ii

DEDICATION

This Smoking and Tobacco Control Monograph is dedicated to the

hundreds of community volunteers who served on community Boards

or task forces or otherwise contributed to the implementation of the

Community Intervention Trial for Smoking Cessation (COMMIT) project.

Without their unstinting energy and enthusiasm, this project could not

have been accomplished. We also wish to pay tribute to the extraordinary

community directors and their staffs who gave more of themselves to this

project than anyone could have expected. They are the real heroes of

COMMIT.
iii

Foreword

Foreword

The first great “public health revolution” in developed countries involved

measures to control infectious disease, and now we are in the midst of the

second revolution: the massive attack on chronic disease. In this revolution,

the dramatic decline in cigarette smoking in the United States since 1964

stands out as the most striking success story, which is especially remarkable

considering the fact that antismoking advocates play the part of David against

the Goliath of the tobacco industry. Antitobacco forces, including public

advocacy groups, have made steady advances in controlling the smoking

epidemic despite the tobacco industry’s greater expenditures to expand

tobacco use. The industry’s counterattacks continue with steadily increasing

intensity; this points to a clear need to increase the scope and effectiveness

of all existing educational and regulatory antitobacco strategies. This

monograph on the Community Intervention Trial for Smoking Cessation

(COMMIT) field experience meets this need extraordinarily well because

organizing, activating, and empowering communities to take action against

smoking surely stands as the most important strategy for use in public

health campaigns that emphasize control of tobacco use.

This monograph, Community-Based Interventions for Smokers: The COMMIT

Field Experience, is one of an excellent series on various aspects of tobacco and

health published since 1991 by the National Cancer Institute and the first to

deal with community-based approaches. It reports exciting victories: (1) a

modest decrease in smoking rates in light-to-moderate smokers, especially in

the hard-to-reach categories of individuals of low educational attainment and

(2) an impressive accomplishment in community empowerment.

Many monographs and most scientific articles either confine themselves

to a description of health problems or concentrate on the final results of

interventions designed to solve these problems. It is indeed rare to find a

document that tells how a problem was addressed: which methods were used,

what resources and training were needed, what barriers were found, how the

barriers were overcome, and how the intervention could have been improved.

This attention to process is long overdue. Given that eight previous

community-based research studies on cardiovascular disease risk factors

(including smoking) from the United States, Finland, Australia, South Africa,

and Switzerland have been reported since 1972 (see Chapter 2), it is striking

to note the absence of reporting on the process of achieving change. The

responsibility for this absence can be laid at the door of the scientific journals,

whose policy is to focus on results rather than methods, thereby excluding

information with the greatest potential to help those who could attempt

such programs.

COMMIT, with its 22 communities comprising 11 treatments and 11

controls, furnishes excellent opportunities for providing information on

process, thanks to the diversity of experience it obtained and the excellence
Smoking and Tobacco Control Monograph No. 6

iv

of its recordkeeping. These factors allow for good estimates of effort expended

and results achieved for multiple intervention strategies carried out in varied

settings, such as the media, health care venues, worksites, community

organizations, and schools.

The authors deserve great praise for putting together 14 chapters of such

value and usefulness. The resultant state-of-the-art compendium will serve

policymakers and practitioners who wish to attempt community-based

programs for virtually any health problem that requires broad community

participation. That COMMIT was organized as a research project gives it the

credibility needed to promote it as a blueprint for success. Both successes and

failures are described, and programs in both the United States and Canada are

described in enough detail to let us appreciate not only the logic of planning

and methods of intervention but also the human drama involved.

Jane Farquharson, a community health specialist from Dalhousie

University, Nova Scotia, Canada, has said, “Scientists learn from data, people

learn from stories.” Stories in this case are the monograph’s details of process,

as mentioned earlier. Lest scientists become offended, one can add that

scientists interpret data as well, but it is only as activists that they, together

with the people they help, can create community change. The stories of

Chapters 5 through 13 are the how-to section of this document and give

the information and inspiration needed to plan and implement simple or

complex community intervention programs.

These chapters, whose stories are rich with lessons that will guide future

community work, are the “trees” of the monograph. The “forest” is the ability

of COMMIT to demonstrate the power of the people to better their lives by

collaborating toward a shared goal. In the 19th century, the French writer

and politician Alexis de Tocqueville labeled this country a “nation of

joiners”—a trait he found admirable. COMMIT illustrates this American

characteristic more than 100 years later, showing how members of the 11

treatment communities joined in a common cause for health.

De Tocqueville’s symbolic nation of joiners was demonstrated in the

community Boards and their task forces, which were created early in the

11 COMMIT communities. As organized events proceeded and gained

recognition, community involvement increased manyfold. COMMIT’s

successes in creating community events (“magnet events”) tell the world

how ferment from “below” (from the people of a community) can change

their local world. For example, imagine the excitement in Bellingham, WA,

as COMMIT staff members paraded in giant turkey costumes, or during an

annual parade, in giant cigarette costumes!

Each element of COMMIT’s multicomponent campaign represented an

innovation—as so often happens when pioneering efforts are made. Many

barriers were encountered along the way, sometimes to be overcome by luck,

sometimes by ingenuity and perseverance, sometimes not at all.

COMMIT staff members encountered a dramatic barrier as they worked

toward adoption of smoke-free school policies in two communities. In each
v

Foreword

instance, a single school board member who was a smoker blocked the policy

change. The obstacle was overcome in only one of these communities, after

intense public discussion sparked by a COMMIT Board member’s letter to

the editor of the local newspaper. Thus, a committed Board member bore

out the wisdom inherent in this quote from anthropologist, Margaret Mead,

“Never doubt the ability of a few dedicated individuals to change the world,

indeed, it is the only way it ever has.” COMMIT, as a laboratory, teaches us

how to create many such dedicated individuals whose talents were enhanced,

for example, during service on the task forces.

The story of many examples of barriers overcome during the COMMIT

trial is a heartening antidote to the undercurrent of cynicism, fear, and

alienation that exists in the United States today. The ultimate power of the

COMMIT monograph will manifest itself when this message of hope (we can

improve our lives if we work together in common cause) and suggestions of

how to accomplish change are disseminated widely to those who need

encouragement.

One community was remarkably successful in “stirring the pot” and

putting the hazards of smoking at the top of the community’s agenda

through skillful use of media advocacy. As such experts in social marketing

as Drs. June Flora and Craig Lefebvre have pointed out, a successful message

often can be grafted onto a topic that already has captured the public’s

attention. At the height of the great public debate over the possibility of

harmful contaminants in a shipment of Chilean grapes, the COMMIT staff in

Medford/Ashland, OR, was able to show that the cyanide content of inhaled

cigarette smoke was potentially much more toxic than the grape’s pesticide

content.

Another COMMIT success was the finding that young people were

surprisingly effective as catalysts for change. This observation highlights

another tenet of social marketing: Messages should be delivered by highly

credible people. COMMIT interventionists discovered that many young

people were eager to help and were often remarkably successful in garnering

the public’s attention. An exciting example occurred during an attempt by

COMMIT to decrease illegal sales of cigarettes to minors in Raleigh, NC.

Three months earlier, the city council had rejected COMMIT’s proposal to

restrict vending machine cigarette sales, but after one adolescent’s testimony

council members rapidly approved the new legislation. The testimony in

part simply stated, “You can’t educate vending machines.”

Community empowerment, including use of volunteers, perhaps the

most important COMMIT result, is evident from all community stories but

was carefully quantified as well; 94 percent of seven categories of process

objectives were achieved and 99 percent for the category “Mobilization of

Boards and Task Forces.”

Given the impressive success in community empowerment, which also

can be called a “bottom-up” approach, a major question is how best to

harness the power of newly activated members of any community. First is
Smoking and Tobacco Control Monograph No. 6

vi

the potential for the COMMIT monograph to be the country’s current best

creative and adaptable “cookbook” for change and thus a vehicle for wide

adaptation. However, as described in the monograph’s last chapter, one

answer to the question of how to channel this “power” is to ask for “topdown” assistance from all levels of government and other policymakers.

As Canada, Australia, and the States of California and Massachusetts have

shown, increasing taxes on tobacco is the single most effective way to

decrease tobacco use in a country or State. Nationally supported antismoking

media campaigns also are needed to interact with and magnify the effect of

community actions. Enforcement of existing laws in tobacco sales to minors,

policies on vending machines, and restrictions and bans on advertising are

also governmental responsibilities.

Adding these governmental activities to countrywide community-based

activities could result in a synergistic interaction that would strengthen and

propel a national movement toward a truly smoke-free society. This also

might help us gain the courage, wisdom, and moral force to mobilize a

nation of joiners and stem the ruthless expansion of tobacco companies

into developing countries.

The COMMIT field experience, as described in this pioneering

monograph, supplies powerful lessons and important tools for the public

health movement by demonstrating the simple truth: Comprehensive

community interventions do make a difference.

John W. Farquhar, M.D.

Professor of Medicine

Professor of Health Research

 and Policy

Stanford University
Acknowledgments

Community-Based lnterventions for Smokers:The COMMIT Field Experience

was developed under the general editorship of the Smoking and Tobacco

Control Program (STCP), National Cancer Institute (NCI), Donald R.

Shopland, Coordinator.

The senior scientific editor for the Community Intervention Trial for

Smoking Cessation (COMMIT) monograph was Beti Thompson, Ph.D.,

Associate Member, Cancer Prevention Research Unit, Fred Hutchinson

Cancer Research Center, Seattle, Washington. Contributing editors were

David M. Burns, M.D., Professor of Medicine, University of California at

San Diego Medical Center, San Diego, California, and William R. Lynn,

COMMIT Project Officer, Cancer Control Science Program, Division of

Cancer Prevention and Control, National Cancer Institute, National Institutes

of Health, Bethesda, Maryland.

The editors and STCP staff members would like to express their sincere

appreciation to Terry F. Pechacek, Ph.D., for the energy he brought to the

COMMIT project, especially during the early stages of the trial, and for the

leadership, direction, and support he gave to COMMIT. Dr. Pechacek served

as the NC1 Program Director for COMMIT from 1987 to 1991; he is currently

with the Department of Social and Preventive Medicine, State University of

New York at Buffalo, Buffalo, New York.

The STCP staff members gratefully acknowledge the COMMIT

field directors, staff members and volunteers, and authors who

made this monograph possible. The organizational/institutional

affiliations listed below represent the authors principal affiliation

during the COMMIT trial. At the end of each chapter, each

author’s current organizational affiliation with complete address

is provided. Individual chapter attributions follow:

Chapter 1. Smoking Control and the Donald R. Shopland

COMMIT Experience— National Cancer Institute

Summary and Overview Bethesda, MD

David M. Burns, M.D.

University of California at San Diego

Medical Center

San Diego, CA

Beti Thompson, Ph.D.

Fred Hutchinson Cancer Research Center

Seattle, WA

William R. Lynn

National Cancer Institute

Bethesda, MD

vii
Chapter 2.

Chapter 3.

Chapter 4.

Chapter 5.

Background for a

Comprehensive

Community-Based

Trial for Smoking

Control

Community

Intervention Trial

for Smoking Cessation:

Description and

Evaluation Plan

Community

Intervention Trial

for Smoking Cessation:

Development of

the Intervention

Mobilizing the Beti Thompson, Ph.D.

COMMIT Communities Fred Hutchinson Cancer Research Center

for Smoking Control Seattle, WA

Norman Hymowitz, Ph.D.

University of Medicine and Dentistry of

New Jersey Medical School

Newark, NJ

Michael D. Mueller, M.S.

R.O.W. Sciences, Inc.

Rockville, MD

William R. Lynn

National Cancer Institute

Bethesda, MD

Beti Thompson, Ph.D.

Fred Hutchinson Cancer Research Center

Seattle, WA

William R. Lynn

National Cancer Institute

Bethesda, M D

Beti Thompson, Ph.D.

Fred Hutchinson Cancer Research Center

Seattle, WA

William R. Lynn

National Cancer Institute

Bethesda, M D

Beti Thompson, Ph.D.

Fred Hutchinson Cancer Research Center

Seattle, WA

Terry F. Pechacek, Ph.D.

Roswell Park Memorial Institute

Buffalo, NY

Linda Nettekoven, M.A.

Oregon Research Institute

Eugene, OR

Dianne Ferster

University of Waterloo

Waterloo, Ontario

CANADA

viii
Chapter 6. Activities To Involve

the Smoking Public in

Tobacco Control in

COMMIT

Chapter 7. Changing Public Policy

Around Tobacco Control

in the COMMIT

Communities

Len C. Stanley, M.P.H.

Research Triangle Institute

Research Triangle Park, NC

Juliet Thompson

Fred Hutchinson Cancer Research Center

Seattle, WA

Kitty K. Corbett, Ph.D., M.P.H.

Division of Research

Kaiser Permanente Medical Care Program

Oakland, CA

Russell C. Sciandra

 Park Memorial Institute

Buffalo, NY

Lawrence Wallack, Dr.P.H.

Division of Research

Kaiser Permanente Medical Care Program

Oakland, CA

Carolyn L. Johnson, R.N.

Oregon Research Institute

Eugene, OR

Janine Sadlik

Roswell Park Memorial Institute

Buffalo, NY

Juliet Thompson

Fred Hutchinson Cancer Research Center

Seattle, WA

David S. Carrell, Ph.D.

University of Washington

Seattle, WA

Carolyn L. Johnson, R.N.

Oregon Research Institute

Eugene, OR

Len C. Stanley, M.P.H.

Research Triangle Institute

Research Triangle Park, NC

Juliet Thompson

Fred Hutchinson Cancer Research Center

Seattle, WA

ix
Chapter 8.

Chapter 9.

Chapter 10.

Activities To Enhance Edward Lichtenstein, Ph.D.

the Use of Cessation Oregon Research Institute

Resources in COMMIT Eugene, OR

Paul R. Pomrehn, M.D.

University of Iowa

Iowa City, IA

Activities To Promote

Health Care Providers

as Participants in

Community-Based

Tobacco Control

Promoting Community

Tobacco Control

Through Worksites

Sandy Tosti, M.A.

Division of Research

Kaiser Permanente Medical Care Program

Berkeley, CA

Russell C. Sciandra

Roswell Park Memorial Institute

Buffalo, NY

Elizabeth A. Lindsay, Ph.D.

University of Waterloo

WaterIoo, Ontario

CANADA

Norman Hymowitz, Ph.D.

University of Medicine and Dentistry of

New Jersey Medical School

Newark, NJ

Robert E. Mecklenburg, D.D.S., M.P.H.

R.O.W. Sciences, Inc.

RockvilIe, MD

Linda C. Churchill, M.S.

University of Massachusetts Medical

School 

Worcester, MA

Blake PoIand, Ph.D.

University of Waterloo

Waterloo, Ontario

CANADA

Linda Nettekoven, M.A.

Oregon Research Institute

Eugene, OR

Russell E. Glasgow, Ph.D.

Oregon Research Institute

Eugene, OR

Robert H. Shipley, Ph.D.

Research Triangle Institute

Research Triangle Park, NC

x
Chapter 11. Involving Diverse

Community

Organizations

in Tobacco

Control Activities

A.J. Roy Cameron, Ph.D.

University of Waterloo

Waterloo, Ontario

CANADA

Lesa T. Dalton

American Health Foundation

New York, NY

Aleena Erickson

University of Iowa

Iowa City, IA

Sharon Ann Rankins-Burd

Roswell Park Memorial Institute

Buffalo, NY

Sandy Tosti, M.A.

Division of Research

Kaiser Permanente Medical Care Program

Oakland, CA

Glorian Sorensen, Ph.D., M.P.H.

University of Massachusetts Medical

School

Worcester, MA

Kitty K. Corbett, Ph.D., M.P.H.

Division of Research

Kaiser Permanente Medical Care Program

Oakland, CA

Kitty K. Corbett, Ph.D., M.P.H.

Division of Research

Kaiser Permanente Medical Care Program

Oakland, CA

Linda Nettekoven, M.A.

Oregon Research Institute

Eugene, OR

Linda C. Churchill, M.S.

University of Massachusetts Medical

School

Worcester, MA

Lesa T. Dalton

American Health Foundation

New York, NY
Chapter 12. Promoting

Communitywide

Tobacco Control

Activities by

Involving Schools

Carolyn L. Johnson, R.N.

Oregon Research lnstitute

Eugene, OR

Lysha Dickinson

Division of Research

Kaiser Permanente Medical Care Program

Oakland, CA

Glorian Sorensen, Ph.D., M.P.H.

University of Massachusetts Medical

School

Worcester, MA

Beti Thompson, Ph.D.

Fred Hutchinson Cancer Research Center

Seattle, WA

Deborah Bowen, Ph.D.

Fred Hutchinson Cancer Research Center

Seattle, WA

Lesa T. Dalton

American Health Foundation

New York, NY

Rosemary Walker, M.Sc.

Research Triangle Institute

Research Triangle Park, NC

Susan Crystal

University of Washington

Seattle, WA

Mario A. Orlandi, Ph.D., M.P.H.

American Health Foundation

New York, NY

Chapter 13. Involving Youth in Robert J. McGranaghan, M.P.H.

Awareness of, Division of Research

Promotion of, and Kaiser Permanente Medical Care Program

Political Activities for Oakland, CA

Tobacco Control Sharon Ann Rankins-Burd

Roswell Park Memorial Institute

Buffalo, NY

Ted Purcell

University of Massachusetts Medical

Center

Worcester, MA

xii
Chapter 14. What Have We Learned Beti Thompson, Ph.D.

and Where Do We Go Fred Hutchinson Cancer Research Center

From Here? Seattle, WA

William R. Lynn

National Cancer Institute

Bethesda, MD

Donald R. Shopland

National Cancer Institute

Bethesda, MD

The editors wouId like to acknowledge with sincere

appreciation the following distinguished scientists, researchers,

and others who contributed critical reviews:

Glen Bennett, M.P.H.

Coordinator

Advanced Technologies Applications

in Health Education Programs

National Heart, Lung, and Blood Institute

National Institutes of Health

Bethesda, MD

Richard A. Carleton, M.D.

Professor of Medicine

Brown University School of Medicine

Chief of Cardiology

Memorial Hospital of Rhode Island

Pawtucket, RI

Michael P. Eriksen, Sc.D.

Director

Office on Smoking and Health

National Center for Chronic Disease Prevention

and Health Promotion

Centers for Disease Control and Prevention

Atlanta, GA

John W. Farquhar, M.D.

Director

Stanford Center for Research

in Disease Prevention

Stanford University

Palo Alto, CA

Terry F. Pechacek, Ph.D.

Associate Professor

Department of Social and Preventive Medicine

State University of New York at Buffalo

Buffalo, NY

xiii
Cheryl L. Perry, Ph.D.

Professor

Division of Epidemiology

University of Minnesota School of Public Health

Minneapolis, MN

THE COMMIT RESEARCH GROUP

The COMMIT Research Group comprises NCI staff members,

advisers, and contractors responsible for the overall design and

implementation of the COMMIT trial and is composed of the

following individuals:

National Cancer Institute

Division of Cancer Prevention and Control (DCPC), Cancer Control Science

Program (CCSP)

CCSP Acting Associate Director, Thomas J. Glynn, Ph.D.; Coordinator,

Smoking and Tobacco Control Program, Donald R. Shopland

Public Health Applications Research Branch, DCPC, CCSP. Chief, Marc

Manley, M.D., M.P.H.; COMMIT Program Director, William R. Lynn

Biometry Branch, DCPC. Acting Chief, Laurence S. Freedman; Lead

Research Investigator, Sylvan B. Green, M.D.; Computer Systems Analyst,

Donald K. Corle, MS.; Mathematical Statisticians, Barry Graubard, Ph.D.,

Stuart Baker, Ph.D.

Prevention and Control Extramural Research Branch, DCPC, CCSP. Acting

Chief, Sherry L. Mills, M.D., M.P.H.; Public Health Adviser, Daria A.

Chapelsky, M.P.H.

Division of Cancer Etiology

Biostatistics Branch. Head, Epidemiologic Methods Section, Mitchell Gail,

M.D., Ph.D.; Medical Statistician, Steven Mark, M.D., Sc.D.

Chair, COMMIT Steering Committee

Erwin Bettinghaus, Ph.D., M.A., Michigan State University

Collaborating Research Institutions

American Health Foundation (New York, New York)

Principal Investigator: Mario A. Orlandi, Ph.D., M.P.H.; Co-Principal

Investigator: Alfred McAlister, Ph.D.; Co-Investigators: Jacqueline Royce,

Ph.D.; Eugene Lewit, Ph.D.; Project Director: Lesa T. Dalton, B.A.; Field

Director: Avril Dawkins, B.A.; Community Analyst: Bonnie Edelman, B.S.

xiv
Fred Hutchinson Cancer Research Center (Seattle, Washington)

Principal Investigator: Beti Thompson, Ph.D.; Co-Investigators: Maureen

Henderson, M.D., Dr.P.H.; Deborah Bowen, Ph.D.; Community Analyst:

K. Mark Leek, M.A.; Field Director: Juliet Thompson, B.A.

Kaiser Permanente Medical Care Program, Northern California Region,

Division of Research (Oakland, California)

Principal Investigator: Lawrence Wallack, Dr.P.H.; Co-Investigator:

Kitty K. Corbett, Ph.D., M.P.H.; Project Director: Robert J. McGranaghan,

M.P.H.; Field Director: Sandy Tosti, M.A.; Field Director (until 1/90):

Joan Bennett, M.A.

Lovelace Medical Foundation (Albuquerque, New Mexico)

Principal Investigator: Neil1 F. Piland, Dr.P.H.; Project Director:

Lawrence R. Berger, M.D., M.P.H.; Community Analyst: Annette M.

Phillipp, M.P.H.; Field Director: Aile Shebar, R.N.

Oregon Research Institute (Eugene, Oregon)

Principal Investigator: Edward Lichtenstein, Ph.D.; Co-Principal

Investigator: Russell E. Glasgow, Ph.D.; Project Coordinator: Linda

Nettekoven, M.A.; Field Director: Carolyn L. Johnson, R.N.; Community

Analyst: Shari Reyna, M.A.

Research Triangle Institute (Research Triangle Park, North Carolina)

Principal Investigator: Tyler D. Hartwell, Ph.D.; Co-Principal

Investigator: Robert H. Shipley, Ph.D.; Project Director: David Austin,

M.S., M.P.H.; Project Director (until 9/89): Elizabeth T. Walker, B.S.;

Field Director: Len C. Stanley, M.P.H.; Community Analyst: Bonnie

Veaner, M.P.H.; Community Organizer: Carol Stephenson, B.S.

Roswell Park Memorial Institute (Buffalo, New York)

Principal Investigator:K. Michael Cummings, Ph.D., M.P.H.; CoPrincipal Investigator: Terry F. Pechacek, Ph.D.; Project Director: Russell

C. Sciandra, M.A.; Community Analyst: Eva Anderson Sciandra, B.S;

Field Directors: Janine Sadlik, B.S., Sharon Ann Rankins-Burd.

University of Iowa (Jowa City, Iowa)

Principal Investigator: Paul R. Pomrehn, M.D., M.S.; Project Director:

John E. Ferguson, Ph.D.; Co-Investigators: Kristi J. Ferguson, Ph.D.;

Robert B. Wallace, M.D., M.S.; Samuel L. Becker, Ph.D.; Harry A. Lando,

Ph.D. (University of Minnesota); Community Analyst: Virginia

Daughety, Ph.D.; Community Analyst (until 2/92): Kelly O’Berry, B.S.;

Field Director: Aleena Erickson, B.A.

xv
University of Massachusetts Medical School (Worcester, Massachusetts)

Principal Investigator: Judith K. Ockene, Ph.D.; Co-Principal

Investigator: Glorian Sorensen, Ph.D., M.P.H.; Project Coordinator:

Linda C. Churchill, M.S.; Field Director: Barbara Silva; Community

Organizers: Philip Merriam, M.S.P.H.; Gary Donnelly, M.P.H.;

Community Analyst: Edward Purcell, B.S.; Community Analyst (until

7/89): Kristine Sanden, B.S.

University of Medicine and Dentistry of New Jersey (Newark, New Jersey)

Principal Investigator: Norman Hymowitz, Ph.D.; Co-Principal

Investigators: Lawrence Meinert, M.D.; Lee B. Reichman, M.D.; Norman

L. Lasser, M.D., Ph.D.; John Slade, M.D.; Project Director: Karel

Campbell, B.A.; Co-Project Director: Janice Marshall, R.N., M.S.N.; Field

Director: Sharon Jones Rudolph, B.S.; Community Analyst: Connie

Strickland Farrakhan, M.A.

University of Waterloo (Waterloo, Ontario) and McMaster University

(Hamilton, Ontario, Canada)

Principal Investigator: J. Allan Best, Ph.D.; Co-Investigators: A.J. Roy

Cameron, Ph.D.; Charles H. Goldsmith, Ph.D.; Elizabeth A. Lindsay,

Ph.D., M.S.; Blake Poland, Ph.D.; Nancy A. Ross, M.A.; Edward Smith,

Dr.P.H. (until (6/89); S. Martin Taylor, Ph.D.; Leslie Van Dover, Ph.D.,

R.N.; Norman F. White, M.D.; Douglas M.C. Wilson, M.D.; Mark P.

Zanna, Ph.D.; Project Director: Rosemary Walker, M.Sc.; Community

Analyst: Terri Finch, B.A.; Field Director: Dianne Ferster

COMMIT Coordinating Center

Information Management Services, Inc. (Silver Spring, Maryland)

Principal Investigator: Janis A. Beach, A.A.; Co-Principal Investigator:

Carol A. Giffen, D.V.M.; Project Director: Marie A. Topor, B.S.; Senior

Information Specialists: Jerome L. Felix, M.A.; Lauren E. Rich, B.S.;

Systems Analysts: James J. Rovan, B.S.; Rusty Shields, B.S.; Survey

Statistician: Charles D. Palit, Ph.D.; Biostatistician: David Pee, M. Phil.;

Project Coordinator: Mary L. Lamb, B.A.

Policy Advisory Committee (PAC)

Chair: Virginia L. Ernster, Ph.D.; Karl Bauman, Ph.D.; David M. Burns,

M.D.; Richard A. Carleton, M.D.; William ‘I’. Friedewald, M.D.; Charles

Hennekens, M.D., Dr.P.H.; Donald Iverson, Ph.D. (also served as Chair

[1987-1988]); Kenneth E. Warner, Ph.D.

Finally, the editors would like to acknowledge the significant

contributions of the following staff members of R.O.W. Sciences,

Inc., Rockville, MD, who provided technical and editorial

assistance in the preparation of this monograph. In particular,

the editors would like to acknowledge the contribution of

xvi
Richard H. Amacher, MS., R.O.W. Project Director, who served as

Project Manager for the contract under which this publication

was produced.

Douglas Bishop, Art Director

Rebecca A. Charton, Senior Librarian

Faye Grant, Administrative Secretary

Catherine Hageman, Word Processing Supervisor

Sabrina Hinton, Administrative Secretary

James R. Libbey, Managing Editor

Frances Nebesky, Senior Copyeditor

Donna Selig, Proofreader

Barbara Shine, Proofreader

Donna Tharpe, Quality Control Proofreader

Ruth Thompson, Word Processing Specialist

Keith W. Stanger, Graphics Services Coordinator

Sonia Van Putten, Word Processing Specialist

COMMIT MONOGRAPH DEVELOPMENT PROCESS

This represents the sixth volume in the smoking and tobacco control

monograph series. The compilation process for this volume was slightly

different from those generally followed in the past.

In 1993, the STCP Coordinator and COMMIT Program Director

presented a concept for the volume to the COMMIT Printing and

Publications Committee (P & P). The committee was established as one

of several mechanisms to help prioritize manuscripts generated from the

trial and to develop a process for coordinating and accessing trialwide data.

In addition to offering helpful suggestions for the content and overall

approach to the volume, the committee asked Dr. Beti Thompson to serve

as one of the volume’s scientific editors. In addition to Dr. Thompson,

editors included Dr. David M. Burns and Mr. William R. Lynn.

STCP staff members, in consultation with the volume’s scientific editors,

developed a detailed outline for the volume along with a list of potential

authors who represented COMMIT Principal Investigators and COMMIT field

staff. The inclusion of the latter was critical given the primary purpose of the

volume was to document the COMMIT intervention field experience-both

positive and negative. Although individual chapters were generally written

by a COMMIT Principal Investigator, the experience of the COMMIT field

staff members formed the basis of what occurred at the community level.

This hands-on experience was documented by COMMIT’s extensive

xvii
Smoking and Tobacco Control Monograph No. 6

collection of program records and case studies. A meeting of authors and

editors was held to help guide the effort, answer questions, develop a

working outline, and make writing assignments. Several iterations of each

chapter were usually necessary before a final draft was submitted to NCI.

Once a “final” draft of the entire volume was completed, NCI sent copies

to a small group of experts who were asked to critically review the volume.

These reviewers, acknowledged above, were chosen for their specific

knowledge and expertise in community-based health programs. Comments

received from these individuals were sent to the scientific editors for their

consideration and possible integration into the volume.

This monograph, Community-Based Interventions for Smokers: The

COMMIT Field Experience, is the work of dozens of individuals-STCP trial

investigators and staff, smoking control experts, and outside scientists and

experts. The monograph is organized into 14 separate chapters within

3 sections as laid out in the “Contents,” which immediately follows.

 xviii
Contents

Dedication..............................................

Foreword...............................................

Acknowledgments ........................................

SECTION I

Chapter 1. Smoking Control and the

COMMIT Experience-Summary and Overview ............

Introduction............................................

Trends in the Magnitude of Smoking as a Public Health Problem...

Activities of the Tobacco Industry ...........................

COMMIT and the Evolution of the National Cancer

Institute’s Smoking and Tobacco Control Program ..............

Purpose of This Monograph ................................

COMMIT Intervention Materials ............................

References .............................................

Chapter 2. Background for a Comprehensive

Community-Based Trial for Smoking Control ............

Introduction............................................

Individual Orientations to Tobacco Control ...................

Public Health Model of Tobacco Control......................

Past Community-Based Studies of Tobacco Control .............

Lessons From Previous Studies ..............................

References..............................................

Chapter 3. Community Intervention Trial for Smoking

Cessation: Description and Evaluation Plan ..............

Introduction ............................................

Trial Communities .......................................

Trial Timeline...........................................

Overall Evaluation Plan ...................................

Outcome Evaluation......................................

Page

ii

iii

vii

7

9

11

11

15

15

16

17

18

21

22

xix
Smokiq md Tobacco Control Mono,qrqd~ No. 6

Chapter 4.

SECTION II

Chapter 5.

Chapter 6.

Impact Evaluation .......................................

Process Evaluation .......................................

Economic Evaluation .....................................

Summary ...............................................

References ..............................................

Community Intervention TriaI for Smoking

Cessation: Development of the Intervention .............

Introduction............................................

Intervention Goals and Objectives...........................

Intervention Areas .......................................

Special Considerations of the Intervention Design ..............

Summary...............................................

References..............................................

MobiIizing the COMMIT Communities

for Smoking Contro1...................................

Introduction............................................

Adaptations for Research Purposes ...........................

Steps in Mobilizing Communities ...........................

Community Analysis .....................................

Mobilization Experiences Across Communities .................

What Could Have Been Done Differently? .....................

Conclusions.............................................

References..............................................

Activities To Involve the Smoking Public

in Tobacco Control in COMMIT

Introduction............................................

RationaIe and Process Objectives ............................

Campaigns ..............................................

Magnet Events...........................................

Media-Advocacy..........................................

What Could Have Been Done Differently? ....................

References..............................................

34

35

36

36

37

39

39

40

43

47

48

50

53

53

55

56

57

66

68

70

70

75

75

76

78

82

88

92

94

xx
Chapter 7.

Chapter 8.

Chapter 9.

Chapter 10.

Changing Public Policy Around Tobacco

Control in the COMMIT Communities ...................

Introduction ............................................

Rationale.. .............................................

Changing Policies ........................................

Challenges to Policy Changes ................................

What Could Have Been Done Differently? ....................

Generic Lessons ..........................................

References ..............................................

Activities To Enhance the Use of Cessation

Resources in COMMIT ..................................

Introduction ............................................

Cessation Resources Activities and Process Objectives ............

Developing and Distributing a Cessation Resources Guide ........

Recruiting Heavy Smokers Into a Network .....................

Distributing a Semiannual Newsletter ........................

Special Recruitment and Intervention Activities ................

References ..............................................

Activities To Promote Health Care Providers as

Participants in Community-Based Tobacco Control ......

Rationale ...............................................

Challenges and Barriers ...................................

Goals and Process Objectives for Health Care Providers ..........

Intervention Activities ....................................

What Happened: Successful Components and Challenges ........

The Future—Recommendations.............................

Conclusions .............................................

References ..............................................

Promoting Community Tobacco Control

Through Worksites ....................................

Introduction ............................................

Goals, Activities, and Process Objectives ......................

Planning Worksite Interventions ............................

Intervention Activities and Their Implementation ..............

Delivering the Intervention to the Community ................

97

97

98

100

113

116

116

119

121

121

122

122

125

126

127

130

133

133

135

135

136

138

145

149

149

153

153

154

156

158

169

xxi
Smoking and Tobacco Control Monograph No. 6

Chapter 11.

Chapter 12.

Chapter 13.

Lessons Learned .........................................

References ..............................................

Acknowledgment.........................................

Involving Diverse Community Organizations

in Tobacco Control Activities ...........................

The Rationale for Involving Community Organizations..........

Other Organizations in COMMlT............................

Successful Efforts With Community Organizations..............

Challenges Encountered With Community Organizations........

Experiences With Other Organizations Across the Communities...

Rethinking How To Work With Community Organizations.......

References ..............................................

Promoting Communitywide Tobacco

Control Activities by Involving Schools ..................

Introduction ............................................

Intervention Activities and Process Objectives for Schools........

Implementing School-Based Interventions....................

Patterns of School-Based Interventions.......................

Lessons Learned From COMMIT School-Based Activities.........

References..............................................

Involving Youth in Awareness of, Promotion of,

and Political Activities for Tobacco Control .............

Introduction ............................................

Goals, Activities, and Process Objectives For Youth ..............

Involving Youth in Communitywide Campaigns and

Intervention Activities ....................................

Monitoring and Promoting Enforcement of Regulations

on Youth Access to Tobacco ................................

Successful Activities ......................................

Enlisting Youth in Communitywide Campaigns ................

Magnet Events ...........................................

Monitoring and Enforcing Tobacco Access ....................

Challenges ..............................................

Lessons Learned ..........................................

References ..............................................

174

177

179

183

183

185

191

195

199

203

206

209

209

212

213

215

222

224

227

227

228

229

231

233

233

236

236

237

238

239

xxii
SECTION III

Chapter 14. What Have We Learned and Where

Do We Go From Here? .................................. 241

Introduction ............................................ 241

Major Lessons Learned .................................... 241

Implications of COMMIT Results on Lessons Learned ............ 246

Future Directions for Community Tobacco Control ............. 249

References .............................................. 251

 xxiii

1

Chapter 1

Smoking Control and the COMMIT

Experience—Summary and Overview

Donald R. Shopland, David M. Burns, Beti Thompson, and William R. Lynn

INTRODUCTION Tobacco use, especially the practice of cigarette smoking, remains

the largest preventable cause of death and disability in the United States,

producing more than $50 billion in health care costs in 1993 (Bartlett et al.,

1994). This continuing disease burden overshadows the substantial progress

made in reducing the prevalence of smoking in the past 40 years (Burns et

al., in preparation; Shopland, 1995). In 1955, nearly 60 percent of adult

men and nearly 30 percent of adult women were regular cigarette smokers

(Haenszel et al., 1956). Currently, 25 percent of adults in the United States

are cigarette smokers, but only 20.4 percent, one in every five, report they

smoke on a daily basis (Centers for Disease Control and Prevention, 1994).

Changes in smoking behavior have occurred with, and been partially

driven by, gradually evolving efforts to influence smoking behavior (U.S.

Department of Health and Human Services, 1991). Initial efforts in public

information and education were followed by the development of behavioral

and pharmacologic approaches to assist smokers to achieve and maintain

a nonsmoking status. The limited success of these efforts with individual

smokers eventually led to an understanding of smoking as an addictive

process in which social forces played a critical role in both initiation and

maintenance of the behavior. The potential of broadly structured communitybased interventions providing persistent and inescapable messages to quit

smoking was recognized and formed the scientific foundation for the

Community Intervention Trial for Smoking Cessation (COMMIT) discussed

in this volume.

As the content of this monograph clearly demonstrates, a great deal has

been learned about mobilizing communities and organizing their efforts to

change smoking behavior. The impact of COMMIT’s community organization

approach on smokers’ behavior was modest, at least for the first 4 years of

the intervention. Although no change was noted in the target group of

heavy smokers, there was a statistically significant difference in the quit rates

between intervention and comparison communities among light-to-moderate

smokers (COMMIT Research Group, 1995a and 1995b). Light-to-moderate

smokers, it should be emphasized, comprise 80 percent of the U.S. adult

smoking population (Giovino et al., 1994).

Although COMMIT did not accelerate the quit rate among heavy smokers,

the larger-than-expected percentage of smokers who quit throughout the

communities demonstrated that many aspects of the national effort were

working. It remains to be determined the extent to which broad policy-based

interventions, other alternative tobacco control strategies, or a longer duration
Smoking and Tobacco Control Monograph No. 6

2

of community-based interventions will substantially alter smoking behavior,

particularly among heavy smokers.

One clear result of the approaches described in this volume was successful

mobilization and organization of communities around an externally defined

public health objective. All the communities were successful in developing

an organizational structure and using that structure to accomplish a defined

set of objectives contained in the COMMIT protocol. This success is the

focus of this monograph. A better understanding of what works and what

does not work in efforts to mobilize a community around a public health

goal is one of the most valuable results of COMMIT.

The findings in the intervention vs. comparison communities in COMMIT

need to be placed in an appropriate perspective. There was no difference

between intervention and comparison communities among smokers

consuming 25 or more cigarettes daily (heavy smokers), but 18 percent of

those smokers in both communities quit smoking during the 4 years of the

trial. Similarly, 30.6 percent of smokers of fewer than 25 cigarettes per day

(light-to-moderate smokers) quit smoking in the intervention communities

vs. only 27.5 percent in the comparison communities (COMMIT Research

Group, 1995a and 1995b). These data clearly demonstrate that substantial

rates of cessation occurred among light-to-moderate and heavy smokers.

The results of the trial do not demonstrate that it is difficult to get smokers

to quit; large numbers of both light-to-moderate and heavy smokers did so.

The results of the trial do demonstrate that it is difficult to use many of the

traditional public health approaches to tobacco control, delivered by means

of a community organization structure, to dramatically accelerate the already

high rates of cessation occurring in the population.

In addition, the intervention approach did demonstrate an effect that has

significant public health implications among the light-to-moderate smokers

in the trial, especially compared with the general difficulty in changing other

addictive behaviors. Furthermore, this effect was greatest among those

smokers with a high school education or less, a group in which cessation

rates have been relatively low and on whom other intervention approaches

have had little effect. This effort, produced by means of a public health mode

of delivery, shows the great potential of such prevention efforts to provide

additional years of quality life to the population in a more cost-effective

fashion than disease treatments by the health care delivery system.

TRENDS IN THE The focus of any public health intervention should be reduction

MAGNITUDE OF of incidence and prevalence rates in the entire population, and

SMOKING AS A it is useful to measure tobacco control efforts by this yardstick.

PUBLIC HEALTH Figure 1 demonstrates that during the past 40 years the prevalence

PROBLEM of smoking among white males has been cut in half, from nearly

60 percent in 1955 to less than 30 percent in 1993 (Haenszel et al., 1956;

Centers for Disease Control and Prevention, 1994). The figure shows that the

change in prevalence among white females is more modest, dropping from

approximately 30 percent in 1955 to 22.5 percent in 1993, but the absolute

prevalence remains lower among females than among males.
3

Chapter 1

Figure 1

Prevalence of cigarette smoking among adults by race and gender, United States, 1955-93

Source: Shopland, 1995.

Figure 1 shows that the change in smoking prevalence among blacks

is only slightly less successful, with rates among black males falling from

60 percent in 1955 to 32.4 percent in 1993. Smoking prevalence changes

among black females are nearly identical to those in white females.

Slowing the rate at which adolescents become smokers has proven more

difficult than convincing older smokers to quit. About one-third of highschool-age adolescents use some form of tobacco (Giovino et al., 1994).

Initiation rates among older adolescents have declined steadily (Burns et al.,

in press; Pierce et al., 1994), but changes among younger adolescents have

been far less positive (Cummings et al., 1995).

Initiation rates among younger age adolescents (14 to 17 years old)

decreased slightly from 1980 to 1984 but increased between 1985 and 1989

(Cummings et al., 1995). The largest annual increase occurred in 1988, the

year the R.J. Reynolds Tobacco Company introduced its now famous “Joe the

Camel” cartoon character. Had initiation rates from 1985 to 1989 remained

at the 1984 level, there would have been more than 500,000 fewer adolescent

smokers in the United States during this time. In comparison, among young

adults (ages 18 to 21), initiation rates decreased slightly during the 1980’s

(Cummings et al., 1995).

Smoking prevalence rates among black adolescents have declined

(Institute of Medicine, 1994), whereas rates among white adolescents have
Smoking and Tobacco Control Monograph No. 6

4

Figure 2

Prevalence of daily smoking among white and black high school seniors in the United States

changed little (Figure 2). Although current estimates of smoking initiation

rates for adolescents are not available, smoking prevalence increased among

8th- and 10th-grade students nationally between 1991 and 1993 (Johnston et

al., 1994). These trends coincided with aggressive new marketing practices by

the cigarette industry, many of which are reaching children (U.S. Department

of Health and Human Services, 1994).

The effort to alter the public health problem of tobacco use has clearly

made substantial progress over the past 40 years; however, we have had

greater success in aiding smokers to break their addiction than we have had

in preventing children from becoming addicted. In understanding this

differing response by adults who are already addicted and children who have

not yet become smokers, it is critical to examine the activities of the tobacco

industry during the period of these tobacco control efforts.

ACTIVITIES Over the past four decades, the tobacco industry has aggressively

OF THE responded to each major public health initiative directed at reducing

TOBACCO smoking with a combination of efforts intended to undermine

INDUSTRY these initiatives. The industry introduced a series of new product

modifications, including filtered cigarettes in the 1950’s and low-tar cigarettes

in the 1970’s, to allay the public’s concern about the health risks of smoking

and to convince people that whatever risks existed had been either reduced

Source: Johnston et al., 1994.
5

Chapter 1

drastically or eliminated. More important, during the past 40 years, cigarette

manufacturers have conducted massive, annual, multibillion dollar

advertising campaigns to convince smokers and potential smokers to smoke.

During the time COMMIT interventions were in the field (midfall

1988 through 1992), outlays for all cigarette advertising and promotional

expenditures almost equaled the amount spent the previous 10 years (Federal

Trade Commission, 1995). Expenditures increased 60 percent during the

relatively brief COMMIT intervention period, from $3.28 billion in 1988 to

more than $5.3 billion in 1992 (unadjusted for inflation) (Figure 3).

The most recent data from the Federal Trade Commission show that

cigarette manufacturers spent more than $6 billion for advertising and

promotional expenditures in 1993, the last year complete data are available

(Federal Trade Commission, 1995). This represents more than a 15-percent

increase over 1992 (Table 1).

Significant changes also have occurred in the types and categories of

advertising and promotional activities conducted. When the U.S. Congress

banned cigarette advertising on electronic media in 1971, the bulk of cigarette

advertising shifted to print media and outdoor and transit advertising. Until

the early 1980’s, these categories accounted for the preponderance of all

cigarette advertising and promotional expenditures.

Figure 3

Domestic cigarette advertising and promotional expenses, 1963-93*

* All expenditures were converted to 1993 dollars.

Source: Federal Trade Commission, 1995.
Smoking and Tobacco Control Monograph No. 6

6

Table 1

Domestic cigarette advertising and promotional expenditures, by type and category, United

States 1992 and 1993 (in thousands of dollars)

1992 % of 1993 % of % Change

Type of Advertising ($) Total ($) Total From 1992

Newspapers 35,467 .7 36,204 .6 +2.0

Magazines 237,061 4.5 235,195 3.9 -.08

Outdoor 295,657 5.7 231,450 3.8 -21.7

Transit 53,293 1.0 39,113 .6 -26.6

Point of Sale 366,036 7.0 400,909 6.6 +9.5

Promotional Allowances 1,514,026 28.9 1,557,505 25.8 +2.9

Sampling Distribution 49,315 .9 40,190 .7 -18.5

Specialty Item Distribution 339,997 6.5 755,761 12.5 +122.0

Public Entertainment 89,739 1.7 84,275 1.4 -6.1

Direct Mail 34,345 .7 31,463 .5 -8.3

Coupons and Retail

 Value-Added Promotions 2,175,373 41.6 2,559,170 42.4 +15.0

All Others 41,608 .8 63,915 1.2 +53.6

Total 5,231,917 100.0 6,034,915 100.0 +15.4

Source: Federal Trade Commission, 1995.

However, from the early 1980’s onward, the cigarette industry increasingly

began to emphasize promotional activities, and each year the industry has

committed a larger share of its total advertising and promotional budgets

to these types of activities. Promotional allowances and coupons and retail

value added accounted for nearly 70 percent of all expenditures in 1993.

Less than 10 percent of all expenditures were devoted to advertising in

newspapers, magazines, and outdoor and transit advertising. Nonetheless,

the dollar amount allocated for these categories was nearly $542 million for

1993, a sum that exceeded the total spent for all domestic cigarette advertising

in 1975 (unadjusted for inflation) (Federal Trade Commission, 1995).

Promotional allowances, which accounted for approximately one-quarter

of the $6 billion spent in 1993, are various incentives and fees paid by a

manufacturer to wholesalers and retailers to stock and promote a company’s

products. By far the single largest amount spent in 1993 was for coupons

and value-added promotions—more than $2.5 billion—an increase of nearly

$400 million from the previous year.

Specialty item distribution accounted for more than $755 million in

expenditures for 1993—more than double the amount spent in 1992—and

now accounts for nearly 12 percent of all advertising expenditures. This

category includes the practice of putting a brand’s logo on such things as

T-shirts, caps, sunglasses, sporting goods, and so forth that either are sold
7

Chapter 1

to the consumer or can be ordered from catalogs in exchange for package

premiums or coupons. Recent studies have shown that tobacco company

advertising of promotional activities is reaching adolescents. Among persons

ages 12 to 17 in 1992, 25 percent of nonsmoking adolescents reported having

received promotional items from tobacco companies; nearly 50 percent of

smoking teens reported having received such items (U.S. Department of

Health and Human Services, 1994). Another study (Biener et al., 1994)

found 52 percent of Boston 12- to 17-year-olds reported having seen a

tobacco company catalog, and 54 percent reported knowing someone

younger than 18 years who owned a tobacco promotional item.

During the interval that public health efforts to reduce tobacco use have

been increasing, there has been a disproportionate increase in advertising

and promotional activity by the tobacco industry, and this increased activity

has been accompanied by a shift to promotional activities that may have a

greater attraction for adolescents than for adults (Institute of Medicine, 1994).

This enormous allocation of resources by the tobacco industry undoubtedly

has slowed the rates of positive changes in smoking behavior over the past

40 years, and all current and future tobacco control efforts should be

examined in the context of this growing industry effort to keep smokers

smoking and recruit adolescents to the smoking ranks.

COMMIT AND THE Tobacco use research at the National Cancer Institute (NCI)

EVOLUTION OF THE began in the early 1950’s when cigarette smoking was first

NATIONAL CANCER linked with lung cancer (U.S. Congress, 1957). Over the

INSTITUTE’S SMOKING next decades, NCI funded hundreds of millions of dollars

AND TOBACCO in basic and applied research on smoking and health (U.S.

CONTROL PROGRAM Department of Health and Human Services, 1990). NCI’s

early research concentrated on the areas of tobacco use epidemiology; the

chemistry, pharmacology, and toxicology of tobacco and tobacco smoke;

autopsy studies; and experimental tobacco carcinogenesis. During the early

1970’s, NCI shifted its research focus to identify hazardous substances in

tobacco smoke and ways to reduce or eliminate their presence (National

Cancer Institute and National Heart, Lung, and Blood Institute, 1978).

In the late 1970’s, NCI’s smoking research focus shifted again to include

an examination of behavioral issues related to why people smoked.

In 1982, coincident with the release of the Surgeon General’s report on

cancer (U.S. Department of Health and Human Services, 1982), NCI began a

major planning effort to reduce the national prevalence of tobacco use and

thereby attain a significant reduction in those cancers most associated with

tobacco consumption. NCI initiated a research program to identify effective

approaches to reach individual smokers and persuade them to quit and to

encourage adolescents not to start.

Priorities for targeting intervention research were identified from a

systematic approach that used consensus development involving hundreds

of scientists and other experts (Greenwald et al., 1987). The resulting

consensus was a two-pronged strategy, the first of which included:
Smoking and Tobacco Control Monograph No. 6

8

• physician and dentist interventions to reduce patient smoking

prevalence;

• self-help and minimal interventions to provide materials and

strategies to individuals who wish to quit on their own; and

• mass media interventions using electronic and print media to

encourage cessation and prevention of tobacco use initiation.

The second prong of the strategy targeted populations with needs for

specific interventions or (as with youth) primary targets for prevention of

initiation. These strategies included:

• population interventions, including people of color, women, and

ethnic populations, to develop appropriate smoking prevention and

cessation programs;

• school-based programs to develop curricula to prevent the onset of

tobacco use among adolescents; and

• interventions to prevent the initiation of spitting tobacco use and

promote cessation.

Results from nearly 60 controlled trials helped guide the COMMIT effort

and efforts by other Institutes within the National Institutes of Health as well

as other Public Health Service (PHS) and non-PHS agencies. For example, the

National Heart, Lung, and Blood Institute has funded community risk-factorreduction projects (Farquhar et al., 1984; Lasater et al., 1984; Blackburn et al.,

1984) as well as clinical interventions directed at individuals considered at

high risk for heart disease (Multiple Risk Factor Intervention Trial Research

Group, 1982), all involving adult smokers. These efforts, like COMMIT, were

designed during the 1970’s and early 1980’s and were based on what, at that

time, was considered the state of the art in smoking cessation interventions,

especially for reaching heavy smokers. Cessation results from U.S.-based

cardiovascular risk reduction trials, although mixed generally, have been

positive. For example, the Stanford Five-City Project observed a greater

decline in smoking prevalence in their treatment communities than in

controls, based on their cohort survey, with a larger treatment effect in men

than women (Fortmann et al., 1993); the Minnesota Heart Health Program

reported a modest intervention effect on prevalence of smoking among

women but not men in their cross-sectional analysis but reported no effect

for either in their cohort sample (Lando et al., 1995; Luepker et al., 1994);

and the Pawtucket Heart Health Program reported no significant intervention

effect (Carleton et al., 1995). Similar findings have been observed from

studies in other countries. (See Chapter 2 for further discussion.)

Recently, it has become clear that policy interventions aimed at changing

the social context and general environment in which tobacco is purchased

and consumed are as or more important than delivery of cessation and

prevention services (U.S. Department of Health and Human Services, 1991).

Smoking control policy interventions need to be integrated with
9

Chapter 1

community-based service delivery efforts if they are to be considered

comprehensive, and many of these policy changes often require change at a

higher social and political level than the local community (e.g., tax increases).

COMMIT did not attempt to change communitywide policies but rather

worked within the policy framework that existed within each community at

the time the interventions were implemented. Although it was not the intent

of the COMMIT protocol to change communitywide laws and regulations,

effort was put into increasing the influence of existing policies and economic

factors that discourage smoking (COMMIT Research Group, 1995a and 1995b).

COMMIT actively emphasized the benefits of policies such as smoke-free

environments for worksites, health care facilities, and other community

organization sites, but these policies were accomplished primarily through

individual consultations or group seminars. No systematic effort was made

to implement change throughout the community either through

communitywide ordinances or regulations.

Scientific evidence continues to accumulate to demonstrate the potential

for policy interventions to modify cigarette smoking behavior among adults

and children (U.S. Department of Health and Human Services, 1991; Tobacco

Control, 1992; Institute of Medicine, 1994). Implementation of tobacco

policy change is best accomplished at the State and local levels through

community and coalition support for policies in several important areas:

smoke-free indoor air, implementation and enforcement of laws and

ordinances limiting minors’ access to tobacco products, cigarette tax

increases, and reduction or elimination of certain cigarette advertising

and promotional activities.

PURPOSE OF The purpose of this monograph is to present a synthesis of

THIS MONOGRAPH the operational and process lessons learned from COMMIT.

The monograph is specifically intended to provide detailed information

about the COMMIT intervention process in a manner not possible in scientific

journals. The writers and editors have attempted to distill this information

in a format that is particularly useful to individuals interested in a communitybased approach to smoking control and that describes how to effectively

organize, develop, and implement a comprehensive program aimed at adult

smokers at the local level.

The overall lessons learned from the COMMIT field experience are

discussed in more detail in Chapter 14. Briefly, they include these findings:

• It is possible to establish a partnership with communities so that they

will organize around a community problem.

• It is possible to promote a research agenda even when that agenda is

not the primary problem facing a community.

• Community volunteers are willing and able to plan intervention

activities that are congruent with an intervention protocol.

• Community volunteers are willing to implement intervention activities.
Smoking and Tobacco Control Monograph No. 6

10

• The COMMIT model of community organization and structure of

Boards and task forces was well received and is relevant for use with

other community problems.

• Community volunteers would have liked outcome data during the

trial so that they could make midcourse corrections, if necessary.

• Communities were interested in continuing tobacco control activities.

An earlier planning period for transition and assistance in obtaining

additional resources would have been useful.

• Resources are important in maintaining tobacco control; however,

organized groups can effectively take on tobacco control with few

external resources.

Operational experience with what works and does not work at the

programmatic level frequently provides the core for interventions tested in

controlled scientific investigations. Current concepts of what constitutes

effective approaches to tobacco control frequently outstrip both the tools

needed to evaluate them and the data needed to definitively prove their

impact.

The focus of this monograph is a description of how COMMIT was

conducted rather than the outcome results. While the experience is fresh,

the monograph attempts to present to the larger public health community

the best judgments of the COMMIT research team about what constitutes a

comprehensive, community-based approach to tobacco control for reaching

adult smokers. It is hoped that this description will aid both those currently

designing and implementing programs and those creating the next

generation of scientific studies in tobacco control.

The monograph is organized to follow the research channels used

in the COMMIT communities. Each chapter contains a brief rationale for

intervening through a particular channel and then describes experiences

across the trial. The monograph is intended to be descriptive. Toward that

end, chapters conclude with a section on lessons learned or what could have

been done differently.

The monograph may be read as a unit or in sections of particular interest.

Chapters 2 through 4 provide descriptions of the project and are included

for those who wish to understand the research aspects as well as applications

from the field. Chapter 2 provides a context for community studies.

Chapter 3 describes COMMIT and the evaluation plan for the trial, and

Chapter 4 focuses on the development of the intervention.

Chapter 5 describes the process of understanding communities and

mobilizing them to participate in tobacco control.

Chapters 6 through 13 cover individual channels of intervention used in

COMMIT. Chapter 6 focuses on public education in COMMIT and includes

information on media campaigns, communitywide campaigns, and contests

to help smokers quit. Chapter 7 describes public policy changes in COMMIT
11

Chapter 1

communities and how community Boards and task forces worked for such

changes. Chapter 8 describes how COMMIT sought to build the capacity of

communities’ cessation resources and services. Chapter 9 reviews the

tobacco control activities of health care providers. Chapter 10 specifies how

worksites were brought into intervention activities and encouraged to make

policy changes. Chapter 11 reviews attempts made to draw community

organizations into participating in intervention activities. Chapter 12

describes interventions conducted in schools, and Chapter 13 demonstrates

how youth can become involved in tobacco control outside the school.

Finally, Chapter 14 presents the overall lessons learned and the implications

for future community-based tobacco control initiatives.

COMMIT The authors especially would like to call the readers’ attention to

INTERVENTION the numerous samples of COMMIT resource materials located

MATERIALS throughout the monograph. These materials represent a mere

fraction of all intervention materials used and are presented to provide a

better understanding of the range of materials developed. Of note is the

variation of materials across the 11 geographically and ethnically diverse

communities. Although the COMMIT sites implemented a standard

protocol, the diversity of materials—from unique logos to culturally specific

materials—reflects the adaptation of the protocol by individual communities.

The community-specific aspect of the intervention materials also is an

important indicator of the true community ownership of the COMMIT

project.

Unfortunately, it was never the intention of NCI or the COMMIT

research team to produce sufficient quantities of these materials for general

distribution. We regret that we are unable to honor requests for COMMIT resource

materials.

REFERENCES

Bartlett, J.C., Miller, L.S., Rice, D.P., Max, W.B.

Medical care expenditures attributable to

smoking—United States, 1993. MMWR. Morbidity

and Mortality Weekly Report 43: 469-472, 1994.

Biener, L., Fowler, F.J., Roman, A.M. Tobacco

Advertising and Promotions: The Impact on

Massachusetts Teens. Boston: Massachusetts

Department of Health, 1994.

Blackburn, H., Luepker, R.V., Kline, F.G., Bracht, N.,

Carlaw, R., Jacobs, D., Mittelmark, M., Stauffer, L.,

Taylor, H.L. The Minnesota Heart Health Program:

A research and demonstration project in

cardiovascular disease prevention. In: Behavioral

Health: A Handbook of Health Enhancement and

Disease Prevention, J.D. Matarazzo, S.M. Weiss, J.A.

Herd, N.E. Miller, and S.M. Weiss (Editors). New

York: John Wiley & Sons, 1984, pp. 1171-1178.

Burns, D.M., Lee, L., Shen, L.Z., Gilpin, E., Tolley, D.,

Vaughn, J., Shanks, T.G. Cigarette smoking

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Cigarette-Related Disease Risks and Their Implication

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National Cancer Institute, in preparation.

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Shopland, D.R. Rates of smoking initiation among

adolescents and young adults, 1907-1981. Tobacco

Control: An International Journal, in press.

Carleton, R.A., Lasater, T.M., Assaf, A.R., Feldman,

H.A., McKinlay, S., and the Pawtucket Heart Health

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Health Program: Community changes in

cardiovascular risk factors and projected disease

risk. American Journal of Public Health 85(6): 777-

785, 1995.
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Centers for Disease Control and Prevention.

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1993. MMWR. Morbidity and Mortality Weekly

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COMMIT Research Group. Community Intervention

Trial for Smoking Cessation (COMMIT): I. Cohort

results from a four-year community intervention.

American Journal of Public Health 85: 183-192,

1995a.

COMMIT Research Group. Community Intervention

Trial for Smoking Cessation (COMMIT): II.

Changes in adult cigarette smoking prevalence.

American Journal of Public Health 85: 193-200,

1995b.

Cummings, K.M., Shah, D., Shopland, D.R. Trends

in smoking initiation among adolescents and

young adults—United States, 1980-1989. MMWR.

Morbidity and Mortality Weekly Report 44(28): 521-

525, 1995.

Farquhar, J.W., Fortmann, S.P., Maccoby, N., Wood,

P.D., Haskell, W.L., Taylor, C.B., Flora, J.A.,

Solomon, D.S., Rogers, T., Adler, E., Breitrose, P.,

Weiner, L. The Stanford Five City Project: An

overview. In: Behavioral Health: A Handbook of

Health Enhancement and Disease Prevention, J.D.

Matarazzo, S.M. Weiss, J.A. Herd, N.E. Miller, and

S.M. Weiss (Editors). New York: John Wiley &

Sons, 1984, pp. 1154-1165.

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Cigarette Labeling and Advertising Act. Washington,

DC: Federal Trade Commission, 1995.

Fortmann, S.P., Taylor, C.B., Flora, J.A., Jatulis, D.E.

Changes in adult cigarette smoking prevalence

after 5 years of community health education: The

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Epidemiology 137: 82-96, 1993.

Giovino, G., Schooley, M.W., Zhu, B.-P., Chrismon,

J.H., Tomar, S.L., Peddicord, J.P., Merritt, R.K.,

Husten, C.G., Eriksen, M.P. Surveillance for

selected tobacco-use behaviors—United States,

1900-1994. MMWR. Morbidity and Mortality Weekly

Report 43: 1-43, 1994.

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prevention and control: From research through

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Monitoring the Future Study, 1975-1993: Vol. I.

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Abuse, 1994.

Lando, H.A., Pechacek, T.F., Pirie, P.L., Murray, D.M.,

Mittlemark, M.B., Lichtenstein, E., Nothwehr, F.,

Gray, C. Changes in adult cigarette smoking in the

Minnesota Heart Health Program. American Journal

of Public Health 85(2): 201-208, 1995.

Lasater, T., Abrams, D., Artz, L., Beaudin, P., Cabrera,

L., Elder, J., Ferreira, A., Knisley, P., Peterson, G.,

Rodrigues, A., Rosenberg, P., Snow, R., Carleton, R.

Lay volunteer delivery of a community-based

cardiovascular risk factor change program: The

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Prevention, J.D. Matarazzo, S.M. Weiss, J.A. Herd,

N.E. Miller, and S.M. Weiss (Editors). New York:

John Wiley & Sons, 1984, pp. 1166-1170.

Luepker, R.V., Murray, D.M., Jacobs, D.R.,

Mittelmark, M.B., Bracht, N., Carlaw, R., Crow, R.,

Elmer, P., Finnegan, J., Folsom, A.R., Grimm, R.,

Hannan, P.J., Jeffrey, R., Lando, H., McGovern, P.,

Mullis, R., Perry, C.L., Pechacek, T., Pirie, P.,

Sprafka, J.M., Weisbrod, R., Blackburn, H.

Community education for cardiovascular disease

prevention: Risk factor changes in the Minnesota

Heart Health Program. American Journal of Public

Health 84(9): 1383-1393, 1994.

Multiple Risk Factor Intervention Trial Research

Group. Multiple risk factor intervention trial. Risk

factor changes and mortality results. Journal of the

American Medical Association 248(12): 1465-1477,

1982.

National Cancer Institute and National Heart, Lung,

and Blood Institute. Smoking and Health. A Program

To Reduce the Risk of Disease in Smokers. Status

Report. Bethesda, MD: National Institutes of

Health, 1978.

Pierce, J.P., Lee, L., Gilpin, E.A. Smoking initiation

by adolescent girls, 1944 through 1988. An

association with targeted advertising. Journal of the

American Medical Association 271: 608-611, 1994.

Shopland, D.R. Effect of smoking on the incidence

and mortality of lung cancer. Chapter 1. In: Lung

Cancer, B.E. Johnson and D.H. Johnson (Editors).

New York: John Wiley & Sons, 1995, pp. 1-14.

Tobacco Control: An International Journal. Policy

research: Strategic directions. Tobacco Control:

An International Journal 1(suppl): S1-S56, 1992.

U.S. Congress. “False and Misleading Advertising

(Filter-Tip Cigarettes).” Hearings before a

Subcommittee of the Committee on Government

Operations. Washington, DC: U.S. House of

Representatives, 85th Congress, First Session, July

18, 19, 23-26, 1957.
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Chapter 1

U.S. Department of Health and Human Services. The

Health Consequences of Smoking: Cancer. A Report of

the Surgeon General. DHHS Publication No. (PHS)

82-50179. Rockville, MD: U.S. Department of

Health and Human Services, Public Health Service,

Office on Smoking and Health, 1982.

U.S. Department of Health and Human Services.

Smoking, Tobacco, and Cancer Program. 1985-1989

Status Report. NIH Publication No. 90-3107.

Bethesda, MD: U.S. Department of Health and

Human Services, Public Health Service, National

Institutes of Health, 1990.

U.S. Department of Health and Human Services.

Strategies To Control Tobacco Use in the United

States: A Blueprint for Public Health Action in

the 1990’s. Smoking and Tobacco Control

Monographs—1. NIH Publication No. 92-3316.

Bethesda, MD: U.S. Department of Health and

Human Services, Public Health Service, National

Institutes of Health, National Cancer Institute,

1991.

U.S. Department of Health and Human Services.

Preventing Tobacco Use Among Young People. A

Report of the Surgeon General. Atlanta, GA: U.S.

Department of Health and Human Services, Public

Health Service, Centers for Disease Control and

Prevention, National Center for Chronic Disease

Prevention and Health Promotion, Office on

Smoking and Health, 1994.

AUTHORS

Donald R. Shopland

Coordinator

Smoking and Tobacco Control Program

National Cancer Institute

National Institutes of Health

Executive Plaza North, Room 241

6130 Executive Boulevard, MSC-7337

Bethesda, MD 20892-7337

David M. Burns, M.D.

Professor of Medicine

University of California at San Diego

Medical Center

200 West Arbor Drive

San Diego, CA 92103-8375

Beti Thompson,Ph.D.

Associate Professor

University of Washington School of Public

Health and Community Medicine

Associate Member

Fred Hutchinson Cancer Research Center,

MP-702

1124 Columbia Street

Seattle, WA 98104
Smoking and Tobacco Control Monograph No. 6

14

William R. Lynn

COMMIT Project Officer

Public Health Applications Research Branch

Cancer Control Science Program

National Cancer Institute

National Institutes of Health

Executive Plaza North, Room 241

6130 Executive Boulevard, MSC-7337

Bethesda, MD 20892-7337
15

Chapter 2

Background for a Comprehensive CommunityBased Trial for Smoking Control

Norman Hymowitz, Michael D. Mueller, William R. Lynn, and

Beti Thompson

INTRODUCTION Americans suffer greatly from diseases that are not the inevitable

consequence of being born or growing old. Diseases that were rare in society

prior to the 20th century, such as coronary heart disease (CHD), lung cancer,

and chronic obstructive pulmonary disease (COPD), now have reached

epidemic proportions (U.S. Department of Health and Human Services,

1989). The dramatic increase in these chronic diseases reflects changes in

20th-century American culture and lifestyle, including changes in dietary

and exercise habits and the explosive increase in cigarette smoking during

the first half of this century. Former U.S. Surgeon General C. Everett Koop

considers cigarette smoking to be the single most important preventable

cause of premature death and disability in society today (U.S. Department

of Health and Human Services, 1988). It is sobering to note that this mass

phenomenon was unknown in America prior to this century.

By the time of the first Surgeon General’s Report in 1964, more than

50 percent of adult males and nearly 30 percent of adult females smoked

cigarettes. The prevalence among men ages 20 to 30 was 70 percent

(Warner, 1986). Since that landmark Surgeon General’s Report, considerable

progress has been made in the nonsmoking arena. By 1993, the prevalence

of smoking in the United States dropped to 27.7 percent for males and

22.2 percent for females. The relatively small drop in prevalence for females

has been attributed variously to the changing role of women in today’s

society and the marketing strategies of tobacco companies (Fiore et al., 1989).

Most Americans, smokers as well as nonsmokers, are aware of the harmful

effects of cigarettes (U.S. Department of Health and Human Services, 1989

and 1991); furthermore, most adult smokers say they would like to stop

smoking (U.S. Department of Health and Human Services, 1990).

The dangers of environmental tobacco smoke (ETS) are now well

established, and the U.S. Environmental Protection Agency has labeled

secondhand smoke as a Class A carcinogen (U.S. Department of Health

and Human Services, 1993a). Legislation and policies curtailing and even

banning smoking in public places have increased dramatically in recent

years (U.S. Department of Health and Human Services, 1993b).

Despite these positive signs, there remains much work ahead. Young

people continue to acquire the smoking habit at an alarming rate (Pierce et

al., 1989; U.S. Department of Health and Human Services, 1994); more than

46 million Americans continue to smoke (U.S. Department of Health and

Human Services, 1990); and progress in the antismoking field is uneven.
Smoking and Tobacco Control Monograph No. 6

16

African-Americans respond less well to antismoking campaigns than whites

(Centers for Disease Control, 1990); the poor and least educated continue

to smoke at a high rate (Pierce et al., 1989); and high smoking rates among

women have boosted lung cancer past breast cancer as the number one cause

of cancer death among American women (American Cancer Society, 1992).

