JosephW. Cullen, Ph.D. 

1936-1990 

The Smoking and Tobacco Control Monographs are dedicated 

to the memory of Joseph W. Cullen, former Depuv Director of 

the Division of Cancer Prevention and Control and architect of 

the National Cancer Institute’s Smoking and Tobacco Control 

Program (STCP). Through his innovative leadership, the 

STCP has now established itself as the world’s premier 

organization in the Feld of smoking and tobacco use control. 

Dr. Cullen was an inspiration to all who knew him, 

representingpublic service at its best. His untimely death in 

November 1990 represents a loss to us all, but most 

important, a loss to the public health of this country. 

Peter G. Greenwald, M.D., Dr. P.H. 

Director 

Division of Cancer Prevention and Control 

National Cancer Institute 

November 1991 
Strategies 

To Control 

Tobacco Use 

In the United 

States: 

a blueprint for public health 

action in the 1990’s 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Public Health Service 

National Institutes of Health 

National Cancer Institute 

NIH Publication No. 92-3316 

October 1991 
BLANK PAGE 
Smokinn and Tobacco Control Mononraph No.1 

Foreword 

Of all the U.S. Public Health Service agencies, the National 

Cancer Institute (NCI) has perhaps the longest history of involvement in the battle against the health consequences of 

smoking. During the early 1950’~~ when the first studies to link 

smoking with increased lung cancer risks were published, the 

Institute included smoking as part of its research agenda. 

In 1955, NCI epidemiologists Haenszel, Shimkin, and Miller 

conducted the first large-scale national survey to assess patterns 

of tobacco use among adults in the United States. Theirs was a 

landmark study in many ways, not the least of which was its 

momentum against the prevailing indifference-and even 

hostility-in the medical community with regard to inferences 

that smoking harmed people. That study clearly defined the 

extent of the smoking problem in American society; nearly 

60 percent of men and 28 percent of women were classified as 

current smokers at the time of interview. Since that time, 

substantial progress has been made in reducing smoking prevalence. Today, only about 25 percent of adult Americans report 

that they are cigarette smokers. 

Figure 1 

Percentage of adults (age 18 and older) who are current 

smokers, by race and gender 

Males Females 

Source: Current Population Survey, 1989. 

iii 
National Cancer Institute 

Figure 2 

Percentage of high school seniors reporting daily cigarette 

smoking 

Percentage 

31 

Year .--. 

Source: Universifyof Michigan 

Nevertheless, nearly 50 million of our citizens are still 

using cigarettes regularly; and, sadly, the percentage of women 

who smoke is about the same now as was reported 35 years 

ago. Indeed, as a direct consequence of smoking, the ageadjusted death rate from lung cancer among women has 

increased by a staggering 420 percent during this same period. 

Further, smoking among black men is 20 percent higher than 

that reported by whites, and black men have the highest lung 

cancer mortality rate of any demographic group in the United 

States. 

Even more discouraging, smoking among our children has 

not declined appreciably over the last decade, despite the 

continuing efforts of public health officials (Figure 2). Approximately 3,000teenagers take up the habit each day. 

The reasons for these developments should not be too 

surprising, as detailed in this monograph (see Chapter 1). 

Smoking is a pervasive social problem of gigantic proportions. 

Last year alone, this Nation consumed 527 billion cigarettes, or 

iv 
Smoking and Tobacco Control Monograph No. 1 

2,828cigarettes for every person 18 and over, smokers and 

nonsmokers alike (see Chapter 3). Cigarettes represent a 

unique class of commercial product in that they are lifethreatening when used as intended by the manufacturer. 

While this Institute spent $47million last year to develop 

and disseminate effective smoking intervention technologies, 

the major cigarette manufacturers spent $3.6 billion in an 

effort to convince people that smoking is necessary for social 

acceptance, that it makes one attractive to the opposite sex, 

and that it enhances self-image. Over the past 4 years alone, 

expenditures for all cigarette advertising and promotional 

activities have increased nearly 50 percent and, increasingly, 

they appear to be targeting youth. 

Perhaps the most criticized campaign of recent years was 

the introduction, in 1988,of the “smooth character” cartoon, 

Joe the Camel (Figure 3). In 1989,RJR Nabisco ran a particularly outrageous four-page ad in youth-oriented Rolling Stone 

magazine, in which dating advice was offered for young men. 

On the first page of the ad is a cartoon of a beautiful woman 

Figure 3 

The “smooth character” 

V 
National Cancer Institute 

asking if the male teen is “bored? lonely? restless?” Inside, the 

“smooth character” gives “foolproof dating advice” for impressing someone at the beach: 

Run into the water, grab someone and drag her back to the 

shore, as if you’ve saved her from drowning. The more she 

kicks and screams, the better [emphasis added]. 

While the tone and slant of this advice constitute an 

insulting provocation to the women of our country, perhaps 

equally troubling is the information on the back page of the 

ad: “How to get a FREE pack even if you don’t like to redeem 

coupons.” The suggestion: Just ask “your best friend” or “a 

kind looking stranger” to redeem the coupon for you. 

Who is really the target of such an advertisement? Certainly, the camel cartoon character could not have much 

appeal for an adult. And how many people would feel compelled to ask “a kind looking stranger” to redeem a coupon for 

free merchandise-unless, of course, they were underage? 

No doubt the success of the “smooth character” campaign 

is one reason that RJR Nabisco more than tripled its advertising 

expenditures for Camel cigarettes. In the wake of Joe the 

Camel’s popularity, Brown & Williamson Tobacco Corp. has 

begun test marketing of a penguin cartoon character to promote Kool cigarettes in billboards, magazines, and store displays. It is not difficult to imagine what impact such largescale, youth-oriented promotions may have on the sale of these 

brands to teenagers. Unfortunately, by the time we resolve this 

question, millions of our young people already will have 

become addicted to cigarettes. While the economic costs to 

our future program of health care delivery will be staggering, 

the future human costs are beyond reckoning. 

As public health officials, we must devise effective strategies to counter such seductive promotions, and we will not 

shy away from this mission. Yet, for every $1that NCI spends 

on research to combat smoking, the tobacco industry spends 

$80 to promote the addiction. Where the cigarette manufacturers can offer free packs of cigarettes, cigarette lighters, and 

premiums such as attractive clothing, we can offer only warnings about the dangers of smoking and advice about how to 

quit. 

As health professionals, we need to understand that 

smoking is not only an individual’s problem, but also a societal 

problem-”a social carcinogen,” as one prominent researcher 

characterized it. Also, it is a problem that can not be left solely 

to Government to solve. It will require the combined efforts of 

vi 
Smokinn and Tobacco Control Mononraph No. 1 

all of us to achieve a tobacco-free society. I call upon the entire 

medical and public health community to become involved in 

the fight against this Nation’s number one public health 

menace-cigarette smoking. 

Samuel Broder, M.D. 

Director, 

National Cancer Institute 

vii 
BLANK PAGE 
Smoking and Tobacco Control Monograph No. 1 

Preface 

In the months immediately after January 1964,when 

Surgeon General Luther Terry released the first official Government report on smoking and health, cigarette consumption in 

the United States declined significantly. It was only the second 

time since the turn of the century that publicity about the 

hazards of smoking had produced a reduction in cigarette use. 

At that time, many leaders in the medical and public health 

arena assumed that, by providing the public with straightforward information about the dangers of smoking, they could 

discourage large numbers of people from using cigarettes. 

While the expected change in behavior did occur, it was far 

more limited than had been hoped-a reflection of the difficulty that individuals often experience when they attempt to 

alter a complex behavior such as smoking, especially one we 

now know to be addictive. 

The recognition that information alone would not eliminate tobacco use shifted the focus to strategies directed to the 

individual. This focus presumed, erroneously as it turned out, 

that the major determinants of smoking behavior were centered 

within the individual rather than sociologic in nature. Subsequent research and natural observation clearly demonstrated 

that behavior change correlated with changes occurring in the 

smoker’s social and economic environment. This recognition 

has led to the adoption of public health strategies that now 

address the smoker’s larger social environment while simultaneously offering programs of assistance for the individual. 

This volume provides a summary of what we have learned 

over nearly 40 years of the public health effort against smoking-from the early trial-and-error health information campaigns of the 1960’sto the NCI’s science-based ASSIST project 

(the American Stop Smoking Intervention Study for Cancer 

Prevention), which began in the fall of 1991. Strategies To 

Control Tobacco Use in the United States: A Blueprint for Public 

Health Action in the 1990’s presents a historical accounting of 

these efforts as well as the reasons why comprehensive smoking 

control strategies are now needed to address the smoker’s total 

environment and reduce smoking prevalence significantly over 

the next decade. 

An important finding discussed in this monograph is how 

different populations were affected by and responded to the 

early 1950’smedia coverage about the dangers of smoking, in 

ix 
National Cancer Institute 

contrast to the effects of more intensive and sustained efforts 

in the late 1960’s (see Figures 8, 9, and 10 in Chapter 1). 

During the latter period, the Federal Communications Commission ruled that cigarette advertising was subject to the 

Fairness Doctrine, and it required that all radio and television 

stations provide significant air time for health organizations to 

counter commercial ads with messages against smoking. 

While the data show clearly that only white male smokers 

reacted to the first wave of public information in the 1950’smost likely because all of the early studies linking smoking and 

lung cancer were conducted with white males-the 

counteradvertising campaigns of the late sixties produced a 

greater level of smoking cessation across all major demographic 

groups. The TV and radio messages against smoking at that 

time employed broader themes and issues and thereby appealed to a more diverse audience. Further, the counteradvertising campaigns under the Fairness Doctrine used farreaching electronic media-primarily television, while the 

public information of the middle 1950’s had relied more 

heavily on print media. 

The lessons gained from such natural experiments and 

from our contextual understanding of social factors that have 

influenced smoking in this century (see Figure 1, Chapter 5) are 

strong complements to our knowledge of what works-from 

the more than 100 controlled intervention trials sponsored by 

NCI in the 1980’s. 

Throughout the first 10 years of its existence, NCI’s Smoking and Tobacco Control Program has operated under the 

philosophy that research, in and of itself, is not capable of 

producing large-scale national change in smoking prevalence 

rates. It was recognized from the outset that there must be a 

concerted effort to systematically and comprehensively apply 

the knowledge gained from the intervention trials. Thus, from 

its inception, the STCP has continually used information from 

such studies to plan the next steps for implementation of a 

national strategy to significantly reduce smoking in the 1990’s. 

The current state of the art in combating tobacco use 

combines multiple environmental changes with multiple 

programs directed to individuals in different stages of the 

smoking initiation and cessation process (see Figures 14 and 

15, Chapter 1). This strategy recognizes that no single approach is best for all individuals, that no one intervention 

channel is capable of effectively reaching all smokers (or, in the 

case of children, potential smokers), and that no single time is 

best for individual smokers to make an attempt to quit. Comprehensive strategies for smoking control are characterized by 

X 
Smoking and Tobacco, Control Monograph No. 1 

Figure 1 

ASSIST states 

the delivery of persistent and inescapable messages to quit, or 

to not start smoking, coupled with continuously available 

support for individual cessation attempts, all provided through 

multiple channels and reinforced by environmental incentives 

for nonsmokers. 

This strategy has provided the scientific foundation for the 

largest, most comprehensive smoking control project ever 

undertaken-the American Stop Smoking Intervention Study 

for Cancer Prevention. ASSIST is a large demonstration project 

designed to significantly reduce smoking prevalence in 17 states 

(Figure 1). Its primary objective is to reduce smoking prevalence to 15 percent or less by the year 2000. 

The ASSIST framework incorporates a three-axis model, 

consisting of target populations, intervention channels, and 

interventions (Figure 2). The model organizes the multiple and 

diverse activities of a comprehensive smoking control initiative: 

Target populations (axis 1) can include youth, ethnic 

minorities, blue-collar workers, individuals with less 

education, women, or other populations with relatively 

high smoking prevalence. 

Channels (axis 2) are the organizational structures or 

mechanisms by which specific intervention activities will 

reach the target populations. In ASSIST, four major 

channels are envisioned as the primary means for contact 

with smokers and potential smokers. 

xi 
National Cancer Institute 

Figure 2 

ASSIST conceptual framework 

Mass Media 

Program Services 

/ 

Worksites 

/ 

Schools 

/ 

Health 

Care 

Settings 

/ 

Community

Groups 

Target Populations

Axis 1 

Interventions (axis 3) are the instruments for producing 

change, both for the individual and in the larger community environment that will effect broader behavior change 

in target populations. In ASSIST, interventions will take 

the form of direct contacts with individuals and groups 

through a variety of program services, while media and tobacco control policies are expected to create broader social 

change and increase the demand for program services. 

More than 90 million Americans will be directly affected by 

ASSIST over the life of the project. If ASSIST project goals are 

achieved, it will result in 4.5 million adults’ quitting smoking and 

prevent 2 million children from ever taking up the habit. More 

important, a successful ASSIST project will have prevented nearly 

1.2 million premature smoking-related deaths, including more 

than 400,000 deaths from lung cancer. 

Claudia Baquet, M.D. 

Associate Director 

Cancer Control Sciences 

Program 

National Cancer Institute 

xii 
Smoking and Tobacco Control Monograph No. 1 

Acknowledgments 

Strategies To Control Tobacco Use in the United States: A 

Blueprint for Public Health Action in the 19903 was developed 

under the general editorship of the Smoking and Tobacco 

Control Program (STCP), Donald R. Shopland, Coordinator, 

National Cancer Institute, Bethesda, Maryland. The senior 

scientific editor was David M. Burns, M.D., Professor of 

Medicine, University of California, San Diego, San Diego, 

California. Consulting scientific editors were Jonathan M. 

Samet, M.D., Professor of Medicine, University of New Mexico, 

Albuquerque, New Mexico, and Ellen R. Gritz, Ph.D., Professor in Residence, Head and Neck Division, Department of 

Surgery, School of Medicine, University of California, Los 

Angeles, and Director of Division of Cancer Control, Jonsson 

Comprehensive Cancer Center, Los Angeles, California. 

The starof the NCI Smoking and Tobacco Control 

Program gratefidly acknowledges the authors who made 

this monograph possible. Attributions for each chapter 

are: 

Chapter 1, “The Scientific Rationale for Comprehensive, 

Community-Based, Smoking Control Strategies’,- 

David M. Burns, M.D., Professor of Medicine, 

University of California, San Diego, San Diego, 

California. 

Chapter 2, “Evolution of Smoking Control StrategiesffJerome Schwartz, Ph.D., Health Care Consultants, Davis, California; Beti Thompson, Ph.D., 

Fred Hutchinson Cancer Research Center, Seattle, 

Washington. 

Chapter 3, “Smoking Prevalence and Lung Cancer Death 

Rates”-H. Dennis Tolley, Ph.D., Department of 

Statistics, Brigham Young University, Provo, 

Utah; Lori Crane, Ph.D., Jonsson Comprehensive 

Cancer Center, University of California, Los 

Angeles, Los Angeles, California; Nikki Shipley, 

M.S.,Jonsson Comprehensive Cancer Center, 

University of California, Los Angeles, Los Angeles, 

California. 

xiii 
National Cancer Institute 

Chapter 4, 

Chapter 5, 

Chapter 6, 

“Approaches Directed to the Individual”- 

Elizabeth Edmundson, Ph.D., The University 

of Texas Health Science Center at Houston, 

Houston, Texas; Alfred McAlister, Ph.D., 

Center for Health Promotion Research and Development, School of Public Health, The University 

of Texas Health Science Center at Houston, 

Houston, Texas; David Murray, Ph.D., Division 

of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota; 

Cheryl Perry, Ph.D., Division of Epidemiology,

School of Public Health, University of Minnesota, 

Minneapolis, Minnesota; Edward Lichtenstein, 

Ph.D., Oregon Research Institute, Eugene, Oregon. 

“Approaches Directed to the Social Environment”-K. Michael Cummings, Ph.D., M.P.H., 

Department of Cancer Control and Epidemiology, 

Roswell Park Memorial Institute, Buffalo, New 

York; Russell Sciandra, Ph.D., Roswell Park 

Memorial Institute, Buffalo, New York; Julia 

Carol, Americans for Nonsmokers’ Rights, Berkeley, California; Susan Burgess, Americans for 

Nonsmokers’ Rights, Berkeley, California; Joe B. 

Tye, M.B.A., President, Stop Teenage Addiction to 

Tobacco, and Chief Operating Officer, Baystate 

Medical Center, Springfield, Massachusetts; 

Robert Flewelling, Ph.D., Research Health 

Analyst, Center for Social Research and Policy 

Analysis, Research Triangle Institute, Research 

Triangle Park, North Carolina. 

“Interdependence and Synergy Among Smoking 

Control Activities” -Beti Thompson, Ph.D., 

Fred Hutchinson Cancer Research Center, Seattle, 

Washington; Enid Fallick Hunkeler, M.A., 

Division of Research, Kaiser Permanente Medical 

Program, Oakland, California; Lois Biener, 

Ph.D., Center for Survey Research, University of 

Massachusetts, Boston, Massachusetts; Carole 

Tracy Orleans, Ph.D., Fox Chase Cancer Center, 

Cheltenham, Pennsylvania; EliseoJ. PCrezStable, M.D., School of Medicine, University of 

California, San Francisco, San Francisco, 

California. 

xiv 
Smoking and Tobacco Control Monograph No. 1 

The editors gratefirlly acknowledge also the following distinguished scientistst researcherst and others, 

both in and outside government, who coordinated 

manuscripts or contributed critical reviews: 

Anthony Biglan, Ph.D., Oregon Research Institute, Eugene, 

Oregon 

Erwin Bettinghaus, Ph.D., College of Communications Arts and 

Sciences, Michigan State University, East Lansing, Michigan 

Dee Burton, Ph.D., University of Illinois at Chicago, Chicago, 

Illinois 

Ronald M. Davis, Deputy Director, Michigan State Department 

of Health, and former Director, Office on Smoking and Health, 

Centers for Disease Control, Rockville, Maryland 

Karen Deasy, M.P.H.A., Associate Director for Policy, Office on 

Smoking and Health, Centers for Disease Control, Rockville, 

Maryland 

Michael P. Eriksen, Sc.D., Assistant Professor of Cancer Prevention and Director, Behavioral Research Program, Department of 

Cancer Prevention and Control, The University of Texas, M.D. 

Anderson Cancer Center, Houston, Texas 

Richard I. Evans, Ph.D., Director, Social Psychology/Behavioral 

Medicine Research and Graduate Training Group, Department 

of Psychology, University of Houston, Houston, Texas 

Michael Fiore, M.D., M.P.H., Director, Tobacco Research and 

Intervention Program, University of Wisconsin-Madison 

Medical School, Madison, Wisconsin 

Greg Getz, Ph.D., Research Coordinator, Social Psychology/ 

Behavioral Medicine, Research and Graduate Training Group, 

University of Houston, Houston, Texas 

Gary Giovino, Ph.D., Acting Chief, Epidemiology Branch, 

Office on Smoking and Health, Centers for Disease Control, 

Rockville, Maryland 

ThomasJ. Glynn, Ph.D., Chief, Prevention and Control Extramural Research Branch, Division of Cancer Prevention and 

Control, National Cancer Institute, Bethesda, Maryland 

Nancy Gordon, Sc.D., Division of Research, Kaiser Permanente, 

Oakland, California 

Edward Guadagnoli, Ph.D., Department of Health Care Policy, 

Harvard Medical School, Boston, Massachusetts 

XV 
National Cancer Institute 

Jan L. Hitchcock, Ph.D., Foundation for Blood Research, 

Scarborough, Maine 

Lynn T. Kozlowski, Ph.D., Professor of Biobehavioral Health, 

The Pennsylvania State University, University Park, 

Pennsylvania 

Marc Manley, M.D., Medical Officer, Division of Cancer Prevention and Control, National Cancer Institute, Bethesda, 

Maryland 

Alfred C. Marcus, Ph.D., Director of Public Health Research, 

AMC Cancer Research Institute, Denver, Colorado 

Stephen E. Marcus, Ph.D., Office on Smoking and Health, 

Centers for Disease Control, Rockville, Maryland 

Sarah McGraw, Ph.D., Senior Research Scientist, New England 

Research Institute, Inc., Watertown, Massachusetts 

Terry F. Pechacek, Ph.D., Expert, Division of Cancer Prevention 

and Control, National Cancer Institute, Bethesda, Maryland 

John Pierce, Ph.D., University of California, San Diego, San 

Diego, California 

Bettye Raines, B.S., Administrator, Social PsychologylBehavioral Medicine, Research and Graduate Training Group, University of Houston, Houston, Texas 

Rose Mary Romano, M.A., Chief, Public Information Branch, 

Office on Smoking and Health, Centers for Disease Control, 

Rockville, Maryland 

Steven P. Schinke, Ph.D., Professor, Columbia University 

School of Social Work, New York, New York 

Saul Schiffman, Ph.D., Associate Professor, Director, Clinical 

Psychology Center, University of Pittsburgh, Pittsburgh, Pennsylvania 

Jesse Steinfeld, M.D., Surgeon General of the United States 

1969 to 1973, San Diego, California 

Alvin V. Thomas, Jr., M.D., Chief, Division of Pulmonary and 

Critical Care Medicine, Howard University Hospital, Washington, D.C. 

