,


357–9


Food and Drug Administration (FDA), 401


Minnesota, tobacco industry toward ASSIST in,


362–6, 407


legal documents, 313–4


legislation


Alcohol, Drug Abuse, and Mental Health Ad­


ministration Reorganization Act (1992), 402


Las Cruces Clean Indoor Air Ordinance, NM,


197


Pro-Children Act (1994), 293


Leischow, Bob, 432n1


Leischow, Scott J., 504, 507


Leonard, Burleigh, 329


lesbians and gays, 259


“Let’s Making Smoking History” campaign,


147–9


Levin, M. L., 5


Levinson, Arnold, 325


Lewis, F. M., 484


Lewit, E. M., 9


LexisNexis, 313


Library of Congress Thomas Web site, 314


licensing for tobacco products in retail venues,


229


Lindsey, Pat, 191, 196


policy interventions, 167


The Link (newsletter), 58


listservs, 65


Lloyd, Jon, 497, 507


lobbying efforts. See also public policies


Coalition on Smoking OR Health, 48


Federal Acquisition Streamlining Act (FASA)


restrictions on, 439


restrictions on, 51–2, 132, 169–70


restrictions on, ASSIST staff understanding,


352–4


Shalala, Donna, questioned on ASSIST practic­


es, 329, 331–3


tobacco industry monitoring ASSIST on, 323–5


local community involvement, 213, 216. See also


communities/community interventions


local health departments, 50–1, 83t. See also com-


munities/community interventions


locking devices on vending machines, 231


Lynn, William R., 481


Community Intervention Trial for Smoking


Cessation (COMMIT) compared with


ASSIST, 10


as contributor to ASSIST project, 507


transition to nationwide program, 443


M

MacKenzie, R., 384


The Madison Group, 335, 345


magazines, tobacco advertising in, 275


Magleby, D., 404


524 
M o n o g r a p h 1 6. A S S I S T 

Mahler, Sara, 324


Maine


audits of ASSIST program, 341


local organizational structures, 50


number of state and local coalitions, 83t


Operation Storefront, 149


opposition to ASSIST from tobacco industry in,


354, 367–9


preemption of tobacco restrictions in, 186


prevention education activities in, 300


smoke-free policy at University of Maine,


302–3


Maldavir, Jerry, 394, 396


Malek, Sally Herndon, 86


as contributor to ASSIST project, 507


Funding Advance Group member, 423n2


media interventions, 119


memo on continuation of ASSIST to,


404–5


North Carolina advocacy for tobacco-free


schools, 216


North Carolina newspaper coverage of tobacco


issues, 134


policy interventions, 167


Malmgren, Kurt, 317–8, 334, 335–6


Malone, Ruth, 309


Manley, Marc, 47


as contributor to ASSIST project, 507


on evaluating tobacco control programs, 503


on media advocacy, 487


Marlboro brand, 272, 277


Martin, Grace, 347


Martin, Jim D.


North Carolina reducing youth access to to­


bacco, 210, 305


policy interventions, 167


program services for interventions, 283


Martinez, Pedro, 148–9


Martinez, Ronaldo, 148


Maryland, cigarette tax, voters favoring increase


in, 176


MASCOT (Multicultural Advocates for Social


Change on Tobacco), 84


Massachusetts


Adult Tobacco Survey, 147


antismoking program, 497


capacity for tobacco control program in, 389


Department of Health brochure, 298


funding for tobacco prevention programs, 492


Get Outraged campaign, 148


increasing tobacco tax to fund healthcare for


children, 201–2


lobbying for cigarette excise tax, 52


Mother’s Stress Management Task Force, 292,


295


number of state and local coalitions, 83t


prevention education activities in, 299


regional networks in, 85


selection for ASSIST program, 31–2


tobacco control as public health initiative,


496–8


Truth Campaign, 148


Massachusetts Tobacco Control Program, 147–8


mass media. See media activities


Master Settlement Agreement (1998). See Tobac­


co Master Settlement Agreement (MSA) (1998)


Matheny, Helen, 143


media interventions, 119


May, Dianne, 138


media interventions, 119


McAdam, Bob, 324, 325–6


complaint by Stuart Cloud against ASSIST, 346


on preemption of local ordinances, 349


restricting ASSIST funds to school-based anti­


tobacco education, 344


McCain, John, 405, 460


McCain bill, 400f, 405, 460


McConnell, Mitch, 329, 330, 337


McDonough, John, 202


McLeroy, K., 86


Mead, Margaret, 213


media activities, 119–66


advocacy, 27, 127–35, 487–8


advocacy countering tobacco advertising ef­


forts, 276–7


ASSIST Media Network, 132–3


clergy helping to ban tobacco advertising in


St. Louis, MO, 195


Indiana case study, 144


mass media and antitobacco campaigns, 142,


145–9


materials for advocacy, 130


Michigan case study, 137–8


Michigan newspapers, policy-related articles in,


153f, 154t


Minnesota lawsuit, 407


National Center for Tobacco-Free Kids as re­


source, 460


news coverage, 135, 140–2, 149–52


nine questions for strategy development, 128


North Carolina case study, 134, 136–7


525 
I n d e x 

media activities (continued) 

piggybacking, 140, 141 

policy changes, influencing, 121, 169 

policymakers’ attention, attracting, 189 

power of, 121–2 

preparation for interventions, 122–7 

R.J. Reynolds Tobacco Company campaign, 

138–9 

relations with, 125–6 

South Carolina, antitobacco campaign in, 146 

spokespeople, training, 126–7 

Virginia’s ASSIST chapter, tips from, 124 

West Virginia case study, 143 

Wisconsin case study, 145 

Media Services Incorporated, 365, 366 

Medrano, Victor, 495, 507 

Melaville, A. I., 80 

Mercer, S. K., 501 

Merlo, Ellen, 185, 370 

Michel, Martha, 309 

Michigan 

audits of ASSIST program, 340 

capacity for tobacco control program in, 389 

countertobacco media campaigns, 146–7 

Grand Rapids sports arena made smoke-free by 

youth advocates, 204–6 

Kent County Health Department newsletter, 51 

media activities in, 137–8 

number of state and local coalitions, 83t 

policy-related articles in Michigan newspapers, 

151, 153f, 154t 

representation on committees, 49 

restriction on official comments on tobacco, 

50 

smoking cessation hotline, 294, 296 

Midwestern Prevention Project, 8–9 

Mills, Dora, 367 

minimum age requirements for tobacco purchasing, 228–9 

Minnesota 

capacity for tobacco control program in, 389 

Clean Indoor Air Act, 108, 252 

coalitions, experience of, 89 

Comprehensive Tobacco Control Plan, 108–10 

countertobacco media campaigns, 146–7 

Ethical Practices Board, 342 

Heart Health Program, 8 

infiltration of ASSIST program by tobacco allies, 343 

number of state and local coalitions, 83t 

opposition to ASSIST from tobacco industry in, 

326, 354, 362–7 

reducing tobacco use among teenagers, 307 

representation on committees, 49 

responsibility matrix from ASSIST, 103 

staff location affecting work in, 52 

suing Philip Morris, 336 

Tobacco Master Settlement Agreement, not participating in, 464 

Tobacco Master Settlement Agreement (1998) 