INDIVIDUAL Research focusing on tobacco control began in the 1970’s. A quick

ORIENTATIONS review of the smoking control research literature indicates that

TO TOBACCO most research has focused on individual-oriented strategies

CONTROL (U.S. Department of Health and Human Services, 1991). Such

interventions usually take place in clinics and involve labor-intensive

treatments, often administered by professional therapists. The objective of

such research is to identify interventions that produce high rates of smoking

cessation. Unfortunately, the effects are limited to the relatively few patients

or clients who can participate in such clinics. For example, multicomponent

group intervention programs (Pechacek, 1979) are among the most effective

clinical strategies available. They feature a synthesis of motivational,

educational, and behavioral approaches to smoking cessation and use

several behavioral strategies to help smokers acquire skills that will enable

them to stop smoking and remain abstinent (Pechacek, 1979). Although

multicomponent group intervention programs may yield impressive initial

and long-term quit rates (Pechacek, 1979), their effectiveness suffers from

the limited availability of skilled therapists, the limited numbers of smokers

who can be accommodated, the cost of the treatment, and often, the

reluctance of smokers to participate in intensive group or individual

programs. However, most smokers stop on their own without the aid

of a specific program, perhaps reflecting an environment that increasingly

favors nonsmokers.

In an attempt to broaden the reach of clinical interventions, strategies

have been “repackaged” for use in other settings. If the successful ingredients

of the multicomponent programs can be packaged into a self-help manual or

videotape that can be used by many smokers with minimal or no professional

supervision, the potential public health effect of the intervention can be

vastly expanded. During the past decade, research interest has shifted from

the search for more effective clinical treatments to an exploration of ways

to repackage existing treatments to enhance their public health impact

(Hymowitz, 1992; Lichtenstein and Glasgow, 1992; Cohen et al., 1989), and

the National Cancer Institute Smoking and Tobacco Control Program has

supported numerous studies in this area. This interest has led to research on

bibliotherapy and self-help manuals (Glasgow et al., 1981), computer-assisted

cessation technologies (Schneider and Benya, 1984), quit-smoking contests

and lotteries (Glasgow et al., 1985), hot lines (Ossip-Klein et al., 1991), and

imaginative use of print (Cummings et al., 1987) and electronic (Flay et al.,

1988) media.

Another relatively new emphasis is the focus on different channels for

reaching smokers and delivering interventions. Nontraditional settings,

such as worksites (Sorensen et al., 1990-91; Hymowitz et al., 1991; Glasgow
17

Chapter 2

and Terborg, 1988), hospitals (Hudzinski and Frohlich, 1990), physician

offices (Ockene, 1987; Cummings et al., 1989), religious organizations (Lasater

et al., 1986; Eng et al., 1985), and health clinics (Mayer et al., 1990) provide

opportunities to reach many smokers from all segments of society, many

of whom are missed by more traditional group-help or clinical approaches.

Moreover, these settings often provide excellent opportunities for long-term

intervention and followup, thereby increasing the likelihood of long-term

success.

PUBLIC HEALTH In the past 15 years, the perceptions of smoking behavior have

MODEL OF changed. Increasingly, it is seen as a public health problem as well

TOBACCO as an individual problem. The public health model is based on

CONTROL the relationship among three factors: (1) the host or recipient of

a disease, (2) the agent or cause of the disease, and (3) the environment or

setting in which the disease occurs. Smoking fits this model. The agent of

the disease is tobacco, the recipient is the smoker, and the environment

includes all those cues and constraints within an individual’s world that

promote or inhibit the use of tobacco. Tobacco control efforts can be built

around this model. Instead of intervening between the agent and the host,

activities can be directed toward the environment that promotes the agent

of the disease. For example,

the tobacco companies

spend more than $4 billion

annually to promote their

products and increase the

companies’ legitimacy

(Warner, 1986), despite

the fact that cigarette

smoking claims the lives

of more than 400,000

Americans each year

(U.S. Department of

Health and Human Services,

1989). Policies that prohibit

tobacco promotion and

advertising, or keep it to

a minimum, can have a

large effect on smoking

onset among youngsters.

Similarly, as demonstrated

in California, taxation

of tobacco can fund

counterpromotion activities

(U.S. Department of Health

and Human Services, 1989).

Societal norms—shared

rules and expectations for

behavior—produce a
Smoking and Tobacco Control Monograph No. 6

18

complex system of formal and informal guidelines for the appropriateness

of behaviors (Robertson, 1977). The most effective strategies for tobacco

control are those that strike at the heart of the social mores and norms that

support the smoking epidemic. However, norms vary by time, social network,

and locality; thus, to produce large-scale changes in smoking behavior,

intervention must target large social entities. To this end, health promotion

researchers now are focusing on the community as the target of intervention.

Community-based interventions have both advantages and disadvantages

over traditional individual-based interventions. As many researchers have

observed, smoking is promoted through the social and physical environment

of the community; thus, it is embedded in the smoker’s way of life. Largescale efforts to change this environment have the potential to affect many

smokers at a lower cost per person. Some disadvantages of community-based

programs, from a research perspective, are the broad secular trends in smoking

behavior that are intertwined with program effect, the quasi-experimental

and often complicated designs of studies that make it difficult to sort out

cause-and-effect relationships, and the lack of long-term followup (Farquhar

et al., 1984).

For these reasons, the mounting national and international experience

in community control of smoking over the past 20 years has not produced

conclusive evidence that these programs bring about either broad or longterm change in smoking behavior in target populations. However, the

evidence is sometimes compelling and offers much value to designers of other

large-scale studies. A brief review of this literature provides a good backdrop

to the Community Intervention Trial for Smoking Cessation (COMMIT).

PAST COMMUNITY- Experience with community intervention for health promotion

BASED STUDIES OF derives largely from a host of multifactor studies of heart

TOBACCO CONTROL disease prevention (Hymowitz, 1987). Several excellent

reviews of the community intervention literature are available (Hymowitz,

1987; Thompson and Pertschuk, 1992; U.S. Department of Health and

Human Services, 1991 and 1987). A few of these are described below.

The Stanford Three Community Study was the first major community

intervention trial. It began in 1972, with three communities randomized to

mass media, mass media plus intensive face-to-face intervention, or control.

Only the community with mass media and intensive face-to-face intervention

showed a substantial decrease in the mean number of cigarettes smoked per

day, with the high-risk group identified for the individual interactions

showing a large and meaningful decrease (–42.3 percent) (Farquhar et al.,

1977). However, the control city showed a decrease of 17 percent for a net

reduction of –25 percent (Farquhar et al., 1977).

The North Karelia Project in Finland was also an initial major community

intervention trial; it focused on the control of cardiovascular disease (CVD) in

one county, with another county selected for control. This demonstration

project, initiated in 1972, was a response to a request of the North Karelians

for assistance in dealing with the high rate of CVD in their population.
19

Chapter 2

Smoking was one component of the intervention (Puska et al., 1976). By

1982, 36 percent of North Karelian men ages 30 to 59 were current smokers

compared with 42 percent in the reference community, a statistically

significant difference (Puska et al., 1983 and 1989). The interpretation of

the trial is difficult given that the community requested the intervention

and that national legislative changes also may have contributed to the

change in prevalence.

The Stanford Three Community Study described above was followed by

three similar studies funded by the National Heart, Lung, and Blood Institute.

These studies, the Stanford Five-City Project, the Minnesota Heart Health

Program, and the Pawtucket Heart Health Program, further investigated the

possibility of changing behavior at the community level. Final results of the

Stanford Five-City Project, conducted in two treatment communities, showed

a statistically significant 13-percent decrease in smoking in a cohort sample

but no significant differences in a cross-sectional sample (Fortmann et al.,

1993). The Minnesota project used three pairs of communities, and within

each pair, one community was nonrandomly assigned to intervention and

one to control. Both cohort and cross-sectional surveys showed no difference

in smoking for males; however, the cross-sectional survey indicated a decline

in smoking for females (Luepker et al., 1994). The Minnesota project also

implemented interventions in schools and found that, in the intervention

communities, 14.6 percent of students were smokers at graduation, compared

with 24.1 percent in the comparison communities (Perry et al., 1992).

Potential weaknesses of this study include the diversity among the

communities, the lack of randomization, and evidence of a strong secular

trend for smoking cessation that may have made it difficult to see any

intervention effects. The Pawtucket project initially focused on social

networks, such as worksites, schools, religious organizations, and other

organizations, to spread an antismoking intervention but later added

social marketing and communitywide activities. A “Quit and Win” contest

showed good participation and good long-term results (Elder et al., 1986).

Overall results from the Pawtucket project showed downward, symmetrical,

and secular trends in smoking prevalence (Carleton et al., 1995).

The Australian North Coast Healthy Lifestyle Programme: Quit for

Life used a social marketing approach to community intervention (Egger et

al., 1983). Professional media and advertising techniques were used to

prepare messages. The media included organizations from television, radio,

and print, and stickers, posters, T-shirts, balloons, and self-help quit kits

were among other advertising techniques used. In addition to the media

campaign, a variety of community antismoking programs were offered in

the community receiving media plus community programs. These programs

included a 5-day plan, commercial quit-smoking groups, a quit club, a quit

1-day workshop, a quit 5-day clinic, hypnotherapy, and doctor’s kits.

The results of prevalence surveys taken at baseline and during years 2 and

3 suggest that the Australian North Coast Healthy Lifestyle Programme:

Quit for Life was effective in reducing the prevalence of smoking in the

experimental communities compared with the reference community
Smoking and Tobacco Control Monograph No. 6

20

(Egger et al., 1983). The biggest change in the prevalence of smoking

occurred in Lismore, the mass media and specific intervention community.

Of the specific quit-smoking programs offered, the most popular were those

that did not require face-to-face contact (kits, informational brochures,

factsheets, and so forth) (Egger et al., 1983). Among smokers who reported

quitting, most reported that they quit smoking on their own, a finding that

emphasizes the importance of creating a social milieu that encourages and

supports self-initiated quit-smoking attempts.

The National Research Program in Switzerland also focused on CVD

prevention. This project involved two pairs of communities, with one

community per pair randomized to intervention. The observed decrease

in smoking prevalence was statistically significant. It also was found that

light and moderate smokers were more likely to quit than heavy smokers

(Gutzwiller et al., 1985). The major weakness of this study was low response

rates to the outcome surveys.

Another Australian study, the Sydney Quit for Life Anti-Smoking

Campaign, used mass media to reduce smoking prevalence in two Australian

cities, Sydney and Melbourne. The remainder of Australia was used as a

control area. The intervention was phased into the two cities, first in Sydney

and a year later in Melbourne. The combined effect of the program was

statistically significant in both intervention cities (Dwyer et al., 1986).

Long-term effects of the trial were most dramatic for men in Sydney, where

smoking prevalence dropped 2.5 percent in the first 6 months of the

intervention and continued at a decline of 1.12 percent per year; similar

trends were seen in Melbourne. However, after an initial decline, women did

not continue to decrease their smoking prevalence rates (Pierce et al., 1989).

Several other important community or large-scale intervention studies

have revealed positive effects on prevalence of cigarette smoking. Among

them are the Community Hypertension, Atherosclerosis, and Diabetes

(CHAD) program in Israel

(Gofin et al., 1981 and 1986),

the Cardiovascular Disease

Prevention Program in an

Austrian community (Rhomberg,

1991), and the Coronary Risk

Factor Study in South Africa

(Steenkamp et al., 1991). In

addition, several community

studies are under way in

Germany, Ireland, Sweden,

and the Netherlands that also

target general risk factors related

to health, including smoking.
21

Chapter 2

LESSONS

FROM

PREVIOUS

STUDIES

The review of studies suggests several lessons on smoking.

• The recognition that behavior occurs within a social environment

has implications for each level of the social environment. Although

communities can be extremely influential in shaping that environment, communities exist within broader systems, including Federal

and State systems, both of which are likely to have a great impact on

smoking behavior. For example, the annual Surgeon General reports

alert health care professionals about new findings in tobacco use and

control. The Federal Government imposes regulations on the sale of

tobacco; it also collects taxes on tobacco. Every State government in

the United States has placed restrictions on youth access to tobacco.

Most recently, one State, California, has experimented with dedicating

State taxes on tobacco products to antismoking media campaigns. This

“top down” support of the greater entities within which communities

operate can be a powerful contributor to community change, as

suggested by North Karelia legislative changes that came during the

intervention period. The recent Canadian and California experiences

with increased taxes and the subsequent greater decrease in smoking

prevalence compared with the United States overall also emphasize

the importance of support from the larger systems.

• It is important to recognize that cigarette smoking and associated

adverse health consequences are community problems that require

community solutions. Individual and clinical interventions have

an important place in the antismoking arena, but true success will

not be obtained until communities and their concerned citizens let

it be known that “enough is enough.” Communities should take a

stand to protect their youth from lung cancer, CHD, COPD, and the

many other ill effects of smoking. Also, it is up to communities to

implement rules and regulations that protect their citizens from the

affliction of ETS. Communities can help create a social climate in

which cigarette smoking is viewed as an unacceptable behavior.

• It is noteworthy that in both the North Karelia and the Australian

studies intervention effects continued to be observed throughout

the 10 years of the study. This finding documents the importance

of long-term commitment. Community intervention studies are

unique public health endeavors, and often, a considerable amount

of time is needed to organize the community, mobilize diverse

intervention channels, and introduce comprehensive social marketing

and behavioral programs that not only lead to the prevention of

smoking onset and the modification of existing smoking behavior

but also contribute to changes in social norms and mores.

• An advantage of community interventions is that the effect of specific

interventions is enhanced by their presentation within the context

of an “enriched” milieu. Hence, coordination of several different

interventions in communities may enhance the effectiveness of all.
Smoking and Tobacco Control Monograph No. 6

22

• Prior community intervention studies underscore the importance of

the considerable thought and attention required for coordination and

planning to maximize community resource and intervention effects.

Together, systematic programming can contribute to a change in the

social milieu, so necessary for the long-term modification of smoking

behavior.

• Although community-based smoking cessation and prevention

approaches are likely to be less efficacious than individual or clinical

programs, they are designed to be more cost-effective and to reach

larger numbers of smokers, thus producing a larger public health

effect.

• There can be little question that Federal, State, community, and

individual approaches to smoking cessation have an important place

in the antismoking arena. Smokers who desire clinical treatment and

support ought to be able to obtain the help they need. However, in

view of the magnitude of the smoking problem in the United States,

the great numbers of smokers in need of assistance, and the terrible

toll that cigarette smoking continues to take on the health of this

Nation, it is also necessary to implement effective public health

strategies.

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25

Chapter 2

AUTHORS

Norman Hymowitz,Ph.D.

Professor of Clinical Psychiatry

Department of Psychiatry and Mental

Health Services

University of Medicine and Dentistry of

New Jersey Medical School

Newark, NJ 07103

Michael D. Mueller,M.S.

Senior Technical Writer

R.O.W. Sciences, Inc.

Suite 400

1700 Research Boulevard

Rockville, MD 20850-3142

William R. Lynn

COMMIT Project Officer

Public Health Applications Research Branch

Cancer Control Science Program

National Cancer Institute

National Institutes of Health

Executive Plaza North, Room 241

6130 Executive Boulevard, MSC-7337

Bethesda, MD 20892-7337

Beti Thompson,Ph.D.

Associate Professor

University of Washington School of Public

Health and Community Medicine

Associate Member

Fred Hutchinson Cancer Research Center,

MP-702

1124 Columbia Street

Seattle, WA 98104
Smoking and Tobacco Control Monograph No. 6

26
27

Chapter 3

Community Intervention Trial for Smoking

Cessation: Description and Evaluation Plan

William R. Lynn and Beti Thompson

INTRODUCTION The Community Intervention Trial for Smoking Cessation

(COMMIT) was a large-scale undertaking that incorporated virtually

all key features of past community trials. It was the largest National

Cancer Institute (NCI) effort to test methods to help people stop smoking.

COMMIT used many methods and strategies developed in smaller NCIfunded trials conducted in the early 1980’s (U.S. Department of Health

and Human Services, 1990) and incorporated many of these methods

into a community-based approach, which involved community groups,

institutions, and organizations in confronting the smoking problem

in their community.

COMMIT focused on heavy smokers (those smoking more than

25 cigarettes per day). At the time of trial development, heavy smokers

represented about one-third of all adult smokers. Heavy smokers account

for nearly half the lung and other smoking-related cancers, and the risk

of disease and death from heart and lung diseases dramatically increases

as the number of cigarettes smoked per day increases (U.S. Department

of Health and Human Services, 1982 and 1989).

Heavy smokers appear to face special problems in quitting. Several

large prospective studies have indicated that spontaneous quit rates are

lower among heavy smokers than among light-to-moderate smokers.

Data from the Multiple Risk Factor Intervention Trial (MRFIT) special

intervention group indicate that even when fairly intensive smoking

cessation interventions are offered on a continuous basis for up to 6 years,

heavy smokers have more difficulty quitting and maintaining abstinence

(Hughes et al., 1981). Similarly, some community-based studies (Gutzwiller

et al., 1985; Steenkamp et al., 1991) suggest that light and moderate smokers

have less difficulty quitting than heavy smokers. Thus, it was appropriate

to target this group of hard-to-reach smokers who account for much of the

excess morbidity and mortality related to smoking.

TRIAL COMMUNITIES In response to a request for proposals from NCI, several

investigators competed for participation in a community-based trial aimed

at reducing smoking rates in heavy smokers. Major criteria for being selected

for participation were the ability to recruit two similar communities that

agreed to be randomized to receive either active intervention or control

surveillance and having experience in smoking control and community

studies. For purposes of the study, a community was broadly defined and

could include a well-defined portion of a major metropolitan area or two

small cities in the same geographic region. Communities within matched

pairs were required to have some boundary separation to maintain
Smoking and Tobacco Control Monograph No. 6

28

independence of intervention activities and to prevent contamination.

Within each pair, communities were matched for general sociodemographic

factors, including population size, age distribution, demographic profile

(ethnicity, proportion female, age distribution, educational distribution,

and mean family income level), mobility and migration patterns, extent of

urbanization, estimated smoking prevalence rates, and access to a variety

of intervention channels.

Criteria for selecting the pair of communities varied by research

institution; however, they were required to fall within certain size parameters.

The communities were later examined for characteristics thought to be related

either to cigarette smoking behavior or access to channels that had been

defined for intervention. Some of the latter characteristics included whether

community residents received their health care within the community,

whether they worked within the community, the availability of media

resources, and baseline smoking prevalence. The research institutions

and their associated community pairs are identified in Table 1.

Table 1

List of the 22 COMMIT communities

Contracting Organization Community Sites

Waterloo Research Institute Brantforda

Waterloo, Ontario, Canada Peterborough

Kaiser Foundation Research Institute Vallejoa

Oakland, CA Hayward

Roswell Park Memorial Institute Uticaa

Buffalo, NY Binghamton/Johnson City

Research Triangle Institute Raleigha

Research Triangle, NC Greensboro

Fred Hutchinson Cancer Research Center Bellinghama

Seattle, WA Longview/Kelso

University of Medicine and Dentistry of New Jersey Patersona

Newark, NJ Trenton

Oregon Research Institute Medford/Ashlanda

Eugene, OR Albany/Corvallis

University of Massachusetts Medical School Fitchburg/Leominstera

Worcester, MA Lowell

The Lovelace Institutes Santa Fea

Albuquerque, NM Las Cruces

University of Iowa Cedar Rapids/Mariona

Iowa City, IA Davenport

American Health Foundation Yonkersa

New York, NY New Rochelle

a

 Community randomized to receive intervention.
29

Chapter 3

The community populations ranged from 49,421 to 251,208 with

comparable statistical means for the pooled intervention and comparison

communities. Overall, the intervention and comparison communities were

well matched with regard to general sociodemographic variables (see Table 2).

A cluster analysis was performed using census data for eight demographic

variables on which the pairs could demonstrate agreement: racial

distribution, Hispanic ethnicity, gender by age, gender by marital status,

general occupational category, educational attainment, family income,

and years resident in the current household. This analysis verified the

comparability of the households in the community pairs.

Table 2

Sociodemographic characteristics of community pairs

High

Ages School Low

White Female 25-64 Graduate Income

Community/Area Population (%) (%) (%) (%) (%)

Vallejo, CA 120,060 52.1 50.2 51.1 80.7 17.1

Hayward, CA 141,893 63.5 50.8 53.9 75.3 16.3

Cedar Rapids/Marion, IA 144,243 96.3 51.7 52.1 85.0 20.6

Davenport, IA 125,593 91.0 52.1 50.5 81.5 24.9

Fitchburg/Leominster, MA 79,339 91.3 51.8 49.8 72.0 24.2

Lowell, MA 103,439 81.2 51.4 47.5 65.8 27.9

Paterson, NJ 141,431 41.3 52.1 49.3 54.9 28.2

Trenton, NJ 91,688 42.0 51.3 49.9 58.2 29.7

Santa Fe, NM 68,092 81.3 52.3 55.7 83.4 22.0

Las Cruces, NM 69,015 88.8 51.0 48.2 78.4 34.3

Yonkers, NY 61,698 68.3 53.6 53.0 72.9 22.5

New Rochelle, NY 49,421 70.9 53.5 52.7 72.5 21.3

Utica, NY 76,967 87.8 53.1 46.8 68.8 37.1

Binghamton/Johnson City, NY 73,632 93.2 53.1 47.8 74.2 35.8

Raleigh, NC 232,652 70.8 51.5 54.8 86.5 18.9

Greensboro, NC 251,208 71.1 52.7 53.4 79.0 21.0

Medford/Ashland, OR 66,832 94.7 52.4 49.1 83.4 29.8

Albany/Corvallis, OR 77,323 92.2 50.4 45.6 87.5 31.4

Bellingham, WA 76,908 92.9 51.3 48.4 85.4 24.9

Longview/Kelso, WA 62,433 95.0 50.9 50.3 77.5 28.2

Brantford, Ontario, Canada 88,525 a 51.5 50.7 56.3 14.9

Peterborough, Ontario, Canada 91,075 a 52.2 49.7 63.4 15.0

Mean for Intervention Sites 105,159 74.6 51.8 51.4 76.2 22.7

Mean for Comparison Sites 103,338 76.6 51.8 50.6 74.5 24.6

a Data not available.
Smoking and Tobacco Control Monograph No. 6

30

TRIAL TIMELINE The COMMIT trial was initiated in September 1986 and was

implemented in three phases. Phase I (October 1986 through October

1988) focused on the development of a standard intervention protocol,

an evaluation plan, and the baseline assessment, randomization, and

mobilization of communities. During Phase II (October 1988 through

December 1992) the intervention was implemented in the 11 intervention

communities. During Phase III (January 1993 through March 1995) final

surveys were conducted, and data from the trial continue to be analyzed.

OVERALL The study’s evaluation plan measures changes in community smoking

EVALUATION patterns and allows for testing the assumptions that have guided the

PLAN development of the intervention strategies. Evaluation strategies are

organized into four components: (1) outcome evaluation, which measures

changes in smoking behavior; (2) impact evaluation, which measures

changes in factors thought to be important in facilitating communitywide

smoking behavior changes (including social norms about smoking, tobacco

intervention activities by health care providers, and media coverage of

tobacco issues); (3) process evaluation, which documents the extent of

intervention implementation; and (4) economic evaluation, which estimates

the costs of the COMMIT interventions.

OUTCOME The primary hypothesis to be tested in the trial was that the

EVALUATION implementation of a defined intervention protocol, delivered through

multiple community groups and organizations and using limited external

resources, would result in a quit rate in heavy smokers that was at least

10 percentage points greater (e.g., 25 versus 15 percent) than that observed

in the comparison communities. Outcome evaluation was designed to

measure the effect of the COMMIT intervention on (1) smoking cessation

rates among cohorts of heavy smokers, (2) smoking cessation rates among

cohorts of light-to-moderate smokers, (3) the prevalence of overall smoking

among adults, and (4) smoking onset among adolescents. The primary

outcome measure was the smoking cessation rate of a representative cohort

of heavy smokers; a secondary outcome measure was the smoking cessation

rate of a representative cohort of light-to-moderate smokers.

Endpoint and To identify residents to be tracked as cohort members and to

Evaluation Cohorts provide baseline prevalence estimates, a telephone survey was

performed at baseline (January 1988) prior to randomization of communities.

The baseline telephone survey provided information on smoking prevalence

and recent quit rates for adults between ages 25 and 64 in the paired

communities. The overall estimated prevalence of cigarette smoking

was about 28 percent, which was comparable with national estimates of

30 percent, as reported in the 1984 National Health Interview Survey (Kovar

and Poe, 1985). The specific estimates for the 22 communities (shown

in Table 3) demonstrate that the community pairs were well matched not

only on demographic characteristics but also on smoking prevalence and

recent cessation behavior.
31

Chapter 3

Table 3

Estimated smoking prevalence (by percent) and quit rates (by percent)

in the COMMIT communities

Quit Rate

Smoking Rate for Rate for Rate for

Prevalence 2.5 Years, 2.5 Years, 5 Years,

Community/Area 1988 1983-85 1986-88 1983-88

Vallejo, CA 26.06 11.8 18.4 28.0

Hayward, CA 24.90 10.6 18.9 27.5

Cedar Rapids/Marion, IA 22.35 14.0 18.8 30.1

Davenport, IA 26.22 14.2 16.3 28.2

Fitchburg/Leominster, MA 26.27 12.2 17.5 27.6

Lowell, MA 29.08 11.1 16.9 26.1

Paterson, NJ 26.49 7.0 14.5 20.5

Trenton, NJ 28.76 9.9 13.3 21.9

Santa Fe, NM 21.96 16.0 22.5 34.9

Las Cruces, NM 19.54 13.6 21.0 31.7

Yonkers, NY 24.76 11.8 18.4 28.0

New Rochelle, NY 24.87 14.0 16.9 28.5

Utica, NY 26.49 11.9 16.9 26.8

Binghamton/Johnson City, NY 25.54 11.4 17.0 26.5

Raleigh, NC 22.84 12.4 19.7 29.6

Greensboro, NC 25.67 11.8 16.9 26.6

Medford/Ashland, OR 21.05 13.5 20.1 30.9

Albany/Corvallis, OR 18.29 13.2 19.2 29.8

Bellingham, WA 20.10 13.1 22.6 32.8

Longview/Kelso, WA 25.53 12.7 18.3 28.7

Brantford, Ontario, Canada 32.02 11.2 13.2 22.9

Peterborough, Ontario, Canada 28.06 10.3 17.0 25.6

Mean for Intervention Sites 24.45 12.3 18.4 28.4

Mean for Comparison Sites 25.44 12.1 17.4 27.4

Source: COMMIT Research Group, 1991.

The baseline telephone survey was conducted centrally using a modified

random-digit-dialing technique with community-specific geographic

screening to identify households within the target areas. Questions about

gender, age, name, and smoking status of each adult household member

(age 18 or older) were asked of an eligible proxy. This roster was used to

identify potential members of the cohorts and to provide the basis for

community smoking prevalence and quit-rate estimates. The response

rate for this survey was 88.1 percent, with an average of 6,000 households

listed in each of the 22 communities.
Smoking and Tobacco Control Monograph No. 6

32

From this roster, current smokers and recent quitters were interviewed

to determine the quantity and duration of cigarette smoking, quit attempts,

desire to quit, and demographic and socioeconomic characteristics and

to obtain tracking information. Groups of about 500 heavy smokers and

500 light-to-moderate smokers between ages 25 and 64 were identified in

each community. (A smoker was defined as one who has smoked at least

100 cigarettes and who smokes currently; a heavy smoker was defined as

one who smokes 25 or more cigarettes per day.) The response rate for

this extended interview was 86.4 percent. The group of approximately

500 heavy and 500 light-to-moderate smokers was then subdivided into

an endpoint cohort and evaluation cohort.

A randomly chosen 80-percent sample was drawn from each heavy

and light-to-moderate smoker group to form the endpoint cohorts. Cohort

members were not explicitly notified of their status; however, respondents

were informed that annual contacts would occur. The endpoint cohorts were

contacted briefly by telephone each year to determine smoking status and

to update tracking information. To minimize reactivity, these cohorts were

resurveyed indepth only at the end of the study. Figure 1 gives information

on cohort size and smoking habits and shows the timing of cohort surveys.

Attrition within cohorts was anticipated; the initial cohort sample sizes were

selected so that sufficient statistical power would exist for the cohorts at the

end of the trial.

The remaining 20 percent (approximately 100 individuals) of each heavy

and light-to-moderate smoker group, along with approximately 100 recent

quitters (who had quit within the previous 5 years) were identified to be part

of the evaluation cohort. In 1989, an additional 100 nonsmokers (who never

smoked or had quit more than 5 years earlier) per community were added to

this cohort. At the beginning of the intervention (1989), members of this

cohort were asked questions to assess three elements related to intermediate

trial goals: the population impact of COMMIT on intervention program

awareness, receptivity, and participation; recognition that smoking is a

public health problem; and change in the social acceptability of smoking

(see Figure 1). Questions also were asked at the midpoint (1991) and the

end (1993) of the intervention. Members of the evaluation cohort also

were contacted in 1990 and 1992 to update smoking status and tracking

information.

The primary analysis compared quit rates among cohorts of heavy

smokers in the pooled intervention and comparison communities. Other

analyses compared quit rates among cohorts of light-to-moderate smokers,

changes in prevalence of smoking, and changes in norms and attitudes

about smoking. To ensure that the cohorts remained as representative as

possible of their communities, no intervention activities were directed at

individual cohort members; trial investigators and local program staff

members had no knowledge of which smokers had been selected for the

COMMIT cohorts. Population-based surveys were conducted centrally by
33

Chapter 3

Figure 1

Surveys to assess smoking status (endpoint) and surveys to assess communitywide

changes (evaluation)

Source: COMMIT Research Group, 1991.

independent contractors. All surveys were identified as being sponsored

by the U.S. Public Health Service and were not linked to local COMMIT

activities.

Definition of At the end of the trial, smoking status among individuals in the

Trial Endpoints heavy smoker cohort was determined and compared for the

intervention and comparison communities. A “quitter” was defined as a

smoker who did not smoke for at least 6 months prior to the final followup

survey in 1993. The quit rates were selected as the primary endpoint and—

because an estimated 6,000 households in each community would have to

be contacted to identify the heavy smokers—community members’ change

in smoking prevalence served as a secondary endpoint. The two endpoints

provided different but complementary information. The cohorts gave

information on individuals followed over time, but the data might have

been complicated by loss to followup and reactivity. The community was

the unit of analysis, and the community quit rates and prevalence of

smoking were also valid indicators of community change.

Key: H = heavy; L/M = light-to-moderate; Ex = ex-smoker; Never = never-smoker.
Smoking and Tobacco Control Monograph No. 6

34

Because the community was the unit of analysis, the power calculations

for the cohort endpoint depend mainly on the number of communities and

the estimates of variance in quit rates between communities. The power was

less sensitive to the number of individuals in the cohort in each community.

Using an estimate of the intercommunity variance based on data from the

MRFIT and assuming that matching was completely ineffective, a cohort of

250 heavy smokers in each community yields a power of about 90 percent

for detecting a 10-percent difference in the quit rate among heavy smokers,

using a one-sided test, with the probability of a Type I error set at .05. The

power to detect a difference of 10 percent among all smokers is also about

90 percent (Gail et al., 1992).

Matching COMMIT was a randomized study employing a matched-pairs design.

Communities Matching was not necessary for evaluation plan efficiency; however,

because the study consisted of matched pairs of communities, efficiency was

increased (Freedman et al., 1990). Pairs of communities were selected on

the basis of their geographical proximity and were later matched on variables

strongly expected to relate to the outcome variable—the smoking quit rate.

The matching variables ideally would be related to the smoking quit rates,

but quantitative data on the gain in efficiency from the matching were not

available. Therefore, before randomization, the baseline survey of each

community was conducted to determine the prevalence of smoking and,

of great relevance, the smoking quit rate over the previous 5 years. When

this sequence (initial matching, acquisition of baseline information,

randomization) was utilized, it was possible, even before the study began,

to estimate the gains in efficiency from the matching. With the use of the

baseline quit rates as surrogates for the quit rates to be observed over the

5 years of the study, an efficiency gain resulting from matching is predicted.

The power for the cohort analyses may be as high as 98 percent, if the

matching is as effective as findings indicate (Freedman et al., 1990).

IMPACT EVALUATION Impact evaluation was conducted by special population

surveys to monitor whether changes in the channels of intervention that

were hypothesized to reach the smokers were occurring. These included

surveys of physicians and dentists, physicians’ and dentists’ office staffs,

worksites, schools, cessation resources and services providers, and religious

organizations. Hypotheses also were suggested that youth would be affected

by a community trial; thus, youth also were surveyed. Each population

is briefly described below; for more detail, see Mattson and colleagues

(1990-91).

Physicians and Surveys of physicians and dentists within the communities were

Dentists conducted to assess the impact of interventions on patients’

counseling. Questionnaire items corresponded to the practice behaviors

that were included in the intervention protocol. Information also was

collected on office environments (smoke-free or not) and opportunities

for training in smoking cessation counseling.
35

Chapter 3

Physicians’ and Surveys of physicians’ and dentists’ office staff were conducted to

Dentists’ Office determine office environments, availability of smoking cessation

Staffs assistance for patients, signage regarding nonsmoking, and presence

of chart reminder systems for smoking patients.

Worksites Worksite surveys focused on the presence of restrictive smoking policies,

the presence or absence of employer motivational or incentive programs, and

the availability of worksite smoking cessation programs.

Schools Surveys in schools focused on restrictive smoking policies, including

identification of groups to whom restrictions applied (e.g., students, staff).

Cessation Resources This survey assessed the number of cessation resources and

and Services Providers services available in the communities and the extent to

which such services were used.

Religious This group was surveyed for the presence of restrictive smoking

Organizations policies as well as the availability of smoking cessation resources.

Youth The COMMIT intervention targeted adult heavy smokers, but it was

likely that a communitywide campaign against smoking would also affect

the smoking behavior of adolescents. For this reason, the COMMIT

evaluation included assessments of the smoking habits and attitudes

of representative samples of ninth-grade students in intervention and

comparison communities in 1990 and 1993. A random sample of

approximately 18 ninth-grade classrooms per community, involving

approximately 450 students, was surveyed in 1990 and again in 1993.

The sample size of the youth survey was designed to permit detection

of a 5-percent net change (e.g., from 10 to 15 percent) in surveyed adolescent

smoking prevalence between intervention and comparison matched

communities.

PROCESS Another level of evaluation revolved around the activities that were

EVALUATION developed to meet the impact objectives. The activities had process

objectives attached to them that were designed to achieve the impact goals.

Process objectives specified what was considered to be the minimal amount

of intervention change required to contribute to the achievement of the

overall trial goal. Information was collected on the implementation of each

protocol activity, including when events were held, number of attendees,

materials distributed, and miscellaneous information. This information

was collected through a computerized tracking system developed for this

project (Corbett et al., 1990-91).

The COMMIT Program Records System (PRS) was a computerized

relational database that had two major purposes: (1) data collection of

activities and participation by local groups and individuals and regular

updating of the denominators for the various process objectives; and

(2) provision of an efficient system to capture, retrieve, display, and report

information both locally and trialwide. Centralized quality control

procedures were followed.
Smoking and Tobacco Control Monograph No. 6

36

The data collection process was based on standard forms completed

by field staff members as specific activities were initiated, planned, and

implemented. The data from the forms were then entered into the system,

using preexisting screens and prompts. During the initial stages of the

local operations, field staff members also entered the names, addresses,

and other contact information for the various groups that were the targets

for intervention (e.g., physicians and dentists, hospitals and clinics,

worksites, schools, cessation resources and services providers, and religious

organizations). These files were named the “affiliate” files and were used

to produce sampling frames for surveys and mailing labels and to provide

the denominators, updated annually, for each of the targeted groups. The

system also allowed recording of data related to other trial objectives, such

as monitoring of media (newspapers, billboards, and some electronic media)

and optional activities conducted by the community.

The system produced, on request, a status report for process objective

attainment. Summary scores of process objectives attained were calculated

by community, intervention channel, and the overall trial.

Another part of process evaluation was the development of a method to

collect regular qualitative data on trial activities, which was done through a

quarterly report that described various interactions with the community

volunteers working on the trial, monitored legislative events, kept track of

changes in the community context, and documented case studies within the

communities (Corbett et al., 1990-91).

ECONOMIC The final level of evaluation for the trial was an economic analysis

EVALUATION to estimate the costs of the trial. The primary outcome of this

analysis would be the estimated marginal societal costs of increased smoking

cessation (Mattson et al., 1990-91). The analysis also would examine

the resources provided by the funding agency and estimate the extent to

which those agency resources generated additional community resources

for smoking cessation.

SUMMARY The COMMIT evaluation was as ambitious as the trial. Trial investigators

developed a multilevel approach to the project evaluation. Each level down

from the outcome evaluation in the cohort of heavy smokers provided a

richer and more indepth understanding of what happened in the trial. In

a symposium held more than a decade ago, researchers acknowledged that

community interventions presented unique problems for assessment of

results because the interventions were designed to reach further than the

individuals being evaluated (Hulley, 1978; Syme, 1978). Using the multilevel

evaluation plan described here will allow researchers to ascertain the “dose”

of intervention delivered to each community, the association between

the dose and the intermediary agents that were expected to change their

activities and behavior to encourage smokers to quit (e.g., policies advocated

by physicians and dentists, worksite policies), the receipt of the interventions

by individuals (change in attitudes and community norms around smoking),

and the change in behavior (smoking cessation).
37

Chapter 3

REFERENCES

COMMIT Research Group. Community Intervention

Trial for Smoking Cessation (COMMIT): Summary

of design and intervention. Journal of the National

Cancer Institute 83(22): 1620-1628, 1991.

Corbett, K., Thompson, B., White, N., Taylor, M. (for

the COMMIT Research Group). Process evaluation

in the Community Intervention Trial for Smoking

Cessation (COMMIT). International Quarterly of

Community Health Education 11(3): 291-309, 1990-

91.

Freedman, L.S., Green, S.B., Byar, D.P. Assessing

the gain in efficiency due to matching in a

community intervention study. Statistics in

Medicine 9: 943-952, 1990.

Gail, M.H., Byar, D.P., Pechacek, T.F. (for the

COMMIT Research Group). Aspects of statistical

design for the Community Intervention Trial for

Smoking Cessation (COMMIT). Controlled Clinical

Trials 13: 6-21, 1992.

Gutzwiller, F., Nater, B., Martin, J. Community-based

primary prevention of cardiovascular disease in

Switzerland: Methods and results of the National

Research Program (NRP 1A). Preventive Medicine 14:

482-491, 1985.

Hughes, G.H., Hymowitz, N., Ockene, J.K., Simon,

N., Vogt, T.F. (for the MRFIT Group). The Multiple

Risk Factor Intervention Trial (MRFIT) V.

Intervention on smoking. Preventive Medicine 10:

476-500, 1981.

Hulley, S.B. Symposium on CHD prevention trials:

Design issues in testing life style intervention.

American Journal of Epidemiology 108(2): 85-86,

1978.

Kovar, M.G., Poe, G.S. The National Health Interview

Survey: Design, 1973-84, and Procedures, 1975-83.

A National Probability Sample Survey of the Civilian

Noninstitutionalized Population of the United States.

National Center for Health Statistics. Washington,

DC: Supt. of Docs., U.S. Govt. Print. Off., 1985.

Mattson, M., Cummings, K.M., Lynn, W., Giffen, C.,

Corle, D., Pechacek, T.F. (for the COMMIT Research

Group). Evaluation plan for the Community

Intervention Trial for Smoking Cessation

(COMMIT). International Quarterly of Community

Health Education 11(3): 271-289, 1990-91.

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

Swanepoel, A.S., Rossouw, J.E. Changes in smoking

during a community-based cardiovascular disease

intervention programme. South African Medical

Journal 79(5): 250-253, 1991.

Syme, S.L. Life style intervention in clinic-based trials.

American Journal of Epidemiology 108(2): 87-91,

1978.

U.S. Department of Health and Human Services. The

Health Consequences of Smoking: Cancer. A Report

of the Surgeon General. DHHS Publication No.

(PHS) 82-50179. Rockville, MD: U.S. Department

of Health and Human Services, Public Health

Service, Office on Smoking and Health, 1982.

U.S. Department of Health and Human Services.

Reducing the Health Consequences of Smoking: 25

Years of Progress: A Report of the Surgeon General.

DHHS Publication No. (CDC) 89-8411. Rockville,

MD: U.S. Department of Health and Human

Services, Public Health Service, Centers for Disease

Control, Center for Chronic Disease Prevention

and Health Promotion, Office on Smoking and

Health, 1989.

U.S. Department of Health and Human Services.

Smoking, Tobacco, and Cancer Program: 1985-1989

Status Report. NIH Publication No. 90-3107.

Rockville, MD: U.S. Department of Health and

Human Services, Public Health Service, National

Institutes of Health, National Cancer Institute,

1990.

AUTHORS

William R. Lynn

COMMIT Project Officer

Public Health Applications Research Branch

Cancer Control Science Program

National Cancer Institute

National Institutes of Health

Executive Plaza North, Room 241

6130 Executive Boulevard, MSC-7337

Bethesda, MD 20892-7337
Smoking and Tobacco Control Monograph No. 6

38

Beti Thompson,Ph.D.

Associate Professor

University of Washington School of Public

Health and Community Medicine

Associate Member

Fred Hutchinson Cancer Research Center,

MP-702

1124 Columbia Street

Seattle, WA 98104
39

Chapter 4

Community Intervention Trial for Smoking

Cessation: Development of the Intervention

William R. Lynn, Beti Thompson, and Terry F. Pechacek

INTRODUCTION The Community Intervention Trial for Smoking Cessation

(COMMIT) intervention protocol was developed by collaborating trial

investigators during a 24-month planning phase. To select the specific

intervention methods included in the COMMIT protocol, the investigators

used a wide variety of data from controlled and demonstration trials of

smoking control strategies as well as advice from public health experts and

their own experience in large-scale behavior change efforts. The protocol

took into account several theoretical perspectives on health behavior change,

including social learning theories (Bandura, 1977 and 1986; Abrams et al.,

1986; Elder et al., 1986), persuasion models for communication and social

influences (Bandura, 1977; Flay et al., 1983; McAlister et al., 1982; Rogers,

1973), the health belief model (Green et al., 1980; Rosenstock, 1974), action

research models for community organization and innovation diffusion

(Rothman, 1979; Grusky and Miller, 1981; Gusfield, 1962; Rogers and

Shoemaker, 1971), and others.

In evaluating smoking control literature, it was obvious that the vast

majority of the published literature had focused on individual-oriented

strategies as discussed in Chapter 2 of this monograph. Although these

interventions were viewed as efficacious in many settings, especially clinical

settings, most COMMIT investigator team members saw them as inefficient

and inconsistent with the overall intervention philosophy of this trial,

which is intended to achieve large-scale change within the community.

In addition, enhancement of traditional cessation services (i.e., quit-smoking

programs and self-help materials) was deemed as supportive of the overall

goals of the trial but insufficient to achieve the breadth of change desired.

The consensus of the investigators was that other primary intervention

strategies were needed to reach large portions of the smokers in the

community; furthermore, such strategies needed a high potential of

increasing both the frequency and success rate of self-initiated quitsmoking attempts.

The investigators were guided in the development of the COMMIT

protocol by the fundamental assumption that a community approach to

smoking control must focus on the social and environmental factors that

influence smokers’ contemplation of quitting, efforts to initiate quitting

behaviors, and ability to maintain abstinence on a permanent basis (Farquhar,

1978; Farquhar et al., 1981; Blackburn and Pechacek, 1986; Thompson and

Kinne, 1990). It also was expected that communitywide intervention

strategies would be more effective because they would provide a sustained

intervention effect on a large segment of the smoking population, as opposed
Smoking and Tobacco Control Monograph No. 6

40

to sporadic higher intensity intervention

contacts with only the small segment of

smokers willing to attend or participate

in more traditional smoking cessation

interventions (Leventhal et al., 1980;

Schwartz, 1991). A significant portion

of the trial intervention effort was

expected to focus on changing the

community’s social norms regarding

smoking as well as the overall

informational environment so that

it would be difficult for any smokers in

the community to escape the consistent

and repeated messages about the

benefits of cessation; simultaneously,

they would be provided with ongoing

cues and opportunities to initiate

quitting behaviors (Lichtenstein et al.,

1990-91; Thompson and Kinne, 1990;

Thompson et al., 1990-91).

Nevertheless, it also was recognized that few tried-and-tested

interventions existed that were not individual oriented. A few community

studies, such as the North Karelia Project (Puska et al., 1983), the Australian

North Coast Healthy Lifestyle Programme: Quit for Life (Egger et al., 1983),

and others discussed in Chapter 2, targeted smoking cessation as one of their

endpoints. The projects used several strategies, including mass media and

skills training, which were examined in the development of the COMMIT

interventions. However, the COMMIT interventions were developed

primarily from existing programs within the Smoking and Tobacco Control

Program of the National Cancer Institute (NCI). The trial investigators

selected the best individual or small-group interventions that existed and

grouped them together in an intervention package that was expected to

reach all facets of the community. Channels of intervention that were

thought to be key for reaching heavy smokers were identified and provided

an organizing structure for specific activities. The interventions were

designed to be delivered through a community-organization approach

so that they would become an integral part of the everyday lives of the

community’s smokers.

INTERVENTION The evaluation of COMMIT specified one primary outcome goal—

GOALS AND an increased cessation rate by heavy smokers in the intervention

OBJECTIVES communities. However, for that goal to be reached, several other

community changes had to occur. Using a public health perspective and a

community focus of intervention, the investigators defined four general

intervention goals to guide the COMMIT effort:

1. Increase the priority of smoking as a public health issue. As previously

discussed, most intervention efforts have focused on smoking as
41

Chapter 4

an individual’s problem behavior, resulting in primarily clinically

oriented cessation methods rather than interventions that involved

the broad social and environmental networks in which a smoker

lives and smokes. The COMMIT intervention defined smoking

as a community problem that requires public health action by the

community at large. Although the COMMIT intervention was focused

primarily on adult smoking cessation, smoking prevention also must

be addressed; hence, activities focusing on youth and prevention

were incorporated into many trial interventions.

2. Increase the community capacity to modify smoking behavior. When

smoking has been viewed as an individual problem, community

resources to assist smokers have tended to be relatively sparse. In

conjunction with efforts to meet the first goal, it is acknowledged

that individual smokers who seek assistance need to have an adequate

system of resources and services available. These resources and

services need to be fully integrated into community institutions

and groups so that the logistical barriers to their use can be reduced

and delivery of these services by the community can increase the

overall capacity to address the smoking problem. The investigators

recognized that traditional clinical programs are used by a small

minority of smokers and that the community resources and services

promoted by COMMIT need to include any and all methods that

may interest smokers. Furthermore, mechanisms must be in place

to remind smokers of the available opportunities to seek help with

cessation.

3. Increase within a

community the influence

of existing policy and

economic factors that

discourage smoking. Local

and State laws and

ordinances controlling

smoking in public places

and limiting tobacco

sales have become

common in the United

States and Canada (U.S.

Department of Health

and Human Services,

1993). It is clear that

such policies and

economic factors can

be an important part of

the social environment

of smokers and their

decisions to attempt

cessation. Factors that
Smoking and Tobacco Control Monograph No. 6

42

can influence smoking rates include cigarette taxes; constraints on

advertising and promotion of tobacco products; policies related

to the sale and distribution of cigarettes, especially to minors; and

restrictions on smoking in public places, worksites, organizations,

and other settings where smokers tend to congregate.

4. Increase social norms and values supporting nonsmoking. The social

acceptability of smoking is steadily declining in the United States

and Canada (U.S. Department of Health and Human Services, 1989).

Although a social norm supporting nonsmoking is emerging, progress

in many communities is still hampered by the prevailing perception

that smoking is a problem of an individual. As intervention efforts

attempt to highlight smoking as a public health and community

problem, opportunities will arise to strengthen the perception that

nonsmoking is normative and to be valued and that smoking is

harmful to the community at large. As the social acceptability of

smoking declines, the negative social consequences of smoking

increase and further reinforce both quitting behaviors and

maintenance of abstinence in recent quitters.

These four overall trial goals led to the establishment of several objectives

that, if reached, could be expected to help meet the goals. Similarly, the

identification of trial activities was predicated on the relationship between

those activities and the objectives they were intended to attain. The

philosophy that a hierarchical association exists between the overall trial

goal, intermediate trial goals, impact objectives, mandated intervention

activities, and process objectives led to a systematic development of goals

and objectives.

Intermediate goals were directed at the various channels of intervention

identified as being critical to achieving community change. The channels

contained intermediary agents that were likely to come into regular and

repeated contact with smokers. In addition, the intermediary agents also

were thought to be amenable to new practices that would encourage

smoking cessation. An example is found in the health care provider channel.

Because the majority of smokers see a health care provider annually, a

relatively simple change on the part of providers—reminding smokers to

stop or setting quit dates with smokers—may be sufficient to lead many

smokers to attempt cessation. The intermediate goal, then, is to build a

critical mass of health care providers who give such regular encouragement.

To achieve that goal, several impact objectives were established; for example,

80 percent of community physicians and 65 percent of community dentists

should receive training in basic smoking cessation practices, and 30 percent

of physicians’ offices should receive training in setting up office systems

to track smokers and document that cessation encouragement was given.

Similar impact objectives were established for each of the four major

channels of intervention (i.e., health care providers, worksites and

organizations, cessation resources and services, and public education), plus

a fifth overarching channel of community mobilization. Attempts also were
43

Chapter 4

made to quantify the degree to which objectives had to change to achieve

the trial goals. Through the use of existing literature, previous intervention

experience, and advice from experts in the smoking field, consensus was

reached among the trial investigators concerning the quantification of the

impact objectives (Wallack and Sciandra, 1990-91; Ockene et al., 1990-91;

Sorensen et al., 1990-91; Pomrehn et al., 1990-91).

Impact objectives, in turn, led to the mandated activities required by

the protocol. The extant literature, experience of investigators, and much

discussion resulted in the identification of a set of activities for each

intervention channel considered likely to lead to realization of the impact

objectives. Assessment of the implementation of intervention activities was

accomplished through the completion of process objectives that documented

various components of the activities. A computerized system for tracking

process objective achievement also was developed (Corbett et al., 1990-91).

INTERVENTION The intervention protocol was divided into five major sections

AREAS corresponding to the channels of intervention: Community

Mobilization, an overarching section to organize the community around

tobacco control; Health Care Providers; Worksites and Organizations;

Cessation Resources and Services; and Public Education. Each of the five

channels was selected for its potential contribution toward achieving the

trial outcome. Most mandated intervention activities within each channel

area had proved efficacious in other settings, and the investigators believed

that combining such intervention activities would result in a synergism

that would lead to change. Each channel is described below.

Community COMMIT’s overall goal of community mobilization was to build

Mobilization the capacity of communities to address smoking control issues.

Channel Community mobilization also was intended to facilitate the

implementation of smoking control activities and ensure maintenance

of these activities.

Achieving citizen participation and community partnership requires

mobilization of a community. Mobilization is a process through which

community members become aware of a problem, identify the problem

as a high priority for community action, and institute steps to resolve the

problem (Thompson and Pertschuk, 1992). Each community has its own

structures, history, and resources necessitating some variation between

communities in the process of mobilization. The logic and philosophy

of the trial provided each community, through standard mobilization

features, with some discretion in local trial management. The basic

mobilization model was designed to provide scientific integrity while

allowing some local flexibility to establish structures and implement

activities in a manner congruent with local practice.

The mobilization plan began with a strong understanding of the

community gained through a community analysis designed to yield a

systematic understanding of community history, social climate, culture,

structures, resources, organizations, and key individuals. Research staff
Smoking and Tobacco Control Monograph No. 6

44

identified several key individuals as candidates for an initial planning group,

where members were introduced to the trial’s rationale, design, and protocol.

Depending on their enthusiasm and availability, they were asked to serve

on a short-term Community Planning Group charged with developing a more

comprehensive and long-lasting community Board. Each intervention

community had to form a new community Board, which was required to

provide project legitimacy, access, and overall management support to

the community; to represent the key sectors considered to be important

in all communities (i.e., health care, business and labor, health voluntary

organizations, media, education); and to accurately represent the community.

Rules were established to maximize community involvement in intervention

planning and implementation. Wherever local groups or organizations

existed that could conduct an intervention activity, they were given highest

priority to do so, even if required training of staff or enhancing the resources

that were already dedicated to the activity was required. Similarly, rules

were established for resource allocation in accordance with the philosophy

that the resources available through the trial were by themselves insufficient

to implement the protocol

but should be perceived as

“seed” resources to develop

existing or new community

mechanisms for smoking

control.

The trial protocol

was developed by the

investigators before the

communities were

randomized; therefore,

the community had no

input into the content of

the protocol. However,

communities were expected

to develop their own plans, consistent with the protocol, to achieve a social

climate that would support non-use of tobacco. To maximize the potential of

communities to make a permanent change, external resources (NCI funded),

both fiscal and human, were limited and considered seed resources. Limiting

resources would encourage the communities to contribute some of their own

resources and thereby eventually incorporate some tobacco control activities

into their own organizational structures.

Health Care Health care providers and the settings in which they work are important

Providers to reaching heavy smokers in the community (Ockene et al., 1990-91).

Channel Targeted health care providers included physicians and dentists,

although it also was considered desirable to involve pharmacists, nurses,

respiratory therapists, and other health care providers. The mandated

intervention activities focused on involving community health professionals

in smoking cessation intervention activities in their practices and in their

roles as community leaders. Each community identified key influential health
45

Chapter 4

professionals who were interested and

able to play leadership roles in the

COMMIT intervention. National training

equipped these influentials to persuade

their colleagues indirectly through

discussions at meetings and social events

and directly through presentation of

types of training events to make smoking

cessation counseling part of their regular

practice. An important component of this

task force was the policy change expected

to take place in all health care facilities in

the communities. Intervention objectives

included smoke-free hospitals, medical

offices, nursing homes, and substance abuse treatment centers. Enhancing

the availability of cessation information and antismoking promotional

messages was also an important goal of this channel.

Worksites and Worksites are an ideal location for promotion and support of

Organizations smoking cessation efforts, including both programs and policies.

Channel Seventy percent of adults between the ages of 18 and 65 are

employed (Sorensen et al., 1990-91). Worksites and community

organizations are opportune places to publicize project activities, offer

quit-smoking programs, promote policy changes, and foster environments

supportive of successful quitting. They also are important as sources for

personnel and local resources to support project activities, particularly

large-scale community events. Intervention activities described for worksites

and organizations were to be offered widely in the community; however,

activities were targeted particularly to sites in which heavy smokers could

be reached most effectively. Worksites offered great potential for reaching

less educated and less motivated heavy smokers who might not volunteer

for or be reached by other community antismoking activities. Restrictive

smoking policies were seen as having much to contribute to the social

environment; therefore, many COMMIT intervention activities in this

channel were oriented to presentations and consultations with worksites

to assist them in implementing policies.

Other organizations also were targeted for intervention. Fraternal

organizations, civic groups, religious organizations, and so forth were used

both for promotion of smoking cessation policies and activities and as targets

for such interventions. The protocol called for intervention activities such as

presentations to encourage more restrictive policies, provide information to

such groups, and attempt to involve these groups in promotion activities.

Cessation In addition to the powerfully addictive nature of tobacco, there are

Resources and many barriers that contribute to the continuing high smoking rate

Services Channel among adults. Although knowledge of the hazards of smoking

and the benefits of quitting provide reasons for cessation, barriers to quitting

include willingness to take a risk, paucity of cues to quit smoking, difficulty
Smoking and Tobacco Control Monograph No. 6

46

in obtaining self-help materials, low awareness and use of existing smoking

cessation services, high relapse rates among smokers trying to quit, and

inadequate social support for smokers who are motivated to quit. A wealth

of information exists regarding methods and techniques that can aid smokers

who are trying to quit (Schwartz, 1991; Thompson and Hopp, 1991). Much

is available in self-help formats, including books, pamphlets, audiotapes, and

videotapes, and most of these materials are available from voluntary health

agencies free or at minimal cost. Numerous

programs to help smokers have been

developed and refined over the past three

decades. Programs offered by the major

health voluntary organizations, local

hospitals, and other community agencies

have benefited from the thousands of

research projects on smoking cessation

conducted in recent years.

A fundamental assumption underlying

COMMIT intervention activities was that an

increase in cessation rates requires a change

in the social circumstances surrounding

smokers’ decisions to quit, to initiate

quitting, and to maintain abstinence

(Pomrehn et al., 1990-91). The aim of

COMMIT was not to provide cessation

services; rather, the aim was to increase the

demand for cessation resources and services

as smokers became more willing to attempt cessation. Thus, activities in

this channel were limited to those that provided the regular, inescapable

messages about opportunities for cessation. Specific intervention activities,

such as a voluntary smokers’ registry, newsletters, and publication of guides

promoting cessation resources and services, were undertaken to increase

the quantity and utilization of existing services. Those activities also were

designed to enhance the efforts of other trial interventions, particularly

worksite, organizational, and health care provider interventions.

Public Communitywide public education efforts were central to the trial’s

Education activities to meet overall intervention goals. Educational efforts

Channel focused on mass media campaigns promoting smoking as a public

health problem, smoking prevention, and communitywide cessation

activities. The media contribute significantly to the overall context in

which personal decisions about initiating, continuing, or quitting smoking

occur. The media are a key source of social-environmental cues regarding

nonsmoking behavior (Wallack and Sciandra, 1990-91). An important

function of this channel was to establish and maintain the visibility and

credibility of COMMIT in the communities.

Mass communication plays a significant role in the ongoing effort to

control smoking. The media can perform an important agenda-setting
47

Chapter 4

function, they can confer status and legitimacy, and they can activate public

discussion. In addition, the media can reinforce nonsmoking behavior

(among both smokers and nonsmokers), generating further help-seeking

behavior (e.g., calling a toll-free number) and recruiting smokers into

treatment programs, and can advertise and promote opportunities for

cessation. The media also can promote norms that are supportive of

nonsmoking and quitting.

Smoking prevention among youth was not a primary program focus

in COMMIT. However, activities targeted at youth have the potential

for increasing the community’s awareness of smoking and health issues

and for shifting social norms. Health promotion through educational,

policy, and regulatory activities aimed at youth have traditionally been

noncontroversial and can provide leverage for community organizing efforts.

Tobacco education activities for youth were used to enhance the visibility,

credibility, and acceptability of COMMIT. Although school-based, tobacco

use education was not emphasized in COMMIT, it is hypothesized that the

overall intervention can decrease the prevalence of adolescent smoking,

can have an effect on smokeless tobacco use among adolescents, and will

modify the precursors of adolescent smoking behavior.

SPECIAL An important factor in the COMMIT intervention was the

CONSIDERATIONS necessity to constrain the intervention to relatively small

OF THE communities so that a rigorously designed trial could be

INTERVENTION implemented. However, it is important to note that

DESIGN communities are not independent social systems. They exist

also in a larger social context, and external events or changes in the broad

social system can have a substantial effect on the local community. As

a conceptual framework, a system’s perspective provides a useful model.

In such a perspective, the community is made up of many different

components, including political, economic, and health sectors (Thompson

and Kinne, 1990). Changes in any part of the system or changes external to

the system reverberate throughout the system and result in adjustments or

responses that will ultimately affect the entire system. Social norms change

along with the system to provide new rules of conduct (Robertson, 1977).

Just as the North Karelia Project showed that an implemented national

policy could affect smoking behavior nationally (Puska, 1983) and just as

the Minnesota Heart Health Program indicated a large secular trend that

may have overwhelmed any intervention effect (Luepker et al., 1994),

several external factors were present during the COMMIT trial that could

have had an impact on the communities involved. For example, California

passed Proposition 99, which released huge amounts of resources for

antismoking activities, including mass media campaigns that directed

attention to minorities, members of low socioeconomic groups, and other

subgroups of smokers. Another example is Canada’s passing an excise tax

that raised the price of a package of cigarettes to new highs and resulted

in a decrease in the prevalence of smoking. Within New York State, policies

on smoking in public places, including worksites, were strengthened.
Smoking and Tobacco Control Monograph No. 6

48

Nationally, the U.S. Environmental Protection Agency classified secondhand

smoke as a Class A carcinogen (U.S. Environmental Protection Agency, 1992),

making employers think more seriously about the liability associated with

smoking in the workplace. National fast-food restaurant chains became at

least particially smoke-free to to project an image of protecting youth. In

short, the broad social environment within which the pairs of communities

were located may have changed substantially, making it difficult to

determine what the effects of the COMMIT intervention alone were.

The COMMIT interventions initially were formulated to provide synergy

between the various activities. Synergy is the cooperation among various

parts of the system or the way the components of a system act together.

When activities are oriented toward a common goal, synergy makes the

net effect of the forces greater than the sum of its parts. Synergy makes it

impossible to separate out the contribution to the outcome of the various

parts of the COMMIT intervention. The investigators had to be satisfied that

the package they developed produced synergy, which meant that no channel

could be emphasized over another and that subsequent analyses to account

for the contribution of specific channels were not possible. This approach

was further complicated by issues of measurement. Only the achievement

of process objectives was measurable; it was not possible to assess the

interaction between various activities or process objectives.

Another key consideration involved the group of investigators involved

in the project. Because the individuals came from a variety of disciplines,

backgrounds, and experience levels, there was initially considerable

controversy over the approach to take. The options were reduced to two

basic approaches: In one approach, the 11 intervention communities would

simply be given resources to design their own studies, whereas a standardized

protocol would be followed in the other. The first approach would produce a

purer community study but

would likely result in many

different interventions. This

could not be regarded as a

rigorous randomized controlled

trial. The second approach

fulfilled the requirements of

scientific rigor but greatly

constrained the role of the

community in designing

interventions. The limited time

for planning and discussion of

these issues made it difficult for

investigators to come to consensus. The design process of the trial alienated

various “stakeholders,” and this resulted in wasted effort and time.

SUMMARY The theoretical base for COMMIT used existing knowledge, state-of-theart interventions, and the wisdom of investigators in the field to develop an

intervention strategy and protocol oriented to meet the trial’s overall goals
49

Chapter 4

and impact and process objectives. Mandated activities were intended to

lead to achievement of the impact objectives, which in turn would lead to

attainment of the intermediate and overall trial goals. A number of lessons

were learned in the development of the protocol.

1. The intervention strategies implemented in COMMIT were designed

to have a large effect on the communities’ attitudes to and behaviors

regarding cigarette smoking, yet there was little in the literature to

provide insights on how best to do this. Even media studies that

had been conducted previously showed only marginal changes in

knowledge and attitudes.

2. Although the COMMIT protocol was built on the best knowledge

available from randomized clinical trials in the area of smoking

control, it is not clear how those experiences can be extrapolated

to a randomized community trial.

3. A unique feature of COMMIT was that the diverse and extensive

interventions were combined in such a manner that a communitywide

effect was anticipated. Based on the supposition that people are more

likely to stop smoking when the policies regulating smoking, the

opportunities for cessation, and the messages about the dangers of

smoking for both smokers and nonsmokers are predominant within

a community, COMMIT wished to create a social environment in the

intervention communities where smoking was nonnormative. Despite

these ambitious goals, it was unclear how best to change policies and

get messages to the target group of heavy smokers.

4. It was assumed that implementation of the mandated activities

through the five intervention channels would make it difficult

for any smoker to avoid messages about or opportunities for smoking

cessation. Again, there was not strong evidence from the results of

other trials to support the assumption.

5. The community is not an entity in and of itself; rather, it exists

in a broader social context that also may be changing. When a

community rides the secular trend, it is difficult to judge the effects

of an intervention; it may have been better to build more flexibility

into the protocol so that different tactics could have been used when

the external environment changed.

6. Synergy is an excellent construct but was impossible to measure in this

trial. That may not be completely negative, but if efficient trials or

interventions are to be devised, it would be helpful to be able to

identify the components of the intervention.

7. Lack of attention to stakeholders in the development of the protocol

led to considerable controversy. More time should have been allowed

to reach consensus in a trial of this magnitude.
Smoking and Tobacco Control Monograph No. 6

50

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Artz, L.M. Social learning principles for

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(Editors). New York: Wiley-Interscience, 1986, pp.

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Bandura, A. Social Learning Theory. Englewood Cliffs,

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Bandura, A. Social Foundations of Thought and Action: A

Social Cognitive Theory. Englewood Cliffs, NJ:

Prentice-Hall, 1986.

Blackburn, H., Pechacek, T.F. Smoking cessation and

the Minnesota Heart Health Program. In: Proceedings

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W.F. Forbes, R.C. Frecker, and D. Nostbakken

(Editors). Ottawa, Canada: Canadian Council on

Smoking and Health, 1986, pp. 159-164.

Corbett, K., Thompson, B., White, N., Taylor, M. (for

the COMMIT Research Group). Process evaluation

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Community Health Education 11(3): 291-309, 1990-

91.

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

Rubenstein, P., Tyler, C., McKay, B. Result of large

scale media antismoking campaign in Australia:

North Coast “Quit for Life” Programme. British

Medical Journal 286: 1125-1128, 1983.

Elder, J.P., McGraw, S.A., Abrams, D.B., Ferreira, A.,

Lasater, T.M., Longpre, H., Peterson, G.S.,

Schwertfeger, R., Carleton, R.A. Organizational

and community approaches to community-wide

prevention of heart disease: The first two years of

the Pawtucket Heart Health Program. Preventive

Medicine 15: 107-117, 1986.

Farquhar, J. The community-based model of life style

intervention trials. American Journal of Epidemiology

108: 103-111, 1978.

Farquhar, J.W., Magnus, P.F., Maccoby, N. The role of

public information and education in cigarette

smoking control. Canadian Journal of Public Health

72: 412-420, 1981.

Flay, B.R., Hansen, W.B., Johnson, C.A., Sobel, J.L.

“Involvement of Children in Motivating Smoking

Parents To Quit Smoking With a Television

Program.” Paper presented at the Fifth World

Conference on Smoking and Health, Manitoba,

Canada, 1983.

Green, L.W., Kreuter, M.W., Deeds, S.G., Partridge,

K.B. Health Education Planning: A Diagnostic

Approach. Palo Alto, CA: Mayfield, 1980.

Grusky, O., Miller, G.A. (Editors). The Sociology

of Organizations: Basic Studies. (2nd ed.) New York:

Free Press, 1981.

Gusfield, J.R. Mass society and extremist politics.

American Sociological Review 27: 19-30, 1962.

Leventhal, H., Cleary, P.D., Safer, M.A., Gutman, M.

Cardiovascular risk factor modification by

community-based programs for life-style changes:

Comments on the Stanford study. Journal of

Consulting and Clinical Psychology 48: 150-158, 1980.

Lichtenstein, E., Wallack, L., Pechacek, T. (for the

COMMIT Research Group). Introduction to the

Community Intervention Trial for Smoking

Cessation (COMMIT). International Quarterly of

Community Health Education 11(3): 173-185, 1990-91.

Luepker, R.V., Murray, D.M., Jacobs, D.K., Jr.,

Mittelmark, M.B., Bracht, N., Carlaw, R.,

Crow, R., Elmer, P., Finnegan, S., Folsom,

A.R., Grimm, R., Hannan, P.J., Jeffrey, R., Lando, H.,

McGovern, P., Mullis, R., Perry, C.L., Pechacek, T.,

Pirie, P., Sprafka, J.M., Weisbrod, R., Blackburn, H.

Community education for cardiovascular disease

prevention: Risk factor changes in the Minnesota

Heart Health Program. American Journal of Public

Health 84(9): 1383-1393, 1994.

McAlister, A., Puska, P., Salonen, J.T., Toumilehto, J.,

Koskela, K. Theory and action for health promotion:

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American Journal of Public Health 72: 43-50, 1982.

Ockene, J.K., Lindsay, E., Berger, L., Hymowitz, N. (for

the COMMIT Research Group). Health care

providers as key change agents in the Community

Intervention Trial for Smoking Cessation

(COMMIT). International Quarterly of Community

Health Education 11(3): 223-237, 1990-91.

Pomrehn, P., Sciandra, R., Shipley, R., Lynn, W.,

Lando, H. (for the COMMIT Research Group).

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community intervention: COMMIT as a prototype.

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11(3): 259-269, 1990-91.

Puska, P., Nissinen, A., Salonen, J.T., Tuomilehto, J.

Ten years of the North Karelia Project. Results with

community-based prevention of coronary heart

disease. Scandinavian Journal of Social Medicine 11(3):

65-68, 1983.

Robertson, I. Sociology. New York: Worth, 1977.

Rogers, E. Communication Strategies for Family Planning.

New York: Free Press, 1973.

Rogers, E.M., Shoemaker, F.F. Communication of

Innovations: A Cross-Cultural Approach. (2nd ed.)