Ernst L. Wynder, M.D., American Health Foundation, New 

York, New York. 

xvi 
Smoking and Tobacco Control Monograph No. 1 

The editor acknowledges the contributions of the 

following staff members of the National Cancer Institute, of R.O.W.Sciences, Inc., Rockvtlle, Maryland, and 

of the University of California, San Diego, who assisted 

in the preparation of this monograph: 

National Cancer Stephanie Carson, Administrative Assistant, Division of Cancer 

Institute Prevention and Control, National Cancer Institute 

R.O.W. Sciences, Inc. Richard H. Amacher, Project Manager 

Douglas Bishop, Art Director 

Lisa Blomquist, Word Processing Specialist 

Caroline Caldwell, Graphics Specialist 

Catherine Godfrey, Word Processing Specialist 

Eunice Hippolyte, Word Processing Specialist 

Diane Levitt, Health Information Specialist 

Cherie Melat, Graphics Specialist 

SteveJ. Niemcryk, Ph.D., Epidemiologist/Biostatistician 

Patricia Perry, Administrative Assistant 

Myrtle Peters, Administrative Assistant 

Dori Steele, Copy Editor 

Barbara Shine, Medical Writer/Editor 

Steven Stocker, Science Writer 

Francis X. Sullivan, Editor 

Donna Tharpe, Copy Editor 

Sonia Van Putten, Word Processing Specialist 

William Ward, Copy Editor 

Ronald W. Wolf, Editorial Coordinator and Senior Copy Editor. 

xvii 
National Cancer Institute 

University of Sharon Buxton, Word Processing Specialist 

California, San Diego, 

Medical Center Tina Kim, Project Assistant 

Jerry Vaughn, Programmer/Analyst 

xviii 
Smoking and Tobacco Control Monograph No. 1 

Introduction 

In 1982, the National Cancer Institute began the Smoking and Tobacco Control Program (STCP). The STCP included 

a comprehensive research program for testing the efficacy of a 

variety of smoking intervention strategies. To date, nearly 

$300 million has been allocated for this effort (Figure l), 

making the STCP the largest program of its kind in the world. 

Figure 1 

National Cancer lnstitute funding for smoking and tobacco 

control research 

(in $000’~) 

1982 10,943 

1983 9,476 

1984 16,721 

1985 21,131 

1986 27,099 

1987 37,288 

1988 39,604 

1989 40,151 

1990 41,500 

1991 46,900 

Total 1982-1 991 $290,813 

Source: National Cancer lnstitute 

STCP TRIAL AREAS The priorities for STCP intervention research grew from a 

systematic planning process for cancer prevention and control 

that had already been developed within the National Cancer 

Institute. This early strategy positioned the control of smoking 

as the cornerstone for NCI’s effort to reduce cancer mortality 

by 50 percent by the end of the 1990’s. The strategy’s blueprint was a model that defined NCI priorities for cancer control 

(Figure 2). 

Priorities for STCP intervention activities evolved from 

state-of-the-art reviews and consensus development incorporating contributions from hundreds of scientists and public health 

experts. The result was the two-pronged strategy now in use. 

The first part involves the study of intervention methods that 

are school-based programs, self-help techniques, physiciandelivered and dentist-delivered interventions, mass media 

xix 
7 

National Cancer Institute 

Figure 2 

Cancer control phases applied to smoking and tobacco control research 

\ 

Basic I 

\ II \ 

111 \ IV \ V 2 Nationwide 

Biomedicalrn Hypothesis Methods Controlled Defined ,+ Demonstration +and Health Prevention

Research 

’Development + Development + Intervention ’+ Population and

Trials Studies Implementation Services \ \ \ Programs 

I I 

Research on Applied : Applications 

Applications I Research of Research 

1982-1986 10% I 80% 10% 

1987-1990 10% I 50% I 40% 

1991-2000 10% 30% 60% 

approaches, and community-based interventions. The second 

strategic arm targets specific populations that are (1)at greater 

risk for developing cancer and/or (2) amenable to prevention/ 

cessation strategies. Included in the second strategy are youth, 

ethnic minority groups, women, smokeless tobacco users, and 

heavy smokers. 

While nearly 100 separate intervention trials and studies 

now make up the NCI portfolio of smoking and tobacco use 

intervention research, 60 trials constitute the original core of 

the STCP program (Figure 3). 

To aid in the national dissemination of STCP trial results, a 

series of monographs, of which this is the first, will be produced. This first monograph, Strategies To Control Tobacco Use 

in the United States: A Blueprint for Public Health Action in the 

19903,presents an overview of the components of an effective, 

comprehensive smoking control strategy. Future monographs 

will focus on individual trial areas or related topics. 

SMOKING Smoking and Tobacco Control Monographs are but one 

AND TOBACCO means that NCI uses for informing both the public health and 

CONTROL research communities of emerging results from the smoking 

MONOGRAPHS intervention trials initiated in the mid-1980’s. While monograph contents will be based primarily on information and 

findings from NCI-funded trials and studies, they also will 

address various issues of importance to the public health 

community in the effort to reduce smoking-related disease. 

One important area, which recently has begun to receive 

increased attention, is that of policies and their effect on 

practices related to smoking and tobacco use. 
Smoking and Tobacco Control Monograph No. 1 

Figure 3 

Smoking and tobacco control intervention trials 

Goal: To develop and evaluate interventions to aid in either stopping or 

preventing tobacco use. 

Number of Trials (1983-1987):60 

Intervention Areas Numberof Trials 

School-Based Interventions 10 

Self-Help Strategies 7 

Physician/Dentist Interventions 6 

Mass Media Interventions 5 

Interventions in Black Populations 8 

Interventions in Hispanic Populations 3 

Interventions in Populations of Women 5 

Control of Smokeless Tobacco Use 5 

Heavy Smoker Interventions 11 

Total 60 

Purpose In developing the concept for the Smoking and Tobacco 

Control Monographs, the Institute intended that the publications serve four major objectives: 

1. Provide a cohesive and integrated description of individual smoking and tobacco issues, control strategies, 

and trial results to allow maximal utilization and 

dissemination of current and evolving knowledge and 

thereby influence the professional and layperson’s 

understanding of these matters. 

2. Significantly reduce the time between availability of 

information emanating from research projects and the 

publication and wide dissemination of this information. 

3. Enhance the rapidity and efficiency with which NCI 

can utilize findings from research trials as a means of 

reducing cancer morbidity and mortality for those 

cancers most associated with tobacco use. 

4. Provide a mechanism for codification and synthesis of 

information relevant to the use of those agencies, 

institutions, and individuals in the Nation that can 

affect the formulation of public policy related to 

smoking and tobacco use. 

The rapidly growing understanding of what constitutes an 

effective strategy for controlling tobacco use has outstripped 

the ability of the peer-reviewed literature to disseminate this 

understanding to those responsible for implementing smoking 

xxi 
Monograph 

Development 

Process 

Topic Selection 

And Outline 

Scientific Content 

Development 

Nutional Cancer Institute 

control programs. The limited space available in peer-reviewed 

journals and the relatively long lag time from the initiation of a 

study to the publication of its results are barriers to the rapid 

dissemination of new information and approaches to tobacco 

control. In addition, the dispersion of information on a given 

smoking control approach across multiple journals and different 

years of publication makes it very time-consuming and complicated to assemble a comprehensive picture of what is known 

about that approach. The Smoking and Tobacco Control Monographs are intended to aid in overcoming these barriers to 

information dissemination. 

The major strength of the peer-reviewed literature and of 

Government reports on smoking, such as the Surgeon General’s 

reports on the health consequences of smoking, has been the 

extensive review provided by individuals knowledgeable and 

experienced in the topic under examination. In establishing the 

editorial system for the STCP monographs, NCI has decided to 

adopt a process that relies extensively on input from the large 

number of talented researchers and program personnel currently 

working to reduce the burden that tobacco places on our society. 

The following summarizes the process for compiling the Smoking and Tobacco Control Monographs. 

The staff of the STCP, in consultation with its support 

contractor and outside experts, develops a short list of possible 

monograph topics or ideas for consideration, and from that list a 

single topic is selected. The selection is based on program need, 

availability of data (both within and outside the program), 

public health importance, and other factors. The monograph’s 

senior scientific editor develops a detailed outline and transmits 

it to Institute staff along with a list of candidate authors for 

individual sections and chapters. 

Individual authors are recruited to produce draft manuscripts. Because the monograph content is based primarily on 

NCI-supported intervention trials, the majority of authors are 

STCP principal investigators. An editorial team is assembled, 

consisting of the senior scientific editor and consulting editors 

with expertise in the area under development. 

Depending on the complexity and length of the proposed 

material, authors are asked to produce an initial draft manuscript between 90 and 120 days after accepting their writing 

assignments. During this time, the authors are encouraged to 

discuss any problems of content, focus, or style with the monograph editorial team. 

After the initial drafts are produced, a l-day working meeting of all monograph participants (authors, editors, and STCP 

and contractor staff) is convened. During that meeting, each 

author is provided with specific comments and suggestions. 

xxii 
Smoking and Tobacco Control Monograph No. 1 

Approximately 60 days after the initial meeting, a second 

meeting of participants is convened, and final suggestions are 

provided. Within 30 to 45 days after the second meeting, a 

final version of each manuscript is delivered to the Institute. 

The individual manuscripts are then edited and consolidated 

into chapters by the Smoking and Tobacco Control Monograph 

editors. 

Peer Review All manuscripts are subjected to a two-tier peer review 

process. This process includes chapter reviews, whereby two or 

three experts in each subject area are asked to provide a critical 

review. Concurrent with the first review, a second peer review 

is conducted, involving senior scientists-individuals who have 

a long history of involvement in smoking control. These 

individuals are sent the entire monograph manuscript. Comments and criticisms from both groups are incorporated into 

the document by the scientific editorial team in collaboration 

with STCP staff. 

The First Volume This monograph was the work of dozens of individualsSTCP trial investigators, public health and smoking control 

experts, and scientists and experts from other disciplines. 

The monograph is organized into six chapters: 

Chapter 1-The Scientific Rationale for Comprehensive, 

Community-Based, Smoking Control Strategies 

Chapter 2-Evolution of Smoking Control Strategies 

Chapter 3-Smoking Prevalence and Lung Cancer Death 

Rates 

Chapter 4-Approaches Directed to the Individual 

Chapter 5-Approaches Directed to the Social Environment 

Chapter 6-Interdependence and Synergy Among Smoking 

Control Activities. 

xxiii 
BLANK PAGE 
Smoking and Tobacco Control Monograph N o. 1 

Contents 

Page 

... Foreword ................................................................................... 111 

Preface....................................................................................... ix 

... Acknowledgments .................................................................. xu1 

Introduction ........................................................................... xix 

List of Tables ........................................................................ xxvll.. 

List of Figures ........................................................................ xxix 

1. The Scientific Rationale for Comprehensive. 

Community-Based. Smoking Control Strategies ................... 1 

Introduction ....................................................................... 3 

Background: Efforts To Control Tobacco Use ................... 5 

Patterns of Smoking Behavior ............................................ 8 

Role of Public Information Campaigns ........................... 11 

Results of Early Tobacco Control Efforts .......................... 12 

Comprehensive Control Strategies .................................. 21 

References ......................................................................... 28 

2. Evolution of Smoking Control Strategies ........................... 33 

Introduction ..................................................................... 35 

Information and Education Campaigns .......................... 35 

Cessation Program Strategies ........................................... 37 

Prevention Strategies ........................................................ 48 

Comprehensive Approach to Smoking Control ..............51 

Conclusions ...................................................................... 60 

References ......................................................................... 61 

3. Smoking Prevalence and Lung Cancer Death Rates ...........73 

Introduction ..................................................................... 75 

Analysis of Smoking Behavior .......................................... 77 

Smoking Prevalence ......................................................... 80 

Lung Cancer Mortality ..................................................... 86 

A Discrete State Model of Health Intervention ..............109 

Conclusions .................................................................... 122 

References ....................................................................... 125 

Appendix A. Data Points for Figures in Chapter 3........127 

4. Approaches Directed to the Individual ............................ 145 

Introduction ................................................................... 147 

Public Information Campaigns ...................................... 147 

Evolution of School-Based Interventions ....................... 152 
National Cancer Institute 

4. (continued)

Clinical Approach to Smoking Control ......................... 170 

Self-Help Approaches ..................................................... 179 

Conclusions .................................................................... 182 

References ........................................................................ 183 

5. Approaches Directed to the Social Environment .............201 

Public Opinion and Tobacco Use ................................... 203 

Intervention Channels ................................................... 205 

Community Mobilization .............................................. 218 

Restrictive Legislation ..................................................... 225 

Preventing Tobacco Sales to Minors .............................. 233 

Economic Incentives ...................................................... 239 

Conclusions .................................................................... 253 

References....................................................................... 254 

6. Interdependence and Synergy Among Smoking 

Control Activities .............................................................. 267 

Introduction ................................................................... 269 

Conceptual Framework .................................................. 270 

Studies of Environmental Change ................................. 272 

Synergistic Effects Among Selected Interventions .........272 

Approaches to Tobacco Companies’ Targets .................276 

Conclusions .................................................................... 289 

References ....................................................................... 290 

Index ...................................................................................... 299 
Smoking and Tobacco Control Monograph No. 1 

List of Tables 

CHAPTER 3 Table 1. 

Table 2. 

Table 3. 

Table 4. 

Table 5. 

Table 6. 

Table 7. 

Table 8. 

Table 9. 

Table 10. 

Table 11. 

Table 12. 

Table 13. 

Table 14. 

Table 15. 

Sample sizes for three major NHIS data sets, by 

birth cohort, gender, and race ............................... 81 

Lung cancer mortality rates, 1950 to 1985, for all 

males born 1901 through 1950, 

by birth cohort ....................................................... 92 

Lung cancer mortality rates, 1950 to 1985, for 

white males born 1901 through 1950, 

by birth cohort ....................................................... 92 

Lung cancer mortality rates, 1950 to 1985, for 

nonwhite males born 1901 through 1950, 

by birth cohort ....................................................... 93 

Lung cancer mortality rates, 1950 to 1985, 

for all females born 1901 through 1950, 

by birth cohort ....................................................... 93 

Lung cancer mortality rates, 1950 to 1985, for 

white females born 1901 through 1950, 

by birth cohort ....................................................... 94 

Lung cancer mortality rates, 1950 to 1985, for 

nonwhite females born 1901 through 1950, 

by birth cohort ....................................................... 94 

Age-specific lung cancer death rates, 1950 

to 1980, for all males born 1901 through 1940, 

by birth cohort ....................................................... 95 

Age-specificlung cancer death rates, 1950 

to 1980, for white males born 1901 through 

1940, by birth cohort ............................................. 95 

Age-specific lung cancer death rates, 1950 

to 1980, for nonwhite males born 1901 

through 1940, by birth cohort .............................. 96 

Age-specific lung cancer death rates, 1950 

to 1980, for all females born 1901 through 

1940, by birth cohort ............................................. 96 

Age-specific lung cancer death rates, 1950 

to 1980, for white females born 1901 through 

1940, by birth cohort ............................................ -97 

Age-specific lung cancer death rates, 1950 

to 1980, for nonwhite females born 1901 

through 1940, by birth cohort ............................. -97 

Distribution of nonsmokers, smokers, and 

ex-smokers in 1980, by race, gender, 

and birth cohort ................................................... 114 

Relative risks of death for current and former 

smokers (males) .................................................... 115 

xxvii 
National Cancer Institute 

Table 16 . Relative risks of death for current and former 

Table 1 7. 

Table 18. 

Table 19 . 

Table 20 . 

Table 21 . 

Table 22 . 

Table 23 . 

Table 24 . 

smokers (females) ....;............................................ 116 

Probability of initiating smoking in future as 

a function of age (5-year rate) .............................. 118 

Probability of termination of smoking during 

5-year period. by 5-year duration ........................ 118 

Forecast mortality rates for select causes of 

Forecast mortality rates for select causes of 

death. white females. ages 55 to 84..................... 120 

Forecast mortality rates for select causes of 

Forecast mortality rates for select causes of 

death. black females. ages 55 to 84 ..................... 122 

Forecast age-standardized mortality rates. 

based on 1980 population ................................... 123 

Forecast age-specific lung cancer mortality 

rates. assuming cessation rates are doubled ........124 

death. white males. ages 55 to 84 ........................ 119 

death. black males. ages 55 to 84 ........................ 121 

CHAPTER 4 Table 1. Table 2 . A 12-session life skills training program ..............156 

A comparison of some psychosocial 

school-based interventions .................................. 157 

Table 3 . Table 4. Table 5 . 

The stage model and smoking motives ...............164 

A program variation of the life skills model ........167 

Methods used by cessation programs ..................173 

CHAPTER 5 Table 1. 

Table 2 . Table 3. 

Examples of tobacco control activities. 

by channel and group responsible for 

performance ......................................................... 219 

Excise taxes as percentage of cigarettes’ 

total cost to consumers ........................................ 241 

Survey of Minnesota 10th graders ....................... 235 

Table 4. Age-specific estimates of the price elasticity 

of demand for cigarettes ...................................... 243 

xxviii 
Srnokinz and Tobacco Control MononraDh No.1 

List of Figures 

CHAPTER 1 Figure 1. 

Figure 2. 

Figure 3. 

Figure 4. 

Figure 5. 

Figure 6. 

Figure 7. 

Figure 8. 

Figure 9. 

Figure 10. 

Figure 11. 

Figure 12. 

Figure 13. 

Figure 14. 

Figure 15. 

CHAPTER 3 Figure 1. 

Figure 2. 

Figure 3. 

Actual (1980) and projected (1985 to 2015)

lung cancer death rates, ages 55 to 84...................4 

Smoking prevalence among men born 

from 1911 to 1920 (through 1987) ....................... 8 

Changes in smoking prevalence among 

U.S. males born from 1901 to 1970 

(through 1987) .................................................... 10 

Changes in smoking prevalence among 

U.S. females born from 1901 to 1970 

(through 1987) ..................................................... 10 

U.S. per capita cigarette consumption for 

adults, aged 18and older (1930 to 1990) ............11 

Percentage of former smokers, black males 

born from 1901 to 1940 (through 1987) .............13 

Percentage of former smokers, white males 

born from 1901 to1940 (through 1987) ..............13 

Percentage of black male current smokers 

quitting over 5-year intervals .............................. 15 

Percentage of white male current smokers 

quitting over 5-year intervals .............................. 15 

Percentage of white female current smokers 

quitting over 5-year intervals ..............................16 

Impact of California state tax increase on 

per capita consumption of cigarettes, adults 

aged 18 and over .................................................. 18 

Smoking relapse rates, by gender and level of 

education (California smokers, 1990) .................19 

Processes of smoking initiation and 

cessation ...... . . . .......,... . . ,. . .,.......... . . ....... . . ........... . . ..22 

Forces that influence adolescent progression 

into adult smoking ...................... .......................23 

Process of cessation .................................... ..........26 

U.S. per capita cigarette consumption for 

adults, aged 18and older (1900 to 1990) ............75 

Changes in prevalence of cigarette smoking 

among successive birth cohorts of U.S. males, 

1900 to 1987 ........................................................ 82 

Changes in prevalence of cigarette smoking 

among successive birth cohorts of U.S. 

females, 1900 to 1987 .......................................... 83 
Figure 4. 

Figure 5. 

Figure 6. 

Figure 7. 

Figure 8. 

Figure 9. 

Figure 10. 

Figure 11. 

Figure 12. 

Figure 13. 

Figure 14. 

Figure 15. 

Figure 16. 

Figure 17. 

Figure 18. 

Figure 19. 

Figure 20. 

Figure 21. 