and lawsuit in, 407 

transition from state to national program, 465–7 

Minnesota Candy & Tobacco Association, 335 

Minnesota Grocers Association, 340, 342, 364–5 

Minnesota Wholesale Marketers Association, 343 

minority communities 

advertising targeted toward, 199, 258–60 

in Funding Advance Group report, 425–6 

Great American Smokeout and African Americans, 141 

Multicultural Advocates for Social Change on 

Tobacco (MASCOT), coalition in New Mexico, 84 

Multicultural Subcommittee, 59–62, 495–6 

multicultural teams in transition to nationwide 

program of tobacco control, 456–7 

proportions of African Americans and Hispanics in states, 36 

“Recommended Benchmarks for Multicultural 

Programs and Activities,” 470–3 

Rhode Island radio campaign in Spanish, 149, 

150 

Training and Technical Assistance Advance 

Group recommendations for including, 434–5 

Mintz, J., 129 

Missouri 

clergy helping to ban tobacco advertising in St. 

Louis, 195–6 

coalitions, experience of, 89 

newsletter from, 64 

number of state and local coalitions, 83t 

program services delivered in, 291 

Tobacco Institute report on ASSIST in, 324–5 

youth appeal to policymakers in, 190–1 

MMWR. See Morbidity and Mortality Weekly Report (MMWR) 

Montigny, Mark, 202 

Moon, Robert W. 

co-chair of Funding Advance Group, 423n2 

conceptual framework, 19 

historical context, 1 

Moore, Jane, 404, 432n1 

Morbidity and Mortality Weekly Report (MMWR), 

447, 459, 487 

526 
M o n o g r a p h 1 6. A S S I S T 

Mother’s Stress Management Task Force in Massachusetts, 292, 295 

Motsinger, Brenda McAdams 

conceptual framework, 19 

letter to Donna Shalala signed by, 405 

national, state, and local coalitions, 77 

national strategy for tobacco control, 394, 396 

promise of ASSIST, 477 

strategic planning, 385 

transition to nationwide program, 443 

Mountain States Employers Council (MSEC), 

301–2 

A movement rising: A strategic analysis of U.S. 

tobacco control advocacy, 461, 462–3 

Mozingo, Roger, 318 

MSA. See Tobacco Master Settlement Agreement 

(MSA) (1998) 

MSEC (Mountain States Employers Council), 

301–2 

Multicultural Advocates for Social Change on Tobacco (MASCOT), 84 

Multicultural Subcommittee, 59–62, 99, 456–7, 

495–6 

Multistate Master Settlement Agreement, 282 

Murphy-Hoefer, Rebecca, 432n1, 495, 507 

N

NACCHO. See National Association of County 

and City Health Officials (NACCHO) 

NALBOH (National Association of Local Boards 

of Health), 399, 405 

NASCAR races, 199 

National Association for the Advancement of Colored People, 53 

National Association of African Americans for 

Positive Imagery, 451 

National Association of County and City Health 

Officials (NACCHO), 399 

meeting with Donna Shalala, 405 

policy statement from, 402 

National Association of Local Boards of Health 

(NALBOH), 399, 405 

National Cancer Act (1971), 5 

National Cancer Institute (NCI). See also ASSIST 

“Advice to NCI About Their Future Role in Tobacco Control,” 395–6 

advising ASSIST staff on legal responsibilities, 

311 

American Cancer Society (ACS), memo of understanding with, 43, 68–72 (See also American Cancer Society (ACS)) 

ASSIST Coordinating Center and strategic 

communications, 66 (See also ASSIST Coordinating Center) 

Centers for Disease Control and Prevention 

(CDC), mission shared with, 447 (See also 

Centers for Disease Control and Prevention 

(CDC)) 

coalition building, recognition of importance, 

79 (See also coalition building) 

on coalition model, 483 

conceptual framework for ASSIST, 21 (See 

also conceptual framework for ASSIST) 

evaluation of ASSIST program, 31 

evaluation of coalition-based community intervention, 33–34 

extending ASSIST program, 387, 403–4, 424 

Federal Acquisition Streamlining Act (FASA), 

340–1 (See also Federal Acquisition Streamlining Act (FASA)) 

five phases of cancer control model, 7f 

formation of ASSIST, 3–17 

funding for studies of interventions, 429–30 

funding for tobacco prevention programs, 8f, 

69, 285 (See also funding for tobacco prevention programs) 

goals for ASSIST, 388, 446f 

Marc Manley on media advocacy, 487 

manual for oral health practitioners, 298 

manual for physicians, 298 

media advocacy workshop, 130 

prohibition on spending money on program services, 285, 288 

public health tobacco control project, 480 (See 

also ASSIST) 

request for proposals from state health agencies, 35–6 

request for research in tobacco control interventions, 503–4 

Smoking, Tobacco, and Cancer Program 

(STCP), 5–6 (See also Smoking, Tobacco, 

and Cancer Program (STCP)) 

Standards for Comprehensive Smoking Prevention and Control, 286, 299 

state health departments, cooperation with, 483 

Strategies to Control Tobacco Use in the United 

States: A Blueprint for Public Health Action 

in the 1990’s, 287 

in structure of ASSIST, 45–7 (See also structure of ASSIST) 

527 
I n d e x 

National Cancer Institute (NCI) (continued)


studies linking smoking to cancer, 4–5


in testimony of Helene Brown, 418, 419


Tobacco Institute obtaining contractual docu­


ments for ASSIST from, 322


training and assistance provided to states,


389–90


transition, responsibilities during, 450–1, 454


National Cancer Policy Board, 418


National Center for Tobacco-Free Kids, 395


conference sponsorship on tobacco control by,


451


as resource for media, 460


National Coalition of Hispanic Health and Human


Services Organizations, 451


National Institute for Occupational Safety and


Health (NIOSH), 239


National Institute on Drug Abuse (NIDA), 286


National Institutes of Health (NIH), 46, 68. See


also National Cancer Institute (NCI)


National Organization for Women, 53


national program for tobacco control, 443–76. See


also transition to nationwide program


National Research Program (Switzerland), 9


National Tobacco Control Program (NTCP), 445,


453, 484


capacity of the Office on Smoking and Health


(OSH) to handle, 451


challenges in transitioning from ASSIST, 449


evaluation and assessment, 458–9


multicultural teams in, 456–7


training in, 457–8


National Toxicology Program, 171


Native Americans, 259, 451, 456


NCI. See National Cancer Institute (NCI)