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Rosenstock, I. Historical origins of the health belief

model. Education Monographs 2: 328-335, 1974.

Rothman, J. Three models of community organization

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Book of Readings, F.M. Cox, J.L. Erlich, J. Rothman,

and J.E. Tropman (Editors). Itasca, IL: Peacock

Publishers, 1979, pp. 86-102.
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Schwartz, J.L. Methods for smoking cessation. Clinics

in Chest Medicine 12(4): 737-768, 1991.

Sorensen, G., Glasgow, R.E., Corbett, K. (for the

COMMIT Research Group). Promoting smoking

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(COMMIT). International Quarterly of Community

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for smoking cessation. Clinics in Chest Medicine 12:

801-818, 1991.

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Applications to community health. In:

Health Promotion at the Community Level,

N. Bracht (Editor). Newbury Park, CA: Sage,

1990, pp. 45-65.

Thompson, B., Pertschuk, M. Community

intervention and advocacy. In: Prevention of

Coronary Heart Disease, J.K. Ockene and I.S. Ockene

(Editors). Boston: Little, Brown, 1992, pp. 493-515.

Thompson, B., Wallack, L., Lichtenstein, E., Pechacek,

T. (for the COMMIT Research Group). Principles of

community organization and partnership for

smoking cessation in the Community Intervention

Trial for Smoking Cessation (COMMIT).

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Education 11(3): 187-203, 1990-91.

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Control, Center for Disease Prevention and Health

Promotion, Office on Smoking and Health, 1989.

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NIH Publication No. 93-3532. Rockville, MD: U.S.

Department of Health and Human Services, Public

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Health Effects of Passive Smoking: Lung Cancer and

Other Disorders. EPA/600/6-90/006F. Washington,

DC: Office of Research and Development, Office

of Health and Environmental Assessment, 1992.

Wallack, L., Sciandra, R. (for the COMMIT Research

Group). Media advocacy and public education in

the Community Intervention Trial for Smoking

Cessation (COMMIT). International Quarterly of

Community Health Education 11(3): 205-221,

1990-91.

AUTHORS

William R. Lynn

COMMIT Project Officer

Public Health Applications Research Branch

Cancer Control Science Program

National Cancer Institute

National Institutes of Health

Executive Plaza North, Room 241

6130 Executive Boulevard, MSC-7337

Bethesda, MD 20892-7337

Beti Thompson,Ph.D.

Associate Professor

University of Washington School of Public

Health and Community Medicine

Associate Member

Fred Hutchinson Cancer Research Center,

MP-702

1124 Columbia Street

Seattle, WA 98104
Smoking and Tobacco Control Monograph No. 6

52

Terry F. Pechacek,Ph.D.

Coinvestigator

Department of Social and Preventive

Medicine

State University of New York at Buffalo

School of Medicine and Biomedical

Services

270 Sarber Hall

Buffalo, NY 14214-3000
53

Chapter 5

Mobilizing the COMMIT Communities for

Smoking Control

Beti Thompson, Linda Nettekoven, Dianne Ferster, Len C. Stanley,

Juliet Thompson, and Kitty K. Corbett

INTRODUCTION Twenty years of community intervention studies have taught us

much about the need to engage communities in health behavior change and

about the processes required to involve communities (Abrams et al., 1986;

Carlaw et al., 1984; Elder et al., 1986; Farquhar et al., 1985; Puska et al.,

1985). Widespread agreement about the benefits of using community

organizations as primary delivery systems in large-scale health behavior

change programs (Green and Raeburn, 1990; McAlister et al., 1982; Tarlov

et al., 1987) has been supported by theoretical arguments that durable

changes in lifestyles of whole populations require changes in the community

environment to support the behavior changes by individuals (Egger et al.,

1983; Fortmann et al., 1990; Puska et al., 1983; Tarlov et al., 1987). Several

community studies have been conducted in recent years, primarily on

cardiovascular risk reduction; initial results from those studies and large-scale

smoking cessation trials indicate that behavior change is possible (Carlaw et

al., 1984; Egger et al., 1983; Elder et al., 1986; Puska et al., 1985; Fortmann

et al., 1990). Most such studies have been carried out with some collaboration

by investigators and the communities.

Collaboration between community and researchers, although seen as

essential to the research project, varies widely in both the form it takes and

the way it is developed. Collaboration can vary from little community

involvement, such as community permission to target a particular place for

intervention activities by an external agent, to total community control,

such as giving a community funds to develop its own solutions to a specific

problem. However, for the majority of external funding agencies, a more

moderate approach is followed in which the community becomes a partner in

the change activity. Increasingly, a strategy called “community organization”

is being used, whereby community members become active participants in

addressing a problem that affects the entire community (Thompson et al.,

1990-91). Theoretically, there are three assumptions that underlie the need

to involve local citizenry in a change effort. The first is that behavior occurs

in a social context rather than in a vacuum or on an individual basis; the

second is that large-scale behavior change requires that the social context be

changed; and the third is that change is more likely when the people affected

by a problem are involved in defining and solving it (Abrams et al., 1986;

Kuriji et al., 1988; Florin and Wandersman, 1990; Thompson and Kinne,

1990). Funding agents and studies that now are attempting to reduce

chronic disease risk factors at the community level almost uniformly foster

relationships with the community receiving interventions so that local
Smoking and Tobacco Control Monograph No. 6

54

citizens participate in the projects (Chavis et al., 1983; Crosby et al., 1986;

Englund, 1986; Millar and Naegle, 1987).

Gaining citizen participation in communities generally requires

mobilization of at least some portions of the community. Community, in

this context, is a group of people sharing a locality, being interdependent,

having interpersonal relationships, and having a sense of belonging to the

larger entity (Thompson and Kinne, 1990; Warren, 1958).

Mobilization is the process whereby the community or some of its

parts become aware of a condition that has negative implications for the

community, identify the condition as a priority

for community action, and institute steps to change

the condition (Thompson and Pertschuk, 1992).

Mobilization is a complex process often idiosyncratic

to a community and a project. Partially as a result, few

data have been systematically gathered or published

about mobilization activities in diverse community

studies; rather, an occasional description of the

mobilization process may be included in a progress

report on research development. A few researchers have

examined the process more concretely (Burghardt, 1982;

Hunkeler et al., 1990; Stunkard et al., 1985; Thompson

et al., 1993), thereby yielding some information on the

processes of initially interesting and involving

communities in health behavior change.

Although any kind of external funding agency

is likely to constrain community efforts to address a

problem, research in communitywide projects addressing

health promotion poses special problems for involving

communities. In a “pure” community approach, community members take

the initiative by defining a problem; however, in externally funded projects,

the original impetus for the community to accept the existence of a problem

comes from external sources that have their own plans for defining and

addressing the problem. In addition, the need for integrity of the research

and the constraints of funding by government agencies generally put strict

limits on the extent to which individual communities can be part of the

decisionmaking processes in health promotion projects. Although

community members may have their own ideas for addressing a problem,

there is likely to be little researcher support for innovation or deviation

from a research plan. For example, the Community Intervention Trial for

Smoking Cessation (COMMIT) project required communities that were

to receive funds to define smoking as a major public health problem. In

addition, it utilized a standardized protocol that required the community

to implement certain activities before turning to activities that came up

from the community.

In spite of the departure from a pure community organization

model, the COMMIT project attempted to build a partnership with the
55

Chapter 5

11 intervention communities; it followed a standardized mobilization

protocol to build community infrastructures that could address the

smoking problems. In this chapter, the mobilization experiences of the

11 communities that participated in COMMIT are described. Because the

communities followed a standardized mobilization protocol to organize

themselves to address tobacco control, this experience offered a unique

opportunity to examine several questions about mobilization and the use

of a common strategy for mobilizing communities.

Specific questions of interest included the following: What are the

important factors in developing a common mobilization process? Can a

single mobilization protocol be implemented across 11 communities? Can

mobilization protocol objectives and timelines be met consistently in the

various communities? Are the experiences of these communities generalizable

to other community health initiatives? What happened in the field as the

communities followed the protocol? The lessons learned from the initial

mobilization process in the 11 COMMIT intervention communities are

presented in this chapter.

ADAPTATIONS COMMIT builds on a community organization perspective

FOR RESEARCH (Blackburn, 1983; Green, 1986; Farquhar, 1978; Kelly, 1979;

PURPOSES Labonte, 1989). The partnership arrangement initially planned

was one that would reflect “community ownership,” important both in

theory and in practice. Essentially, the outside experts—the researchers—

would be facilitators to guide change, not to control and define it. The

general principles of partnership and community ownership were adopted by

COMMIT investigators; however, early in the trial, investigators recognized

that the design features of COMMIT introduced many potential problems

for establishing partnerships with the communities.

After much debate about the shape of the trial (see Chapters 3 and 4),

the research direction adopted for

COMMIT treated the project as a

single study with the equivalence

of 22 “subjects”: 11 intervention

and 11 control communities.

With the community as the unit of

randomization, it became necessary

to define a basic intervention to be

tested, with a decision to provide

basic commonality in the intervention

to permit comparisons across

communities (see Chapters 3 and 4).

Investigators decided that total local

ownership of the project might result

in significantly different organizational

structures and foci of interventions;

indeed, there was a concern that the

project might produce 11 different
Smoking and Tobacco Control Monograph No. 6

56

demonstrations rather than a single trial. Researchers also were aware of the

danger of too much mandated structure and the threat it might present to

local involvement and participation. A compromise approach was developed

to maintain trial integrity and provide enough flexibility to accommodate

local variations.

Trial integrity was achieved through a protocol that defined a general

mobilization process for organizing the intervention communities,

establishing a basic structure for organizing local projects, implementing a

set of required intervention activities consistent with community customs,

and carefully documenting the process (Thompson et al., 1990-91). The

general mobilization process and the requirements for establishing the

organizational structure are described in this chapter.

The approach used for COMMIT does not meet all the criteria for an

equal partnership with the community: As in other community research

projects (Chavis et al., 1983; Goodman and Steckler, 1989), scientific goals are

a higher priority than the community development goals (Rothman, 1979).

Although COMMIT sought to promote partnership whenever possible, it

was an unequal process, and the community had less power than either the

funding agency (National Cancer Institute [NCI]) or the research institutions

receiving funds to administer local projects.

STEPS IN Significant effort was devoted to defining both the community

MOBILIZING mobilization process and the resulting structure. The “leadership

COMMUNITIES board” model served as the

basic organizational structure. In

this structure, a community Board

of influential and informed people,

often leaders representing key

organizations in the community,

was formed. The process required

an understanding of the community

through an examination of secondary

sources, conversations with key

informants, and involvement of

local people with influence in their

community to identify and nominate

members to serve on a community

Board. The approach encourages

the inclusion of other community

members, especially through

task forces, but the focus is on

identification and recruitment of known

community leaders who have access to, or control over, resources and

policy decisions. The model emphasizes participation by members of key

community sectors (Thompson and Kinne, 1990) so that the majority

of the community is represented.
57

Chapter 5

The COMMIT research team established 12 activities (Table 1) that

each site was expected to do in support of its mobilization efforts. Most

were undertaken during the initial planning phase of the trial before

implementation of the intervention. Both the activities and the percent

of communities completing each activity are given below:

COMMUNITY An old Chinese proverb advises: “Go in search of people. Begin

ANALYSIS with what they know. Build on what they have.” This is the challenge

facing health promotion advocates as they attempt to design and implement

community interventions. The first step in meeting this challenge is

to systematically gather information about the strengths, resources,

opportunities, and needs in a community. This process has been labeled

variously as community diagnosis, community needs assessment, health

education planning, and community mapping (Haglund et al., 1990).

Ideally, health promotion advocates undertake such a process with rather

than to the community and create opportunities to increase awareness and

ownership of any health interventions that result.

The community analysis is designed to provide an indepth, comprehensive look at the community. For lasting change to occur, attention

must be paid to the underlying factors that influence behavior, including

the factors that might facilitate or inhibit a proposed change within a

community as well as the factors that are likely to make a given approach

a “good fit” with its host environment. Drawing on the experiences of

other community-based health programs, the COMMIT project undertook

a series of information-gathering steps in the 11 pairs of communities

targeted for study.

Table 1

Mobilization activities and process objectives

Activities To Be Conducted Communities Completing

by Each Community Activities (%)

Establishment of Community Planning Group 100

Planning for Program Office and Staff 100

First Community Board Meeting 100

Creation of Task Force Member List and Recruitment 100

Writing of By-Laws 100

Field Site Management Plan 91

Smoking Control Plan 100

First Annual Action Plan 100

Second Annual Action Plan 100

Third Annual Action Plan 100

Fourth Annual Action Plan 100

Transition Plan 100
Smoking and Tobacco Control Monograph No. 6

58

Prerandomization In the first step, researchers prepared a community profile

for each of the 22 communities in the trial. Each document blended

quantitative information, such as demographic indicators and lists of

programs and services, with qualitative information on the community’s

history and image of itself. The analysis required the collection of extensive

information about the communities, including identification of media

outlets, health care providers and settings, worksites and business groups,

local organizations, available smoking cessation services, and schools

and other youth-serving agencies. The analysis also contained a crude

assessment of potential intervention channels and resources.

To avoid activation of any of the communities prior to randomization,

the report drew primarily on secondary and archival sources (e.g., census

data, chamber of commerce publications, local business and trade lists, local

media). In addition, a few key informants (people who are knowledgeable

about the community) were identified. Discussions with these individuals

provided additional information about community structures, key players,

influence networks, and previous examples of collaborative effort that

focused on public issues.

Postrandomization For each of the 11 randomly selected intervention communities,

a more detailed community analysis was conducted. The postrandomization

community analysis assessed the major factors likely to facilitate or inhibit

the accomplishment of project goals and the tobacco control activities

required for each intervention area.

The analysis identified additional key

players and stakeholders, provided an

assessment of community programs

and resources that might be relevant

to future tobacco control efforts,

and more closely examined the

intervention channels. Methods

the COMMIT project could use

to build on established community

organizations were closely explored

because a key tenet of the project was

to avoid competing with, duplicating,

or replacing existing program services.

Information gained from the analysis

helped staff members work with local

organizations.

As part of the postrandomization

analysis, investigators developed a

description of the community sectors

whose participation was considered essential for the project to succeed.

Building on the prerandomization analysis, a Community Planning group,

consisting of community members representing a variety of sectors and

agencies, was convened. The planning group had several responsibilities,
59

Chapter 5

including providing input to and refinement of the community analysis.

The analysis ended with a community-specific blueprint for forming the

community Board, including the sectors to be represented and a list of

candidate Board members.

The community analysis is the cornerstone of any community

intervention. Across communities, it appears the community analysis

is an important tool for both researchers and field staffs as they engage in

the initial activation of the community to address tobacco control. In most

cases, the community analysis process identified community leaders and

other influentials, and it informed participants which groups had been

involved in prior health promotion efforts or had a current stake in the

tobacco control issue. It laid out a plan for establishing a Board and task

forces with a list of possible participants from all fundamental sectors of the

community. Community representatives consistently commented that all

groups and agencies that became involved in COMMIT were appropriate

participants. Yet even after 4 years of effort, all communities could point

to one or more groups that did not participate in the project.

What the analysis did not provide in some instances was sufficient

insight about the priorities and concerns of key groups that had not been

involved previously in tobacco control. This information had to be gathered

as the intervention progressed, and many communities were less successful

than expected at involving groups that might have provided access to the

heavy smoker target group, whether they were unions, blue-collar worksites,

racial or ethnic minority organizations, low-income residents, or less

educated people. Somehow the analysis failed to provide some communities

with the necessary “hooks and handles” to reach into those heavy-smoker

enclaves.

Even when such information was available, staff members sometimes did

not produce the expected results. In Utica, NY, for example, representatives

of the minority community were invited to

participate in project planning and management via

the COMMIT Board and task forces. Later meetings

focused on finding ways to tailor COMMIT activities

to fit the needs and culture of minority residents.

However, despite repeated contacts with appropriate

community leaders, other problems, such as drug

abuse, crime, and unemployment, continued to

receive a higher priority than tobacco use.

Having members of key target groups as

volunteers or project employees did pay off in some

cases. In Bellingham, WA, the initial Board included

both minorities and representatives from blue-collar

worksites, and this was seen as important in helping

oil refineries become smoke-free. The Vallejo, CA,

site attributes much of its success in reaching out to

religious organizations to the fact that the staff
Smoking and Tobacco Control Monograph No. 6

60

person doing the outreach was active in the religious community prior to the

beginning of the project.

The community analysis was a useful tool for the initial phases of

mobilization. Its utility during subsequent years of the trial is more difficult

to assess. About half the communities continued to find it useful; however,

others complained that it was not user-friendly, seemed redundant, and

required the reader to “jump around” the document to find information.

Because the community analysis was almost completed before the field staff

members and volunteers were deeply involved in the project, many felt

little ownership of the document. As a result, some communites reviewed

and ratified the community analysis, as required by the protocol, and set

it aside and did not consult it again.

Community Community activation is the process of familiarizing community

Activation members with the issue under investigation—in this case, smoking—

and involving them in activities to address the problem. The community

analysis provided the basic plan for

activating the community. The

information gathered in that analysis

gave the Community Planning

Group the basis for nominating and

recruiting Board members and for

selling the project to other community

members. The short timeframe

led many communities to involve

research institution staff members in

the recruitment process. The haste

needed for the initial Board formation

reflects yet again the contradiction

between the community needs and

the research constraints.

The planning group also had the

responsibility for hiring a local field

director to run the project. The limited

period, the hiring regulations of

the research institutions, and the position of the field director vis-a-vis the

community Board and the research institution made this task difficult for

some communities. The short time allotted to recruiting a field director

sometimes made it a process conducted largely by the research institution

because the planning group was busy recruiting Board members. Research

institutions had their own regulations concerning employees (field directors

were the institutions’ employees), and this sometimes interfered with the

process.

The mobilization protocol acknowledged that the field director would be

required to serve two masters: the research institution and the community.

For many communities, this duality became an immediate issue in the

hiring decision. In some communities, the selection of the field director
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Chapter 5

became a researcher decision, with little or no input by the community

Board. In Cedar Rapids/Marion, IA, the Board complained about the research

institution’s choice but was overruled. (Fortunately, the person hired soon

won over the Board members.) In another community (Bellingham), the

research institution’s first choice of candidates was different from those of

the planning group, but the planning group’s choice was accepted when

members argued that it was their community and they knew best who would

be a good fit. (Fortunately, the person selected soon won over the research

institution staff.)

The hiring of the field director and the formation of the community

Board occurred simultaneously. The basic organizational structure for the

communities is shown in Figure 1. The community Board was to be broad

based. It would identify and nominate members to serve on four task forces

corresponding to the four channels of intervention (public education, health

care, worksites and organizations, and cessation resources). Flexibility was

allowed in the basic structure: Some Boards added executive committees

to make decisions for the Board; two groups added broader community

coalitions to meet annually and review project progress; and some Boards

added task forces to focus on specific activities.

The process of forming the Board and hiring the field director meant that

most communities were prepared to begin in terms of other organizational

requirements (e.g., establishing bylaws, recruiting task force members,

producing a smoking control plan), and this had implications for the local

project. The examples of three communities may be illustrative.

The Board recruitment experience in Brantford, Ontario, Canada, was

typical of many communities. The research institution checked the “pulse”

of the community through the community analysis and identified influential

and interested people in Brantford to participate in the project. The Medical

Officer of Health identified individuals who would best represent the

Figure 1

Standardized organizational structure
Smoking and Tobacco Control Monograph No. 6

62

community. The principal investigator of the research institution then

contacted those people and requested their involvement. The group that

joined (the Community Planning Group) was responsible for planning the

Board formation. They also were invited to become Board members; only a

few refused. The initial Board had some conspicuous gaps, most notably

representatives of local voluntary agencies. However, once the field director

was hired, the executive committee of the community Board and the field

director developed think-tank sessions to identify people from various sectors

to become involved in the project. This approach seemed to work well, and

the Board that emerged stayed strong and committed throughout the project.

In Raleigh, NC, the planning group expedited the hiring of a field

director so she could assist with the formation of the community Board.

Once the field director was on staff, the planning group met with her,

identified community sectors that were critical for involvement, and suggested

individuals who were good choices to serve on the Board. The planning

group members contacted the nominees first; if nominees were willing to

serve, the field director followed up. The next step was a letter outlining the

project and the expectations held for the volunteers. The personal contact

was emphasized as the key to recruiting Board members. This approach was

followed throughout the mobilization process in this community. Task forces

and replacement members to the Board also were recruited this way as the

project continued. Another fruitful recruitment method was inviting the

prospective member to serve on an ad hoc committee with a time-limited

commitment for a specific event or campaign. Regular meetings of the ad

hoc committee with the field director allowed the necessary facilitation

without taking the process and product away from the subcommittee.

The research institution in Bellingham selected the small Community

Planning Group of seven people. The group worked closely with research

institution staff members to identify the important

community sectors and potential community Board

members from those sectors. They also agreed

to recruit specific individuals for the local project.

Through their efforts, a Board of 18 members was

nominated and recruited within a week after the

field director assumed her position. Although the

entire group knew a little about the project, the

normal complexities of setting up new projects

were evident. In an early meeting, the Board

members heard a presentation about the project

along with a description of their roles and

responsibilities. Nevertheless, there were many

unanswered questions, including questions about

budget and the paperwork required to set up an

office. Researchers were honest in their responses;

they did not know all the answers at that stage.

Group members kept their good humor by telling

themselves that the protocol was their “friend”
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Chapter 5

and following it would help them in the organization and implementation

process.

The field director’s first priorities were orienting the new Board members

to the project, explaining their relationship with the research institution,

and familiarizing them with the “joys and sorrows” of the protocol. This

orientation led to some initial cohesion among the group, which took

seriously the task of writing bylaws and recruiting task force members.

During the process, some issues emerged that further helped the group

come together. Early conflicts among Board members actually facilitated

and expedited unity. The issues involved conflicts of interest of Board

members who wished to take personal advantage of the project’s resources.

When the issues came to light, the research institution offered to deal with

the problem, but the response from the Board was unanimous: “This is

our community; we are responsible for the project; and we will take care

of this problem.”

Community Buy-In A major hope in the COMMIT project was that communities

would become partners with the research institutions. Because the agenda

imposed on the community was artificial—tobacco control was the problem

to be addressed, regardless of other problems in the community—effort was

needed to promote partnership and ownership. After establishment of the

Board and task forces, their first activity was the creation of a comprehensive

smoking control plan that would be the framework for intervention activities

for the entire project. The plan document was to be produced locally and

tied to local facts, figures, and plans. Some communities found the process

of producing the plan an important part of the partnership-building process.

Other activities, described below, were reported by the field directors as

important parts of the buy-in process. There is little doubt that the time

required to build feelings of partnership varied among communities;

however, representatives from all communities reported that they felt

a strong partnership by about the middle of the

trial. A few examples follow.

For Brantford, buy-in occurred in small

steps. The production of bylaws and the

smoking control plan joined people together

in understanding the project. The big step

occurred with the purchase of office furniture.

The frustration of not getting furniture in

the field office when it was needed led to a

confrontation between the Board members

and the staff from the research institution.

The research institution responded by

changing the process so the community

Board could be more active.

For Brantford, as for most communities,

a large boost for ownership came when the

community Board chairpersons for all the
Smoking and Tobacco Control Monograph No. 6

64

intervention communities were invited to a national COMMIT meeting to

see how different groups operated. Other communities also were energized

by this meeting. Many Board chairpersons or representatives renewed their

energy and gained a common understanding of what it was possible to ask

from research institutions.

Some communities relied on specific activities to foster buy-in. For

Raleigh, several specific activities pulled the Board and task forces closer

together. A COMMIT To Quit contest required much planning that involved

many sectors of the community. Board and task force members distributed

brochures in health care provider offices, worksites, churches, grocery stores,

and malls. They also recruited people and organizations from the larger

community to get involvement; that is, they solicited prizes, time, or energy

from local radio disk jockeys, a basketball coach, and a drugstore chain. The

final tally of more than 1,000 smokers who joined the contest astounded

the Board members and made them proud.

A less successful example of buy-in in the same community involved

protesting the Philip Morris-sponsored Bill of Rights tour. Despite

preparations of Board and task force members to protest the tour under

the sponsorship of another tobacco control agency, the research institution

stepped in at the last minute to cancel the protest.

Several key activities marked the early buy-in of the project in

Bellingham. The initial activity was a daylong retreat of the Board members

and task force chairpersons to produce the smoking control plan for the

community. After examining the protocol requirements, the group decided

to transform the plan into something useful and applicable to their own

community. Their plan focused on health, used local people as models and

local data, and used a logo created by graphics students at the local college.

The group’s pride in the way they adapted a protocol requirement to a unique

plan for their community contributed quietly to a strong sense of ownership.

Other activities also led to ownership in this community. Early formation

of a finance committee ensured that the Board knew as much as the research

institution about the financial status of the trial. From the beginning, the

Board members and task force chairpersons had a friendly relationship

with the protocol, viewing it as a roadmap rather than a roadblock. The

group also donated space, reduced-cost products, prizes for contests, in-kind

resources, and countless volunteer hours, which led to strong feelings of

ownership.

Maintaining Mobilization does not end when the organizational structure is

Community formed. It is an ongoing process that requires attention to volunteers,

Involvement adaptations of the initial structure, careful attention to allocation

of tasks, and rewards, such as information about the outcome of the

interventions. Any organization that relies on volunteers may expect attrition

as individuals’ lives change, their interest wanes, and other activities compete.

Recognizing the likelihood of such attrition means that project staff members

need to establish processes to bring on new members. As the COMMIT

project continued, it was often obvious that the existing organization had
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Chapter 5

to adapt to make the work flow more smoothly. Some groups added a finance

committee, a transition committee to begin thinking about what would

happen after the project ended, and ad hoc committees focused on specific

events and activities. These activities allowed a more directed approach to

some of the issues and problems facing the Board. Another common problem

that faced some Boards was that apathy developed among their members as

the task forces and field staff members did most of the work. This apathy

among their members was probably perpetuated by the trial rules about data

disclosure; aside from process data, no data were available, to either the

communities or the research institutions, about whether the intervention was

leading to smoking cessation.

Communities dealt with those ongoing mobilization problems in

different ways. Brantford volunteers for the Board were asked for a 4-year

commitment up front; this kept their attrition low. The Board continued to

be active, especially in the face of controversy. When a proposed task force

activity was rejected by officials in the community, the Board responded,

“Let’s go for it . . . .”

The Brantford group dealt with the above-mentioned data problem

by requesting a monthly status report from the research institution that

summarized activities and groups reached (e.g., health care providers,

worksites). Although the report could not discuss success in outcome,

it did reassure the Board that progress was being made in the intervention.

The Raleigh Board recognized that attrition was likely and, 2 years into

the project, conducted another recruitment of Board and task force members.

As previously mentioned, the Board used ad hoc

committees for specific events. Because the bursts

of intensive and dedicated activity necessary to a big

event are almost impossible to sustain with the same

people over a long period, the ad hoc committee

approach was ideal for maintaining enthusiasm

and interest. A side benefit was that it brought

into the COMMIT project other organizations and

individuals who continued their interest in tobacco

control. The field staff members in this community

also divided groups into subgroups for discussion

and brought them back together for decisionmaking.

This process, requiring that everyone be involved at

some level, prevented the tedium of sitting through

countless meetings merely listening to reports. The

field director also emphasized that lively, timely,

and productive meetings were essential to

maintaining interest.

The Raleigh community used the processobjective information as a way to document progress. The members were

cognizant of the process objectives and took pride in meeting or exceeding

them. The baseline data were used by the director of the health department
Smoking and Tobacco Control Monograph No. 6

66

in Raleigh in initiating a policy, and later an ordinance, that restricted

smoking in public buildings. Board members saw that event as evidence

that things were working.

More than one community (e.g., Bellingham, Cedar Rapids/Marion)

suffered from a case of the “middles”: The Board was active initially and

toward the end of the project but became apathetic in the middle period

as work and activities were distributed to

task forces and field staff. Some Board

members left during this time; however,

their leaving provided opportunities

to recruit new members who had

enthusiasm and different views about

tobacco control. In Bellingham the

Board became energized when it

discovered that it would have a small

amount of discretionary funding to give

to individuals or groups that proposed

ideas for tobacco control. The projects

proposed had to be consistent with the

overall goals of the protocol but were

considered optional activities. This action

led to funding activities directed to lowincome pregnant women through the

county health department. Another

activity funded was through the D.A.R.E.

(Drug Abuse Resistance Education)

program; tobacco control was

incorporated as part of the D.A.R.E. curriculum and activities. The Board

took pride in reviewing the proposals and deciding about the use of

discretionary funds.

From the beginning, Bellingham used the process data to assess

achievements and progress. Quarterly reports of process objectives attained

were supplemented with large wall charts that showed the timeline for

activities for a year, by task force, with lines colored in as activities

were completed. The charts provided an immediate overview of

accomplishments.

MOBILIZATION Although the protocol provided a general mobilization process,

EXPERIENCES there were different experiences among the 11 intervention

ACROSS communities. Both field staff and Board members across the

COMMUNITIES 11 communities cited factors that they found critical in the

mobilization process.

One positive feature of the trial was that it provided funds for the

communities. This was seen as a great asset by many community

members because it meant they could focus on the intervention and

not on fundraising activities. Another positive factor mentioned was the
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Chapter 5

approach taken by the trial; it focused on helping smokers to quit rather than

portraying them in a negative light.

Many obstacles to mobilization also were seen by project staff and Board

members. The short time allocated for initial mobilization was cited by many

respondents as a barrier to effective mobilization. As the Bellingham field

director noted, “We had to move so quickly, learn what was required of us,

and produce accurate and complete plans, that at times we literally felt we

were singing in a foreign language.” Community Boards and staff members

were further frustrated by the time it took to obtain space and set up offices,

because such processes had to be approved by NCI (the sponsoring agency)

and often by the research institution as well.

Another constraint on mobilization was the approach taken by research

institution. Research institutions had different levels of experience with

community work, and this led to differing degrees of control. Similarly,

research institutions had different types of connections with the intervention

communities; where they were not well connected, it was more difficult

to mobilize the community. Proximity of the research institutions and

intervention communities also had an effect; more distance between the

two made it more difficult for research institution staff members to assist

with mobilization. The reputation of the research institution within the

community was also important. It was easier to approach a community

if the research institution working with COMMIT had high credibility and

visibility than if the community was unfamiliar with the research institution

or had negative experiences with it.

Three intervention communities were dual communities (Cedar Rapids,

IA, Fitchburg/Leominster, MA, Medford/Ashland, OR); these resulted from

the inclusion of two cities as the target for intervention. In two cases, two

communities were combined to make populations sufficiently large to meet

research guidelines. In the third case, geographic proximity led to the

decision to include both communities. The process of mobilizing them was

slowed by the need to contact two sets of city officials, civic organizations,

school districts, and so forth. This also complicated hiring, meeting

arrangements, and the logistics of some intervention activities. In addition,

it was difficult to determine which community should house the field office

so that both communities could participate easily in the project.

There was substantial initial confusion over ownership and partnership.

In some instances, Board members became frustrated or demoralized when

they realized some of the limitations of the protocol because they had

developed expectations about the level of control they would have over the

intervention. However, other Board members commented that the protocol

was a great help to them in both mobilization and implementation because

it allowed them to get to work immediately without needlessly repeating

earlier efforts. Others commented that it was a broad blueprint that allowed

the community to determine strategic details.
Smoking and Tobacco Control Monograph No. 6

68

In general, the organizational structure required by the protocol was

seen as good, and few staff members found it unduly cumbersome. A problem

that emerged was the composition of the Board and task forces. The protocol

suggested that community leaders be recruited for the Board because of their

ability to open doors and lend credibility to the project. Although many

communities opted for this approach, some established a Board of people

who had reputations for getting things done. There were problems with

both approaches. The Boards comprising community leaders soon found it

convenient to delegate all the tasks to either field staff or task force members,

which somewhat removed the Board from the project. The other approach

suffered from a lack of credibility, which slowed down some activities. Many

communities combined the two approaches by having a leadership Board

with task force members who were more likely to do the work required.

However, there was almost unanimous agreement that all Boards and task

forces delegated more work to the field staff than had been expected.

As the mobilization process continued, the relationship between research

institutions and field staff members became increasingly important. In

communities where both understood and accepted the constraints of the

protocol and were able to develop a relationship based on trust and mutual

respect, mobilization seemed to proceed more smoothly. This tone was

passed on to Board members and enhanced the process. In communities

where the lines of authority were unclear or information was withheld (e.g.,

about the budget), the process was delayed. However, it also was noted that

in some cases Board cohesion increased when the funding agent or the

research institution was seen by the Board as the “common enemy.”

A related issue was the transition of activities from the research institution

staff to the community and subsequent role clarification. As the field director

was hired and began taking responsibility for project activities, the project

director at the research institution had to step back gracefully and play a

behind-the-scenes role. As the Board became more familiar with the protocol

and wanted to take charge of certain activities, the field director had to give

way to task force members, other field staff members, and volunteers. In

communities where adaptation to changing roles was poor, conflict often

was the result.

WHAT COULD In the interest of providing information for other groups

HAVE BEEN and projects contemplating a community intervention in

DONE DIFFERENTLY? the future, the field staff and Board members were asked

to comment on what could be done differently to make the mobilization

process run more smoothly. Some responses apply not only to a randomized

trial but to any community project.

The most common response was that a more realistic, longer timeframe

must be allowed for the initial mobilization. Ideally, field staff members

should be hired and Board and task force members thoroughly familiar with

the project, their roles, and any constraints before intervention activities

begin. Staff members need time to get to know people, to find common

ground, and to develop reciprocity. More time would allow the entire group
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Chapter 5

to know whether it had found the appropriate people for the Board and

task forces. This is especially important when the agenda is an artificial

one to which the community has not given a high priority; momentum

must build slowly as people are educated about the problem.

Individuals involved in the COMMIT project also were frustrated by

the shortness of the intervention period. Mobilizing an entire community

requires much time. Volunteers noted that the project had just begun to

develop good community recognition

when the project ended.

Field directors recommended

beginning community projects with

small tasks so that immediate success

can be seen. For achieving this, a

suggestion was made to capitalize

more effectively on the development

of the smoking control plan as an early

mobilization activity. In communities

where developing the plan was

identified as an objective, a sense of

partnership emerged sooner than in

those where the community Board had

little input into the plan.

Almost all the communities

acknowledged that they did not have

enough representation from minorities

and heavy smokers on their Boards and

task forces. Again, more time to explore these populations and engage them

in the project was seen as potentially having a large payoff. One person

recognized that attention to the protocol shifted priorities away from

organizing hard-to-reach groups such as blue-collar and ethnic minority

groups. Involving such groups would have enhanced the likelihood of

reaching heavy smokers. Putting minority recruitment directly into the

protocol would have accomplished the inclusion of hard-to-reach groups

and thereby reached heavy smokers more easily.

Many respondents noted that training should have been more specifically

focused; for example, training should be more culturally relevant, deal with

conflicts, and use the project materials more.

The early products of the trial, such as the prerandomization and

postrandomization analyses, were not seen as user-friendly by many

communities. This seemed to be partly because the communities’

involvement in producing the documents was limited; most groups

ratified the documents but never used them as resources for ongoing

mobilization activities. It was suggested that the Community Planning

Group prepare the analysis so that the community would have some

ownership of the report.
Smoking and Tobacco Control Monograph No. 6

70

CONCLUSIONS The COMMIT mobilization protocol attempted to integrate the

best known principles of community organization into an approach that

required standardization. Several key principles of community organization

were reinforced. Several community studies have noted the need for good

community analysis prior to intervening with a community (Bracht, 1988;

Haglund et al., 1990). This chapter recognizes that need and suggests that

such an analysis include community input as well as comment because

understanding the community is a critical step in successful mobilization.

Analysis identifies key leaders and actors whose participation is required.

Unfortunately, the trial completely locked communities out of early

involvement in trial design and planning. Also, contrary to the basic

premises of community organization, it limited their involvement in the

community analysis that is the groundwork for later intervention. As a

result, there was substantial early confusion over roles and responsibilities.

Community ownership, control, and maintenance are concepts based

on the traditions of local autonomy and general community development.

In practice, the realization of the overall ownership goal was slow, was not

always well understood, and required continuing clarification. Some factors

helped: sharing as much information as possible, recognizing the need for

joint decisionmaking, and acknowledging that conflict and tension are

inevitable in work with large, diverse groups.

Would the COMMIT mobilization status have been different if a

standardized protocol had not been used? Would the communities have

come to the same place in the same time? Would they have felt more

ownership of the project or less? The lessons from the field may not answer

these questions, but they do provide insights and suggestions for other

groups contemplating community organization strategies for research

projects.

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the ten years of the North Karelia Project. Annual

Review of Public Health 6: 147-193, 1985.

Rothman, J. Three models of community organization

practice. In: Strategies of Community Organization,

F.M. Cox, J.L. Erlich, J. Rothman, and R.E. Tropman

(Editors). Itasca, IL: Peacock, 1979, pp. 86-102.

Stunkard, A.J., Felix, M., Cohen, R. Mobilizing

a community to promote health: The Pennsylvania

County Health Improvement Program (CHIP). In:

Prevention in Health Psychology, J.C. Rosen and L.J.

Solomon (Editors). Hanover, NH: University Press

of New England, 1985, pp. 143-189.

Tarlov, A.R., Kehrer, B.H., Hall, D.P., Samuels, S.E.,

Brown, G.S., Felix, M.R., Ross, J.A. Foundation

work: The health promotion program of the Henry

J. Kaiser Family Foundation. American Journal of

Health Promotion Fall: 74-80, 1987.

Thompson, B., Corbett, K., Bracht, N., Pechacek, T.

Lessons learned from the mobilization of

communities in the Community Intervention

Trial for Smoking Cessation (COMMIT). Health

Promotion International 8(2): 69-83, 1993.

Thompson, B., Kinne, S. Social change theory:

Applications to community health. In:

Health Promotion at the Community Level,

N. Bracht (Editor). Newbury Park, CA: Sage,

1990, pp. 45-65.

Thompson, B., Pertschuk, M. Community

intervention and advocacy. In: Prevention

of Coronary Heart Disease, I.S. Ockene and

A.K. Ockene (Editors). Boston: Little, Brown,

1992, pp. 493-515.
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Thompson, B., Wallack, L., Lichtenstein, E.,

Pechacek, T. Principles of community

organization and partnership for smoking

cessation in the Community Intervention Trial

for Smoking Cessation (COMMIT). International

Quarterly of Community Health Education 11(3):

187-203, 1990-91.

Warren, R. Toward a reformulation of community

theory. Community Development Review 9: 41-48,

1958.

AUTHORS

Beti Thompson,Ph.D.

Associate Professor

University of Washington School of Public

Health and Community Medicine

Associate Member

Fred Hutchinson Cancer Research Center,

MP-702

1124 Columbia Street

Seattle, WA 98104

Linda Nettekoven,M.A.

Project Coordinator

Oregon Research Institute

1715 Franklin Boulevard

Eugene, OR 97403

Dianne Ferster

Executive Director

COMMIT to a Healthier Brant

Suite 403

233 Colborne Street

Brantford, Ontario N3T 2H4

CANADA

Len C. Stanley,M.P.H.

Program Director

Tobacco Control Training Center

Department of Family Medicine

University of North Carolina

Aycock Building, CB-7595

Manning Drive

Chapel Hill, NC 27599

Juliet Thompson

Field Director

Bellingham COMMIT Site

4407 Wilkin Street

Bellingham, WA 98226
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Chapter 5

Kitty K. Corbett,Ph.D.,M.P.H.

Adjunct Investigator

Division of Research

Kaiser Permanente Medical Care Program

3505 Broadway

Oakland, CA 94611

and

Assistant Professor

Health and Behavioral Sciences, CB-103

Department of Anthropology

University of Colorado at Denver

P.O. Box 173364

Denver, CO 80217
Smoking and Tobacco Control Monograph No. 6

74
75

Chapter 6

Activities To Involve the Smoking Public in

Tobacco Control in COMMIT

Russell C. Sciandra, Lawrence Wallack, Carolyn L. Johnson, Janine Sadlik,

and Juliet Thompson

INTRODUCTION Public education is a necessary tool to facilitate smoking control

efforts. For many years, the tobacco industry has used public education in

the form of advertising to promote the use of its products in such a way that

exposure to tobacco cues is virtually impossible to ignore (Johnston et al.,

1987; Centers for Disease Control, 1990). The information presented by

the tobacco industry regarding the consequences of tobacco use is often

fallacious. For example, cigarette advertisements link smoking with images

of fitness, health, beauty, and social acceptance (Warner, 1986). There

is increasing evidence linking such false advertising to an increase in

consumption (Seldon and Doroodian, 1989; Tye et al., 1987). Furthermore,

the clout exerted by the advertisers often results in limited coverage in the

media of the ill effects associated with tobacco use (Weis and Burke, 1986;

Minkler et al., 1987). An excellent example of this occurred when lung

cancer became the primary cancer killer of women, exceeding breast cancer,

and the issue was largely ignored by women’s magazines, which are also

primary recipients of tobacco advertising revenues (Kessler, 1989).

Although public education in the interest of reducing public health

problems has few resources at its disposal relative to the tobacco industry,

some important efforts have been made to use this channel to reduce

tobacco use. Flay (1987), in a review of 56 evaluated media tobacco control

programs, came to the following conclusions:

• Such programs inform people.

• People are motivated to attempt to quit.

• Potential quitters can be encouraged to take some kind of action (e.g.,

calling a hotline).

• Smokers can quit for extended periods.

Smoking reductions in mediated quit programs also have been reported

by Cummings and colleagues (1987 and 1989), Pierce and coworkers (1990),

and Thompson and Curry (1994). Although the cessation rates associated

with such programs are low, their public health effect is significant because

they reach many people. However, the majority of the tobacco control

interventions have been directed at individual smokers in an attempt to

encourage them to quit.

In the past few years, new efforts have been added to the general use

of public education and the media for tobacco control. Rather than relying

only on activities designed to assist smokers in quitting or preventing youth
Smoking and Tobacco Control Monograph No. 6

76

from beginning smoking, tobacco control advocates are taking an aggressive

approach to the use of mass media. This approach has been called “media

advocacy,” and its central approach is to reframe public debate so that more

support is generated for effective policy change around a public health issue

(U.S. Department of Health and Human Services, 1989). Media advocacy is

not targeted to the individual and does not focus on changing individual risk

behavior; rather, it focuses on the larger, structural factors that might make

a problem a public health issue (Advocacy Institute, 1987). For example, in

the tobacco control arena the emphasis is placed on the ethical and legal

liability of the tobacco companies, which make a product responsible for

much premature morbidity and mortality. An example of effective media

advocacy was apparent in the negative framing of the attempt to introduce

a new brand of cigarettes, “Uptown,” to urban minorities. Antitobacco

advocates were successful in convincing the public and opinion leaders

that this targeting was a deliberate effort to exploit the minority group.

Demonstrations and protests ultimately led R.J.Reynolds to withdraw the

product (Freedman, 1990).

RATIONALE Communitywide public education efforts were central to the

AND PROCESS Community Intervention Trial for Smoking Cessation (COMMIT).

OBJECTIVES The public education channel was seen as a way to coordinate and

promote the activities of the other channels by providing media campaigns

to promote smoking as a public health problem, to promote smoking

cessation, and to encourage the prevention of smoking.

The overall strategy for the public education channel was to increase

community activities that would stimulate public debate about smoking. Of

key concern was that such a debate help create a social environment where

support for nonsmoking was increased and support for continued smoking

decreased.

Three overall goals were developed for the public education channel:

• promote social norms and actions toward a smoke-free community;

• promote the importance of smoking as a public health issue; and

• enhance the effectiveness of smoking control in other program areas.

The process objectives shown in Table 1 were developed to meet these goals.

The activities can be categorized into three major types: (1) activities

designed to change the community climate for smoking through media

campaigns, (2) activities designed to change the community climate through

media advocacy, and (3) activities to enlist smokers in quit attempts.

Changing the To introduce the project to the community, activities in this area

Community began with a kickoff event, the major element of which was a

Climate Through news conference involving as many media outlets as possible.

Media Campaigns Annually, another major news conference was held to describe

the achievements of the past year and plans for the next intervention year.

A few months after the announcement of the project, the communities
77

Chapter 6

Table 1

Activities and process objectives for involving the public

Cumulative Process Objectives

Objectives Number Achieveda

Activities for Each Community (1988-1992) Completed (%)

Nationally, Train One Person (e.g.,

field director) in Media Advocacy 11 people trained 11 100

Train Minimum of Eight Community

Members in Advocacy 88 people trained 80 91

Hold News Conference for Smoking

Control Plan 11 conferences 11 100

Hold Annual News Conference for

Annual Action Plan 44 conferences 44 100

Annually Provide Eight Local News

Releases on Tobacco Issues 352 news releases 345 98

Develop Campaigns To Publicize

Availability of Cessation Resources

Guide and Other Aspects of

Smoking Cessation All communities 11 100

Annually (from 1989) Design and

Implement Two Magnet Events 66 magnet events 95 144

a Average for combined communities.

released their own locally developed smoking control plans. This plan

summarized the framework for the entire 4-year intervention period. It

used local data and local individuals to present the smoking problem.

Another key charge in this area was to publicize smoking control activities

in other task force areas. Community campaigns were to be developed

to fit with other activities. Each community was required to conduct a

campaign to publicize the availability of a Cessation Resources Guide

(CRG) (see Chapter 8), a campaign to publicize the Smokers’ Network

(see Chapter 10), and a campaign to encourage heavy smokers to ask their

health care providers for advice about smoking cessation (see Chapter 9).

At least two other campaigns, of the community’s choosing, also were

required.

Media Advocacy Media advocacy also was an important part of changing the

community climate. Within each community, a staff person was trained

in media advocacy. The training, conducted during a half-day session

by qualified trainers, sought to convey the skills needed to put smoking

control on media agendas. The trained staff person was then responsible

for organizing media advocacy training sessions in the community. As part

of an ongoing effort to find appropriate information for media advocacy,
Smoking and Tobacco Control Monograph No. 6

78

each field office was connected to a communication network that provided

regular information on national or regional events that could contribute

to public awareness if a local “spin” was put on the story.

Enlisting The public education channel also had the goal of enlisting smokers

Smokers in in quit attempts. Each community was responsible for designing

Quit Attempts and implementing two “magnet events” annually. A magnet event

is a well-publicized, communitywide activity that stimulates smokers to quit.

Examples of magnet events include the American Cancer Society’s The

Great American Smokeout (GASO), in which a week’s worth of activities

precede a day when smokers quit for the day, and communitywide “Quit

and Win” contests, in which incentives are used to get smokers to quit

for a certain period (usually 30 days). Quit and Win contests provide

a communitywide outreach that involves not only smokers but also

nonsmokers in assisting smokers in quitting. They have been used

successfully in several communities (Elder et al., 1991; Lando et al., 1990;

Cummings et al., 1990).

CAMPAIGNS The resources available to COMMIT communities exceeded what is

usually available for smoking interventions; however, they were not adequate

to mount fully developed media campaigns, especially compared with the

media assets commanded by the tobacco industry for promoting cigarettes.

Therefore, it was necessary to leverage what was available from the funding

agency to maximize its impact. This was done in a variety of ways that are

more fully discussed below but can be briefly summarized as drawing on

community resources not previously involved in tobacco control.

There was significant variability in how communities implemented

media activities. Although most sites were able to initiate the minimum

number of activities required by the protocol, there was considerable variety

in the quality of the interventions. Moreover, some sites substantially

exceeded protocol requirements, whereas others devoted more effort to

other intervention channels. This disparity arose from differences among

communities (some had limited free-standing media; some had media that

overlapped with the comparison community) and from variations in the

interests and skills of community staff and volunteers.

Medford/Ashland, OR The experience of the Medford/Ashland, OR, site was typical

of many in the trial. The Medford/Ashland intervention community, one of

the smallest in the trial, had a relatively large number of media outlets at its

disposal. These included 2 well-read daily newspapers; 3 local, commercial

television stations; 1 public broadcast system; 1 public access television

channel; and 11 radio stations. Based on previous experience in the

community, COMMIT staff members had contacts with several media

personalities and spent considerable time and effort maintaining these

relationships throughout the trial.

Early in the intervention phase, “COMMIT To Quit,” as the program was

named in Medford/Ashland, used media advocacy techniques to seize the

news media’s attention. For example, it held news conferences complete
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Chapter 6

with visual aids comparing cyanide levels in cigarettes to cyanide levels in

tainted Chilean grapes declared unfit for consumption. Following this event,

COMMIT To Quit became recognized as the “local expert” when reporters

were working on tobacco-related stories.

During the first intervention year, the Public Education Task Force

relied almost solely on voluntary press coverage of COMMIT events. A few

paid print advertisements were run to promote a Worksite Smoking Policy

Workshop and a Win a (Cold) Turkey contest as part of the GASO. The task

force was disappointed at the numbers of participants generated and decided

that the poor reponse was the result of a heavy reliance on public service

advertising. Despite cautions from the representatives of voluntary agencies,

which use no paid advertising, the task force decided to set funds aside to

buy air time. COMMIT To Quit was viewed by media outlets as a voluntary

organization and given the nonprofit, column-inch rate in the newspapers

and the two-for-one rate in radio and television commercials.

In the second intervention year (1990), the task force contacted a

marketing instructor at a local 4-year college and asked whether he would

make the design of a 3-month campaign to reach heavy smokers a class

project. When he agreed, the class was divided into three groups. Each

group had to research the target audience; select a slogan; generate artwork,

scripts, and storyboards for television and radio commercials; and propose

the media placements. The winning group developed the concept of

maximizing the small budget by partnering with a local minor league

baseball team. The campaign included a billboard for the ballpark, a fullpage advertisement in the program, busboards for the Rapid Transit District

buses, and radio commercials. The campaign culminated in participants

signing up for a stop-smoking contest, with free admission to the ballpark

and a barbeque celebration for those that did so. The winning theme was

“Time To Quit!” A request for proposal was sent to all advertising agencies

in the county, and an agency contracted to produce a jingle, a 60-second

radio commercial, and a 30-second television commercial. (Seven other

COMMIT sites later bought copies of the television commercial.) The task

force decided to use the agency to create print advertisements and to

negotiate advertising purchases throughout the remainder of the project.

The advertising agency proved a wonderful

asset in leveraging advertising dollars.

Despite the fact that COMMIT tripled its

paid advertising, it continued to receive

public service advertising.

During the last year of the intervention

(1992), the Public Health Task Force

produced a four-page newspaper insert

titled “A Resolution You Can Live With.”

A student poster replaced the Time To Quit

artwork on the busboards, and COMMIT

donated billboards at the ballparks to a local
Smoking and Tobacco Control Monograph No. 6

80

drug prevention group in exchange for its pledge to address tobacco and

nicotine in its programs. The highlight of this year of the project was the

production of a 30-minute documentary about COMMIT’s 4 years in the

community. The documentary was premiered at COMMIT’s gala farewell

celebration before an audience of dignitaries and volunteers and was later

aired in prime time to promote participation in that year’s GASO.

In summary, the Medford/Ashland experience demonstrates how the

creative use of community resources (college classes, student art, songwriter

and composer, filmmaker) and the use of leveraged media buying

(partnerships, piggybacking, multiple cosponsors, professional agency)

can maximize the reach and frequency of health promotion messages on

a shoestring budget.

Utica, NY The Utica, NY, program devoted more resources to media-related

activities than any other site. At the beginning of the project, the volunteer

Board suggested that an advertising agency be retained to produce a consistent

theme for the project’s antismoking messages. The agency that was selected

developed a slogan, “Yes, You Can,” which was integrated into all the project’s

messages over the next 4 years. The advertising campaign consisted of radio

and television advertisements, bus cards, billboards, and point-of-purchase

displays. Some advertising was developed locally, but for the most part,

advertisements produced elsewhere were borrowed and

tagged with the project’s slogan. As in Medford/

Ashland, the program received two- or three-for-one

advertising rates in broadcasting. There were several

campaigns over the 4 years, all tied together by the

“Yes, You Can” theme. The repetition of this theme

helped build public awareness of the program.

As in other communities, the COMMIT office

soon became the recognized source of information

and comment for media stories on tobacco. The

computerized communication network provided by

the trial gave advance notice that news was breaking

nationally; this allowed staff members and volunteers

to contact local media to alert them and provide local

comment and statistics. Being in the news so frequently

built credibility and awareness of the program.

Sometimes this had unforeseen benefits.

The Utica field director stopped in a pharmacy to pick up a prescription,

and the pharmacist recognized her from television as the COMMIT

spokesperson. As a professional pharmacist, he was interested in doing

something about smoking. This chance encounter led to activities involving

a major pharmacy chain in a series of smoking cessation activities.

Bellingham, WA The Bellingham, WA, site had to cope with several media problems.

None of the major television outlets viewed by residents had local offices.

One cable station existed, and it provided some local access but little else.
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The local newspaper was read widely but was part of a chain, which placed

constraints on local practices. Nevertheless, COMMIT staff members and

the Public Education Task Force took on the challenge of providing the

information to the community.

The task force did not elect to use one theme for the entire intervention

period of the project. It tied campaigns to specific community activities

and events that would capitalize on local values and characteristics. The

first media campaign developed by volunteers and staff took place during

the 1989 holiday season (November 1989 through January 1990). This

holiday gift campaign was based on the theme that “The best gift you can

give yourself and your loved ones is the gift of your own good health.”

Several radio commercials were developed with the collaboration of a local

disc jockey who donated his time. The commercials urged listeners who

were interested in giving themselves good health by stopping smoking

to call the COMMIT office number to receive a free “holiday quit kit.”

The commercials began playing on four local radio stations just after

Thanskgiving and continued until the first part of January. The radio

stations were selected to reach diverse audiences and included a local popular

news station, a country-western music station, a rock music station, and

another station that had a variety of programming. Good coverage was

obtained by varying the time of day when the commercials were aired.

Costs were kept reasonable by obtaining two or three advertisements for

every one that was purchased.

Individuals who responded to the radio commercials were given a gift

package that included a quit kit (containing quit tips, items to keep their

hands busy while quitting smoking, cartoons, sugarless mints and gum,

and various other aids intended to make cessation easier), a gift card to

present to a friend or family member stating the respondent was giving the

person the gift of his or her health, and self-help materials on smoking

cessation. The response was overwhelming. From the first day the messages

aired, telephone calls and visits were received from people who heard the

messages and wanted to quit. In 6 weeks more than 400 gift packages were

distributed.

The Bellingham group also developed the “Be a Winner” campaign

that commenced in fall 1990. The COMMIT staff members and volunteers

worked with a local television production company to develop a message

that winners were people who tried, often many times, to achieve a goal.

Football players provided the basic image, and they were shown running

down the field many times and finally scoring a touchdown. This theme

was used in the hope of reaching blue-collar smokers and convincing them

that repeated attempts to win (i.e., quit) were normal in many aspects of life.

In this way, perhaps they could be motivated to try to quit more than once.

The football and winner theme was chosen to coincide with the National

Football League season, and especially the playoffs, so that interest in a Quit

and Win contest that was scheduled to begin in January would be high.
Smoking and Tobacco Control Monograph No. 6

82

The response to the campaign was good. Although no quantitative data

were collected on the campaign, anecdotal data indicated that people saw

the commercials (they were mentioned when people signed up for the

contest) and liked them. The connection with the football theme was seen as

positive, and no negative comments were received.

Raleigh, NC The project in Raleigh, NC, began with a large kickoff event that was

well received; however, staff members soon discovered that it was difficult to

convince the daily newspaper to cover issues considered

by COMMIT volunteers to be important. Their strategy

became one of presenting unique analyses of tobacco

issues and staging visually interesting events by

members of the community.

The kickoff event coincided with Raleigh’s

Downtown Beautification Project. After learning

of the attention that would be paid to the project, the

COMMIT project donated 100 oak tree saplings to the

city, a symbol of Raleigh’s “turning over a new leaf.”

During the presentation, COMMIT volunteers tied to

the saplings construction-paper leaves with the names

of recent quitters on them. This activity received much

media attention.

The Raleigh group had great success in publicizing

the 1990 Surgeon General’s report as well as several local

youth-buying operations. The media response to the

first part of their COMMIT To Quit program, a Quit and Win contest, was

outstanding. However, as the project continued, it was apparent that gaining

media attention was not always easy. For example, the 1991 COMMIT To

Quit occurred at the same time as the Persian Gulf War, and it was difficult

to keep the media’s interest. Furthermore, staff members discovered that it

was hard to sustain enthusiasm in a yearly event; the media prefer new angles.

The Raleigh group, being in the heart of tobacco country, faced

particular hardships. The newspapers often overlooked them. Any

competing events seemed to draw the media away from COMMIT activities.

Even the introduction of “big name” speakers did not generate media

coverage. The biggest, consistent media success for this community was

the coverage generated by underage teen-buying operations.

MAGNET EVENTS All COMMIT communities had numerous magnet events. Every

community had at least one Quit and Win contest, with a total of 26 such

contests held throughout the trial. The contests varied in length and awards

but had some commonalities. First, efforts were made to extensively promote

the contest in the community. In addition to the usual media outlets, small

media also were used to advertise the event. For example, contest organizers

convinced grocery stores to print information on grocery bags; leaflets were

distributed in specific neighborhoods; posters with attached entry forms were
83

Chapter 6

distributed to retail stores, doctors’ offices, public buildings, and worksites;

and brochures were distributed. Second, some biochemical verification of

smoking status (usually expired carbon monoxide) at the end of the contest

was required. Third, there was a period for registration before the big

“quit day,” which was usually tied to a date that is noteworthy for smoking

cessation (e.g., New Year’s Day, the GASO). Fourth, many prizes were

distributed, with a major grand prize of $1,000 in almost every contest.

Fifth, the event ended with a celebration for all participants and their

families. The examples that follow give a flavor of the activities involved

in conducting Quit and Win contests.

Fitchburg/ Fitchburg/Leominster, MA, initiated the first of their three Quit

Leominster, MA and Win contests in 1990. Planning for the activity, called Time

To Quit, began 2 1/2 months before the contest. Most preparation work

was done by field staff. COMMIT paid for advertising, which included radio

commercials, newspaper advertisements, discussions on local talk radio,

and a videotape that was aired on the local cable television channel. Posters

and registration cards were sent to community worksites and health care

providers. Entry forms also were included in the COMMIT newsletter.

A local supermarket printed 200,000 grocery bags with registration forms

that could be cut out and mailed.

One hundred and five smokers registered for the

contest; of those, approximately 40 quit for a month.

Most registrations came from the COMMIT newsletter.

Every week during the contest, COMMIT staff members

sent postcards containing support messages and quit tips

to the participants. These were reported to be helpful in

reinforcing quit attempts. The end of the contest, which

coincided with the American Lung Association’s (ALA)

Non-Dependence Day, was celebrated in the parking lot

of the local mall. A local radio station donated 3 hours to

broadcast the events, including the drawing of winners,

and to interview contest participants and volunteers.

The contest was considered a success; however,

volunteers also learned from this first activity. COMMIT

staff members and volunteers believed a longer planning

period was necessary. There also was a feeling that

promotion of the event was too narrowly focused and

began too close to the start date; thus, fewer people enrolled than might

have. For example, the grocery bags appeared only 1 week before the start

date. The following year (1991), planning began much earlier, and promotion

was more extensive. In addition, entrants received a “scratch” lottery ticket

just for entering. Other venues were targeted for recruitment, including bingo

halls, bowling alleys, and Lamaze classes. Worksites were enrolled, and a

between-worksites competition of four platoons of firefighters brought more

entrants. Approximately 200 smokers participated in this second effort.
Smoking and Tobacco Control Monograph No. 6

84

Paterson, NJ Paterson, NJ, has a high proportion of ethnic minorities; thus,

involvement in a Quit and Win contest had to appeal to several different

groups. The COMMIT Board and task forces planned a long-term,

comprehensive contest that focused on recruiting the

heavy smokers in the community. The contest began on

January 24, 1991, and ended June 30, 1991. The basic

format of the contest involved an ongoing recruitment

effort, with drawings made monthly for a prize ($250) to

be given to a quitter at the end of the contest (provided

he or she remained in the quit category), followed by a

final cash award of $1,000 given to a quitter whose name

was drawn from all quitters at the end of the contest.

The recruitment effort dominated the activity.

The group began with the usual methods of information

dissemination: media promotion, use of a graphic artist

to design a contest theme, distribution of promotional

items, and mailings of entry forms. The contest also was

promoted in Spanish-language media. As time went on,

volunteers became more active in getting registrants;

they went to barbershops, beauty shops, day-care

centers, family centers, supermarkets, shopping malls,

and other areas to sign up smokers to participate. Additional promotion

efforts included giving economic incentives to youth to sign up smokers, and

even police departments were contacted to invite area convicts to participate.

The Worksites and Organizations Task Force contacted all local workplaces to

sign up smokers; 7,000 flyers were sent home with children in the Paterson

school system, and 9,000 payroll stuffers were distributed to all area hospital

and city employees. By the end of June, 501 smokers had participated in the

contest. A grand finale was held during a local festival, with the overall

winner’s name drawn by the mayor of Paterson.

This ambitious effort required significant time and resources, and the

COMMIT staff members and volunteers learned from the event. First,

they learned that recruiting smokers was more difficult and tedious than

anticipated. Ultimately, door-to-door recruitment was seen as the most

effective method of getting smokers involved in the contest. This group

also experienced problems with late promotion of the event, largely as a

result of initial difficulties with the graphics firm that was to design and

conduct the publicity. Although these problems eventually were resolved,

time was lost in promoting the event. Logistics problems also emerged in

this community; there were some incomplete entries that led to the inability

to find entrants. Overall, however, this contest was considered successful.

It reached the targeted smokers as evidenced by the demographic

characteristics of the participants (which closely matched the community

demographics); it increased the number of smokers who signed up for the

Smokers’ Network; and it greatly increased the visibility of COMMIT.
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Chapter 6

Santa Fe, NM Santa Fe, NM, held a 3-month Quit and Win contest in 1991 that

culminated on the ALA’s Non-Dependence Day. Participants were eligible

for interim awards. Relapsers

in the first month of the

contest were encouraged

to sign up again for the

remainder of the contest. A

total of 377 people initially

joined the contest, with an

additional 46 April relapsers

joining in May or June.

Contest participants were

encouraged to find people to

support them in their quit

efforts. At the grand finale,

quitters (verified by expired

carbon monoxide) were

eligible for first-, second-, or

third-prize drawings, based on

the amount of time they had

been tobacco-free. Followup

telephone calls were made to entrants every week to ascertain whether they

needed materials or support in quitting or remaining abstinent. A grand

finale was held on the Santa Fe Plaza on July 5, 1991. Music was provided by

a local group; a puppet show was held for children that included content on

smoking; a city council member read a proclamation declaring July 5 NonDependence Day; and the awards were given.

This event ran smoothly, and recruitment of participants exceeded

expectations. All task forces were involved in the recruitment process and

in promotion of the event. The Public Education Task Force worked with a

public relations firm to plan the promotion of the activity and helped to

plan all aspects of the promotion. Schools were involved in spreading the

word about the contest. Puppet shows presented to children were designed

to get the message to parents. Peer educators helped with mailings and

other logistics. Cessation Resources Task Force members assembled materials

and delivered them to health care facilities and provider offices. They also

convinced local cessation resources to provide discounts during the contest.

The Health Care Provider Task Force ensured that materials were available

in all provider offices. They also set up five “minicontests” between

individual offices and clinics. The Worksites

and Organizations Task Force contacted local

businesses and organizations to inform them

of the contest and to recruit from the employees

or membership. Few problems were encountered

in this community. One disappointment was the

inability to find a celebrity to hand out the awards.

This was attributed to the event occurring on the
Smoking and Tobacco Control Monograph No. 6

86

holiday weekend. Another problem was that the ALA changed NonDependence Day from July 5 to July 3; nevertheless, the Smoke-Free Santa Fe

group continued with July 5 as the date of the finale.

Yonkers, NY Yonkers, NY, ran its second contest, called “A Thousand Good Reasons

To Quit Smoking,” from January to February 1992. The activity focused on

the effects of smoking on children; thus, each entrant in the contest was

required to designate a youth supporter between the ages of 5 and 18. The

grand prize for the contest was a $1,000 U.S. savings bond for the child’s

education and a $250 gift certificate for the quitter. Only residents of

Yonkers were eligible. All quitters had to undergo cotinine testing to

verify their smoking status. Many community sectors participated. The

school system sent home 12,000 newsletters advertising the contest with

elementary school students. Several worksites permitted staff members to

personally register smokers. Media promotion was used, and many articles

about the contest appeared in the local newspaper. Prizes were donated by

several local businesses; these included monetary donations, a weekend for

two at a local inn, dinner for two at a theater club, movie tickets, and gift

certificates. A total of 164 smokers entered the contest.

Staff members and volunteers felt the contest was successful but had

hoped for a larger enrollment. Staff members felt that there were several

constraints on the enrollment. First, the prize that went to the winner was

not large because the youth supporter received most of the benefits. Second,

a number of smokers did not enroll with youth and had to be contacted to

provide the name of a youth supporter. This suggested that many smokers

may have declined to enroll because of that stipulation. Third, the cotinine

testing presented a problem because it required 2 weeks to obtain laboratory

results. Participants found it annoying to come in to provide a saliva sample.

Fourth, a staff suggestion to initiate a contest between schools and worksites

to sign up smokers was vetoed by the Board. Fifth, the grand finale was not

well attended, probably because it was held in a relatively obscure location

in a local mall.

Cedar Rapids/ Cedar Rapids/Marion, IA, took advantage of the newly imposed ban

Marion, IA on smoking on commercial air flights to institute a magnet event.

Working with a representative of the ALA Iowa affiliate, COMMIT staff

members and volunteers planned an event at which materials would be

distributed at the Cedar Rapids airport on the day the ban started.

Permission was readily given by the airport administration, and “panic

packs” were assembled. These were packages that contained tips for

surviving the flight, a CRG, balloons, hard candy, buttons, wrist snappers,

and headless matches. The event was held in late afternoon on the day

of the ban and was well covered by the media. The event served the

additional purpose of providing an energy boost for COMMIT staff members

and volunteers who saw that, with a little extra effort, it was possible to

“seize the moment” and get substantial media attention.
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Medford/ The third intervention year (1991) in this community began with

Ashland, OR a locally produced and televised “Freedom From Smoking” cessation

program cosponsored by a television station, the local power company, and

the county library system. A small group of smokers was recruited to meet

daily for a week and share experiences in following each activity in the

cessation guide. Five thousand guides were distributed throughout southern

Oregon. Each night during the news, the anchor showed a segment of

the discussion among the smokers and directed viewers to the next day’s

assignment in the guide. Print advertisements and other promotional

features directed smokers to pick up guides at several prominent locations.

The program continued to use a combination of press releases and print,

radio, and television commercials to promote activities, and participation

rates increased each year.

Medford/Ashland, OR, These two areas conducted a “friendly” competitive

and Bellingham, WA magnet event. Because each community has a minor

league baseball team, COMMIT staff members collaborated on a joint activity.

The impetus came from Medford (the ballpark is located in Medford, not

both communities), where a promotional campaign was designed to link

with the local baseball team, the Southern Oregon Athletics (minor league

team for the Oakland Athletics). Conditions of the competition were that

both communities would have a smoke-free family night at the baseball

game and sign up smokers for the Smokers’ Network. Dates were set for

when the teams would be playing against each other. The Southern Oregon

Athletics challenged the Bellingham Mariners (minor league team for the

Seattle Mariners) to go smoke-free for the night, and the challenge was

reversed when the Medford team came to Bellingham. In both communities,

COMMIT purchased (or received donated) tickets to the game. Also, smokers

or chewers received a free ticket in exchange for a packet of cigarettes or

a can of snuff. Arrangements were made for the announcer to mention

frequently the COMMIT To Quit message.

In Medford, the teams backed out of their commitment to go tobacco-free

for the night for fear that playing would be affected. Fifty smokers signed up

to participate and received free tickets to the game. The smoke-free family

section censured an individual who tried to light up a cigarette in that section

of the ballpark, and many smokers in the smoking section were cajoled by

family and friends into going to the COMMIT booth for testing. Although

participation was less than expected, the clown hired by COMMIT, the favors

passed out, and a bright, sunny day made it an enjoyable event. One of the

COMMIT volunteers noted that the event was charming because it recruited

smokers and rewarded nonsmokers.