National Cancer Institute 

Changes in prevalence of cigarette smoking 

among successive birth cohorts of white U.S. 

males, 1900 to 1987 ............................................. 84 

Changes in prevalence of cigarette smoking 

among successive birth cohorts of black 

U.S. males, 1900 to 1987 ..................................... 84 

Changes in prevalence of cigarette smoking 

among successive birth cohorts of white U.S. 

females, 1900 to 1987 .......................................... 87 

Changes in prevalence of cigarette smoking 

among successive birth cohorts of black U.S. 

females, 1900 to 1987 .......................................... 87 

Age-adjusted cancer mortality rates, 

all males ............................................................... 88 

Age-adjusted cancer mortality rates, 

white males .......................................................... 89 

Age-adjusted cancer mortality rates, 

nonwhite males ................................................... 89 

Age-adjusted cancer mortality rates, 

all females ............................................................ 90 

Age-adjusted cancer mortality rates, 

white females ....................................................... 91 

Age-adjusted cancer mortality rates, 

nonwhite females ................................................ 91 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for white U.S. males 

born 1901 to 1910 ............................................... 98 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for black U.S. males 

born 1901 to 1910 ............................................... 98 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for white U.S. males 

born 1911 to 1920 ............................................... 99 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for black U.S. males 

born 1911 to 1920 ............................................... 99 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for white U.S. males 

born 1921 to 1930 ............................................. 100 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for black U.S. males 

born 1921 to 1930 ............................................. 100 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for white U.S. males 

born 1931 to 1940 ............................................. 101 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for black U.S. males 

born 1931 to 1940 ............................................. 101 
Smoking and Tobacco Control Monograph No. 1 

Figure 22. 

Figure 23. 

Figure 24. 

Figure 25. 

Figure 26. 

Figure 27. 

Figure 28. 

Figure 29. 

Figure 30. 

Figure 31. 

Figure 32. 

Figure 33. 

Figure 34. 

CHAPTER 5 Figure 1. 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for white U.S. males 

born 1941 to 1950 ............................................. 102 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for black US.males 

born 1941 to 1950 ............................................. 102 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for white U.S. females 

born 1901 to 1910 ............................................. 103 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for black U.S. females 

born 1901 to 1910 ............................................. 103 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for white U.S. females 

born 1911 to 1920 ............................................. 104 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for black U.S. females 

born 1911 to 1920 ............................................. 104 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for white U.S. females 

born 1921 to 1930 ............................................. 105 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for black U.S. females 

born 1921 to 1930 ............................................. 105 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for white U.S. females 

born 1931 to 1940 ............................................. 106 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for black U.S. females 

born 1931 to 1940 ............................................. 106 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for white U.S. females 

born 1941 to 1950 ............................................. 107 

Changes in current smokers, ever-smokers, 

and lung cancer deaths, for black U.S. females 

born 1941 to 1950 ............................................. 107 

Compartment model schematic of morbiditymortality process with discrete risk states .........109 

Per capita consumption of cigarettes 

(18 years and older), 1925 to 1990 .................... 204 

xxxi 
BLANK PAGE 
Chapter 1 

The Scientific Rationale for 

Comprehensive. Community.Based. 

Smoking Control Strategies 

CONTENTS Introduction .............................................................................. 3 

Background: Efforts To Control Tobacco Use .......................... 5 

Patterns of Smoking Behavior ................................................... 8 

Role of Public Information Campaigns ................................... 11 

Results of Early Tobacco Control Efforts ................................. 12 

Approaches to Influencing the Individual ....................... 14 

Approaches to Influencing the Environment .................. 17 

Comprehensive Control Strategies ......................................... 21 

Affecting the Initiation Process ........................................ 23 

Affecting the Cessation Process ....................................... 25 

References................................................................................ 28 

1 
BLANK PAGE 
Chapter 1 

The Scientific Rationale for 

Comprehensive, Community-Based, 

Smoking Control Strategies 

INTRODUCTION The use of tobacco predates the discovery of the New 

World by Columbus, and tobacco was one of the major cash 

crops of the early American colonies (Robert, 1967). Efforts to 

control tobacco use have a history almost as long and colorful, 

including King James 1’s “Counterblaste to Tobacco” in 1604 

(International Agency for Research on Cancer, 1986). However, in the last century the use of tobacco has become more 

widespread and more hazardous. The development of machines that could manufacture cigarettes in the late 1800’sand 

safety matches at the turn of the century set the stage for mass 

marketing of cigarettes. This mass marketing of cigarettes in 

the United States resulted in a rapid rise in per capita cigarette 

consumption that began around 1910 and provided one of the 

first demonstrations that advertising could create demand for a 

product where no previous demand existed (Whelan, 1984). 

Coincident with the increasing use of cigarettes was a 

change in the tobaccos used to manufacture U.S. cigarettes

(International Agency for Research on Cancer, 1986). The 

smoke from those tobaccos was milder and easier to inhale and 

had a pH that prevented absorption of nicotine across the oral 

mucosa; users had to inhale the smoke into the lung to absorb 

substantial amounts of nicotine. The deep inhalation of 

tobacco smoke, with the subsequent deposition, retention, and 

absorption of the smoke’s toxic and carcinogenic substances, 

dramatically changed the risks associated with tobacco use and 

resulted in the proliferation of lung cancer and other smokingrelated diseases. 

During the 1930’s and 1940’s, the rapidly rising rates of 

lung cancer in men led scientists to investigate possible causes 

of the epidemic, using the newly developed tools of casecontrol and cohort epidemiologic studies. By the mid-l950’s, 

data from these studies allowed the scientific community to 

conclude that cigarette smoking clearly was hazardous to 

health (Study Group on Smoking and Health, 1957), and the 

public health community began its continuing effort to reduce 

the burden of tobacco-related disease by reducing smoking 

initiation and promoting smoking cessation. 
National Cancer Institute 

Figure 1 

Actual (1980) and projected (1985 to 2015) lung cancer death 

rates, ages 55 to 84: 

Death Rate per 100,000 500 

450 

400 

350 

300 

250 

200 

150 

100 

50 

0 

1980 1985 1990 1995 2000 2005 2010 2 15 

Year 

'Forecast age standardized moflatify rates usiflg 1980population. 

The rapid rise in lung cancer death rates during this 

century can be closely linked to the rise in cigarette consumption by men and women of both black and white races. A 

model presented later in this volume (Chapter 3) predicts 

future lung cancer death rates based on the recent and projected future changes in smoking prevalence (see Figure 1). 

This model predicts that changes in smoking behavior that 

have already occurred will produce a decline in the lung cancer 

death rates for white males within the next decade, but the 

rates for women and for black males would not be expected to 

fall until after the year 2000. This prediction is based on a 

continuation of the current trends in smoking behavior. If the 

rate of smoking cessation can be increased, then an even more 

substantial fraction of the expected mortality from lung cancer 

can be averted. The comprehensive strategies for controlling 

tobacco use described in this volume offer the best hope of 

reversing and ultimately eliminating the epidemic of lung 

cancer that has characterized this century. 

4 
Smoking and Tobacco Control Monograph No. 1 

This volume synthesizes what has been learned in the past 

40 years of efforts to control tobacco use. As with most successful public health efforts, the current state of the art in 

control of tobacco use is built on a broad base of scientific investigation and includes the equally broad experience of 

successful and unsuccessful program activities that evolved in 

parallel with our scientific knowledge (Cullen, 1989). 

BACKGROUND: Frequently, it is the operational experience with what 

EFFORTS works or does not work at the programmatic level that forms 

TO CONTROL the core of interventions tested in controlled scientific investiTOBACCO USE gations. It should come as no surprise, therefore, that current 

concepts of effective approaches to controlling tobacco use 

frequently outstrip both the tools needed to evaluate them and 

the data needed for definitive proof of their impact (US DHHS, 

1990a). This volume presents our current best judgment of 

what constitutes an effective, comprehensive strategy to 

control tobacco use, and it draws extensively, and without 

apology, on the broad bodies of understanding developed by 

both controlled scientific investigation and the trial-and-error 

experience of interventions conducted in the community 

(Schwartz, 1987; US DHHS, 1990a). 

The clear identification of cigarette smoking as a major 

health risk led to efforts to persuade current smokers to quit 

and to keep new smokers from beginning. Early approaches 

relied heavily on providing information about the risks of 

smoking (see Chapter 4). Although the impact of information 

campaigns was demonstrated by an increased awareness of 

smoking-related health risks and a decline in per capita consumption of cigarettes in the population at the time of the 

campaigns, it rapidly became apparent that information alone 

would not solve the problem. Knowledge of the health risks of 

smoking was transmitted to smokers and is probably a major 

motivational force in cessation attempts, but the vast majority 

of these cessation attempts failed, leaving most smokers wanting to quit but unable to do so. 

In assessing the limited success of the educational campaigns against smoking, it is important to recognize that these 

campaigns were not presented in isolation (Schwartz, 1969). 

Rather, they were confronting the tobacco companies’ much 

larger effort to promote smoking and to confuse the public

about the risks of tobacco use (Whelan, 1984). In contrast to 

other health-based information campaigns, the effort to provide information on the risks of smoking was, and is, conducted against the backdrop of a multibillion-dollar advertising 

and promotional campaign that encourages cigarette smoking 

(Centers for Disease Control, 1990; Davis, 1987). 

5 
National Cancer Institute 

The tobacco industry responded to the initial burst of information on the risks of tobacco use with a combination of 

(1)a media effort designed to cast doubt on the level of scientific certainty about the risks and (2) a series of modifications 

to cigarettes (filters and lower tar content) designed to convince the public that the risk had been removed. It is not 

known how effective the antismoking public information 

campaign might have been if it had been delivered in the 

absence of the tobacco industry’s much larger, competing 

campaign (Warner, 1977). 

The recognition that information alone would not eliminate tobacco use shifted the focus of control strategies to the 

individual; programs were developed to help adults in their 

efforts to quit smoking and to prevent adolescents from beginning to smoke (see Chapter 4). The goal of these programs was 

to create psychological change within the individual that 

would enable successful change in smoking behavior and 

resistance to environmental stimuli that induce the start of 

smoking or a return to the practice after quitting. This focus 

on the individual presumed that the major determinants of 

smoking behavior are within the individual, a premise that 

turned out to be faulty, in part because many of the forces that 

promote smoking initiation and smoking cessation are sociological in nature rather than purely psychological. Also, the 

difficulty of attracting smokers and the limited resources for 

behavioral change that many smokers bring to such programs 

predict a very limited impact for individual-centered approaches relative to population-wide programs. 

To broaden the appeal of individual-centered approaches, 

self-help programs and telephone hotlines to counsel smokers 

were developed (Glynn et al., 1990). These strategies did, 

indeed, attract a larger fraction of the smoking population, but 

their less intensive methods are also less effective at creating 

behavioral change by the smoker, leading to a lesser individual 

effect on a larger number of smokers. 

Research on the determinants of smoking behavior and the 

observation that declines in cigarette consumption corresponded to changes in smokers’ social and economic environment (Warner, 1977) led to a recognition that a focus on the 

larger social environment, rather than on the individual, could 

be an effective strategy for controlling tobacco use (see Chapter 5). Environmental changes that are believed to influence 

smoking initiation and smoking cessation include 

Increased tobacco costs; 

Antitobacco media campaigns; 

Declining social acceptability of smoking; 

Limitations on where smoking is allowed; and 

Restricted access for minors. 

6 
Smoking and Tobacco Control Monograph No. 1 

The impact of these changes is diffuse and, therefore, 

difficult to link to any change in the smoking behavior of an 

individual. However, the underlying premise of these social 

environment-centered efforts is that removal of environmental 

stimuli and reinforcements for smoking and the simultaneous 

creation of environmental disincentives for smoking markedly 

alter the personal psychological and sociological utility of 

smoking. This leads to higher rates of smoking cessation and 

lower rates of smoking initiation. If barriers to smoking are 

raised, the social reinforcement of smoking changed to social 

disapproval, and the smoker continually bombarded with 

messages to quit, then it is less likely that adolescents experimenting with cigarettes will continue on to dependence, more 

likely that smokers will attempt to quit, and, once they have 

quit, less likely that they will relapse. 

As efforts to control tobacco use began to incorporate these 

social environmental approaches, it was realized that the two 

approaches, individual and environmental, were not competing strategies, but that they could be combined in a way that 

might synergistically increase their effect on smoking behavior 

(see Chapter 6). The combination of changing the environment to discourage smoking while simultaneously providing 

resources to increase smokers’ ability to control their own 

behavior has the potential to effect substantial, sustained, 

population-wide change in smoking behavior (Pomrehn et al., 

1990-91). These changes in the individual and in the social 

environment often occur incrementally and at a modest pace. 

Therefore, smoking behavioral changes may lag behind 

changes in policies or social norms. Changes in the social 

environment would be expected to have a modest initial 

impact that increases with time as the social changes percolate 

through the environment in which the smoker lives. 

As the basis for current, comprehensive, community-based 

efforts to control tobacco use, this combined approach recognizes that individual and environmental inputs can be provided at multiple levels, through multiple channels, and over a 

relatively continuous time. Persistent and inescapable messages to quit are provided to the smoker concurrent with 

repeated offers of support and assistance in the quitting process 

(US DHHS, 1990a). 

The description of control strategies presented in this 

volume recognizes that there is no single solution to the problem of tobacco use. Different programs have impact on different points in the process of initiation, maintenance, and 

cessation of smoking behavior. More than one program may 

simultaneously influence an individual to alter smoking 

behavior, and a single program may have different effects on 

7 
National Cancer Institute 

PATTERNS 

OF SMOKING 

BEHAVIOR 

Figure 2 

Smoking prevalence among men born from 1911 to 1920 

(through 1987) 

Percentage 

80 , I I I 1 I 

individuals at different stages of smoking behavior. The recognition that smokers use the cigarette to interact and cope with 

their environment has led to current efforts to change both the 

smoker and the smoker’s environment. 

The prevalence of cigarette smoking is not uniformly distributed across the U.S. population. Cigarette smoking varies 

with age, gender, race, education, year of birth, and other 

factors (Pierce and Hatziandreu, 1989). These differences are 

important for assessing the disease risks associated with tobacco use, and knowledge of these patterns is essential to the 

development of strategies to control tobacco use. 

The initiation of regular smoking is confined almost completely to those under the age of 25, and 90 percent of cigarette-smoking initiation is complete by age 21 among current 

cohorts (Pierce and Hatziandreu, 1989). Figure 2 shows the 

pattern of smoking initiation and cessation for men born in 

the years 191 1through 1920; initiation of smoking occurred 

only in early life, and the major change in smoking behavior 

after age 25 was cessation. This general pattern (smoking 

8 
Smoking and Tobacco Control Monograph No. 1 

initiation early in life and cessation later in life) appears among 

all subgroups of the population, but different subgroups have 

different rates and ages of initiation, achieve different rates of 

peak smoking prevalence, and have different rates of cessation 

(Harris, 1983). For instance, the rates of cessation are lower 

and prevalence of smoking is higher among individuals at 

lower socioeconomic levels and with lower levels of formal 

education (Pierce and Hatziandreu, 1989). In addition, differences in the pattern of smoking behavior between black Americans and white Americans (see Chapter 3) include a much 

smaller decline in the prevalence of smoking among blacks 

(Fiore et al., 1989). 

Gender differences in patterns of smoking behavior are 

illustrated in Figures 3 and 4, which contrast the smoking 

behavior of men and women born during different decades of 

this century, from 1901 through 1970. The men born in the 

first few decades took up smoking early in the century and 

early in life and reached a very high peak prevalence of smoking. In contrast, the women born during the same periods 

began to take up smoking later in the century and consequently later in life, and they reached peak prevalence levels 

that were much lower than those of their male counterparts 

(Harris, 1983). The gender-related differences in smoking 

behavior among the cohorts born later in the century are far 

smaller, and the patterns of smoking behavior for men and 

women in the most recent birth cohort (1961 to 1970) are 

almost identical. 

These differences in smoking behavior are important to the 

understanding of comprehensive strategies to control tobacco 

use because they explain the requirement for multiple channels 

and multiple interventions. Because of the diversity of smoking subgroups, no single approach should be expected to work 

for all smokers, and no single channel can be expected to reach 

all smokers. 

The comprehensive strategies described in this volume are 

based on the premise that (1) specific programs to alter smoking behavior can be aimed at different points in the process of 

initiating, maintaining, and quitting smoking behavior and 

(2)a concerted effort to attack smoking behavior at each of 

these points will yield results far greater than those expected 

from the sum of the programs applied independently. Furthermore, there is an assumption that smokers must be reached 

within and by the structures where they live and work; therefore, a comprehensive strategy must include participation by a 

broad and representative selection of the groups and social 

structures that constitute the community in which the smoker 

lives (Thompson et al., 1990-91). 

9 
10 
Smokinx and Tobacco Control Monograph No. 1 

Figure 5 

U.S. per capita cigarette consumption for adults, aged 18 and 

older (1930 to 1990) 

Cigarettes per Year 

ROLE OF PUBLIC 

INFORMATION 

CAMPAIGNS 

F 

One of the earliest responses to the scientific data that established the risks of smoking was an information campaign to 

communicate the health risks of cigarette smoking with the expectation that relaying the risk information to the smoking 

public would lead to changes in smoking behavior. Clearly, 

these information campaigns have been successful in communicating risk information at the simplest level: In recent 

surveys, more than 80 percent of current smokers agreed that 

smoking is harmful and even that it is harming them as individuals (Pierce and Hatziandreu, 1989). Information campaigns have been less successful, though, at transmitting an 

understanding of the magnitude of the risks associated with 

smoking (Shopland et al., 1990). 

The expected change in smoking behavior did occur, but it 

was far more limited than had been hoped (US DHHS, 1989), 

suggesting the individual smoker’s difficulty with breaking his 

or her dependence on tobacco. Figure 5 shows the changes in 

cigarette consumption during this century and suggests the 

relation of such changes to media information campaigns. Per 

11 
RESULTS OF 

EARLY TOBACCO 

CONTROLEFFORTS 

National Cancer Institute 

capita consumption of cigarettes declined with each of these 

major informational events: 

A substantial downturn in consumption coincided with 

the lay media’s presentation of scientific evidence 

establishing the risks of smoking in the mid-1950’s. 

A smaller downturn occurred with the publication of the 

first Surgeon General’s Report in 1964 (US DHEW, 1964) 

and the resultant media coverage. 

A major downturn in per capita cigarette consumption 

also occurred during the late 1960’s; between 1967 and 

1970, mandated antitobacco spots were shown on television to counter cigarette advertisements. When cigarette 

advertisements were banned from television in 1970, the 

bulk of the antitobacco advertising campaign also disappeared, and per capita cigarette consumption again 

increased. 

Information alone is often dismissed as a means of influencing smoking behavior, but information about smokingassociated disease risks provides much of the motivational 

substrate for individual cessation efforts and is likely to trigger 

cessation attempts. It is clear, however, that these informational campaigns of themselves were unable to create and 

sustain cessation in the majority of smokers. 

The decline in smoking prevalence over time within a 

given birth cohort has led to the suggestion that aging is the 

dominant influence on smoking cessation. But the attribution 

of cessation to advancing age ignores the fact that activities to 

control tobacco use have increased over the last four decades, 

concurrent with the aging of the individuals that make up the 

birth cohorts. By examining the changes in smoking prevalence for the four oldest birth cohorts of males, one can see 

that the point where smoking prevalence begins to decline in 

each cohort is in the mid-l950’s, which suggests that events in 

the social environment influenced all of the different cohorts 

simultaneously, regardless of age. The four earliest cohorts are 

cited because men born later would not have completed the 

initiation of smoking by the time of the 1950’s campaigns. 

Figures 6 and 7 present these data more clearly, showing 

the percentage of former smokers in each of these four earliest 

cohorts of black and white men, plotted by calendar year. The 

percentage of former smokers among white males in the 

earliest cohorts begins to rise in the 1950’s. There appears to 

be an effect of age, with the oldest cohorts having the highest 

percentage of former smokers, but all of the cohorts show steep 

rises in the proportion of former smokers during the 1950’s 

and 1960’s, which suggests that the major effect is related to 

calendar year rather than to age. 

12 
13 
Approaches to 

Influencing 

The Individual 

National Cancer Institute 

The change in the percentage of former smokers that 

occurs with calendar year is quite different for black males 

than for white males. Among the white males, a sharp upturn 

in the prevalence of former smokers begins in the 1950’s and 

accelerates during the late 1960’s. For black males, the prevalence of former smokers remains almost zero until the late 

1960’s. This difference between white and black males is even 

more evident when the fraction of smokers who have quit 

during each 5-year period (Figures 8and 9) is plotted against 

the calendar year. Both black and white males show large 

changes in smoking prevalence during the period of counteradvertising on television (1967 to 1970), but only white males 

show a change in smoking behavior during the first wave of 

public information on the risks of tobacco use (in the mid1950’s), which relied much more heavily on print media. 