Nebraska, tobacco control program in, 307


Nelson, Craig, 341


Nerness, Barbara, 365


New England Convenience Store Association,


335–6


New England Journal of Medicine, 492


New Jersey


advertisement banning smoking in casinos, 

339–40


coalitions developed in, 53


lack of allies for tobacco industry in, 336


number of state and local coalitions, 83t


pilot study on state coalitions, 87–8


New Mexico


Albuquerque case study, 84


Las Cruces Clean Indoor Air Ordinance, 197,


222–3


Mesilia, NM, smoke-free restaurant policy, 219


On Target (newsletter), 81


prevention education activities in, 299


representation on committees, 49


restriction on official comments on tobacco, 50


state and local coalitions, number of, 83t


tobacco control coalition formed in Silver City


by teenagers, 206–7 

news coverage, 135, 140–2


advertising in newspapers, 275


ASSIST Print Media Database, 503


monitoring newspapers, 149–52


North Carolina newspapers, 131, 134, 135t


News for a change: An advocate’s guide to work­


ing with the media (Wallack et al.), 127, 131


New York


coalitions developed in, 53


countering tobacco industry arguments on


economy, 208–9


Kick Butts Day, 141


mandatory counteradvertising in, 270


number of state and local coalitions, 83t


opposition to ASSIST from tobacco industry in,


354, 369–71


pilot study on state coalitions, 87–8


poster contest in, 275


restriction on official comments on tobacco, 50


Vallone Bill, 348, 369–71


New York Restaurant and Tavern Association, 370


Nichols, Tim


policy interventions, 167


nicotine, 238, 316, 415


NIDA (National Institute on Drug Abuse), 286


Niemeyer, Dearell R., 498n


promise of ASSIST, 477


strategic planning, 385


transition to nationwide program, 443


NIH (National Institutes of Health), 46, 68. See


also National Cancer Institute (NCI)


Ninth Report on Carcinogens (National Toxicolo­


gy Program), 171


NIOSH (National Institute for Occupational Safe­


ty and Health), 239


Nisker, Scoop, 203


Nodora, Jesse, 435n2, 438n2


No more lies: Truth and consequences for tobac­


co, 124, 139


clergy helping to ban tobacco advertising in St.


Louis, MO, 196


528 
M o n o g r a p h 1 6. A S S I S T 

Mother’s Stress Management Task Force in


Massachusetts, 295


Washington State’s smoke-free policy on state


ferries, 221


Non-Dependence Day, 140


North Carolina


advocacy for tobacco-free schools, 215–6


counseling of pregnant women on quitting


smoking, 298–9


evaluation of coalitions in, 86


Mecklenburg County Health Department guide


to smoke-free restaurants, 172


media activities in, 134, 136–7, 152


newsletter from, 64


newspaper editorials, 135t


newspapers, benefits of using, 131


number of state and local coalitions, 83t


preemption of tobacco restrictions in, 186


tobacco prevention program in schools, 293–4


youth access to tobacco, reducing, 209–10


North Karelia Project (Finland), 9


NTCP. See National Tobacco Control Program


(NTCP)


nutrition, 500–2


O 

obesity, 500–2 

Office on Smoking and Health (OSH), 445, 447.


See also Centers for Disease Control and Pre­


vention (CDC)


ad hoc workgroup formed by, 452–3


Association of State and Territorial Health Offi­


cials (ASTHO), working with, 456


capacity of, 451


mission statement, 450


in transition team, 454


Oglesby, M. B., Jr., 318


O’Hara, James, 406, 424–5


O’Keefe, Anne Marie, 507


challenges from tobacco industry, 309


lobbying, limitations on, 132


media interventions, 119


opposition from tobacco industry in Washing­


ton State, 362


opposition to ASSIST from tobacco industry in


Maine, 368


On Target (newsletter), 81


Operation Storefront, 149, 199, 210–2


Oregon, target populations with high tobacco use,


organizational culture, 81–2


OSH. See Office on Smoking and Health (OSH)


Ostronic, John, 347


O’Sullivan, Gael A.


program services for interventions, 283


strategic planning, 385


structure and communications, 41


P

Pacific Islanders, 259


participatory decision making, 494–5


Partnership for Tobacco-Free Maine, 302, 303


passive smoking. See environmental tobacco


smoke (ETS)


Pataki, George, 348, 369


Patterson, Tracy Enright, 435n2, 438n2


program services for interventions, 283


Pawtucket Times (newspaper), 139


Pertschuk, Michael, 9, 52


as contributor to ASSIST project, 507


leadership styles, 188


Smoke in their eyes: Lessons in movement lead­


ership from the tobacco wars, 442


Philip Morris company. See also tobacco industry


advertising targeting Hispanics/Latinos, 259


on ASSIST as abuse of public funds, 328


Bill of Rights tour, 276–7


Briant, Tom, memo on Minnesota ASSIST


project, 364–5 

CancerScam: The Diversion of Federal Cancer 

Funds to Politics (Bennett and DiLorenzo) 

on Web site, 346–7 

discrediting ASSIST program, 336–7 

Environmental Protection Agency (EPA), discrediting research from, 185


gift to George Pataki, 369


“It’s the Law” youth initiative, 344


lack of involvement from smokers in defending


tobacco industry, 336


on lobbying efforts from ASSIST, 323, 324


media fly-arounds in Minnesota, 366


opposition to ASSIST, 314, 316–7, 327


preemption of antismoking ordinances, 347–8


Slavitt, Josh, at, 334 (See also Slavitt, Josh)


state audits of ASSIST program, 340


State of Minnesota and Blue Cross/Blue Shield 

of Minnesota v. Philip Morris, Inc. et al., 362


“Think. Don’t Smoke” campaign, 132–3, 185–6


Walls, Tina, on tobacco control policies, 183,


186


Web site, 384


529 

307 
I n d e x 

physical activity, 500–1 

piggybacking, 140, 141 

“Planning for a Durable Tobacco Prevention 

Movement,” 392–5


Executive Summary, 411–3


possible factors affecting, 393–4, 411–2


recommendations, 394–5


“Planning for Durability: Keeping the Vision 

Alive” (training module), 390 

point-of-purchase advertising, 199, 210–2. See 

also advertising from tobacco industry 

displays, 268–9 

voluntary restrictions on, 276 

point-of-purchase warning signs, 233–4 

policies, 167–282. See also public policies 

policy advocacy, 352. See also lobbying efforts; 

public policies 

populations. See also minority communities 

education geared toward segments of, 300 

exposing advertising that targets, 199 

identifying at-risk for cancer, 6–7 

multicultural inclusion amongst, 495–6 

priority, for ASSIST, 23, 24–5 

at worksites, 29–30 

Portland, ME, 83 

Portnoy, Sharon, 369, 370–1 

poster contests, 275 

preemption laws, 186–7, 491 

Vallone Bill in New York, 369–71 

youth access bill in Minnesota, 366 

pregnancy, 171 

Pressl, Lance, 327, 346–7 

press releases, 135 

priority populations, 24–5. See also populations 

prisons, restrictions on smoking in, 248–9 

Pritzl, Jane, 507 

clean air ordinance passed in Denver, CO, 302 

Colorado tobacco-free schools law, 297 

member of Training and Technical Assistance 

Advance Group, 432n1 

program services for interventions, 283 

Pro-Children Act (1994), 293 

product samples, free, 232–3, 268 

Program and Funding Guidelines for Comprehensive Local Tobacco Control Programs, 464 