Bellingham COMMIT needed to beat the number of participants recruited

by Medford/Ashland COMMIT. The group was successful in convincing the

Bellingham Mariners players to go tobacco-free for the night. Media coverage

of the event included interviews with players who stated that youth should
Smoking and Tobacco Control Monograph No. 6

88

not start chewing because it is a difficult habit to break. Thirty participants

gave a package of cigarettes or chew in exchange for a free ticket; however,

the game was repeatedly delayed by bad weather. By the time the game

began, there were virtually no spectators. Determining that Medford/Ashland

had won, the Bellingham field director had a plaque made for the Oregon site

and presented it to the COMMIT Board representatives at an annual meeting

in February 1991.

The between-community competition generated a great deal of interest

and fun. Media coverage was excellent in both communities. Interestingly,

the between-community competition portion of the event was not much

added effort because the events were already scheduled in each community.

It is surprising that more events like this did not occur throughout the

various intervention communities. There was much sharing of material

and promotional campaigns, but it may have been threatening to various

staff members to feel that they had to compete with each other.

Other Magnet Quit and Win contests were not the only magnet events devised

Events to draw smokers into quit attempts. Every community conducted

numerous activities around the GASO

or, in the case of the Canadian

communities, “Weedless Wednesday.”

Activities focused on this annual

event included providing cold turkey

sandwiches, setting up a “survival

camp” for smokers who pledged to

quit for the day, providing smokers’

quit kits to interested smokers, having

someone dress as a 7-foot turkey to

symbolize “quitting cold turkey,”

organizing competitions to see which

worksites could have the most quitters

and supporters during the GASO, and

providing the community with

messages about tobacco control.

Numerous other magnet events

were held in the intervention

communities. In Medford/Ashland,

staff members and volunteers designed, constructed, and staffed a float for

an Independence Day parade. Brantford, Ontario, Canada, held a community

forum to gain community input on tobacco control. Brantford also held a

“Butt Out” party to encourage quitters to keep their New Year’s resolutions.

Bellingham COMMIT sponsored a team for an annual fitness race from

Mount Baker to Puget Sound. Paterson organized a rally against cigarette

advertisements on billboards. Other events also were held.

MEDIA ADVOCACY Media advocacy is the strategic use of mass media to advance

a public policy initiative. Media advocacy involves capitalizing on news
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Chapter 6

events (or creating news events) to stimulate broad-based coverage and

reframe public debate, in contrast to the tendency of the news media to

present health problems as a function of personal choice or circumstances.

Media advocates focus on factors shaping the environment in which

individuals’ decisions about health behavior are made. By exploiting the

news media’s appetite for conflict, controversy, irony, innovation, and the

“local angle,” advocates can redefine the issue as a social problem and

promote a public policy solution.

The ability of COMMIT to openly advocate for legislative and regulatory

change was limited by restrictions on the use of Federal funds. Therefore,

communities used the media to advocate for the view that tobacco is a

communitywide problem and for certain general principles, such as the right

to a smoke-free environment. A consistent theme was to shift attention (and

blame for the problem) from tobacco users to tobacco-product manufacturers

and marketers. This enabled smokers and nonsmokers to identify a common

enemy—the tobacco industry.

Utica, NY The Utica site conducted a series of media advocacy events throughout

the intervention. Many of these events were intended to focus public

attention on the predatory nature of the tobacco industry and to portray

it as an intruder from outside the community (as opposed to the communitybased COMMIT program). Among the media advocacy events staged by

Utica COMMIT were:

• picketing and leaflet distribution at a dance performance sponsored by

Philip Morris;

• an appearance by members of the national boomerang team, which

had refused tobacco industry sponsorship;

• a news conference with alcohol and other substance abuse agencies

calling on the proposed director of national drug policy to break his

nicotine addiction;

• a news conference announcing the results of a survey checking

merchant compliance with the law against selling tobacco to minors;

and

• a youth antitobacco rally in the hotel room next to an RJR Nabisco,

Inc., “smokers’ rights” meeting.

Media advocacy, which is based on opposition and conflict, makes many

community health professionals and volunteers uncomfortable. Advocacy

challenges traditional notions of public health based on education and

consensus building, and COMMIT sites encountered some resistance from

community members unwilling to engage in confrontation. However,

as the program continued to repeat advocacy events, members of the

coalition became more comfortable with the concept. By the 3rd year, it

was community members who, learning of the smokers’ rights meeting

described below, organized the counterdemonstration and contacted the
Smoking and Tobacco Control Monograph No. 6

90

media. The event was a watershed in Utica, marking the advent of a new

level of activism by grassroots tobacco control advocates.

Several volunteers in Utica had signed up to receive regular information

from smokers’ rights groups, and in early March 1991, they were notified of

a smokers’ rights meeting to be held in Utica. A coalition member contacted

the field director, who also had received a notice, and both agreed to talk

to as many coalition members as possible about the upcoming meeting.

Fortuitously, all the task forces were meeting at about that time, and they

all were informed of the upcoming event. Volunteers were outraged that

the tobacco industry was bringing its extensive lobbying into their

community, and they agreed that something had to be done, although

there was no immediate agreement on what that would be.

After much discussion, the group decided there should be some

physical presence at the meeting but that it was important not to be too

confrontational and not to do anything illegal. COMMIT staff members

noted that it was important to frame the smokers’ rights meeting as part

of an industry lobbying campaign, in this case, directed at proposed State

legislation to further restrict youth access to cigarettes. The group decided

this meant that youth and children should be involved. The field director

and COMMIT volunteers mobilized a local advocacy agent for low-income,

at-risk youth to participate. A local physician, who was also a COMMIT

volunteer, was recruited to attend, along with her daughter. Another

volunteer, whose father had died of lung cancer earlier that year, agreed

to come. While participants were being recruited, the media were alerted

about the event. News releases were prepared, and spokespersons were

briefed on the areas they should cover.

The COMMIT group had rented a room in the same hotel as the

smokers’ rights group. Forty-two COMMIT volunteers, staff members, and

young people arrived 30 minutes before the smokers’ rights meeting and

were briefed on the counterdemonstration agenda. They were told they

could observe the smokers’ rights meeting as long as they did not disturb

the proceedings. Teens handed out antitobacco flyers to people who

came to the smokers’ rights meeting. The tobacco company employee

was surprised by the countermeeting. He asked a radio reporter who had

contacted the media. Without asking their ages, he also gave written

materials about cigarettes and lighters to the teens who entered the

smokers’ rights meeting.

Broadcast and print news coverage of the dual event surpassed all

expectations. The field director, the physician, and a local teen were

interviewed by media at the event. Four radio stations covered the activity,

and two asked the field director to appear on half-hour talk shows. The

television station gave the event coverage on the nightly news. The

newspaper ran a story and a photograph, which generated an editorial

and seven letters to the editor, only two of which were for smokers’ rights.
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Chapter 6

Board members were enthusiastic about the event and the publicity it

generated. A few who had initially expressed reservations about possible

negative publicity were especially pleased and expressed hope that other,

similar opportunities would appear. The Utica physician used an excellent

reframing strategy in her letter to the editor. She said, “Utica smokers

don’t need political consultants from R.J. Reynolds telling them what to do.

They need the support and concern of their families, friends, and neighbors.

We will be here next week, next month, next year. R.J. Reynolds’ political

consultant left town the same night” (McCall, 1991).

Brantford, Ontario, The Brantford community had a difficult time involving

Canada volunteers in media advocacy; indeed, the Public Education

Task Force was initially reluctant to become involved in this area at all.

Volunteers were not comfortable with the type of confrontation and conflict

displayed in Utica and were

inclined to move more

slowly. It was not until an

individual was hired to deal

specifically with the media

that things began to happen

with the community media.

The media staff member

designated a spokesperson

for each news conference,

and she fully briefed that

spokesperson ahead of time. Other staff members and community volunteers

were recruited to assist with the conference as required. She also ensured that

press kits were available ahead of time, and she was willing to reorganize her

time to be responsive to the changing needs of the media.

The majority of the staff person’s time was spent in building relationships

with the media. Because of the patience and prompting she provided, the

media now turn to COMMIT for information. However, the form of media

advocacy taken in Brantford is largely confined to writing letters to the editor

and writing op-ed pieces.

Bellingham, WA From the beginning, media advocacy was a problem in Bellingham.

In the first year of intervention, a large media advocacy workshop was held.

It was well attended by COMMIT volunteers and other community members.

The workshop was thorough and covered issues besides the confrontation

methods. At a subsequent COMMIT Board meeting, there was significant

discomfort about the workshop and the methods of media advocacy that

had been portrayed. Board members had no problem with trying to increase

media coverage and shifting blame for the tobacco problem from smokers to

the tobacco industry but found it difficult to advocate by using conflict and

confrontation. From the outset, Board members wanted the project to be

encouraging and reinforcing and, indeed, would not even allow the universal

nonsmoking emblem to be used on the COMMIT letterhead.
Smoking and Tobacco Control Monograph No. 6

92

Over time, the Board members relaxed their stance somewhat. They, like

their Brantford counterparts, began writing letters to the editor of the local

newspaper. Some volunteers were especially good at writing pieces about the

effects of smoking relative to other risks. They wrote effective pieces about

the cyanide in Chilean grapes compared with the cyanide in cigarettes and

about the benzene in Perrier compared with the benzene in cigarettes.

They began leaving stickers in restaurants complimenting owners for a

smoke-free environment or stating that their dining experience would have

been enhanced by a smoke-free environment. They encouraged youthbuying operations and urged media coverage of the results. However, the

kind of media advocacy that occurred in Utica never really got a foothold

in this community.

WHAT COULD This public education channel was a source of both frustration

HAVE BEEN and pride for most of the communities. Initial reaction to

DONE DIFFERENTLY? changing the community environment through media

campaigns was positive. The media seemed pleased to hear about COMMIT,

wrote stories about COMMIT, and provided cut rates for advertising.

However, it soon became clear that the media would tire of writing and

covering the same themes over and over. Their focus is on items that are

new and newsworthy. Few COMMIT staff members had the skills and

resources to constantly attract the media.

In retrospect, more attention should have been paid to training field

staff members to deal with the media. Training sessions where staff members

produced news bites and news releases would have been good practice for the

implementation of the activities in this channel. Training also should have

been given in adding gimmicks to the press conferences about the annual

action plans so that media representatives had a reason to continually attend.

It might have been wise to build in an activity and

resources for establishing a relationship with a public relations

or advertising firm from the beginning of the project. Such

groups are experts in gaining access to media and in designing

campaigns to meet the needs and desires of specified target

groups. Communities that used such groups seemed to do

better than those that relied on volunteers or field staff

members to conduct those activities. For example, the “Yes,

You Can” campaign designed for Utica lasted the length

of the project and provided a foundation for many media

promotions. The “Kiss Your Butts Good-bye” campaign

in Paterson also provided a visible identification with

the COMMIT project. The “Hooked” campaign in Cedar

Rapids/Marion was an eye-catching symbol of the addictive

nature of tobacco. All these campaigns could be shaped

by the advertising firms into the more specifically required

campaigns such as “Ask a Doc” or promotion of the CRG or Quit and

Win contests.
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Chapter 6

COMMIT staff members and volunteers

were comfortable with the idea of using paid

media. Many had previously worked with other

volunteer groups and were accustomed to relying

on public service announcements to promote

projects. The COMMIT projects saw real

advantages in having control of the content of

messages and the times those messages were aired.

This advantage, when combined with the ability

to leverage more air time than was paid for, was

seen as beneficial for the trial. In addition, staff

members and volunteers liked the ability to target

media outlets that were most likely to reach the

target population. However, the amount of

money allowed for media campaigns was still

relatively modest, and many staff members

thought that more resources should have been

allocated for media campaigns.

Most communities were frustrated by media advocacy expectations.

As previously noted, media advocacy is not an easy thing to do, and many

staff members and volunteers elt uncomfortable with it. Even more indepth

training did not seem to provide many people with the skills needed to

do good media advocacy. The reluctance to get involved in this cannot be

attributed to the lack of information. A computerized system regularly

provided each community with relevant national news items, along with

sound bites and brief statements that could be used in news conferences,

op-ed pieces, and so forth. The constant competition for getting on the

media’s agenda was frustrating to many COMMIT staff and volunteers.

Careful preparation of news releases and planned press conferences that

were ignored because of some other breaking story wore down many people

involved in the project.

Probably the main reasons media advocacy was not used more were the

fear of confrontation and the reluctance to engage in open, conflict-filled

debate. To be comfortable in this process requires more training than

COMMIT staff members or volunteers received. In addition, most Boards

did not want to alienate other community members by publicly proclaiming

their stance on specific issues. The one exception was in the area of youth.

Without exception, Boards, staff members, and other volunteers were

willing to take a stand when youth were involved. Thus, communities were

willing to openly advocate for restrictions on youth access, even if it meant

conducting undercover merchant compliance checks and presenting the

results to the media. Similarly, Boards were willing to support the banning

of billboards that advertised products considered harmful to youth or

exploitive of youth, women, and minorities (i.e., alcohol and tobacco

products).
Smoking and Tobacco Control Monograph No. 6

94

It may not be possible to expect everyone to be a media advocate and

confront a tobacco company employee as was done in Utica. It may not be

possible for community members to boycott stores that sell tobacco products.

Communities that have received support from the tobacco industry for

cultural sports events may be reluctant to give up that support in the absence

of other sponsors. As Wallack and Sciandra (1990-91) noted, much more

work and research are needed on this issue.

This channel also provided some of the best experiences in the various

communities. The magnet events were universally well received. For the

staff, it was gratifying to see some real progress in terms of people who

actually quit smoking. Staff members were working “blind” when it came

to knowing whether their activities had any effect on smokers. This was

because of the design of the trial that blinded investigators and the staff to

trial outcomes throughout the intervention period. The appeal of the Quit

and Win contest is understandable in that context. Staff members and

volunteers alike could document how many smokers joined and how many

quit smoking at least for a certain period. In addition, these events were

usually fun and interesting. Many artifacts could be distributed, many

volunteers could become involved, and a celebration at the end gave the

event some closure.

One thing that is clear about the contests is that many resources—

human and otherwise—go into them. A recent study of the COMMIT Quit

and Win contests noted that for the 26 trial contests, the mean cost per

participant, including staff and contributed community resources, was

$78.57 (Shipley et al., submitted for publication). Estimating a 16 percent,

8-month continuous abstinence rate, the authors determined that the mean

cost per quitter was $428. Interestingly, a high correlation (> .70) was seen

between resources expended and participation. Finally, the most highly

correlated measure (.82 on a per smoker basis) was between participation

and the total value of nonprize resources. These findings suggest that such

contests are a good way to draw smokers into quit attempts.

In summary, the public education channel, as most of the others, had

good and bad points. Whether the communities achieved the channel goals

of promoting social norms and actions toward a smoke-free community,

increasing the perception of smoking as an important public health issue,

and enhancing the effectiveness of smoking control in other program areas

remain to be determined as the data are analyzed. The major positive point

of this channel was the gratification of working with smokers and seeing

them quit. The main downside was trying to understand how to deal with

media, keep them interested, and deal with the new strategy of media

advocacy.

REFERENCES

Advocacy Institute. “Smoke Signals: The Smoking

Control Handbook.” Prepared for the American

Cancer Society, 1987.

Centers for Disease Control. Cigarette advertising—

United States, 1988. MMWR. Morbidity and

Mortality Weekly Report 39(16): 261-265, 1990.
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Chapter 6

Cummings, K.M., Kelly, J., Sciandra, R., DeLoughry,

T., Francois, F. Impact of a community-wide stop

smoking contest. American Journal of Health

Promotion 4(6): 429-434, 1990.

Cummings, K.M., Sciandra, R., Davis, S., Rimer, B.

Response to an anti-smoking campaign aimed at

mothers with young children. Health Education

Research 4: 429-437, 1989.

Cummings, K.M., Sciandra, R., Markello, S. Impact

of a newspaper-mediated quit smoking program.

American Journal of Public Health 77: 1452-1453,

1987.

Elder, J.P., Campbell, N.R., Mielchen, S.D., Hovell,

M.F., Litrownik, A.J. Implementation and

evaluation of a community-sponsored smoking

cessation contest. American Journal of Health

Promotion 5: 200-207, 1991.

Flay, B. Selling the Smokeless Society: Fifty-Six Evaluated

Mass Media Programs and Campaigns Worldwide.

Washington, DC: American Public Health

Association, 1987.

Freedman, A. New smoke from RJR under fire. Wall

Street Journal, February 20, 1990. p. B1.

Johnston, L.D., O’Malley, P.M., Bachman, J.G.

National Trends in Drug Use and Related Factors

Among American High School Students and Young

Adults, 1975-1986. DHHS Publication No. (ADM)

87-1535. Rockville, MD: U.S. Department of Health

and Human Services, Public Health Service,

Alcohol, Drug Abuse, and Mental Health

Administration, National Institute on Drug Abuse,

1987.

Kessler, L. Women’s magazines’ coverage of smoking

related hazards. Journalism Quarterly 66: 316-323,

1989.

Lando, H.A., Loken, B., Howard-Pitney, B., Pechacek,

T.F. Community impact of a localized smoking

cessation contest. American Journal of Public Health

80: 601-603, 1990.

McCall, M. Letter to the Editor. Utica, NY: ObserverDispatch, April 10, 1991.

Minkler, M., Wallack, L., Madden, P. Alcohol and

cigarette advertising in Ms. magazine. Journal of

Public Health Policy 8: 164-179, 1987.

Pierce, J.P., Macaskill, P., Hill, D. Long-term

effectiveness of mass media led antismoking

campaign in Australia. American Journal of Public

Health 80: 565-569, 1990.

Seldon, B., Doroodian, K. A simultaneous model of

cigarette advertising: Effects on demand and

industry response to public policy. Review of

Economics and Statistics LXXI: 673-677, 1989.

Shipley, R., Hartwell, T., Austin, W., Clayton, C.,

Stanley, L. (for the COMMIT Research Group).

Community-wide stop-smoking contests in the

COMMIT trial: Resource inputs, contest

participation percentages, and the association

between the two. American Journal of Public Health,

submitted for publication.

Thompson, B., Curry, S. Characteristics and

predictors of participation and success in a

televised smoking cessation activity. American

Journal of Health Promotion 8: 175-177, 1994.

Tye, J., Warner, K., Glantz, S. Tobacco advertising

and consumption: Evidence of a causal

relationship. Journal of Public Health Policy 8:

164-179, 1987.

U.S. Department of Health and Human Services.

Media Strategies for Smoking Control Guidelines.

DHHS Publication No. (PHS) 89-3013. Rockville,

MD: U.S. Department of Health and Human

Services, Public Health Service, National Institutes

of Health, 1989.

Wallack, L., Sciandra, R. (for the COMMIT Research

Group). Media advocacy and public education in

the Community Intervention Trial to reduce

heavy smoking (COMMIT). International Quarterly

of Community Health Education 11(3): 205-222,

1990-91.

Warner, K. Selling Smoke: Cigarette Advertising and

Public Health. Washington, DC: American Public

Health Association, 1986.

Weis, W., Burke, C. Media content and tobacco

advertising: An unhealthy addiction. Journal of

Communication 36: 59-69, 1986.

AUTHORS

Russell C. Sciandra

Director

Tobacco Control Program

New York State Department of Health

Empire State Plaza

Corning Tower, Room 515

Albany, NY 12237
Smoking and Tobacco Control Monograph No. 6

96

Lawrence Wallack,Dr.P.H.

Principal Investigator

University of California, Berkeley School

of Public Health

516 Warren Hall

Berkeley, CA 94720

Carolyn L. Johnson,R.N.

Program Manager

Healthy Start Program

Jackson County Department of Health and

Human Services

Building A

1005 East Main Street

Medford, OR 97504

Janine Sadlik

Executive Director

Court Street Diagnostic and Treatment

Center

430 Court Street

Utica, NY 13502

Juliet Thompson

Field Director

Bellingham COMMIT Site

4407 Wilkin Street

Bellingham, WA 98226
97

Chapter 7

Changing Public Policy Around Tobacco

Control in the COMMIT Communities

David S. Carrell, Carolyn L. Johnson, Len C. Stanley, Juliet Thompson,

and Sandy Tosti

INTRODUCTION Public policy is a potentially powerful tool for changing individual

and group behaviors (Jason et al., 1991). Through ordinances, regulations,

and other policies, local governments can influence a wide variety of

behaviors concerning the promotion, sale, and consumption of tobacco

products (Bierer and Rigotti, 1992; Thompson et al., 1990-91; U.S. Department

of Health and Human Services, 1991). Creating smoke-free indoor air spaces,

preventing illegal sales of tobacco to minors, and prohibiting the distribution

of free cigarette samples are policy actions that can influence individual

behavior and community norms regarding health-related behaviors. Over

the past decade local governments have become the primary innovators in

the use of public policy as an instrument for preventing or controlling

tobacco use (Samuels and Glantz, 1991; U.S. Department of Health and

Human Services, 1993).

This chapter describes the contributions of the Community Intervention

Trial for Smoking Cessation (COMMIT) intervention activities to tobacco

control policy changes in selected communities and distills lessons from

these experiences that may be useful to others engaged in or considering

similar undertakings. Although every attempt to bring about policy change

is unique, some themes, challenges, and strategies are common. Familiarity

with the experiences of others can be valuable.

Intervention designers anticipated that many COMMIT activities were

likely to translate into demands for more aggressive and better enforced

tobacco control policy (COMMIT Research Group, 1991). Media campaigns

were designed in part to raise public awareness of tobacco hazards and foster

community ownership of the problem. COMMIT Board and task force

membership often included local government officials, other influential

members of the community, and advocates for improving the health of the

community. As these individuals became more fully informed about the

hazards of tobacco use, their commitment to intervention opportunities

(including policy change) was expected to increase. Invigorated grassroots

advocacy groups helped to keep these issues on local government agendas

and in the public eye. The COMMIT field office acted as a clearinghouse

for technical information (e.g., how to conduct compliance checks, provide

model language for proposed clean indoor air policy) and a center of

communication among various local groups and influential leaders.

Recognition and ownership of tangible local problems, public support for

government action, committed leaders, coalition building, and technical

know-how are among the important factors affecting the political climate
Smoking and Tobacco Control Monograph No. 6

98

for local policy change (Reich, 1988; Kingdon, 1984; Weiss and Tschirhart,

1993).

Although policy change was recognized as an important avenue of

community change, it was not a primary objective of COMMIT. Federal

regulations prohibited use of COMMIT monetary contributions for lobbying

in State and local political arenas. However, there were no such restrictions

on indirect activities, such as provision of information and coalition

building. In addition, project staff and Board and task force members

were allowed to advocate for policy change as long as they did so on their

own behalf, not as representatives of COMMIT. During the intervention,

important policy changes occurred in many intervention communities.

Tobacco control policy is defined here as any ordinance, regulation, or

directive issued by a governmental body intended to alter individual behavior

regarding the promotion, sale, or consumption of

tobacco products. Some governmental policies affect

the general public, such as smoking restrictions in cityor county-owned facilities. Others may affect only

city or county employees, such as office no-smoking

policies or city personnel policies requiring newly

hired police officers and firefighters to be nonsmokers.

It is important to remember that “policy” includes

both the scope and content of the policy “on paper”

as well as related efforts by official agencies to monitor

and enforce its provisions. Other entities, such as

employers, retailers, and restaurants, also set policy

that may influence the public. Such regulations are

sometimes referred to as “informal” public policy.

When shopping malls, public schools, or individual

restaurants decide to become smoke-free, a limited but

potentially significant portion of the community is

affected. Smokers encounter domains in which they

cannot smoke, and nonsmokers enjoy and become

accustomed to smoke-free air. (For a discussion of

informal, nongovernmental policies, see Chapters 10, 12, and 13.)

RATIONALE The rationale for promoting tobacco control policy change in

community-based health promotion interventions is compelling. First

and foremost, public policy is believed to have a powerful influence on

the broad social environment or context within which health-related

individual behavior occurs (U.S. Department of Health and Human Services,

1989; Glynn, 1991; Bracht, 1990; Frankel, 1988; Wynder, 1988). Regulating

or preventing the promotion and use of tobacco products may significantly

affect social norms and practices concerning tobacco use. Over time, as

the public presence of smoking, environmental tobacco smoke (ETS), and

tobacco product promotion is reduced within a community, members

of that community may grow increasingly accustomed to tobacco-free
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environments. Whereas it was once normal for people to smoke in enclosed

public places, for cigarettes to be advertised on television, and for merchants

to sell tobacco to underage youth (despite laws to the contrary), public

attitudes toward these activities have begun to change. Many communities

now consider smoke-free public environments to be the norm and have

come to believe that youth should be protected from the hazards of tobacco

use by putting a stop to illegal sales and youth-oriented promotion of

tobacco products. Public policy can be an effective tool for promoting

and reinforcing norm changes by giving official, communitywide sanction

to the regulation of tobacco-related behaviors.

Policy is also an important health promotion tool because it is capable

of reaching people who are difficult to reach through other intervention

channels, such as cessation counseling or public education campaigns.

Some members of minority populations, blue-collar workers, and youth

are included in this category (Escobedo et al., 1990). Many of those who do

not receive public health education messages or health care provider-based

cessation interventions will be employed at worksites or will patronize public

places where smoking is restricted or banned for health protection reasons.

Protecting youth from the health hazards of both firsthand and secondhand

tobacco exposure continues to be a powerful argument for policies restricting

smoking in public places and preventing tobacco sales to minors.

Finally, substantial experience from Project COMMIT

indicates that there is a potential for synergy between

local policy efforts and other intervention activities,

such as youth education, workplace policy, cessation

campaigns, and media advocacy efforts (see also U.S.

Department of Health and Human Services, 1991).

Messages conveyed through public school curricula,

the media, or health care providers can be bolstered

and reinforced by the messages implicit in smoking

restrictions at the workplace, in restaurants, or in

public buildings. Once smoke-free office policies

are demonstrated to be feasible and desirable in local

city or county offices, private sector offices may be

encouraged to follow suit. Thus, policy can be an

important component of a community’s multifaceted

approach to reducing tobacco-related morbidity and

mortality.

Over the past two decades the tobacco control policy

movement in the United States has moved its focus away from Federal and

State policy arenas and is now aggressively and effectively pursuing means

within local jurisdictions (U.S. Department of Health and Human Services,

1993). As policy activity within cities and counties continues to build

momentum, excellent opportunities to improve public health through

tobacco control policy will continue to present themselves.
Smoking and Tobacco Control Monograph No. 6

100

CHANGING This section illustrates the challenges, strategies, and themes—some

POLICIES common and others unique—encountered in local policy change efforts.

Vending machine bans, clean indoor air ordinances, smoke-free school

policies, and a billboard ban are described. Many of the policy activities

focused on youth. This was because policy changes directed at restricting

youth access are generally not controversial; thus, such activities could be

used to gain the participation of many community members.

Vending Communitywide policy change was not a focus of COMMIT intervention

Machine activities. However, some of the COMMIT intervention communities’

Bans efforts to reduce youth access to tobacco resulted in policy actions to

restrict or ban cigarette vending machines. Children can easily purchase

cigarettes from unattended vending machines with little fear of being

detected. Vending machine ordinances are particularly popular among

tobacco control advocates because vending machines are one of the most

common sources of illegal sales to underage youth, particularly the very

young (U.S. Department of Health and Human Services, 1990). As a result,

local youth and community groups are often eager to assume ownership

of and work toward addressing this problem, and the case for banning

machines can be effectively communicated to local policymakers. As of

1992, 161 communities throughout the United States were known to have

ordinances restricting or banning the use of tobacco vending machines

(U.S. Department of Health and Human Services, 1993). In this section,

experiences with vending machine ordinances in the North Carolina,

California, and Oregon intervention communities are described.

Raleigh, NC In 1991, COMMIT sponsored a 14-month initiative, the Tobacco-Free

Youth Project, designed to reduce illegal tobacco sales to youth through

merchant education. This initiative continued beyond COMMIT and was

a major factor in the successful passage of a Raleigh, NC, city ordinance

restricting placement of cigarette vending machines. Although banning

vending machines was not one of COMMIT’s intended goals, the ordinance

came about as a direct result of the

activities and actions of people involved

in the initiative. Strategic framing of the

issue, effective use of locally collected

information, and a readiness to seize

the moment were key ingredients in

the passage of this ordinance.

Compliance in Raleigh with an existing

State law prohibiting tobacco sales to

persons younger than 18 years of age was

poor, as is the case in many communities

throughout the United States. Because the

local community was generally unaware

of the extent of illegal sales (or even the

existence of the State law), it was decided

that an awareness-raising effort was needed.
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Chapter 7

Project personnel believed that city authorities were unlikely to improve

enforcement efforts unless they perceived the community to be informed of

and concerned about the problem. Therefore, the Tobacco-Free Youth Project

initiative began with an undercover compliance check (see Chapter 13 for a

complete description of such operations) to document the ease with which

underage youth could purchase cigarettes, both over the counter and from

vending machines. The procedure involved underage youth going out with

an adult superior to buy cigarettes, which they are not legally allowed to do.

Two-thirds of over-the-counter and more than 90 percent of vending machine

purchase attempts were successful.

To communicate this information to the general public, a youth-led

press conference was orchestrated that received excellent media coverage

and followup through editorials, feature stories, and a local radio talk show.

Two months later, in an attempt to keep the issue in the public eye, the same

youths presented their compliance check results to the Raleigh City Council.

They also presented national data showing that vending machines are a

primary source of cigarettes for very young (11- to 12-year-old) adolescents.

Their presentation concluded with a plea to ban vending machines by a

city ordinance. The youths reminded the council that, although it may

be feasible to achieve compliance with tobacco sales laws by educating

merchants, “You can’t educate a vending machine” (unpublished quotation).

The Raleigh City Council had voted down a similar proposal several months

earlier; however, this time they referred the vending machine proposal to

their newly created Substance Abuse Commission, to whom the youths

again presented their compliance check results.

Subsequent negotiations between the Raleigh city attorney, tobacco

industry representatives, and local vending machine owners yielded a

compromise proposal allowing machines only in establishments licensed

by the State to serve liquor, which mollified the vending machine owners.

Although the Tobacco-Free Youth Project went back to the city council

with data showing that most liquor-licensed establishments were family

restaurants or local motels where youngsters gathered, by that time the

compromise proposal had been drafted into a policy statement that the

city council was reluctant to alter. The city council soon passed a precedentsetting municipal tobacco vending machine restriction in the capital city

of the largest tobacco-producing State in the Nation. The Tobacco-Free

Youth Project claimed victory.

Vallejo, CA Before the COMMIT intervention began in Vallejo, CA, the North Bay

Health Resources Center launched a 5-year project called the Solano County

Cancer Prevention Program to address the problem of illegal access to

tobacco by youth.

The cancer prevention program laid thorough groundwork in Vallejo in

1988 and 1989 by conducting undercover compliance checks to assess the

ease with which over-the-counter and vending machine sales could be made

to minors. This activity was followed by a merchant education campaign,

another compliance check, more merchant education, and a third compliance
Smoking and Tobacco Control Monograph No. 6

102

check in May 1990. By this time the COMMIT intervention was under way

with 1 year of community organizing and intervention behind it.

COMMIT was a resource to the Solano County Cancer Prevention

Program during this first year by providing background data from the

COMMIT baseline survey regarding local public opinion in support of

tobacco control efforts. In addition, the coalition network built by COMMIT

provided a natural clearinghouse for information sharing and cooperation

among the various related agencies in Vallejo.

In June 1990, COMMIT cosponsored a dinner meeting with the cancer

prevention program to bring together community leaders and interest groups

to discuss ways to deal with illegal sales to youths and the lack of consistency

in civil fines levied on merchants for illegal sales. The primary outcome of

discussion among the 30 community representatives attending the dinner

was a proposal to ban vending machines and prohibit free distribution of

tobacco products in Vallejo.

A key advantage in the passing of the proposal was a political one: The

chair of the Solano County Cancer Prevention Program was also a member of

the Vallejo City Council.

Members of the cancer prevention program joined forces with the

Minority Coalition for Cancer Prevention, a Vallejo organization that

targeted African-Americans, to expand their own networks and mobilize

a newly formed ad hoc coalition to propose the legislation to the Vallejo

City Council.

COMMIT served as a resource here also, with staff members providing

supporting survey data as background information. Because many members

of this new coalition were also COMMIT Board and task force members,

COMMIT meetings provided an avenue for information sharing. In fact,

individual COMMIT volunteers were directly involved in testifying at the

city council hearings and orchestrating the passage of the vending machine

ordinance. Those individuals, representing their own organizations,

included the administrator of the local private hospital (and COMMIT

Board chair), the executive director of the local American Lung Association

(ALA) (and COMMIT Board member), and the project directors of the Solano

County Cancer Prevention Program and the Minority Coalition for Cancer

Prevention (and COMMIT Board members).

The most important factor contributing to the successful passage of

the vending machine ordinance was the role of three Vallejo youth groups:

the Students Against Cancer (a subgroup of the minority coalition), the

city-sponsored Youth Activities Commission (whose two adult advisers were

another city council member and a COMMIT task force member), and the

Vallejo chapter of Friday Night Live.

Ironically, these three youth groups were pulled together earlier in the

year by a North Bay Health Resources Center staff member on contract with
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COMMIT to involve community teens

in an activity that would monitor youth

access to tobacco. As the teens organized

themselves around this activity, became

educated about youth access problems,

and began to develop ways to educate the

public about the problem, the coalition

was mobilizing and planning its strategy

for proposing a vending machine

ordinance.

For their COMMIT activity, the three

youth groups launched a media campaign

called “Fight It, Don’t Light It.” One of

the teens sketched a poster drawing,

which was enlarged, duplicated, and

placed inside Vallejo transit buses in June

1990. This was the first time the transit company allowed anyone to place

“advertisements” in the interior of its buses.

The contribution of this COMMIT youth group was significant for

two reasons. First, the youth coalition was organized and in place at the

time of the city council’s public hearings on the proposed ordinance. Now

knowledgeable about the issues of youth access, the teens were invited to

speak at the public hearings. The passion of the teens’ testimony and the

public evidence of their ability to buy cigarettes just prior to the council

meeting swayed at least one council member from a “no” to a “yes” vote.

Second, the posters indicated their design was the work of Vallejo teens.

Although the posters appeared in city buses after the ordinance was passed,

they added impetus to the fact that local youth demanded that their

community protect their health.

One source of embarrassment in the vending machine ordinance

campaign was the lone vote in opposition to the ban. That council member

was a member of the COMMIT Board of Directors!

After the ordinance passed, the COMMIT Board chair wrote a letter to

the editor of the Vallejo Times Herald praising the work and wisdom of the

city council.

Medford/ Community-based youth groups also played a central role in efforts to

Ashland, OR obtain vending machine bans in Medford/Ashland, OR. In preparation

for these efforts, a COMMIT task force reviewed the community analysis

report (see Chapter 5) to identify existing youth groups that could be

asked to participate. It was felt that local youth would be most effective

in pressuring law enforcement agencies to regulate access to tobacco products

by minors.

COMMIT staff members approached the Medford Mayor’s Youth

Commission, a group of 15 high school students representing 5 high schools.
Smoking and Tobacco Control Monograph No. 6

104

The group was looking for a project and was willing to put youth access to

tobacco on their agenda. With organizational assistance from COMMIT,

they conducted a compliance check in which 95 percent of over-the-counter

purchase attempts were successful. The group presented these findings at

a press conference and to the Medford City Council. The presentations

concluded with a plea for police cooperation in enforcing the existing State

law.

The following day the chief of police called a press conference to pledge

support for an educational campaign to increase voluntary compliance

among area merchants. In conjunction with this announcement, the Youth

Commission sent a letter asking store managers to provide in-service training

for their clerks. A cash register sign reminding clerks and patrons of the

State law also was included in the mailing.

In 1990 the Mayor’s Youth Commission repeated the compliance check,

this time including vending machine purchases. The success rate for overthe-counter purchase attempts dropped to 72 percent, but 100 percent of

vending machine attempts were successful.

With evidence that illegal sales were persisting and with other

background information provided by the COMMIT staff, the students met

with the city attorney who helped them draft a vending machine ordinance

proposal. The proposal would restrict tobacco vending machines to premises

not accessible to persons younger than age 18, private workplaces, or retail

locations where the machine would be within direct view of an employee

who could see the facial features of machine users at all times. Failure to

comply would result

in a $250 fine.

The students testified at a public hearing to consider the proposal. Only

one vending machine distributor testified against the ordinance. Another

tobacco distributor was quoted in the newspaper as being supportive of the

goal to help prevent youth from smoking. He complained that the only

reason he had cigarette machines is that some local employers requested

them. The council adopted the ordinance by a unanimous vote.

Realizing that youth access to vending machines remained unabated

in the county’s 10 other cities and unincorporated areas, the following year

COMMIT staff members and task force volunteers approached the youth

group of a countywide drug prevention organization. The group was readily

mobilized and eager to conduct its own compliance check.

With evidence of successful purchases in 75 percent of over-thecounter and 100 percent of vending machine purchase attempts, the students

presented their findings to the district attorney and asked that an ordinance

similar to that in Medford be drafted. Representatives of the youth group also

made a presentation to the county commissioners, who subsequently ratified

the ordinance.
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COMMIT then focused attention on the city of Ashland. High school

students associated with Students Against Drunk Driving (SADD) and

Responsible Educated Adolescents Can Help (REACH) were recruited to

conduct compliance checks, draft an ordinance, and make a presentation

to the city council. The night of the public hearing, because of final exams,

only one student was available to testify. Despite this, the city council

adopted an even stricter ordinance limiting tobacco vending machines

to places not accessible to minors.

Both ordinance campaigns in Oregon took about 3 months to plan,

execute, and complete. It was very labor intensive for COMMIT staff

members to plot the locations of businesses on maps, set up routes for

each team, obtain subjects’ permission as required by the research institute,

obtain parental permission as required by local law enforcement agencies,

recruit volunteer drivers, perform fundraising for the money used in

purchase attempts and a pizza party following the compliance checks,

draft ordinances, rehearse their testimony before appearing in front of

government bodies, and make presentations. Such efforts are essential

to the success of these campaigns.

The presence of several municipal or county jurisdictions within a single

geographical area can complicate policy change efforts and multiply the

amount of work required. In the campaign for a county vending machine

ban, the Oregon COMMIT staff members had to gather data and present

arguments in each separate city within the county and in the unincorporated

areas. The result was three different ordinances, each with different

provisions.

After COMMIT staff members worked for 3 years of effort to work within

the many jurisdictions, the State of Oregon passed a law prohibiting tobacco

vending machines from places accessible to minors but exempted hotels,

motels, industrial plants, and restaurants with liquor licenses. This excludes,

for example, many pizza parlors. Not only was this a much weaker law, but

it also included a preemption provision, requested by the tobacco industry,

that prevented local governments from having more stringent ordinances.

This law undermined many of the provisions of the ordinances enacted

in Medford/Ashland and continues to prevent other communities from

aggressively controlling illegal cigarette sales to youth.

Initial sponsorship of State laws by the “right” organizations does not

eliminate the preemption threat. The Oregon law was originally promoted

by a coalition composed of the American Heart Association, American Cancer

Society, State Department of Health, and ALA. However, once a proposed

law enters the State legislative arena, the tobacco industry lobbyists can be

counted on to do everything within their power to alter, minimize, or

undermine the proposal’s original intent. Often, what tobacco lobbyists

convince legislators is a “fair compromise” is a relatively weak State bill that

is difficult to enforce or incorporates preemptive language forbidding cities

and counties from adopting more stringent local ordinances (Pertschuk and

Shopland, 1989).
Smoking and Tobacco Control Monograph No. 6

106

Clean Indoor The enactment of new or strengthened clean indoor air ordinances

Air Ordinances was a policy change strategy pursued in many COMMIT

communities. During the trial, policy changes restricted smoking in a

variety of public places, including government buildings and vehicles,

restaurants, office buildings, schools, retail shops, sporting venues, and

public transportation facilities. This section describes the events leading

up to the adoption of three such ordinances, one in Medford and two in

Raleigh.

Medford, OR When the COMMIT intervention began, Oregon had a State law

requiring designated smoking areas in public buildings, and Ashland had

already adopted a smoke-free policy for city employees. The COMMIT staff

members thus focused their attention on Medford. A consultation with the

city personnel director was arranged to provide information on the benefits

of clean indoor air policies and to discuss effective strategies for developing

and implementing a policy that was acceptable to employees. Medford was

advised to conduct an in-house survey of its employees to determine their

attitudes toward an office smoking ban. The survey indicated strong support,

even among smokers. Three months later Medford adopted a smoke-free

workplace policy for its employees.

Jackson County, within which Medford and Ashland are located,

decided to take a more radical step. Following informational consultations

with COMMIT staff members, county officials announced in July 1990

that all county-owned buildings would become smoke-free within 30 days.

Designated smoking areas were to be eliminated entirely. The ruling exempted

the baseball park, the fairgrounds, an outdoor music arena, and the airport.

The policy banned smoking in the county jail (by employees and the

190 inmates) and in all county vehicles. The policy was supported by the

public employees union and the sheriff’s employees union, both of which

had been notified beforehand of the county’s intentions.

The media reported that the county adopted the policy in response to

rising health costs. The county, which underwrites its own insurance, had

an active wellness program and expressed concerns about the health effects

of ETS.

Despite the lack of forewarning, the ban was implemented with little

fanfare or controversy. Six months later a group of inmates staged a brief

hunger strike to protest conditions in the jail and included the smoking ban

along with other complaints. Jailers reported that cigarettes replaced other

drugs as the primary contraband smuggled into the jail and that inmates were

observed drying lettuce leaves, wrapping them in paper, and short-circuiting

the television cord to get a light.

Raleigh, NC, Wake The first clean indoor air ordinance passed in Raleigh during the

County Ordinance COMMIT project was a Wake County ordinance banning smoking

in all county buildings, including offices housing county employees. The

campaign to pass this ordinance was led by the director of the county health
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department, a dynamic dentist who worked closely with COMMIT staff and

volunteers throughout the effort.

The power to adopt the proposed ordinance ultimately rested with the

Wake County Board of Commissioners. Through an informal polling of

commissioners, the health department chief learned that support for the

ordinance existed but that an influential tobacco grower on the board was

likely to challenge the policy change.

COMMIT personnel recommended that the county conduct an in-house

survey of employee attitudes regarding the proposed no-smoking policy.

Such surveys can provide powerful evidence to challenge unsubstantiated

claims of those opposed to such policies (tobacco farmers in this case).

Previous surveys in other communities (outside North Carolina) indicated

that between two-thirds and three-fourths of employees favored workplace

restrictions on smoking. However, without tangible evidence of local

opinions, some feared that the views of the silent majority would be

overshadowed by the impressions created by a small but vehement minority

opposing the ordinance. Furthermore, to the extent that a survey would

involve those affected by the ordinance in the decisionmaking process,

a sense of ownership can be promoted that can, in turn, fortify support.

COMMIT staff members and county officials felt that employees would be

more inclined to support a policy they helped develop than one mandated

from “on high.”

When the commissioner opposed to the ordinance learned that the

county was preparing to conduct an employee survey, he attempted to

influence its content. For example, he suggested that, in addition to

questions about ETS, the survey should ask employees whether breathing

perfume, aftershave, or another person’s body odors was bothersome. Such

questions were perceived by those conducting the survey as an attempt

to trivialize the survey and the public health issue it addressed. The

commissioner’s questions were not included.

Results of the employee survey were presented at a public hearing

attended by more than 100 tobacco farmers and their families. Emotional

pleas by farmers about the eventual hardships the ordinance would cause

them and their families were answered by survey evidence that 77 percent of

employees—including many smokers—supported the proposed restrictions.

By doggedly insisting that the issue be positively framed in terms of protecting

employee health and by giving the commissioners survey evidence justifying

a yes vote, backers of the ordinance successfully guided it through local

political channels with a 7-to-2 vote, despite vocal and well-orchestrated

opposition.

Prior to its formal implementation, a single exception to the ban was

granted to one section within the county courthouse. Although the

exception was presented as a compassionate provision for smokers under

the stress of the legal system, the widely acknowledged truth was that a
Smoking and Tobacco Control Monograph No. 6

108

prominent judge was a smoker and was furious about the ban. The oftenrepeated maxim “all politics is local” applies to local politics as well.

Raleigh, NC, In 1991 Raleigh passed citywide restrictions on smoking in public

City Ordinance places. Again, the campaign was spearheaded by the director of the

Wake County Department of Health working in conjunction with COMMIT

advisers, members of the Raleigh City Council, lawyers, and personnel from

the Wake County Department of Health and the North Carolina State

Division of Health.

This is a case in which a legacy of State-level tobacco policy efforts placed

limitations on what was politically feasible at the local level. Some historical

background is thus in order.

Raleigh is the capital of North Carolina and home to numerous State

office buildings. In 1989 the director of the North Carolina Division of

Health, a physician, imposed a smoking ban in all State health department

offices under the division’s jurisdiction. Within 24 hours the Governor held a

press conference in which he publicly rescinded the ban. Such policies, the

Governor maintained, were unfair to the tobacco industry and would not be

tolerated. Two years later when the Raleigh city ordinance was proposed, it

was clear that any attempt to regulate smoking in State buildings would be

opposed.

Public opinion in Raleigh was far ahead of the Governor on this issue.

As two previous COMMIT surveys confirmed, high percentages of Raleigh

residents favored restrictions on smoking in a variety of public places. These

survey results provided the impetus for proposing a comprehensive nosmoking ordinance for the city. The State policy legacy meant that careful

political maneuvering would be required to secure its passage.

The proposed city ordinance was among the most stringent in the country

at the time. It banned smoking in enclosed entertainment venues, sports

arenas, educational facilities, shopping malls, elevators, health care facilities,

pharmacies, and publicly accessible restrooms and on public transportation.

The ordinance also required employers to provide “reasonable provisions”

for smoke-free workplaces, and restaurants were required to reserve at least

one-third of their tables for nonsmokers.

Ironically, this ordinance was passed by the Raleigh City Council with

virtually no public opposition by the tobacco industry. Several factors

accounted for the absence of opposition.

Perhaps the single most important factor was a strategic decision, made

early in the process, to exclude all State government buildings from the

provisions of the ordinance. The stated rationale for this was that State

buildings are under separate jurisdiction. In reality, the decision was

motivated almost entirely by political considerations. In North Carolina,

as in many States, the tobacco industry can exert considerable political

influence within the State legislature. If the Raleigh ordinance had included

State buildings, the tobacco industry would have had an opportunity to
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Chapter 7

redefine the issue as a State issue and unleash its lobbying machinery against

the ordinance, perhaps defeating it entirely. By conceding State buildings

from the outset, this controversy and the involvement of the tobacco lobby

were avoided entirely.

Another factor accounting for the relative absence of tobacco industry

opposition during this campaign was the leadership provided by the health

department chief. There is no substitute for the careful planning, political

aptitude, thoroughness, and diligence she exhibited in spearheading this

effort. The value of such leadership cannot be overstated.

Another notable development during this campaign involved the use of

survey data to counter the opposition’s attempts to spread misinformation.

Prior to the city council vote, the Restaurant Owners’ Association and

the chamber of commerce suggested to the news media that there was

considerable public opposition to the proposed ordinance. These claims

were reported in the local newspaper. Supporters of the ordinance responded

immediately by providing the newspaper with results from COMMIT’s 1989

Evaluation Cohort Survey (COMMIT Design and Evaluation Working Group,

1989) refuting the unsubstantiated claims. Ordinance supporters felt that

publication of these survey results served to contain the opposition.

Another interesting phenomenon observed during the city ordinance

campaign was the reluctance of many local businesses to publicly reveal their

support for the proposed policy. Fear of alienating other members of the

business community appeared to be the motivation behind this behavior.

Representatives of these businesses were willing to recount their own

experiences with workplace smoking policies at COMMIT-sponsored

workshops and for use in a COMMIT-produced policy handbook. When

they were asked to testify at public hearings, their enthusiasm waned. Of

more than a dozen major companies in Raleigh that could have helped the

cause of the campaign by describing their own positive experiences with

smoking policies, only two would testify at public hearings. Both of these

had strong connections with health care—the North Carolina Medical

Society and Duke University.

Several contacts within the business community indicated that the

decision not to participate was made at the highest levels within some

organizations and was motivated out of fear of alienating the tobacco

industry, whose representatives sit on the boards of some of these

corporations. For other businesses, the reluctance to testify seemed to be

an attempt to avoid open conflict with the chamber of commerce, which

openly opposed the ordinance. In either case, the experiences in Raleigh

suggest that unwillingness to publicly endorse a city ordinance does not

necessarily indicate opposition within the business community.

Indeed, once the ordinance went into effect, some businesses used the

mandate as an excuse for implementing more stringent workplace policies

than required. That is, they banned smoking entirely when “reasonable

accommodation” of nonsmokers was all the ordinance required. Apparently,
Smoking and Tobacco Control Monograph No. 6

110

these businesses were taking advantage of an opportunity to pursue their

own more aggressive agendas while channeling any criticisms thereby

generated toward the city.

Smoke-Free In 1991 the school districts of Medford and Ashland adopted regulations

School that virtually banned smoking from public school facilities but only after

Ordinances successfully overcoming several political and operational barriers.

At the start of the COMMIT intervention there was some awareness

within the Medford and Ashland School Districts of smoking as a public

health issue. Both districts had established wellness committees focusing

on school health issues and had participated in local health fairs and The

Great American Smokeout events. Still, smoking was allowed in designated

teachers’ lounges, and there were designated smoking areas for students on

high school campuses. Student smoking areas had been established to

accommodate neighbors bordering the school who complained about

students smoking in their front yards.

In 1990 both the Medford and Ashland School Districts’ wellness

committees began to spearhead efforts to achieve smoke-free school

buildings, although efforts were slowed by union negotiations.

Custodians wanted a policy that would allow them to drive off

campus to smoke during their breaks. Initially, there was no plan

to eliminate designated outdoor smoking areas on school grounds.

However, in June 1991 the State legislature passed a law making

possession of tobacco by minors illegal. This legislation also required

schools to adopt policies regarding smoking and the use of other

drugs on public school grounds.

Concerned that previous State laws regarding youth access to

tobacco products had been poorly and inconsistently enforced,

COMMIT staff members arranged two meetings to discuss the new

State law and the need for coordination of policies across the

county’s seven school districts. In attendance were representatives

from COMMIT, the school districts, law enforcement, and the

juvenile justice system. Frustration with the poor enforcement of

minor-in-possession laws by local police was expressed.

Ultimately, school officials decided to take an active approach to

enforcement and handle most violations in-house; they would not simply

notify local police when violations occurred. Each school district adopted

its own multistage disciplinary policy. Generally, these policies began with

confiscation of the tobacco (or other drug) for a first offense and ended

with suspension from school in the case of frequent repeated offenses.

With respect to smoking policies for teachers and staff, COMMIT

personnel presented the argument that adults, and especially teachers,

should act as role models for healthy lifestyle behaviors for children. They

argued that teachers and students should be subject to the same smoking

policy; smoking should be banned entirely, for everyone, on all school

grounds.
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Chapter 7

Heeding this appeal, the Ashland School District adopted a tobacco-free

campus policy that stipulated no tobacco use by anyone at anytime on any

school grounds, including the football stadium. The Medford School District

adopted a similar policy but allowed teachers to smoke in their cars in the

faculty parking lot.

Billboard Ban In spring 1990 the city of Bellingham, WA, passed an ordinance

phasing out all billboards within the city limits. By 1996 this ordinance

will have eliminated what in most communities is a pervasive form of

tobacco advertising. Passage of the billboard ban was the result of

cooperation by several different community groups. Although motivations

for supporting the ban differed, the groups’ collective efforts produced an

outcome that was beneficial to all.

Two years before the question of a billboard ban caught the attention

of local policymakers, a COMMIT project staff member sought and obtained

information from Scenic America, a national organization advocating removal

of billboards as a means of beautifying the environment. Her interest in

Scenic America was less associated with its goal than its means; elimination

of billboards was one way to reduce the promotion of tobacco products

because a large percentage of Bellingham’s billboards regularly displayed

cigarette advertisements.

In an attempt to initiate local action on this issue, the Scenic America

materials were sent to a Bellingham City Council member who chaired the

council’s Public Works Committee and who was a personal friend of the

COMMIT field director. In a followup contact, the council member was

polite but indicated no interest in the matter.

About a year later Bellingham was in the throes of a transition. In

summer 1987, a large regional shopping mall had opened north of the

downtown area, an event that divided both the business community and the

general public. The result was a relocation of businesses from the downtown

area to the mall, leaving one city building after another vacant.

At this same time Bellingham was receiving numerous requests for

permits to erect billboards on newly vacated downtown properties, a

development that alarmed several members of the city council. The council

swiftly imposed a moratorium on all new billboards until it could study the

issue.

At this point the council member who had been given the Scenic America

materials reconnected with the COMMIT field director and asked whether

she would be willing to testify at a Public Works Committee hearing on the

billboard issue. Support was building within that committee for addressing

the billboard problem by proposing a full ban on all billboards to the city

council.

Several billboards at that time displayed liquor advertisements featuring

a reclining blond model in a revealing black gown. These advertisements

played an important role in the outcome of the proposal because they
Smoking and Tobacco Control Monograph No. 6

112

angered and activated other local groups, including alcohol abuse treatment

professionals, parents, and women’s groups.

The hearing was attended by an attorney representing the community’s

largest billboard owner, another local billboard owner, and numerous local

advocates and concerned citizens. Most of the people in the latter group

favored the ban. Much of the testimony focused on the liquor advertisements.

The COMMIT representative detailed the enormous amounts of advertising

revenues spent by both tobacco and alcohol companies each year, how the

advertising affects youth who are captive viewers, and how the advertising

gives youth the impression that alcohol and tobacco are socially acceptable.

One argument that played well in the discussion was that, because it was

impossible to selectively ban “bad” advertising messages, the only recourse

was to eliminate the vehicle for these messages.

Many, including the billboard owner’s attorney, were surprised and

moved by the power of the COMMIT field director’s testimony. When it

was the attorney’s turn to speak, he looked sheepish and confessed in an

apologetic tone that he did not even let his own youth wear T-shirts with

beer logos on them.

To enhance the effectiveness of her presentation, the field director had

invited a retired Washington State senator who was a highly respected

member of the community to accompany her in the hearing. The retired

senator briefly reiterated and endorsed the field director’s remarks.

The proposed ordinance was approved by the Public Works Committee

and shortly thereafter passed by a majority vote of the city council. A 6-year

phase-in period was provided to give billboard owners time to absorb and

adjust to the economic impact of the ordinance.

Several months later COMMIT was asked to provide the same testimony

to the Whatcom County Council as it reviewed its outdoor advertising

policies. This time the billboard owners were more organized and presented

more effective counterarguments. Instead of instituting a ban, the county

council voted to forbid construction of any new billboards and specified

that when existing structures were removed, they could not be replaced.

Ultimately, the billboards will go, but it will be a more gradual process.

When attempts are made to change policy, the importance of laying

foundations early on to ensure that some of those changes take place in the

future cannot be overemphasized. Providing a council member with the

billboard abatement materials long before the issue was on the local political

agenda illustrates this point. That the mayor was a member of the COMMIT

community Board also was not accidental. The COMMIT project wisely

chose to hire a field director who was well known in the community and

who knew how to “work the community” to ensure some success. The initial

informational contact with the chair of the council’s Public Works Committee

was facilitated by a previously established relationship. The willingness of a
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highly regarded community influential (the retired senator) to advocate for

this policy provided additional credibility and stature to the effort.

Another critically important strategy is to be poised and ready to “seize

the moment” whenever it may arise. The success of the billboard bans

turned largely on the fact that when an opportunity presented itself, tobacco

control advocates were able to assemble their resources swiftly and strike

with a certain element of surprise. Surprise was not an element in the

hearings for the county ordinance, and the results were less impressive.

It is also essential to consider how issues are framed. From beginning to

end, the supporters of the billboard ban focused exclusively on the issue of

youth exposure to unhealthy images and messages. Because they did not

deviate from that posture, the hazards of being portrayed as antibusiness or

as infringing on first amendment rights were avoided. Opponents’ attempts

to reframe the issue must be assiduously resisted.

Diligence is essential in all efforts to change local policy, the process

of which is often long and arduous. Even after ordinances are adopted,

opponents may later attempt to have them overturned. As this volume goes

to press, the billboard ban in Bellingham (which is not yet fully phased in) is

under attack by a small but vocal group of local entrepreneurs who view the

policy as an infringement of their business opportunities.

CHALLENGES It is often the case that more is learned from failures and mistakes than

TO POLICY from successes. This section examines two unsuccessful attempts at

CHANGES policy change. The first involved a county ordinance to address youth

access problems; the second was an attempt to pass a local clean indoor air

ordinance that was preempted by a tobacco industry-sponsored State law.

Unsuccessful Early in the intervention (1989), the Public Education Task Force in

Youth Access Bellingham identified the need for a policy initiative restricting youth

Ordinance access to tobacco products. Task force members arranged a joint

meeting of the mayor of Bellingham, the chief of police, two city council

members, and a task force member who was a highly respected and

influential member of the community. Everyone at the meeting agreed

that this was a great idea, but there was no commitment by anyone to

spearhead the initiative. Vague promises were made that something

would happen, but nothing was forthcoming.

Several months later the county health officer contacted the COMMIT

offices and discussed the possibility of putting forth some sort of effort

toward restricting youth access to tobacco. His idea was to cast this effort as

a health department initiative promoting the health and well-being of youth

rather than as an effort to beef up law enforcement or a program that could

be construed as blaming the business community (retailers) for the problem.

The effort would include the entire county.

The proposal called for licensing all tobacco vendors in the county

and collecting a licensing fee. The fees would be earmarked for health
Smoking and Tobacco Control Monograph No. 6

114

department-sponsored educational and enforcement activities. The

proposal also prohibited the sale of single cigarettes.

One surprising twist in this venture was the rapid response of the

tobacco industry. The proposal was first presented to the county executive

and chief of police in a closed-door meeting with the health officer and

county counsel on a Friday afternoon. The following Monday morning

the health officer received a telephone call from a representative of the

tobacco industry asking about the proposed health department activity and

requesting that the industry be kept informed of any further progress in this

area. All involved became understandably paranoid. Nevertheless, there

appeared to be no further involvement on the part of the tobacco industry.

Prior to the presentation of the proposal to the county council,

COMMIT conducted two compliance checks to document the ease with

which underage youth could purchase tobacco products in the county

(for a discussion of compliance checks, see Chapter 13). Additional

political groundwork was completed by the health officer, who made several

informational presentations to various sectors of the community (such as

a meeting of small retailers). At the health officer’s request, COMMIT made

a presentation to the county health advisory board. It was the health

officer’s belief that all stakeholders should have input into the initiative.

The presentation was made, and the proposed ordinance was forwarded

to the county council for action. This was the last anyone heard of it.

Apparently, the council simply did not put the proposal on its agenda for

discussion. The reasons for this are unknown.

There are a multitude of potential barriers and challenges that must be

successfully negotiated to pass an ordinance of this type. It is thus difficult

to say with certainty why the effort failed. That there were seven separate

municipal jurisdictions within the county that had to sign off on the policy

undoubtedly complicated matters. In addition, the local political climate

during the time the ordinance was under consideration was unfavorable

for any significant policy change: Budgetary anxieties were high, and

relationships between the county executive, the county council, and the

health officer were strained.

There was a sense among some people close to the effort that key

players involved were not able to respond swiftly enough—to seize the

moment—at critical junctures during the process. Leadership plays a

central role in determining the tone and course of such endeavors. In the

opinions of some, the deliberate and at times overly cautious style of the

health officer leading this effort did little to mitigate what was already a

slow and inherently cumbersome process that called for exceptional political

sophistication. The best of motives do not mitigate such shortcomings.

Ultimately, the passage of a State-level youth access bill made all

attempts to reactivate the county ordinance moot because the State bill

preempted similar local policies.
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State Preemption In 1992 an attempt was made to pass a county ordinance in Wake

of a Clean Indoor County, NC, restricting smoking in public places. Although this

Air Ordinance ordinance was almost identical to a successful city ordinance

passed a year earlier (described above), the controversy surrounding it was

much larger.

The successful city ordinance had been proposed by the county board

of health but was actually voted on by the city council. In the case of the

attempted county ordinance, when the county commissioners succumbed

to tobacco industry pressure and would not consider the proposal, the Wake

County Board of Health decided to conduct hearings and exert its authority

to protect the public health. Citing the recently released U.S. Environmental

Protection Agency report (U.S. Environmental Protection Agency, 1992) as

a justification for action, the board of health passed a countywide policy

(as a health board directive) in early 1993.

The opponents to this action consisted of tobacco farmers, the tobacco

industry, and restaurant owners. The industry’s primary strategy was to

challenge the board of health’s authority to regulate smoking in public,

arguing that the board was not an elected lawmaking body.

Meanwhile, the industry sponsored a preemption bill at the State level

that was passed in June 1993 and took effect in October. It purported to be

a clean indoor air bill. It required that allowing smoking (or nonsmoking—

many say the wording is deliberately unclear) be guaranteed in 25 percent

of seating sections in public places across the State. A “small print” clause

at the end of this bill stated that no municipalities could pass more stringent

regulations. A “grandfather” clause permitted more stringent ordinances

only if they were in place before October 1993.

Most preemption laws are extremely damaging to local policy efforts.

However, in this case the process had a surprise ending. Local tobacco

control proponents joined forces with the League of Municipalities (which

was furious at this transgression of local ordinance-making authority) and

other allies across the State to urge local governments to quickly enact

smoking control policies under the grandfather clause. Some counties went

to their county commissioners or city councils for ordinances, but many

proposed ordinances through the more sympathetic and less industryinfluenced county boards of health.

In the ensuing flurry of local policy action, more than 40 counties in

North Carolina passed or strengthened no-smoking ordinances, rendering

the industry’s preemption bill much less effective than it otherwise would

have been. A local newspaper story describing the tobacco industry’s attempt

to preempt local actions of this sort ran under the headline “Snatching

Defeat From the Jaws of Victory” (Williams, 1993).

In retaliation, the tobacco industry targeted one “weak” county with

lawsuits challenging the authority of every North Carolina county board of

health to pass smoking control regulations. It will take years to resolve, and
Smoking and Tobacco Control Monograph No. 6

116

counties do not have the resources for protracted legal battles, so the outlook

is not optimistic. The industry (through a 15-restaurant front group) had

already sued the Wake County Board of Health for its ordinance on similar

grounds.

As this experience illustrates, the strength that tobacco control proponents

have at the local level can be offset by the strength of the tobacco industry in

State legislative and legal arenas.

WHAT COULD How could the design of the COMMIT intervention be altered

HAVE BEEN to improve opportunities for and the outcomes of policy

DONE DIFFERENTLY? change efforts? The major design feature that significantly

impeded progress in these efforts was the prohibition on the use of COMMIT

resources, especially money, to engage in political lobbying efforts (such as

advocating an improved clean indoor air ordinance). Virtually everyone

involved in the project’s policy-related activities felt frustrated

by this restriction. It was unavoidable in that COMMIT’s

funding came from the Federal Government, and Federal

law prohibits use of Federal funds for State or local lobbying

activities in deference to principles of jurisdictional

separation.

Identifying funding for political lobbying is an everpresent challenge. The Federal Government is not the

only entity that limits use of its funds. Even independent,

nonprofit organizations that are otherwise free to engage

in lobbying efforts may have self-imposed limits of this

nature, often to avoid being seen as overly “political” by

the public or to avoid the appearance of conflict with

elected officials.

There is no simple solution to this problem. In some

cases it may be possible to forge an alliance with another

local group supportive of the policy change that is able and

willing to fund a particular lobbying activity. In Paterson, NJ, the National

Council of Negro Women (NCNW) initiated a campaign to petition State

legislators and citizens to support a bill prohibiting cigarette advertisements

on billboards in low-income and minority neighborhoods. Although this was

not a COMMIT-sponsored activity, COMMIT played an important role in the

effort. The NCNW member who organized the campaign was also a member

of the COMMIT Board. Once NCNW decided to pursue the campaign, it

turned to COMMIT for advice and assistance, illustrating the importance of

being open to creative approaches to dealing with restrictions on use of funds.

GENERIC LESSONS The experiences recounted above and numerous others not

mentioned here suggest certain generic lessons or rules of thumb useful in

planning and carrying out tobacco control policy change campaigns. This

section summarizes some of these lessons.

First, framing tobacco control policy issues in terms of health promotion,

such as the protection of young people from unhealthy influences, is usually
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the best strategy. Opponents will often attempt to reframe the issues as

antibusiness or in terms of infringements of individual rights. Anticipate

this and be prepared to respond without delay.

As illustrated in several examples above, attempting to pass ordinances

in geographical areas where political jurisdiction is shared by several entities

can be especially challenging. Sometimes this is unavoidable, as is the case

when a county ordinance is needed and the county encompasses several

municipalities. Whenever possible, work within one jurisdiction at a time.

Be prepared to devote considerable attention to consensus building when

working with more than one jurisdiction.

Be poised to seize opportunities as they arise. Unanticipated developments

often occur in the political arena. As some of the examples discussed above

indicate, such developments can often be used to advance the tobacco control

policy agenda.

When policies are being considered, do not let momentum and attention

wane while a governing body “sits” on the issue. Keep your issue in the news

to build public pressure. High public visibility creates pressure for political

figures to act.

Strategies for maintaining visibility include announcing new endorsements

or resolutions of support for the initiative by locally influential groups such

as medical societies, parent and teacher associations, and health promotion

organizations; writing opinion editorials and letters to the editor; conducting

and reporting followup data-gathering efforts (such as compliance checks for

sales of chewing tobacco after having done the same for cigarettes); requesting

time in the policymaking body’s meeting agenda to present new findings or

arguments; and linking your issue to media coverage of related events or

activities (such as a quit-smoking contest) by highlighting the connections

between the issues.

Attentiveness to stages of change is essential in policy change efforts.

For example, in youth access policies many communities may feel tough

enforcement is the only way to make an ordinance work. However,

raising a strong cry for more aggressive police action may only alienate the

community, particularly when law enforcement is preoccupied with other

problems. When there is little awareness of the legal buying age for tobacco

(let alone awareness of how easily underage youth can purchase tobacco),

educating the community as well as policymakers must be the first order

of business.

Once awareness of a problem exists, fostering ownership of the problem

and, ultimately, promoting community involvement in the solution are

important second and third steps. When the community becomes involved

in a policy change effort, it is much more difficult for opponents to claim that

the need for policy action is merely a false perception created by a few zealots.

A corollary to this kind of community ownership is to involve a broad,

diverse group of advocates in the effort. In addition to building clout and
Smoking and Tobacco Control Monograph No. 6

118

momentum, this also helps protect against being labeled and dismissed as

“those zealots” or “those health people.” A coalition of advocates from

multiple sectors of the community tells the public and policymakers that

this issue is important to many people and that something needs to be

done about it.

Recruit “victims” or others directly affected by an issue to be public

spokespersons. Even if they are not the most articulate, they tend to be

the most powerful proponents. Sometimes this is because they lack the

polished style of a professional or “expert.” Youth can be particularly

powerful. They can say things to elected officials that adults could never

say, and they can give the issue a reality that can impress even the most

cynical media representatives.

Locally collected data, such as opinion surveys and compliance check

results, can be powerful tools, especially when opponents are trying to

deny the magnitude or relevance of the issue in the local community.

Such surveys, conducted by major employers and city and county agencies,

were used to great advantage several times during the COMMIT project.

The enactment of an ordinance is not a guarantee of success from a

health promotion perspective. Getting a law on the books does not mean

that it will be enforced. Nor does it mean that the underlying health

promotion objective—changing community norms concerning healthrelated behaviors—has been accomplished, especially if increasing

community awareness and involvement did not contribute to the law’s

passage. Remember that forging strong community alliances, fostering

leadership opportunities for youth and other members of the community,

and involving citizens in the public health policymaking process are worthy

ends in themselves.

Know your opponents and understand their strategies. Exchanging

information with advocates undertaking similar efforts in other communities

can be invaluable. National information networks can facilitate this.

Count on the tobacco industry to use State preemptive legislation to

foil local tobacco control efforts whenever they can. To combat this, be

watchful of all State laws related to tobacco control, even if they appear to

be uncontroversial. Seemingly minor 11th-hour changes in the wording of

proposed laws have been used by the tobacco industry to cripple otherwise

sound legislation. A dismal example of this occurred in Washington State

in 1993, when a bill originally intended to strengthen the law against illegal

sales of tobacco to youth was ultimately passed with language preempting

many local ordinances that were stronger than the new State policy. The bill

also incorporated weakened enforcement provisions.