The question of racial differences in source or timing of information transfer can be explored through comparison of the 

5-year quit rates in the same birth cohorts of white women 

(Figure 10). The pattern in the white female cohorts is similar 

to that of black men rather than that of white men, with very 

little change in smoking behavior until 1965 to 1970. This 

suggests that the absence of an effect in black men corresponding to the early public information campaigns is not solely a 

racial phenomenon. The early studies of smoking-related 

disease risk were conducted largely with white males (US

DHHS,1982), so the absence of data on women and on black 

men may have prevented these groups from relating the risk 

information to themselves. On the other hand, the counteradvertising campaign of the late 1960’s used messages and 

themes that addressed a range of issues in addition to health 

risks (Warner, 1977). This broader range of messages may have 

reached women and black males unaffected by the earlier 

health messages and may have been responsible for the greater 

level of smoking cessation in all racial and gender groups. 

For all of the racial and gender groups, the rates of cessation plummeted when the antismoking spots were removed 

from television. This observation lends further support to the 

theory that the intensive media campaign against smoking had 

a profound effect on smoking behavior (US DHHS, 1989; 

Warner, 19 7 7). 

The provision of information to the smoker on the disease 

risks of smoking did not lead to successful cessation by the 

majority of smokers. The recognition that most smokers who 

wanted to quit were unable to do so on their own led to the 

development of programs that would produce change within 

smokers that would help them to break their addiction. The 

goals of these programs included providing smokers with the 

14 
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15 
National Cancer Institute 

Figure 10 

Percentage of white female current smokers quitting over 

5-year intervals 

5-Year Cessation Rate (%I 

tools to change their behavior, changing the behavioral conditioning surrounding smoking, and altering the coping strategies used by smokers (see Chapter 4). However, the common 

link in all of these approaches was the attempt to alter the individual so that he or she could make the desired change in 

behavior in spite of environmental influences that promote 

smoking. 

It was believed that the individual could be strengthened 

and retrained to eliminate dependence on cigarettes, and the 

multicomponent programs described in this volume have demonstrated that it is possible to produce long-term cessation in a 

large proportion of smokers willing to complete these programs. The major problem with clinic-based cessation programs has been the difficulty of convincing smokers to participate. An overwhelmingly large percentage of those who 

successfully quit smoking, and an even larger fraction of those 

who attempt to quit, do not use a clinic-based cessation program but try to quit on their own (Fiore et al., 1990; US DHHS, 

1990b). 

16 
Smoking and Tobacco Control Monograph No. 1 

A companion problem has been program costs. One concept that emerges from evaluations of the various clinic programs presented in Chapter 2 is that the more intensive the 

program, the more likely it is to be successful. Programs with a 

greater number of sessions, professional rather than volunteer 

leaders, and more extensive followup and maintenance support 

show better results. As a result, the current state-of-the-art 

clinic-based cessation programs are expensive in time, energy, 

and dollars. The high costs for individuals, for insurance companies, and for health care providers are barriers to access. 

It is unlikely, however, that cost alone is the major reason 

why clinic-based cessation programs get little use, since other, 

more expensive prevention efforts (such as diagnosis and management of essential hypertension) have enjoyed excellent 

results. It is more likely that the major limitation is the low 

demand for these programs by U.S. smokers. The long-term 

financial benefit for the individual and for society may outweigh the short-term cost, but those short-term costs, coupled 

with smokers’ perceptions of little need for the programs, have 

markedly constrained the impact of clinic-based cessation 

programs on the prevalence of smoking. 

Approaches to The limited impact of clinic-based cessation programs, 

Influencing together with growing recognition of the importance of enviThe Environment ronmental factors in smoking behavior, led to the shift in 

tobacco control strategies described in Chapter 5. The association of shifts in global measures of U.S. tobacco use, such as per 

capita consumption, with changes in the environment, such as 

the shrinking social acceptability of smoking, has led to attempts to alter those environmental factors as a means of 

altering smoking behavior. 

Raising the cost of cigarettes as a public health strategy has 

been accomplished through increased excise tax on tobacco, 

and the manufacturers have also substantially increased the 

cost of cigarettes (Grise, 1991). As described in Chapter 5, 

increases in the excise tax have generally resulted in a substantial and immediate fall in cigarette consumption, but the effect 

dissipates with time (Tobacco Institute, 1990). The experience 

in California, which raised its excise tax on tobacco by 25 cents 

on January 1, 1989, is presented in Figure 11,wherein California’s per capita cigarette consumption is contrasted with that 

for the rest of the United States (California Department of 

Health Services, 1990). There was a rapid decline in per capita 

consumption coinciding with the California tax increase that 

was not present in the rest of the country. Analysis of those 

data suggests that there was a 5 percent decline in per capita 

cigarette consumption attributable to the increase in the tax 

0. Elder, personal communication). 

17 
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18 
Smokinn and Tobacco Control Monograph No. 1 

Figure 12 

Smoking relapse rates, by gender and level of education 

(California smokers, 1990) 

One concern about using cost as a strategy to control 

tobacco use has been that the resulting decreases in tobacco 

consumption may be transitory; they may reflect large numbers of smokers trying to quit around the time of the tax increase, then relapsing, with no long-term change in the prevalence of smoking in the population. Evidence to support this 

concern is provided by a survey of California smokers conducted 18 months after the 1989 excise tax increase (California 

Department of Health Services, 1990). Figure 12 shows the 

status of all those who had been smoking 12 months prior to 

the survey. About one-half of those Californians who had been 

smoking 12 months prior to the survey made an attempt to 

quit, in contrast to approximately one-third of smokers in 

national surveys. However, the fraction of those who were 

smoking 12 months previously and who currently had been 

nonsmokers for 3 months or more is no larger in California 

than in the national surveys. This suggests that the tax may 

19 
National Cancer Institute 

have stimulated an increase in the number of cessation attempts

but not increased the number of smokers able to quit successfully. 

Because the majority of current smokers began smoking 

before the age when it is legal to buy cigarettes in most states, 

the access of minors to cigarettes is seen as an important precondition for the initiation of smoking behavior (US DHHS, 

1989). The disparity between the consequences of cigarette use 

and the availability of cigarettes to minors through legitimate 

channels is greater than for any other dependence-producing 

substance in our society. More than 80 percent of children are 

able to purchase cigarettes over the counter, and minors essentially have no difficulty buying cigarettes from vending machines (see Chapter 4). The fact that this country’s single 

largest cause of death and disability is sold to children through 

unattended vending machines has galvanized legislators in an 

increasing number of jurisdictions to restrict or ban the sale of 

cigarettes through vending machines (Tobacco-Free America, 

1990), and it has promoted efforts to educate merchants and 

enforce the law prohibiting sales to minors (US DHHS, 1990~). 

The social acceptability of cigarette smoking has been 

declining since at least the early 1970’s (US DHHS, 1989). This 

decline is based on concerns about the disease risks of exposure 

to environmental tobacco smoke as well as irritation and annoyance produced by exposure to others’ tobacco smoke. By 

early 1971, the probability that environmental tobacco smoke 

exposure could cause a substantial disease risk had been clearly 

annunciated by then U.S. Surgeon General, Jesse L. Steinfeld, 

M.D. (Steinfeld, 1972). The body of scientific data on this topic 

that developed subsequently and the national reviews of those 

data (US DHEW, 1972,1975, and 1979; US DHHS 1982 and 

1986; National Research Council, 1986; U.S. Environmental 

Protection Agency, in press) have led to increasing restrictions 

on where smoking is allowed (Pertschuk and Shopland, 1989). 

Regulations that established separate seating areas in airplanes 

and restaurants and banned smoking in public places put 

smokers on notice that their behavior annoyed a substantial 

number of nonsmokers, and the new rules empowered those 

nonsmokers to express that annoyance. The outcome was a 

slow but steady erosion of the rewards of smoking and a 

change in the smoker’s self-image. A large part of the smoker’s 

dependence on the cigarette is conditioned by the personal 

psychological and sociological utility of smoking. Removing 

this utility undercuts the foundation of tobacco addiction. 

A more recent outgrowth of the increasing concern about 

the risks associated with exposure to environmental tobacco 

smoke has been absolute bans on smoking at worksites, on 

airlines, and in other locations (Shopland et al., 1990) (see 

20 
Smoking and Tobacco Control Monograph No. 1 

COMPREHENSIVE 

CONTROL 

STRATEGIES 

Chapter 5). These bans reinforce the social unacceptability of 

smoking by incorporating it into the norms for workplace 

behavior, and they keep the smoker from smoking on the job. 

Eliminating smoking at work may prevent young smokers from 

learning to use the cigarette to deal with workplace stress and 

may give older smokers experience in coping with life stresses 

without cigarettes, thereby improving their chances for success 

when they try to quit smoking. In addition, a smoker who has 

quit may be less likely to relapse in a work environment where 

smoking is not permitted. 

The specific relationship of advertising and promotion to 

smoking initiation and tobacco use is not clear, but it is clear 

that tobacco advertising presents images of smoking and smokers that are attractive to adolescents (Fischer et al., 1989). A 

concern is that the advertising images are most attractive to 

those adolescents with the least objective verification of their 

self-worth from their own social environment. This effect may 

explain the differences in smoking behavior between adolescents in school and adolescents who have dropped out (Pirie et 

al., 1988). The potential effect of advertising on the most vulnerable segments of society has led to efforts to restrict tobacco 

advertising and promotion at both national and local levels. 

As the focus of control strategies expanded beyond the individual to include the environmental factors described above, 

our understanding of smoking initiation and cessation also expanded. Researchers and health educators came to recognize 

that both smoking initiation and smoking cessation are dynamic, multistage processes, rather than linear, dichotomous 

events (Prochaska and DiClemente, 1986). It was also understood that smoking could be attacked at multiple stages in 

these processes and that different strategies could affect different stages with potentially synergistic outcomes. Programs 

that alter environmental influences, such as media campaigns, 

have proven much more effective when they are supported by 

resources to help individual smokers in their cessation efforts 

(see Chapter 5). 

The current state of the art in controlling tobacco use 

combines multiple environmental changes with multiple programs directed to individuals in different stages of the initiation and cessation processes. It recognizes that no single 

approach is best for all smokers and that different smokers are 

most attracted to and most affected by different programs. 

Perhaps more importantly, it recognizes that no single channel 

reaches all smokers and that no single time is best for all 

smokers to make an attempt to quit. Comprehensive strategies 

are characterized by the delivery of persistent and inescapable 

messages to quit, or to not start, smoking, coupled with continuously available support for individual cessation efforts 

21 
National Cancer Institute 

Figure 13 

Processes of smoking initiation and cessation 

Never-Smoker

1 

ThinkingAbout Smoking

1 

Experimentation

4-b Nonsmoker Nonsmoker 

Regular Use 

4-b 1-b Quit

Dependent Smoker

Shott-Term

r 

Success 

>

contemplation 

A c t i o n 2 

Long-Term Success 

provided through multiple channels, and reinforced by environmental incentives for nonsmokers. 

One formulation of the processes involved in cigarette 

initiation and cessation is presented in Figure 13. Exploration 

and initiation of regular cigarette use is largely confined to 

adolescents, with the transition from regular use to dependence during late adolescence and early adulthood. Experimentation with cigarettes and initial use is heavily influenced by

issues that are active during adolescent development, whereas 

dependent use of cigarettes develops when smokers incorporate

the personal psychological and sociological utility of smoking

into the methods by which they function in and cope with the 

adult world. Many adolescents experiment with tobacco use 

but never become regular smokers, and some adolescent 

regular smokers stop before they become dependent on cigarette use. 

The process of quitting smoking is often a cyclical one, 

with the smoker making many attempts to stop before finally 

22 
Smoking and Tobacco Control Monograph No. 1 

Figure 14 

Forces that influence adolescent progression into adult 

smoking 

Never-Smoker 

Advertising Counteradvertising 

Adult and Older Sibling Example 

Thinking About 

1

Smoking 

Availability of Cigarettes Bans on Vending Machine Sales 

Free Promotions Restricting Sales to Minors 

Peer Pressure IT Bans on Smoking on School Grounds 

Peer Resistance Training 

Experimentation 

Availability School-Based Programs 

Advertising 1. ::I Validatio; Self-worth 

Social Unacceptability 

Nonsmoker 

Regular Use 

Smoking Role Models in the Work Restrictions on Smoking in the 

Environment Workplace 

Use of the Cigarette To Adjust Mood 

and Cope With Stress 

Individual Psychologic and 

Utility of Smoking 

Dependent Smoker 

gaining success. About one-third of current smokers attempt to 

quit each year, but 90 percent or more of those attempts fail 

(Pierce and Hatziandreu, 1989). Clearly, those who have unsuccessfully tried to quit need to be motivated to try again. A 

useful conceptualization of the cessation process is one in 

which smokers cycle through the stages of cessation, and each 

time smokers go through the cycle, a few more succeed in their 

efforts to quit. One goal of control strategies, then, is moving 

smokers from one stage of the cessation cycle to another, 

rather than using long-term cessation as the only goal and 

outcome measure of a program. 

Affecting the The development of tobacco dependence is not sudden, 

Initiation Process and the process of initiating tobacco use is a gradual one that 

probably begins early in adolescence or preadolescence. As 

outlined in Figure 14, the first step in the process is thinking 

about smoking cigarettes, and as children move into their teen 

years, a substantial fraction change from believing that they 

23 
National Cancer Institute 

will never use cigarettes to considering experimentation with 

smoking. The omnipresent images from tobacco advertising of 

the smoker as a confident, attractive, and secure individual 

(Tye, 1985), as well as examples of adult and older sibling 

smokers, are powerful inducements for children to perceive 

smoking as an entry into adulthood. Counteradvertising that 

creates a negative image of the smoker-for example, the 

smoker as inadequate and less mature-can be used in an effort 

to offset these influences. 

The transition from thinking about smoking to having the 

first cigarette may not lead irreversibly to adult smoking, but 

clearly it is an important milestone in that passage. The widespread availability of cigarettes to teenagers and, particularly, 

the promotional distribution of free cigarettes, many of which 

are given to teens either directly or indirectly, clearly facilitate 

the teenager’s experimentation with smoking. In contrast, 

programs that immunize teens through assertiveness training 

and modeling of refusal responses can be used to block this 

stage of initiation (Glynn, 1989). 

The change from occasional experimentation with cigarettes to regular cigarette use is critical, because with regular use 

the adolescent develops a body of experience in which smoking is psychologically and sociologically useful. Clearly, the 

ability to purchase cigarettes easily, the social rewards, and peer 

acceptance of the teen’s smoking behavior are critical to the 

development of regular use. However, the images created by 

tobacco advertising may also play an important role. The 

advertising images of the smoker as a confident, physically and 

sexually attractive, successful, and secure adult may resonate 

strongly in the adolescent who desperately wants to adopt and 

project those images. The ability to superimpose the advertising image on his or her own inadequate self-image makes the 

adolescent feel better, at least temporarily, and teenagers thus 

begin to develop a body of experience with the use of the cigarette to adjust their internal mood. Those adolescents without 

external validation of their self-worth have the greatest need to 

adjust their self-image and thus may be more likely to use 

cigarettes to do so. 

School-based health education programs and programs 

that raise adolescents’ self-esteem, as well as efforts to restrict 

advertising and promotional activities, are aimed at altering 

the transition to regular smoking (Glynn, 1989). Raising the 

cost of cigarettes, because adolescents have limited disposable 

income, and increasing the social unacceptability of smoking,

even among teens, are further barriers to the transition. 

Progressing from regular use to dependent use requires that 

the utility of tobacco use persist after the pervasive anxieties of 

24 
Smoking and Tobacco Control Monograph No. 1 

Affecting the 

Cessation Process 

adolescence dissipate. For utility of the cigarette to continue, 

cigarette smoking has to be allowed in those situations when 

the smoker wants to use the cigarette. For smokers to learn to 

use cigarettes to handle stress at work, they must be allowed to 

smoke at the time when those stresses occur. If smoking is 

banned in the worksite, not only do smokers learn to not use 

the cigarette to cope with those stresses, but also they are obligated to develop alternative mechanisms to handle stress, and 

those mechanisms may be substituted for smoking in other 

settings as well. 

The socialization of an adolescent into the workforce may 

include powerful social reinforcement for smoking behavior, 

particularly in the military environment. Older role models 

and social norms that promote smoking can increase the utility 

of smoking for the young smoker and facilitate the transition 

to dependency. Conversely, the elimination of smoking from 

the worksite and the development of workplace norms that discourage smoking may weaken the dependence on tobacco and 

increase the development of other coping skills. 

The majority of smokers want to quit, and this desire culminates in attempts to quit by approximately one-third of 

smokers each year (Pierce and Hatziandreu, 1989). The cyclical 

pattern of not thinking about quitting (precontemplation), 

thinking about quitting (contemplation), and attempting to 

quit-with success or failure-generates a new set of nonsmokers each time a group of smokers passes through the cycle (Prochaska and DiClemente, 1986). One formulation of the process of cessation, and the points at which specific smoking 

control interventions can influence the stages of cessation, is 

presented in Figure 15. The diagram is a simplification of the 

effects of smoking control efforts, but it gives an overview of 

the possible interactions in a comprehensive control program. 

Many environmental influences and programs for controlling tobacco use are intended to influence smokers at different 

points in this cycle. Public information campaigns that present 

the risks associated with smoking are intended to move smokers from the precontemplation to the contemplation stage, as is 

personalizing of the risk of smoking through physicians’ warnings. However, there are other reasons why smokers think 

about quitting, including concerns about addiction to cigarettes and interest in being a good example. Recently the 

negative image of the smoker and the social unacceptability of 

smoking have also provided strong reasons why smokers think 

about quitting. Individual programs to control tobacco use can 

aim and have been aimed at altering the frequency and intensity with which these motivational issues are presented to the 

smoker. 

25 
National Cancer Institute 

Figure 15 

Process of cessation 

Personal and 

Envlronmental Stress Physiclan or Dentist 

Warning of Risk 

Peers and Family 

Who Smoke 

Concern About 

Acceptability of by Physlclan or Dentist Dependence 

Negatlve Images 

Short-Term Success Contemplation 

cost 

Acute illness 

Self-Help Programs Media Campalgns 

Telephone Hotlines Social Pressure 

Nlcotlne Gum Cessation Events 

Physiclan or Dentlst JAdvice To Quit 

Action Restrlction on Smoklng 

Cilnic-Based Cessation Programs 

Envlronmentai Restrictions on Smoking 

Soclal Norms 

Long-Term Success 

The move from thinking about quitting to making an 

attempt to quit is often triggered by a variety of environmental 

stimuli. The data from California presented above suggest that 

an increase in the cost of cigarettes can be a powerful trigger 

for cessation attempts. 

A physician’s or dentist’s advice to quit smoking, particularly when it is related to an acute illness, also is a powerful 

trigger for cessation, with up to half of the patients who are 

advised to quit making a cessation effort (US DHHS, in press). 

Media campaigns, especially when coupled with cessation 

events such as the Great American Smokeout, also can trigger 

cessation attempts by large numbers of smokers (Gunby, 1984). 

Changes in workplace rules to restrict smoking on the job have 

been associated with attempts to quit by a substantial number 

of workers. 

26 
Smoking and Tobacco Control Monograph No. 1 

Triggering cessation efforts, whether or not they succeed, is 

an important strategy because each round of cessation activity 

results in a few more nonsmokers. The large proportion of 

smokers who attempt to quit each year is a testament to the 

success of those components of the control effort that are 

designed to move smokers from precontemplation to contemplation and from contemplation to action. The major gap in 

current control efforts is in converting cessation attempts into 

long-term successes. 

Self-help programs, telephone hotlines, and nicotine gum 

are all useful enhancers of short-term success in smoking 

cessation, and clinic-based programs have a substantial benefit 

for long-term cessation for those who can be recruited to participate (Schwartz, 1987). However, the major barriers to longterm success remain difficult to alter and, with the exception of 

addiction, are largely in the smoker’s environment. They 

include social norms and workplace rules that promote smoking and facilitate relapse, the continued smoking behavior of 

peers and family members, and unusual episodes of stress that 

lead the smoker to fall back on old coping strategies, including 

smoking. Long-term success remains the most elusive component of a comprehensive strategy to control tobacco use; however, the prospect of continued changes in social norms and 

tighter restrictions on where smokers can smoke offers hope 

that even this component may show improvement in the 

future. 