program services for individuals, 28, 283–308 

cessation of smoking, support for, 290, 294, 

296 

challenges of, 286–9 

Colorado clean air ordinance passed in Denver 

stimulating, 301–2 

Colorado tobacco-free schools law creates demand for, 297 

delivery capacities, increasing, 291–2 

education for general public, 299–300 

identification of, 291, 294, 298–9 

North Carolina reducing youth access to tobacco products, 304–5 

as part of ASSIST program, 169 

policy interventions, interaction with, 300–5 

smoke-free policy at University of Maine, 302–3 

strengthening other programs, 305–6 

tobacco prevention program in North Carolina 

schools, 293–4 

types of provided by ASSIST, 289–91 

Project Management Plans, 92–3, 111–2 

Project Managers Subcommittee, 63–4 

Prom, Jeanne, 432n1 

Promoting Health: Intervention Strategies from 

Social and Behavioral Research (Institute of 

Medicine), 484 

promotions, 255–6, 271–4. See also advertising 

Prospect Associates Ltd., 43, 54 

PSAs. See public service announcements (PSAs) 

public health 

achievements in tobacco cessation, 308 

ASSIST cube conceptual framework, 485f 

awareness of dangers of tobacco, 122 

burden of tobacco-related health problems, 414 

cardiovascular health initiatives, 500 

health advocacy groups, 345 

model for, 22f 

obesity initiatives, 500–2 

policy changes, 486–7, 488, 491 (See also public policies)


prevention of tobacco usage, 21–4


research publicized in media, 142


tobacco control initiatives, 496–9


public policies, 9, 167–282 

advertising for tobacco, limitations for, 179–82 

See also advertising from tobacco industry 

advertising from tobacco industry, exposing, 

199–200 

ASSIST’s focus on, 371–2 

ban on smoking in baseball stadiums in Virginia, 192–3


challenges to interventions, 183, 185–7


Clean Indoor Air: A Guide to Developing Policy, 235–52 (See also Clean Indoor Air: A 

Guide to Developing Policy) 

clergy helping to ban tobacco advertising in 

St. Louis, MO, 195–6 

530 
198 

M o n o g r a p h 1 6. A S S I S T 

coalitions creating success, 194, 196 

community involvement, 198 

environmental tobacco smoke (ETS), elimination of, 171–4, 175t 

flexible strategies required for changing, 212–3 

framing the issues, 203, 207, 212 

Grand Rapids, MI, sports arena made smokefree by youth advocates, 204–6 

groundwork for, 189, 191 

Indiana’s battle against preemption of local ordinances, 217 

influence of, 218–9, 221, 223 

as interventions, 26, 169–70, 488, 491 (See 

also interventions, potential of) 

Las Cruces Clean Indoor Air Ordinance, NM, 

197, 222–3 

lobbying restrictions, 51–2, 132 (See also lobbying efforts) 

local community involvement, 213, 216 

media interventions used in changing, 121, 169 

Mesilia, NM, smoke-free restaurant policy, 219 

New York countering tobacco industry arguments, 208–9 

North Carolina advocacy for tobacco-free 

schools, 215–6 

North Carolina reducing youth access to tobacco, 209–10 

Operation Storefront, 210–2 

persistence in changing, 216, 218 

policymakers, preparation of, 187–9, 190–1 

political boundaries, 191, 193 

preemption laws, 186–7 

reversals, guarding against, 218 

skill-building among various participants, 196, 

small changes add up, 213 

South Carolina bans smoking in State House, 

214–5 

taxes for tobacco, 174, 176–9 

teenagers, involving in changing, 200, 202–3 

teenagers’ access to tobacco products, restricting, 182–3, 184t (See also underage tobacco 

usage) 

Tobacco Advertising and Promotion: A Guide 

to Developing Policy, 253–77 (See also Tobacco Advertising and Promotion: A Guide 

to Developing Policy) 

tobacco control coalition formed in Silver City, 

NM, by teenagers, 206–7 

tobacco industry monitoring ASSIST for lobbying activities, 323–5 

tobacco industry tactics, 198 

volunteers in advocacy, 482–3 

Washington State’s smoke-free policy on state 

ferries, 220–1 

Wisconsin’s Annual Action Plan for advocacy, 

106 

Youth Access to Tobacco: A Guide to Developing Policy, 224–34 (See also Youth Access to 

Tobacco: A Guide to Developing Policy) 

public relations, tobacco industry tactics against 

ASSIST, 345–7 

public service announcements (PSAs), 271 

public transportation 

restrictions on smoking on, 248 

restrictions on tobacco advertising on, 264 

Washington State’s smoke-free policy on state 

ferries, 220–1 

Q 

Quinones, Deborah, 432n1, 435n2, 438n2 

quitting smoking, support for, 289, 290. See also 

program services for individuals 

R

R.J. Reynolds Tobacco Company. See also tobacco industry 

Briant, Tom, memo on Minnesota ASSIST 

project, 364–5 

“Joe Camel” character, 179, 258, 266–7 

opposition to ASSIST, 314, 327 

Preston, MN, case restricting point-of-sale advertising, 363–4 

recommendations for opposition to ASSIST 

program, 318–9 

Shalala, Donna, questioned on lobbying from 

ASSIST, 329–30 

state audits of ASSIST program, 340 

Uptown cigarette brand, 258 

Web site, 384 

Winston cigarettes as additive-free campaign, 

138–9 

radio campaign in Rhode Island, 149, 150 

Realizing America’s Vision for Healthy People: 

Advancing a Federal Commitment to Effective 

Tobacco Control, 408–9, 421–40 

Advocacy Opportunities Advance Group report, 438–40 

context for national tobacco control program, 

423–5 

as framework for transition teams, 455 

531 
I n d e x 

Realizing America’s Vision for Healthy People: 

Advancing a Federal Commitment to Effective 

Tobacco Control (continued) 

Funding Advance Group report, 421–31 

Funding Advance Group report, recommendations of, 421–2 

Funding Advance Group report, values guiding, 

425–7 

funding requirements for national tobacco-control program, 427–30 

Surveillance, Evaluation & Applications Advance Group report, 435–8 

Training and Technical Assistance Advance 

Group report, 432–5 

“Recommended Benchmarks for Multicultural 

Programs and Activities,” 470–3 

recreational facilities 

ban on smoking in baseball stadiums in Virginia, 192–3 

restrictions on smoking in, 249–51 

restrictions on tobacco advertising in, 265–6 

Reducing Tobacco Use: A Report of the Surgeon


General—Executive Summary, 445


Remington, Patrick L., 145, 507


media interventions, 119


research 

advertising, impact on consumption, 256–7 

Agency for Healthcare Research and Quality 

disseminating results of, 446


cancer control and, 5


data sources for evaluation of ASSIST pro­


gram, 32–3 

environmental tobacco smoke (ETS), 171 (See 

also environmental tobacco smoke (ETS))


framing the issues, 203, 207, 212


interventions and, 6 (See also interventions, po­


tential of)


reports on future of tobacco control, 397


results publicized in media, 142, 145, 149


search terms for tobacco industry documents,


313t


tobacco industry discrediting, 185


tobacco industry documents, 312–5


Research and Publications Subcommittee, 62–3 

resources for ASSIST, 73–5. See also Web sites 

The ASSIST Guide to Working with the Media, 

52


bibliography, 155–63


The Cancer Letter and The Link, 58


Information Exchange and Training conference


materials, 89


materials for media advocacy, 130


newsletters from Michigan and West Virginia, 51


orientation guide and brochure, 49


“The Tobacco Challenge: Communities at


Work” (video), 390, 406


training for coalition building, 93–5 (See also


training)


training materials, 90


Respiratory Health Effects of Passive Smoking:


Lung Cancer and Other Disorders (Environ­


mental Protection Agency), 135, 171


challenges from tobacco industry toward, 185


health risk factors, 237–8


preemption against, 186


restaurants, 241


Mecklenburg County (NC) Health Department


guide to smoke-free restaurants, 172


Mesilia, NM, smoke-free restaurant policy, 219


policies restricting smoking in, 245–6


Restrictions on Lobbying and Public Policy Advo­


cacy by Government Contractors: The ASSIST


Contract, 170


retail licensing for tobacco products, 229


Reynolds, R.J., 122


Rhode Island


coalitions, experience of, 89–90


Kick Butts Day, 141


membership in ASSIST state coalition, 101–2


number of state and local coalitions, 83t


radio campaign in Spanish, 149, 150


Winston cigarette campaign in, 139


Rice, J., 405


Rimer, B. K., 484


Robbins, Harriet


Massachusetts Adult Tobacco Survey, 147


media interventions, 119


national, state, and local coalitions, 77


regional networks in Massachusetts, 85


Robert Wood Johnson Foundation (RWJF), 60


Coalition for a Tobacco-Free Colorado (CTFC)


application for funds, 357–8


conference sponsorship on tobacco control by,


451


Robert Jaffe as principal investigator with, 326


National Center for Tobacco-Free Kids funded


by, 395


New York countering tobacco industry argu­


ments on economy, 208–9


SmokeLess States National Tobacco Policy Ini­


tiative, 21, 398, 496 (See also SmokeLess


States National Tobacco Policy Initiative)


532 
M o n o g r a p h 1 6. A S S I S T 

tobacco control programs, support for, 393


Tobacco Technical Assistance Consortium, 499


Robinson, Mikelle, 296


program services for interventions, 283


Robinson, William S., 423n2


Rocky Mountain Center for Health Promotion and


Education, 297


Rocky Mountain Tobacco-Free Challenge, 13


Roessler, April, 432n1


Ronan, Marianne, 435n2, 438n2


strategic planning, 385


RWJF. See Robert Wood Johnson Foundation


(RWJF)


S

Saccenti, J., 404, 405


Sackman, Janet, 148


Sack the Pack campaign, 192


St. Louis Post-Dispatch (newspaper), 195


Salas, Nancy, 423n2, 507


strategic planning, 385


SAMHSA. See Substance Abuse and Mental


Health Services Administration (SAMHSA)


Satcher, David, 82


SCARCNet (Smoking Control Advocacy Re­


source Center Network), 65


Schaafsma, Krista V., 205, 206


policy interventions, 167


Schmidtke, Judy, 432n1


schools, 25


Colorado tobacco-free schools law, 297


North Carolina advocacy for tobacco-free


schools, 215–6


objectives of program for, 29t, 30


policies restricting smoking in, 246


school-base tobacco prevention programs as


part of national program, 428


tobacco prevention program in North Carolina


schools, 293–4


tobacco prevention programs in, 286, 287, 288,


290


Schroeder, Steven, 492


Schwartz, J., 139


Schwartz, Randy H., 405


challenges from tobacco industry, 309


Schwartz, Tony, 270


Sciandra, Russell


challenges from tobacco industry, 309


New York countering tobacco industry arguments, 208


New York state preemption plan, 371


policy interventions, 167


science. See research


Scientific Advisory Committee, 46


search terms for tobacco industry documents,


313t


Second Chance (tobacco use prevention program


booklet), 287


secondhand smoke, 171. See also environmental


tobacco smoke (ETS)


self-service displays of tobacco products, 232


Shalala, Donna (Secretary, Health and Human


Services Department)


approached by tobacco-control organizations,


388, 403


Centers for Disease Control and Prevention 

(CDC) given national tobacco control program by, 449–50 

health officials meeting with, 404, 405, 424


lobbying, against using funds for, 323


national tobacco prevention program, commit­


ment to, 406, 409


testifying at a congressional hearing, 331–3


on using the ASSIST model, 448


Sherwood, Ron, 432n1 

Shopland, Donald R., 12–3 

policy interventions, 167


Shultz, J., 129


Singapore Declaration in ASSIST cube conceptu­


al framework, 485f


site analyses, 91


Site Trainers Network (STN), 98–9


skills for workforce, 493–4. See also workforce


Slavitt, Josh, 317, 320


Bennett, James, information given to, 347


on lobbying efforts from ASSIST, 323


on local information on ASSIST, 328


on needing more knowledge of ASSIST activi­


ties, 322


New Jersey, lack of allies for tobacco industry


in, 336


on tobacco industry allies, 334


tobacco industry youth initiatives, 344


Smith, Adam, 174


Smoke in their eyes: Lessons in movement leader­


ship from the tobacco wars (Pertschuk), 442


SmokeLess States National Tobacco Policy Initia­


tive, 21, 496


533 
I n d e x 

SmokeLess States National Tobacco Policy 

Initiative (continued) 

coalitions with states recommended, 413 

funding affecting durability of tobacco prevention programs, 412 

providing assistance to ASSIST, 498–9 

support from Robert Wood Johnson Foundation 

(RWJF), 393, 398 (See also Robert Wood 

Johnson Foundation (RWJF)) 

smokeless tobacco, 136, 299 

Smoker Friendly Stores, 356 

Smokers’ Rights ForceS Web site, 346 

Smoking, Tobacco, and Cancer Program (STCP) 

approval of ASSIST program, 12 

creation of, 5–6 

creation of ASSIST program, 46 

funding for, 8f 

motivation for, 15 

studies on tobacco reduction interventions, 10 

tobacco reduction plan, 7 

Smoking and Health in the Americas, 174, 387 

Smoking Control Advocacy Resource Center Network (SCARCNet), 65 

Sneegas, Karla S., 217 

policy interventions, 167 

Sondik, Edward J., 395 

South Carolina 

antitobacco campaign in, 146


coalitions developed in, 53


Kick Butts Day, 141


number of state and local coalitions, 83t


pilot study on state coalitions, 87–8


post-ASSIST funding in, 460


program services delivered in, 292


State House smoking ban, 214–5


sponsorship by tobacco companies, 267–8, 272–3 

sports facilities, 249–50, 265–6. See also recreational facilities 

Spurlock, Shannon, 432n1 

stadiums, 249–250 

Standards for Comprehensive Smoking Prevention 

and Control, 286, 299 

Stanford Three-Community Study, 8 

Stanley, André G. 