Finally, be bold and persistent. In the examples cited, many times the

“gatekeepers” were acting on the basis of assumed or feared reactions by

industry, businesses, influential officials, or even their allies. Politicians

are especially prone to see certain issues as “sacred cows” and are loath
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to take stands perceived to be politically risky. However, with diligence,

community-based advocates armed with locally relevant data and forming

a united front with other community groups and supporters can challenge

the status quo and bring about effective change.

REFERENCES

Bierer, M.F., Rigotti, N.A. Public policy for the

control of tobacco-related disease. Medical Clinics

of North America 76: 515-539, 1992.

Bracht, N. (Editor). Health Promotion at the

Community Level. Newbury Park, CA: Sage, 1990.

COMMIT Design and Evaluation Working Group.

“1989 Evaluation Cohort Survey.” (5/26/89

version.) Unpublished document, 1989.

COMMIT Research Group. Community Intervention

Trial for Smoking Cessation (COMMIT): Summary

of design and intervention. Journal of the National

Cancer Institute 83(22): 1620-1628, 1991.

Escobedo, L.G., Anda, R.F., Smith, P.F., Remington,

P.L., Mast, E.E. Sociodemographic characteristics

of cigarette smoking initiation in the United

States: Implications for smoking prevention

policy. Journal of the American Medical Association

264(12): 1550-1555, 1990.

Frankel, B.G. Reducing tobacco consumption: Public

policy alternatives for Canada. Canadian Medical

Association Journal 138: 419-423, 1988.

Glynn, T. Comprehensive approaches to tobacco use

control. British Journal of Addictions 86: 631-635,

1991.

Jason, L.A., Ji, P.Y., Anes, M.D., Birkhead, S.H. Active

enforcement of cigarette control laws in the

prevention of cigarette sales to minors. Journal of

the American Medical Association 266(22): 3159-

3161, 1991.

Kingdon, J. Agendas, Alternatives, and Public Policy.

Boston: Little, Brown, 1984.

Pertschuk, M., Shopland, D.R. (Editors). Major Local

Smoking Ordinances in the United States: A Detailed

Matrix of the Provisions of Workplace, Restaurant,

and Public Places Smoking Ordinances. NIH

Publication No. 90-479. Rockville, MD: U.S.

Department of Health and Human Services,

Public Health Service, National Institutes of

Health, National Cancer Institute, 1989.

Reich, R.B. Policy making in a democracy. In:

The Power of Public Ideas, R.B. Reich (Editor).

Cambridge, MA: Harvard University Press, 1988.

pp. 123-156.

Samuels, B., Glantz, S.A. The politics of local tobacco

control. Journal of the American Medical Association

266: 2110-2117, 1991.

Thompson, B., Wallack, L., Lichtenstein, E.,

Pechacek, T. (for the COMMIT Research Group).

Principles of community organization and

partnership for smoking cessation in the

Community Intervention Trial for Smoking

Cessation (COMMIT). International Quarterly

of Community Health Education 11(3): 187-203,

1990-91.

U.S. Department of Health and Human Services.

Reducing the Health Consequences of Smoking:

25 Years of Progress. A Report of the Surgeon General.

DHHS Publication No. (CDC) 89-8411. Rockville,

MD: U.S. Department of Health and Human

Services, Public Health Service, Centers for Disease

Control, Center for Chronic Disease Prevention

and Health Promotion, Office on Smoking and

Health, 1989.

U.S. Department of Health and Human Services.

Youth Access to Cigarettes. DHHS Publication No.

OEI-02-90-02310. Rockville, MD: U.S. Department

of Health and Human Services, Office of Inspector

General, Office of Evaluations and Inspections,

1990.

U.S. Department of Health and Human Services.

Strategies To Control Tobacco Use in the United

States: A Blueprint for Public Health Action in the

1990’s. Smoking and Tobacco Control

Monographs–1. NIH Publication No. 92-3316.

Rockville, MD: U.S. Department of Health and

Human Services, Public Health Service, National

Institutes of Health, National Cancer Institute,

1991.

U.S. Department of Health and Human Services.

Major Local Tobacco Control Ordinances in the United

States. Smoking and Tobacco Control Monograph

No. 3. NIH Publication No. 93-3532. Rockville,

MD: U.S. Department of Health and Human

Services, Public Health Service, National Institutes

of Health, National Cancer Institute, 1993.

U.S. Environmental Protection Agency. Respiratory

Health Effects of Passive Smoking: Lung Cancer and

Other Disorders. EPA600/6-90/006F. Washington,

DC: Office of Research and Development, Office

of Health and Environmental Assessment, 1992.

Weiss, J.A., Tschirhart, M. Public information

campaigns as policy instruments. Journal of Policy

Analysis and Management 13(1): 82-138, 1993.
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Williams, B. Snatching defeat from the jaws of

victory. Raleigh News and Observer, September 19,

1993. pp. F1, F7.

Wynder, E.L. Tobacco and health: A review of the

history and suggestions for public health policy.

Public Health Reports 103: 8-18, 1988.

AUTHORS

David S. Carrell,Ph.D.

Research Assistant Professor

Community Health Care Systems, SM-24

University of Washington

Seattle, WA 98195

Carolyn L. Johnson,R.N.

Program Manager

Healthy Start Program

Jackson County Department of Health and

Human Services

Building A

1005 East Main Street

Medford, OR 97504

Len C. Stanley,M.P.H.

Program Director

Tobacco Control Training Center

Department of Family Medicine

University of North Carolina

Aycock Building, CB-7595

Manning Drive

Chapel Hill, NC 27599

Juliet Thompson

Field Director

Bellingham COMMIT Site

4407 Wilkin Street

Bellingham, WA 98226

Sandy Tosti,M.A.

7335 Franco Lane

Vacaville, CA 95688
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Chapter 8

Activities To Enhance the Use of Cessation

Resources in COMMIT

Edward Lichtenstein, Paul R. Pomrehn, and Russell C. Sciandra

INTRODUCTION Cessation resources include a wide range of methods and materials

aimed at encouraging and assisting people to quit smoking. The range

includes educational or self-help materials such as books, pamphlets, and

audiotapes or videotapes; support services such as smoking hotlines or

information services; and group and individual treatment programs offered

by nonprofit agencies or proprietary firms or individual practitioners. The

Community Intervention Trial for Smoking Cessation (COMMIT) project

made several key assumptions that influenced protocol development and

implementation. First, because a wide variety of services and resources are

generally available in communities through existing agencies, it was not

necessary for COMMIT to develop new cessation services. If other COMMIT

programs increased demand for services, local agencies would be responsive.

Second, the individual smoker is

probably the best judge of which

method meets his or her needs and

should be offered a range of options.

Third, because 90 percent of smokers

quit on their own, providing

motivation and improving their

access to self-help materials appear

to be the most promising intervention

strategies (Pomrehn et al., 1990-91).

Considerable COMMIT resources

were directed toward public education

(Wallack and Sciandra, 1990-91),

health care settings and providers

(Ockene et al., 1990-91), and worksites

and other organizations (Sorensen et

al., 1990-91), with the expectation

that the supply of cessation resources—

for example, cessation classes and

individual counseling—would expand as need and demand increased. As

reflected in the protocol, communities were charged with promoting cessation

resources that were available and providing regular notice of opportunities

for smokers to quit. Because heavy smokers (≥ 25 cigarettes a day) were the

primary target for COMMIT, communities also sought to identify and use

avenues for reaching them.

This chapter has a twofold purpose: first, to present the rationale for

the three required activities, describe how they were implemented, and offer
Smoking and Tobacco Control Monograph No. 6

122

some practical advice for communities interested in mounting such services

with their own resources; and second, to describe how several COMMIT sites

used the protocol or conducted optional activities to target heavy smokers

and culturally diverse smokers. Both successes and failures are chronicled

along with suggestions to guide communities in doing better.

CESSATION RESOURCES Each COMMIT channel had overall goals, a set of impact

ACTIVITIES AND objectives, and a set of mandated activities designed to

PROCESS OBJECTIVES meet these objectives if they were successfully implemented

(see Chapter 4). The overall goals of the cessation resources and services

channel were to:

• increase smokers’ awareness of cessation resources in their community;

• assist smokers in identifying cessation assistance; and

• promote participation in community cessation programs and services.

The impact objectives for cessation resources reflect the emphasis on

increasing awareness of cessation programs, distributing self-help materials,

and reaching out to heavy smokers. This corresponds with the trialwide goal

to increase the capacity to modify smoking behavior. In accordance with

the focus on self-help or nonassisted quitting, low objectives were set for

attending cessation clinics by heavy smokers. The impact objectives were:

• By 1993 80 percent of smokers will be aware of the availability of

stop-smoking programs or classes in their community as measured

in the evaluation cohort survey.

• By 1993 cessation materials will be distributed to the equivalent of

20 percent of smokers as measured by the cessation resources survey.

• By 1993 cessation clinics will have been attended by the equivalent

of 8 percent of smokers as measured by the cessation resources survey.

• By 1993 the Smokers’ Network will have enrolled 8 percent of heavy

smokers as measured by the COMMIT Program Records System.

The cessation resources channel consisted of five major activities. These

activities and their process measures are listed in Table 1.

DEVELOPING AND Smokers are likely to be unaware of all the available

DISTRIBUTING A resources in their community. Information about timing,

CESSATION RESOURCES location, and expense is important to smokers who are

GUIDE seeking assistance in quitting or who are advised to do

so by friends or health care

professionals. Many health

care professionals—for example,

physicians, and dentists—and

friends and relatives of smokers

would like to be able to provide

cessation resource information

to smokers as they advise them
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Chapter 8

Table 1

Cessation resources activities and process objectives

Cumulative Number/ Process Objectives

Activities for Objectives Percent Achieveda

Each Community (1988-1992) Completed (%)

Produce Cessation

Resources Guide All communities 11 100

Annually Deliver Cessation

Resources Guide to:

Physicians 90% 107

Dentists 90% 104

Targeted worksites 90% 101

Targeted organizations 90% 78

Semiannually Produce and

Distribute Newsletters 66 newsletters 92 newsletters 139

Develop Network

Recruitment Plan All communities 11 100

Recruit Heavy Smokers

Into a Network 8% 8.4% 105

a Average for combined communities.

to quit. For these reasons, a community-specific Cessation Resources Guide

(CRG) was developed in each COMMIT site.

Resource guides are community-specific, nonevaluative descriptions

of local cessation resources. The guides listed organizations or individuals

offering smoking cessation programs, sources of self-help

materials and cessation aids, and any other resources

deemed appropriate by each local task force. A brief

description of each service included names and

telephone numbers of contact persons and often some

information about fees or costs. Decisions about which

services to include were made locally and were generally

inclusive; those who wished to be listed were. There was

virtually no conflict over listings. Most sites included

the names of physicians and dentists who had received

COMMIT-supported training in cessation counseling

(Ockene et al., 1990-91). Several of the guides were

formatted as 3 × 8 pamphlets that easily fitted into a

purse or pocket and unfolded into a small poster that

could be displayed on a bulletin board. The guides

sometimes included motivational material to encourage

smokers to quit on their own, such as a self-administered
Smoking and Tobacco Control Monograph No. 6

124

quiz on nicotine addiction or some other attention-getting visual or verbal

material. In one site, a Spanish-language edition was prepared and

distributed.

The CRG was probably the most popular and successful COMMIT activity

across all 11 communities. Table 2 lists the number of CRG’s distributed

by each community as derived from the COMMIT Program Records System

(Corbett et al., 1990-91). Distribution channels were determined partly

by the protocol, with some opportunity for local creativity, and typically

involved physicians’ and dentists’ offices, clinics, hospitals, pharmacies,

and health fairs. CRG’s also were part of self-help packets distributed during

community events such as The Great American Smokeout or “Quit and Win”

contests (as described in Chapter 11). In Medford/Ashland, OR, one of the

smallest COMMIT sites, nearly 35,000 guides were distributed primarily

through health care provider offices and worksites. A key distribution tactic

developed by the Medford/Ashland site was the use of clear plastic racks for

the CRG’s; they were seen as useful and convenient by health care offices.

Such racks helped make the guides visible for patients and providers, a

strategy emulated by many other communities and proven to be popular

at those sites.

The cost of the guides included staff time to collect the information,

formatting and layout, printing, and distribution. Obviously, startup costs

are greatest, and economies of scale will be realized with larger printings. As

popular as this service was during COMMIT, it is not surprising that many

sites wished to see it maintained after project funding ended.

A CRG could be produced by a county health department; a voluntary

organization, such as the American Cancer Society or American Lung

Association; or some consortium of these. A small fee (e.g., $25 per listing)

could defray expenses, or one of the pharmaceutical companies producing

the nicotine patch might be willing to bear some of the cost. In addition,

Table 2

Cessation Resources Guide distribution, by community

Vallejo, California 76,575

Brantford, Ontario, Canada 16,617

Cedar Rapids, Iowa 16,183

Fitchburg/Leominster, Massachusetts 12,323

Paterson, New Jersey 17,445

Santa Fe, New Mexico 3,566

Utica, New York 46,217

Yonkers, New York 42,089

Raleigh, North Carolina 191,830

Medford/Ashland, Oregon 34,990

Bellingham, Washington 8,719
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Chapter 8

there could be flexibility in how often such a guide needs to be revised

and updated; every 3 years could be sufficient. Many of the COMMIT

communities printed extra covers and gave a computerized listing of the

contents of the CRG to a local health voluntary agency or health department

so that the guide could be updated annually or biannually.

RECRUITING Quitting smoking is a process, and smokers typically go through

HEAVY SMOKERS the stages of quitting several times before achieving long-term

INTO A success (DiClemente et al., 1991). Therefore, it is desirable to

NETWORK maintain communication with those who are contemplating

quitting or trying to quit as a way of encouraging quit attempts, preventing

relapse, and encouraging relapsers to try again. For this reason, each

COMMIT community established a computerized registry, called a

Smokers’ Network, that provided a database of smokers who desired

regular communication on cessation opportunities. Smokers joined

the COMMIT network voluntarily when participating in communitywide Quit and Win contests (see Chapter 6) or when attending health

fairs or other promotional events. Some sites used standing displays

or posters with tear-off registration forms that could be mailed to the

COMMIT office. Several sites struggled to meet network recruitment

goals early in the trial, but most eventually succeeded. By the end

of the COMMIT trial, seven sites each had recruited at least 8 percent

of their total local population of adult heavy smokers. The range of

percentage of heavy smokers in the network was 3.1 to 21.7 percent,

and for light-to-moderate smokers 1.8 to 10 percent, with average

trial percentages of 8.4 and 3.9, respectively. This indicates that

efforts were generally successful in enrolling heavy smokers into the

registry; more surprising was that a greater portion of heavy smokers

enrolled than light-to-moderate smokers.

There were inherent barriers to entering the network: Smokers

had to choose to complete and sign the card and sometimes had to mail it to

the COMMIT office. COMMIT’s contractual Federal

funding required that registration cards contain the

following statement, “The information you provide

will be kept confidential, and will only be used for the

purposes of this mailing list and will only be available

to the appropriate staff, or as required by law. You may

request removal from this mailing list at any time by

contacting (local COMMIT ID) at the phone number

and address provided in the newsletter.” Although

this statement may have inhibited some smokers from

registering, many sites minimized this impact by sizing

and creative placement on the registration cards. Sites

found it neccessary to use incentives (e.g., pens or

coffee mugs imprinted with nonsmoking messages)

to help with network recruitment. Others distributed

promotional items, such as a paper clip holder with a

“join the network” message, to physicians’ offices or
Smoking and Tobacco Control Monograph No. 6

126

worksites. Many sites creatively developed registration cards

for magnet events, such as Quit and Win contests, so that as

smokers registered for contests, they concurrently registered

for the Smokers’ Network.

Perhaps the major lesson learned from COMMIT’s

network experience is that it is possible to use various

cessation and promotional activities to develop a mailing

list of smokers. Simple registration cards can be easily filled

out and subsequently entered into a database for future

contact. Individual agencies conducting smoking control

activities could develop their own lists for their own

purposes, or such lists could be shared or merged into a

centralized resource for a community. Such a network

could serve a variety of purposes, including newsletter

mailings, supportive mailings or telephone calls to prevent

relapse or urge recycling to another quit attempt, or offerings

of new cessation programs or services. Such a system also

can tell sponsors where in the community people are getting their tobacco

information.

For COMMIT, the network was limited to the receipt of periodic

newsletters. Enrolling in a network may be a signal that a smoker is

considering quitting or is ready to quit (DiClemente et al., 1991). A

mechanism that provides a more timely response than that of an

infrequently issued newsletter can capitalize on this opportunity.

DISTRIBUTING The COMMIT newsletters also were aimed at maintaining ongoing

A SEMIANNUAL communication with smokers to encourage movement along the

NEWSLETTER process-of-change continuum (DiClemente et al., 1991). Although

COMMIT newsletters were initially aimed primarily at network-registered

smokers, most sites distributed them more broadly, including to physician

offices, worksites, organizations, and even locales where smokers were likely

to be found. The newsletters attempted to be sensitive to and supportive

of smokers and their needs. Content usually included a calendar of local

smoking cessation events, tips on quitting, stories or testimonials from local

people who had quit, interesting facts about smoking, and often humorous

material in the form of cartoons or stories. Most newsletters used testimonials

from successful quitters as a way of providing role models for quitting.

Forthcoming programs or activities, such as Quit and Win contests, were

also routinely featured. The newsletter was produced by COMMIT staff or

volunteers using the desktop publishing capabilities of ordinary personal

computers. Production sometimes strained the resources of COMMIT

personnel who had limited prior experience with such an activity, but by

the close of the intervention, the activity had become routine.

During the final 2 years of intervention, COMMIT sites averaged three

newsletters a year, and all distributed the required minimum of two. At two

sites, newsletters were mailed to all homes in the community, which resulted

in many telephone calls to the COMMIT office as well as to other agencies
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Chapter 8

concerned with smoking control. However, such a broad mailing, even with

bulk mail rates, can raise cost barriers to programs with limited funding. Most

agencies involved in tobacco control already produce newsletters or bulletins

for their membership. This technology and capability can be readily adapted

to newsletters or to other mailings directed at smokers. Newsletters could be

piggybacked onto existing mailings, thereby reducing postage costs, one of

the major barriers for this activity. A less desirable but still cheaper option is

to include smoking cessation material within a broader health newsletter.

Many health maintenance organizations already do so.

In summary, the three mandated cessation resources activities were

successfully implemented across the 11 COMMIT sites. The CRG appeared

to be the most popular and deserving of attention from communities

wishing to enhance their tobacco control capabilities.

SPECIAL RECRUITMENT Heavy smokers are less successful in quitting smoking

AND INTERVENTION compared with light smokers (Ockene et al., 1991). Less

ACTIVITIES educated and economically disadvantaged populations

are likely to have greater proportions of smokers and are also less likely to

use or be reached by conventional cessation programs. The goals of increasing

awareness of cessation resources and promoting participation in programs

apply equally to disadvantaged segments of the community, but special

tailoring of approaches and means is required. For these reasons, COMMIT

communities were encouraged to develop and implement optional programs

to reach the heavy or disadvantaged smoker. All COMMIT sites did so, and

this section describes some of the successes and failures and offers some

suggestions for future programs.

Paterson, NJ, an urban site with a high proportion of African-American

residents, used an existing network of well-attended hypertension screening

clinics to reach the black community. CRG’s and self-help materials were

displayed at these clinics and were well received. Information about smoking,

smoking cessation, and COMMIT activities also was distributed at screening

sites in Yonkers, NY. Yonkers COMMIT also participated in city-sponsored

summer cultural festivals, including the Arab-American Festival and the

African-American Heritage

Festival. Network cards and

CRG’s were distributed, and

carbon monoxide testing

was offered. Thus, network

recruitment and CRG process

objectives also were served

by this activity.

In Utica, NY, COMMIT

staff members and volunteers

identified 90 distribution

locations for CRG’s in

neighborhoods with expected

high concentrations of heavy
Smoking and Tobacco Control Monograph No. 6

128

smokers. Indicators used to identify these locations included neighborhood

socioeconomic status (SES), proximity to large blue-collar worksites, and retail

sites known to be popular places for cigarette purchases (e.g., convenience

stores, gasoline stations, corner grocery stores). Merchants agreed to cooperate

by providing readily visible locations for brochure holders. The holders were

restocked monthly by COMMIT and cooperating agencies. The Utica site also

provided one-on-one cessation counseling in Women, Infants, and Children

(WIC) program clinics, which serve young, disadvantaged women who have

high rates of smoking prevalence. WIC nurses were trained in counseling

techniques by COMMIT staff. There were Valentine’s Day quit smoking

challenges for WIC clients, and successful quitters received donated prizes.

The Cedar Rapids/Marion, IA, site used a local telephone information

service, CityLine, to provide cessation services using taped messages and

a voice mailbox. The telephone service was promoted through the media.

During a 9-month period, the service received 2,450 calls, and 972 “Quitpacks”

(cessation materials) were requested. The CityLine was particularly useful for

promoting cessation events such as The Great American Smokeout and the

“Cold Turkey Challenge.”

Fitchburg/Leominster, MA, decided to target smokers in what was

referred to as the Four B’s: barber shops, bars, bowling alleys, and bingo

sites. Field staff members began targeting smokers in these locations and

eventually other locations where it was determined that high volumes of

heavy smokers would congregate. Activities involved visiting locations

with bingo nights and bowling leagues to recruit smokers for the network.

This activity also was done to recruit participants for annual Quit and Win

contests. A great deal of information was gained about the views and

opinions of smokers concerning cessation, policies, and general behavior.

Staff members succeeded in recruiting more smokers for the network than

were recruited through previous efforts. Field staff members also began to

set up booths at community blood donor activities sites, food distribution

sites for welfare recipients, and functions held in neighborhood centers.

Smoking cessation activity was particularly successful at blood donor activities

sites because American Red Cross volunteers routinely tell donors not to

smoke for half an hour after donating. This afforded COMMIT volunteers

an interesting lead-in when many smokers inquired as to why they should wait

the half hour. COMMIT volunteers actually served as attendants in the

recovery area, which afforded more opportunity to interact with smokers.

By volunteering, COMMIT staff members were rewarded with reciprocal

volunteerism from American Red Cross members who recruited smokers

even when staff members were not present.

The staff at the Medford/Ashland site also had observed that there was

much smoking in bowling alleys and that bowlers were often blue-collar

workers likely to have high smoking rates. They designed a campaign to

appeal to bowlers—”Spare Your Lungs to Quit and Win”— featuring a Medford

native who is a nationally known professional bowler. Unfortunately, few

smokers signed up for the program at the various bowling alleys where
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Chapter 8

campaign publicity was displayed. A great deal of staff time and energy was

expended with minimal return in participation or quitting. Staff members

concluded that this was not cost-effective. On the more positive side, Yonkers

distributed bowling towels and COMMIT network cards at a Big Brother/Big

Sister Bowl-a-thon, thereby bringing awareness of COMMIT to

an existing, well-attended bowling event.

The Bellingham, WA, site also targeted one of the Four B’s—bars or

taverns. “Adopt a Tavern” was the name of a program wherein members

of the Cessation Resources Task Force each adopted three to five places

that they visited approximately once every 2 months to leave COMMIT

brochures and newsletters in public places. All were good locations for

reaching smokers. They included three golf courses, the Department of

Social and Health Services, pharmacies, a bingo hall, two blue-collar taverns,

one laundromat, Norway Hall, a Veterans of Foreign Wars hall, a Dairy

Queen, the YWCA (Young Women’s Christian Association) and YMCA

(Young Men’s Christian Association), and three alcohol abuse centers.

These examples illustrate the various ways that COMMIT cities tried to

reach heavy smokers and ethnically diverse populations of smokers. These

efforts typically required much staff and volunteer time. One lesson learned

is that it requires extra resources—time and money—to reach ethnically

diverse and disadvantaged segments of the smoking population. Staff

members sometimes experienced frustration when outcomes did not seem

commensurate with effort.

One general strategy that emerged is to integrate or piggyback smoking

cessation messages and materials into existing activities or programs. This

was done with hypertensive screening clinics, blood donor clinics, ethnic

cultural festivals, and bowling matches. This strategy “captures” ethnic or

disadvantaged smokers at events they have chosen to attend. This is efficient

and economical and helps to integrate smoking cessation with ongoing

health screening and health promotion activities. Relatedly, identifying

settings with heavy or ethnically diverse smokers—for example, taverns,

low SES food markets—and then bringing cessation materials to such

settings also proved useful.

Heavy smokers (≥25 cigarettes a day) may profit from more intensive,

pharmacologically assisted programs (e.g., the nicotine patches). COMMIT

sites reported that there was great interest in nicotine patches when they

came on the market in 1991. Cessation programs providing access to nicotine

patches seemed to attract more participants than those that did not. In 1991

there appeared to be a pent-up demand for nicotine patches and, therefore,

an opportunity to use them to attract heavy smokers. Several years later, this

may be less true. Some COMMIT sites were also successful in nurturing

Nicotine Anonymous support groups modeled after the 12-step Alcoholics

Anonymous programs.

In summary, COMMIT’s cessation resources activities were effectively

implemented, and communities displayed much ingenuity in shaping them
Smoking and Tobacco Control Monograph No. 6

130

to particular needs. Efforts to reach ethnically diverse, disadvantaged, and

heavy smokers varied widely both in content and in success in reaching

the target population. The most promising strategies appear to involve

(1) identifying activities (e.g., hypertension clinics) or events (e.g., cultural

celebrations) that such smokers already attend and integrating smoking

cessation activities into them or (2) bringing cessation materials to the

natural enviroment of heavy smokers by identifying locations they are

most likely to frequent.

REFERENCES

Corbett, K., Thompson, B., White, N., Taylor, M.

(for the COMMIT Research Group). Process

evaluation in the Community Intervention Trial

for Smoking Cessation (COMMIT). International

Quarterly of Community Health Education 11(3):

291-309, 1990-91.

DiClemente, C.C., Fairhurst, S.K., Velasquez, M.M.,

Prochaska, J.O., Velicer, W.F., Rossi, J.S. The

process of smoking cessation: An analysis of

precontemplation, contemplation, and preparation

stages of change. Journal of Consulting and Clinical

Psychology 59: 295-304, 1991.

Ockene, J.K., Hymowitz, N., Lagus, J., Shaten,

J. (for the Multiple Risk Factor Intervention Trial

[MRFIT] Research Group). Comparison of smoking

behavior change for Special Intervention and

Usual Care study groups. Preventive Medicine 20:

564-573, 1991.

Ockene, J.K., Lindsay, E., Berger, L., Hymowitz, N.

(for the COMMIT Research Group). Health care

providers as key change agents in the Community

Intervention Trial for Smoking Cessation (COMMIT). International Quarterly of Community Health

Education 11(3): 223-237, 1990-91.

Pomrehn, P., Sciandra, R., Shipley, R., Lynn, W.,

Lando, H. (for the COMMIT Research Group).

Enhancing resources for smoking cessation

through community intervention: COMMIT as

a prototype. International Quarterly of Community

Health Education 11(3): 259-269, 1990-91.

Sorensen, G., Glasgow, R.E., Corbett, K. (for the

COMMIT Research Group). Promoting smoking

control through worksites in the Community

Intervention Trial for Smoking Cessation (COMMIT). International Quarterly of Community Health

Education 11(3): 239-257, 1990-91.

Wallack, L., Sciandra, R. (for the COMMIT Research

Group). Media advocacy and public education in

the Community Intervention Trial to reduce heavy

smoking (COMMIT). International Quarterly of

Community Health Education 11(3): 205-222, 1990-

91.

AUTHORS

Edward Lichtenstein,Ph.D.

Research Scientist

Oregon Research Institute

1715 Franklin Boulevard

Eugene, OR 97403

Paul R. Pomrehn, Ph.D.

Associate Professor

Department of Preventive Medicine

University of Iowa

2812 Steindler Building

Iowa City, IA 52242
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Chapter 8

Russell C. Sciandra

Director

Tobacco Control Program

New York State Department of Health

Empire State Plaza

Corning Tower, Room 515

Albany, NY 12237
Smoking and Tobacco Control Monograph No. 6

132
133

Chapter 9

Activities To Promote Health Care

Providers as Participants in CommunityBased Tobacco Control

Elizabeth A. Lindsay, Norman Hymowitz, Robert E. Mecklenburg,

Linda C. Churchill, and Blake Poland

RATIONALE The goal of the Community Intervention Trial for Smoking Cessation

(COMMIT) was to implement community-based interventions that had

been demonstrated to help smokers, especially heavy smokers, achieve and

maintain cessation. Building on the extensive experiences of past and

ongoing smoking cessation studies supported by the National Cancer

Institute (NCI), community-based heart disease prevention efforts, and

other groups involved with smoking cessation, COMMIT combined

interventions into a comprehensive program designed to have an effect

on the smoking patterns of entire communities (COMMIT Research Group,

1991; Lichtenstein et al., 1990-91). Through a community organization

approach, citizens from the community, with professional staff member

support, assumed the major role in planning, adapting, and implementing

the interventions. The COMMIT protocol was a mix of activities designed

to create a supportive context for not smoking as well as activities that

provided direct education or other services to smokers. To create a context

for stopping smoking within this channel of activities, COMMIT promoted

nonsmoking policies in all health care facilities. To reach smokers directly,

planners considered who had personal access to heavy smokers and who

might influence them. Physicians and dentists are among the few direct

communication lines (i.e., person-to-person contact) to the majority of

heavy smokers. On average, 70 percent of smokers see their physicians

each year (Centers for Disease Control and Prevention, 1993), and more

than 60 percent visit their dentists (Hayward et al., 1989).

A series of studies with physicians and dentists have demonstrated

that, if appropriately trained and motivated, these health care professionals

can give cessation advice and support to a large enough number of smokers

who respond successfully to justify the time spent (Wilson et al., 1988;

Cohen et al., 1987, 1989a, and 1989b; Ockene et al., 1991 and 1990-91;

Janz et al., 1987; Gilbert et al., 1992; Ockene, 1987; Gerbert et al., 1989;

Jones et al., 1993). Several trials demonstrated that physicians and dentists

have an important effect on smokers. Although the success rates varied

and often were modest, if this effect were spread across a community of

physicians and dentists, the impact would be substantial and greater than

any other single strategy (Russell et al., 1979). Although other health care

providers also could be important in helping smokers, there is little research

on which to base an approach to other health professionals.
Smoking and Tobacco Control Monograph No. 6

134

Proponents of physician interventions argue that, in addition to having

frequent contact with both healthy and ill smokers, physicians are ideally

placed to influence smokers to quit because they are respected and trusted

(in a way that cajoling friends or family members may not be) and patients

see their physicians when perceived vulnerability to health threats is highest.

Thus, there is an opportunity for intervention, especially if complaints can

be related to patients’ smoking.

There were preliminary evidence and a strong rationale that the dental

profession also could play an important role in smoking cessation. More

than 85 percent of dentists are general practitioners and thus in family

practice (U.S. Department of Health and Human Services, 1990). Because

of the frequency and continuity of dental care, the relationship between the

dentist and the patient, and often the patient’s family, is well established.

Knowledge about each patient’s social background can be useful during

the intervention process. Regular dental care provides opportunities for

accelerating the prequitting decisionmaking process and for postquitting

followup reinforcement. Patients can be shown tobacco effects in their

own mouths (e.g., gum disease and buildup of plaque on teeth) effects that

are real to them at the moment rather than a more distant threat to their

future health. In addition, dental visits often are longer than medical visits

and can provide quality, face-to-face interactive time that provides many

opportunities to reinforce patients’ reasons for wanting to stop and for

assisting patients with the process (Mecklenburg et al., 1993). In the early

stages of the COMMIT intervention, the major national dental organizations

adopted policies urging members to integrate tobacco intervention services

into their clinical practices. For example, workshops on smoking cessation

were offered at national and State meetings.

Previous studies made it clear that training physicians and dentists

in smoking cessation was not sufficient in and of itself for a practice to

reach the number of smokers necessary to produce a measurable change in

smoking cessation at the 1-year followup (Kottke et al., 1989; Cummings et

al., 1989). A comparison of studies that produced significant changes in

smoking cessation with those that did not pointed to the importance of

the presence of a reminder system in the office routine to cue health care

professionals to address the smoking issue with patients. This meant

motivating and training office staff members to set up office procedures

that would make cessation interventions happen systematically.

There is evidence that the potential for physician and dental professional

effect on smokers goes unrealized. Physicians and dentists believe that they

should advise patients to stop smoking and have taken steps to eliminate

smoking in their offices, but they often feel unprepared to intervene or feel

that their intervention is unlikely to make a difference (Secker-Walker et al.,

1989). In two random statewide surveys of Michigan adults, Anda and

colleagues (1987) reported that fewer than half of smokers indicated that

their physicians had ever asked them to quit. Based on surveys of physicians

in the United States, Ockene and colleagues (1988) reported that, although
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Chapter 9

physicians feel a responsibility to help smokers, fewer than two-thirds advise

all smoking patients to quit. COMMIT baseline surveys of physicians and

dentists indicated that 71 percent of physicians and 51 percent of dentists

said that they routinely asked patients about smoking (Lindsay et al., 1994;

Jones et al., 1993). In comparison, baseline surveys of smokers in the

COMMIT communities indicated that only 39 percent of smokers had been

told to stop smoking by either their physicians or their dentists (Lindsay et al.,

1994). It appears that physicians had intentions to address the smoking issue

with patients but perceived that they were intervening more often than they

actually were. It is important to note that patients’ recall of whether their

physicians did raise the issue with them also will include errors, and therefore,

it could be concluded that there was little congruence between perceptions

of physicians and patients.

CHALLENGES Barriers to physicians’ efficacy have been explored by several

AND BARRIERS surveys. These barriers include restrictions of the time that can

be spent with each patient, remuneration for counseling patients, medical

school training that provides little in prevention skills, low success rates

that are discouraging, and lack of knowledge about how to be more

successful (Anda et al., 1987; Orlandi, 1987; Orleans et al., 1985). There

was evidence that few physicians or dentists went beyond offering advice

to stop and rarely made referrals, handed out self-help literature, set quit

dates, or offered followup (Ockene et al., 1991). Addressing these issues

became an important foundation for the protocol activities planned for

the health care provider channel.

In summary, medical and dental care teams became the focus of the

health care provider channel activities. There was evidence that physician

and dentist offices could change with appropriate motivation, education, and

followup. There also was evidence that patients would appreciate the advice

of these health care professionals and often would respond by trying to stop

smoking. It also was clear that an integrated approach should be promoted

that involved key roles for office staff members and a smoke-free office

environment. It was important to mobilize other health care providers in

the community, but at the time of protocol development, there was no

systematic approach to recommend because of the lack of research among

nurses, pharmacists, and other providers. Therefore, the primary mandate

was to involve all health care providers in planning activities but to focus

training on medical and dental care teams. COMMIT planners anticipated

that activities directed at health care professionals beyond physicians and

dentists would evolve as appropriate according to the needs of individual

communities, but no resources were allocated specifically for this purpose.

GOALS AND PROCESS Based on the understanding of how health care providers

OBJECTIVES FOR HEALTH can influence smoking cessation, the following overall

CARE PROVIDERS goals were set to guide activities in this channel:

• Involvement and leadership: Health care providers will be aware of,

promote, and play an active role in smoking intervention efforts in

the community.
Smoking and Tobacco Control Monograph No. 6

136

• Changes in clinical procedures: Health care providers will regard

smoking cessation advice as the minimal standard of practice; they

will ask all patients whether they smoke; and some providers will go

beyond providing advice.

• Policy changes: All health care facilities will adopt and effectively

implement policies for a smoke-free environment.

• Public response: Smoking patients will more actively seek assistance

from the health care system to stop smoking.

The health care provider channel received considerable emphasis in

COMMIT, which is clearly evident by the range and number of intervention

activities involved (Table 1).

INTERVENTION As a community health project, COMMIT needed “buy-in” and

ACTIVITIES leadership from many members of the health care community.

Participation took many forms. Each community identified

Activities of influential health care professionals who were interested in

“Influentials” smoking as a community health problem. In addition to

their involvement in continuing medical and dental education, these

influentials stimulated community change by promoting smoke-free

health care facilities; supporting new regulations—and the enforcement

of existing regulations—on the sale of tobacco to minors and smoking in

public places, schools, and worksites; and serving as spokespersons with

the media, schools, and community groups. COMMIT organizers invited

known leaders from the physician and dental communities to take

on educational roles and to guide activities in a health care provider

task force, which involved representatives from many other professions.

Most communities involved nurses and pharmacists in these efforts.

Chiropractors were active participants in some communities, and in

others, occupational and public health

nurses played important roles.

Physician and There were three levels of

Dentist Training training activities provided

for medical and dental care teams

designed to achieve the educational

goals and facilitate regular counseling

of all smokers following a standard

protocol. These activities have been

described in detail elsewhere (Lindsay

et al., 1994; Ockene et al., 1990-91;

Manley et al., 1991); they include

a basic program, comprehensive

program, and a more advanced

program to develop skills to teach

others the basic and comprehensive

programs.
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Chapter 9

Table 1

Health care provider activities and process objectives

Process

Cumulative Objectives

Objectives Number Achieved

Activities for Each Community (1988-1992) Completed (%)

Three or More Local Influential Medical Care

Providers Trained 33 providers 74 providers 224

Three or More Local Influential Dental Care

Providers Trained 33 dentists 49 dentists 148

Annually, At Least Three Physicians Will Be

Active on Community Board 132 physicians 211 physicians 160

Annually (from 1989) At Least One Dental Care

Provider Will Be Active on Community Board 33 dentists 93 dentists 282

Annually (from 1989) At Least Three Dental Care

Providers Will Be Active on Community Board 99 providers 124 providers 125

At Least One Physician Attended National Training 11 physicians 23 physicians 209

At Least One Dentist Attended National Training 11 dentists 17 dentists 155

At Least Two Dental Care Providers Attended

National or Regional Training 22 providers 25 providers 114

Basic Training of Physicians 80% 101

Basic Training of Dentist/Dental Care Providers 65% 94

Comprehensive Training of Physicians 25% 100

Comprehensive Training of Dentist/Dental

Care Providers 20% 95

Physician Office Staff Training 30% 200

Dentist Office Staff Training 30% 147

Resource Materials Sent to Physician Offices 90% 111

Resource Materials Sent to Dentist Offices 90% 111

Promotional Materials Sent to Physician Offices 90% 110

Promotional Materials Sent to Dentist Offices 90% 108

Presentations to Physician Offices Not Smoke-Free 60% 147

Presentations to Dentist Offices Not Smoke-Free 60% 138

Presentations to Health Care Facilities Not

Smoke-Free 100% 100

a Average for combined communities.
Smoking and Tobacco Control Monograph No. 6

138

The most advanced level of training was provided centrally for several

individuals from each community and was intended to develop leadership

and educational skills for medical and dental care teams within the

intervention communities. These central training events provided guidelines

for how to deliver the NCI-developed programs (basic and comprehensive

programs) and how to plan community-level educational programs. Basic

(approximately 45 minutes, like that of traditional rounds presentations)

and comprehensive training (a minimum of a 2 1/2-hour workshop) that

included didactic presentations, opportunities for discussion, and planning

as well as skills-building exercises were then made available to all medical

and dental care teams at the community level.

In the 11 COMMIT communities, there were 909 primary care physicians

(mean = 83 per community) and 731 general care dentists (mean = 66 per

community) in the intervention communities. During the 4 years of the

COMMIT intervention, an estimated 80 percent (727) of primary care

physicians and 65 percent (475) of general care dentists attended some

level of training.

WHAT HAPPENED: Representatives from many health professions spent time

SUCCESSFUL as volunteers to provide leadership through the COMMIT

COMPONENTS AND Board and task forces. Most of these volunteers took on a

CHALLENGES 4-year commitment and sustained their involvement with

project. The chairs of the health care provider task forces

Goal 1. Involvement usually were physicians. Participants on this task force

and Leadership provided many different kinds of leadership and support to

the COMMIT intervention. The specific contributions were dependent on

individual interests and skills and the opportunities afforded by the particular

form of activities in each community. The role of the knowledgeable expert

on health was always important for media

events. Radio, television, and newspapers

often looked to the health care provider

leaders for comment on the smoking

issue. The experts participated in talk

shows, wrote articles for newspapers,

and responded to health issues at press

conferences. For example, at the time

of the release of the 1989 U.S. Surgeon

General’s report (U.S. Department of

Health and Human Services, 1989), there

was an opportunity to discuss implications

of the report at the community level.

Physicians, dentists, and other health professionals played leadership roles

in creating smoke-free hospitals and other medical and dental facilities,

submitting articles for the COMMIT Newsletter, and encouraging their

colleagues to prescribe the nicotine patch when it was first introduced.

The importance of this visibility and the sense of local expertise are difficult

to measure but are critical in the diffusion process as a context for promoting

other activities.
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Task Force Issues The protocol’s emphasis on physician and dentist training interfered

with smooth functioning of task forces in several communities. Planning of

training events was time consuming, and committees spent an inordinate

amount of time attempting to deal with physician and dentist reluctance to

attend comprehensive training. At the same time, there was concern that,

even with training, these health care professionals could have only a minimal

effect on patients’ smoking behavior.

Representatives of other health care professions could see an important

role for their groups in COMMIT but did not see sufficient resources allocated

for this purpose. This lack of resources was overcome in many communities

by local initiatives, but the group process suffered because of the resentment

engendered by this perception of inequality and inappropriate attention to

physicians and dentists. At the same time, there was a reluctance among staff

members and other members of the task force to address issues because of the

(1) traditional independence, rank, and respect for physicians and dentists

and (2) possibility of not meeting project objectives.

Some communities reported that the task force lacked a strong,

visionary, and powerful leadership committed to the spirit as well as the

letter of the protocol. Some groups tended to focus on meeting the minimum

requirements of the protocol and did not push their creativity beyond the

minimum. This was unfortunate because a community approach, by its

nature, should be comprehensive and coordinated. For example, physicians

and dentists are in an excellent position to refer smokers to other health

professionals for quit-smoking therapy, and they may work jointly by

providing a prescription for nicotine replacement therapy. In urban

settings, where physicians and dentists often work in combination clinics

and free-standing health centers, such cooperation and interaction among

physicians, dentists, nurses, and other health professionals may be more

readily anticipated than in private office settings that are often more

limited in scope.

Although these limitations within the protocol were a problem for many

communities, there were many examples of pushing beyond the protocol

requirements. For example, the Santa Fe, NM, group developed a videotape

that was circulated among a variety of health professionals. In Paterson, NJ,

a poor urban community with a large minority population, hypertension

nurses and clinicians who conducted onsite high blood pressure screening

programs throughout the community were trained to measure the carbon

monoxide in the expired air of smokers and to counsel smokers, particularly

those with high blood pressure, to quit smoking. In several communities,

“grand rounds” presentations and comprehensive symposia and workshops,

although targeted to physicians and dentists, were extended to include other

professionals. In one instance, a comprehensive training event included

presentations (e.g., a lawyer from the Rose Cipollone case in New Jersey

[Cipollone v. Liggett Group], a presentation on environmental tobacco smoke,

an update on smoking and health issues) of interest to a diverse audience.

By offering Continuing Medical Education (CME) credits for nurses and other
Smoking and Tobacco Control Monograph No. 6

140

Figure 1

Chain of events that enable health professionals to help patients

health professionals, it was possible to attract a varied concerned audience,

boost attendance, and add to the success of the program. Sometimes training

was provided specifically for other health care providers. For example, in

Fitchburg/Leominster, MA, special training was offered to hospital nurses who

wanted to take advantage of the “teachable moment” when smoking patients

in a smoke-free hospital must deal with a period of abstinence.

Goal 2. Changes To ensure that medical and dental care teams put state-of-the-art

in Procedures procedures into place, a chain of events appears necessary (Figure 1).

This is a complex process, and breakdowns at any stage in the

Changes in chain will compromise the overall impact on patient outcomes.

Procedures Require There were challenges to be met and solutions to be found at

a Chain of Events every link of this chain.

Link 1. Physicians and Dentists and Their Office Staffs Must Want To

Learn About and Be Willing To Attend Training for Smoking Cessation. Most

communities were able to

provide basic training to more

than 80 percent of physicians

and 65 percent of dentists.

However, physicians and

dentists were reluctant to

attend comprehensive training.

Some communities made an

effort to schedule the

comprehensive training

at “attractive” times, such

as in association with the

American Cancer Society’s The

Great American Smokeout (GASO) or in conjunction with a New Year’s “Quit

and Win” contest. Some communities expanded the training program to

enhance its attractiveness to other health professionals and to use the

event as an occasion to train and educate members of the COMMIT Board

and task forces, local health department staff members, and other key people

in the community. This ensured strong attendance and enhanced the ability
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Chapter 9

of the entire community to intervene on smoking. However, not all

communities followed this procedure.

In many communities, training events were cancelled because of

insufficient registration. Most task forces spent many meetings considering

how to attract professionals to 2 1/2 hours of training about smoking

cessation. A wide range of incentives was offered, such as CME credits,

dinners in pleasant locations, and in one community, eligibility for a drawing

for a weekend of skiing. Across the COMMIT communities, there were many

variations on optimum timing for training events; virtually every possibility

was explored. In some communities, experts were imported, local opinion

leaders made personal telephone calls, and so forth. In several communities,

the organizers took the program to health care providers in their offices. This

strategy provided an excellent opportunity to meet with office staff members,

help them tailor and “mobilize” the office for intervention on smoking, and

provide necessary followup and continued contact.

The nicotine patch became available early in 1992, during the final

9 months of the 4-year intervention period. Some communities saw the

patch as an opportunity to make a final push to attract health care providers

to training events. Rather than physicians raising the issue of smoking

cessation with their patients, many smokers were asking their physicians

about the patch. The need to know more about how to prescribe the patch

provided a window of opportunity to attract physicians to training. In

addition, drug company representatives were willing to work with COMMIT

staff members to help promote and stage the training events.

However, in some communities the task force did not respond to this

opportunity because it had already reached its objectives and because of

the perception that there was not sufficient demand among physicians and

dentists for more training on smoking cessation. This reality was borne

out in one community that cancelled a workshop as the result of a lack

of registration during the height of the nicotine patch campaigns.

Link 2. The Faculty Members for Training Events Need To Have the Knowledge,

Skills, and Motivation To Deliver Effective Training to Their Colleagues in the

Community. Some communities reported that they felt they needed “an

out-of-town expert” to attract physicians and dentists to a training event.

Others noted that the individuals trained to lead sessions were not available

or tended not to be committed to the need for training or, in some cases,

the content of the recommended training. On the other hand, the local

physician and dentist leaders were important in many communities because

of their role in persuading their colleagues to attend at least one training

event. The local professionals also demonstrated that the recommended

intervention could be implemented within regular practices and were able

to address in a credible manner the practical concerns related to the local

situation.

Most often, the organizers were satisfied with the quality of the

presentations but not with the level of participation. There are advantages
Smoking and Tobacco Control Monograph No. 6

142

to a mix of outside expertise and

inside leadership. In addition, when the

audience at the training events included

nurses, dental hygienists, or other health

care providers, there was not only more

satisfaction in terms of levels of

participation but also more interest and

richness in what the audience brought to

the session.

Link 3. The Education Provided

Must Be Effective Enough To Motivate

Practitioners To Address Smoking More

Systematically and To Provide Enough

Knowledge and Other Resources To Enable

Changes in Procedures. (Note: It was

important that the presentations provided

through COMMIT have an effect on health

professionals’ behavior similar to the effect of the educational programs

tested in the research that provided the basis for the training program

[Wilson et al., 1988; Ockene et al., 1990-91; Gilbert et al., 1992; Kottke et al.,

1989; Cummings et al., 1989].) There was a wide range in the quality of the

educational programs provided. In many instances, staff and participants

reported high-quality presentations. Sometimes the faculty members for

these sessions would present what they were comfortable with rather than

the NCI training package. There was no centralized evaluation of training

sessions; therefore, it is unknown whether specific training events had the

effect on practices that was intended in the original training objectives.

Link 4. After Attending These Training Events, Physicians and Dentists and

Their Office Staff Members Need To Take Action by Setting Up Their Offices To

Facilitate Smoking Control Activities and To Provide Effective Advice and Support

to Their Smoking Patients. It takes motivation, knowledge, and support to

make changes in procedures. It also is necessary to reduce the barriers to

action that exist for health care providers. Health care providers have often

listed lack of reimbursement for smoking cessation advice as an important

barrier to implementing the procedure, and it was found that in communities

where this activity is billable (for example, Bellingham, WA, and Brantford,

Ontario, Canada), knowledge about the use of appropriate billing codes

appeared to be one of the most powerful elements in the training program.

It is not known whether those who attended training changed the way they

dealt with smokers because the observation of changes in practices among

those who attended training was not part of the evaluation process. Project

staff members noted that little change in office systems was evident unless

COMMIT staff members personally visited offices. In other words, training

of office staff members was essential. Instructing physicians and dentists

to make changes in their office systems to help them remember to address

smoking often did not lead to these systems being set up. Even with in-office
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Chapter 9

training, many offices resisted setting up a reminder system but welcomed

the other office support resources that COMMIT offered.

Link 5. Patients Need To Respond to the Advice and Support Provided by These

Health Care Professionals and Successfully Stop Smoking. Even if a health care

professional does everything right, a patient’s ability to successfully stop

smoking depends on many factors. Degree of nicotine dependence; level

of motivation beliefs about the determinants of health, self-confidence,

perceived self-efficacy and locus of control; and presence of a supportive

environment at work, home, and among peers contribute to individuals’

willingness and ability to follow through on their physicians’ advice (U.S.

Department of Health and Human Services, 1989). Previous studies have

shown that stopping smoking is a long-term process and that it is often

important to help smokers move through stages of change prior to their

final successful attempt to stop. For example, helping contented smokers

become discontented with their habit, shortening the number of years that

individuals think about stopping before making their first attempt, helping

relapsers start thinking about quitting again, and supporting ex-smokers are

all potentially important effects of the interventions taught to health care

providers through the training and materials. Baseline and midpoint

surveys of smokers in the COMMIT communities indicated that smokers

do take the advice of their physicians seriously and, if advised, do try to stop

smoking (Ockene et al., 1991 and 1990-91). Final analysis of the COMMIT

surveys of smokers will provide some insight into their responses to these

aspects of the intervention. Unfortunately, specific physician intervention

cannot be linked with patients’ success in stopping smoking.

Goal 3. Leaders in the health care provider community approached by

Policy Changes COMMIT organizers to participate on the Board and task forces

often already had played a key role in advocacy and policy issues change

within their communities prior to the beginning of COMMIT. This history

varied by community, but when these leaders were already in place, it often

gave those communities a headstart on this aspect of COMMIT work.

However, this history may not be an advantage if these individuals have

alienated stakeholders through their previous efforts within the community.

The baseline survey demonstrated that most large health care facilities in

most communities had some smoking control policies in place. However,

the objective to have totally smoke-free hospitals, including their psychiatric

and substance abuse wings, was ambitious. Success with enforcing this strict

definition varied, but overall progress was made in strengthening the number

and comprehensiveness of the policies. Some communities were more

successful than others in this area. Factors that appear to have a positive

impact on large health care facility changes were the influence of State health

department initiatives, leadership provided by State or county medical and

dental societies, interest of key influentials, and influence and momentum

from the national media and professional journals.

At the end of the 4-year intervention, approximately 96 percent of

medical offices and 88 percent of dental offices were totally smoke-free.
Smoking and Tobacco Control Monograph No. 6

144

In the comparison communities, the rates were approximately 91 and

92 percent, respectively (Poland, 1993). The identification of leadership,

staff support for the activities, and the climate created by the overall

intervention may have been key factors in explaining the difference in

physicians’ offices. However, it appears that dentists’ offices were not

similarly influenced.

Goal 4. The baseline surveys for COMMIT indicated that smokers would

Public Response welcome their physicians’ or dentists’ offer to help them stop

smoking. Seventy-one percent of heavy smokers and 81 percent of light-tomoderate smokers said that they would try to stop if directed to do so by

their physicians (Ockene et al., 1990-91). These data contradict what

health professionals have expressed as a concern, that is, that their

patients are not interested in talking about smoking cessation and may

respond in a hostile manner to such overtures. It is important to correct

this misconception. However, it is also important to state that some

approaches by health care providers are more welcome than others.

Poland’s interviews (Ockene et al., in preparation) with patients in

Brantford revealed diversity among patient responses. Some were

immediately defensive when the topic was raised by their physicians;

some indicated the need for more empathy from their physicians; and

others simply wanted to be told to stop. There was a sense among many

patients that physicians had little to offer them to help with smoking

cessation. Health care providers need to know that there are standards

of practice for cessation intervention developed through consensus that

they can learn by attending an appropriate training event. At the same

time, they must listen carefully to their patients to understand the

individual nature of the help each patient

will need.

To encourage patients to become aggressive consumers of stop-smoking

advice, most communities sponsored Ask Your Doc campaigns, often in

association with cessation events such as the GASO, Quit and Win contests,

and making New Year’s resolutions. COMMIT posters throughout the town

and in health care provider offices and public service announcements on

the radio encouraged the public to quit smoking and to ask their health

care providers for help. One community purchased advertising space to

announce which physicians and dentists were particularly interested in

providing smoking cessation counseling. The aggressive marketing of the

nicotine patch early in 1992 led many smokers to ask their physicians

about the patch and smoking cessation, which was an excellent time for

a community to set up an Ask Your Doc campaign as well as to offer

additional training events.

Linkages to Other Many COMMIT activities were promoted through medical and

Activities in the dental offices, and this linkage made an important contribution

Intervention to the comprehensive strategy. In general, office staff members

were receptive to requests to distribute cessation resource guides and self-help

material and to publicize the Smokers’ Network and other magnet events
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such as Quit and Win contests. These activities did not increase their

workload and in some cases provided tools that made their job easier.

Taking advantage of and coordinating with ongoing events in the

community enhanced the effect of the physicians’ and dentists’ interventions.

Not only could practitioners encourage patients to quit smoking, they could

encourage them to use self-help materials distributed in association with

a community Quit and Win contest and use the contest as an occasion to

select a quit date. Indeed, one community conducted a competition among

physicians’ offices, with the prize a color television set for the winner’s waiting

room. The winning office enrolled 150 smokers in the Quit and Win contest.

In general, a good response can be expected from medical and dental

office staff members if the focus is on enhancing what they already feel they

need to do and making that easier for them. Organizers can expect a less

enthusiastic response when a request involves any extra work or does not fit

within the regular office routine. A key factor is how an office is set up to

provide resources to patients. An office with mechanisms in place will be

much more receptive than one that is disorganized with regard to this aspect

of its work. Sometimes providing the rack on which materials can be

distributed will persuade some offices to distribute antismoking materials

to patients.

The Nicotine Patch— The availability of the nicotine patch provided a focal point

An Opportunity for linkages among several task forces and activities. Several

for Linkages communities, such as Utica, NY, built a campaign around the

availability of the nicotine patch. For example, media attention given to the

patch encouraged the public to ask questions of COMMIT offices and health

care providers. This, in turn, provided an opportunity to distribute cessation

resources and hold training events for health care providers. On the other

hand, several communities were reluctant to become involved with the patch

promotion, particularly if it meant affiliation with one pharmaceutical

company rather than a more generic approach.

THE FUTURE— The first and most important recommendation is to approach

RECOMMENDATIONS the health care provider community as a whole and develop

a team approach to how they can best be part of a communitywide program.

Allow the leadership to emerge from the group without preconceptions about

the professional affiliation of the leadership. Physician and dentist trainings

are valuable tools and are an important part of the approach, but they should

be part of an overall strategy for all health care providers.

Remember that physicians and dentists are members of a community

as well as health care professionals. Include them on working groups and

task forces responsible for formulating local policy, whether the policy

concerns smoke-free hospitals or a communitywide ordinance banning

sales of cigarettes to underage youth. Physicians and dentists also are

members of special societies that can play leadership roles in the formulation

of policy and legislation. Call on the lung association, cancer society, or

heart association local affiliates for guidance and tap the resources of the
Smoking and Tobacco Control Monograph No. 6

146

State or local medical and dental societies. Local boards of health, health

departments, and hospital associations also have an interest in promoting

sound policy for the control of tobacco. Call on them. The more key people

included in the development of the policy in the first place, the more support

will be generated for the policy later.

Policies and practices in individual clinics can create a nonsmoking

environment that can affect smokers. Creating no-smoking offices with no

ashtrays, signs posted, literature available, and support for staff training is

part of a comprehensive approach to tobacco control.

To promote changes in practices and policies in physicians’ and dentists’

offices requires applying everything known about helping people and

communities change behavior. Just as smoking cessation is a process,

integration of smoking intervention in an office is a long-term process.

One strategy is almost never enough to bring about changes. Some

professionals will need motivation; some will need information; others

will be ready to act but need the skills to implement new procedures

(Prochaska and DiClemente, 1983).

Creativity and good marketing strategies are essential. If physicians or

dentists will not attend training programs, it is possible to use other means

to reach them. Bring pizza for office staff members and show them a

videotape during lunch hours on how to help smokers stop smoking, set

up a wall rack with self-help quit-smoking material, present the physician

or dentist with the “Heart Rx Kit” from the American Heart Association,

and review the material on smoking cessation. Revisit the office, bringing

more materials and supplies and using each visit as an occasion to encourage

intervention on smoking. Involve the office in the GASO activities, Quit

and Win contests, and other community events. The physician or dentist

may never become as personally involved in the smoking issue as is wished,

but small changes in procedures among many health professionals are

important outcomes. People do not take action unless they feel that they

should and that what they do will make a difference. In addition, practical

issues that make the actions feasible also will determine whether change

happens.

During the COMMIT intervention, the acceptance by the medical

profession regarding smoking as a professional responsibility was different

from that by the dental profession. Randomized controlled trials had

demonstrated the efficacy of physicians’ interventions, and the professional

literature urged the medical profession to take action on the smoking issue.

Lomas and colleagues (1991), in their studies of the implementation of

consensus guidelines, concluded that it takes approximately 7 years for an

accepted change in procedure to be integrated by the majority of physicians.

Dentistry was many years behind medicine in recognizing the relationship

between smoking and oral disease. The connection has been made stronger

in the past 5 years with an increase in the number of published research

articles and literature reviews as well as the establishment of new standards
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in dental education curricula. Although substantial action was taken at the

national level to promote the role of the dental care team in smoking

control, it appears that at the community level the profession was not yet

ready to accept this responsibility.

Although the medical profession appeared ready to accept smoking

control as part of regular practice, there were many factors that determined

whether physicians learned how to implement it effectively and whether

they put what they learned into practice. Attracting medical and dental

care teams to the COMMIT training events was challenging in most of the

COMMIT communities, and in some

communities, it was almost impossible.

Baseline surveys showed that physicians felt

adequately prepared to help their patients

stop smoking, yet they were not doing

things known to be part of an effective

approach (Lindsay et al., 1994). This lack

of perceived need to know could have been

a block to attending training. Physicians

needed to know that there was more that they could do within the confines

of their regular practices to help patients stop smoking. Those factors should

be considered in promoting training to community health care providers.

The CME literature shows that information exchange presented in a

regular lecture format affects knowledge and attitudes but is rarely sufficient

to bring about any change in procedures. More experiential learning

strategies, such as discussion and practice with followup in the office and

supplemented by techniques to cue or reinforce the procedure, are critical

to integrating changes into practice (Davis et al., 1992). Basic training (less

than 1 hour) was primarily a motivational tool to stimulate involvement.

Seventy-five percent of physicians and eighty percent of dentists in many

COMMIT communities received no training beyond the basic session. It is

likely that almost no changes in procedures followed these training events.

(Analysis and reporting of the postintervention survey is under way.)

However, it is possible that basic training raised awareness and motivation

sufficiently that physicians and dentists started to pay more attention to

what resources were available and began to mention smoking more

frequently to their patients. It is also possible that after attending basic

training, many physicians and dentists perceived no need to attend

comprehensive training.

The quality of the comprehensive training, which included

demonstration and practice opportunities, varied across the communities.

Some health care providers trained to lead these sessions were highly

committed and good educators. Others had strengths as community leaders

but, in some cases, were not strong advocates of the COMMIT activities that

they were representing. It was often difficult for dedicated leaders to remain

enthusiastic and strong proponents of comprehensive training when they

had such difficulty in attracting their colleagues to sessions.
Smoking and Tobacco Control Monograph No. 6

148

Cessation counseling can be a frustrating process when a 15-percent

quit rate is considered success in primary care settings. It may be unrealistic

to expect health care provider leaders in the community to remain dedicated

to this issue when there are many competing issues. Although it made

sense from a cost perspective to train local health care providers to lead the

educational activities, the presentations may have been more effective when

a local leader was teamed with a cessation expert brought in for the training

event. However, this strategy also met with mixed success. It is possible that

by the time a community offered a session with an expert, those who had

an interest in smoking cessation felt that they had already given this issue

sufficient time.

COMMIT staff members across the study attempted many format

variations in marketing, timing, speakers, location, and incentives to attract

medical and dental care teams to training. There appears to be no ideal

format. Because it is so difficult to attract health professionals to training

session that is longer than 1 1/2 hours, it may be better to divide the program

into bite-size pieces with realistic goals in each session for making changes

in health care providers’ interactions with smokers. However, it may be

unrealistic to think that health care providers will attend more than one

session. Another approach, when time is short, is to ensure that the audience

is homogeneous in terms of its learning needs and then focus the approach

on those needs. For example, if the participants are not convinced that

they should bother with smoking cessation in their practices, presenters

can provide a motivational approach that will move them closer to action.

If audience members are ready to learn what to do, they should be told

clearly and convincingly what they can do. This type of approach requires

strong and versatile educational leaders. Therefore, ongoing training and

support for these leaders are important.

The integrated approach to practitioners’ offices taken by the COMMIT

protocol appears to have been successful. COMMIT staff members reported

good results when physician or dentist training was followed by a visit

to offices to reinforce the training, train office staff, and introduce other

COMMIT activities. This approach was labor intensive, and those who

consider adopting it will need to consider its costs and benefits.

It is important to consider the large systemic forces that direct change

in professional practices. For the medical profession, procedures that are

perceived to be required for competency and demands from patients are

two of these important forces (Fox, 1989). Changes at the level of policy

within the professions were occurring before and continued throughout

the COMMIT intervention period. In the medical profession, these changes

were under way early in the study; however, change occurred at a much

later stage in the dental care profession. The pacing of changes in professional

standards of practice was beyond the control of this intervention. On the

other hand, it was possible to promote patient demand. The attention given

to Ask Your Doc campaigns and the availability of the nicotine patch

increased this demand. The analysis of the final survey of smokers will

demonstrate the effect of these approaches.
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CONCLUSIONS Support is growing within both the medical and dental professions

to make smoking cessation a part of competent practice. This support from

the professions is critical, and as more health care professionals perceive

endorsement and support of this work as a standard of competent practice,

there should be an increased openness to opportunities to learn more about

smoking cessation interventions.

Dental and dental hygiene schools are adding tobacco issues to their

undergraduate curricula and continuing education programs. Recently

revised curriculum guidelines for all professional schools have incorporated

tobacco topics. In 1993, the American Association of Dental Schools

established a Tobacco-Free Initiatives Special Interest Group so that educators

could share experiences and accelerate the process of developing student

knowledge, skills, and interest in tobacco intervention services. In addition,

the importance of the dental profession is recognized in fulfilling the national

health objectives for the 1990’s; tobacco objective 3.16 (U.S. Department of

Health and Human Services, 1991) states: “Increase to at least 75 percent

the proportion of primary care and oral health care providers who routinely

advise cessation and provide assistance and follow-up for all of their tobaccousing patients.”

The medical profession has established smoking cessation as an issue

clearly within the jurisdiction of primary care providers as well as of many

specialists. Indicative of this support is the recent dedication of a full issue

of the Journal of the American Medical Association (1994) to the subject of

smoking. Surveys indicated that physicians and dentists now clearly perceive

smoking as a problem they should address. However, they are not yet

applying state-of-the-art interventions in their practices. COMMIT offered

training to medical and dental care teams who did not perceive the need to

attend training on smoking cessation or who felt that the many demands on

their continuing education time prevented making smoking a high priority.

It is likely that there will be an increasing readiness to attend training as

these professionals see this issue as a part of a competent practice and as

their patients increasingly ask them for help.

Through COMMIT, many things have been learned about how to

approach the medical and dental professions. It is time now to expand

this learning through work with all health professionals in communities.

An integrated approach to planning and implementing a communitywide

approach to smoking cessation will create congruence and synergy among

providers that should help more patients stop smoking.

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Cohen, S.J., Stookey, G.K., Katz, B.P., Drook, C.A.,

Christen, A.G. Helping smokers quit:

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152, 1989b.

COMMIT Research Group. Community Intervention

Trial for Smoking Cessation (COMMIT): Summary

of design and intervention. Journal of the National

Cancer Institute 83(22): 1620-1628, 1991.

Cummings, S., Coates, T., Richard, R. Training

physicians in counseling about smoking cessation:

A randomized trial of the “Quit for Life” program.

Annals of Internal Medicine 110: 640-647, 1989.

Davis, D.A., Thomson, M.A., Oxman, A.D., Haynes, B.

Evidence for the effectiveness of CME: A review of

50 randomized controlled trials. Journal of the

American Medical Association 268(9): 1111-1117,

1992.

Fox, R.D. (Editor). Change and Learning in the Lives of

Physicians. New York: Praeger, 1989.

Gerbert, B., Coates, T., Zahnd, E., Richard, R.J.,

Cummings, S.R. Dentists as smoking cessation

counselors. Journal of the American Dental

Association 118(1): 29-32, 1989.

Gilbert, J.R., Wilson, D.M., Singer, J.S., Lindsay, E.A.,

Taylor, D.W., Willms, D., Best, J.A. A family

physician smoking cessation program: An

evaluation of the role of follow-up visits. American

Journal of Preventive Medicine 8(2): 91-95, 1992.

Hayward, R.A., Meetz, H.K., Shapiro, M.F., Freeman,

H.E. Utilization of dental services: 1986 patterns

and trends. Journal of Public Health Dentistry 49(3):

147-152, 1989.

Janz, N.K., Becker, M.H., Kirscht, J.P., Eraker, S.A.,

Billi, J.E., Woolliscroft, J.O. Evaluation of a

minimal-contact smoking cessation intervention

in an outpatient setting. American Journal of Public

Health 77: 849-851, 1987.

Jones, R.B., Pomrehn, P.R., Mecklenburg, R.E.,

Lindsay, E.A., Manley, M., Ockene, J.K. The

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and attitudes. Journal of the American Dental

Association 124(9): 92-104, 1993.

Journal of the American Medical Association 271(8):

569-636, 1994.

Kottke, T.E., Brekke, M.L., Solberg, L.I., Hughes, J.R.

A randomized trial to increase smoking intervention by physicians. Journal of the American

Medical Association 261(14): 2101-2106, 1989.

Lichtenstein, E., Wallack, L., Pechacek, T.F.

Introduction to the Community Intervention

Trial for Smoking Cessation (COMMIT).

International Quarterly of Community Health

Education 11(3): 173-185, 1990-91.

Lindsay, E.A., Ockene, J.K., Hymowitz, N., Giffen, C.,

Berger, L., Pomrehn, P. Physicians and smoking

cessation: A survey of office procedures and

practices in the Community Intervention Trial for

Smoking Cessation. Archives of Family Medicine

3(4): 341-348, 1994.

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Vayda, E., Singer, J. Opinion leaders versus audit

and feedback to implement practice guidelines.

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2202-2207, 1991.

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Shopland, D. Clinical interventions in tobacco

control: A National Cancer Institute training

program for physicians. Journal of the American

Medical Association 266(22): 3172-3173, 1991.

Mecklenburg, R.E., Christen, A.G., Gerbert, B., Gift,

H.C., Glynn, T.J., Jones, R.B., Lindsay, E., Manley,

M.W., Severson, H. How To Help Your Patients Stop

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and Human Services, Public Health Service,

National Institutes of Health, 1993.

Ockene, J., Lindsay, E.A., Manley, M. Tobacco

control activities of primary care physicians in

the Community Intervention Trial for Smoking

Cessation, in preparation.

Ockene, J.K. Physician-delivered intervention for

smoking cessation: Strategies for increasing

effectiveness. Preventive Medicine 16: 723-737,

1987.