27 
National Cancer Institute 

REFERENCES California Department of Health Services. Tobacco Use in 

California 1990: A Preliminary Report of the Decline of Tobacco 

Use. San Diego: University of California, 1990. 

Centers for Disease Control. Cigarette advertising-United 

States, 1988. Morbidity and Mortality Weekly Report 39(16): 261- 

265,1990. 

Cullen, J.W. Strategies to stop smoking. Cancer Prevention 

May: 1-12, 1989. 

Davis, R.M. Current trends in cigarette advertising and 

marketing. New England Journal of Medicine 316(2): 725-732, 

1987. 

Fiore, M.C., Novotny, T.E., Pierce, J.P., Giovino, G.A., 

Hatziandreu, E.S., Newcomb, P.A., Surawicz, T.S., Davis, R.M. 

Methods used to quit smoking in the United States. Do cessation programs help? Journal of the American Medical Association 

263: 2760-2765, 1990. 

Fiore, M.C., Novotny, T.E., Pierce, J.P., Hatziandreu, E.J., 

Patel, K.M., Davis, R.M. Trends in cigarette smoking in the 

United States: The changing influence of gender and race. 

Journal of the American Medical Association 261(1): 49-55, 1989. 

Fischer, P.M., Richards, J.R., Jr., Berman, E.J., Krugman, 

D.M. Recall and eye tracking study of adolescents viewing 

tobacco advertisements. Journal of the American Medical Association 261: 84-89, 1989. 

Glynn, T.J. Essential elements of school-based smoking 

prevention programs. Journal of School Health 59(5): 181-188, 

1989. 

Glynn, T.J., Boyd, G.M., Gruman, J.C. Essential elements 

of self-help/minimal intervention strategies for smoking 

cessation. Health Education Quarterly 17(3): 329-345, 1990. 

Grise, V.N. Domestic tobacco and tobacco products: Situation and outlook. Tobacco International April 1: 24-28, 1991. 

Gunby, P. Smokeout could preface “smoke-free society.” 

Journal of the American Medical Association 252: 2803-2804, 

1984. 

Harris, J.E. Cigarette smoking among successive birth 

cohorts of men and women in the United States during 1900-

80.Journal of the National Cancer Institute 71(3): 473-479, 1983. 

International Agency for Research on Cancer. Tobacco 

Smoking: IARC Monographs on the Evaluation of Carcinogenic Risk 

of Chemicals to Humans, (volume 38). Lyons, France: IARC, 

1986. 

28 
Smoking and Tobacco Control Monograph No. 1 

National Research Council. Environmental Tobacco Smoke: 

Measuring Exposures and Assessing Health Effects. Washington, 

DC: National Academy Press, 1986. 

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

Public Health Service, National Institutes of Health, National 

Cancer Institute. NIH Publication No. 90-479, 1989. 

Pierce, J., Hatziandreu, E. Report of the 1986 Adult Use of 

Tobacco Survey. U.S.Department of Health and Human Services, Public Health Service, Centers for Disease Control, Office 

on Smoking and Health, Publication No. 10491,1989. 

Pirie, P.L., Murray, D.M., Luepker, R.V. Smoking prevalence in a cohort of adolescents, including absentees, dropouts, 

and transfers. American Journal ofPublic Health 78: 176-178, 

1988. 

Pomrehn, P., Sciandra, R., Shipley, R., Lynn, W., Lando, H. 

Enhancing resources for smoking cessation through community intervention. International Quarterly of Health Education 

ll(3): 259-269, 1990-91. 

Prochaska, J.O., DiClemente, C.C. Toward a comprehensive model of change. In: Treating Addictive Behaviors, W.R. 

Miller and H. Heather (Editors). New York: Plenum Press, 

1986, pp. 3-27. 

Robert, J.C. The Story ofTobacco in America. Chapel Hill, 

NC: University of North Carolina Press, 1967. 

Schwartz, J.L. A critical review and evaluation of smoking 

control methods. Public Health Reports 84: 483-506, 1969. 

Schwartz, J.L. Review and Evaluation of Smoking Cessation 

Methods: The United States and Canada, 1978-1 985. U.S. Department of Health and Human Services, Public Health Service, 

National Institutes of Health, National Cancer Institute. NIH 

Publication No. 87-2940, 1987. 

Shopland, D.R., Pechacek, T.F., Cullen, J.W. Toward a tobacco-free society. Seminars in Oncology 17: 402-412, 1990. 

Steinfeld, J.L. The public’s responsibility: A bill of rights 

for the nonsmoker. Rhode Island Medical Journal 55(4): 124- 

126,138,1972. 

Study Group on Smoking and Health. Smoking and 

health: Joint report of the Study Group on Smoking and 

Health. Science 125: 1129-1133, 1957. 

29 
National Cancer lnstitute 

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 ll(3): 187-203, 1990-91. 

Tobacco-Free America. State Legislated Actions on Tobacco 

Issues. Washington, DC: Tobacco-Free America, 1990. 

Tobacco Institute. The Tax Burden on Tobacco. Historical 

Compilation (volume 25). Washington, DC: Tobacco Institute, 

1990. 

Tye, J.B. Cigarette marketing: Ethical conservatism or corporate violence. New York State Journal ofMedicine 82: 324-327, 

1985. 

U.S. Department of Health and Human Services. The 1990 

Health Objectives for the Nation: A Midcourse Review. U.S. Department of Health and Human Services, Public Health Service, 

Office of Disease Prevention and Health Promotion, 1986. 

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

Consequences of Smoking: A Report of the Surgeon General. U.S. 

Department of Health and Human Services, Public Health Service, Office on Smoking and Health. DHHS Publication No. 

(PHS)82-50179, 1982. 

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

Consequences of Involuntary Smoking. U.S. Department of Health 

and Human Services, Public Health Service, Office of the Assistant Secretary for Health, Office on Smoking and Health. DHHS 

Publication No. (PHS)87-8398, 1986. 

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

Consequences of Smoking: Nicotine Addiction. A Report of the 

Surgeon General. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center 

for Health Promotion and Education, Office on Smoking and 

Health. DHHS Publication No. (CDC) 88-8406, 1988. 

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

the Health Consequences of Smoking: 25 Years of Progress. A Report

of the Surgeon General. 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. DHHS Publication No. (CDC)

89-8411, 1989. 

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

Benefits of Smoking Cessation: A Report of the Surgeon General. 

U.S. Department of Health and Human Services, Public Health 

Service, Centers for Disease Control, Office on Smoking and 

Health. DHHS Publication No. (CDC) 90-8416, 1990b. 

30 
Smoking and Tobacco Control Monograph No. 1 

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

the Sale of Tobacco to Minors. Proceedings of the Interagency 

Committee on Smoking and Health. U.S. Department of Health 

and Human Services, National Advisory Committee, Washington, DC, May 31, 199Oc. 

U.S. Department of Health and Human Services. Physicianand Dentist-Directed Smoking Interventions. National Cancer Institute Smoking and Tobacco Control Monograph No. 2, (in 

press). 

U.S. Department of Health and Human Services. Smoking,

Tobacco, and Cancer Program: 1985-1989 Status Report, D.R. 

Shopland and M.M. Massey (Editors). U.S. Department of 

Health and Human Services, Public Health Service, National 

Institutes of Health, National Cancer Institute. NIH Publication No. 90-3107, 1990a. 

U.S. Department of Health, Education, and Welfare. Smoking and Health: A Report of the Advisory Committee to the Surgeon 

General of the Public Health Service. U.S. Department of Health, 

Education, and Welfare; Public Health Service; Center for 

Disease Control. PHS Publication No. 1103, 1964. 

U.S. Department of Health, Education, and Welfare. 

Smoking and Health: A Report of the Surgeon General. U.S. Department of Health, Education, and Welfare; Public Health 

Service; Office of the Assistant Secretary for Health; Office on 

Smoking and Health. DHEW Publication No. (PHS) 79-50066, 

1979. 

U.S. Department of Health, Education, and Welfare. The 

Health consequences of Smoking: A Report of the Surgeon General. 

1972. U.S. Department of Health, Education, and Welfare; 

Public Health Service; Health Services and Mental Health 

Administration. DHEW Publication No. (HSM) 72-75 16, 1972. 

U.S. Department of Health, Education, and Welfare. The 

Health Consequences ofsmoking 1975. U.S. Department of 

Health, Education, and Welfare; Public Health Service; Office of 

the Assistant Secretary for Health; Center for Disease Control. 

DHEW Publication No. (CDC) 77-8704, 1975. 

U.S. Environmental Protection Agency. Health Effects of 

Passive Smoking: Lung Cancer in Adults and Respiratory Disorders 

in Children (in press ). 

Warner, K.E. The effect of the anti-smoking campaign on 

cigarette consumption. American Journal of Public Health 67: 

645-650, 1977. 

Whelan, E.M. A Smoking Gun: How rhe Tobacco Industry 

Gets Away with Murder. Philadelphia: George F. Stickley, 1984. 

31 
BLANK PAGE 
Chapter 2 

Evolution of Smoking Control 

Strategies 

CONTENTS Introduction ............................................................................ 35 

Information and Education Campaigns ................................. 35 

Cessation Program Strategies .................................................. 37 

Withdrawal Clinics .......................................................... 38 

Medication ....................................................................... 41 

Behavior Modification ..................................................... 42 

Self-Help Materials ........................................................... 46 

Multiple-Component Programs ....................................... 48 

Prevention Strategies ............................................................... 48 

Relapse Prevention ........................................................... 48 

Efforts To Prevent Initiation ............................................ 50 

Comprehensive Approach to Smoking Control ..................... 51 

The Political Sector .......................................................... 53 

The Economic Sector ....................................................... 54 

The Education Sector ....................................................... 56 

The Communication Sector ............................................. 57 

The Health Professional Sector ........................................ 58 

The Health Voluntaries' Sector ........................................ 59 

Conclusions............................................................................. 60 

References................................................................................ 61 

33 
BLANK PAGE 
Chapter 2 

Evolution of Smoking Control 

Strategies 

INTRODUCTION Evidence linking cigarette smoking with cancer began to 

accumulate in the 1930’s and rapidly increased in the late 

1940’s and early 1950’s. Four retrospective studies of the smoking habits of lung cancer patients and controls were published 

in 1950 (Doll and Hill, Levin et al., Schrek et al., Wynder and 

Graham), and each noted a consistent, statistically significant 

association between smoking and cancer of the lung. 

Between 1954 and 1958, Hammond and Horn reported the 

findings of their large-scale prospective study of 187,783 U.S. 

males ‘that showed significantly higher overall death rates for 

smokers than for nonsmokers. In the same years, a prospective 

mortality study of 40,000 British physicians provided independent demonstration of the relationship between cigarette 

smoking and disease (Doll and Hill, 1954 and 1956). The 

strength and consistency of these results, combined with 

evidence from laboratory and autopsy studies, led a national 

scientific study group to conclude that there was a causal 

relationship between smoking and lung cancer (Study Group 

on Smoking and Health, 1957). 

In the following sections, this chapter describes how 

strategies for reducing the prevalence of smoking in the United 

States have evolved from the simplest approaches to information dissemination, through clinics and self-help techniques, to 

contemporary, comprehensive approaches to smoking control-employing multiple strategies drawn from every relevant 

sector of our environment. The discussion is organized under 

topic headings, as follows: 

Information and Education Campaigns 

Cessation Program Strategies 

Prevention Strategies 

A Comprehensive Approach to Smoking Control 

Conclusions. 

INFORMATION In the early 195O’s, a few popular publications transmitted 

AND EDUCATION the new scientific findings about smoking to the lay public. 

CAMPAIGNS There were several reports in Reader’s Digest (Lieb, 1953; Miller 

and Monahan, 1954; Norr, 1952; Riis, 1950) and in Consumer 

Reports (1953, 1954, and 1955) that informed the public of the 

health hazards of smoking. By the mid-l960’s, information 

35 
National Cancer Institute 

and education campaigns-both private-sector and Government-funded-became more intensive. 

Recognition of the health hazards of smoking led to organized efforts to inform smokers about the risks of tobacco use, 

with the expectation that large numbers of smokers would be 

convinced of the need to quit (Flay, 1987a). Media-based 

messages and educational campaigns were the earliest smoking 

control activities. 

The 1964 Surgeon General’s Report on Smoking and 

Health accelerated the Government and the voluntary health 

organizations’ efforts to educate and inform the public about 

the hazards of smoking (US DHEW, 1964). The attention generated by the legislative requirement for an annual Surgeon 

General’s Report, and the media coverage surrounding its 

release, became one of the primary ways that the Federal 

Government informed the public about the health consequences of tobacco use. Since 1966, the Government has required a health warning on all cigarette advertising and on 

every package of cigarettes sold in the United States. 

The National Clearinghouse for Smoking and Health and 

national voluntary health organizations were also among the 

early sponsors of newspaper advertisements against smoking 

and of antismoking campaigns on television and radio. The 

American Cancer Society, the American Lung Association, and 

the American Heart Association used mass distributions of 

pamphlets, posters, and films to detail the risks of tobacco use. 

The voluntary health agencies also developed antismoking 

public service announcements. 

Interagency councils on smoking and health and Federal, 

state, and local health departments participated in the antismoking campaign. Educational materials and programs were 

introduced in local communities, schools, hospitals, and businesses. Medical, dental, and public health groups joined in the 

campaign to curtail smoking. As a result of the educational 

campaigns precipitated by the accumulation of scientific 

evidence, temporary declines in total per capita consumption 

of cigarettes occurred during 1953 to 1954, 1964, and 1968 to 

1970. These declines coincided with periods of increased 

publicity about the health hazards of cigarette smoking (US 

DHEW, 1979). 

The statutory ban on broadcast cigarette advertisements 

virtually eliminated antismoking messages, as well, from prime 

viewing hours after 1971. Some studies (Schneider et al., 1981; 

Warner, 1977) attribute the subsequent increase in cigarette 

consumption in 1972 and 1973 to the discontinuation of the 

antismoking commercials. 

36 
Smoking and Tobacco Control Monograph No. 1 

CESSATION 

PROGRAM 

STIWTEGIES 

The tobacco industry responded to these public information campaigns by denying that cigarette smoking caused 

disease, and industry spokespeople used the media to dispute 

the link between smoking and disease. In addition, they 

adopted a strategy that included attacking weaknesses in 

individual scientific studies-as a method of discrediting the 

large and growing body of information that was establishing 

the risks of smoking-and confusing smokers about the level of 

scientific certainty about the causal relationship and the importance of quitting. 

At the same time, cigarette manufacturers were developing 

and marketing new filter cigarettes to ease (and take marketing 

advantage of) smokers’ growing health concerns. Filters were 

advertised as a technological improvement to remove the 

harmful elements of smoke (US DHHS, 1989). In 1952, when 

reports linking cigarettes to lung cancer first appeared, 1percent of all cigarettes were filter-tipped (US DHHS, 1989). By 

1954, the percentage of filtered cigarettes had increased to 

9 percent. The filter-tip market share rose by at least 9 percentage points during each of the next 3 years, reaching 38 percent 

by 1957. By the time the 1964 Surgeon General’s Report was 

published, the market share of filter cigarettes had reached 

61 percent. 

During the 1970’s, the industry adopted a second marketing strategy in response to the increasing awareness and 

concerns of smokers. The advertising campaigns of this period 

encouraged smokers to switch to low-tar and low-nicotine 

cigarettes. Smokers’ acceptance of low-tar and low-nicotine 

cigarettes accelerated rapidly. 

At least 3 million people succeeded in quitting smoking in 

1954 (Horn, 1978). In subsequent years, between 1million 

and 3 million people gave up smoking each year (Horn, 1978); 

however, many more smokers tried to quit but did not succeed. 

Many smokers were dismayed to discover that long-term 

success was elusive. 

Increasing awareness of the problems created by tobacco 

use, and the difficulties associated with achieving and maintaining cessation, led to the gradual adoption of more comprehensive and intensive approaches to the reduction of tobacco 

use. 

Smoking cessation clinics were developed to address the 

difficulties smokers had in quitting on their own. Early clinics 

combined medication with educational lectures, pamphlets, 

and physician counseling over a 10-day course. During the 

1960’s, more than 100 smoking cessation programs were 

reported in the United States, Canada, 11European countries, 

37 
Withdrawal 

clinics 

National Cancer Institute 

and Australia (Schwartz, 1969). During the 1970’s, about 300 

cessation methods were reported in the literature (Pechacek, 

1979; Schwartz, 1977 and 1987). 

A listing of cessation programs reported over the past four 

decades reveals a change in the emphasis of cessation methods 

(Schwartz, 1987). In the late 1950’s, methods were primarily 

educational or medication-based (Schwartz, 1969). The leading 

programs in the 1960’s and 1970‘s were 5-day plans, group discussion, and conditioning-based procedures such as rapid 

smoking and satiation (Schwartz and Rider, 1978). Other 

popular treatments in the 1970’s were self-help in the form of 

ffhow-to-quit” manuals, books, filters, and over-the-counter 

drug products; group therapy; professional counseling; hypnosis; and cognitive-based, self-management approaches. The approaches that were emphasized in the 1980’s (Schwartz, 1987) 

include self-help, multiple-component programs, hypnosis, 

acupuncture, physician advice and counseling, nicotine chewing gum, skills training and relapse prevention, and mass 

media and community programs. 

Most of the early smoking cessation clinic approaches 

focused on changing smokers to enable them to alter their 

behavior and to resist environmental influences to smoke. The 

limited success of these early approaches, in terms of both 

smoker recruitment and long-term cessation, has led to a 

greater appreciation of the role of environmental influences on 

smoking behavior. A major emphasis of efforts to control 

tobacco use has been on altering the smoker’s environment in 

ways that will promote cessation and facilitate long-term abstinence. Cessation clinic approaches are one component of the 

current comprehensive approach to smoking control, and they 

have incorporated awareness and manipulation of environmental factors in their program content. 

Following the lead of clinic programs in Europe, the 

National Interagency Council on Smoking and Health assisted 

local interagency councils in the development of smoking 

cessation activities. The National Council sponsored a series of 

workshops on smoking cessation and, with the American 

Cancer Society, initiated the First World Conference on Smoking and Health in 1967. The U.S. National Clearinghouse for 

Smoking and Health sponsored community antismoking 

campaigns in San Diego, California, and Syracuse, New York. 

Local units of the cancer, lung, and heart associations also 

initiated clinic programs. The American Cancer Society developed a manual for withdrawal clinics based on a work conference attended by scientists who had experience with cessation 

methods. The Seventh-Day Adventist Church offered a highly 

38 
Smoking and Tobacco Control Monograph No. 1 

structured, intensive 5-day plan in many localities. Community health agencies, public health departments, hospitals, 

sanitariums, and group health plans also conducted cessation 

programs (Schwartz and Rider, 1978). The evolution of smoking cessation theories and programs through a variety of 

provider types is discussed below. 

Health Voluntaries’ Clinic methods generally employed either an educational 

Efforts approach or a support-group format. The American Cancer 

Society “Helping Smokers Quit” clinics were an educational 

approach that was standardized throughout the United States 

via use of selected guides, printed materials, and trigger films 

presented by extensively trained volunteers (Schwartz and 

Rider, 1978). Groups met for eight 2-hour sessions, generally 

twice a week. Interaction of group members facilitated personal growth and helped to reinforce abstinence from smoking. 

The clinic had three phases: self-appraisal and insight development, practicing abstinence under controlled conditions, and 

maintaining abstinence. Volunteer clinic leaders were recruited from graduates who had quit smoking. American 

Cancer Society clinics spread to the organization’s 58 divisions 

and 3,100 local units. 

In the 1980’s,the cancer society revised its clinic program. 

The revamped program, .Freshstart, consists of four 1-hour, 

small-group sessions designed to help participants understand 

why people smoke, handle withdrawal symptoms, practice 

stress management, and assimilate tips to help them refrain 

from smoking. 

Local units of the American Lung Association sponsored a 

variety of cessation clinics. The American Lung Association 

provided clinic guidelines to local units, but individual chapters designed their own programs. In the 1980’s, the lung 

association produced excellent quitting and maintenance 

manuals that emphasized self-help. The lung association also 

developed a clinic program based on education and principles 

of behavior modification. The clinic used the Freedom from 

Smoking manuals in a seven-session format, a method that 

offered a systematic approach for reducing the stress of quitting. The American Lung Association initiated a national 

program to train staff members to run clinics, manage publicity, and recruit clinic leaders. The promotion’s emphasis was 

to interest major corporations in sponsoring programs that 

used the self-help and clinic modes. 