strategic planning, 385 

State Cancer Legislative Database, 34–5 

state health departments. See also states 

contract with ASSIST, 43 

meetings with the ASSIST Coordinating Committee, 56 

newsletters from, 64


orientation to core concepts of ASSIST, 45


selection for ASSIST program, 70


in structure of ASSIST, 48–9


Washington State, 111–2


State of Minnesota and Blue Cross/Blue Shield of 

Minnesota v. Philip Morris, Inc. et al., 362 

State Programs Can Reduce Tobacco Use, 174, 

492 

state project executive committees 

structure of ASSIST, 49–50 

states. See also under individual states 

advertising, exposing tactics in, 199–200 

advertising, ordinances against, 181t 

Annual Action Plans, 91–2 

audits of ASSIST program, 340 

Best Practices for Comprehensive Tobacco 

Control Programs, used as guide by, 463–4 

clean indoor air policies/laws, 175t, 240–1, 491 

coalition building in, 79, 83–90 

coalitions, state and local, 33–4, 83t 

Comprehensive Tobacco Control Plans, 91–2 

federal funding for tobacco control programs, 

recommendation for, 426–7 

Freedom of Information Act (FOIA), responding to requests, 351–2 

guidance on acquiring funding from national 

program, 463–4 

health departments (See state health departments) 

health departments cooperating with organizations, 481–2 

limitations on tobacco advertising, 181t 

lobbying, instructions about, 353 

Operation Storefront, 210–2 

opposition to ASSIST from tobacco industry in, 

319–20 (See also tobacco industry) 

ordinances enacted in four areas, 170 

preemptions of local antismoking ordinances, 

348–9 

recommendations for coalitions within for tobacco prevention programs, 412–3 

Rocky Mountain Tobacco-Free Challenge, 13 

selection for ASSIST program, 31–2, 35–7 

site analyses, 33, 91 

strategic planning, involvement in, 388–91 

Synar Amendment, 316 (See also Synar 

Amendment) 

taxes for cigarettes by, 177–8t, 489f, 490t (See 

also taxes) 

tax increases in ASSIST, 176 

534 
M o n o g r a p h 1 6. A S S I S T 

teenagers’ access to tobacco products, policies 

restricting, 184t, 227 

transition from National Cancer Institute to 

Centers for Disease Control and Prevention 

(CDC), 454 

State Tobacco Activities Tracking and Evaluation 

System (STATE), 459 

State Tobacco Control Highlights, 459 

STAT (Stop Teenage Addiction to Tobacco), 342 

Steckler, A., 86 

Steger, Carter, 423n2 

Steinfeld, J. L., 9 

Stillman, Frances A. 

conceptual framework, 19 

promise of ASSIST, 477 

Stine, Joan, 423n2 

STN (Site Trainers Network), 98–9 

Stoddard, Rick, 148 

Stop Teenage Addiction to Tobacco (STAT), 342 

strategic communications, 65–7. See also communication with ASSIST 

strategic planning, 385–442 

“Advice to NCI About Their Future Role in Tobacco Control,” 395–6 

ASSIST as turning point for tobacco control, 

387–8 

ASSIST subcommittee, long-term plans for, 

392f 

ASSIST transitioning to national program, 410 

Brown, Helene, testimony, 418–20 

commitment toward, 398–403, 409–10 

Health and Human Services and ASSIST, 

403–6, 408–9 (See also Health and Human 

Services Department (DHHS)) 

national program for, developing, 391–398 

“Planning for a Durable Tobacco Prevention 

Movement,” 392–5, 411–3 (See also “Planning for a Durable Tobacco Prevention 

Movement”) 

Realizing America’s Vision for Healthy People: 

Advancing a Federal Commitment to Effective Tobacco Control, 408–9, 421–40 (See 

also Realizing America’s Vision for Healthy 

People: Advancing a Federal Commitment to 

Effective Tobacco Control) 

state involvement in, 388–91 

“Turning Point for Tobacco Control,” 396–8, 

414–7 

Strategic Planning Subcommittee, 58–9 

Strategies to Control Tobacco Use in the United 

States: A Blueprint for Public Health Action in 

the 1990’s, 15, 287 

Strategy development: Key questions for developing an advocacy strategy (Shultz), 129 

Strauss, A. L., 315 

Strength of Tobacco Control index (SoTC), 32, 

503 

stress management, 295 

structure of ASSIST, 43–76, 45f 

American Cancer Society (ACS), 47–8, 49 

coalition building, 52–3 

committees, 55–64 (See also committees of 

ASSIST) 

communication within, 64–7 

coordination between organizations, 53–5 

local organizations, 50–1 

memo between National Cancer Institute (NCI) 

and American Cancer Society (ACS), 68–72 

National Cancer Institute (NCI), 46–7 

organizational units, 43–6 

policy advocacy issues, 51–2 

resource materials for, 73–75 (See also resources for ASSIST)


state health departments, 48–9


state project executive committees, 49–50


Stuntz, Susan, 316, 335, 481 

Substance Abuse and Mental Health Services Administration (SAMHSA), 402, 460 

conference sponsorship on tobacco control by, 

451


Synar Amendment, 460 (See also Synar


Amendment) 

Suchomski, Lois, 435n2, 438n2 

Suhr, Karen Fernicola, 323 

Sullivan, Louis W., 37 

lobbying using ASSIST funds sent to, memo 

on, 329, 330 

on opposition from tobacco industry, 315–6 

vending machine, ban on tobacco, 230 

Surgeon General’s Report on Preventing Tobacco 

Use Among Young People, 257 

Surveillance, Evaluation & Applications Advance 

Group report, 435–438. See also Realizing 

America’s Vision for Healthy People: Advancing a Federal Commitment to Effective Tobacco 

Control 

Switzerland, National Research Program, 9 

Sydney Quit for Life, 9 

535 
I n d e x 

Synar, Mike, 402


Synar Amendment, 227, 228


cigarettes and substance abuse grants, 316


North Carolina enforcing, 304


Slavitt, Josh, on, 317


stimulating demand for program services, 300,


303


Substance Abuse and Mental Health Services


Administration created by, 402


T 

Taking Action to Reduce Tobacco Use (Institute of 

Medicine), 483, 492, 503


target populations, 24n. See also populations


taxes


California increasing cigarette, 497


for cigarettes by state, 177–8t, 489f, 490t


Colorado initiative for increasing cigarette,


355–6


deduction of advertising expenses, 266


influencing smoking behavior, 27


Massachusetts increasing tobacco tax, 201–2,


498


New York countering tobacco industry argu­


ments on economy, 208–9


ordinances enacted in states, 170


policies for increasing on tobacco, 174, 176–9


Tax Reform Act (1976), 354


Technical Assistance and Training Subcommittee,


58, 62


technical assistance from ASSIST Coordinating 

Center, 54–5, 93–4, 97. See also ASSIST Coordinating Center 

teenagers. See also underage tobacco usage


appealing to policymakers in Missouri, 190–1


brand identification, 179


Grand Rapids, MI sports arena made smoke-


free by youth advocates, 204–6 

impact of advertising on, 257–8 

North Carolina reducing youth access to tobacco, 209–10 

policies, involving in changing, 200, 202–3 

restricting access to tobacco products, 

182–183, 184t 

tobacco control coalition formed in Silver City, 

NM, by, 206–7 

Youth Access to Tobacco: A Guide to Developing Policy, 224–34


“Think. Don’t Smoke” campaign, 132–3, 185–6


Thomas, Margaret, 139


media interventions, 119


Thornton, Amber Hardy


national, state, and local coalitions, 77


“Through With Chew” campaign, 299


Thurm, Kevin, 403, 424


Tobacco Advertising and Promotion: A Guide to 

Developing Policy, 253–77 

advertising, restrictions on, 263–7 

advertising targeted toward minorities and 

women, 258–60


advertising vs. promotion, 255–6


cartoon characters, 266–7


counteradvertising, 269–71


counterpromotions, 271–4


deductions for advertising expenses, 266


impact of advertising on children, 257–8


impact of advertising on consumption, 256–7


industry expenditures, 256


media advocacy, 276–7


overview of policy options, 261–2


promotional activities, restrictions on, 267–9


public opinion on advertising restrictions, 260


voluntary approaches to tobacco advertising,


274–6 

“The Tobacco Challenge: Communities at Work” 