Ockene, J.K., Aney, J., Goldberg, R.J., Klar, J.M.,

Williams, J.W. A survey of Massachusetts

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Penelope, P.S., Hosmer, D., Quirk, M., Kalan, K.

Increasing the efficacy of physician-delivered

smoking intervention: A randomized clinical trial.

Journal of General Internal Medicine 6: 1-8, 1991.

Ockene, J.K., Lindsay, E., Berger, L., Hymowitz, N.

Health care providers as key change agents in

the Community Intervention Trial for Smoking

Cessation (COMMIT). International Quarterly of

Community Health Education 11(3): 223-237,

1990-91.
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Orlandi, M.A. Promoting health and preventing

disease in health care settings: An analysis of

barriers. Preventive Medicine 16: 119-130, 1987.

Orleans, C.T., George, L.K., Houpt, J.L., Brodie, K.H.

Health promotion in primary care: A survey of

U.S. family practitioners. Preventive Medicine 14:

636-647, 1985.

Poland, B. “Concept and Practice in Community

Mobilization for Health: A Qualitative Evaluation

of the Brantford COMMIT Smoking Cessation

Intervention Trial.” Unpublished doctoral

disseration, McMaster University, 1993. 402 pp.

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processes of self-change of smoking: Toward an

integrative model of change. Journal of Consulting

and Clinical Psychology 51(3): 390-395, 1983.

Russell, M.A., Wilson, C., Taylor, C., Baker, C.D.

The effect of general practitioners’ advice against

smoking. British Medical Journal 2: 231-235, 1979.

Secker-Walker, R.H., Solomon, L.J., Hill, H.C.

A statewide survey of dentists’ smoking cessation

advice. Journal of the American Dental Association

118(1): 37-40, 1989.

U.S. Department of Health and Human Services.

Reducing the Health Consequences of Smoking:

25 Years of Progress. A Report of the Surgeon General,

1989. DHHS Publication No. (CDC) 89-8411.

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for Disease Control, Center for Chronic Disease

Prevention and Health Promotion, Office

on Smoking and Health, 1989.

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Status of Health Personnel in the United States. DHHS

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U.S. Department of Health and Human Services.

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Disease Prevention Objectives. DHHS Publication

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Lindsay, E.A., Willms, D.G., Singer, J. A

randomized trial of a family physician

intervention for smoking cessation. Journal

of the American Medical Association 260(11):

1570-1574, 1988.

AUTHORS

Elizabeth A. Lindsay,Ph.D.

Associate Professor

Community Health Research Unit

Department of Epidemiology and

Community Medicine

University of Ottawa

Ottawa, Ontario K1H 8M5

CANADA

Norman Hymowitz,Ph.D.

Professor of Clinical Psychiatry

Department of Psychiatry and Mental

Health Services

University of Medicine and Dentistry of

New Jersey Medical School

Newark, NJ 07103
Smoking and Tobacco Control Monograph No. 6

152

Robert E. Mecklenburg,D.D.S.,M.P.H.

Oral Health Coordinator

R.O.W. Sciences, Inc.

Suite 400

1700 Research Boulevard

Rockville, MD 20850-3142

Linda C. Churchill,M.S.

Project Director

Department of Preventive and Behavioral

Medicine

University of Massachusetts Medical School

Room S-7, 746

55 Lake Avenue North

Worcester, MA 01655

Blake Poland,Ph.D.

Scientist

Social Evaluation and Research Department

Addiction Research Foundation

33 Russell Street

Toronto, Ontario M5S 2S1

CANADA
153

Chapter 10

Promoting Community Tobacco Control

Through Worksites

Linda Nettekoven, Russell E. Glasgow, Robert H. Shipley, A.J. Roy Cameron,

Lesa T. Dalton, Aleena Erickson, Sharon Ann Rankins-Burd, Sandy Tosti,

Glorian Sorensen, and Kitty K. Corbett

INTRODUCTION As the move toward health care reform focuses increasing attention

on health promotion and disease prevention, the worksite becomes an

increasingly attractive setting from which to influence health behaviors,

such as tobacco use. Project designers identified worksites as one of four

major “channels” for promoting smoking cessation within the Community

Intervention Trial for Smoking Cessation (COMMIT). Because 70 percent

of adults between ages 18 and 65 are employed (U.S. Bureau of the Census,

1986), worksites can provide access to many community residents who may

not be reached through other means, including low-income and minority

groups (Nathan, 1984; Shipley et al., 1988; Terborg and Glasgow, in press).

Interest in worksite health promotion continues to increase; national surveys

of a random sample of private sector worksites with 50 or more employees

indicated that 65.5 percent of worksites surveyed offered at least one type

of health promotion activity (Fielding and Piserchia, 1989), and by 1992

this figure had increased to 81 percent (U.S. Public Health Service, 1993).

Worksite health promotion often is viewed as a way to reduce company

and employee health care expenditures through the provision of convenient,

free or low-cost prevention and early detection interventions. Proponents

also credit worksite health promotion efforts with improving labormanagement relations, increasing employee productivity, decreasing

absenteeism resulting from illness and injury, and reducing employee

turnover and insurance costs (Glasgow et al., 1990; Sorensen et al., 1990).

Previous research suggests that worksites can offer special opportunities

for the promotion and support of smoking cessation efforts, using both

policies and programs. Multiple types of intervention can be offered

repeatedly over time in worksites. By such continual contact, smokers

at varying stages in the process of change, including those not yet

contemplating change as well as those trying to quit, may be motivated

to quit and to sustain cessation (Abrams et al., 1994; Rossi et al., 1988).

This contact may include the promotion of communitywide cessation

events or activities sponsored by other agencies.

Changes in worksite norms and in the social environment, such as

those that may be fostered by no-smoking policies, can provide critical

support for cessation and its maintenance (Sorensen et al., 1986). The

percentage of companies with restrictive smoking policies has increased

steadily in recent years. Whereas 27 percent of private worksites with
Smoking and Tobacco Control Monograph No. 6

154

50 or more employees had policies that either banned or severely restricted

smoking in 1985, 59 percent had such policies by 1992 (U.S. Public Health

Service, 1993).

Those conducting reviews of the worksite health promotion literature

(Fielding, 1984; Terborg and Glasgow, in press), including a meta-analysis of

worksite smoking cessation studies, generally have concluded that worksite

smoking cessation programs have been efficacious (Fisher et al., 1990) and

cost-effective (Warner et al., 1988). However, a recent literature review

concludes that positive effects are not always found in more highly controlled

studies and that outcomes often vary across worksites (Jeffrey et al., 1993;

Terborg and Glasgow, in press).

This chapter reviews the experiences of the 11 COMMIT intervention

communities in implementing worksite-based activities and describes

the following aspects of the workplace intervention effort: (1) goals for

worksites and the assessment methods used to measure progress in this

channel; (2) methods for planning worksite interventions; (3) intervention

activities delivered to worksites throughout the trial, along with examples

of the successes and challenges that accompanied the implementation

process; (4) means used to deliver the intervention, including tailoring

protocol activities to fit the cultures of the diverse localities and the role

of staff, volunteers, and community structures; and (5) lessons learned from

activities that seemed to work and those that did not, along with suggestions

for approaches that might prove effective in other community settings.

A more detailed description of the evaluation methods and results of the

COMMIT worksite intervention can be found elsewhere (Sorensen et al.,

1990-91; Glasgow et al., submitted for publication).

GOALS, ACTIVITIES, The COMMIT worksite intervention was designed to support

AND PROCESS smoking cessation by changing social norms both in individual

OBJECTIVES worksites and in the overall business community. The emphasis

was on reaching many community residents through repeated interventions

that together would affect social norms as well as change individual behavior.

Thus, the COMMIT worksite plan was guided by four intervention goals.

1. increase smoking cessation among workers who smoke;

2. produce changes in worksite norms to support no-smoking;

3. increase adoption and effective implementation of comprehensive

worksite nonsmoking policies; and

4. enhance support for no-smoking in the business and labor sectors of

the community.

The effectiveness of intervention efforts was measured by the extent to

which specified impact objectives were achieved. The impact objectives

related to the goals listed above for the worksite plan are presented in Table 1.

Achievement of these objectives was assessed through surveys of

randomly selected community residents—the evaluation cohort (described
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Chapter 10

Table 1

Impact objectives, by 1993

1. Seventy percent of employed smokers will report that their worksites

ban smoking completely or restrict smoking to designated areas.

2. Fifty percent of heavy smokers will report feeling pressure from coworkers

to quit smoking.

3. Eight percent of heavy smokers will report having participated in stopsmoking programs or contests/lotteries to promote cessation at their

workplace.

4. Seventy percent of targeted worksites will report offering, within the

past 12 months, lectures, classes, materials, or other programs to help

or encourage employees to quit smoking.

Source: Sorensen et al., 1990-91.

in Chapter 3)—and worksite respondents. In each community, measurement

(intervention and comparison) at the worksite level was assessed with a

survey of 30 worksites (or a census, whichever measurement number was

smaller) in each of three size strata (50 to 99, 100 to 249, and 250 or more

employees). Worksite respondents were asked about the level of company

participation in several different types of smoking control activities as well

as worksite characteristics potentially associated with different smoking

control activities. These assessment procedures, described in more detail

by Mattson and coworkers (1990-91)

and Glasgow and colleagues (1992), are

modeled after those used in previous

national surveys of worksites (Fielding,

1991; U.S. Public Health Service, 1993).

To assist COMMIT project

staff members and community

volunteers in delivering a comparable

intervention across all 11 communities,

an intervention protocol was developed

by the COMMIT Steering Committee.

Additional information on the COMMIT

protocol is contained in Chapter 4.

For each of the nine mandatory

worksite intervention activities listed in

Table 2 and discussed later in this chapter, the protocol established standard

process objectives and timelines to be met by all intervention communities

when conducting that activity.

The process objectives established the minimum level of activities to

be conducted annually in each intervention community. Compliance with

these objectives was monitored by Program Records, a computerized database

recordkeeping system (Corbett et al., 1990-91).
Smoking and Tobacco Control Monograph No. 6

156

Table 2

Worksite activities and process objectives

Cumulative Process

Objectives Number Objectives

Activities for Each Community (1988-1992) Completed Achieved (%)

Presentation to Business Groups 88 presentations 88 presentations 100

Annual Workshop for Worksites: 44 workshops 47 workshops 107

Large worksites 30% 133

Small worksites 20% 105

Compile Resource List for

Smoke-Free Worksites All communities 11 guides 92

Distribute Resource List

to Worksites Annually 90% 92

Policy Consultations to:

Large worksites 20% 145

Small worksites 165 sites 150 sites 91

Promotional Activities to:

Large worksites 70% 140

Small worksites 50% 180

Distribute Incentive Guidebooks to:

Large worksites 80% 118

Small worksites 50% 194

Three Between-Worksite Competitions 33 competitions 33 competitions 100

Distribute Self-Help Cessation

Materials to:

Large worksites 50% 180

Small worksites 20% 450

Promote Smokers’ Network in:

Large worksites 85% 113

Small worksites 20% 460

a Average for combined communities.

PLANNING To become familiar with the needs, resources, and organizational

WORKSITE structures present in both the intervention and comparison

INTERVENTIONS communities, project staff members conducted an extensive

community analysis in all COMMIT communities (see Chapter 5). Using

nonreactive approaches, qualitative and quantitative sources, and discussion

with key informants, staff members gathered information to help them

begin to understand the two types of communities.

For the worksite channel, this community analysis served several

functions. The analysis identified key community players and major

employers, including business leaders, union representatives, and providers
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Chapter 10

of smoking cessation programs (commercial as well as nonprofit). Many of

these people were eventually invited to serve on the community Board or

the Worksites and Organizations Task Force. To aid in program planning,

information was compiled on community smoking policies and cessation

resources available to worksites, and gaps in these services were identified.

An attempt also was made to identify “early adopter” worksites that already

had implemented exemplary policies or programs so that they could serve

as role models for other workplaces.

The community analysis drew on a variety of archival information

sources. These included lists of worksites and their characteristics (e.g., size,

type of industry) from the chamber of commerce, State business census, or

local business license records; newspapers and other public documents

reviewing community and business concerns; and annual reports from

local businesses and business organizations. Interviews with community

representatives provided a more indepth picture, including information

on the business and labor community’s culture and history. For example,

the following questions were asked.

• Do worksites have a history of promoting smoking cessation or other

healthy behaviors?

• How extensively have the media covered worksite health concerns?

• Which health issues are of highest priority to the business and labor

communities?

• What other community issues are of great concern to employers and

workers?

• Are there regular meetings, networks, or other community structures

that bring together representatives of various worksites?

In this way the community analysis identified potential barriers and

opportunities, highlighted issues likely to compete with tobacco control as a

priority for this sector of the community, and provided an assessment of the

capability and readiness of local worksites to address the tobacco issue. The

report also suggested ways to begin tailoring the intervention protocol to fit

the unique configuration of needs and resources within each intervention

community.

In Yonkers, NY, for example, the analysis report accurately anticipated

that the many small worksites would require special strategies for

implementing the large-scale protocol activities, such as the annual

smoking policy workshops, between-worksite competitions, and recruitment

for magnet events. However, several COMMIT sites reported that the

community analysis was not totally reliable in identifying the business

community’s key players. In some communities the analysis overestimated

the activity level of one or more of the voluntary health agencies; in Medford/

Ashland, OR, the status (funding levels and staffing) of the voluntary agencies

changed so rapidly that this portion of the report had to be updated before
Smoking and Tobacco Control Monograph No. 6

158

the Community Planning Group could begin its work. Some of these gaps

and inconsistencies were immediately apparent to community volunteers

who joined the project, and modifications were made; others emerged much

later as activities were being planned and implemented.

INTERVENTION Worksites were viewed as a key natural channel for reaching

ACTIVITIES less motivated or less educated smokers who might not

AND THEIR volunteer for or be reached by other project activities. The

IMPLEMENTATION worksite intervention offered a comprehensive, coordinated

set of tobacco control activities designed to build on each other over time

and to support the momentum being created in other sectors of the

community. Worksite activities were based on a three-faceted approach:

promotion of restrictive smoking policies, use of motivational and incentive

techniques to encourage participation and cessation, and provision and

promotion of smoking cessation and maintenance resources. A description of

the activities and examples that illustrate the experiences of communities in

implementing each activity are given below.

Decisions about which worksites to target in a communitywide initiative

like COMMIT are often influenced by two considerations: (1) how to achieve

the maximum intervention effect (in this case, impact on tobacco use) and

(2) how to make the best use of the limited staff time and other project

resources that are available for this purpose. After weighing these concerns,

project designers came to view larger worksites as a more efficient setting

for the delivery of worksite intervention activities. Worksites were categorized

according to size, and the protocol defined which worksites would be

targeted in each community. Large targeted worksites were defined as

those employing 100 or more persons, and initially, small targeted worksites

included only those that employed 50 to 99 persons. These categories

included all worksites in which at least 30 percent of the work force lived

within the boundaries of the intervention community. In some communities

this meant that additional worksites located in proximity to, but outside of,

intervention community boundaries were also targeted for intervention.

However, this emphasis changed somewhat during the second half of the

intervention.

The initial COMMIT evaluation cohort survey indicated that 60 percent

of smokers were employed in workplaces with fewer than 100 employees;

37.6 percent of smokers in the intervention communities worked in settings

with fewer than 25 employees, and another 22.4 percent were employed in

companies with between 25 and 99 workers (Glasgow et al., 1992). After the

first 2 years of the intervention, the protocol was modified, and COMMIT

sites were encouraged to expand their efforts to include smaller worksites

(those employing 25 to 49 people) in some workplace intervention activities.

Promotion Adopting policies to restrict or ban smoking was the type of

of Worksite smoking control activity undertaken at worksites according to

Smoking Policies recent national studies (Fielding and Piserchia, 1989; U.S. Public

Health Service, 1993). In addition, some workplaces removed cigarette

vending machines from their premises.
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Chapter 10

Smoking control policies are important for several reasons. First, their

primary purpose is to protect employees from exposure to environmental

tobacco smoke (ETS). Second, they serve an educational function, sending

messages to smokers about the seriousness of the health risks involved in

smoking and the impact their smoking may have on others. Third,

restrictive policies create a no-smoking environment that may stimulate

quit attempts and increase opportunities for long-term cessation by reducing

exposure to smoking situations.

Some recent studies have reported an increase in smoking cessation

following a worksite’s adoption of a restrictive smoking policy (Emont and

Cummings, 1990; Millar, 1988; Sorensen et al., 1989; Stave and Jackson,

1991), although others have found no effect on cessation but have reported

a decrease in the number of cigarettes smoked at work (Biener et al., 1989;

Borland et al., 1990; Petersen et al., 1988; Rosenstock et al., 1986). Adopting

a restrictive smoking policy also may stimulate interest in smoking cessation

classes (Martin, 1988; Sorensen et al., 1989; U.S. Department of Health and

Human Services, 1986) and may support norms that promote cessation and

the maintenance of a smoke-free lifestyle (Sorensen and Pechacek, 1989).

Within the COMMIT worksite effort, four intervention activities

promoted the adoption of restrictive smoking policies: (1) smoking policy

presentations; (2) annual smoking policy workshops; (3) onsite smoking

policy consultations; and (4) development of a Worksite Smoking Policy

Network Guide. When writing their final reports, all intervention

communities pointed to an increase in the number of worksites and

restaurants with restrictive smoking policies as one of their major successes.

However, many intervention sites also reported some difficulty in achieving

one or more of the following smoking policy objectives.

Smoking Policy To begin to raise awareness of smoking policy issues within the

Presentations business community, staff members and volunteers made presentations

on health of at least 15 minutes to

worksite groups, such as chambers

of commerce or other business groups,

during their regular meetings.

Presentations focused on effects of

ETS, health and legal issues pertaining

to smoking policies, national and local

trends, and policy and program options.

During the first intervention year, a

minimum of one presentation was

given in each COMMIT community;

in subsequent years, at least two

presentations were made annually.

The underlying strategy was for

COMMIT to join with the groups that the

project hoped to reach and to become

part of the agenda in their usual settings
Smoking and Tobacco Control Monograph No. 6

160

before attempting to involve them in COMMIT activities. The interest of

local business groups in tobacco control information varied over time across

COMMIT sites. Nearly two-thirds of COMMIT intervention communities

(64 percent) met the process objective for this activity, but some reported

difficulty in involving business groups in worksite efforts. Many local

COMMIT organizations became card-carrying members of one or more of

these business groups during the course of the project. Some communities,

Paterson, NJ, for example, enjoyed a highly supportive relationship with

the local chamber of commerce. At least one of Paterson’s annual awards

dinners to honor COMMIT project volunteers was held in conjunction

with a chamber meeting.

Finding an active member who was also concerned about the tobacco

issue seemed central to success in this area. Despite resistance from a key

chamber officer, Fitchburg/Leominster was able to develop strong ties with

its chamber group by building a strong relationship with an active member

who had recently lost a relative to lung cancer and became a COMMIT

volunteer. On the other hand, without a key contact, Medford/Ashland

struggled for 4 years to arrange for space on a chamber meeting agenda,

despite being a chamber member in good standing from the beginning of

the project. Because staff members could not arrange to give a presentation

to the full chamber membership until near the end of the intervention,

they chose an alternative strategy of becoming active in the early morning

“Chamber Greeters’ Group,” which allowed them to informally publicize

project activities to those members who attended these drop-in, getacquainted sessions.

Annual Smoking Annual smoking policy workshops were conducted in each

Policy Workshops intervention community. Workshop agendas included information

on smoking as a public health issue, ETS, laws and regulations, and policy

options and recommended procedures for implementing new policies.

Smoking policy workshop guides, one each for large and small worksites,

were developed for COMMIT to assist project staff members and community

representatives in planning workshops (Institute for the Study of Smoking

Behavior and Policy, 1989a and 1989b). These guides and COMMIT

promotional efforts emphasized the advantages of smoke-free facilities

over segregated smoking arrangements that do not completely eliminate

exposure to ETS.

COMMIT communities adopted different strategies in presenting the

annual workshop, which was to run 2 to 3 hours. For example, some

communities elected to offer a workshop in conjunction with another

worksite issue, such as alcohol and drug education. Others targeted one

of their annual workshops toward unions or small businesses. In many

COMMIT sites, the workshops were cosponsored by local chapters of the

American Lung Association, American Cancer Society, or local chamber

of commerce. Brantford, Ontario, Canada, capitalized on the business

community’s interest in “sick building syndrome” by sponsoring a workshop

on that topic. It became evident to participants that the major source of
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Chapter 10

pollution in buildings where smoking occurred was ETS. This served to

educate those attending about the health risks of ETS and the need for

restrictive smoking policies.

There was general agreement among staff members that the workshops

were well designed and beneficial for those attending. Although most

communities were successful in reaching the required number of targeted

worksites, worksite smoking policy workshops received mixed reviews from

staff and volunteers: Some found them to be well attended and well received;

others described them as costly in terms of staff effort and project dollars,

with a low response rate from the community. The investment of significant

project resources to bring in outside experts did not necessarily lead to

increased attendance. During the early phases of the intervention, only

a few COMMIT sites exceeded their participation target levels. However,

a few sites canceled workshops because of low registration despite extensive

publicity and preparation.

Smoking policy workshop attendance appeared to be linked to three

factors: (1) environmental or external support for policy change, (2) number

of larger worksites in the community available to attend such presentations,

and (3) promotional strategies used. Foremost was

the influence of external events within the larger

environment, such as the passage or consideration

of clean indoor air legislation at the State or local

level. The enactment of the New York State Clean

Indoor Air Act in January 1990 provides an example

of the impact of external events. After workplace

smoking policies were mandated by law, Utica and

Yonkers, NY, found their worksites to be much

more interested in assistance in formulating policy

and more receptive to cessation resource materials

from COMMIT and voluntary health agencies.

Yonkers reported that its policy workshops “created

additional visibility, allowed COMMIT to attract

media attention, receive free publicity, and reach

large numbers of worksites (53 percent during the

4 years of the trial) all at the same time.” Utica had

similar success, reaching 44 percent of large and

17 percent of small worksites.

One external event on which COMMIT sites had planned to capitalize

from the outset of the project was the release of the Environmental

Protection Agency’s (EPA) report labeling ETS as a Class A carcinogen.1

After repeated delays, the report was finally released in January 1993

(U.S. Environmental Protection Agency, 1992), 1 month after the COMMIT

1 A Class A carcinogen designation is used “when there is sufficient evidence from epidemiologic

studies to support a causal association between exposure to the agents and cancer” (U.S.

Environmental Protection Agency, 1986).
Smoking and Tobacco Control Monograph No. 6

162

intervention ended. One COMMIT site managed to exploit the situation

despite the delays. By highlighting the controversy surrounding the draft

report’s key findings, staff members and volunteers from Cedar Rapids/

Marion, IA, were able to generate additional interest in worksite policies

during the final year of the project.

A second factor was the size of the COMMIT community and the number

of worksites potentially available to attend policy workshops. For example,

Cedar Rapids/Marion, one of the largest intervention communities and one

with a large number of worksites, attracted 45 participants to its first smoking

policy workshop. Three television stations, four radio stations, and a

newspaper provided coverage of the event. Some of the smaller COMMIT

communities (with few worksites of more than 100 employees) reported

difficulty generating sufficient interest in policy workshops, especially on

an annual basis. As the project continued, more worksites already had

policies in place, had attended an earlier workshop, or were not willing to

devote a half day of company time to a workshop devoted exclusively to

smoking policy.

A third factor, the type of promotional strategies used, proved critical

to workshop success, regardless of community size and number of large

employers present. With workshops required on an annual basis, program

planners worked hard to avoid offering what might appear to be repetitious

events. They attempted to capitalize on new or timely angles for their policy

workshops and varied their promotion strategies to attract new attendees

as well as repeat participants. For example, in Raleigh, NC, workshops in

1989 and 1990 focused on health and safety (e.g., “Avenues to a Safe and

Healthy Workplace: Exploring Worksite Policy Options”). Later workshops

emphasized the costs to business owners of workplace smoking (e.g., “Is

Smoking Affecting Your Bottom Line?”) and included information on

fine-tuning existing policies.

Even those communities experiencing lower

than anticipated turnouts reported participant

satisfaction with the content and format of their

workshops. Medford/Ashland, one of the smaller

communities, used a format that included

presentations from multiple speakers followed

by a panel discussion involving representatives

from local worksites that had implemented policies.

Panel members then joined participants for lunch,

which provided further opportunities to interact

informally and share information. In Raleigh, the

largest site, COMMIT staff members developed

a similar format based on feedback from workshop

participants.

Many project personnel recognized the

importance of reaching out to smaller worksites,

and COMMIT developed a policy workbook geared
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to their concerns (Institute for the Study of Smoking Behavior and Policy,

1989b). However, several COMMIT sites noted additional needs in such

settings in terms of both policy and cessation activities. Many smaller

worksites felt they could not afford the time away from work necessary to

send employees to attend a worksite policy workshop or felt such policies

were not relevant to their settings. Consultations, written materials, or

small-group sessions may be more effective ways to reach some small

worksites.

Onsite Smoking COMMIT staff members and volunteers in each intervention

Policy Consultations community also provided worksites with onsite smoking policy

consultations in which information and materials were provided to assist

worksites in adopting and implementing smoking policies. Building on

external events was seen as critical to ensuring the success of these free

policy consultations. In addition to the demand for consultations generated

by new State legislation mandating policies (e.g., New York State), COMMIT

staff members also found that companies tended to be more receptive

to consultations when they were opening a new facility, remodeling,

overhauling general company policies, or adjusting health benefits or

when the media focused substantial attention on rising health care costs.

Worksite smoking control policies, long seen as a potential source of

conflict between management and labor, sometimes improved relations

between the two sectors when consultations were handled sensitively and

were tailored to the needs of the specific setting. One consultation at a

local grocery store was so successful in this respect that a group of employees

who smoked sent flowers to Cedar Rapids/Marion’s worksite specialist to

acknowledge her care in representing their concerns while negotiating their

new smoking policy. Another success involved a unionized company in

Bellingham, WA; however, in other instances, the stance of union officials

hindered efforts to develop a smoking policy. Even the expectation of union

resistance was enough to cause some worksites to defer action.

In some cases, the needed policy information was provided in a single

meeting, whereas for other worksites, multiple meetings were necessary. For

small targeted worksites, small-group consultations with representatives from

two or three worksites were sometimes conducted. Some communities relied

on project staff members to conduct consultations; others subcontracted this

activity to a local agency with expertise in this area. Some also provided

special training for community representatives in the hope that they might

be encouraged to continue consultations after the project ended.

The experience of the Vallejo, CA, site with worksite consultations is

especially interesting because the project used two subcontractors, and

each used a different approach in delivering onsite consultations (California

COMMIT staff, 1992). Both approaches were effective in meeting the

process objectives for this activity. The first subcontractor viewed a policy

consultation as an opportunity to accomplish multiple project objectives

during a single visit by offering an array of tobacco control information and

resources to the “client.” During a 1-hour visit, the consultant attempted
Smoking and Tobacco Control Monograph No. 6

164

to accomplish several of the following process objectives: (1) present

information and advice about how to design and implement a no-smoking

policy, (2) discuss how to set up onsite cessation classes and describe other

community cessation resources, (3) distribute tobacco cessation self-help

materials and cessation resource guides, (4) explain the Smokers’ Network and

deliver registration materials, (5) outline the value and strategies for utilizing

incentives for employees trying to quit, (6) generate interest in participating

in a stop-smoking competition with another worksite, and (7) deliver

promotional materials for any communitywide cessation events that

may be planned for the near future.

The second subcontractor’s approach was to make “cold calls” by

knocking on doors of businesses all day if necessary. For this subcontractor,

the focus of the visit was to convince the client of the need for a restrictive

smoking policy using whatever motivational strategies might be appropriate

in that workplace. The multipurpose mindset used by the first subcontractor

was assumed not to be optimal for the customer. Business representatives

might be overwhelmed with too much information on cessation and be

unable to concentrate on policy. Using this strategy, a 1-hour block of time

for a policy consultation (as required by the protocol) was often too long;

many employers were not willing to allocate that much time for an initial

visit. A series of 15- to 20-minute visits discussing overall policy issues and

strategies with a busy worksite contact, while using followup telephone calls

to deal with specifics, also proved to be an effective way to advance worksite

smoking policy efforts.

Regardless of which approach a consultant used initially, the process

of developing and implementing a worksite smoking policy often required

ongoing support from COMMIT personnel. For example, in Bellingham, staff

members worked with a hospital for 2 years, carefully prompting without

pushing, amid personnel turnovers and competing issues until the institution

finally became smoke-free.

Development of Each intervention community developed a

Worksite Smoking Worksite Smoking Policy Network Guide,

Policy Network Guide which was updated annually, and attempted

to promote the use of existing smoking policy resources

within the community. The guide identified local

worksites with different types of smoking control policies

and a contact person who was willing to serve as a “peer

counselor” and confer with people from other companies

about the worksite’s experiences in developing and

implementing its policy. The network was designed to

facilitate the diffusion of smoking control innovations by

identifying early adopters—individuals and companies

that had been successful in implementing a smoking ban

or restrictions. A few communities were able to identify a

wide cross-section of businesses; others either had trouble

identifying places with strong policies or, as in the case of
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Raleigh, located in the heart of tobacco country, encountered some reluctance

among worksites about receiving such publicity because of concern for

repercussions from the tobacco industry. The number of companies on the

first Worksite Smoking Policy Network Guide lists ranged from 6 (Yonkers and

Vallejo) to approximately 30 (Bellingham). By the end of the intervention

these numbers had increased greatly across all communities. For example,

Brantford, which began with 23 businesses (24 percent of targeted worksites),

reported that 97 (98 percent) targeted worksites were part of the network at

the end of the project.

Although the basic list of worksites with policies was similar, the amount

and format of additional information (rationale for policies, implementation

guidelines, sample policies, cessation resources, case studies) contained in

the network guide varied. Early versions of the guide often involved multiple

pages of information contained in a folder or small notebook. By the end of

the project, some sites sensed that the network guides were not being widely

used and resorted to a trifold pamphlet format, which was less cumbersome

and seemed more readable. Staff members and subcontractors frequently

used the guide when doing consultations as a way to point to local policy

exemplars. In addition, a list of local worksites with policies already in

place seemed to encourage other worksites to take action. However, several

COMMIT community final reports indicated the guides had failed to generate

the projected level of independent networking among businesses, and the

process of updating the guides on an annual basis involved a significant

amount of time for an already busy staff.

Motivational and This category includes three major types of activities:

Incentive Activities (1) promotional activities, (2) incentive programs, and

To Encourage (3) between-worksite competitions. These activities were

Smoking Cessation designed to encourage employees to initiate smoking cessation

attempts, maintain recent changes in smoking behavior, and provide

increased support to coworkers for cessation attempts. Promotional activities

served to increase participation in worksite-based or communitywide

cessation events. Incentive programs required little professional time to

administer, could be used to encourage participation in educational or skillstraining activities, and may address issues of long-term behavior change and

maintenance (Sorensen et al., 1990). Incentives also can encourage those

not yet ready to quit smoking to consider doing so (Winett et al., 1989)

and may help those who have already quit not to start again (Mattson et

al., 1993). Use of various types of incentives have been reported, including

the use of guaranteed incentives to reinforce workers’ attempts to quit for a

specified period (Jeffrey et al., 1988; Shepard and Pearlman, 1985), contests

or lottery drawings within a given worksite (Emont and Cummings, 1990),

and competitions between organizations (Brownell and Felix, 1987; Klesges

et al., 1986). Three worksite intervention activities involved the use of

motivational and incentive activities: (1) promotion activities in the worksite

accompanying magnet events; (2) promotional of worksite stop-smoking

incentives; and (3) between-worksite challenges and competitions.
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166

Promotional Activities Promotional activities were conducted in targeted worksites

in the Worksite to foster participation in communitywide magnet events, such

Accompanying Magnet as “Quit and Win” contests, the GASO, Non-Dependence Day,

Events and other events designed to encourage cessation attempts and

attract attention to the smoking issue. COMMIT sites reported success in

promoting these events in worksites through display of materials, registration

at the worksite, or other activities, such as expired carbon monoxide testing.

Worksite promotions were designed to enhance the impact of communitywide events by integrating activities across channels and by increasing the

likelihood of multiple exposures to a given event. Process objectives defined

a cumulative increase over time in the number of worksites to be personally

contacted about these events. Several sites relied on worksite task force

members and other volunteers to assist with the delivery of promotional

materials to identified worksite contacts. For example, Medford/Ashland’s

task force members agreed to “adopt” specific worksites; each member took

responsibility for developing contacts and delivering materials to a given

number of community workplaces.

Promotion of Because the use of stop-smoking incentives was expected to be a new

Worksite strategy for many worksites, the COMMIT project developed a workbook

Stop-Smoking to explain this approach. The COMMIT Incentives Programs Workbook

Incentives (Glasgow and McRae, 1989) was distributed in person to worksites to

provide information about how to use incentives in the workplace to

encourage smoking cessation and maintenance activities. It included

guidelines on selecting awards, setting contest rules, and promoting and

evaluating an incentive program and contained an overall timeline and several

activity planning worksheets to facilitate implementation. Consultation on

implementing the plans was provided on request. Many communities

reported that employers viewed support for cessation as an extracurricular

activity, not as a priority item. These attitudes made it difficult, especially

during the hard economic times many communities were experiencing, to

persuade employers to devote resources, or even experiment with incentives,

to encourage cessation among their employees. The workbook also provided

information on between-worksite challenges and competitions, which

intervention sites were expected to conduct each year.

Between-Worksite Between-worksite competitions proved more challenging to

Competitions implement than expected in many COMMIT communities, despite

plentiful resource materials. Such contests often generated excellent

media coverage for worksite tobacco issues as well as the COMMIT project.

Competitions were easiest to arrange and implement when staff members

were able to identify a committed “champion” within each company. Such

a person was able to generate real enthusiasm from within that helped foster

participation and support from others in the worksite. For example, the

COMMIT project in Brantford enlisted senior executives from the two local

hospitals, who were already friends, to arrange a highly successful betweenworksites competition. In Bellingham the co-owner of an auto parts business

arranged a competition among the divisions of her company and offered

to cook a gourmet dinner in her home for the winners and their spouses.
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The amount of staff member and volunteer effort devoted to the

competition did not seem to correlate directly with the level of smoker

participation, as examples from Vallejo and Medford/Ashland illustrate.

In Vallejo volunteers and staff members carried out a successful worksite

challenge among five local auto dealerships (involving 40 participating

smokers) in June 1990. A young project subcontractor working closely with

COMMIT staff and task force volunteers arranged for auto mechanics and

salespersons to launch a successful competition. Careful communication with

all constituencies involved was critical to the success of the event and helped

sensitize the subcontractor to the barriers and limitations facing dealerships

and their employees. Face-to-face meetings with dealership owners or

managers provided information about what motivated them to support and

encourage participation by their employees. Meetings with employees who

smoked helped determine what incentives would motivate them to quit.

During the competition, labor-intensive, one-to-one check-ins with competing

participants helped to sustain motivation. Participants later reported that the

support provided by these personal contacts “made the difference in their

ability to remain smoke-free.” Sharing the results of the competition with the

rest of the community had a positive, ripple effect. The media coverage was a

“win-win” situation: Auto dealerships received positive publicity (a key

incentive for their participation) and successful participants received public

recognition. People who had never heard of COMMIT heard about the

worksite challenge, which enabled COMMIT staff members and volunteers to

take further pride in their projects and increased local awareness of the tobacco

issue.

Medford/Ashland also carried out a competition involving auto

dealerships. The effort here also generated extensive publicity and was

well executed and labor intensive. However, weeks of work resulted in only

a few participants; only 13 smokers entered from across the 6 participating

dealerships. Seven of the eight people successful in quitting for the 1-month

contest also completed a special Freedom From Smoking clinic, a program of

the American Lung Association, held in conjunction with the competition.

Fitchburg/Leominster used a competition among fire stations to

enhance participation in a Quit and Win contest. Project staff members made

regular visits, sometimes at rather strange hours, to recruit and later provide

support and encouragement to participating firefighters. Besides increasing

participation in the Quit and Win contest, the event helped encourage

firefighters to begin talking more constructively about smoking restrictions

in the fire stations where they lived and worked.

However, despite these successes, most COMMIT final reports indicate

that staff members viewed these competitions as among the most difficult to

accomplish and least efficacious worksite activities. The large amount of staff

and volunteer effort involved often did not seem justified by the few smokers

who participated. For example, a report from Yonkers summarizes the

frustrations common to many COMMIT communities:
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Each year our task force brainstormed new ways to recruit worksites

to engage in competitions. Many companies were approached

through key contacts within each workplace, but most declined for

a variety of reasons such as time restrictions, poor economic climate,

or not enough smokers in the company. One worksite actually

worked with COMMIT for several months to plan a competition,

met extensively with project staff and the task force chair, set up

a planning committee, and asked COMMIT to purchase pro-health

buttons with the company’s name on them. At the last minute the

company canceled the competition citing economic constraints.

Promotion of Activities and materials teaching the skills needed to quit

Self-Help Materials smoking were generally available in most communities prior to

and Cessation COMMIT’s arrival on the scene. Therefore, the project sought

Services to enhance the reach and effectiveness of these existing

community resources through two activities designed to bring them into

the workplace: (1) distribution of self-help materials and (2) promotion of

a Smokers’ Network.

Distribution of Tobacco cessation self-help materials available through voluntary or

Self-Help governmental health agencies were personally distributed to targeted

Materials worksites. Staff members or volunteers from local voluntary agencies,

representatives of the Smoking Cessation Resources Task Force or Worksites

and Organizations Task Force, or COMMIT project staff delivered materials

to a worksite representative willing to take responsibility for the

dissemination of the information within that worksite. To generate

additional interest in these self-help resources, some intervention sites used

special promotional materials, such as buttons, posters, mugs, and desk

accessories, to gain access to companies either for initial visits or followup

activities.

Promotion of a The Smoking Cessation Resources Task Force also established a

Smokers’ Network Smokers’ Network, a voluntary list or registry of smokers in each

community who received mailings and materials several times a year to

encourage cessation and its maintenance (see Chapter 8). This network

was promoted in worksites through posters, flyers, and other informational

materials distributed in conjunction with the promotion of communitywide

and worksite events. Many of these materials contained stamped, selfaddressed network registration cards that allowed a smoker to join the

network simply by completing the card and returning it to the local

COMMIT office. Smokers could also request Spanish-language materials

as part of the network registration process.

Project staff members stressed the need to stagger visits to worksites

and to coordinate efforts with other organizations doing worksite health

promotion to ensure continued business community cooperation. The need

to coordinate visits sometimes created new opportunities for collaboration

with the voluntary health organizations. For example, in one COMMIT

site the worksite specialist helped to orient an American Heart Association
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volunteer interested in the Heart at Work project so that

they could share the work of delivering health materials

to worksites.

The worksite activities described above were designed

to be incorporated into the communitywide intervention

implemented by the COMMIT project. By building

ongoing relationships with local worksites and voluntary

health organizations, COMMIT was able to provide

multiple and sustained interventions rather than single

programs. Prior research suggests that no one treatment

strategy can guarantee success; the more successful

programs use multifaceted, multicomponent

interventions. Such programs tend to be highly flexible

and are designed to reach employees at various points on

the “stages of change continuum” (Abrams et al., 1994;

DiClemente et al., 1991; Prochaska and DiClemente,

1983).

DELIVERING THE Effective delivery of intervention activities to worksites

INTERVENTION was contingent on each COMMIT site’s ability to convince

TO THE COMMUNITY workplace personnel of the relevance and importance of

community tobacco control efforts. The COMMIT project relied on a

community Board and task forces to assist field staff in reaching out to

the many businesses and labor organizations in each community.

Participation of The design of the COMMIT project called for a community Board

Board and Task accountable for the overall goals—how to increase quit rates in the

Force Members community at large—and task forces responsible for the planning

and implementation of activities specific to a given channel—in this case, the

worksite channel. The Worksites and Organizations Task Force was charged

with overseeing activities involving civic and religious organizations as well

as worksites. Each community was responsible for reaching many diverse

organizations, and most COMMIT sites experienced significant difficulties

in achieving the objectives established for these groups. Efforts directed

toward other organizations are described in Chapter 11. The impact of

this dual focus on task force functioning is discussed in more detail in the

“Lessons Learned” section below. In brief, given that there were more

objectives under “Other Organizations” than under “Worksites” and that

the organizational objectives proved difficult to achieve, considerable task

force effort was devoted to organizations other than worksites.

The roles played by the community Boards and task forces in the worksite

channel included the following (Kizer, 1987; Sorensen et al., 1990):

• catalyst for the support and involvement of community leaders;

• key informant on ways to tailor the intervention to community needs

and available resources;

• liaison with community service providers and service vendors;
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170

• information clearinghouse on health information, community resources,

and effective implementation models of health promotion;

• coordinator in sponsoring communitywide health promotion activities;

and

• supporter of ongoing program implementation.

Some worksite task forces experienced significant turnover in membership

and found the mobilization of community leaders for worksite endeavors to

be an ongoing effort. In several COMMIT sites, the task force had to be

rebuilt, sometimes more than once, after resignations of key members and

significant member attrition. Turnover occurred for many reasons: For

instance, in the Brantford and Raleigh sites, several Board and task force

members resigned because of expected pressure from the local tobacco

industry. Other communities had difficulty filling the position of task force

chair; therefore, the task force lacked the leadership it needed to move ahead.

Brantford’s experience highlights the importance of recruiting effective

leadership for worksite efforts. For the first 2 years the project was unable

to develop a viable worksite task force. The initial worksite chair, a local

union leader, was highly regarded in the community. However, his time

was limited, his employer discouraged him from attending meetings during

working hours, and smoking was not high on his list of priorities. A second

chair, also highly regarded in the community, had a leadership style that

others perceived as autocratic and not good for the project.

The turning point came when management personnel from two local

hospitals (the chief executive officer from one and the director of education

from the other) agreed to serve as cochairs of the task force. Each had good

leadership and organizational skills and a commitment to smoking control

that included a personal as well as professional dimension. Both were well

connected to the business community and used their contacts to assemble

an effective team. The task force cochairs, both senior executives, also used

their worksites as models. For instance, they quickly organized a Quit and

Win competition between the two hospitals in town, a successful, high-profile

event that encouraged staff and provided a model for other worksites.

Another cornerstone of effective leadership, according to several

COMMIT communities, was the ability of task force chairs to involve task

force members in activity planning. Meetings devoted to recitation of activity

reports with little opportunity for volunteers to engage in creative thinking

were less likely to maintain member interest and produce results. When

volunteers could see that their ideas and opinions were a vital part of the

intervention process, their creativity and productivity increased.

During the second half of the project, Brantford elicited so many good

ideas from its task force that not all of them could be implemented. To

keep track of these ideas for future consideration, the essence of the idea

was captured in a few words and posted on the wall of the meeting room

where the Board and task forces met. The “idea bank” was embraced,
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and ideas from many sources were accepted and saved for possible later

implementation. Individuals who contributed these ideas felt they were

recognized, the visible idea bank helped establish a “culture of creativity,”

and new brainstorms occurred as ideas posted on the walls stimulated

further thinking by participants.

Gaining Access COMMIT staff members and volunteers were expected to work first

to Worksites with high-profile and early adopter worksites to build community

awareness and confidence in program efforts, thereby laying the groundwork

for efforts with worksites less ready for change (Abrams et al., 1994). Although

the community analysis identified business and labor leaders targeted for

membership on the community Board and its various task forces, recruitment

of these individuals often proved more difficult than anticipated. In many

cases the early adopter worksites did not have high profiles in the community.

Often, business and labor leaders with the most extensive histories of

community volunteer work did not view smoking control as a high priority.

In many communities potential task force members had to be convinced first

of the extent of the tobacco problem and then of the merits of the COMMIT

project. Initially, the worksites most often represented on the task force were

those already providing health promotion programs or otherwise supportive

of smoking control efforts. These worksites sometimes served as role models

for other businesses, enhancing the attractiveness of participating in the effort

(Orlandi, 1986; Rogers, 1983), but this did not occur as readily as expected.

COMMIT personnel used a variety of approaches for engaging

worksites in COMMIT efforts. All agreed that having a “well-connected”

employee or employees committed to tobacco control inside a workplace

who could serve as a program or issue champion was critical for effective

implementation. However, the definition of a well-connected employee

varied across intervention communities.

Some COMMIT sites felt that the project’s original emphasis on recruiting

chief executive officers and top-level management was misplaced. These

sites saw occupational health nurses, human resource managers, or worksite

health and safety committees as key to obtaining worksite involvement.

For example, Brantford informants reported notable success with some of

these groups. They obtained their best results by working with human

relations officials. Canadian health and safety officers also expressed interest

in the smoking issue and invited COMMIT representatives to speak to large

audiences at their regional events, but those officers were less well positioned

to provide entree into individual worksites. Other sites reported frustrations

in working with these midlevel contacts because although they were often

knowledgeable and highly motivated, the contacts were less successful in

getting worksite decisionmakers to implement activities. Most intervention

sites agreed that efforts to work through unions were unsuccessful or slow to

provide results.

After reaching out to human relations officers, health and safety

representatives, and union officials, Brantford reported that the best results

were obtained by working with human relations officials. Although health
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172

and safety officers were interested in smoking and invited COMMIT to

speak to large audiences at regional events, they were less well positioned

to provide access to individual worksites. However, others felt they were

unable to obtain access through such contacts because they could not

capture the attention of worksite decisionmakers when it was time to

implement activities.

Tailoring The community Board and the Worksites and Organizations Task Force,

Project working with project staff, were responsible for tailoring the intervention

Activities activities to fit the community, which happened in several ways. In

most communities, the COMMIT Board reviewed the priorities set by

individual task forces through the development of annual action plans.

These plans described how the intervention activities would be implemented

during the coming year, outlined the tasks necessary to implement each

intervention activity, identified who would carry out each task, established

a timeline for task completion, and specified the money and other resources

required. The development of the annual action plans helped to encourage

community partnership in implementing the mandated protocol activities.

The amount of resources allocated and the number of community members

involved in implementing a given activity depended primarily on local

staffing patterns as well as the makeup of the community, especially the

configuration of worksites and cessation services.

In addition to the activities mandated by the protocol, some COMMIT

sites conducted optional activities that were designed to take advantage of

special opportunities present at a given time in the community. For example,

in Santa Fe, NM, community analysis showed that the business sector had

an unusual configuration, dominated by State government offices and a large

tourist industry. Therefore, the task force assembled a booklet called “Santa

Fe’s Guide to Dining and Lodging,” which included information on the

smoking policies of restaurants and hotels. This was the only restaurant

guide available in Santa Fe and was in great demand. Paterson, one of the

most racially and ethnically diverse of the COMMIT communities, was

especially concerned about reaching blue-collar workers. A useful strategy

involved teaming COMMIT with other health promotion efforts in the

community. For example, expired carbon monoxide testing and feedback

to smokers and ex-smokers were offered regularly in conjunction with blood

pressure screenings provided at worksites by a local hospital. One of the

challenges facing Fitchburg/Leominster was lack of participation from labor

groups. COMMIT staff members met with representatives of several unions

during a regular union meeting to make a brief presentation and to conduct

a focus group discussion. The focus group allowed them to begin to identify

labor’s concerns about tobacco control and to devise strategies to encourage

union involvement.

Worksite COMMIT Boards and task forces tended to use two types of staffing

Implementation arrangements to deliver worksite activities. In eight COMMIT

Structures sites, a decision was made to hire and use a half-time or full-time

COMMIT staff member (e.g., an “intervention specialist,” “task force
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coordinator,” or “worksite specialist”) who devoted

from 20 to 40 hours per week to worksite activities.

Such staff members were often responsible for

publicizing worksite events; arranging for

dissemination of cessation information and

promotional materials; planning worksite smoking

policy workshops, sometimes in collaboration with

one or more of the local voluntary organizations;

and providing worksite policy consultations.

Another site also used a paid staff member for

worksite activities, but this person provided support

to several of the task forces.

In the two remaining sites, Utica and Vallejo, the

COMMIT leadership opted to subcontract many or

all the worksite activities to a local agency. In both

instances staff members learned from experience how to work effectively with

subcontractors and found that subcontracting, although a well-intentioned

strategy and an excellent use of community resources, brought its own set

of challenges. There was general agreement that substantial supervision

was required, especially during the first year of a contract, if activities were

to be implemented effectively by subcontractors who often had a lesser

commitment to the tobacco issue than did COMMIT staff and volunteers.

Initially, Utica set up two subcontracts with community agencies, one for a

“worksite policy consultant” and one for a “worksite liaison,” to carry out

most of the task force’s directives. A year’s experience taught that overlaps

between the subcontracts resulted in duplicate contacts to worksites. This,

along with subcontractor reporting problems, led the Board to combine all

worksite activities the next year and rebid the subcontract to a single agency.

After subcontracting some worksite activities, Vallejo found that project

staff members and worksite task force members were becoming insulated

from contact with the employers and employees who were targeted for

participation in worksite activities. They found themselves forced to depend

on the subcontractor for a picture of the business climate and the concerns

and needs of employers. When the accuracy of this picture was called into

question, the task force responded by developing more measurable outcomes,

clarifying lines of accountability, and extending the timeline for activities.

These actions increased opportunities for collaborative planning between

the subcontractor and COMMIT staff and volunteers, allowed for more timely

feedback, and left time for fine-tuning the plans prior to implementation.

Both Utica and Vallejo reported difficulty in maintaining task force interest

when meeting agendas focused on reports from subcontractors with no

opportunity for creative planning by members. Whether worksite activities

were implemented by subcontractors or project staff, COMMIT participants

stressed the importance of bringing in these individuals early in the project.

Most intervention sites did not hire staff members or subcontractors to

handle worksite activities until well into the second year of the intervention,

which delayed progress in the worksite channel.
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LESSONS Workplaces can be ideal for reaching smokers, and initial COMMIT survey

LEARNED findings indicated there was substantial opportunity for intervention

in all three of the following targeted areas—smoking policies, incentive

and motivational programs, and the provision of cessation resources to

employees—especially in smaller worksites (Sorensen et al., 1989).

To optimize these opportunities for intervention, COMMIT personnel

stressed the need to take advantage of external changes and link tobacco

control activities to larger events such as clean indoor air laws or the release

of information at the national level (such as the EPA report on ETS [U.S.

Environmental Protection Agency, 1992]). A well-publicized smoking policy

change by a major employer also could be used to generate interest among

other worksites. For example, Paterson reported that policy changes by school

districts, changes in standards by hospital accreditation agencies, and passage

of more stringent youth access laws all generated further interest in worksite

smoking policy consultations.

The value of time was one of the lessons from Vallejo. COMMIT staff

members reported that long seminars, offsite trainings that took people away

from their work, usually did not draw as high attendance as brief trainings or

lunch-time gatherings. Brief materials were more likely to be read by busy

employers than large, elaborate packets of information.

COMMIT interventionists quickly learned or remembered the old adage,

“if they won’t come to you, then go to them,” and attempted to incorporate

their programs, materials, and information within settings where targeted

individuals and worksite representatives gathered for other purposes. For

example, in Medford/Ashland where it proved difficult to attract significant

numbers of worksite representatives to annual worksite smoking policy

workshops, staff members began to incorporate their smoking policy

information within the agenda of the community’s “drug-free workplace”

workshops. These workshops were held several times a year and drew

many worksite representatives. The substance abuse awareness group

in turn began to incorporate tobacco use into its ongoing agenda. Staff

members from Cedar Rapids/Marion indicated they might have been even

more effective in reaching worksites had they begun to work with substance

abuse prevention groups earlier in the process.

Most communities reported that the expected synergistic effect among

intervention channels did bolster worksite efforts. Cedar Rapids/Marion

found that Quit and Win contests, radio advertisements, billboards, and

media spots publicizing other COMMIT activities all generated name

familiarity for the project and made it easier for the worksite specialist to

get management’s attention about the tobacco issue. The project in turn

used worksite successes to generate additional media coverage by creating

a public education campaign based on testimonials from a wide variety

of workplaces.

Using worksites as a setting to recruit for community events and

distribute cessation materials was recognized by all COMMIT sites as a
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Chapter 10

highly successful approach. Magnet events such as Quit and Win contests

and the GASO or National Non-Smoking Week (Canada) reached many

smokers across communities, and worksites often played an integral part

in these efforts. Publicly recognizing worksites that went smoke-free via

newspaper advertisements, plaques, or decals often encouraged others to

emulate their decisions and created a sense of growing momentum in the

community. Building on this awareness, staff members and volunteers

were better able to use a peer approach to sell no-smoking policies in their

worksite consultations.

Although smoking policy interventions were recognized as a key strategy,

they did not receive as much consistent emphasis across the trial as planned

because of difficulties encountered in generating interest from worksites in

some communities. This apparent lack of interest in policies at the worksite

level prompted some communities to suggest that efforts be devoted to

passing municipal, county, or State clean indoor air ordinances before trying

to convince worksites to establish or strengthen their policies. Such actions

created opportunities in States where such regulations were passed.

Despite the recognized importance of worksite smoking policy

interventions in shaping community smoking norms, staff members

from one site questioned whether:

from a quitting smoker’s point of view, the workplace is the most

opportune place to receive cessation services. Onsite cessation

classes were often not well attended, and “public” team events, like

cessation competitions, were problematic, i.e., didn’t appeal to the

numbers anticipated by project designers—many of those smokers

who remain do not seem interested in quitting in groups or do not

necessarily want to quit at the same time.

In their final reports, most COMMIT communities pointed to the

implementation of no-smoking policies by worksites and restaurants as

one of their most significant accomplishments. One community asserted

that the institutionalization of smoking control through worksite policies

was the most effective way to bring about lasting change in the smoking

behavior of the community.

Although smoking control efforts through workplaces seem to hold

great promise for reducing the burden of smoking in communities,

achieving process objectives in this arena required exceptional effort

from several COMMIT communities. The process objective data indicate

that the majority of objectives were achieved (see Table 2). However, most

COMMIT sites found that successfully involving smokers was not simply a

function of the level of effort invested. There were several reasons for this.

First, businesses were selected and contacted according to the protocol

for targeting worksites, but they often had to be convinced to endorse and

carry out smoking control activities. Resistance may have stemmed from the

ideas or smoking habits of powerful individuals in a worksite, organizational
Smoking and Tobacco Control Monograph No. 6

176

culture, perceptions by company leadership of the larger community culture

as unsympathetic to smoking control activities, potential for aggravating

relations between labor and management, threat or actuality of economic

downturn, or existence of competing priorities. Few worksites in any

community were recruited easily, and even when management cooperated

fully, workers, especially heavy smokers, often did not come forth in large

numbers to participate in programs.

Unlike most prior research involving worksites, the COMMIT project

ultimately involved all those worksites in the community that satisfied

project basic inclusion criteria, rather than concentrating on a relatively

few motivated worksites selected and “cultivated” by the researchers.

Most worksite research has taken place in major metropolitan areas with

activities designed for large worksites (often more than 500 employees)

with considerable resources. The scope of the COMMIT effort and the

inclusiveness of its sample of large worksites presented special challenges,

especially for some of the smaller size intervention communities.

The many small worksites in most COMMIT communities also required

special efforts. Collectively, these worksites may employ more people than

large workplaces, but staff resources limited the amount of outreach that

could be done. Small businesses often felt they could not afford to send

someone to a half-day policy workshop. Yet, they often benefited from extra

attention in the form of special materials, incentives, and encouragement.

To meet these needs, communities worked through chambers of commerce,

small business associations, educational institutions serving small business,

and other settings where small businesses sought information and support.

The structure and financing of health care reform may help to shape future

efforts to reach small businesses.

COMMIT’s focus on a single health risk factor—in this case, tobacco

use—may have been an impediment to forming ongoing relationships with

worksites. In Brantford one cochair of the worksite task force went on to

become a volunteer with the Heart and Stroke Foundation and, in this

capacity, became involved in its worksite programs. He found worksites

much more receptive to him when he was tied to an organization that was

interested not only in smoking but also in broader lifestyle issues, which

meant he was able to generate interest among a higher proportion of

worksites. It also meant that it was easier for him to establish ongoing

relationships and repeat business.

Some COMMIT researchers stress the efficacy of approaches used in

other worksite interventions. For example, using a health risk appraisal

as a tool for gaining entree to worksites might have allowed project staff

members and volunteers to generate more involvement in activities. The

health risk appraisal could have provided special feedback to smokers and

shown the unique role of smoking as a risk factor for heart disease and

cancer, while generating more widespread interest in the project among

nonsmoking employees. Giving something to managers for their employees
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Chapter 10

at the onset might have generated a greater willingness to participate in other

project activities. The demands of the protocol limited the ability of staff

members to join with worksites to carry out other health promotion goals,

but establishing workplace steering committees in some worksites to tailor

activities and provide options might create a greater sense of ownership as

well as opportunity for more frequent contacts with the worksites (Sorensen

et al., 1992).

Finally, the decision to combine worksite activities with efforts

directed toward other community organizations within the same task

force resulted in an awkward, sometimes totally unworkable, structure.

In some intervention sites the structure diverted scarce volunteer energy

from the business community away from worksite activities or away from

the project altogether. In other cases community organizations were

neglected in favor of worksites where chances of success seemed greater.

The two types of settings are different; the sheer numbers of worksites and

organizations to be reached were overwhelming for staff and volunteers,

especially when combined. Task force members became frustrated and

were often uninterested in one or the other half of this two-part task force

agenda. By the end of the intervention, several COMMIT sites had

established separate task forces for involving organizations or had reached

agreements with existing community structures to take on some of the

activities targeting other organizations.

A participant from Brantford summed up his site’s struggles to balance

the demands of science with the demands of the community by speaking

of the “opportunity costs” associated with implementing the worksite

intervention. All the worksite activities were effective in reaching some

smokers or policymakers in some communities at some times. However, with

limited resources, staff members and volunteers sometimes were frustrated at

having to carry out protocol activities that they suspected (based on recent

experience) were likely to have limited impact in their community. The task

force found itself struggling to avoid tying up too many of its resources in

required “good” activities when those resources might be invested in a few

“better or best” activities, all of which were part of the COMMIT protocol.

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nonsmoking policies in the private sector

and assessing their effects. New York State

Journal of Medicine 89(1): 11-15, 1989.

Sorensen, G., Rigotti, N., Rosen, A., Pinney,

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Evidence for Increased Cessation.” (Abstract.)

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Stave, G.M., Jackson, G.W. Effect of a total worksite

smoking ban on employee smoking and attitudes.

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Terborg, J.R., Glasgow, R.E. Worksite interventions:

A brief review of health promotion programs at

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and Medicine, A. Baum, C. McManus, S. Newman,

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Docs., U.S. Govt. Print. Off., 1986.

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Health Consequences of Using Smokeless Tobacco. A

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of Health and Environmental Assessment, 1992.

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Worksite Health Promotion Activities: Summary.

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1993.

Warner, K.E., Wickizer, T.M., Wolfe, R.A., Schildroth,

J.E., Samuelson, M.H. Economic implications of

workplace health promotion programs: Review of

the literature. Journal of Occupational Medicine 30:

106-112, 1988.

Winett, R.A., King, A.C., Altman, P.G. Health

Psychology and Public Health: An Integrative

Approach. New York: Pergamon, 1989.

ACKNOWLEDGMENT The authors wish to acknowledge Tom Weldon, Community

Board Chair and Chair of the Worksites and Organizations Task Force,

Medford/Ashland, OR, for his helpful comments.

AUTHORS

Linda Nettekoven,M.A.

Project Coordinator

Oregon Research Institute

1715 Franklin Boulevard

Eugene, OR 97403
Smoking and Tobacco Control Monograph No. 6

180

Russell E. Glasgow,Ph.D.

Research Scientist

Oregon Research Institute

1715 Franklin Boulevard

Eugene, OR 97403

Robert H. Shipley,Ph.D.

Department of Psychiatry

Duke University Medical Center

Box 3964

Durham, NC 27710

A.J. Roy Cameron,Ph.D.

Professor

Department of Health Studies and

Gerontology

University of Waterloo

BMH, Room 2311

Waterloo, Ontario N2L 3G1

CANADA

Lesa T. Dalton

Project Director

Division of Health Promotion Research

American Health Foundation

Fifth Floor

800 Second Avenue

New York, NY 10017

Aleena Erickson

2117 Washington Avenue, S.E.

Cedar Rapids, IA 52403

Sharon Ann Rankins-Burd

Box 99

North Winfield Road

West Winfield, NY 13491

Sandy Tosti,M.A.

7335 Franco Lane

Vacaville, CA 95688

Glorian Sorensen,Ph.D.,M.P.H.

Associate Professor

Department of Epidemiology and Cancer

Control

Dana Farber Cancer Institute

Harvard School of Public Health

44 Biney Street

Boston, MA 02115
181

Chapter 10

Kitty K. Corbett,Ph.D.,M.P.H.

Adjunct Investigator

Division of Research

Kaiser Permanente Medical Care Program

3505 Broadway

Oakland, CA 94611

and

Assistant Professor

Health and Behavioral Sciences, CB-103

Department of Anthropology

University of Colorado at Denver

P.O. Box 173364

Denver, CO 80217
Smoking and Tobacco Control Monograph No. 6

182
183

Chapter 11

Involving Diverse Community Organizations

in Tobacco Control Activities

Kitty K. Corbett, Linda Nettekoven, Linda C. Churchill, Lesa T. Dalton,

Carolyn L. Johnson, Lysha Dickinson, Glorian Sorensen, and Beti

Thompson

THE RATIONALE In the Community Intervention Trial for Smoking Cessation

FOR INVOLVING (COMMIT), the active participation of multiple sectors of the

COMMUNITY community was a fundamental vehicle for comprehensive

ORGANIZATIONS changes in the “tobacco control environment” in communities.

In addition to focusing on the workplaces, clinical settings, and school-based

organizations so necessary to health promotion, the COMMIT project from

the outset recognized that community and civic organizations were important

targets of and channels for pursuit of health promotion objectives (Sorensen

et al., 1990; Lasater et al., 1986). Some organizations representing employees

and employers, medical care practitioners and clinical settings, and schools

were considered so necessary to COMMIT’s goals that from the outset they

warranted separate, dedicated channels (and are discussed in separate chapters

in this monograph). Miscellaneous remaining community organizations

were handled within the separate and more amorphous channel of “other

organizations.” This chapter summarizes the experiences of the 11 COMMIT

intervention communities in working with diverse civic and community

organizations to accomplish tobacco control objectives. The rationale for

such involvement is compelling. However, the process of engaging such

organizations in tobacco control was highly challenging for participants.

All community-based health promotion efforts use community

organizations in many ways (Cuoto, 1990; Hatch et al., 1993; Nickens,

1990; Shea, 1992). Organizations are points of access to targeted individuals

for planned interventions. Many organizations are involved in publicity,

magnet events, assistance with logistics for activities, and provision of

expertise for health promotion efforts. When hospitals, other clinical

settings, educational institutions, and worksites are enlisted in multifaceted

community projects, staff members are recruited from organizations with a

health promotion or social service focus. Representatives of organizations

that have implemented smoking bans have been involved in conferences

and other educational forums throughout the country. Voluntary agencies

(e.g., American Lung Association [ALA], Canadian Cancer Society [CCS])

and health departments have sponsored many health promotion activities.

Community organizations also have been useful in efforts to secure funding

of health promotion efforts, for example, through written endorsements of

and involvement in specific projects.

Community organizations offer opportunities for identifying smokers and

others at risk from tobacco, and they also are sources of persons and resources
Smoking and Tobacco Control Monograph No. 6

184

for fostering change and its maintenance (Roncarati et al., 1989; DePue et al.,

1987; Eng et al., 1985; Carlaw et al., 1984). Community organizations are

important local institutions through which to implement policy changes,

publicize project activities, offer programs, provide education, and otherwise

create an environment supportive of health. Organizational policies and

opinions of leaders may have considerable influence on members’ attitudes

and behaviors. Networks of organizations in the form of coalitions may wield

considerable influence in a community, and their activities and policies are

often well covered by local media. Some types of community organizations

have a long history of community service, outreach, and participation in

health promotion and education. Many such

groups already regard health-related social

service as part of their mission. Organizational

facilities, many of which are in neighborhoods,

are centers for their members and often

for other people and functions. They allow

dissemination of information to people

outside usual health promotion settings (i.e.,

educational and medical care settings). Some community organizations

(e.g., church groups, community centers) also deal with families, which is

another important sector infrequently addressed as a unit elsewhere and

which may not be readily reached via other channels. Programs such as a

Salvation Army mission, those dealing with employment and training, and

the Women, Infant, and Children’s program (WIC) also can be seen as

organizations providing important access to diverse special populations.

Religious organizations appear to have enormous potential as a channel

for smoking control messages and activities. They are central social and

cultural institutions in American and Canadian communities. Membership

in a religious organization in 1990 was reported by 69 percent of American

adults in a Gallup Poll, and 40 percent said they had attended a church or

synagogue in the past 7 days (Princeton Religious Research Center, 1993).

Many religious organizations already take part in health-related activities,

such as education, treatment, and screening programs dealing with subjects

such as diet and nutrition, fitness, alcohol and substance abuse, mental

health, stress management, AIDS (acquired immunodeficiency syndrome),

heart disease prevention, and CPR (cardiopulmonary resuscitation), to name

a few (Corbett et al., 1991; Elder et al., 1989). Many religious organizations

also are interested in prevention programs, have restrictive smoking policies,

and have become involved in a variety of programs for their members (Emory

University, Carter Center and Park Ridge Center, 1990; Foege, 1990; Hatch

and Lovelace, 1980; Hatch and Johnson, 1981; Lasater et al., 1986; Levin,

1984; Saunders and Knog, 1983; Smith, 1983; Wiist and Flack, 1990; Stillman

et al., 1993). It is reasonable to assume that clerics, who have seen members

die of smoking-related diseases and counseled them and their grieving

families, would be receptive to tobacco control. In addition, many members

of religious organizations may live with a smoker, have a child who smokes,

work with smokers, or have friends who smoke; nonsmokers who become
185

Chapter 11

informed and involved through a religious (or other) organization may be

useful channels of tobacco control messages and information to smokers

they encounter in their daily lives. Even in those religious organizations

with few members who are smokers, nonsmokers could endorse communitywide nonsmoking norms and communicate information about tobacco

control and cessation resources to their family members, friends, associates,

and acquaintances who are smokers.

The developers of the COMMIT protocol recognized that success required

having enduring, influential community organizations endorse the project’s

goals, steer interventions over the period of Federal funding, enhance their

own smoking control policies, participate in tobacco control activities, and

provide access to targeted smokers (Lichtenstein et al., 1990-91; Thompson et

al., 1990-91). Community organizations beyond health care, worksite, and

educational institutions needed to be incorporated into COMMIT’s plan, but

which ones, and how?

OTHER In COMMIT’s protocol, organizational entities dealing with health

ORGANIZATIONS care, public education, and cessation resources were targeted

IN COMMIT through channels handled separately from other organizations.

Worksites were structurally linked with other organizations into a single

channel but also were dealt with separately in the delineation of activities

and process objectives. Other organizations, by virtue of the nebulous

character of the channel as well as their diversity, became in effect the

stepchild of the worksites and organizations channel.

Community organizations are diverse and complex, with no standard

configuration across communities. They vary in type, mission, values,

structure, leadership,

demographic representation,

sheer numbers, charter,

rules, and relationships with

members. A nonexhaustive

list of types of community

organizations would include

religious organizations,

service and fraternal

organizations, coalitions

(e.g., for health promotion,

drug use prevention,

community beautification),

ethnic organizations,

voluntary agencies, business

groups, unions, veterans’ organizations, social service locales (e.g., WIC

program offices, employment development offices), self-help and support

groups, and other local groups such as recreational, neighborhood, and social

clubs. Membership or affiliation in community organizations is voluntary,

and in many, leadership is short term or rotating. Organizational rules often

are derived from tradition and consensus and are adhered to or enforced
Smoking and Tobacco Control Monograph No. 6

186

internally and informally, without support from formal legal sanctions. In

most organizations, participation is occasional, optional, or sporadic. The

manner of implementation of activities must be responsive to the special and

diverse characteristics of organizations. In addition, specific organizations

vary in their potential for assisting with the achievement of COMMIT’s

objectives. Some organizations were clearly less appropriate for COMMIT

activities than others.