Many schools offered smoking prevention programs and 

cessation classes for high school students and adults; colleges 

and universities also provided quit courses (Schwartz and Rider, 

1978). Hospitals, health departments, and physicians sponsored educational sessions for smoking cessation, generally 

39 
Five-Day Plan 

Commercial 

Programs 

National Cancer Institute 

consisting of lectures, films, literature, instructions on how to 

quit, diet information, and responses to questions. The 

Smoker’s Self-TestingKit (US DHEW, 1969) was used often, and 

each person was paired with a “buddy.” 

In 1960, the Seventh-Day Adventist Church launched the 

Five-Day Plan To Quit Smoking (McFarland et al., 1964), which 

consisted of five consecutive sessions of 90 to 120 minutes 

each. There were no followup sessions in the first several years 

of the program, but maintenance meetings were added later. 

Groups varied in size from 15 people to several hundred. 

Usually, at the first session, a film showing surgery on a 

cancerous lung was presented. Immediate smoking cessation 

was prescribed, and participants were temporarily prohibited 

from drinking coffee, tea, cola, and alcohol. Physical fitness, 

exercise, balanced diets, increased fluid intake, warm baths, hot 

and cold showers, body rubs, deep breathing, and a “buddy 

system” were encouraged to offset the potential difficulties of 

withdrawal from nicotine. The physiological effects of smoking were discussed in these sessions, and lung specimens were 

displayed. Clergymen, psychologists, or physicians presented 

spiritual, mental, or medical lectures and conducted counseling. 

The Five-Day Plan was copied widely, in modified form, by 

professionals and laypersons. The main aspects that other 

programs copied were the 5-day format and the buddy system. 

Proprietary groups began offering cessation programs in 

the late 1960’s (Schwartz and Rider, 1978; Schwartz, 1987). 

Smoke Watchers, formed in 1968, offered slow withdrawal and 

weekly goals. Smokers attended open group meetings, with 

new members joining and graduates and dropouts leaving the 

group. 

SmokEnders, started in 1969, ran chapters directly and 

granted some franchises. SmokEnders did not build centers; 

instead, community facilities were used (e.g., churches, 

schools, and hotels). In terms of acceptance and marketing, 

SmokEnders has been the most successful commercial stopsmoking program. SmokEnders is a highly structured, systematic technique that emphasizes positive reinforcement and 

changing attitudes. The original format consisted of eight 

weekly meetings with a “cut-off day” after the fifth meeting 

(Schwartz, 1987). The last three meetings were intended as reinforcement, and all moderators were graduates of the program. The course was subsequently reduced to 6 weeks, with 

the quit day after the fourth session. 

Schick Centers for the Control of Smoking started in 1971. 

The company operated all centers and invested in building 

40 
Smoking and Tobacco Control Monograph No. 1 

facilities and television promotion. When the public did not 

respond, Schick closed its Eastern U.S. units and concentrated 

in five states. The Schick method consists of 5 days of aversive 

conditioning (low-grade shocks and smoke satiation), followed 

by 6 weeks of predominately educational group meetings 

(Schwartz, 1987). 

Two other national commercial organizations with similar 

programs were formed in the 1980’s. SmokeLess and Smoke 

Stoppers license their treatment programs mainly to hospitals 

and businesses. These organizations conduct training and 

provide materials to licensees. The SmokeLess and Smoke 

Stoppers systems are educational, intensive, and highly structured. Attractive pamphlets guide the smoker through the 

program, with methods that include stress management, 

positive rewards and reinforcements, food management, and 

negative smoking practices. Four classes designed to enable 

smokers to quit are held the first week, followed by 2 or 

3 weeks of maintenance sessions. 

A review of the 1967 through 1977 telephone yellow pages 

from more than 200 U.S. cities revealed that commercial stopsmoking programs were available in most major cities and 

many smaller communities (Schwartz and Rider, 1978). A similar review of the 47 largest U.S. cities for the years 1984 and 

1985 showed an increase in such listings from 112 to 385 

(Schwartz, 1987). What was striking about the differences 

between these two periods was that commercial programs, 

which made up about one-half of the listings in the first 

survey, accounted for only one-fifth in the later survey. 

Hypnosis programs made up 17 percent of the listings in the 

earlier survey but almost one-third in the second survey. The 

proportion of physician and acupuncture listings also increased 

in the second survey. 

Medication Chemical agents have been offered as smoking deterrents 

since before 1900. Early deterrents consisted of herbs, spices, 

and mouthwashes that produced a disagreeable taste for the 

smoker (Schwartz, 1969). Other products aimed at diminishing 

the sensory drives or creating a dry mouth (US DHEW, 1964). 

In 1982, a Food and Drug Administration panel concluded that 

drug products such as chewing gum, mouth sprays, and tablets 

containing silver acetate were not effective as aids to smoking

cessation (Food and Drug Administration, 1982). 

A variety of drug types, including anticholinergics, sedatives, tranquilizers, sympathomimetics, and anticonvulsants, 

have been used to reduce the psychologica€ and physiological 

symptoms of withdrawal. Prior to the introduction of nicotine 

chewing gum, Jarvik and Gritz (1977) reviewed the literature 

and concluded that drug therapy was not particularly useful in 

curing the smoking habit. 

41 
Nicotine Gum 

Other Drug 

Treatments 

Behavior 

Modification 

National Cancer Institute 

Nicotine polacrilex (Nicorette) is a prescription drug in the 

form of chewing gum that contains 2 mg of nicotine bound by 

an ion exchange resin that allows for a slow release of nicotine 

when chewed. Patients are advised to use the gum for at least 

3 months. However, some smokers need to use the gum for 

6 months or more to alleviate their urge to smoke. 

In 1984, Lakeside Pharmaceuticals, a division of Merrell 

DOW,undertook a massive promotional campaign after the 

Food and Drug Administration approved its nicotine gum. The 

result of this campaign was that nicotine polacrilex became 

one of the fastest selling prescriptions ever introduced. Sales 

were $42 million in 1984 and grew to $60 million in 1987 (US 

DHHS, 1989). 

The availability of nicotine gum has encouraged physicians and dentists to advise their patients to quit smoking 

because now these providers have some assistance to offer the 

patient who wants to quit. There are indications, though, that 

most physicians do not provide proper instructions on the use 

of the gum. Schneider et al. (1984) and Sachs (1986) have 

cautioned that the patient must understand the limitations of 

the prescription and be instructed carefully on its use. Practitioners who have experience in the use of nicotine gum, and 

who provide instructions and additional advice and counseling, have achieved good results (Fagerstrom, 1982; Hall et al., 

1987; Killen et al., 1984; US DHHS, 1988). In the absence of 

counseling or therapy, success rates are low (Schwartz, 1987; 

US DHHS, 1988). 

More recent approaches to drug therapy include citric acid 

spray, nasal nicotine solution (Jarvis, 1986), nicotine vapor 

(Russell et al., 1987), nicotine-containing skin patches (Rose et 

al., 198S), and clonidine, a drug used to treat hypertension. 

Clonidine has been found to reduce the urge to smoke, and researchers have speculated that it may relieve nicotine withdrawal symptoms (Glassman et al., 1988). A clonidine 

transdermal patch is currently being tested as an aid to smoking cessation (US DHHS,1989). 

Mecamylamine has been suggested as an antagonist to 

block the nicotine-mediated reinforcing consequences of 

cigarette smoking (Henningfield et al., 1982; Pomerleau et al., 

1987). Mecamylamine is not meant as a cessation aid; rather, 

it is used to maintain abstinence. In one clinical trial, however, heavy smokers were treated with mecamylamine and 

showed short-term positive cessation effects (Tennant et al., 

1984). 

Behavior modification entails two divergent approaches to 

behavior change. One approach uses punishment and the 

other uses positive reinforcement-including self-management 

42 
Smoking and Tobacco Control Monograph No. 1 

procedures. For a detailed overview of behavioral methods, the 

reader is referred to reviews by Best and Bloch (1979), Glasgow 

(1986), Hall and Hall (1985), Lando (1981), Lichtenstein and 

Brown (1983), Pechacek (1979), Pechacek and McAlister (1980), 

Schwartz (1969 and 1987), and Schwartz and Rider (1978). 

Aversive Aversion therapy for smoking developed in the 1960’s and 

Procedures included electric shock, desensitization training, breathholding, overexposure to stale smoke, and covert sensitization. 

The use of electric shock as a punishing stimulus to eliminate 

smoking behavior has had limited success. The most promising techniques use some form of smoke aversion. 

Satiation. Wilde (1964) attempted to induce a dislike for 

the taste of cigarettes by combining satiation with aversive, 

avoidance, and instrumental conditioning. This procedure 

showed only limited success. Subjects were required to increase the number of cigarettes they smoked and the rate at 

which they smoked. Early reports by Resnick (1968) claimed 

positive results for satiation, but other investigators were not 

able to replicate that success. Satiation has generally been 

combined with other procedures. Lando (1977) and Best et al. 

(1978) designed successful multicomponent programs that 

included satiation. 

Rapid smoking. Lublin and Joslyn (1968) combined hot, 

smoky air with rapid smoking and reported fair results. Their 

study was criticized for invalid methodology, but it set off a 

series of experiments by Lichtenstein and his colleagues, which 

subsequently produced impressive results for rapid smoking. 

Their procedure required the subject to inhale from a cigarette 

once every 6 seconds for the duration of the cigarette or until 

nausea developed. 

In the early trials, Lichtenstein’s group used warm, smoky 

air along with rapid smoking but dropped the warm air when 

they found it did not contribute to effectiveness (Lichtenstein 

and Brown, 1983). There was some concern that rapid smoking created a risk to the cardiopulmonary system, but serious 

consequences have not been evident. Nevertheless, subjects 

should be screened and monitored closely during treatment. 

Rapid smoking has continued to be a popular treatment for 

smoking, and multiple-component treatments that include 

rapid smoking have shown good long-term success (Hall et al., 

1984; Pechacek, 1979). 

Covert sensitization. The objective of covert sensitization is 

to produce avoidance behavior through use of the subject’s 

imagination. Both the behavior to be modified and the noxious stimulus are imagined. This procedure showed promise in 

early case studies, but controlled trials failed to replicate the 

early success (Pechacek, 1979; Schwartz, 1987). 

43 
Self-Management 

Techniques 

National Cancer Institute 

Other smoke aversion procedures. Other smoke aversion 

methods include the use of smoky air, chain smoking, regularpaced aversive smoking, and smoke-holding. Regular-paced 

aversive smoking may be performed in a variety of ways. 

Generally, the procedure is done at home. Subjects smoke at 

their usual rate while focusing on the negative features of 

cigarettes, such as the irritation in the mouth and throat, 

coughing, and the accumulation of smoke. When regularpaced smoking is the only treatment, the procedure yields low 

success rates, but when it is used with a treatment program, the 

quit rates are much improved (Schwartz, 1987). 

Smoke-holding consists of retaining the smoke in the 

mouth for 30 seconds or until feelings of discomfort reduce the 

desire to smoke. This appears to be a safe procedure, but there 

are not enough data for assessing its efficacy in smoking 

cessation. 

Strategies for quitting smoking though self-management 

encompass a variety of techniques, some of which are employed with aversive methods. These techniques generally are 

initiated and directed by leaders or therapists. Predominant 

self-management methods are those based on concepts of selfmonitoring, nicotine fading, stimulus control, contingency 

contracting, systematic desensitization, and restricted environmental stimulation therapy. Self-management techniques also 

have been employed in multiple-component programs, discussed below. 

Self-monitoring Program requirements for self-monitoring 

have differed greatly-from having the participants count the 

number of cigarettes smoked in just 1day to having them keep 

elaborate records for 1or more weeks, noting the time, place, 

activity, and mood when smoking each cigarette and somehow 

rating or ranking the perceived need for each. McFall (1970) 

demonstrated that, when people begin paying close attention 

to their smoking behavior, it is likely to change even though 

no change may be intended or desired. Glasgow (1986) commented that self-monitoring can be useful, provided that 

monitoring assignments are not overly complex, are varied, 

and are not continuously required throughout a lengthy 

program. 

Nicotine fading. Slowly reducing nicotine intake by changing to brands with lower nicotine content (brand fading) or 

cutting down the number of cigarettes smoked (tapering) are 

ways of gradually withdrawing from nicotine. Smoke Watchers, the first national commercial program, based its method 

on gradual withdrawal and weekly goals assigned by the group 

leader (Schwartz and Rider, 1978). Although Smoke Watchers 

had some success with tapering, the evidence for gradual 

44 
Smoking and Tobacco Control Monograph No. 1 

reduction in numbers is not very positive. As the number of 

cigarettes is reduced, each remaining cigarette can become 

more reinforcing. However, with nicotine fading, individuals 

can continue to smoke the same number of cigarettes while reducing their nicotine intake. Some investigators have shown 

good results with brand fading. Several commercial filters are 

marketed with the aim of progressively reducing the tar and 

nicotine content of a cigarette as a way of helping smokers to 

break the habit. 

Nicotine fading by changing brands was introduced by 

Foxx and Brown (1979), who advocated nicotine content 

reductions of 30, 60, and 90 percent over a 3-week period. 

Some investigators use a different schedule, and most include 

other procedures in the treatment. The many trials conducted 

in the 1980’s attest to the level of interest in nicotine fading. 

Brown and Lichtenstein (1980) combined nicotine fading with 

relapse training, whereas Lando and McGovern (1985) used it 

with smoke-holding. 

Stimulus control. In the mid-1960’s a number of behavioral 

investigators used stimulus control techniques as a treatment 

for smoking (Schwartz, 1969). Stimulus control is intended to 

eliminate undesirable behaviors by altering the situations in 

which the maladaptive response occurs. Either the situation 

can be altered or the individual’s response to the situation can 

be altered. Generally, smoking is associated with a variety of 

specific environments and internal events, and these associations trigger the smoking response. 

One strategy seeks to increase the stimulus interval 

through use of a cueing device (e+, pocket timer or signal 

device). Once the new smoking cue is well established, it is 

gradually faded out via increased time intervals. 

Another type of stimulus control is hierarchical reduction. 

Subjects are asked to monitor their smoking activity carefully 

and identify situations in which they are more likely or less 

likely to be smoking. The subject then eliminates smoking in a 

cumulative and progressive fashion, from the easiest situation 

to the hardest. Limiting the circumstances in which smoking 

is allowed is another strategy. The procedure permits smoking 

only in a deprived setting, one devoid of all possible distractions and accompanying reinforcers. 

The reported studies do not provide evidence to support 

stimulus control as an effective cessation procedure (Schwartz, 

1987). Keeping a detailed account of the subject’s feelings and 

activities related to smoking provides insight to the habit, 

which can assist the smoker in quitting as long as the treatment also includes other features, such as counseling, maintenance, and relapse prevention. 

45 
Self-Help 

Materials 

National Cancer Institute 

Contingency contracting. The purpose of contingency contracting is to enhance the smoker’s motivation through commitment. Two forms of these contracts are monetary deposits 

and social contracts with peers. Early studies (Elliott and 

Tighe, 1968; Winett, 1973) demonstrated that refunding 

portions of deposits to subjects for continued abstinence 

influenced long-term cessation. 

Signing formal contracts with subjects is one program 

aspect that achieved good success rates (Lando, 1977). Subjects 

pledged to forfeit money for every cigarette smoked and agreed 

to undergo an aversive booster treatment after any smoking. 

Stitzer and Bigelow (1982) offered contingency payments to 

subjects who reduced their smoking and thereby reduced their 

carbon monoxide levels by 50percent. Including contingency 

contracting as one aspect of a multicomponent program may 

contribute to success, but it has limited application as a primary treatment. 

Systematic desensitization and relaxation. Desensitization 

was intended to strengthen responses that are incompatible 

with smoking. It was hypothesized that smoking behavior is 

frequently cued by anxiety, and if the prior and proximal 

stimuli leading to smoking were desensitized, then smoking 

would diminish. Other investigators suggested that subjects 

could be conditioned to relax as an alternative to smoking. 

Still others believed that reducing the stress generated by 

quitting would help to create positive results. 

Many investigators have incorporated desensitization and 

relaxation training into their programs. However, controlled 

studies do not support desensitization as a treatment for smoking. Although relaxation seems to make sense as a helpful 

procedure, nicotine has primarily stimulating effects, and the 

smoker seeking stimulation may not find a satisfactory replacement in relaxation. 

Restricted environmental stimulation therapy. The form of 

therapy known as restricted environmental stimulation derives 

its rationale from evidence that a period of sensory deprivation 

increases persuadability and responsiveness to external cues 

(Suedfeld and Best, 1977; Suedfeld, 1984). Although several 

investigators have demonstrated success with this method, the 

need to keep a subject in a soundproof chamber and provide a 

monitor has discouraged use of this procedure. 

The large number of smokers who attempt to quit each 

year, coupled with the reluctance of smokers to participate in 

cessation clinic promotions, has led to the production of a 

variety of aids to assist smokers in their self-directed efforts to 

quit smoking (Schwartz and Rider, 1978; Schwartz, 1987). The 

earliest materials were stop-smoking books, quit kits, and 

46 
Smoking and Tobacco Control Monograph No. 1 

filters; later, audiotapes, correspondence courses, and smokeless 

cigarettes were marketed. Videocassettes and computer programs have become available more recently (Schwartz, 1987). 

The Smoker’s Self-Testing Kit was used by several million 

smokers (Horn, 1972; US DHEW, 1969). It helped smokers gain 

insight about their habit by providing an understanding of 

how one feels about cigarettes, how one uses them, and the 

factors that inhibit or enhance the effort to quit. 

Several dozen quit-smoking books and guides have been 

produced (Schwartz, 1987). In 1977, the American Cancer 

Society developed the I Quit Kit, which consisted of portions of 

the Smoker’s Self-Testing Kit, instructions for quitting, and tips 

on how to stay away from smoking. The Federal Office on 

Smoking and Health provided smoking cessation pamphlets, 

and NCI designed the Helping Smokers Quit Kit, which contained materials for the smoker and the physician. 

The American Lung Association produced two manuals for 

people who aim to quit on their own: Freedom From Smoking in 

20 Days, a 64-page cessation guide, and A Lifetime ofFreedorn 

From Smoking, a 28-page maintenance booklet. The cessation 

guide includes part of the Smoker’s Self-Testing Kit, identifies 

smoking triggers, and offers information about controlling 

weight, handling smoking situations, and performing deep 

breathing and relaxation exercises. The maintenance booklet 

supports ex-smokers’after they quit. These are well-designed 

manuals that have proven to be very popular (Lando et al., 

1990). 

“How-to-quit-smoking” books have been written primarily 

by ex-smokers and psychologists. Glasgow et al. (1981) compared the cancer society’s I QuitKit to two behavioral self-help 

books, one by Pomerleau and Pomerleau (1977) and the other 

by Danaher and Lichtenstein (1978). Under self-help conditions, the American Cancer Society manual was rated best. 

Glasgow (1986) postulated that subjects using relatively complex self-administered behavioral programs would have great 

difficulty in following them. When a therapist led the treatment using the same materials, the behavioral books came out 

better than the cancer society’s manual. 

An early aid to quitting, still marketed today, is a filter that 

reduces the nicotine level in cigarette smoke and permits the 

smoker to be weaned from the chemical addiction (Schwartz, 

1987). The device, marketed by Teledyne Water Pik, consists of 

four reusable filters that reduce the nicotine content of inhaled 

smoke progressively. The smoker is supposed to use each filter 

for 2 weeks. As with any cessation method that does not attack 

the psychological addiction to smoking, evaluations of filter 

use have shown little long-term success. 

47 
MultipleComponent 

Programs 

PREVENTION 

STRATEGIES 

Relapse 

Prevention 

National Cancer Institute 

A new filter system is currently being marketed by Vipont 

Pharmaceuticals; it consists of three nicotine-fading filters to be 

used over 21 days. To address psychological addiction, the 

system includes a deck of cards to help in overcoming dependence and provide coping tips to be used after quitting. 

Other self-help cessation aids include quitting by mail, 

taped telephone messages, cigarette holders and dispensers, 

videotapes, and several types of computer-based methods. 