(video), 390, 406


Tobacco Control (journal), 147


Tobacco Control Network of State Health Agency


Program Managers for Tobacco Prevention and


Control, 401


Tobacco Control Resource Center, Inc. & The To­


bacco Products Liability Project, 282


Tobacco Documents Online, 312, 384


tobacco farming, 467–8


Tobacco-Free Communities for Children Initiative


(MN), 465, 466


Tobacco free future: Shining the light, 193, 215


Tobacco-Free Michigan Action Coalition, 137


Tobacco Free Washington Coalition, 111


tobacco industry, 309–84. See also Philip Morris


company; R.J. Reynolds Tobacco Company;


Tobacco Institute


advertising from, 121–2 (See also advertising


from tobacco industry)


on antismoking infrastructure in California, 482


ASSIST’s response to opposition from, 350–72


(See also ASSIST) 

business and consumer allies, enlisting, 333–6 

Coalition on Smoking OR Health challenging, 

48


Colorado, opposition to ASSIST in, 355–60


536 
M o n o g r a p h 1 6. A S S I S T 

congressional allies, enlisting, 328–33 

countering ASSIST programs, plans for, 318– 

21


discrediting ASSIST, 65–6, 336–42, 345–7


discrediting research from Environmental Pro­


tection Agency (EPA), 185


expenditures on advertising, 256


funds diverted from Community Environment


Channel, 343–5


infiltrating ASSIST, 342–3


internal documents, analysis of, 312–5


lobbying tactics, 198


Maine, opposition to ASSIST in, 367–9


Minnesota, opposition to ASSIST in, 362–7


monitoring ASSIST activities, 321–8


New York, opposition to ASSIST in, 369–71


New York countering arguments on economy


from, 208–9 

perception of ASSIST as major threat, 315–8 

policies limiting advertising from, 179–82 

preemption laws, 347–9, 491 (See also preemption laws) 

promotion of preemption laws and ballot initiatives, 347–9 

in public health model, 22f 

search terms for documents from, 313t 

on smoke-free workplace ordinances, 173–2 

sponsorship by tobacco companies, 267–8 

Walls, Tina, from Philip Morris on tobacco 

control policies, 183


Washington State, opposition to ASSIST in,


361–2


The tobacco industry documents: An introductory 

handbook and resource guide for researchers 

(MacKenzie, Collin and Lee), 384


Tobacco Institute, 314


Briant, Tom, memo on Minnesota ASSIST


project, 364–5


California, antismoking infrastructure in, 316


Colorado, legal action in, 337


on Community Environment Channel, 317


contractual documents for ASSIST from Na­


tional Cancer Institute (NCI), 322


diverting ASSIST funds, 344


evaluation of ASSIST information, 325–6, 327


on infiltrating ASSIST, 342–3


Malmgren, Kurt, strategy paper from, 334–5


New York State Preemption Plan, 370–1


obtaining ASSIST proposals, 323


public relations campaign against ASSIST,


345–7 

recommendations for opposition to ASSIST 

program, 318, 319


requests for ASSIST information, 324


Washington State, strategy in, 361


Web site, 384


Tobacco Master Settlement Agreement (MSA)


(1998), 144, 194


challenges to, 459


documents from tobacco industry, 312


funding of foundation to reduce teen smoking,


458


Minnesota lawsuit and, 407


negotiation milestones, 400f


as source of funding, 460–1


state attorney generals monitoring compliance


to, 360


Virginia’s use of funds from, 467–8


Tobacco prevention: The next generation, 138


Tobacco Smoke and Involuntary Smoking, 171


Tobacco Technical Assistance Consortium, 493–4,


499


Tobacco Use Supplement for the Current Popula­


tion Survey (CPS), 34


Todd, R., 405


Todd, Ron, 423n2, 507


Todo a Pulmón (With Full Breath), 150


tombstone listings, 269


training


ASSIST Information Exchange and Training 

conference materials, 89


ASSIST materials, 90


on clean air ordinance passed in Denver, 301


coalition building, 93–5


events during implementation phase, 113–7


implementation, transition to, 96–8


media advocacy, 130–1


planning phase, 95


program services in South Carolina and Wis­


consin, 292


recommendations for, 432–40


reducing youth access to tobacco products in


North Carolina, 304


Site Trainers Network (STN), 98–9


skills for workforce, 493–4


spokespeople for media activities, 126–7


team assigned to in transition to nationwide


program, 457–8


Washington State’s program, 112


workshops for states from National Cancer In­


stitute, 389–90 

537 
I n d e x 

Training and Technical Assistance Advance 

Group (TAT) report, 432–5. See also Realizing 

America’s Vision for Healthy People: Advancing a Federal Commitment to Effective Tobacco 

Control 

transition to nationwide program, 443–76


ad hoc workgroup, 452–4


administrative issues in agencies, 449–51


coordination and support team, 455


core program elements, integration of, 451–9


dissemination challenges, 445–9


evaluation and outcomes assessment team,


458–9


Minnesota’s transition, 465–7


multicultural teams, 456–7


organizational structure during, 452f


political climate during, 460–1, 463


“Recommended Benchmarks for Multicultural


Programs and Activities,” 470–3 

states, guidance on acquiring funding, 463–4 

status of tobacco control movement, 462–3 

technical assistance and training team, 457–8 

technical teams, 455–6 

transition teams, 454–5 

Virginia’s Tobacco Settlement Foundation, 

467–8


traveling for training, 435


Treating Tobacco Use and Dependence (Fiore,


et al.), 290, 296


Trimpa, Ted, 317, 325, 326


Truth and the Consequences of Cigarette Adver­


tising: An Advocate’s Guide to Arguments in


Support of Banning Cigarette Advertising and


Promotions, 260


Truth Campaign in Massachusetts, 148


T-shirts, 273


Tsongas, Paul, 202


“Turning Point for Tobacco Control: Toward a


National Strategy to Prevent and Control Tobacco Use,” 396–8, 414–7 

U

underage drinking, 502


underage tobacco usage. See also teenagers


age requirements for tobacco purchasing,


228–9


Minnesota youth access bills, 365–6


nicotine addiction, 415


North Carolina, 136


North Carolina reducing youth access to tobacco products, 209–10, 304–5 

policies limiting access to tobacco products, 

170, 182–3, 184t 

Synar Amendment, 402 (See also Synar 

Amendment) 