The 11 COMMIT intervention communities had diverse constellations

of organizations that appeared appropriate for tobacco control activities. The

visibility, influence, and penetration of specific organizations were different

in various sites. Organizations varied greatly in size in a community. An

initial tally of other organizations in the 11 sites (from a review of telephone

book classified listings [e.g., “Yellow Pages”] and chamber of commerce lists

and modified by other sources, including staff members’ knowledge of the

community) was more than 1,500 groups, of which about 56 percent were

religious organizations and 24 percent were civic and fraternal organizations

(Table 1). The number of religious organizations serving the communities

totaled more than 800.

All communities contained a wide range of organizations, such as those

listed above. In addition, various communities mobilized less traditional

organizations such as Drug Abuse Resistance Education (DARE), WIC agency

offices, the Puerto Rican Day Committee, and summer youth programs to

implement successful intervention activities. In one site, Medford/Ashland,

OR, there was no local health voluntary association presence at all, whereas

in another, there was a small operation dedicated to preserving its existing

mandate and tasks rather than expanding its role. In the Vallejo, CA, and

Raleigh, NC, sites, health voluntary associations were the most powerful,

Table 1

Initial tallya

 of other organizations in the COMMIT intervention sites, by type of organization

Type Number Percent

Religious Organizations 843 55.7

Business/Professional Groups 101 6.7

Fraternal/Sorority Groups 80 5.3

Civic Groups 281 18.6

Trade/Labor/Union Groups 105 6.9

Groups With Health Mandateb 80 5.3

Miscellaneous Groups 23 1.5

Total 1,513 100.0

a These numbers reflect the specific organizations generated by staff in each site in the preliminary community

analysis from review of telephone book classified listings, chamber of commerce lists, and other local sources prior

to final trialwide adjustment of operational criteria for interventional and promotional organizations.

b This category includes organizations beyond those that would be targeted through the health care providers or

worksites channels.
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best funded, and most visionary tobacco control advocates. Both wellknown, longstanding groups (e.g., health voluntaries, the Rotary Club)

and local, shorter term, grassroots coalitions (e.g., Minority Coalition for

Cancer Prevention, Coalition for Health and Responsible Public Policy,

Healthy Mothers/Healthy Babies, Community Partnership for Substance

Abuse, neighborhood coalitions) played central roles in COMMIT’s attempts

to meet its objectives.

A typology of community organizations was developed in response

to cross-community diversity and COMMIT’s varied needs. The activities

mandated by the COMMIT protocol for organizations were designed on the

premise that community organizations tend to play one or both of two basic

roles in tobacco control efforts: (1) acting as institutions through which

smokers can be contacted directly or (2) serving as a source of volunteers

and other resources that can be engaged in tobacco control efforts directed

broadly at the community. In the first case, the organizations were expected

to provide a locale where smokers periodically gathered or through which

smokers might be reached with mailings, organizational policies, activities,

special events, and cessation programs. Organizations so identified were

designated as “interventional” organizations. Particular organizations such

as large churches and business-related groups such as chambers of commerce,

unions, and service organizations were designated interventional

organizations when they met the following criteria:

• Active membership of at least 50 adults as evidenced by:

— size of attendance at meetings;

— size of attendance at organization-sponsored events; and

— number of dues-paying members (persons committed enough to

send in dues are likely to be accessible through an organization’s

mailouts).

• Meet at least six times a year.

• Have a regular meeting place.

• Have a number of members who smoke, as determined by available

information (e.g., key informant, informal conversations with one or

more members).

• At least 30 percent of membership are estimated to be community

residents.

In addition to those criteria, limits were placed on the size of religious

organizations targeted for intervention activities. Given the many religious

organizations in some COMMIT sites, limited resources did not permit

that interventions be directed at all of them. Reasoning that religious

organizations with 250 or more members would be likely to reach more

smokers than those with fewer than 250 members, the size of the religious

organization became an additional eligibility criterion.
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188

Other targeted organizations

were designated as “promotional”

organizations, although some fit in

both promotional and interventional

categories. Promotional activities were

those that were held to contribute to

community smoking control efforts in

one or more of the following ways:

• generating community

recognition of, interest in, and

sanction for the COMMIT project;

• providing greater access to the

socioeconomically disadvantaged

and other nonmainstream groups

likely to include heavy smokers;

• increasing the amount of

information available in the

community regarding smoking cessation/control efforts and resources;

• generating volunteer support for COMMIT activities;

• providing material resources (e.g., money, supplies, equipment,

meeting space);

• enhancing media coverage, publicity, and other public relations

activities related to smoking control;

• contributing to community mobilization for smoking control through

the creation or enhancement of local networks; and

• helping to increase the number of quit attempts made by community

residents.

This approach was designed for organizations that did not necessarily

include a substantial number of smokers within their membership yet might

be willing because of their mission or role in the community to involve

volunteers or other resources to the tobacco control cause.

Once revised operational criteria were employed, the number of

organizations designated for assessment of progress toward process objectives

totaled 726 interventional and 702 promotional organizations across the

11 sites (Table 2). Beyond the challenge posed by the sheer numbers

involved, the numbers by community illustrate the diversity existing among

the sites: The number of interventional organizations ranged from a low

of 46 to a high of 138, and promotional organizations ranged from a low

of 21 to a high of 256. Site ratios of the number of organizations targeted

for intervention activities to the total population ranged approximately from

.0005 to .001, with only slight agreement between size of community and

number of organizations identified for intervention.
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Table 2

Numbers of interventional and promotional organizations for assessing annual achievement of

process objectives, by site, for the initial 3 years of interventiona

Sites Interventional Promotional Both

Site A 50 77 127

Site B 57 78 135

Site C 47 27 74

Site D 103 53 156

Site E 138 256 394

Site F 54 69 123

Site G 46 21 67

Site H 67 105 172

Site I 86 34 120

Site J 85 24 109

Site K 50 36 86

Total 726 702 1,428

a Adjusted totals for the final intervention year summed only a few more: 727 and 713 for interventional and

promotional organizations, respectively. Sites are listed in random order.

The emphasis in the channel of other organizations shifted early in the

COMMIT project. In the planning phase, a wide variety of organizations

were featured as potentially equivalent, with the relative importance of

their diverse types to be

determined locally. However,

as the evaluation requirements

of the overall project were

articulated into mandated

activities and concrete process

objectives, religious organizations

emerged as the sole type of

organization in the channel that

could be formally evaluated in

standardized fashion (Mattson et

al., 1990-91; Corbett et al., 1990-

91). In light of the considerable

diversity of organizations in

communities and the difficulty of

generating comparable sampling

frames of organizations across

communities, a decision was

made to use a survey of religious

organizations as a kind of proxy

for assessing the penetration and
Smoking and Tobacco Control Monograph No. 6

190

efficacy of COMMIT activities in diverse organizations. The articulation of

this in the mandates expressed in the COMMIT protocol (i.e., required

activities and process objectives) and the recognition of the survey of

religious organizations as a critical evaluation tool resulted in a shift in local

understandings of priorities in the channel. In most sites there was also a

corresponding shift in activities implemented in the channel. Religious

organizations came to preeminence in this channel at a trialwide level and in

most communities. Requirements for evaluation data drove the intervention

to a degree unforeseen by COMMIT’s designers.

The mandated activities of this channel are given in Table 3 and reflect

the difference between interventional and promotional organizations.

Presentations To increase awareness of the tobacco problem, COMMIT staff

on Smoking members and volunteers made short presentations of at least

Issues 15 minutes to organizations targeted for intervention during the

groups’ regular meetings. Presentations included information on smoking

cessation, the health implications of tobacco use and secondhand smoke,

policy and program resources, and national as well as local trends in tobacco

control. If appropriate, COMMIT speakers also provided information on

legal issues and publicized upcoming smoking policy and cessation seminars

and workshops. Organizations likely to include a high proportion of smokers

on their membership rolls, such as labor unions or veterans’ groups, were

emphasized. Promotional organizations also were contacted in an effort to

strengthen local tobacco control networks.

Table 3

Activities and process objectives for organizations

Cumulative Process Objectives

Objectives Number Achieveda

Activities for Each Community (1988-1992) Completed (%)

Short Presentations to Organizations

Targeted for Intervention 30% 83

Comprehensive Seminars to

Organizations Targeted for Intervention 44 seminars 40 seminars 91

30% 77

Promotional Activities in Organizations

Targeted for Intervention 50% 152

Distribution of Self-Help Materials in

Organizations Targeted for Intervention 50% 160

Distribution of Promotional Materials to

Organizations Targeted for Intervention 50% 172

Annually Involve Organizations Targeted

for Promotion in Magnet Events 440 497

organizations organizations 113

a Average for combined communities.
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Seminars Seminars or policy presentations of at least 1 hour in length were

on Smoking offered to representatives of organizations targeted for intervention.

Issues The longer format allowed presenters to cover tobacco control topics

in more detail. Workshop content included the health implications of

tobacco and secondhand smoke, cessation resources and strategies, national

and local trends, legal issues, and policy and program options. Examples of

nonsmoking policies and cessation efforts from local organizations were

highlighted. In some communities separate seminars were held, for example,

for religious groups or labor organizations. In other cases, tobacco control

issues were covered as part of a larger workshop agenda on a related topic,

such as substance abuse, that was designed to reach larger numbers of

participants.

Activities To foster member participation in communitywide cessation events,

Promoting COMMIT staff members and volunteers conducted promotional

Magnet Events activities in organizations targeted for interventional and

promotional activities. In conjunction with “magnet events” such as

“Quit and Win” contests, The Great American Smokeout (GASO), and

Non-Dependence Day, COMMIT staff members distributed event materials,

solicited signups, displayed information, and conducted other activities

such as carbon monoxide testing.

Promotion Although activities and materials teaching the skills needed to quit

of Self-Help smoking were already available in most communities, the COMMIT

Materials project sought to enhance the effectiveness and penetration of these

and Cessation cessation resources by directly targeting interventional organizations.

Services Posters, flyers, brochures, pamphlets, and other information were

delivered directly to organizations for distribution to their members who

smoke. In addition, materials encouraged smokers to join the Smokers’

Network. The network, created by COMMIT, was a voluntary list of smokers

in each community who were interested in receiving mailings designed to

provide information on how to quit smoking and remain smoke-free (see

Chapter 8 [Lichtenstein and colleagues]).

SUCCESSFUL EFFORTS Community groups already existed in most sectors of the

WITH COMMUNITY community and, consequently, provided useful structures

ORGANIZATIONS for enlisting smokers on the network, reaching diverse

populations, and bringing about restrictive tobacco control policies and

bans. To recruit smokers to COMMIT’s Smokers’ Network, communities

enlisted the support of groups as diverse as the Girl Scouts of U.S.A., WIC

providers, ethnic organizations, sports groups, and the American Red Cross.

Activities ranged from health fairs, materials dissemination, and a “Butt-out

Party,” including a display of the domino effect of 720 cigarette packages.

Diverse populations were reached through DARE in Bellingham, WA,

the Puerto Rican Day Parade in Paterson, NJ, and food distribution at

neighborhood health centers. Community grants also were given to

various organizations to reach diverse populations in creative ways, thereby

promoting cessation and maintenance. The Vallejo site provided a positive,

high-energy experience in tobacco prevention and cessation through its
Smoking and Tobacco Control Monograph No. 6

192

“African-Americans Celebrate Life” event. In sites

that achieved restrictive tobacco control policies

and bans (e.g., local ordinances banning vending

machines), success resulted from the collaboration

of tobacco control advocates with other coalitions,

such as substance abuse prevention groups,

community organizations such as the Boy Scouts

of America, and police and health departments.

Communities used sports and recreational events;

for example, Utica, NY, disseminated a tobacco-free

message to 1,500 fans of the Champion Boomerang

Team in a “Throw Tobacco Out of Sports Campaign.”

Medford/Ashland and Bellingham each held a

“Smoke-Free Night” with local baseball teams, and Yonkers, NY, promoted

a “Nix to Nicotine” basketball game. Paterson held a rally against cigarette

billboards in collaboration with the National Coalition of Negro Women.

Organizations involved in promotional activities included groups

with a health orientation (e.g., American Red Cross, American Dietetic

Association, American Chiropractic Society, community hospital

auxiliaries), service and civic organizations (Big Brothers/Big Sisters, Hispanic

Community Progress Foundation, Rotary Club, Soroptimists), and business

and professional organizations (e.g., chambers of commerce, downtown

merchants’ associations, personnel directors’ associations). Examples of

their “promotional” involvements with COMMIT included assisting with

the development of local tobacco control events; staffing the GASO and

Tobacco Free Young America activities; generating publicity for smoking

control efforts and specific events through meeting announcements,

networking, newsletters, and bulletin boards; providing volunteers, local

staff, and Board members for smoking control efforts; and providing

other resources, advice, and expertise for the implementation staff.

In all sites, representatives of community organizations were integrally

involved in local COMMIT planning, program design, and decisionmaking.

Health-related organizations such as local health departments and health

voluntary agencies, such as the American Cancer Society (ACS), ALA, and

American Heart Association (AHA), played key roles in many communities.

Members of civic and service clubs were mobilized to assume promotional

roles as the project’s leaders sought broader participation and outreach

by citizens. From the outset COMMIT sought existing coalitions for

health promotion or substance abuse prevention and joined with them or

encouraged them to participate in COMMIT’s efforts. In many communities,

civic task forces and community coalitions that addressed drug-related

issues were encouraged to add smoking control and educational efforts.

In Brantford, Ontario, Canada, town forums were called to foster grassroots

ideas and involvement in the initial stage of the project; these events also

generated some volunteers for the project. In a few communities, COMMIT

formally subcontracted with local organizations to carry out mandated
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activities, thereby capitalizing on a local agency’s experience and creativity

with, for instance, smoking cessation resources or media advocacy. In

Utica, the Summer Youth Employment Program trained and employed

young people from low-income families to counsel smokers to quit while

those smokers were attending community centers (e.g., health clinics or

WIC clinics) or community sponsored programs (e.g., blood pressure

screening programs).

Cooperating with existing groups in public events was a creative way

to foster partnership with the community as well as gain publicity. A youth

theater group in Vallejo, eager for an opportunity to be involved, produced

skits that humorously illustrated the fact that smoking is not at all glamorous

or sophisticated. In Bellingham, COMMIT participants paraded publicly in

a turkey costume, to promote

“quitting cold turkey,” and in

cigarette costumes in an annual

parade. Vallejo and Medford/

Ashland used a Statue of Liberty

and “Statue of Liberation from

Tobacco” theme, one site for

Halloween and the other for a

Fourth of July parade. In Cedar Rapids/Marion, IA, Girl Scouts marched

in a parade along with a COMMIT float, and the entry won second prize.

Publicity through such activities may well have assisted in establishing

the legitimacy of COMMIT efforts in the community as well as furthering

smoking control goals.

COMMIT communities’ successes included an “Adopt-A-Tavern”

campaign, as in Bellingham and Fitchburg/Leominster, MA, in which

volunteers became responsible for keeping taverns, bars, bowling alleys,

and other facilities where smoking is prevalent

supplied with materials about tobacco control and

cessation. Paterson found it beneficial to work

through youth groups in religious organizations to

get information about tobacco control to the entire

membership.

The primary emphasis in COMMIT’s other

organizations arena was on large religious

organizations. Although this was found by all

communities to be a difficult channel, several

experienced successes using a variety of innovative

approaches. In Cedar Rapids/Marion, a coalition of

representatives from the U.S. Attorney’s Office,

Substance Abuse Free Environment (SAFE) coalition,

Iowa Substance Abuse Information Center, and

COMMIT Cedar Rapids sponsored “Congregations

for a Substance-Free Environment: A Conference

for Clergy and Lay Leaders.” The conference was
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194

attended by 150 people representing a broad spectrum of religious and

ethnic groups. As one of the financial sponsors for this conference, COMMIT

was able to contact difficult-to-reach organizations and encourage religious

organizations and social service organizations to think of tobacco use as

an addiction. Specifically, the conference asked attendees to consider the

following issues: (1) tobacco as a drug along with alcohol and drugs,

(2) the dangers of passive smoking, (3) the need for education and cessation

interventions, (4) the establishment of smoke-free policies at places of worship

as well as worksites, and (5) the continuing efforts of tobacco companies to

thwart these efforts through extensive advertising. This event led to a halfday strategic planning conference to discuss possible interventions and a

workshop to train ministers and lay leaders in intervention skills.

To involve churches in more than just the provision of self-help materials

and information about local cessation resources, Paterson implemented a

proactive “adopt-a-smoker” campaign aimed at nonsmoking church members

who were asked to do the “morally right thing,” that is, help someone in

need: a smoker. Working through the Paterson Pastor’s Workshop, an

organization composed of about 32 area ministers, a “Smokeless Sabbath”

program was initiated. It was a day of religious observance that would be

declared by the congregation as a day during which smoking issues would

be the focus of the sermon, educational materials would be disseminated,

and available community resources would be identified.

COMMIT in Vallejo reported some success in this channel. An

ecumenical focus group of local ministers was convened to develop strategies

for effectively involving religious organizations in tobacco control. The

focus group generated one consensus issue that they believed would be of

universal concern to religious organizations: They did not want young

people to start smoking. Based on shared information from recent research

about tobacco use and youth, the clergy members recommended moving

away from the “tired and worn” health education approach to tobacco

prevention and suggested highlighting instead the youth-oriented marketing

efforts of the tobacco industry (Fischer et al., 1991; DiFranza et al., 1991;

Pierce et al., 1991). COMMIT staff members reported that once they

understood churches’ perceived role in promoting ethical standards among

their congregations (and especially with youth), staff members were able to

engage them in advocating against the tobacco industry marketing strategies.

Staff members designed a biblically based curriculum using discussion and

visual aids to encourage youth to discuss how to assess claims to truth made

in tobacco advertising, how such marketing affects youth, the health effects

of smoking, and potential advocacy opportunities to combat the efforts of

the tobacco industry. The foundation for the 1-hour curriculum was the

story of King Solomon’s gift of wisdom that enabled him to discern right

from wrong. The “Mission Possible: Target YOUth” curriculum was reviewed

and approved by a panel of teachers, ministers, and health educators and is

still being used in some Sunday school programs.
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CHALLENGES The key process objective for this channel, making

ENCOUNTERED presentations to at least 30 percent of organizations targeted

WITH COMMUNITY for intervention activities, was not achieved on a trialwide

ORGANIZATIONS basis. The average across sites was 25 percent, and only four

sites met the goal of 30 percent. Although one community succeeded in

in reaching 52 percent of rostered organizations, two sites reached only

10 percent of the organizations. Problems were experienced by all the

communities in using other organizations.

A few problems were linked to the protocol’s definitions and

specifications. For the initial 2 years of COMMIT’s intervention phase,

staff members across the 11 sites struggled with the protocol’s nebulous

distinction between interventional and promotional organizations.

Definitional ambiguities across the trial were not resolved until late 1990.

Gathering the necessary information for categorizing specific religious

organizations was a burdensome task. Once designated as promotional,

an organization may not have been targeted for attention until late in the

intervention. Although it may have been logical to present an informational

talk to a promotional organization before requesting cooperation or

resources, staff members reported that such a step was often neglected

because, by the protocol’s mandates, only presentations to interventional

organizations “counted” toward process objectives (see Table 3). Many

communities expressed greater success, or greater optimism, only in the

final year or two of the intervention period.

COMMIT’s designers underestimated the difficulty COMMIT staff

members and volunteers would experience in establishing contact with and

gaining access to interventional organizations that were assumed to have

smoking members. Although some activities were as simple as the delivery

of cessation information and materials, many fraternal, service, and laborrelated organizations such as the Elks, Lions, Masons, Veterans of Foreign

Wars groups, and unions had no one onsite during business hours. In many

organizations, access to meetings was restricted to members only. Often, it

was only after repeated return visits that contact was established with a

member or staff person. In at least one site, gatekeepers were then found to

be protective of members who smoked and resistant to smoke-free policies

or dissemination of cessation information. Many groups met only for social

gatherings and business meetings and had no forum for outside speakers to

present programs.

There were also multiple challenges in dealing with promotional

organizations such as parent-teacher associations (PTAs), substance abuse

prevention programs, and service clubs (e.g., Rotary, Lions, Soroptimists).

These organizations were diverse, each with its own established mission

and full agenda. Many did not perceive community tobacco control

activities as a priority. Staff members typically found that getting to know

organizations well was labor intensive, and they questioned the efficacy

of the time spent making these contacts. Likewise, in many communities

the ideas of reciprocity, linking with organizations’ existing agendas, or
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196

expanding beyond a single-issue approach were not developed until late

in the project. Finding a “hook” with which to involve organizations with

COMMIT required knowledge of their missions and structures. One potential

hook was to highlight concerns about youth (everyone wanted to help young

people), but with COMMIT’s focus on adult smokers, staff members and

volunteers were reluctant to use children’s issues as “bait.”

COMMIT’s most logical ally among community organizations was

thought to be the health voluntaries (ACS, CCS, AHA, ALA), but experiences

with them varied across sites. In six sites (Bellingham, Medford/Ashland,

Fitchburg/Leominster, Santa Fe, NM, Paterson, and Yonkers), the local

voluntaries were found to be struggling for volunteers and funds. In these

sites COMMIT became responsible for the smoking problem and the local

health voluntaries focused their resources on programs targeting other risk

factors or diseases, such as breast cancer, high cholesterol, asthma, and

tuberculosis. In a few communities where the voluntaries were strong,

COMMIT Boards and staff members had to deal with competition, conflictof-interest, and turf issues. Recruitment of volunteers for COMMIT through

other organizations was sometimes viewed as competition in a shrinking

community pool of potential volunteers. Four communities (Utica, Vallejo,

Cedar Rapids/Marion, and Raleigh) contracted with or gave grants to the

voluntaries to carry out some required activities. Developing requests for

proposals and reviewing them, plus monitoring progress toward achieving

process objectives, took a great deal of COMMIT staff time.

As the intervention progressed, several sites added community organizers

to the staff to concentrate their efforts to achieve process objectives. Sites

began to recognize that combining worksites and organizations under one

task force was not effective because outreach to organizations tended to

become a low priority on an already crowded task force agenda. The sheer

numbers of organizations in some communities was daunting (see Table 2);

for many staff members and volunteers, there seemed to be barely enough

time to say hello as flyers and informational materials were delivered to

organizations. Paterson set up a separate community task force to target

this channel.

In the last 2 years of intervention, most COMMIT sites designed

new strategies to reach heavy smokers. Although the protocol did not

specifically target low-income, minority, or high-risk populations, there

was a growing awareness of their importance as targets and messengers

for tobacco control. Staff members and volunteers focused on agency

settings such as employment offices, job training programs, WIC food

voucher distribution clinics, American Red Cross blood drives, gospel

mission shelters, and community centers serving minority populations.

Special events were targeted at places smokers frequent, including outdoor

sports stadiums, bowling alleys, bingo halls, and bars/taverns. At the

same time communities used umbrella organizations such as human

services coalitions, minority coalitions, and community action agencies

to promote intervention activities.
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Although some COMMIT communities experienced successes in working

with their community’s religious organizations, many reported facing a

multitude of problems in forming partnerships with this sector. Pursuing

clerics as intermediaries in smoking control seemed to be a natural course

because bonds often are formed between congregations and clerics who are,

in general, respected members of the community. However, many clergy

were not receptive to COMMIT’s attempts. For some,

resistance was passive; clergy did not respond to verbal

or written attempts to enlist their support. Others

explained that tobacco control was not a priority issue.

The Brantford site had an involved and helpful minister

on the community Board, but as its final report stated,

“even with his help” they were unable to “crack”

religious organizations. Smoking was not common

among parishioners, and it was not a priority issue.

The failure of some clerics to view smoking as an

important issue had several explanations. In some

sites clerics immersed in the issue of substance abuse

and other social problems did not acknowledge the

connection between smoking and other drug use.

Others felt that churchgoers were not involved in drug

use. Often, staff members heard that smoking is not an

issue because “no one smokes in church.” Some who

did acknowledge the problem of smoking and nicotine

addiction resisted outside intervention efforts, relying

on the religious organization to provide answers. Some

clerics, especially smokers, expressed skepticism as to their ability to help

people quit. Other reasons for resistance included the clergy’s already taxing

workload and an unwillingness to take on another burden or join one more

community organization. Some congregations were concerned that

implementing smoking policies would conflict with income-producing

church functions such as wedding receptions and bingo games. One

church was reluctant to implement a smoking policy for fear of alienating

a church board member who smoked.

Resistance also was fostered by the diversity of religious denominations.

In some communities religious organizations or clergy were responsive to

umbrella organizations that often had different agendas. For example,

in Yonkers, two of the four umbrella groups were involved in the city’s

struggle to introduce desegregated housing. In Cedar Rapids/Marion, plans

for a clergy conference were complicated by competing events, including the

actions of an ecumenical clergy group (spanning Christian denominations)

that sought to exclude non-Christian faiths from participating in the planning

committee and refused to change its name to an interfaith council.

Work with religious organizations relative to other efforts within

COMMIT was often so labor intensive that staff members wondered whether

results were worth the level of effort and resources invested. Because most
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198

churches had few or no paid staff members, many attempts were made

to reach the cleric before receiving a response. In Medford/Ashland, staff

members reported that it took an average of six attempts before contact was

made. Staff members became frustrated with unreturned telephone calls

and having to leave messages on machines. When a staff person was reached,

he or she was frequently unwilling to act as a representative for the church.

At least two communities reported that some church staff members refused

to accept materials while the pastor was out.

Despite difficulties, communities continued to develop strategies to

include religious organizations in smoking control activities. In some

cases, task forces developed activities specifically to elicit clergy support

and address their issues. Based on feedback from a presentation to the clergy,

Yonkers COMMIT developed a seminar on addiction to educate clergy on

the problems of nicotine and other drug

addiction and to give them specific tools

for identifying and addressing this

problem. A planning committee

was established, and outreach efforts

were extensive; however, only two

clerics participated in planning the

event. The clergy’s lack of response

prompted the committee to broaden

the seminar’s focus to include other

community intermediaries as well as

the general public. In Raleigh, a

seminar incorporating nicotine with

substance abuse was designed for clergy.

Staff members felt challenged to keep

peace within planning meetings and

were disappointed by the limited clergy

turnout. Other issues arose regarding

the view by some major religious

denominations that alcohol and drug

use is a sin; thus, an individual smoker’s need for the church’s help would be

viewed as an admission of sinning. Although a similar conference in Cedar

Rapids was mostly successful, staff members faced challenges in maintaining

the issue of tobacco use on the program because the conference planners and

audience had more interest in alcohol and drugs. Staff members had to

repeatedly remind the planning committee to include tobacco in each

part of the event.

Making presentations to church groups also proved to be challenging.

In Fitchburg/Leominster, three staff members repeatedly contacted religious

organizations to schedule presentations, with little response. In Medford/

Ashland, the community involvement coordinator focused much of her

energy on reaching clergy through presentations but had little return on

her time and effort. Similarly, in Yonkers, staff members devoted many

hours to reaching targeted churches but made minimal progress. Although
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presentations were made at two meetings of the community’s largest umbrella

group, attendance was poor, and staff members felt that participants were

merely being polite. At the second meeting, clergy admitted that smoking

was not a priority issue; housing, desegregation, and substance abuse were

their primary concerns. When offered suggestions for prohealth activities

that would involve the congregation, attendees stated that they could only

post informational and cessation materials. However, when following up

on the attendees’ willingness to display cessation information, staff members

found that, in reality, few were willing to help.

Overall, COMMIT communities had to overcome many obstacles to

accomplish objectives with religious organizations. Staff members and task

forces often redefined objectives to make progress in enlisting support and

involvement. Eventually, communities were gratified by even minimal

successes, and project reports packaged these achievements in a positive light,

perhaps to help maintain morale. Regardless of the individual experiences,

staff members learned a valuable lesson in attempting to work with religious

organizations on the issue of smoking control: Be prepared for a challenge.

EXPERIENCES Overall, the community organizations channel was reported to be

WITH OTHER the most problematic, difficult, and frustrating of the intervention

ORGANIZATIONS channels. In most

ACROSS THE instances even high

COMMUNITIES levels of staff and

volunteer effort did not

produce much return on their

investment. Communities

were concerned that they did

less well than they would have

liked in reaching blue-collar

workers, ethnic minority

groups, and low-income

smokers.

The development of

relationships with existing

organizations was a critical

task at each site. Involving

existing community

organizations in the local

definition, refinements, and

governance of the project was

a basic strategy for community

mobilization in COMMIT, and

community groups were a

prime source of grassroots

support, volunteers, and staff.

Community groups provided

an extensive network of local
Smoking and Tobacco Control Monograph No. 6

200

persons from multiple backgrounds and with a great variety of affiliations.

Working with or joining existing organizations and coalitions was valued

over creating new, competitive, or exclusive structures or replacing activities

that were within another group’s domain. However, gaining entree into

much of the other organizations channel was inordinately time consuming

for representatives of all the COMMIT communities. As several sites’ final

reports explicitly stated, community organizations may have been a more

useful target for the dissemination of information than for direct involvement

in activities. “The payoff isn’t worth it,” said Raleigh’s report, “unless it’s

already part of their agenda. Otherwise the most impact you get is to become

‘speaker of the week’” (Community Intervention Trial for Smoking Cessation,

1993a, p. 8). Medford/Ashland staff members summarized their experiences,

“No real successes here” (Community Intervention Trial for Smoking

Cessation, 1993b, p. 10), and Bellingham COMMIT said it was “never able

to convince organizations to be concerned about this issue” (Community

Intervention Trial for Smoking Cessation, 1993c, p. 2).

Why were so many organizations, across all the communities, difficult to

penetrate? Some staff members speculate that they may have been besieged

already with requests from nonprofit organizations and community causes.

Organizational “gatekeepers” may have been protecting the organization

from outsiders’ requests. Some organizations were inaccessible by telephone

or in person; presumably, some were without a paid staff, street address,

regular office location, or telephone-answering machine. The meetings of

some organizations included no forum open to outside speakers or issues.

Most key organizations already had full agendas, and tobacco may not have

been a logical add-on. COMMIT recognized also that smoking and health

issues were often seen as unrelated to the group’s purpose. The charter of

organizations with regard to such issues varied widely, and whereas one

group (e.g., the high school PTA) might have been eager to emphasize

smoking control and prevention, another seemed to regard it as counterproductive interference with their principal objectives. Yet another

organization might have seen smoking as irrelevant to their activities.

Finally, and importantly, COMMIT brought a single-issue, time-limited

mission into intervention communities that had many existing, longstanding

organizations, and COMMIT was a new, “outsider” organization with no

local history, name recognition, or promise of longevity.

Productive relationships required knowledge of organizations individually

as well as existing coalitions, networks, and other umbrella organizations.

To be successful, COMMIT intervention activities had to be congruent with

the contexts and cultures of each community (Bracht and Gleason, 1990).

Community analyses developed in the first months of the project (see Chapter

5 [Thompson and colleagues]) were essential sources of information for later

programs (Bracht, 1988). They were based on review of media, secondary

sources, and interviews with informants from the communities and described

community organizations, leaders, and historical considerations that acted as

potential facilitators of or barriers to COMMIT efforts. The trial also required

that a local Community Planning Group be formed to nominate and recruit
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Chapter 11

COMMIT Board members. The planning group was to recruit members

who were representative of the various key local organizations as well as

to modify the community analysis so that good decisions about involving

various groups could be made. However, the planning did not predict the

amount of time and ongoing interpersonal interaction with organizations

that most sites believed would have been essential to success in this channel.

The COMMIT protocol called for a Worksites and Organizations Task

Force. The task force was a means of involving organizations in tailoring

and implementing the specifics of intervention activities in the communities.

The task force, under the direction and guidance of the COMMIT Board,

prepared an annual action plan to specify how activities would be

implemented in its community. In some communities, other groups

were used or formed to target organizations more effectively. For instance,

Vallejo drew on the community’s minority coalition, and Paterson

established a separate community task force.

Activities mandated by health promotion projects needed to be flexible,

creative, and sensitive enough to reflect varied needs of diverse situations.

Significant time and resources were needed to identify sites, develop creative

ideas, and maintain individuals’ involvement throughout the project with

an issue whose relative priority was low to begin with or was threatened by

other issues. Communities noted that being put on organizations’ agendas

was often difficult and labor intensive and staying on the agendas and

producing results required ongoing “nurturing.” Many organizations had

no forum available for presentations on tobacco issues. Decisions had to be

made about the level of participation to be solicited from different groups,

taking into account the level of effort necessary for recruitment, training,

and coordinating activities. In some situations, despite COMMIT staff

members’ allegiance to principles of cooperation and the enhancement of

local resources, COMMIT was perceived by persons in other organizations

as a competitor for local resources, such as volunteers or funding.

All communities found it useful to localize and tailor their approaches

with community organizations based on the staff members’ and task forces’

knowledge of the group’s goals,

needs, structure, and general

mode of operation. The level

of participation solicited

varied along a continuum

of involvement from little

to extensive and intensive.

Between those poles were

activities such as one-time

involvement on a specific

activity (e.g., posting flyers

about the GASO on a bulletin

board, speaking out at a city

council meeting), to regular
Smoking and Tobacco Control Monograph No. 6

202

information dissemination (e.g., publishing notices each month about

smoking cessation classes in the organization’s bulletin), to central

involvement in an event (e.g., designing and riding on a theme float

in a parade), to an ongoing role on a task force.

Many organizations had little interest in participating in assessing

needs, designing elements of the project, setting smoking control agendas,

or otherwise taking on leadership roles. Their representatives may have

had little experience with, understanding of, or interest in several optional

activities around tobacco control or were not interested in adding another

item to an already full agenda. However, many appeared to be comfortable

with small roles in specific activities. A typical mode for addressing social

issues that fell outside the organization was to respond to specific requests

from other groups or people for concrete, time-limited help. Consequently,

it was a sound, appropriate strategy for COMMIT task force members and

their staffs to decide how they could best use the services of selected

organizations and to make specific, direct requests of them.

Given the different nature, size, and history of communities and

their associations, a major focus on a particular type of organization (e.g.,

religious organization) was deemed wise in some communities but not in

others. For instance, in the COMMIT sites situated in metropolitan areas,

the membership of some organizations contained many nonresidents,

so targeting them for interventions was not thought to be as useful as

emphasizing other organizations or even other intervention channels.

For example, a community where a ministerial association already included

innovators in church-based health promotion warranted a different approach

and expectations than a community where major religious institutions

were only marginally involved in communitywide social concerns or

where competing agendas overwhelmed the attention of the leaders.

With only a few exceptions, the COMMIT communities questioned

whether pursuing religious organizations as a means to reach smokers was a

productive use of staff time and resources. A Cedar Rapids/Marion informant

described churches as “the most difficult of the difficult” groups to reach, and

a staff member from Raleigh said, “Forget them; they might not have been

worth the effort.” Field staff members in Brantford rated their religious

organizations’ involvement and use of resources as low and the difficulty of

working with them as high. Although in these sites the field staffs attempted

to maintain a minimum level of contact with these target groups, they often

redirected energies to other channels where the anticipated effect was greater.

For those communities able to overcome some obstacles, progress was made

through hours of staff time and one-on-one contacts. The key to Vallejo’s

moderate success was reported to have been a staff person’s being a practicing

Christian. As that site reported, “Once religious organization leaders learned

this, doors started to open.” But just as having the right person among the

staff members or volunteers was critical, so was finding the right counterpart

in the religious organization.
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Chapter 11

Overall, few religious organizations were perceived by staff members

to have participated in COMMIT’s motivational, educational, or cessation

activities. Attendance by representatives of religious organizations at

workshops or seminars on smoking issues was reported to be low. A few

religious organizations already prohibited smoking by members (e.g., SeventhDay Adventists, Mormons), and some seemed to regard a smoking control

focus as unnecessary, unless like some Seventh-Day Adventist congregations

they regard tobacco control and education as part of their mission.

Special skills were needed by the COMMIT staff members charged

with conducting mandated activities in the diverse organizations found

in the sites. Knowledge was needed of current and past activities of local

organizations in health and smoking issues and of organizations’ histories

of working with other groups. Staff members needed special skills for

encounters and meetings with people of different education, class, and

ethnic backgrounds, including chief executive officers, union representatives,

blue-collar workers, grassroots activists, and representatives of ethnic groups.

They needed to understand the benefits and problems of working with

volunteers and to be able to work effectively with them. Staff members

also needed to recognize that some citizens and organizations (e.g., unions,

blue-collar smokers) objected to smoking control activities and had to be

prepared to address these objections with clarity and sensitivity. They

needed to attend to media coverage as well as promotional activities of

local organizations. Staff members’ efforts required creativity in tailoring

or designing activities for local organizations and in enlisting support for

promotional activities. They also needed to be committed to recruiting

diverse persons and organizations, especially underserved groups and those

with a high prevalence of heavy smokers.

RETHINKING HOW With the benefit of hindsight, what should or could have

TO WORK WITH been done differently with community organizations? To

COMMUNITY meet its objectives, COMMIT needed to generate community

ORGANIZATIONS recognition of, interest in, sanction for, and practical support

of the project and its goals among all sectors. COMMIT required more time

to nurture relationships with organizations, to address smoking appropriately

within local and parent organizations, and to tailor activities to them.

Community groups and organizations presented unique opportunities and

stages for information dissemination and enhancement of project visibility

in the community. Nevertheless, the consensus was that this was a timeconsuming and often thankless channel where few “victories” occurred.

If the protocol were rewritten with the benefit of hindsight, the

mandates for handling other organizations would need to define better

which constellation of organizations and which specific organizations in

the communities should have highest priority. Perhaps an innovative way

to map and visualize community organizations and the sectors they serve

could be developed, and the Program Records onsite data management

system could be expanded to allow for better cross-referencing and tracking

of organizations. That other organizations were linked with worksites in
Smoking and Tobacco Control Monograph No. 6

204

the Worksites and Organizations Task Force probably contributed to most

communities’ lesser emphasis on organizations through much of the trial.

It may have been productive to tie organizations more explicitly to the

Cessation Resources Task Force, or a task force dedicated only to organizations

might be considered. Finally, the protocol’s nature may have inhibited

pursuit of some needed but neglected onsite activities. Concrete numbers

specified in process objectives became targets, and the concern for evaluation

data outcomes may have unwittingly driven decisions in the field. Although

communities were encouraged to tailor the protocol to the local context, as

one staff member said, “Instead, we let it creep in and color our thinking

about the smoking problem. The protocol encouraged us to think like

managers (civil servants) counting off numbers of organizations contacted

instead of thinking like entrepreneurs, being creative about how to work

effectively with those that might be most important to our success.”

Experiences affirmed the need for fitting COMMIT’s agenda and plans

into those of targeted community organizations. To implement activities for

COMMIT’s other organizations channel, special skills, information, creativity,

and access to expertise were needed. This included information about the

structure, goals, formal and informal modes of operation, means of economic

support, management practices, governing bodies, and decisionmaking

mechanisms of diverse individual organizations. Activities may be more

effectively and efficiently implemented when there is a period of ongoing

involvement during which trust can be built, when there is regular attendance

at community events, and when collaboration among participants and of

agendas occurs between organizations.

COMMIT staff members and volunteers found that having a person

supportive of COMMIT’s goals working inside a community organization

was useful. The personal ties of task force, Board, and staff members with

leaders in other organizations opened many doors. Where these bonds did

not already exist, entrée often required a high personal investment of time

and energy, commodities that were sometimes in short supply.

In working with religious organizations, communities usually proceeded

from the assumption that the largest, most prominent religious organizations

in communities should be the primary targets for COMMIT because they

had the greatest potential for affecting the most people. In hindsight, a better

strategy would have been to initially target the religious organization with

which a staff or task force member had a personal affiliation or which had a

clergy member known in the community for social activism involvement in

health promotion. Where it is determined that religious organizations should

be brought into smoking cessation and control activities, emphasis should be

placed on strategies for reaching and engaging them.

Discussions late in the project with Christian clerics in COMMIT-related

focus groups generated suggestions for approaching religious organizations

with tobacco control messages. Two key variables emerged: (1) moral codes

regarding smoking and (2) the size of the organization. First, churches with
205

Chapter 11

strong moral codes (i.e., smoking regarded as a “sin” and unlikely to be

discussed openly by smokers) should be approached with an outreach

ministerial program to offer to other family members, friends, or coworkers.

The basic assumption is that although the church members may not smoke,

they may live next to, work with, or know people who do. The program can

focus on how individuals can help others quit smoking. In churches without

clear moral codes around smoking and where smoking is often allowed

during social gatherings, the approach of having a smoke-free activity and

offering an educational program around passive or secondhand smoke can

be used. In such a setting it would then be possible to offer self-help

materials and possibly a smoking cessation class. Given that a program

taking place in a religious organization already has a certain moral tone, care

should be taken to ensure that any smoke-free message be as positive and

nonblaming as possible. In developing a program for any size church (moral

code or not), a packaged approach would be best. If the message is directed

toward youth, prevention education programs can be offered to both types

of churches during Sunday School or youth education classes.

Second, church size and type should inform program implementation.

For the purposes of developing intervention strategies, knowledge of the

relationship between the size and characteristics of religious organizations

would be useful. Local church leaders readily supply ideas of categories

and critical features of different organizations, as in Vallejo where a focus

group generated a set of types, including family churches, pastoral churches,

program churches, and corporate churches. A shortage of research in this

area precludes firm recommendations, but it is important that approaches

to churches be carefully tailored to general and local considerations.

Seminars and workshops designed to attract representatives of diverse

organizations should address topics relevant to them, based on careful needs

assessment and groundwork. If tobacco is not immediately recognized as an

important issue, it may be more productive to add it to whatever agenda is

already a central theme in the organization, whether family life, substance

abuse, or social outreach.

Was specifically targeting community and civic organizations, clubs,

churches, and other local associations for interventional activities worth

the substantial effort involved? Significant problems were reported in

every community. Given the limited resources and the competing priorities

of other trial activities, it remains unclear whether the energy needed to

mobilize these diverse groups was well spent.

In sum, the other community organizations channel was more nebulous

and equivocal in COMMIT than the more conventional channels relating

to health care, worksites, cessation resources, and the media. It may have

considerable potential for targeting smokers, reinforcing smoking control

messages and policies in the wider community, and disseminating smoking

cessation information, but strategies for efficient and effective cooperation

still need work.
Smoking and Tobacco Control Monograph No. 6

206

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AUTHORS

Kitty K. Corbett,Ph.D.,M.P.H.

Adjunct Investigator

Division of Research

Kaiser Permanente Medical Care Program

3505 Broadway

Oakland, CA 94611

and

Assistant Professor

Health and Behavioral Sciences, CB-103

Department of Anthropology

University of Colorado at Denver

P.O. Box 173364

Denver, CO 80217

Linda Nettekoven,M.A.

Project Coordinator

Oregon Research Institute

1715 Franklin Boulevard

Eugene, OR 97403

Linda C. Churchill,M.S.

Project Director

Department of Preventive and Behavioral

Medicine

University of Massachusetts Medical

School

Room S-7, 746

55 Lake Avenue North

Worcester, MA 01655
Smoking and Tobacco Control Monograph No. 6

208

Lesa T. Dalton

Project Director

Division of Health Promotion Research

American Health Foundation

Fifth Floor

800 Second Avenue

New York, NY 10017

Carolyn L. Johnson,R.N.

Program Manager

Healthy Start Program

Jackson County Department of Health and

Human Services

Building A

1005 East Main Street

Medford, OR 97504

Lysha Dickinson

Research Associate/Project Coordinator

Division of Research

Kaiser Permanente Medical Care Program

3505 Broadway

Oakland, CA 94611

Glorian Sorensen,Ph.D.,M.P.H.

Associate Professor

Department of Epidemiology and Cancer

Control

Dana Farber Cancer Institute

Harvard School of Public Health

44 Biney Street

Boston, MA 02115

Beti Thompson,Ph.D.

Associate Professor

University of Washington School of Public

Health and Community Medicine

Associate Member

Fred Hutchinson Cancer Research Center,

MP-702

1124 Columbia Street

Seattle, WA 98104
209

Chapter 12

Promoting Communitywide Tobacco

Control Activities by Involving Schools

Deborah Bowen, Lesa T. Dalton, Rosemary Walker, Susan Crystal,

and Mario A. Orlandi

INTRODUCTION Tobacco use among youth is a critical public health problem.

National surveys from high school classes from 1975 to 1990 indicate that

smoking rates among adolescents had not declined in comparison with

adult smoking rates (Johnston et al., 1991). Recently, rates of lifetime use,

use in the past 30 days, and half-pack daily use have not declined from 1991

and 1992 to 1993 among 8th, 10th, and 12th graders (National Institute

on Drug Abuse, 1994). Trends in smoking prevalence among high school

seniors of both sexes are presented in Figure 1. These data indicate clearly

that cigarette use rates among adolescents have changed little over the past

decade and also suggest that smoking could be on the increase among those

in this age group. Similar findings have been reported by others, including

reports in a series of nationally representative estimates of smoking among

U.S. youth ages 12 to 18 conducted by the U.S. Public Health Service since

1968 (U.S. Department of Health and Human Services, 1994). The trend for

teens is directly opposite that for adults, whose smoking rates have declined

steadily among both men and women since the mid-1970’s (Shopland, 1995).

The data presented in Figure 1 represent an older, in-school population

and do not include those youth who dropped out of school before their

senior high school year and who have higher smoking rates than those who

stay in school. Thus, the magnitude of the youth smoking problem is likely

to be higher than the figures for high school students suggest. The lack of

progress in reducing youth tobacco use on a national level has led researchers

and community health experts to search for opportunities to influence youth

smoking behavior. The Community Intervention Trial for Smoking Cessation

(COMMIT) has provided several of these opportunities. This chapter describes

COMMIT intervention activities to reduce youth tobacco use that were

connected with schools. It describes the rationale for including youth and

schools in COMMIT and the intervention and evaluation strategies related

to schools. It also includes the field experiences in implementing the schoolbased youth tobacco use interventions and discusses some of the lessons

learned about working with schools in the hope that the knowledge of

those experiences might help others working with school-based public

health tobacco programs.

Rationale for As discussed in Chapter 2, the main goal of COMMIT is cessation

Including Youth among adults who are heavy smokers, with the primary

in COMMIT intervention targets being adult smokers who smoke more than

25 cigarettes per day. The initial reaction of investigators to including youth

as a focus within COMMIT was that it was inappropriate. Youth are not
Smoking and Tobacco Control Monograph No. 6

210

Figure 1

Prevalence of daily smoking among high school seniors, by gender, 1976-93—

percentage smoking one or more cigarettes per day during previous 30 days

Source: Lynch and Bonnie, 1994.

likely to be found in the target group (i.e., heavy smokers) of COMMIT.

Many members of the steering committee thought that including a focus on

youth would detract from the focus on adults and on heavy smokers. Some

further thought that all available resources should be spent on heavy smokers

and that there were not enough funds for targeting youth. Over time, the

scientific groups realized that COMMIT would enhanced the likelihood of

change in the communities by including youth, so a youth intervention

and evaluation component was added.

The decision to broaden the intervention and evaluation targets to

include youth was based on several arguments. First, it was hoped that

youth could serve as a conduit to reach heavy smokers. Anecdotal evidence

from school-based smoking prevention programs indicates that many

parents are pressured to quit by their children. There is a consistently

positive relationship between parent and youth smoking, indicating that

influencing youth smokers may help reach adult smokers. It was hoped

that targeting youth would prove an additional source of both pressure

on and encouragement for heavy smokers to quit. Second, and equally

important, it was hoped that communitywide intervention targeting adults,

especially heavy smokers, would increase awareness of smoking as a public

health problem among young people and those who deal with them in their

daily activities. Such awareness could reduce youth smoking as well. If adults

are actively involved in trying to quit smoking, they might present smoking

in a negative light to their children and other youth. This could result in
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Chapter 12

fewer adolescents starting to smoke. In a larger perspective, youth as well as

adults should be aware of several components of the COMMIT intervention,

including communitywide media intervention, advertising bans, and

interventions in public places. These communitywide interventions

theoretically should change community norms about smoking and make

it more difficult for youth to begin using tobacco.

Rationale for Schools are an excellent channel for reaching youth and have

Recommending received much research attention. There is an extensive body of

School-Based knowledge about the most efficacious school-based smoking

Interventions prevention curriculum to implement at the junior high school level

in COMMIT (Flay et al., 1983). School-based curriculum programs have been

evaluated in previous vigorous research programs and are widely available.

There is evidence that these programs have consistent short-term effects

(Best et al., 1988) and therefore should form part of a comprehensive

communitywide effort to reduce smoking. Many schools across the country

have mandates to include or mention smoking as part of general health

education or drug abuse prevention, although this varies by region and

locale. However, few schools provide focused attention and curriculum

time to tobacco control without guidance and support from experts, and

it is in this expert role that COMMIT staff members could collaborate with

schools to implement appropriate curricula.

School policy regarding tobacco, and subsequent policy enforcement,

is another area of school-based intervention, with support for efficacy in

preventing onset. Policy alters health behavior when the policy is clearly

and simply stated, when it is fairly and consistently enforced, and when

the means for following it are available to all whom it affects (Sabatier

and Mazmanian, 1979). Most COMMIT schools had a policy limiting

smoking in some fashion (Bowen et al., in press). Many schools had a

smoking area or allowed smoking outside the school building. However,

few schools disseminated the policy clearly, enforced it consistently, or

provided full resources for students to follow it. The limited data on the

effects of policy on smoking rates indicate that school policy, when clearly

stated and enforced in a positive manner rather than a punitive one, is

related to lower levels of youth smoking (Penz et al., 1989).

Youth are essentially a captive audience at school for several hours per

day. To affect youth smoking it is essential that the school be used as a

channel for providing clear, strong messages against smoking and other

tobacco use. Policies involving no smoking on school grounds or at school

events could be one strong message, provided it is enforced and supported.

Other ways to provide messages at school include the policies that govern

teachers’ smoking behavior. Community activities that involve youth in

the planning or the activities are appropriate for increasing the visibility of

smoking as a social problem. COMMIT interventions attempted to include

all these strategies in their arsenal.
Smoking and Tobacco Control Monograph No. 6

212

INTERVENTION The goals for this channel were to (1) increase the percentage of

ACTIVITIES public schools that are tobacco-free, (2) increase the percentage

AND PROCESS of heavy smokers in the community who perceive social pressure

OBJECTIVES from their children to quit smoking, and (3) decrease the

FOR SCHOOLS prevalence of smoking among youth. To achieve those

objectives, several mandated activities (see Table 1) were developed. The

interventions were based on the previously cited literature on school-based

intervention where available (e.g., Glynn, 1989 [see below]). Where other

information was not available, interventions were based on examples of

tobacco-related youth activities that, in the experience of the intervention

teams, had been successful in involving youth. The major strategies are

described below.

Curriculum Initiatives Each site was given several resources to encourage schools

to initiate tobacco use prevention curricula in schools or to improve on

existing efforts. These included an article by Thomas Glynn, then program

director for smoking research at the National Cancer Institute, called

“Essential Elements of School-Based Smoking Prevention Programs” (Glynn,

1989), which discussed strategies within existing programs that seem most

critical for successful smoking prevention packages, including prices,

descriptions, and ordering information. The field staff members at each

site were encouraged to use these and other available materials.

School Policy Policy changes of all types were a major focus of COMMIT, in keeping

with the community and public health nature of the intervention focus.

Influencing school policies on smoking was thought to be different from

influencing State or community law about smoking because of the process

by which organizations such as schools make decisions about their internal

rules and functioning. However, some COMMIT communities sought to

make changes in school policy at the State level (e.g., Oregon). Although

knowing that clear, enforced school smoking policies could prevent tobacco

use, COMMIT staff members used care in coming from outside the school

system to alter policy. To promote policies, many communities used a

manual created by the National School Board Association on creating

Table 1

Activities and process objectives for schools

Cumulative Objectives Process Objectives

(1988-1992) Achieveda

Activities for Each Community (%) (%)

Distribute Smoking Policy Materials

to School Boards 100 94

Annually Contact Schools Not

Smoke-Free 100 96

Provide Tobacco Curriculum

Information to Educators 85 104

a Average for combined communities.
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Chapter 12

and implementing school policies. This well-written manual includes a

description of types of nonsmoking policies, methods of deciding on and

implementing the policies, examples of policies that have been implemented

and all the supporting legal and other documents used in the implementation

process, and a list of school districts nationally that were willing to provide

technical assistance. Again, COMMIT field staff members were encouraged

to use these documents to assist schools in forming strong, restrictive tobacco

use policies.

School-Based Other activities involving schools were not clearly defined in a

Activities That protocol and were left up to the field staff and schools to negotiate.

Target Youth These included using schools to publicize community events

involving youth and recruiting youth from schools to help with covert

tobacco-buying adventures (see Chapter 13). The accessibility of youth

through schools enabled many community-based activities to involve

youth more fully.

School Activities Youth were used as a conduit to reach the adults in their lives,

That Target Adults both passively and actively. The school student is a conduit

for information to smokers or potential smokers at home.

Young people can be organized into groups to seek out and recruit adults

into antismoking activities. These adults can be relatives, other community

members, or even members of the press, who can send a powerful message

about smoking’s harm. COMMIT interventionists were encouraged to

consider using youth to “hook” adults whenever they could.

IMPLEMENTING In many of the 11 COMMIT intervention sites, community Boards

SCHOOL-BASED included representation from the education sector, such as district

INTERVENTIONS personnel (e.g., superintendents, assistant superintendents), health

educators specializing in drug abuse prevention, teachers, and

Community parent-teacher association (PTA) members. Although sites with

Board school gatekeepers (i.e., those who could “open doors” to

Membership individuals) on their Boards expected to have fairly easy access

to the school system, that was not necessarily the case. Some sites were

hampered by uncooperative key contacts whose individual personalities

or smoking status created difficulties in working with the schools. At sites

with school decisionmakers in a COMMIT leadership role, there was

occasional conflict between the task force and the Board over youth or

school activities, thus reducing some of the task force’s autonomy. In one

site this occurred so frequently that the uncooperative COMMIT member

was bypassed whenever possible by directly approaching the targeted

schools or teachers to plan activities.

Boards were generally enthusiastic about youth activities and, in

particular, activities with an educational focus. However, there was criticism

from Boards about the protocol’s minimal focus on youth tobacco use

prevention education. Project staff members often struggled to explain

the reasoning behind the protocol’s relatively minimal focus on youth

activities and to involve schools in cessation activities. Activities like the

American Heart Association’s (AHA) Save a Sweet Heart (SASH) campaign
Smoking and Tobacco Control Monograph No. 6

214

were embellished to increase their educational focus; for example, in some

sites teachers were given educational materials for classroom use.

Task Force Youth and school activities fell under the jurisdiction of the public

education task force; however, a few sites divided the public education task

force into a media task force and a youth task force, thereby creating five

task forces to carry out COMMIT activities in those communitites. Many

communities formed formal subcommittees within the public education

task force to carry out youth- or school-based activities and planned

activities under their general task force agendas; other sites established

ad hoc subcommittees. Many sites had some school personnel representation

on task forces or subcommittees, although these individuals were not

necessarily decisionmakers. Even individuals holding high-level positions

within the school system often acted more as liaisons to COMMIT than

as representatives of the schools. In sites where there was no school

representation on the task force, planning for activities that were either

promoted or conducted through the schools was complicated; task forces

had to negotiate several tiers of decisionmakers to obtain approval for

implementation. Some sites established separate task forces comprising

youth. These task forces then took on the responsibility of ensuring that

mandated and other activities within schools were implemented.

Volunteers Teachers, guidance and peer assistance counselors, school nurses, PTA

members, students, and others played key roles in implementing schoolbased youth activities. Volunteerism was essential for implementing policy

initiatives, “magnet events,” and promotional activities within the schools.

Without the dedication and enthusiasm of these volunteers, task forces would

have had little support for implementing or promoting activities for youth

within the complex structure of most sites’ school systems. Volunteers from

the schools were also essential when youth attempted to recruit adults into

programs, as was done in New York in Yonkers’ second “Quit and Win”

contest and other campaigns.

In addition, volunteers played a key role in promoting school-based

youth activities. For instance, in Brantford, Ontario, Canada, teachers were

supportive of a poster campaign based on the themes “How to get your

friends to quit smoking.” They incorporated the campaign into a classroom

activity and made nominations for a poster contest. Many students in grades

1 through 8 entered the contest, and the 18 winners of free tickets to the

Toronto Blue Jays baseball game on “World No Tobacco Day” arrived in

chauffeured limousines. In Yonkers, teachers were instrumental in the

implementation of two annual “No Proof, No Puffs” campaigns within the

schools. These campaigns focused on activities to encourage stores to ask

for age identification before selling tobacco products to adolescents.

Teachers who are also COMMIT volunteers worked with staff and students

to incorporate smoking prevention and cessation education into classroom

activities. The first year, after writing to local area merchants, students

went with their teachers from store to store to deliver their letters and other

information regarding legislation on youth access to tobacco. The second
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Chapter 12

year, teachers helped students write letters to merchants about youth

access and to magazine publishers asking them to stop accepting tobacco

advertisements. There were other classroom activities on the issues of

smoking, and teachers developed a “Smoke-Free for a Week Partnership”

campaign in which students encouraged the adults of their choice to quit

smoking for a week. In all these examples, volunteer support provided the

mechanism for educating youth and helped to foster good will for tobacco

control efforts throughout the community because of the publicity these

activities received.

Other types of volunteer support included stuffing envelopes, staffing

booths, distributing survival kits, disseminating materials, and promoting

activities.

Sometimes

gatekeepers

provided access

for volunteer

support by

appointing staff

members within

the schools to

assist with a given

activity or by

identifying

personnel

interested in

smoking control

activities.

Gatekeepers also

helped COMMIT

by directing staff

or task forces through appropriate channels for implementing smoking

control activities within the schools. At other times, staff members and task

forces enlisted volunteers through personal and professional contacts.

PATTERNS OF The types of activities implemented by COMMIT interventionists

SCHOOL-BASED that focus on schools are summarized in Table 2. This list of

INTERVENTIONS activities was obtained from quarterly reports submitted by each

study center (Corbett et al., 1990-91). This table does not represent

Intervention all activities for each community but only the most salient for the

Activities data collection staff. The four categories (activities For Youth, To

Influence Youth, Involving Youth, and Through Youth) represent the four

common methods of targeting youth, each with different purposes, potential

efficacy, and commitment of staff and other resources.

The first category of activities, For Youth, included those types of

activities that were relatively easy to do and included information provided

to students in the context of an existing meeting, class, or structure. Many

schools produced displays about smoking and quitting. Curricula were
Smoking and Tobacco Control Monograph No. 6

216

Table 2

Types of youth-related activities in COMMIT

For Youth To Influence Youth Involving Youth Through Youth

School displays School policies Art, theater Outreach to other youth

Classes/curricula Teacher exposure Special events Outreach to adults

Substance abuse focus School staff exposure Advertising

Events during school Public statements Contests

Events after school Resources

Social events Projects

offered as part of health or physical education classes. Although COMMIT

sites were mandated to provide state-of-the-art educational materials to

schools, there was little opportunity for task forces and staff members to

work one on one with educators to expand this activity beyond the mandated

material dissemination process. Most sites were able merely to supply their

school district with curriculum materials. However, some States like Iowa

and Massachusetts held teacher training workshops, or as in Brantford, staff

members were given the opportunity to schedule a workshop. Many times

these curricula were integrated with a drug abuse prevention program, such

as Drug Awareness Resistance Education (DARE) or SASH. For example, in

Yonkers field staff members worked with the AHA and the Yonkers Pulse

Healthy Heart Project to disseminate educational packets promoting SASH

to more than 12,000 students’ homes. The packets contained interactive

materials for parents to use in talking about smoking with their children,

AHA SASH pledge cards to quit smoking for a specified time, activity sheets,

and COMMIT smoker registration cards in English or Spanish. Students were

asked to encourage their smoking parents to return the registration cards by

mail. In addition, part of the intervention was to have parents and students

work on the activities together at home, and students were expected to bring

completed sheets back to school for class discussion. Unfortunately, few

smoker registration cards were returned through the mail, and few activity

sheets were returned through the schools.

However, COMMIT staff members were able to work onsite with SASH

youth volunteers and student assistance counselors at information booths

in the schools on SASH days. Staff members performed expired carbon

monoxide testing on adult smokers; distributed self-help brochures, cessation

guides, and survival kits; and registered some faculty and school personnel

in the Smokers’ Network.

As a result of these efforts, the issue of smoking is permanently integrated

into a community organization in the form of sessions, movies, and ongoing

discussions. Events that occurred during or after school hours, such as

assemblies and club meetings, were used as vehicles for getting word about

smoking to youth. Speakers at classes and gatherings were included to
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Chapter 12

emphasize a motivating aspect of quitting smoking. Social activities, such

as adopt-a-younger-student days and career days, were used to include an

antismoking message. Special antismoking activities, such as puppet shows,

rallies, and theater presentations, were used to increase awareness about

smoking in an enjoyable and entertaining manner.

The second category of activities, To Influence Youth, was conducted on

the social and environmental structures that can promote or reduce smoking

in the youth environment. Contact with

teachers was used as a consistent way to

indirectly influence youth. Teachers attended

special COMMIT-led training sessions as an

in-service requirement and received advice

from COMMIT staff on the choice of curricula

and other teaching devices. Other school

personnel and youth-oriented staff members

were exposed to COMMIT messages via staff

discussion, training, and encouragement.

Counselors at schools received special training

in helping students quit smoking. PTAs and

school boards received presentations and

encouragement from COMMIT staff. Officials

from schools were encouraged to take a public

stand on the problem of tobacco use. Coaches

at schools and in the community were urged

to treat tobacco use as a health problem.

Several local restrictions on access, including

sales to minors, were organized first through schools and school personnel.

Enforcement of existing school policies with positive supportive approaches

and penalties was encouraged. These broadbrush intervention strategies

probably helped to reach students who would not have been reached by the

more traditional curriculum-based interventions.

The third category of activities, Involving Youth, involved youth

as players in the planning or execution of the activity. Several different types

of art projects and drama projects were developed, written, staged, or played

by youth as part of class or school projects. Contests were held to get the

messages of COMMIT out to youth, including contests in art, kite making,

floats, athletics, essays, rap music, and photographs. In addition, youth in

several communities attempted to counter the tobacco companies by creating

counteradvertising. These activities often were sponsored by COMMIT staff,

but young people were asked to plan and create the activities and often

became involved in the final products.

Finally, for the fourth category of activities, Through Youth, young

people served as a conduit to other youth groups and to adult heavy smokers.

Individual COMMIT sites used this option in different ways. For example,

some sites distributed cessation flyers and materials for youth to take home

to give to family and community members. Some sites organized youth to
Smoking and Tobacco Control Monograph No. 6

218

speak to other young people, often to groups of younger or disadvantaged

youth. Some sites had youth recruit and enroll adult smokers in the COMMIT

Smokers’ Network. Students wrote to local officials, tobacco companies, and

their school personnel. Most sites found youth willing to participate actively

in helping others to stop smoking.

Successes and In general, communities wanted to do more in prevention than

Failures Across the protocol provided for; in fact, in many communities task force

Communities members were more interested in prevention than cessation and

had difficulty understanding why the project did not have a stronger

prevention focus. Communities thought that youth are important as

a channel to reach adult smokers. Youth also provided a channel to the

media when they were involved in newsworthy activities.

Most sites found schools to be fairly difficult to work with compared

with other groups in the community. Field directors believed that a

comprehensive approach was needed to involve schools, which COMMIT

did not have a clear mission to provide. The amount of effort for COMMIT

staff members to get schools involved varied from site to site, ranging from

one site reporting that it took little effort to three sites reporting that it took

a great deal of effort. The tendency of schools to leave tasks to the COMMIT

staff was not as great as that of some other groups, but this also varied greatly

from site to site. The extent to which schools used COMMIT information was

high, with nearly half the sites reporting they used it a lot.

Schools collaborated willingly with COMMIT at most sites. Often, they

showed some ownership of COMMIT activities or the project as a whole.

Several sites found that schools showed innovation in implementing or

institutionalizing COMMIT activities. There was considerable variation

in the extent to which schools showed leadership or creativity in designing

activities. There was also considerable variation in the provision of resources;

several sites reported that schools provided many resources and in-kind

donations, especially for poster contests and flyers, whereas other sites

reported that few resources were provided.

Two communities had smokers on the school board who opposed smokefree school policies. In one community, this barrier was not overcome. In the

other, a COMMIT letter to the editor in a local newspaper initiated a public

dialog that resulted in the policy’s being implemented successfully. When nosmoking policies were implemented, schools in some communities became

more amenable to COMMIT activities. For instance, in Brantford the school

board enlisted COMMIT’s assistance in handling the logistics of implementing

its new smoke-free buildings policy. Oregon held a successful school and law

enforcement summit following the passage of an antismoking ordinance.

Some communities felt constrained in their approach to schools, either

because there were limited entry points to schools—they required a formal

approach through appropriate administrative channels—or because other

groups already were involved in selecting and providing school

smoking curricula.
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Chapter 12

An Example of Brantford held a poster contest with the theme “How to get your

a Successful friends to quit smoking” in early 1991. There were 18 prizes—

Youth Activity tickets to a Toronto Blue Jays baseball game on World No Tobacco

Day—with the winners to be driven to the game by limousine. Two prizes

were allocated for each grade (1 through 8), and two prizes were to be

allocated by a random draw from early entrants. On the advice of a task

force member, prizes were awarded randomly as opposed to through a

judging process. Task force members obtained the necessary school board

approval, with the assistance of two COMMIT Board members (an elementary

school principal and a superintendent) who were familiar with the system.

A letter was sent to each school principal, and if the principal agreed to

participate, classroom packages were sent to each teacher in the school

through the board’s mail system. Each child was given a flyer and an entry

form to take home, both describing the contest and containing educational

information on smoking. A parent’s signature was required to allow the

poster to be displayed publicly and to indicate that the child was permitted

to accept the prize if he or she won. Several classroom teachers supported

the contest enthusiastically, and there were several instances where a whole

class submitted an entry as well as the anticipated individual entries. In

addition to creating a focus on smoking cessation in the schools, the contest

also provided some publicity opportunities. There was press coverage of

the winners heading to the baseball game, and a selection of the posters

was subsequently displayed in the community at the public library and

at a health fair mall display.

Youth Activities Across Ontario in winter 1992, a petition for a smoke-free

With Some School planet was circulating and collecting names, with the objective

Involvement of being able to measure the length of the petition in miles.

(and Mixed Success) The activity was sponsored by the Council for a Tobacco-Free

in Brantford, Ontario (CTFO), which at that time functioned primarily

Ontario, Canada as a coalition of the various agencies involved in smoking

reduction and focused on events for National Non-Smoking Week and, to

a lesser extent, World No Tobacco Day. COMMIT was one of the partner

organizations in the CTFO. The petition was launched during National

Non-Smoking Week and was to be presented to a government official in a

ceremony to take place in Brantford on World No Tobacco Day. In almost

all involved communities, the petition was circulated through the schools.

Brantford public health nurses, who had contact with the schools, led the

effort. However, a resident from the nearby tobacco-growing area objected

to the antitobacco information that accompanied the petition, and as a

result, the Brant County Board of Education recommended that each

principal decide whether to allow the petition to circulate in his or her

school. Some allowed it, and some did not. The final petition was two

and a half times as long the Canadian National tower (the world’s tallest

freestanding building) in Toronto.

In another example, the worksite task force held a video contest.

The theme was smoking cessation, and one objective was to obtain some

short videos that could be used in conjunction with presentations. One
Smoking and Tobacco Control Monograph No. 6

220

place targeted for contest entries was the schools. Getting appropriate

administrative approvals proceeded smoothly, but because of either an

administrative problem or lack of interest, the contest registration and

information materials did not get distributed in the schools for several

weeks. When COMMIT staff members noticed this, they succeeded in

arranging distribution, and there were several excellent entries from

students. Audiovisual staff and teachers at the schools were supportive

of the students who prepared entries.

Examples of Some COMMIT sites achieved success in promoting changes in school

Successful smoking policies. For instance, in Cedar Rapids/Marion, IA, the public

School Policy education task force formed a smoke-free schools subcommittee in

Initiatives September 1989 to change the school district’s smoking policy.

Although the standing policy prohibited youth from smoking on school

grounds, it allowed teachers and employees to smoke in designated areas.

The proposed change was complete ban in all district buildings and vehicles,

but no restriction on smoking outside the buildings.

The smoke-free schools subcommittee wrote letters and disseminated

policy information to the PTA presidents and school board members. They

also obtained 300 signatures from individuals supporting smoke-free schools

and presented their proposal to the school board. In response to the proposal,

the school board scheduled two public hearings. At the first hearing, which

was not well attended, there was no opposition to the proposal. The only

two people to address the school board were members of the subcommittee.