Many clinic approaches combine several procedures in 

their methods. Almost all multiple treatments include selfcontrol procedures (e.g., nicotine fading, abstinence training, 

relaxation, or stimulus control). Many multicomponent programs include smoke aversion as a way of breaking the habit 

and self-control to maintain nonsmoking (Best et al., 1978; 

Lando, 1977). Some of the very best results have been 

achieved with multiple-component programs (Hall, 1980; 

Killen, 1984;Lando, 1977). 

Lando (1977)has used satiation, contractual management, 

and group support for his multicomponent program; and 

Pomerleau et al. (1978)provided a multicomponent treatment 

consisting of stimulus control, covert conditioning, contingency management, relaxation, and use of pocket timers. 

Multicomponent programs have achieved the highest quit 

rates at 1-year followups (Schwartz, 1987). For example, Lando 

(1977)reported 76percent success at 6 months after combining satiation, contractual management, and group support; and 

Hall et al. (1984)achieved a 52percent quit rate at 1 year by 

using rapid smoking and relapse prevention. On the other 

hand, Beaver et al. (1981)scored only 6percent success at 

6 months with the combination of nicotine fading and anxiety 

management training, which suggests that not all multicomponent programs are highly successful. 

Lichtenstein and Brown (1983)and Glasgow (1986)have 

cautioned that more is not always better. Too many procedures may confuse subjects and make it difficult to provide an 

integrated treatment. Multicomponent treatments remain 

attractive because they deal with the multiple factors involved 

in smoking, as well as the considerable differences among 

smokers (Lichtenstein and Brown, 1983). 

Once smokers have quit, there are myriad environmental, 

social, and psychological forces that act to influence them to 

return to smoking (Schwartz and Rider, 1978). During the first 

4 months after treatment, many successful quitters become 

recidivists, and during the next 8 months, other ex-smokers 

return to smoking. Some people return to smoking after a year 

or more of abstinence (Schwartz, 1987). During the 1980’s, 

48 
Smoking and Tobacco Control Monograph No. 1 

Relapse Situations 

Maintenance 

Strategies 

Skills Training 

investigators studying relapse identified high-risk situations. 

Multicomponent programs included training in cognitive 

behavioral skills to help quitters develop strategies for identifying and coping with high-risk situations. 

Marlatt and Gordon (1980) found that the majority of 

relapse situations involved social pressure to smoke. They 

indicated that causes for relapse fell into three categories: 

social pressures, coping with negative emotional states, and 

coping with interpersonal conflict. They concluded that 

effective maintenance requires that the smoker be taught 

coping responses to relapse stimuli. 

Shiffman (1984) interviewed people who called a relapse

counseling hotline and found that most of their relapse crises 

were associated with negative feelings (e.g., anxiety, anger, 

depression). One-third of the crises however, were linked to 

positive emotional states and frequently involved other smokers. Ex-smokers who used coping responses more often were 

able to refrain from smoking. 

Lichtenstein (1979) identified three maintenance strategies: social support, coping skills, and cognitive restructuring. 

Social support is based on the theory that a group of close companions can provide support or influence to help the exsmoker sustain the motivation to continue abstaining. Coping 

skills are required to help the new nonsmoker deal with withdrawal symptoms, develop substitute responses that will 

replace smoking, and learn to recognize and modify cues to 

smoke (Lichtenstein, 1979). Cognitive restructuring involves 

changing attitudes and self-perceptions related to smoking. 

Support may come also from a support group or from the 

teaming of two or more clients as “buddies” to telephone each 

other and provide mutual support. Another support tactic is 

continued contact between the program and the client via telephone, letters, and personal meetings. Other support techniques include contingency contracting, bonuses, self-rewards, 

and positive feedback. 

Effective treatment procedures include cognitive recognition and behavioral training in coping with abstinence violation (defined as a slip by a quitter that leads to backsliding) and 

self-efficacy factors (Marlatt and Gordon, 1980). Investigators

caution that effective maintenance calls for minimizing the 

impact of slips as a way of coping with abstinence violation. 

Coping strategies can be used both to prevent high-risk 

situations and to respond to them (US DHHS, 1988). Both 

knowledge and performance of relapse prevention skills are 

needed to maintain change. Lichtenstein and Brown (1983) 

cite a number of studies that yielded favorable results from use 

of coping skills or self-management training. 

49 
Efforts To 

Prevent 

Initiation 

National Cancer Institute 

Schwartz (1987) found differences between some programs 

that offered self-management procedures and those that 

offered coping skills, relapse management training, or abstinence training. For example, Hall et al. (1984) combined rapid 

smoking with a relapse prevention program that included both 

behavioral and cognitive components. The coping skills 

addressed withdrawal symptoms and situational factors related 

to relapse (skills training for high-risk situations). This program attempted to individualize techniques. Relaxation was 

presented as a means of coping with the anger and anxiety that 

often precipitate a relapse. Four relapse prevention sessions 

were devoted to skills training, and subjects role-played alternate responses to high-risk situations. 

Another example is the relapse prevention program 

devised by Brown and Lichtenstein (1980), which was based on 

strategies suggested by Marlatt and Gordon (1980). It consisted 

of five components: identification of high-risk situations, 

coping rehearsal, avoidance of the abstinence violation effect, 

lifestyle balance, and self-rewards. 

Killen et al. (1984) studied the effects of skills training and 

nicotine gum, as separate methods and combined, in promoting abstinence after smoking cessation. Therapists demonstrated how strategies for selected target situations might be 

implemented. Participants then rehearsed coping responses 

specific to personal high-risk situations in front of the group. 

Therapists and group members provided corrective feedback 

after each rehearsal. Positive results were obtained in both 

skills training treatments. 

Fortmann et al. (1988) studied self-directed relapse prevention in combination with nicotine polacrilex. Sixteen modules 

were written to provide self-instruction on avoidance of smoking in specific high-risk situations. All subjects perceived 

efficacy in coping with different high-risk situations. The study 

demonstrated that relapse prevention could be self-directed. 

The recognition of the disease risks associated with tobacco use led to efforts to educate nonsmokers and to prevent 

adolescents and women from initiating tobacco use. These 

efforts evolved from preexisting campaigns to prevent women 

and children from smoking, programs that were based on 

concerns about the effects of smoking on morals and behavior 

(Troyer and Markle, 1983). 

During the 1950’s and 1960’s, the major efforts directed at 

preventing initiation focused on adolescents. Unfortunately, 

little effort was directed at countering the advertising and promotional campaigns of the cigarette manufacturers that were 

directed to women, blacks, and Hispanics. The cigarette 

manufacturers’ targeting may be largely responsible for the 

50 
Smoking and Tobacco Control Monograph No. 1 

current higher prevalence of cigarette smoking among young 

women than among young men, and the higher prevalence of 

smoking among black males than among white males (see 

Chapter 3). 

The efforts directed at preventing adolescent initiation fell 

into two categories: school-based smoking prevention education and restrictions on the availability of cigarettes to adolescents. However, the perception that either or both of these 

approaches could eliminate use of tobacco by adolescents has 

led to disappointment and to recognition of these efforts as important components of a comprehensive smoking control 

strategy that requires the support and activity of other channels to be maximally effective. 

We now have several comprehensive and effective curricula that deal with tobacco use (see Chapter 5); however, these 

curricula are not being used in the majority of U.S. school districts. Most states have mandates requiring that health education be taught in schools, but the task of implementing these 

mandates has often proven difficult or impossible. School 

health educators have come to realize that community perception of the importance of smoking as a problem, financing the 

costs of curricula and teacher training, and involvement of 

parents and the community in implementation of the curriculum are as important as the curriculum content for the success 

of these programs. 

Similarly, the efforts to restrict adolescents’ access to 

tobacco have been largely unsuccessful. Although 44 states 

have laws restricting the sale of cigarettes to adolescents, young 

people report little difficulty in obtaining cigarettes from stores 

and vending machines. Passage of legislation to limit tobacco 

sales to adolescents is ineffective in the absence of community 

support and enforcement. 

COMPREHENSIVE The recognition that most adult smokers first become 

APPROACH TO regular smokers as adolescents led to an early and continuing 

SMOKING concern about the role of mass media, particularly through 

CONTROL their advertising, in promoting tobacco use by adolescents. 

Some gains were made initially, most notably the effort to 

reduce the positive images of smoking in motion pictures, the 

ban of advertising on radio and television, and the elimination 

of sports personalities from cigarette ads. However, these early 

efforts did not prevent the continued targeting of adolescents, 

minorities, and women in the advertising and promotional 

efforts of the tobacco industry. 

Perhaps the most visible failure to prevent use of tobacco 

by adolescents came in the late 1970’s,with the reintroduction 

of smokeless tobacco products. These products were advertised 

on television with endorsement by sports personalities, and 

51 
National Cancer Institute 

adolescents were induced to use them through give-away 

programs. All of this activity occurred at a time when the 

scientific evidence establishing the carcinogenicity of these 

products had already been published. Once again, the failure 

in the effort to prevent initiation occurred secondary to the 

absence of a societal consensus and concern rather than an 

absence of knowledge or effective programs. 

The recognition that efforts directed at educating the 

individual smoker and treating the individual to change 

smoking behavior had limited impact has led to an appreciation of the role of environmental influences in changing 

smoking behavior. Examples of more environment-related 

strategies that are believed to have had substantial impact on 

tobacco use include the nonsmokers’ rights movement, which 

is changing the image of the smoker and restricting the number of locations where smoking is permitted, and the increase 

in taxes on cigarettes, which is creating a financial disincentive 

to smoke. These approaches reflect a growing understanding of 

environmental influences on the smoker, but even more important, they acknowledge the necessity of approaching the 

control of tobacco use through multiple channels and multiple 

programs. We now recognize that changes in the community’s 

perception of smoking risks influence the adoption of school 

curricula and their effectiveness. By bringing all of the elements of society to bear on the problem, we hope to reduce 

initiation of smoking, provide persistent and inescapable messages to the smoker to quit, and create an environment where 

the smoker who is trying to quit has a better chance of success. 

Six major subsystems, or sectors, are important in a comprehensive approach to smoking control: (1)the political 

sector, in which laws and policies are made; (2) the economic 

sector, which includes general taxation, workplace, business, 

and insurance policies concerning smoking control; (3) the 

educational sector, in which youth are educated about tobacco 

use; (4) the communication sector, through which information 

is disseminated to the general public; (5) the health care sector, 

in which health professionals play a crucial role in smoking 

control; and (6)the health voluntary sector, which provides 

many of the resources and coordination efforts directed to 

control of tobacco use. 

Any system contains a number of established structures 

that can be mobilized to address smoking control; however, 

each structure must be examined for what the subsystem itself 

can do, for the opportunities it provides for multiple activities 

related to smoking control, and for opportunities for synergism 

with other sectors. In the following sections, the six subsystems named above are reviewed in this light. 

52 
Smoking and Tobacco Control Monograph No. 1 

ThePolitical 

Sector 

The political sector is viewed as the major authority in determining what behavior is considered normative and what is 

deviant. This sector is especially important in defining ambiguous norms, because it is often the final arbiter in the 

interpretation of societal norms. In addition, societal norms 

are frequently codified into laws and/or policies; the political 

sector provides the mechanisms for such codification. 

The political sector has already contributed enormously to 

tobacco restrictions. At the Federal level, tobacco use restrictions have been placed on transportation and in Federal Government workplaces (US DHHS, 1989). Through a number of 

initiatives, more than 40 states and the District of Columbia 

now have laws restricting smoking in at least one public place 

(US DHHS, 1989). Some states have comprehensive restrictions, and there is a trend toward increasing restrictiveness in 

such legislation. Local jurisdictions are rapidly taking the lead 

in tobacco use restrictions; close to 400 cities and counties have 

enacted smoking control ordinances (Pertschuk and Shopland, 

1989). 

Diverse groups that have some interest in smoking control 

have banded together, an increasingly common tactic, to 

present a united front to legislatures. Recruiting support from 

their various constituencies, such coalitions have been influential in convincing state legislators to increase cigarette taxes 

(Pertschuk and Shopland, 1989), provide smoke-free schools 

(Minnesota Department of Health, 1984; New Mexico Health 

and Environment Department, 1988; Pennsylvania Department of Health, 1986), and restrict sales of tobacco products to 

minors (Minnesota Department of Health, 1984; Pennsylvania 

Department of Health, 1986). 

Enacting legislation at the local rather than the state level 

has been hailed as a method for controlling tobacco use while 

minimizing the influence of the tobacco lobby. This method 

has resulted in a number of local initiatives that range from 

control of minors’ access to tobacco to mandated nonsmoking 

restaurant seating (Pertschuk and Shopland, 1989). 

Interventions within the political sector are appealing for 

many reasons. First, smoking control activities may be implemented at multiple levels-by Federal, state, and local governments. Second, the political sector is the most likely sector to 

reach all members of the smoking population. Third, there is a 

high potential for synergy between the political sector andother subsystems within our society; legislative actions may be 

accompanied by economic resources for tobacco control 

activities, media attention, or cessation opportunities. A good 

example of how synergy can occur is found in the response of 

Iowans to a smoking ban on commercial airlines: A local group 

53 
The Economic 

Sector 

Taxation 

Workplaces 

National Cancer Institute 

produced “quitters’ survival kits,” distributed them to smokers 

at the municipal airport on the effective date of the ban, and 

garnered a great deal of local publicity in the process. 

In terms of the relative influence and importance of smoking control activities, there are three major aspects of the 

economic sector to review: taxation of individuals, workplace 

policies on smoking, and practices in other economic institutions (e+, businesses). 

The taxation of tobacco products has a predictable effect 

on tobacco use (Harris, 1982; Lewit and Coate, 1982). Studies 

have examined the decrease in smoking prevalence that accompanies a tax increase on tobacco products (Harris, 1982; 

Lewit and Coate, 1982; Warner, 1986); this type of decrease 

was particularly pronounced among adolescent and young 

smokers (Warner, 1986). In addition to a Federal cigarette tax, 

all states now have their own cigarette taxes (US DHHS, 1989), 

and some municipalities and counties have added taxes on 

tobacco products as well (Pertschuk and Shopland, 1989; US 

DHHS, 1989). 

A few state governments have allocated a portion of the 

tobacco taxes to general health-promotion activities, and a few 

have dedicated some portion of the taxes to antitobacco activities (US DHHS, 1989). Early in 1989, California imposed a 

large additional tax on cigarettes (25 cents per pack), with a 

portion of the funds going to antitobacco research and activities (US DHHS, 1989). This strategy has a direct economic 

effect on smoking behavior and provides the resources to 

support a comprehensive, long-term intervention designed to 

alter tobacco use. Municipal and county government units 

could also examine taxation as a method of increasing resources for smoking control. 

Taxation is an especially appealing form of smoking 

control intervention, because only tobacco users bear the costs. 

When accompanied by prevention activities in other channels, 

taxation appears to be especially effective in preventing young 

people from beginning to smoke. Its synergistic potential is 

enormous, because taxation can help fund smoking control 

activities in multiple intervention channels. 

Working adults spend nearly one-half of their waking 

hours on the job. They are strongly affected by the norms of 

the environment in which they work, and managers of 

workplaces are rapidly adopting policies to restrict tobacco use 

(Bureau of National Affairs, 1986; US DHHS, 1987). 

Although restrictive policies are a key factor of worksite 

involvement in smoking control, there are other smoking 

cessation opportunities in the work setting as well. Worksites 

54 
Smoking and Tobacco Control Monograph No. 1 

Other Economic 

Influences 

have engaged in internal and external competitions, as well as 

incentive programs, to encourage employees to stop smoking 

(Cummings et al., 1988; Klesges et al., 1986; Rosen and Lichtenstein, 1977). The basic philosophy behind such an approach is that the workplace can provide a supportive environment for smoking cessation; furthermore, incentives for smokers to achieve and maintain cessation can add to the environmental support and lead even more smokers to try quitting. 

Employers have collaborated with other groups to offer 

smoking cessation programs at the worksite, both on and off 

company time (Klesges et al., 1987; Omenn et al., 1988; 

Schilling et al., 1985). Synergy is assumed to occur when a 

program is offered in a setting where coworkers are also attempting cessation and providing support for fellow quitters. 

Results of such programs are generally comparable with those 

of clinic-based programs, but costs are considerably lower. 

Some employers have institutionalized regular smoking cessation programs at the worksite, in which employees are free to 

enroll at their own convenience. Other programs go even 

further and encourage the smoker’s spouse and/or significant 

others to participate. 

Typically, the American Cancer Society’s annual Great 

American Smokeout has a segment designed for workplaces, 

and employers can use that opportunity to encourage smokers 

to quit for a day by organizing smoking cessation activities for 

the day. Similarly, the American Lung Association sponsors an 

annual Non-Dependence Day and produces many materials 

and suggestions for worksite participation in nonsmoking 

activities. The American Heart Association promotes a SweetHeart Day in February, with smoking cessation opportunities, 

advice, and materials incorporated in the day’s activities. 

Workplaces afford multiple opportunities to promote 

smoking cessation, and a restrictive smoking policy can establish not smoking as the appropriate behavior in a particular 

workplace. Smokers may be encouraged to attempt cessation 

as regular smoking control events are incorporated into the 

work environment. Incentives and competitions can increase 

smokers’ motivation to try cessation. Activities that build on 

national or local events can reinforce the messages that a nonsmoking environment is desirable and that the employer 

supports such an environment. As a group, these smoking 

control activities in the workplace can have a powerful influence on smokers. 

Restaurants. A number of states have laws that require restaurants to offer nonsmoking sections (Hanauer et al., 1986; US 

DHHS,1986). Public opinion surveys support the value of such 

restrictions. In one poll, 85 to 91 percent of restaurant-goers 

55 
National Cancer Institute 

The Education 

Sector 

expressed a desire for restrictions on smoking in restaurants 

(Gallup, 1983); in another, 39 percent of people surveyed said 

they would not return to a restaurant that did not offer a nosmoking section (Gallup, 1985). 

Insurance. The insurance sector offers an economic incentive for smoking cessation and prevention that cuts across both 

employment and other business sites. Reductions in insurance 

premiums for nonsmokers and smoke-free workplaces offer individuals and organizations an added stimulus for smoking 

control activities. Although insurance premium reductions are 

not as influential as other sectors might be, they can add to the 

economic benefits that accrue from avoidance of tobacco use. 

The insurance industry has reacted to the demonstration 

of the disease risks associated with smoking by discounting life 

insurance premiums for nonsmokers who purchased their own 

policies (Cowell, 1985). The vast majority of states now allow 

differential pricing of life insurance premiums according to 

smoking status (National Association of Insurance Commissioners, 1987a). Movement in other forms of insurance incentives has been slower. Health insurance providers have had difficulties in offering reduced premiums for nonsmokers because 

(1)the vast majority of health insurance policies are written for 

groups where smoking prevalence is difficult to determine; 

(2)actuarial data that support reduced health insurance premiums for nonsmokers are scarce; and (3) Federal regulations 

make it difficult for some health insurance plans (e.g., health 

maintenance organizations) to set premiums based on smoking 

status (US DHHS, 1989). Property and casualty insurance has 

fared somewhat better-homeowner policies are routinely 

offered at reduced premiums to nonsmokers. A few companies 

also provide nonsmoker discounts for automobile policies 

(National Association of Insurance Commissioners, 1987b). 

To the extent that premium differentials by smoking status 

become institutionalized within society, and depending on the 

amount that insurance carriers reimburse for cessation treatment, a number of synergistic effects may result: (1)worksites 

and businesses could offer encouragement for nonsmoking; 

(2) worksites and businesses could make smoking cessation assistance available; and (3) the political sector could place economic sanctions on smokers. 

The education sector can have an influence on children 

and their possible initiation of tobacco use. In the educational 

setting, there are opportunities to expose children to antitobacco information and provide them with nonsmoking role 

models. Educational interventions have focused on incorporation of tobacco information in school curricula; however, 

56 
Smoking and Tobacco Control Monograph No. 1 

when such programs are provided without a companion 

community intervention, their effects appear to be small. Current research is examining ways to increase the influence of the 

educational programs by linking them with community and 

parent-related activities. 

Educators can have an influence on children in ways other 

than the formal school curriculum. Educational facilities that 

are smoke-free for employees as well as for children can provide 

good models for nonsmoking environments. Students may 

participate in antitobacco activities through the schools; for 

example, many schools collaborate with advocacy groups to 

sponsor poster contests for children, sports activities with 

antitobacco sponsors, and other antismoking activities in the 

community. 