Tobacco Master Settlement Agreement (1998)


funding of foundation to reduce teen smok­


ing, 458


Youth Access to Tobacco: A Guide to Developing Policy, 224–34 (See also Youth Access to 

Tobacco: A Guide to Developing Policy) 

United Restaurant and Tavern Association, 

369–70


United States Tobacco Journal, 255


Up in Smoke: The Transformation of America’s


Billboards (video), 123


Uptown cigarette brand, 258


U.S. Congress, 328–33

U.S. Public Health Service, 486

U.S. Tobacco, 364–5


USA Today, 189


Utah, banning tobacco billboards, 263


V

Vallone, Peter, 369


Vallone Bill (New York), 348, 369–71


Van Andel Arena, Grand Rapids, MI, 204–5


vending machines, 230–1


Vermeulen, Sue, 221


policy interventions, 167


videos


from American Cancer Society (ACS), 52


“The Tobacco Challenge: Communities at


Work,” 390, 406


Up in Smoke: The Transformation of America’s 

Billboards, 123


Vietnamese population, 300


Vignes-Kendrick, M., 404


Virginia


ban on smoking in baseball stadiums in, 192–3


merchant education assessment, 149


number of state and local coalitions, 83t


program services delivered in, 291


tips for media activities from chapter, 124


Tobacco Settlement Foundation, 467–8


Virginia Slims tennis sponsorship, 259


Vollinger, Robert E., Jr.


538 
M o n o g r a p h 1 6. A S S I S T 

Community Intervention Trial for Smoking


Cessation (COMMIT) compared with


ASSIST, 10


conceptual framework, 19


historical context, 1


policy interventions, 167


promise of ASSIST, 477


volunteers, 482–3


in Colorado, 89


loss of in Washington State, 90


W

Wallack, L., 127, 131


Wallop, Malcolm, 329, 330


Walls, Tina, 183, 186, 327, 347–8


Wall Street Journal, 139


Warner, D., 147


Warner, Kenneth E., 9, 13, 208


Washington State


audits of ASSIST program, 341


billboard in, 122


coalitions, experience of, 89, 90


cross-cultural workshops in tobacco prevention,


308


enforcement of restrictions in selling tobacco to


teenagers, 229


number of state and local coalitions, 83t


opposition to ASSIST from tobacco industry in,


354, 361–2


prevention education activities in, 299


Project Management Plan from ASSIST, 111–2


public relations campaign of tobacco industry


against ASSIST, 346


recommendations for opposition to ASSIST


from tobacco industry, 326


restrictions on tobacco advertising in recre­


ational facilities, 265


smoke-free policy on state ferries, 220–1


The Washington Post (newspaper), 126


ASSIST article, 129


on obesity, 502


Winston cigarette campaign, story on, 139


Web sites


Achievements in Tobacco Cessation: Case


Studies, 308


Advocacy Institute, 463


Americans for Nonsmokers’ Rights (ANR) da­


tabase, 35


Association of State and Territorial Health Offi­


cials (ASTHO), 399


Campaign for Tobacco-Free Kids (CTFK), 395


Citizens Against Government Waste, 334


Community Guide to Preventive Services, 27


cross-cultural workshops in tobacco prevention


in Washington State, 308


Legacy Tobacco Documents Library, Universi­


ty of California, 312, 384


LexisNexis, 313


Library of Congress Thomas Web site, 314


Multistate Master Settlement Agreement, 282


National Association of County and City


Health Officials (NACCHO), 399


National Association of Local Boards of Health


(NALBOH), 399


Philip Morris company, 384


R.J. Reynolds Tobacco Company, 384


reducing tobacco use among teenagers in Min­


nesota, 307


Smokers’ Rights ForceS, 346


target populations with high tobacco use in Or­


egon, 307


thecommunityguide.org, 17


tobacco control program in Nebraska, 307


Tobacco Control Resource Center, Inc. & The


Tobacco Products Liability Project, 282


Tobacco Documents Online, 312, 384


Tobacco Institute, 384


Treating Tobacco Use and Dependence (Fiore,


et al.), 290


Weigum, Jeanne, 354


challenges from tobacco industry, 309


Weld, William, 202


West Virginia


Coalition for a Tobacco-Free West Virginia


newsletter, 51, 64


prevention education activities in, 299


state and local coalitions, number of, 83t


tobacco advertising prohibited in Charleston,


143


tobacco usage research, 149


Wexler, Scott, 370


What it takes: Structuring interagency partner­


ships to connect children and families with


comprehensive services (Melaville and Blank),


80


Whelan, E. M., 9


Whipple, Kerry, 432n1 

539 
I n d e x 

White, Gregory, 215


policy interventions, 167


White, Jenny


challenges from tobacco industry, 309


White, Marge


ban on smoking in baseball stadiums in Vir­


ginia, 193


media interventions, 119


policy interventions, 167


tips for media relations, 124


Whitt, Mikelle, 432n1 

Who Will Keep The Public Healthy? (Institute of 

Medicine), 484, 493


Wilson, Gary, 432n1


Winner, Carol A.


strategic planning, 385


Winston cigarettes, 138–9


Winston-Salem Journal (newspaper), 133


Wisconsin


Annual Action Plan for 1993–94, 106–7


Comprehensive Smoking Control Plan from


ASSIST, 104–5


dissemination of tobacco and health informa­


tion, 145


Great American Smokeout and African Ameri­


cans, 141


local organizational structures, 50


prevention education activities in, 299


program services delivered in, 292


representation on committees, 49


state and local coalitions, number of, 83t


women


counseling of pregnant women on quitting


smoking in North Carolina, 298–9


Females Against Secondhand Smoke and To­


bacco (FASS/T), 303


Mother’s Stress Management Task Force in


Massachusetts, 292, 295


Virginia Slims tennis sponsorship, 259


Woodruff, K., 127, 131


workforce, skills for, 493–4


worksites, 25


California study on smoke-free, 172


environmental tobacco smoke (ETS), policies


to eliminate in, 240, 243–4


objectives in Wisconsin’s Comprehensive


Smoking Control Plan, 104–5, 107


objectives of program for, 29–30


World Bank, 174


World Health Organization, 176


World No Tobacco Day, 300


Wynder, E. L., 5


Y 

Yoe, Cathey, 318, 329


Young, Walter ‘Snip,’ 486, 507


challenges from tobacco industry, 309, 360


lawsuits against, 355, 356, 358, 359


program services for interventions, 283


Youth Access to Tobacco: A Guide to Developing 

Policy, 224–34 

free tobacco product samples, 232–3 

minimum age requirements, 228–9 

point-of-purchase warning signs, 233–4 

policy options to reduce youth access to tobacco, 226–8


retail licensing, 229


self-service displays, 232


single cigarette sales, 233


vending machines, 230–1


youth prevention programs, 147–9. See also teenagers; underage tobacco usage 

540 
N I H P U B L I C A T I O N N O . 0 5 - 5 6 4 5 • MAY 2005