The second hearing received greater publicity and attracted more than

20 individuals. Opposition to the proposed policy changes was evident

from the statements of several teachers and other school employees. A

counterpetition with 281 signatures opposing the change was submitted

to the school board. Despite opposition, almost 6 months after the initial

presentation to the school board, the smoke-free schools proposal was

approved on a 4-to-2 vote. The new policy was instituted at the beginning

of the next calendar year, and cessation classes were offered to help smokers

quit.

Another successful school policy initiative occurred in Yonkers. In

response to the New York State Clean Indoor Air Act, the Yonkers school

district decided to institute a restrictive smoking policy. After the school

board approved the policy, administrators worked with legal counsel to

develop a written policy and distributed a lay version to all employees.

Friendly reminders were disseminated to all district personnel over the

3-month planning phase informing them of the number of days until the

implementation of the new policy. Concern over employee welfare prompted

the formation of a wellness committee that COMMIT joined. Although the

district wanted to set an example for students and the community, it also

hoped to minimize tensions among school district employees.

COMMIT worked with district personnel and the Yonkers Pulse Healthy

Heart Program to provide materials for the district’s approximately 950

smokers at the initiation of the new policy. Heart-healthy snacks, bottled
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Chapter 12

water, and cessation referral information as well as self-help materials were

given to each of the 37 schools to help support smokers during the first

week of the policy’s implementation. Volunteers were recruited to prepare

materials, and school nurses assisted by staffing tables and counseling

smokers. These supportive efforts helped to minimize employee hostility

over the new policy and maintained a feeling of good will between the

district and its employees. It also helped to promote smoking as a public

health issue and educated nonsmokers about the difficulties smokers face

in quitting.

Using Youth Although some youth channel activities were conducted within school

and Schools systems, others were only promoted there. The Yonkers second annual

as a Channel quit-smoking campaign, called “A Thousand Good Reasons,” used

youth as a draw or hook to motivate adults to quit. The event matched

an adult smoker with “an adopted child” in a 6-week campaign resulting

in a grand prize of a $1,000 savings bond for the youth’s education and a

$250 supermarket gift certificate for the adult smoker. This effort sought

to entice community participation by children, ages 5 to 18, encouraging

adult smokers to quit. Promotion of this event occurred throughout the

community in a variety of sectors, including the public schools. COMMIT

was able to enlist the support of the school district through the district’s

public relations director, principals, and teachers. The public relations

director contacted all elementary school principals, requesting their support

in the dissemination of information promoting the contest. Through the

schools, COMMIT was able to reach the parents of 12,000 students by

having the students distribute flyers. In addition, through the district’s

central office, registration forms were sent to 1,360 teachers, administrators,

and maintenance personnel. Posters were hung in each school, and the

assistant superintendent was interviewed on the local cable television station

to promote the campaign. One teacher who registered allowed her quitting

progress to be followed throughout the 6-week period by the community’s

major daily newspaper and the cable station.

Yonkers’ COMMIT field staff members also helped to organize two

annual “No Proof, No Puffs” campaigns. The first-year elementary students

went to local merchants to distribute information regarding the New York

State law prohibiting the sale of tobacco products to minors, statistics on

youth smoking, and display signs promoting the law. COMMIT staff

members arranged for publicity, helped prepare materials, and provided

a luncheon for students and teachers. Teachers enhanced this activity by

planning a week’s worth of lessons on smoking issues and helped students

develop a song about preventing youth smoking that was performed for the

entire school. Likewise, field interventionists played a significant part in the

implementation of the second annual No Proof, No Puffs campaign. Field

staff members worked with teachers to develop and plan activities as well as

to coordinate the intervention. Staff members provided resource materials,

collated “survival kits” for the Smoke-Free Partnership participants, gave

T-shirts to student participants, arranged publicity, and even served pizza

to students, teachers, and parents at the culminating celebration.
Smoking and Tobacco Control Monograph No. 6

222

In the above examples, the schools were an effective vehicle for promoting

smoking control activities. However, there were other instances throughout

the trial where local districts hampered COMMIT’s efforts to promote change,

ignoring the fact that adults are critical role models for children. For example,

in Vallejo, CA, the local school board sought to obtain a $700,000 grant for

the school district from RJR Nabisco Foundation. A vocal group of COMMIT

volunteers organized to block the school board’s efforts to obtain the grant

because of the “tainted” funding source. The COMMIT volunteers chose to

frame the issue as a problem of insufficient school funding and an increase

in the tobacco companies’ handouts for youth projects, rather than reflect

negatively on the school board’s actions. The volunteers met, formulated

plans, and presented resolutions to the school board and other community

groups. Fortunately, the school district was not awarded the grant, although

its attempts forced COMMIT volunteers into action to enlighten the school

board about the hypocrisy of accepting money from the tobacco industry.

Another example of a school district hampering COMMIT efforts occured in

Brantford, as discussed above. The Council for a Tobacco-Free Ontario

sponsored a petition for a smoke-free planet to coincide with World No

Tobacco Day and National Non-Smoking Week; its goal was to measure

petition length in miles. Almost all Ontario communities circulated the

petition through the schools, but the Brantford school district would not

permit the petition to be circulated even though the community was one

of COMMIT’s intervention sites.

In other cases, individuals presented barriers to change. For example,

although administrators in Utica, NY, were supportive of implementing a

smoke-free school district, they were not ready to fight the school board

and local unions, which had smoking members. This resistance became

even more frustrating to COMMIT when another school district outside the

intervention community asked for help in initiating a smoke-free policy.

LESSONS LEARNED Several lessons were learned from implementing COMMIT

FROM COMMIT school-related activities, although these lessons were not

SCHOOL-BASED completely understood until the end of the intervention

ACTIVITIES project. For example, distributing materials to schools is

relatively easy, but getting schools to use the materials and institute projects

is more difficult. Often, materials would sit forgotten on a shelf until a

COMMIT volunteer found them and reminded someone to use them.

School personnel have many issues and activities to deal with, and a

smoking prevention curriculum was sometimes not high enough on the

list of priorities to move forward. Most COMMIT sites would have liked

more direct input into planning school-based intervention activities, but

the role of COMMIT field staff members was often restricted by the school

administration. Field staff members found the dissemination process for

curriculum and school policy information frustrating because they were

allowed only minimal contact with individual school decisionmakers and

had little information about how (if at all) COMMIT materials were used

in most cases.
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Another difficulty was a difference in the definition of the role of the

school in children’s lives. Some school administrators and teachers (and

parents) saw themselves as the purveyors of knowledge and not as the

conveyance for the solutions to social problems. Smoking, by COMMIT’s

definition a social problem, sometimes did not fit under what was perceived

as the school’s mandate. The COMMIT interventionists thought that they

needed more time to work with school personnel to help them see themselves

as health promotion agents and as well as educators. This translated into

a need for more followup on delivery of curriculum and policy recommendations regarding smoking.

Some COMMIT interventionists found that encouraging the enforcement

and implementation of school policy is more difficult than setting policy.

Enforcement of policy often requires resources and constant monitoring,

sometimes beyond the strained limits of schools today. At times the

enforcement of policies limiting smoking in schools put teachers and staff

in awkward positions (i.e., the role of the cop or “bad guy” rather than the

students’ friend). The issue of enforcing smoking or tobacco policy when

other seemingly more important policies go unenforced is a difficult choice

for officials who are overworked and whose schools are understaffed. The

COMMIT teams believed that there was much more to be done to enforce

current policies in schools.

Most COMMIT field staff members found that youth could function well

within the structure of COMMIT. The caution for the field staff was not to

underestimate the effectiveness of teenagers, because they can be incredibly

competent. In many sites, youth identified activities, planned the strategies,

and participated fully in community organizing. Youth need “hands-on”

projects with lots of activities for them to do. Youth of all ages participated

in COMMIT, from elementary school children to college artists who designed

some of the projects, logos, and other materials. Involving youth in as many

activities as possible was encouraged and can be increased in an intervention

like COMMIT.

Youth smoking is a highly visible issue in a community and draws

attention from many groups and constituencies. Prevention is a high-profile

media issue. Print and broadcast media writers and photographers will use

information from youth in addition to expert or community testimony.

Schools can help community organizers by providing good access to media

for students. Youth can be coached to respond well to the limelight and

can testify before local and State governing bodies with effectiveness.

Young antismoking advocates can be effective for prevention and

cessation. Adults can be pressured by their children or by any children to

quit smoking, and older children can influence younger children not to

start smoking. In addition, prevention is a more compelling concept

for volunteers than cessation. Many people want to help keep children

from smoking, whereas some feel uncomfortable pushing adults to quit.

Community Boards felt that organizing a community for prevention could
Smoking and Tobacco Control Monograph No. 6

224

help to encourage adults to quit as a side benefit. In some cases, community

interest in youth antismoking efforts threatened to overshadow adult

cessation activities. It took a great deal of planning and encouragement

for interventionists to redirect the focus and energy on youth smoking to

a broader one of tobacco control in the community.

REFERENCES

Best, J.A., Thompson, S.J., Santi, S.M., Smith, E.A.,

Brown, K.S. Preventing cigarette smoking among

school children. Annual Review of Public Health 9:

161-201, 1988.

Bowen, D.J., Kinne, S., Orlandi, M. School policy in

COMMIT: A promising strategy to reduce smoking

in youth. Journal of School Health, in press.

Corbett, K., Thompson, B., White, N., Taylor, M.

Process evaluation in the Community Intervention

Trial for Smoking Cessation (COMMIT).

International Quarterly of Community Health

Education 11(3): 291-309, 1990-91.

Flay, B.R., D’Avernas, J.R., Best, J.A., Kersell, M.W.,

Ryan, K.B. Cigarette smoking: Why young people

do it and ways of preventing it. In: Pediatric and

Adolescent Behavioral Medicine, P. McGrath, and P.

Finestone (Editors). New York: Springer-Verlag,

1983, pp. 132-183.

Glynn, T.J. Essential elements of school-based

smoking prevention programs. Journal of School

Health 59: 181-186, 1989.

Johnston, L., O’Malley, P.M., Bachman, J.G. Drug

Use Among American High School Seniors, College

Students, and Young Adults, 1975-1990. Volume 1.

High School Seniors. DHHS Publication No. (ADM)

91-1813. Rockville, MD: U.S. Department of Health

and Human Services, Public Health Service,

Alcohol, Drug Abuse, and Mental Health

Administration, National Institute on Drug

Abuse, 1991.

Lynch, B.S., Bonnie, R.J. (Editors). Growing Up

Tobacco Free: Preventing Nicotine Addiction in Children

and Youths. Committee on Preventing Nicotine

Addiction in Children and Youths. Washington,

DC: Institute of Medicine, National Academy of

Sciences, 1994, p. 10.

National Institute on Drug Abuse. NIDA Notes. Vol. 9,

no 1. NIH Publication No. 94-3478. Rockville, MD:

U.S. Department of Health and Human Services,

Public Health Service, National Institutes of Health,

National Institute on Drug Abuse, 1994, p. 19.

Penz, M.A., Brannon, B.R., Charlin, V.L., Barrett, E.J.,

MacKinnon, D.P., Flay, B.R. The power of policy:

The relationship of smoking policy to adolescent

smoking. American Journal of Public Health 79(7):

857-862, 1989.

Sabatier, P.A., Mazmanian, D.A. The conditions of

effective implementation: A guide to establishing

policy objectives. Public Policy Journal 5: 481-504,

1979.

Shopland, D.R. Effect of smoking on the incidence

and mortality of lung cancer. In: Lung Cancer,

B.E. Johnson and D.H. Johnson (Editors). New

York: Wiley, 1995, pp. 1-14.

U.S. Department of Health and Human Services.

Preventing Tobacco Use Among Young People: A Report

of the Surgeon General. Atlanta, GA: U.S. Department

of Health and Human Services, Public Health

Service, Centers for Disease Control and

Prevention, National Center for Chronic Disease

Prevention and Health Promotion, Office

on Smoking and Health, 1994.

AUTHORS

Deborah Bowen,Ph.D.

Associate Member

Fred Hutchinson Cancer Research Center

1124 Columbia Street

Seattle, WA 98104
225

Chapter 12

Lesa T. Dalton

Project Director

Division of Health Promotion Research

American Health Foundation

Fifth Floor

800 Second Avenue

New York, NY 10017

Rosemary Walker,M.Sc.

Research Associate

Department of Health Studies and

Gerontology, MC-6081

University of Waterloo

Waterloo, Ontario N2L 3G1

CANADA

Susan Crystal

Research Assistant

Fred Hutchinson Cancer Research Center

1124 Columbia Street

Seattle, WA 98104

Mario A. Orlandi,Ph.D.,M.P.H.

Chief

Division of Health Promotion Research

American Health Foundation

Fifth Floor

800 Second Avenue

New York, NY 10017
Smoking and Tobacco Control Monograph No. 6

226
227

Chapter 13

Involving Youth in Awareness of,

Promotion of, and Political Activities

for Tobacco Control

Robert J. McGranaghan, Sharon Ann Rankins-Burd, and Ted Purcell

INTRODUCTION Despite numerous efforts to prevent youth from beginning the

addictive practice of smoking, the rates of youth smoking remain alarmingly

high, with the age of onset varying between 11 and 15 (U.S. Department of

Health and Human Services, 1989; Johnston et al., 1991; DiFranza et al.,

1987). Surveys of youth tobacco use have been conducted regularly for the

past 15 years. Although the figures for smoking prevalence vary by survey

and definition, one trend emerges: There has been little change since 1981

in the percentage of high school seniors who smoke cigarettes. Recent

data show a statistically significant increase of 1.8 percent in high school

senior daily smoking from 1992 to 1993 (Johnston et al., 1994). Almost

as many young females now smoke as males, and those with no plans

for higher education have higher prevalence than those with such plans

(U.S. Department of Health and Human Services, 1989 and 1994). White

adolescents have a higher prevalence than their African-American or

Hispanic counterparts (Centers for Disease Control, 1990). The data do

not capture the dropouts who are likely to have higher smoking prevalence

rates (U.S. Department of Health and Human Services, 1989). The use

of smokeless tobacco also is increasing, with males more likely to use this

form of tobacco than females. At present, more than 1 million adolescent

males use smokeless tobacco (Centers for Disease Control, 1990).

The addictive nature of tobacco is as evident in adolescents as it is in

adults. Among adolescents who smoked at least half a pack of cigarettes

per day, more than half

had made an unsuccessful

attempt to stop smoking.

In addition, only a small

portion (5 percent) thought

they would still be smoking

5 years later; however, after

7 to 9 years, about 75 percent

were still smoking (Johnston

et al., 1991).

The use of tobacco by

adolescents is particularly

important because almost all

first tobacco use occurs before graduation from high school (U.S. Department

of Health and Human Services, 1994). For all adults, 89 percent began
Smoking and Tobacco Control Monograph No. 6

228

smoking prior to age 18, and 71 percent began daily smoking by age 18 (U.S.

Department of Health and Human Services, 1994). Adolescents, because of

the addictive nature of nicotine, become “hooked” and are the smokers of the

future. Preventing onset of tobacco use by youth will gradually result in the

decline of smoking prevalence and, eventually, in the demise of all manner

of tobacco use.

The Community Intervention Trial for Smoking Cessation (COMMIT)

did not initially target youth in its intervention plans. The primary reason

for excluding youth was that the trial was seen as being oriented toward

heavy smokers (25 or more cigarettes per day), and young smokers rarely fall

into that category. Nevertheless, some investigators and policy advisory

committee members encouraged the inclusion of activities that targeted and

included youth in intervention activities (see Chapter 12). The activities that

targeted youth were primarily school based and are described in Chapter 12

(Bowen and colleagues). Activities that involved youth were important

because they contributed to building awareness of smoking as a public

health problem, increasing visibility of tobacco control efforts, and

changing policies on youth access to tobacco.

This chapter describes some activities oriented toward youths in settings

other than schools. Although Chapter 12 addresses in-school activities, it

should be noted that schools were often the initial setting in which students

were contacted or recruited to participate in communitywide campaigns

and activities. This chapter also discusses the challenges encountered by

COMMIT staff members and volunteers as they balanced a desire by

volunteers for more attention to youth with COMMIT’s goal of increasing

cessation rates among adults. Finally, the chapter includes some key lessons

learned from the COMMIT communities about this intervention channel.

The overall goals of this aspect of the youth channel were to:

• enlist participation of students and teachers in communitywide

campaigns and intervention activities; and

• increase community interest and activity in regulations and

enforcement of policies to reduce youth access to tobacco products.

The required activities involving youth in nonschool settings are discussed in

Table 1.

The range of creative activities within each category demonstrates

the extent to which COMMIT communities involved youth in the overall

intervention beyond what was minimally required by the protocol. One

recurring theme found in the records of the COMMIT communities was

the lament by volunteers that COMMIT could not focus more attention on

prevention and youth. Many communities reported that their community

Boards or public education task forces (under which most communities

coordinated youth activities) were initially inclined to put more resources

into youth activities than were justified by the design of the intervention.

This may be the result of a tendency of COMMIT volunteers to prevent

GOALS,

ACTIVITIES,

AND PROCESS

OBJECTIVES

FOR YOUTH
229

Chapter 13

Table 1

Activities and process objectives for youth

Process

Cumulative Objectives

Objectives Number Achieveda

Activities for Each Community (1988-1992) Completed (%)

Annually Promote Participation in

Magnet Events (1/2,000 of total

community population) 100% 485

Annually Initiate a Youth Access

to Tobacco Campaign 33 campaigns 46 campaigns 139

Establish Liaison With TobaccoFree Young America Project All communities 8 liaisons 73

Establish Cooperative Agreement With

Tobacco-Free Young America Project All communities 10 communities 91

a Average for combined communities.

what had not begun rather than intervening to change the behavior of adults

who had already chosen to smoke. At the same time, a natural tendency to

protect youth from the mistakes of their elders may have inclined volunteers

to be more interested in preventing youth from smoking. This dilemma,

and how COMMIT communities dealt with it, are discussed below in the

“Challenges” section of this chapter.

Communities involved youth in a wide variety of campaigns

and interventions. These campaigns focused on reframing

the tobacco message to raise awareness of tobacco industry

marketing tactics, especially advertising. Boards and task

force members recognized that advertising of tobacco products

is difficult to escape (Johnston et al., 1991; Centers for Disease

Control, 1990). Despite industry disclaimers that influencing

adolescents is a goal (O’Toole, 1986; Weil, 1986), there is

much evidence that young people are aware of the images

presented by the tobacco companies. A study of 6-year-olds showed that

91 percent were able to recognize Joe Camel (Fischer et al., 1991). A survey

of 5,000 adolescents selected at random indicated that 42 percent identified

Marlboro as the most advertised cigarette brand, followed by Camel at 30

percent (and also showed that Camel advertisements were most often recalled

by the youngest adolescents and seldom recalled by older adult smokers)

(Pierce et al., 1991). Similar results were reported in analyses of the 1992

California Tobacco Survey (McCan, 1992). In other studies amon youth,

recall of cigarette advertisements is high, especially compared with recall

of the U.S. Surgeon General’s warning labels (Fischer and Magnus, 1981).

Tobacco advertising is seen in print media, billboards, sponsorship of

events, and point-of-sale messages. Advertising and promotion are most

INVOLVING YOUTH

IN COMMUNITYWIDE

CAMPAIGNS AND

INTERVENTION

ACTIVITIES

Involving Youth

in Community

Campaigns
Smoking and Tobacco Control Monograph No. 6

230

likely to operate in an unconscious way; they provide images that support

the attractiveness of smoking (U.S. Department of Health and Human

Services, 1989 and 1991; Warner et al., 1992; Hensley, 1989). The images

that are used are usually sexy, independent, adventure seeking, or funny

(cartoon characters). Such images are often appealing to adolescents.

Indirectly, adolescents may look at such advertising as evidence that it is

“okay to smoke” because if smoking were not acceptable adolescent behavior,

the Government would not allow the advertising of a product with such

negative health consequences for adolescents (U.S. Department of Health

and Human Services, 1989). For these reasons, many COMMIT communities

conducted activities designed to reduce the appeal of tobacco advertising.

Counteradvertising campaigns using posters developed by and targeted to

youth were displayed on buses and in bus shelters in Vallejo, CA. Some

antitobacco advertisements, such as those put on billboards in commercial

districts, were designed by youth. Advertising of tobacco products was

removed from several sporting events, including basketball in Yonkers, NY,

baseball in Medford/Ashland, OR, and Bellingham, WA, and tennis in

Santa Fe, NM.

Other informational and awareness programs and campaigns involving

youth and targeting adults included writing letters to the editor of local

newspapers. For example, letter-writing campaigns by youth supported public

discussions of enforcing or enhancing policies on youth access to tobacco.

Videotape productions and slide shows, developed with creative input

from youth, documented local examples of the pervasive marketing of

tobacco to young people throughout the community. Theatrical events,

such as puppet shows and musical plays, were produced to help youth

deal with situations involving smoking and to highlight the dangers of

secondhand smoke to children and adults.

Some communities trained youth to be speakers or developed peer-topeer education to prevent smoking and to raise awareness of the problem.

This strategy used students who were trained to teach their peers how to

refuse cigarettes. In some cases, youth were trained to make presentations

to legislators and community leaders.

Involving Youth The protocol required communities to conduct community

in Magnet Events magnet events (Chapter 6). The Great American Smokeout

(GASO) is a magnet event sponsored by the American Cancer Society, and

every COMMIT community in the United States was involved in promoting

this event. Youth played an important role in helping communities spread

the message about the GASO. Some communities used youth brigades to

distribute door hangers and fliers in targeted neighborhoods to advertise

GASO events. Others involved youth in distributing information on quitting

for the day. Many communities conducted poster contests in conjunction

with the GASO. These contests were another strategy for youth to express

themselves to peers and adults in creative ways, raise awareness, and spread

basic information about the problem of smoking. Winning entries were

displayed in shopping malls and community centers, and in Paterson, NJ,
231

Chapter 13

the winning entries were made into a

calendar. In some cases, posters were

judged by employees of companies

participating in GASO activities and

were displayed in their worksites.

Newspaper coverage of the contests

amplified the messages of the posters

to the community. Local media also

publicized essay contests by printing

articles about the winning writers and

their tobacco control messages. Essays

were reprinted in local newspapers and,

in some cases, were broadcast by radio

stations, providing further promotion

of the no-smoking message.

Non-Dependence Day, the fifth of July,

was a summertime event sponsored by the

American Lung Association allowing for

more community-based involvement by youth to promote antismoking

messages. For example, youth participated in local Fourth of July parades to

encourage smokers to be independent by overcoming their dependence on

tobacco. As with the GASO, poster contests were used to involve youth and

spread the no-smoking message of this campaign.

MONITORING The national health objectives for the year 2000 have targeted

AND PROMOTING substantial reductions in smoking among persons younger than

ENFORCEMENT 20 years and reductions in smoking onset. Reducing access

OF REGULATIONS to cigarettes through policies or laws is an important strategy

ON YOUTH ACCESS in reaching this goal. Those younger than age 18 have little

TO TOBACCO difficulty in purchasing tobacco products even though it is

illegal in all of the United States and

Canada. With few exceptions, there is

little enforcement of the laws prohibiting

tobacco access by minors. Studies

indicate that the vast majority of tobacco

retailers sell to children (Doctors and

Lawyers for a Drug-Free Youth, 1991;

Altman et al., 1989). For this reason,

COMMIT communities were required

to develop activities to monitor and

promote enforcement of regulations

on youth access to tobacco.

Almost all communities used

compliance checks as an initial step in

the process of examining what their

communities were doing about the

accessibility to tobacco by youth. The
Smoking and Tobacco Control Monograph No. 6

232

compliance check was a systematic method to investigate whether merchants

were adhering to local and State laws regarding the sale of tobacco to minors.

In essence, a compliance check is an undercover buying operation using

underage youth who have been trained in the operation to go into stores and

attempt to purchase cigarettes. Prior arrangements are often made with law

enforcement agencies so the youth are protected from legal action resulting

from their purchasing tobacco. Accompanied by an adult driver who waits

outside the retail establishment, an underage adolescent attempts to buy

cigarettes or other tobacco products. The young people are trained to give

truthful answers about their age if asked and to avoid any education of the

retailer during the operation.

The results of compliance checks were used to educate merchants and

the general public. Merchants who refused to sell to minors were usually

given a certificate or a letter of commendation. Those who did sell to minors

received some type of education about sales to youth. As a followup to

compliance checks, interviews with store personnel about their selling

behavior were sometimes conducted. Checks also documented how and

where tobacco products, promotional materials, and legal age warning

signs were placed.

Some communities began this activity with a merchant education

campaign. Volunteers, often youth groups, visited local tobacco merchants

and distributed information about local and State laws pertaining to sales

to minors. Articles and letters to the editor about the dangers of smoking

and the easy accessibility to tobacco by minors accompanied this outreach

to merchants. Following this outreach, compliance checks were conducted

to determine the extent of the problem and the effects, if any, from the

merchant education campaign. Merchants were not informed at this point

that a compliance check was in progress; however, some communities chose

to publicize the campaign in local newspapers to warn the merchants before

the youth buyers were sent out to the stores.

Initial compliance checks demonstrated that a majority of underage

buyers were able to purchase cigarettes. In most communities, this outcome

resulted in widespread local publicity and paved the way for public debate

about enforcement and stricter laws. Youth were instrumental in promoting

the importance of enforcing laws and advocating for the strengthening or

changing of existing laws, such as bans on cigarette vending machines.

Young volunteers spoke at city council hearings and displayed packs of

cigarettes they were able to purchase during compliance checks. Students

wrote letters to the editor to encourage local lawmakers to consider tougher

policies on access to tobacco by youth. The visible and enthusiastic

involvement of youth in this activity was an important factor in getting

communities to discuss and in some cases make policy changes restricting

sales to minors.
233

Chapter 13

SUCCESSFUL The process objectives for youth activities required involving as many

ACTIVITIES children as possible in smoking control activities and mounting at least

one visible youth-related policy initiative each year. Success was measured

primarily by meeting process objectives for the required activities, and the

community measured success by the amount and frequency of media

coverage, positive feedback from the community to staff members and

volunteers after events, letters to the editor, attendance at public hearings,

changes in local public policy, and attendance at and response to other

special events that created an environment for public discussion of the issue.

ENLISTING YOUTH COMMIT found many agencies eager to involve their youth

IN COMMUNITYWIDE groups in smoking control activities. Boy and Girl Scouts,

CAMPAIGNS youth activities commissions, church and synagogue youth

groups, children’s program directors at YMCA’s and afterschool programs,

Students Against Drunk Driving (SADD) chapters and Friday Night Live

groups, and antidrug coalitions, such as Drug Abuse Resistance Education

(DARE), were eager to incorporate COMMIT’s antismoking message into

their activities.

The extent to which communities became involved in youth activities

was based on the priority given to youth issues by community Boards, public

education task forces, and program staff. Some communities, such as Utica,

NY, and Raleigh, NC, created youth subcommittees of the public education

task forces. Other communities, such as Fitchburg/Leominster, MA, and

Bellingham, assigned youth the status of a full task force, including direct

representation on the community Board. Most communities did not separate

youth from the public education task force but still devoted much time and

attention to this channel.

Counteradvertising campaigns helped to reframe the message of smoking

as a public health issue and provided excellent activities to involve the

creativity and enthusiasm of young

volunteers. In Vallejo, a youth group

called Students Against Cancer developed

a poster titled “Fight It! Don’t Light It!”

that was displayed in buses and bus

shelters throughout the city. The Southern

Oregon Drug Awareness (SODA) youth

committee worked with the Medford/

Ashland COMMIT community and adopted

a counteradvertising billboard project.

Volunteers from this group also helped

place antitobacco stickers on tobacco advertisements in magazines in

school libraries.

Essay contests were yet another method used to promote community

campaigns and magnet events. Raleigh conducted an essay contest on the

theme “Smoking Restrictions and Their Associated Benefits.” Winning

entries were reprinted in a local newspaper. In Fitchburg/Leominster,

winning essays on no-smoking themes were read over local radio stations.
Smoking and Tobacco Control Monograph No. 6

234

In both Santa Fe and Paterson, adults and children used their musical

and dramatic talents to bring an antitobacco message to audiences. In Santa

Fe, a puppet show was developed that stressed the hazards of secondhand

smoke. Children were taught how to deal with situations involving smoking,

including how to refuse cigarettes. Scripts were developed for both elementary

and higher grades. Children who saw the show at school received brochures

containing antitobacco information for their parents. In Paterson, the “Smart

Moves” play also traveled to schools. The play was interactive and included

a simple antitobacco song taught to the children who were encouraged to

bring the song home to their parents.

A teacher and student in Fitchburg/Leominster rewrote the screenplay

“Cold Turkey” as a play titled “Unfiltered Rock.” The play was produced

during the week of The Great American Smokeout. Advertisements were

run in the newspaper and on the radio to promote the play and the GASO.

Forty students participated in this theatrical venture, and 600 people

attended the play.

Training youth to be speakers and active participants in events was

another strategy used by communities to involve youth in educational

campaigns. Utica trained young people to participate in a hypertension

screening project to talk about the risks of smoking to people who have

high blood pressure. Medford/Ashland sponsored two students from the

SODA youth committee to attend one of the annual Stop Teen Addiction

to Tobacco (STAT) conferences. These students were an important source

of ideas for involving Medford/Ashland youth in more visible and active

antitobacco efforts.

Vallejo’s Students Against Cancer provided important help in promoting

antismoking messages to adults and youth through a wide variety of

campaigns and activities. This group, a youth component of the Minority

Coalition for Cancer Prevention, was recruited from Vallejo high schools

and the Continentals of Omega Boys & Girls Club. Students Against Cancer

was routinely involved in Vallejo’s community events, such as the GASO,

summer antidrug block parties, and Fourth of July parades. In some cases,

these youngsters helped to promote the events to their peers and adults, and

in other cases, they participated actively at the events in skits and on floats

that had no-smoking themes.

Santa Fe COMMIT worked with student interns who developed a

presentation for other children and adults focusing on cessation. During

one summer, COMMIT sought office help from student interns who were

asked to make these presentations. When the students returned to high

school in the fall, they worked as volunteers within the school, helping

other teens to give up tobacco. By the second year of the program, funding

was obtained from outside sources to continue support of the peer-to-peer

program. An at-risk student, also an ex-smoker, became one of the trainers

who helped reach other at-risk youth in Santa Fe, thereby lending even

more credibility to his work among teens and young adults.
235

Chapter 13

Vallejo’s slide show “Provocative and Pervasive: Tobacco Messages

Bombard Our Youth” is another example of a strategy that used youth to

raise awareness among adults. The slide show depicted locations in Vallejo

where tobacco products, advertisements, and tobacco-like candies and gum

are placed at eye level in and near areas frequented by youth. The show

included facts about smoking and health and was targeted primarily to

adult audiences who attended meetings of community organizations such

as the Rotary Club and church groups. The slide show drew strong reactions.

Adults were indignant and sometimes outraged when they saw the extent

to which the products were promoted in local stores and other locations in

Vallejo. This slide show was eventually made into a short videotape starring

local youth titled “Reaping Profits by Stalking Youth” and was made available

to local community groups and agencies as a COMMIT legacy at the end

of the project. Similarly, Bellingham adopted “Ad-libbing It” as part of its

curriculum in grades 5 through 9. The videotape, developed by a physician

from the Washington State affiliate of Doctors Ought to Care (DOC), shows

young people how the tobacco industry manipulates them by presenting

false images of smokers.

Some communities used athletic events and organizations to target both

adults and youth with antismoking messages. In Medford/Ashland, a minor

league baseball team sponsored a Family-No Smoking-No Drinking section

for games. Medford/Ashland also purchased a billboard with an antismoking

message for players and their adult supporters at a Little League field. Vallejo

distributed promotional materials targeted to Little League supporters who

smoke while watching the games.

Over the years, several campaigns were developed in Utica, including one

for the winter holidays. A radio commercial featured a young girl who wrote

to Santa asking for a Quit Kit for her dad. People were encouraged to give the

kits to loved ones who smoke. One local hospital extended its heart disease

prevention program to include radio advertisements using youngsters who

asked their parents to quit smoking or start exercising so they will live to see

their children grow up.

Vallejo offered minigrants (matched by the school district) to youth

organizations, such as the Camp Fire Girls, YMCA, 4-H Club, and the

Continentals of Omega Boys & Girls Club, for projects involving youth

in magnet events. These grants were used as incentives to encourage

youth organizations to think of creative ways to involve their members

in activities targeting adults. The Boys & Girls Club used its grant to

support an antidrug block party during which T-shirts with antismoking

messages were distributed. The YMCA used its grant to develop a prevention

curriculum for a summer day camp program. Antismoking youth groups

were established through schools and community organizations and

coalesced with antidrug groups. Communities reported that incorporating

tobacco into their community’s antidrug movements, while challenging,

was a promising strategy for raising awareness of the problem of smoking

and involving new groups of youth and adults.
Smoking and Tobacco Control Monograph No. 6

236

MAGNET EVENTS Magnet events included poster contests to promote cessation

themes. In Paterson, winning posters were produced as a calendar and

distributed widely throughout the community. In Cedar Rapids/Marion,

IA, third-grade students were matched to local companies for the GASO.

Students created posters encouraging the employees at their company to

stop smoking for the day. A committee of smokers and former smokers

at each company judged the posters and displayed the winner at their

worksites.

In many communities, children marched in Fourth of July parades in

conjunction with Non-Dependence Day or in other local parades. Young

people contributed energy, enthusiasm, and much creativity during floatmaking enterprises for these

parades. One of Vallejo’s July

Fourth floats featured a

dinosaur theme and relied

on young volunteers riding

on the floats to spread the

message “Smoking: The Real

Reason Dinosaurs Became

Extinct.”

Young people were

recruited to attend rallies

where antismoking speakers,

such as David Goerlitz (the former Winston cigarette advertising-modelturned-antitobacco advocate) or Dr. Alan Blum (of DOC), were featured.

Rallies with such notable speakers as Mr. Goerlitz and Dr. Blum were held

in conjunction with magnet events and received local media coverage and

enhanced the promotional activities of antismoking campaigns.

In Raleigh, a local chapter of SADD was recruited to participate in a

Non-Dependence Day rally at the city plaza. The students performed skits

and rap songs with an antitobacco theme. As a followup to that event,

Raleigh kept the SADD members involved in additional tobacco control

activities. Thus, some members of this group became involved in the GASO

later that year and organized a small-scale “Quit and Win” contest as part

of the event. They recruited prizes; made a banner; signed up students,

faculty, and staff; and learned how to use a carbon monoxide monitor

to determine contest winners.

MONITORING All communities conducted compliance checks to demonstrate

AND ENFORCING the easy access children have to tobacco. These compliance

TOBACCO ACCESS checks also served to raise community awareness of the problem

of smoking generally and the need for enforcement of a minimum purchase

age. In some communities, such as Raleigh and Vallejo, youth buys were the

first step to new or additional legislation aimed at keeping children away

from tobacco. In Vallejo, a concerted campaign that began with compliance

checks resulted in the passage of local legislation banning cigarette vending

machines and free distribution of tobacco products.
237

Chapter 13

In Fitchburg/Leominster, youth task force members became masterful

at involving other young people in activities that focused on prevention of

youth access to tobacco. This activity received extensive media coverage

and succeeded in moving debate forward on the need for stricter regulations

at the municipal level. This activity was controversial and not always popular

among adults in the community. Some felt it was a form of entrapment and

that it did not set a good example to youth in the community. Nevertheless,

health officials in one community moved quickly to adopt stricter regulations

concerning youth access to tobacco.

Health officials in one Massachusetts COMMIT intervention community

were reluctant to move as quickly because they were philosophically opposed

to youth involvement in undercover operations. Board and task force

members began to work with the community’s youth commission, a peer

leadership group with a positive image among adults. Through a series of

educational sessions, the youth commission adopted protection from tobacco

as one of its charges. The youth commission made a proposal to the health

department asking for adoption of stricter regulations. When the health

department did not act, the commission took its proposal to the city

council. Members of the commission testified at hearings and succeeded

in convincing the city to adopt the regulations, including provisions for

monitoring enforcement using compliance checks, which had been the

major stumbling block for the health department.

Youth also reminded the public and legislators about existing nonsmoking

laws. Santa Fe held a major event at the State capitol building. COMMIT

held a news conference in the rotunda and enlisted help and support from

youth and adults. The youth issued smoking “tickets” to those who lit up

in the building because New Mexico law prohibits smoking in public places.

However, not every lawmaker had a sense of humor about the event. One

refused to be seen on camera with his citation in hand.

For many communities, compliance checks and merchant education

programs provided an excellent opportunity to involve youth in an activity

that sought to protect youth and raise awareness among adults about the

dangers of smoking and the pervasiveness of tobacco advertising and products

in places where youth congregate. Some communities were more aggressive

in their willingness to tackle this activity, especially in their use of young

people to purchase cigarettes in bars or cocktail lounges. Buying operations

usually resulted in media attention that kept the issue alive for public

discussion, although the attention was not always favorable. The payoff for

communities that successfully used compliance checks and related activities

was a more powerful groundswell of support among adults for enactment of

local ordinances to strengthen access laws. In addition, a cadre of dedicated

youth, now schooled by COMMIT’s buying operations, became involved in

other COMMIT activities.

CHALLENGES Perhaps the most significant challenge that communities encountered

with this channel was the desire of many of their community Boards and

public education task forces to focus more attention and resources on youth
Smoking and Tobacco Control Monograph No. 6

238

and prevention activities. Thus, COMMIT staff members were faced with

the challenge of steering their volunteers away from this focus and providing

consistent reminders to them that the goal of COMMIT was to increase

cessation rates among adult smokers.

For some communities, the emphasis was on policy change, thought

to be the only effort worth supporting in this channel. For example, in

Fitchburg/Leominster, disagreement arose in the third year among youth

task force members as to which activities for youth were most worthwhile.

Two members of the task force, who were the major forces behind the

implementation and enforcement of regulations prohibiting youth access,

were adamant that these types of activities were the only effective activities

for preventing youth access and that educational programs were a waste

of time and money. Ultimately, task force members agreed that both

educational and enforcement activities were to be part of the action plan.

In other communities, volunteers expressed many concerns and fears

about involving youth in monitoring access to tobacco, resulting in much

weaker compliance checks and, in some cases, cancellation of these types

of operations. For example, the Paterson public education task force opposed

a staff-planned compliance check because most members were concerned

that it might be viewed as an attack on merchants, not on the law and its

enforcement. They subsequently canceled all plans for that activity.

In Utica, concerns also were raised during plans for a second compliance

check. Volunteers felt that COMMIT might receive bad publicity and were

also concerned about COMMIT’s liability if the local district attorney decided

to file charges against merchants caught in the operation. No one wanted

to risk that possibility, so the compliance check was canceled.

Another challenge facing this channel was that most at-risk youth

do not belong to the kinds of organizations and groups that rallied to

COMMIT’s message. Targeting this hard-to-reach population, although

not a primary objective of the intervention, was a challenge for project

staff members and volunteers. Santa Fe used the peer-to-peer education

program described above to target some of these students.

LESSONS LEARNED The youth channel was not a major priority for the intervention;

the majority of COMMIT’s required activities were targeted to adults.

Nevertheless, most communities felt that their youth activities were among

the most successful of all the interventions. In the final reports of the

COMMIT intervention, 6 of the 11 communities included at least 1 youthrelated intervention among their “most successful activities.” That subjective

evaluation by the communities provides some indication of the degree to

which their volunteers were eager to focus on youth issues. Almost every

community noted in its final reports that the youth channel (and its implicit

message of prevention) was an important issue for volunteers. Perhaps

this reflects a natural “protective” tendency on the part of adults to be

concerned about creating and maintaining a safe and healthy environment

for children. Such a tendency for protectiveness toward children may
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Chapter 13

override the desire to intervene in the choices adult smokers have already

made in their lives.

Staff members and community volunteers realized that youth could be

used to heighten awareness of the problem of smoking among both adults

and young people. Furthermore, youth served a critical public relations

function in getting the cessation message to adults, a realization that

helped communities with objectives that targeted adults and enhanced

their work by involving youth and adults in magnet events and monitoring

and promoting enforcement on youth access to tobacco. In fact, many

communities documented that involving youth groups in monitoring youth

access to tobacco became a galvanizing force for changes in local policy.

For example, the Vallejo City Council ultimately responded to the strong

foundation of community support given to bans on vending machines and

free distribution of tobacco products. This strong foundation resulted largely

from the coalescing of diverse segments of the community, a coalescing that

ultimately became the “pulse” (perceived standard operating pattern) of

Vallejo, to which the council responded. However, the participation of

many enthusiastic, articulate, and sincere young people in the process

may have been the most critical ingredient in this effort.

The linkage of tobacco use with substance abuse programs met with

initial resistance (especially from the community of recovering addicts) but,

in some cases, proved to be an effective strategy to merge with other groups

and increase resources directed to antidrug, antismoking messages.

Young people also serve as a convenient channel from which to recruit

volunteers. Youth can support program staff when adults are neither able

nor willing to volunteer. As was borne out frequently with the youth-buying

operations and merchant education programs, everyone seems to listen when

young people deliver a message. This may be the most valuable lesson

learned from COMMIT’s experiences with youth activities.

REFERENCES

Altman, D., Foster, V., Rasenick-Douss, T., Tye, J.

Reducing the illegal sales of tobacco to minors.

Journal of the American Medical Association 261:

80-83, 1989.

Centers for Disease Control. Cigarette advertising—

U.S., 1988. MMWR. Morbidity and Mortality Weekly

Report 39: 261-265, 1990.

DiFranza, J.R., Norwood, B.D., Garner, D.W., Tye,

J.B. Legislative efforts to protect children from

tobacco. Journal of the American Medical Association

257: 3387-3389, 1987.

Doctors and Lawyers for a Drug-Free Youth.

Cigarettes Readily Sold to Children in 90 U.S.

Communities, Tobacco Legislation Recommended.

Champaign, IL: Doctors and Lawyers for a DrugFree Youth, 1991.

Fischer, D.A., Magnus, P. “Out of the mouths of

babes . . . .” The opinions of 10 and 11 year old

children regarding the advertising of cigarettes.

Community Health Studies 5: 22-26, 1981.

Fischer, P.M., Schwartz, M.P., Richards, J.W., Jr.,

Goldstein, A.O., Rojas, T.H. Brand logo

recognition by children aged 3 to 6 years. Mickey

Mouse and Old Joe the Camel. Journal of the

American Medical Association 266: 3145-3148,

1991.

Hensley, T. Congress considers eliminating nearly all

tobacco advertising. Journal of the National Cancer

Institute 81: 128-129, 1989.

Johnston, L., O’Malley, P., Bachman, J. “Monitoring

the Future Study.” Press release, University of

Michigan, Ann Arbor, MI, January 31, 1994.
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Johnston, L.D., O’Malley, P.M., Bachman, J.G.

National Trends in Drug Use and Related Factors

Among American High School Students and Young

Adults, 1975-1990. Rockville, MD: U.S. Department

of Health and Human Services, Public Health

Service, Alcohol, Drug Abuse, and Mental Health

Administration, National Institute on

Drug Abuse, 1991.

McCan, J. Tobacco logo recognition. Journal of Family

Practice 34: 681-684, 1992.

O’Toole, J. Testimony at the hearings on the

advertising of tobacco products before the

Subcommittee on Health and the Environment

of the Committee on Energy and Commerce,

U.S. House of Representatives, 99th Congress,

2nd Session, Serial No. 99-167, 1986.

Pierce, J.P., Gilpin, E., Burns, D.M., Whalen, E.,

Rosbrook, B., Shopland, D., Johnson, M. Does

tobacco advertising target young people to start

smoking? Evidence from California. Journal of the

American Medical Association 266(22): 3154-3158,

1991.

U.S. Department of Health and Human Services.

Reducing the Health Consequences of Smoking:

25 Years of Progress. A Report of the Surgeon General,

1989. DHHS Publication No. (CDC) 89-8411.

Rockville, MD: U.S. Department of Health and

Human Services, Public Health Service, Centers

for Disease Control, Center for Chronic Disease

Prevention and Health Promotion, Office on

Smoking and Health, 1989.

U.S. Department of Health and Human Services.

Strategies To Control Tobacco Use In the United States:

A Blueprint for Public Health Action in the 1990’s.

Smoking and Tobacco Control Monographs-1.

NIH Publication No. 92-3316. Washington, DC:

U.S. Department of Health and Human Services,

Public Health Service, National Institutes of

Health, National Cancer Institute, 1991.

U.S. Department of Health and Human Services.

Preventing Tobacco Use Among Young People: A

Report of the Surgeon General. Atlanta, GA: U.S.

Department of Health and Human Services, Public

Health Service, Centers for Disease Control and

Prevention, Center for Chronic Disease Prevention

and Health Promotion, Office on Smoking and

Health, 1994.

Warner, K., Butler, J., Cummings, K.M., D’Onofrio,

C., Davis, R., Flay, B., McKinney, M., Myers, M.,

Pertschuk, M., Robinson, R., Ryden, L., Schudson,

M., Tye, J., Wilkenfield, J. Report of the tobacco

policy research study group on tobacco marketing

and promotion. Tobacco Control 1(Suppl): S19-S23,

1992.

Weil, G. Testimony at the hearings on the

advertising of tobacco products before the

Subcommittee on Health and the Environment

of the Committee on Energy and Commerce,

U.S. House of Representatives, 99th Congress,

2nd Session, Serial No. 99-167, 1986.

AUTHORS

Robert J. McGranaghan,M.P.H.

Research Associate

Division of Research

Kaiser Permanente Medical Care Program

3505 Broadway

Oakland, CA 94611-5714

Sharon Ann Rankins-Burd

Box 99

North Winfield Road

West Winfield, NY 13491

Ted Purcell

Project Coordinator

Division of Preventive and Behavioral

Medicine

University of Massachusetts Medical Center

Seventh Floor

55 Lake Avenue North

Worcester, MA 01655
241

Chapter 14

What Have We Learned and Where

Do We Go From Here?

Beti Thompson, William R. Lynn, and Donald R. Shopland

INTRODUCTION The Community Intervention Trial for Smoking Cessation

(COMMIT) provided unique opportunities for learning about community

interventions. From the beginning of the project, when design issues played

an important role in determining the extent to which communities would

be involved in decisionmaking, to the final dissemination of trial data, we

learned much about understanding communities, mobilizing and working

with communities to implement interventions, sustaining key aspects of the

intervention after the funding ended, and disseminating final results to the

communities. This monograph puts together the lessons learned from the

field so that future community studies can benefit from the COMMIT

experience.

MAJOR The individual chapters in this monograph discuss the lessons learned in

LESSONS specific channels and activities, but there are also overarching implications

LEARNED for other community projects that revolve primarily around community

mobilization and the utility of the COMMIT approach for other community

and social problems. This section focuses on these lessons.

The COMMIT project required communities to be heavily involved in

the implementation of the intervention. This requisite led to many other

demands. First, a necessary condition for intervention was that communities

organize for action. Because the project was primarily a research project,

the impetus for organization came from an external source rather than a

ground swell within the community. Furthermore, once some community

organization had been achieved, community groups had to be convinced

that tobacco control was a significant problem in their community. Even

when groups were convinced of that, mobilizing people to plan and

implement interventions was not easy.

Establishing It is clear from the COMMIT experience that identifying and involving

a Partnership community members who represent the community to serve on

With the Boards and task forces is both necessary and possible. The extensive

Community community analysis conducted in all communities led to the

involvement of appropriate individuals and organizations, as shown in a

questionnaire disseminated at the end of the intervention part of the trial.

Each site was asked how well the Board and task forces represented the

community, and the respondents confirmed that the composition of the

volunteer membership was appropriate. The process of identifying and

recruiting community members to become involved in a research partnership,

more fully explained in Chapter 5, resulted in structures of Boards and task

forces that provided good representation of the communities. Furthermore,

the process happened quickly, generally within 7 months of randomization.
Smoking and Tobacco Control Monograph No. 6

242

We also learned that the membership of Boards and task forces was fluid,

with members resigning and new individuals being recruited according to

the specific project focus and the interests and availability of individuals.

Promoting the Initially, there were concerns that communities would not think

Research Agenda of tobacco control as being a sufficiently important issue or as

requiring the amount of volunteer time we were requesting. In the early

days of the project, some community members argued that there were other

compelling problems in their communities (such as alcohol, other drugs,

and violence) and that those problems should be the focus of attention.

As a result, there was some natural dropout in volunteer membership as

individuals decided not to participate in this research. However, within a

short time, all 11 intervention communities, and the individuals, groups,

and organizations representing them, became heavily involved in organizing

the community to help smokers achieve cessation. Thus, we learned that

communities will enthusiastically embrace an externally imposed research

agenda, even when that agenda is not seen as including key problems or

issues facing the community. One community member stated that there

were enough community problems for everyone to get involved in, and if

resources were available, she was determined to make a difference where

she could.

As Chapters 5 through 13 indicate, community Boards, task forces,

and individual volunteers took on most of the activities with enthusiasm,

which should not be construed to mean that community representatives

were always pleased with the constraints of the protocol. After some practice

and experience, many communities wished to rearrange the focus of the

protocol, spending less time on organizations (Chapter 11) and more on

preventing smoking onset (Chapter 13). Nonetheless, community volunteers

regarded the protocol as being important and tried to conduct the activities

in a manner congruent with the needs of their communities.

As discussed in Chapter 5, the need to put research aims before

community aims was a compromise made among the investigators in the

early days of COMMIT. Although every attempt was made to allow for

flexibility, the intervention was set up as a “one size fits all” model, which

was occasionally frustrating to investigators and community members alike.

Future community intervention planners might consider ways to better

incorporate the changing interests and agendas of communities into a

protocol.

Planning The initial task of the Boards and task forces was to develop a Smoking

Intervention Control Plan, the blueprint for the 4 years of intervention activities

Activities that were to occur in a community. The plan served many purposes:

It introduced the project to the community, provided an overall guide for

what would be done and when it would be done, gave the community

volunteers their first real opportunity to work together, and forced volunteers

to agree on how the tobacco control issue would be approached in their

community. Because of the research nature of the project, the timeline for
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Chapter 14

producing this plan was extremely short. The community Boards and task

forces were organized by the end of January 1989. By May 1989, they were

expected to produce this comprehensive plan and to prepare its presentation

to the community. Familiarizing the volunteers with the project and the

protocol required a significant amount of learning; thus, the May deadline

for developing the Smoking Control Plan was not ideal. Although staff

members experienced considerable anxiety (and worked many extra hours),

the volunteers put forth superb efforts, and plans were produced.

Immediately after the overall Smoking Control Plan was developed,

volunteers had to begin producing Annual Action Plans, which specified

the activities to be accomplished in the first intervention year. Action plan

development required that Boards and task forces identify how activities

would be implemented, what the activities would build on, who would do

them, how much they would cost, and other details. The Boards and task

forces accepted this task and devised plans that incorporated creativity in

the implementation of activities, added other community groups to the

intervention process, and allocated resources wisely. (Indeed, many

communities used this as an opportunity to generate in-kind contributions.)

Thus, it was clear that community volunteers were eager and able to

become involved in planning intervention activities.

Implementing The final community task was to implement the intervention

Intervention activities so that research objectives could be achieved. The data in

Activities Table 1 indicate that community volunteers and staff members took

that task seriously, with 94 percent of process objectives achieved across

COMMIT. In planning the trial, investigators outlined the percentage of

intermediary groups, such as health care providers, workplaces, and schools,

that had to be reached for a minimal intervention to be achieved (see

Chapter 2). Community volunteers took pride in feedback that indicated

they were making progress in achieving process objectives. Community

volunteers participated in diverse activities, ranging from stuffing envelopes,

to recruiting worksites to become involved in community promotions, to

becoming media and legislative advocates, to being regular speakers at

schools, and many activities in between. Some of these activities are

described in Chapters 5 through 13.

Utility As COMMIT drew to a close, we began asking our community partners

for Other for input on the process. One item put forward by all communities was

Community the relevance of the COMMIT use of community organizations to other

Projects types of community interventions. Volunteers commented that the

COMMIT experience provided them with excellent skills that could be

applied subsequently to other community problems. Specifically, they liked

the idea of drawing on volunteers from the entire community to organize

around a problem. They also liked the structures set up by COMMIT that

distributed work among a Board and separate task forces. Volunteers from

at least three communities stated that they had used that approach in other

projects.
Smoking and Tobacco Control Monograph No. 6

244

Table 1

Percentage of process objectives achieved trialwide by intervention channel

Average for All Intervention

Communities Combined

Intervention Channel (number of activities) (%)

Mobilization of Boards and Task Forces (34) 99

Health Care Providers (30) 96

Worksites (31) 92

Organizations (13) 83

Cessation Resources (24) 92

Public Education: Media (20) 94

Public Education: Youth (15) 90

Total (167) 94

Feedback Issues Research projects often do not have data until late in the trial.

In COMMIT, a deliberate decision was made to keep everyone, including

investigators, from seeing any outcome data until the project was over.

More than one community representative was disturbed that outcome data

were not available throughout the trial. Being blinded from outcome data

made it impossible to institute midcourse corrections. Similarly, data on the

attainment of impact objectives came late in the trial and were not useful for

communities in planning how to direct their energies. Providing feedback

during the intervention using process and outcome data can be important

for motivating communities and tailoring intervention to individual

communities.

Durability of Another lesson was learned late in the trial. As COMMIT ended,

Intervention many investigators, community representatives, and National Cancer

Activities Institute (NCI) personnel expressed an interest in continuing tobacco

control activities. The COMMIT Steering Committee developed plans for

encouraging the communities to make “transition plans” for the future.

Each community expressed an interest in continuing some aspects of tobacco

control activities and spent considerable time on this process. Unfortunately,

when intervention funding ended, the communities were left on their own

to carry out their plans to institutionalize tobacco control activities. We

learned that the process of ensuring longevity of intervention activities or

structures needed to begin early in the trial, not in the last 18 months.

Despite the problems with trying to continue intervention activities, 9 of

the 11 intervention communities were still conducting tobacco control

activities a year after the project ended and had dedicated staff and resources

to do so. Two communities, which had received large State or provincial

grants, expanded activities greatly, but the remaining communities were

selective in choosing which activities to continue. Nevertheless, we learned

that communities will continue tobacco control activities even after external

funding ends.
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The Role NCI, which funded COMMIT, perceived that resources would go to

of Resources the community as “seed resources” that would generate other means

to conduct activities. In many communities, the reality differed. For small

communities, resources of $150,000 per year were seen as highly significant,

especially because volunteers and staff members did not have to engage in

fundraising to acquire those resources. This is counter to the practice in most

community projects where a volunteer board is responsible for activities to

generate resources. Interestingly, although the funds ended, organized, welldefined groups continued in many communities.

The following list summarizes the overall lessons learned from COMMIT

field activities:

• It is possible to establish a partnership with communities so that they

will organize around a community problem. The process of forming

the partnership requires extensive understanding of the community

and substantial input from key informants in the community regarding

recruitment of appropriate individuals, organizations, and groups.

• It is possible to promote a research agenda even when that agenda is

not necessarily viewed as the primary problem facing a community.

The COMMIT experience indicates that external resources for

addressing a problem that may not be the community’s primary

concern are a strong incentive for participation. Furthermore, the

COMMIT communities had some existing groups and organizations

that were interested in and committed to dealing with tobacco

control, and those groups were able to draw other community

members into the project.

• Community volunteers are willing and able to plan intervention

activities that are congruent with an intervention protocol. As

community volunteers gain more familiarity with projects and see

other potential options for solving the problem, they may wish to

change the focus of the intervention protocol. This was evident in

COMMIT where, by the end of the trial, all the communities expressed

a desire to spend more time and resources on prevention as opposed

to cessation. Although the COMMIT project maintained the original

intervention protocol to achieve its research emphasis, it may be more

desirable to allow protocol changes during the intervention, as long as

those changes apply to all the communities. In fact, COMMIT did

allow such changes in the organizations channel (Chapter 11), and

those changes were accepted by the communities.

• Community volunteers are willing to implement intervention

activities. However, one cannot assume that volunteers possess all

the information and skills needed to implement interventions. For

that reason, ongoing training opportunities are required for individuals

to learn the skills of advocating positions, presenting tobacco issues to

other community sectors, and placing tobacco control on the agenda

of diverse community groups and organizations. In addition, the
Smoking and Tobacco Control Monograph No. 6

246

training programs provided by COMMIT (i.e., training for physicians,

dentists, other health care professionals, worksites, organizations,

cessation services providers, and educators) were generally well

received and left a substantial legacy in the communities.

• The COMMIT model of community organization and a structure of

Boards and task forces was well received and has utility for other

community problems. Board and task force members also found it

a good structure to distribute COMMIT’s work activities.

• As noted above under “Feedback Issues,” community volunteers

would have liked outcome data during the trial so that they could

have made midcourse corrections, if necessary. Formative evaluation

methodology requires continuous feedback to revise interventions.

Availability of process and early outcome data also would have

provided opportunities to sell the project to other groups and

organizations in the community. Process data on events, contests,

and new strategies to recruit heavy smokers also would have allowed

for changes to be made the next time those activities were conducted.

Community volunteers felt hampered by lack of data.

• Communities were interested in maintaining tobacco control activities.

Unfortunately, the COMMIT protocol did not include durability as one

of its goals or intervention objectives. Despite this, all 11 communities

discussed the issue and developed plans for sustaining at least some

project activities. An earlier planning period for transition and

assistance in obtaining resources would have been useful for the

communities. The plan for durability and transition from a funded

research project to a community-supported project should have been

an explicit COMMIT goal, and steps to achieve that should have

been incorporated from the beginning of intervention activities.

• Resources are important in maintaining tobacco control; however,

organized groups can undertake tobacco control. The COMMIT

experience suggests that a foundation was laid by the project,

considerable enthusiasm and energy were developed, and avenues

were found for maintaining many project activities. Although these

results differed by community, 9 of the 11 communities continued

some form of activity for a year after the project ended, and 2 expanded

activity with new funding.

IMPLICATIONS OF Although COMMIT data continue to be assessed, especially

COMMIT RESULTS in terms of impact objectives, the outcomes of the trial have

ON LESSONS LEARNED been published (COMMIT Research Group, 1995a and

1995b). A statistically significant difference in the proportion of light-tomoderate smokers who quit during the 4 years of the intervention was noted

in the intervention communities (30.6 percent) compared with control

communities (27.5 percent). However, there was no difference in smoking

cessation between intervention and control communities among heavy

smokers.
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Chapter 14

Cessation among light-to-moderate smokers was associated with

educational level, with most of the beneficial effect of the intervention

seen in the less educated subgroup (no college education). This is contrary

to other studies that indicate cessation is more likely to occur among more

educated groups (Pierce et al., 1989). It may be that less educated smokers

benefit more from a community-based intervention.

Receipt indices were calculated from questions regarding respondents’

experiences in the various intervention channels; for example, individuals

were asked whether their physician had talked with them about stopping

smoking, whether there were any antismoking activities in their worksite,

and whether they had participated in any stop-smoking contests. Separate

indices were devised for cessation resources, health care, worksites, public

education and media, religious organizations, programs and materials,

contests and events, and perceived unacceptability of smoking. Summary

standardized scores of those indices for heavy smokers were 0.695 for the

intervention communities and 0.118 for the control communities (p = .012).

For light-to-moderate smokers, the summary scores were 0.386 for the

intervention communities and -0.178 for the control communities (p = .004).

These scores indicate that cohort members in the intervention communities

were more aware of and had participated in more smoking control activities

than their counterparts in the control communities. There also was a

significant rank order correlation between community receipt indices and

the quit rate for the light-to-moderate cohort (rank order correlation = .75,

p = .01). In addition, an examination of the observed quit rates over time

shows an emerging difference between intervention and control communities

for light-to-moderate smokers.

Quitting was measured in 1990, 1991, 1992, and at the end of the trial in

1993. Heavy and light-to-moderate smokers showed an increase in quitting

over time in both the intervention and control communities. However,

Figure 1 suggests an emerging difference in quit rates for light-to-moderate

smokers, one that could perhaps attest to the durability of the community

intervention approach if smoking cessation were to be measured again

(COMMIT Research Group, 1995a). One of the primary considerations in

selecting a community-based approach for the COMMIT intervention was

the potential for a sustained intervention effect.

The COMMIT findings regarding heavy smokers and cessation are

consistent with other studies (Luepker et al., 1994; Dwyer et al., 1986). The

difference detected in light-to-moderate smokers is consistent with those

reported earlier in eight community studies in seven different countries.

Furthermore, the difference observed in COMMIT is greater than that in the

Minnesota Heart Health Program, where a difference was seen only among

women (Luepker et al., 1994), and the Pawtucket Heart Health Program,

where there was no significant difference in cessation rates (Carleton et al.,

1995). Based on their cohort sample, the Stanford Five-City Project observed

a greater decline in prevalence in treatment cities compared with controls,

and light-to-moderate smokers did better than heavy smokers; however,
Smoking and Tobacco Control Monograph No. 6

248

Figure 1

Observed quit rates over time for heavy and light-to-moderate smoker cohorts

nearly half the cohort could not be followed (Fortmann et al., 1993). No

difference was detected between treatment and controls based on crosssectional data in the Stanford Five-City Project (Fortmann et al., 1993).

Although process objectives were achieved and the intervention receipt

indices were favorable for reaching smokers, they had an influence on the

quit rates of only light-to-moderate smokers. These outcomes, although

significant in terms of potential public health benefit, are more modest than

the investigators had hoped to achieve and should be interpreted in light of

the successful implementation of the intervention protocol. Several possible

reasons for this limited impact of community organization on smoking

behavior exist.

First, the project may not have lasted long enough to realize the link

between process objectives and impact objectives or between impact
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Chapter 14

objectives and outcomes. This has been the case in other studies, such as

the North Karelia Project, where significant results were not seen until

the 10-year followup (Puska et al., 1983). Conversely, the Stanford Three

Community Study saw results in the 2nd and 3rd years of intervention,

although that study did not focus on heavy smokers. It may be that heavy

smokers take longer to move from awareness and participation to cessation

than do light-to-moderate smokers. Second, the group of interventions,

although efficacious in specific settings, may not have been the right ones

for a community trial. Clearly, the interventions did not reach heavy

smokers who are strongly addicted to nicotine, so it is possible that they

need more individualized and clinical attention to quit. Third, COMMIT

did not emphasize policy and media interventions; there is some evidence

that these could be more effective, especially if done in conjunction with

the other COMMIT activities (Flora and Cassidy, 1990; Sorensen and

Pechacek, 1989).

Other investigators believe that behavioral outcome measures may

not be the only appropriate outcome for a community trial. Mittelmark and

colleagues (1993) argue that problems of secular trend, sampling, economic

patterns that can contribute to migration, difficulty of measuring outcomes,

need to follow cohorts, and need to repeatedly survey large cross-sections of

the population make it unreasonable to rely on behavioral change outcomes

as indicators of success; rather, they argue that assessing participation may

be the most important measure of success. Although COMMIT investigators

were not willing to give up the behavioral outcome, they did believe it

necessary to collect enough process data so that outcomes could be better

understood. Only a few of those process data have been published to date.

The process objectives indicate that interventions targeting heavy smokers

were conducted. The intervention receipt indices described above indicate

heavy smokers received the intervention. Other process measures, such as

those documenting policy changes in worksites, organizations, and schools,

remain to be analyzed. Similarly, we do not know yet whether there was an

impact on the intermediary agencies (e.g., health care providers, cessation

resources) that serve smokers. Those analyses are being conducted.

FUTURE DIRECTIONS Increasingly, community intervention programs for tobacco

FOR COMMUNITY control are being funded and implemented. Sponsorship

TOBACCO CONTROL varies from support from public health departments, to grants

and contracts from Federal agencies (e.g., NCI’s American Stop Smoking

Intervention Study for Cancer Prevention [ASSIST] and the Centers for

Disease Control and Prevention’s Initiatives To Mobilize for the Prevention

and Control of Tobacco Use [IMPACT] program), to foundation support

(e.g., the Robert Wood Johnson Foundation Program for Smokeless States).

However, fiscal resources for these projects vary considerably. In ASSIST,

NCI has committed $20 million annually to support smoking interventions

in 17 States, whereas 33 States are due to receive approximately $5 million

annually under the IMPACT program. Staff members who are charged with

implementing the programs seek information from COMMIT and other

previously implemented community tobacco control projects to determine
Smoking and Tobacco Control Monograph No. 6

250

how best to address tobacco control. Given the limited resources of an

implementation project compared with a research project, important

decisions must be made as to project emphasis.

The cornerstone of COMMIT and any other community intervention

project is community organization. Community representatives know how

their communities operate and how to reach individuals or groups who

practice unhealthy behaviors such as smoking. Although community

organization may require a considerable amount of work at the beginning

of a project, it is effective in mobilizing a community because a variety of

volunteers can be recruited to participate in the project and the diversity

of representatives will ensure that all community sectors are involved.

Community organization requires a careful and thorough community

analysis. All sectors of the community must be analyzed for their potential

contribution to reaching project goals within the community. This analysis

is the basis for forming community structures to take on tobacco control

or other community problems. For some communities, a small coalition

may work best; for others, one existing community agency may be

prepared to take on the implementation role while involving others in

the decisionmaking processes. The importance of community analysis

cannot be overemphasized; an incomplete or erroneous analysis can omit

the very groups or individuals who are most necessary to reach a target

population.

Community tobacco control projects must be clear as to their specific

aims. For example, Fisher (1995) has argued that what needs to be tested

in community studies is a defined approach to community organization,

not a defined intervention. Such an approach would require considerable

flexibility for program planning, development, and implementation.

Funding agencies may need to accept that greater flexibility and community

freedom are necessary for effective community interventions. On the other

hand, ASSIST embraces coalitions as a defined organizational structure

(Shopland, 1993) but requires an intervention that focuses on policy and

media (National Cancer Institute, 1991). The defined intervention has

some general components but is not as regulated as COMMIT. Perhaps that

approach will be more suitable to coalitions and the groups they represent.

Community groups must consider many factors when deciding on

tobacco control activities. Are there particular subgroups that must be

reached? How can they best be reached? Is addiction a major issue for

the intervention the community groups wish to implement? If so, is a

community study the best avenue for dealing with addiction? Is prevention

the primary goal? If so, a focus on policy and media is probably most

appropriate. Community projects that are not part of research have

the advantage of picking their area of emphasis and then using the

best knowledge available to tackle that problem. Community projects

involved in research have less latitude.

Future tobacco control activities must be seen as part of a comprehensive

national agenda. In COMMIT, most communities did not have the
251

Chapter 14

concurrent stimulus from Federal, State, county, and local regulations and

ordinances that could form a synergy between local efforts and broader

efforts. Although it is well known that the price of cigarettes is a major factor

in consumption (Warner, 1986; Sweanor et al., 1993), only recently have

substantial increases in tobacco taxation been instituted. Both Canada and

California saw significant decreases in smoking prevalence after such tobacco

tax increases. Environmental restrictions also have an impact on decreasing

prevalence (Borland et al., 1990; Brighan et al., 1994). Taxation,

environmental restrictions, and government-funded mass media campaigns

are necessary elements for a comprehensive, synergistic approach to tobacco

tax control. Communities do not operate independently of the broader

political and social systems, and sources of future community projects may

be limited without support from those broad sectors.

The tobacco problem is likely to continue for some time. Community

projects are ways to organize entire communities to combat this problem,

and all the evidence from COMMIT indicates that communities will organize

and implement many activities to fight tobacco use. The lessons learned

from the field in the COMMIT project can and should be used to help

communities develop and implement their own tobacco control activities.

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AUTHORS

Beti Thompson, Ph.D.

Associate Professor

University of Washington School of

Public Health and Community Medicine

Associate Member

Fred Hutchinson Cancer Research Center,

MP-702

1124 Columbia Street

Seattle, WA 98104

William R. Lynn

COMMIT Project Officer

Public Health Applications Research Branch

Cancer Control Science Program

National Cancer Institute

National Institutes of Health

Executive Plaza North, Room 241

6130 Executive Boulevard, MSC-7337

Bethesda, MD 20892-7337

Donald R. Shopland

Coordinator

Smoking and Tobacco Control Program

National Cancer Institute

National Institutes of Health

Executive Plaza North, Room 241

6130 Executive Boulevard, MSC-7337

Bethesda, MD 20892-7337