Curricula that incorporate annual segments on tobacco 

use, a smoke-free environment, and annual smoking control 

activities in the community could be instrumental in developing the norm of not using tobacco. Activities in the educational sector can be synergistic with other sectors; for example, 

students may be enlisted to participate in a supervised “sting,” 

where minors’ success rates at purchasing tobacco products are 

documented, which can raise community awareness about the 

accessibility of tobacco products to minors, thereby melding 

the political and educational sectors. 

The Communica- The media play a pivotal role in smoking control activities. 

tion Sector Mass media provide information to the public on facts and 

issues related to smoking, and they also influence public perceptions of appropriate behavior by portraying certain people 

either engaging in or abstaining from a particular behavior. 

The media have presented images and taken direct action 

against smoking. Media information dissemination has been 

designed to stimulate help-seeking behavior by smokers 

(Danaher et al., 1984; McGuire, 1984). Public service announcements have been used to encourage people to call a 

hotline for information (Cummings et al., 1986) and to recruit 

smokers into treatment programs (Jason et al., 1988; 

Mogielnicki et al., 1986). 

Electronic media campaigns designed to assist people in 

achieving smoking cessation have been somewhat successful 

(Flay, 1987b). The American Lung Association “Freedom From 

Smoking in 20 Days” program has been used in many mass 

media markets, and the results appear quite favorable (Flay, 

1987b). Print programs for smoking cessation have been 

successful as well (Cummings et al., 1987). 

There is little doubt that the media can keep tobacco news 

and messages in the public eye; however, there is evidence that 

the media are somewhat constrained by the influence of the 

57 
TheHealth 

Professional 

Sector 

National Cancer Institute 

tobacco companies. Media that carry tobacco advertisements 

give differential attention to tobacco issues compared with 

those that do not carry such advertisements (Warner, 1985; 

Whelan et al., 1981). In spite of these constraints, the media 

can be used for creative smoking control activities. 

The communication sector is the conduit by which other 

sectors may publicize and disseminate their smoking control 

information and activities. The communication sector can be 

synergistic with all other sectors in four ways: (1)It can reinforce norms that promote smoking control by presenting 

positive images with respect to nonsmoking behavior and 

refusing to portray smoking as glamorous or desirable; (2) it 

can raise the public’s awareness of smoking as an important 

issue; (3) it can provide direct information to the public about 

tobacco use; and (4) it can provide direct services in recruiting 

people into smoking cessation activities. 

As a group, health professionals are an extremely influential force for reaching smokers. The vast majority of smokers 

see a physician each year (Ockene, 1987), providing an excellent opportunity for physicians to advise and counsel smokers 

to abandon their habit. Health professionals also can have an 

influential role in national policymaking and in promoting 

societal norms related to healthy living. 

Increasingly, health professional associations are adopting 

an assertive stance with respect to controlling tobacco use. The 

American Medical Association has recognized smoking as a 

“serious health problem” since 1964 (Lundberg, 1985) and has 

advocated education about smoking since 1969 (Rosenberg, 

1983). As early as 1964, the American Dental Association 

urged its members to educate patients about tobacco use, and it 

recently hosted its first national dental symposium on smoking 

cessation (McCann, 1989). The American Pharmaceutical 

Association has recommended that pharmacies not sell tobacco 

products (Smith and Fincham, 1989). Other health care 

provider groups, including nurses, have not taken official 

antismoking stands but are beginning to address the issue. 

Counseling against tobacco use is an appropriate topic for physicians’ and dentists’ continuing education, and many medical 

and dental schools are now incorporating such training into 

their disease prevention curricula. 

Health professionals’ advice about ceasing tobacco use is 

accompanied by inherent opportunities for expanding the 

effect of a single message about cessation. An office system 

that identifies smokers will help ensure that smoking patients 

receive repeated messages about smoking cessation and assistance with quitting. Smoke-free health care environments will 

support that goal by providing positive sanctions for a norm 

that health professionals are advancing. 

58 
Smoking and Tobacco Control MonographNo. 1 

The Health 

, Voluntaries’ 

Sector 

In addition to multiple opportunities for intervention, 

health professionals’ activities can lead to synergy with other 

intervention channels. For example, physicians have participated in the cancer society’s Great American Smokeout by 

organizing activities, staffing information booths, and prescribing nicotine replacement therapy for their smoking patients. 

Some physician groups, such as Doctors Ought to Care, have 

participated in many visible antitobacco events. There is an 

increasing awareness of the importance of joint activities with 

other health professional groups in smoking control activities. 

Just as physician input can be synergistic with other channels of smoking control activity, other sectors can be synergistic 

with physician efforts. The development of standards for physician management of smoking patients in the outpatient care 

setting and the implementation of these standards through the 

quality assurance auditing process are examples of how governmental and regulatory agencies can influence physician motivation and behavior. Physicians have an important role in establishing societal norms, particularly with respect to health issues, 

but societal norms and expectations are also important determinants of physician behavior. For example, the majority-about 

two-thirds-of prescriptions for nicotine gum as a smoking cessation aid are written at the patient’s request rather than on the 

physician’s initiative (US DHHS, 1989). 

Three national voluntary groups, the American Cancer 

Society, the American Heart Association, and the American Lung 

Association, have a rich history of smoking control efforts. In 

addition to these three groups, a number of other voluntaries, 

such as Americans for Nonsmokers’ Rights and Fresh Air for 

Nonsmokers, emphasize smoking control activities in their 

mandates. These organizations are influential in that their staffs 

and volunteers form networks that extend to almost all geographic sections of the United States. 

The cancer society, heart association, and lung association 

have a variety of events and activities that support tobacco 

control. Each of the groups has a major annual event that 

emphasizes nonsmoking. The American Cancer Society sponsors 

the Great American Smokeout in November; the American Heart 

Association promotes SweetHeart Day in February; and the 

American Lung Associatidn coordinates activities around NonDependence Day in July. The voluntaries have also produced 

various smoking cessation materials and free or low-cost programs for smokers who are trying to quit. Special programs have 

been developed for some targeted populations, such as lowincome pregnant women-the cancer society’s “Special Delivery” and lung association’s “Freedom from Smoking for You and 

Your Baby.” The voluntary groups also offer self-help programs. 

59 
CONCLUSIONS 

National Cancer Institute 

The strength of the health voluntaries lies in their networks of volunteers throughout the country, and antitobacco 

activities that build on that strength are likely to be successful. 

Door-to-door fundraising campaigns also serve as public 

education opportunities. Collaboration with other sectors, 

such as smoking cessation media campaigns, may be successful 

(Flay, 1987b). Multiple opportunities for smokers to attempt 

cessation are available, because the voluntaries provide ongoing cessation services and resources. Public information 

campaigns detailing the available resources will help ensure 

that smokers are aware of the assistance that is available in any 

geographic location. 

In terms of synergism, voluntaries may be considered the 

resource centers of diverse cessation activities and events in the 

community. To the extent that information on smoking 

control activities, on smoking cessation opportunities and 

materials, and on special communitywide events is widely 

available and publicized, this sector helps to coordinate all 

sectors of the community in promoting smoking control 

efforts. 

Smoking control strategies have evolved and expanded 

during the last 40 years as our understanding of smoking 

behavior and its risks has developed. 

Attempts to educate smokers and treat them individually 

have given way to more comprehensive efforts to treat 

both the individual smoker and the environment within 

which smoking takes place. 

Multiple channels and approaches to all sectors of the 

social environment characterize the state of the art in 

comprehensive control of tobacco use. This approach is 

used because different channels may reach different 

groups of smokers and because the synergism of multiple 

inputs to the smoker may create an effect greater than 

the sum of the effects of the individual channels. 

60 
Smoking and Tobacco Control Monograph No. 1 

REFERENCES Beaver, C., Brown, R.A., Lichtenstein, E. Effects of monitored nicotine fading and anxiety management training on 

smoking reduction. Addictive Behaviors 6: 301-305, 1981. 

Best, J.A., Bloch, M. Compliance in the control of cigarette 

smoking. In: Compliance in Health Care, R.E. Haynes, D.W. 

Taylor, and D.L. Sackett (Editors). Baltimore: Johns Hopkins 

University Press, 1979, pp. 202-222, 488-497. 

Best, J.A., Owen, L.E., Trentadue, B.L. Comparison of 

satiation and rapid smoking in self-managed smoking 

cessation. Addictive Behaviors 3: 71-78, 1978. 

Brown, R.A., Lichtenstein, E. Effects of a cognitive-behavioral relapse prevention program for smokers. Paper presented 

at the 88th Annual Convention of the American Psychological 

Association, Montreal, 1980. 

Bureau of National Affairs. Where There’s Smoke: Problems 

and Policies Concerning Smoking in the Workplace. Washington, 

DC: Bureau of National Affairs, 1986. 

Colletti, G., Kopel, S.A. Maintaining changed behavior: 

An investigation of three maintenance strategies and the 

relationship of self-attribution to the long-term reduction of 

cigarette smoking. Journal of Consulting and Clinical Psychology 

47: 614-617, 1979. 

Condiotte, M.M., Lichtenstein, E. Self-efficacy and relapse 

in smoking cessation programs. Journal of Consulting and 

Clinical Psychology 49: 648-658, 1981. 

Consumer Reports. Cigarettes, the industry and its advertising: How harmful are they? Consumer Reports 18 (February): 

58-74, 1953. 

Consumer Reports. Cigarette smoking and lung cancer. 

Consumer Reports 19 (February):54-92, 1954. 

Consumer Reports. Cigarettes. Consumer Reports 20 (February): 56-73, 1955. 

Cowell, M.J. An insurance company perspective on 

smoking. New York State Journal of Medicine 85: 307-309, 1985. 

Cummings, K.M., Emont, S.L., Jaen, C., Sciandra, R., Jacobson, D. Experience With a Stop Smoking Hotline. Roswell Park 

Memorial Institute, Department of Cancer Control and Epidemiology, Buffalo, NY,1986. 

Cummings, K.M., Hellman, R., Emont, S.L. Correlates of 

participation in a worksite stop-smoking contest. Journal of Behavioral Medicine 2: 267-277, 1988. 

61 
National Cancer Institute 

Cummings, K.M., Sciandra, R., Markello, S. Impact of a 

newspaper mediated quit smoking program. AmericanJournal 

ofPublicHealth 77(11): 1452-1453, 1987. 

Danaher, B.G.Research on rapid smoking: Interim 

summary and recommendations. Addictive Behaviors 2: 15 1-

166,1977. 

Danaher, B.G., Berkanovic, E., Gerber, B. Mass media 

based health behavior change: Televised smoking cessation 

program. Addictive Behaviors 9: 245-253, 1984. 

Danaher, B.G., Lichtenstein, E. Becoming An Ex-Smoker. 

Englewood Cliffs, NJ: Prentice-Hall, 19 78. 

DiClemente, C.C. Self-efficacy and smoking cessation 

maintenance: A preliminary report. Cognitive Therapy and Research 5:175-187, 1981. 

Doll, R., Hill, A.B. Smoking and carcinoma of the lung: 

Preliminary report. British Medical Journal 2: 739-748, 1950. 

Doll, R., Hill, A.B. The mortality of doctors in relation to 

their smoking habits: A preliminary report. British Medical 

Journal 1: 1451-1455, 1954. 

Doll, R., Hill, A.B. Lung cancer and other causes of death 

in relation to smoking: A second report on the mortality of 

British doctors. British Medical Journal 2: 1071-1081, 1956. 

Ejrup, B., Wikander, P.A. Fortsatta forsoktill awanjing 

fran tobak medelst injektions behandling. Svenska Iakartidn 56: 

1975-1986,1959. 

Elliot, R., Tighe, T. Breaking the cigarette habit: Effects of 

a technique involving threatened loss of money. Psychological 

Record 18: 503-513, 1968. 

Fagerstrom, K.O. A comparison of psychological and pharmacological approaches in smoking cessation. Journal of 

Behavioral Medicine 5: 343-352, 1982. 

Ferno, 0.Nicotine chewing gum as an aid in smoking 

cessation. World Smoking and Health 5 (Spring): 24-29, 1980. 

Ferno, O.,Lichtneckert, S., Lundgren, C. A substitute for 

tobacco smoking. Psychopharmacologia 31: 201-204, 1973. 

Flay, B.R. Selling the Smokeless Society: 56 Evaluated Mass 

Media Programs and Campaigns Worldwide. Washington, DC: 

American Public Health Association, 1987a. 

Flay, B.R. Mass media and smoking cessation: A critical 

review. American Journal of Public Health 77(2): 153-160, 1987b. 

62 
Smoking and Tobacco Control Monograph No. 1 

Food and Drug Administration. Smoking deterrent drug 

products for over-the-counter human use: Tentative final 

monograph. Federal Register 47 (January 5): 490-500, 1982. 

Food and Drug Administration. Smoking deterrent drug 

products for over-the-counter human use: Tentative final 

monograph. Federal Register 50 (July 3): 27552-27557, 1985. 

Fortmann, S.P., Killen, J.D., Telch, M.J., Newman, B. 

Minimal contact treatment for smoking cessation. A placebo 

controlled trial of nicotine polacrilex and self-directed relapse 

prevention: Initial results of the Stanford Stop Smoking 

Project. Journal of the American Medical Association 260: 1575- 

1580,1988. 

Foxx, R.M., Brown, R.A. Nicotine fading and self-monitoring for cigarette abstinence or controlled smoking. Journal of 

Applied Behavior Analysis 12: 111-125, 1979. 

Gallup Organization. Monthly Report on Eating Out. Princeton, NJ: Gallup Organization, March 1985. 

Gallup Organization. Survey of Attitudes Toward Smoking: 

American Lung Association Survey. Princeton, NJ: Gallup Organization, April 1983. 

Gelb, B.D. Preventive medicine and employee 

productivity. Harvard Business Review 63: 12, 1985. 

Glasgow, R.E. Smoking. In: Self-Management of Chronic 

Disease and Handbook of Clinical Interventions and Research, 

K. Holroyd and T. Creer (Editors). Orlando, FL: Academic 

Press, 1986, pp. 99-126. 

Glasgow, R.E., Rosen, G.M. Behavioral bibliotherapy: A 

review of self-help behavior therapy manuals. Psychological

Bulletin 85: 1-23, 1978. 

Glasgow, R.E., Schafer, L., O’Neill, H.K. Self-help books 

and amount of therapist contact in smoking cessation 

programs. Journal of Consulting and Clinical Psychology 49: 659- 

667,1981. 

Glassman, A.H., Stetner, F., Walsh, T., Raizman, P.S., Fleiss, 

J.L., Cooper, T.B., Covey, L.S. Heavy smokers, smoking cessation, and clonidine: Results of a double-blind, randomized 

trial. Journal of the American Medical Association 259: 2863- 

2866,1988. 

Glynn, T.J. Relative effectiveness of physician-initiated 

smoking cessation programs. Cancer Bulletin 40: 359-364, 1988. 

Glynn, T.J., Manley, M.W. How To Help Your Patients Stop 

Smoking: A National Cancer Institute Manual for Physicians. U.S. 

Department of Health and Human Services, Public Health 

63 
National Cancer Institute 

Service, National Institutes of Health, National Cancer Institute. NIH Publication No. 90-3064, 1989. 

Hall, S.M. Self-management and therapeutic maintenance: 

Theory and research. In: Improving the Long-Term Effects of 

Psychotherapy, P. Karoly and J. Steffan (Editors). New York: 

Gardner Press, 1980,pp. 263-300. 

Hall, S.M., Hall, R.G. Treatment of cigarette smoking. In: 

Applications in Behavioral Medicine and Health Psychology: A 

Clinician’s Book, J.R. Blumenthal and D. McKee (Editors). Sarasota, FL: Professional Resource Exchange, 1985. 

Hall, S.M., Rugg, D., Tunstall, C., Jones, R. Preventing 

relapse to cigarette smoking by behavioral skill training. Journal of Consulting and Clinical Psychology 52: 372-382, 1984. 

Hall, S.M., Tunstall, C., Ginsberg, D., Benowitz, N.L., 

Jones, R.T. Nicotine gum and behavioral treatment in smoking 

cessation. Journal of Consulting and Clinical Psychology 55:603-

606,1987. 

Hamilton, J.L. The effect of cigarette advertising bans on 

cigarette consumption. In: Proceedings of the Third World Conference on Smoking and Health. Volume II. Health Consequences, 

Education, Cessation Activities, and Social Action, J. Steinfeld, W. 

Griffiths, K. Ball, and R.M. Taylor (Editors). U.S. Department of 

Health, Education, and Welfare; National Institutes of Health; 

National Cancer Institute. DHEW Publication No. (NIH) 77-

1413, 1977, pp. 829-850. 

Hammond, E.C., Horn, D. The relationship between 

human smoking habits and death rates. Journal ofthe American 

Medical Association 155: 1316-1328, 1954. 

Hammond, E.C., Horn, D. Smoking and death ratesreport on forty-four months of follow-up of 187,783men. I. 

Total mortality. Journal of the American Medical Association 166: 

1159-1172,1958. 

Hammond, E.C., Horn, D. Smoking and death ratesreport on forty-four months of follow-up of 187,783men. 11. 

Death rates by cause. Journal of the American Medical Association 

166: 1294-1308, 1958. 

Hanauer, P., Barr, G., Glantz, S.A. Legislative Approaches to 

a Smoke-Free Society. Berkeley, CA: Americans for Nonsmokers’ 

Rights Foundation, 1986. 

Harris, J.E. Increasing the federal excise tax on cigarettes. 

Journal ofHealth Economics 1: 117-120, 1982. 

Henningfield, J.E., Miyasato, K., Johnson, R.E., Jasinski, 

D.J. Rapid physiologic effects of nicotine in humans and 

64 
Smoking and Tobacco Control Monograph No. 1 

selective blockade of behavioral effects of mecamylamine. In: 

Problems of Drug Dependence, 1982, L.S. Harris (Editor). U.S. 

Department of Health and Human Services; Public Health 

Service; Alcohol, Drug Abuse, and Mental Health Administration;National Institute on Drug Abuse, 1982, pp. 259-265 

(NIDA Research Monograph 43). 

Horn, D. Smoker’s Self-Testing Kit. U.S. Department of 

Health, Education, and Welfare; Public Health Service; National 

Clearinghouse for Smoking and Health. DHEW Publication 

NO. (HSM) 72-7506,1972. 

Horn, D. Who is quitting and why? In: Progress in Smoking Cessation. Proceedings of International Conference on Smoking 

Cessation,J.L. Schwartz (Editor). New York: American Cancer 

Society, 1978, pp. 27-31. 

Jarvik, M.E., Glick, S.D., Nakamura, R.K. Inhibition of 

cigarette smoking by orally administered nicotine. Clinical 

Pharmacology and Therapeutics 11: 574-576, 1970. 

Jarvik, M.E., Gritz, E.R. Nicotine and tobacco. In:Psychopharmacology in the Practice of Medicine, M.E. Jarvik (Editor). 

New York: Appleton-Century-Crofts, 1977, pp. 493-498. 

Jarvis, M. Nasal nicotine solution: Its potential with 

smoking cessation and as a research tool. In: Pharmacologic

Treatment of Tobacco Dependence, J.K. Ockene (Editor). Cambridge, MA: Institute for the Study of Smoking Behavior and 

Policy, Harvard University, 1986, pp. 167-173. 

Jason, L.A., Tait, E., Goodman, D., Buckenberger, L., 

Gruder, C.L. Effects of a televised smoking cessation intervention among low-income and minority smokers. American 

Journal of Community Psychology 16(6): 863-876, 1988. 

Killen, J.D., Maccoby, N., Taylor, C.B. Nicotine gum and 

self-regulation training in smoking relapse prevention. Behavior Therapy 15: 234-238, 1984. 

Klesges, R.C., Cigrang, J., Glasgow, R.E. Worksite smoking 

modification programs: A state-of-the-art review and directions 

for future research. Current Psychological Research Review 6: 26- 

56, 1987. 

Klesges, R.C., Vasey, M.W., Glasgow, R.E. A worksite 

smoking modification competition: Potential for public health 

impact. American Journal ofPublic Health 76: 198-200, 1986. 

Lando, H.A. Successful treatment of smokers with abroadspectrum behavioral approach. Journal of Consulting and 

Clinical Psychology 44: 361-366, 1977. 

65 
National Cancer Institute 

Lando, H.A. Behavioral treatments in the modification of 

smoking. In: Clinical Behavior Therapy and Behavior Modification, R.J. Daitzman (Editor). New York: Garland, 1981. 

Lando, H.A., McGovern, P.G. Nicotine fading as a nonaversive alternative in a broad-spectrum treatment for eliminating smoking. Addictive Behaviors 10:153-161, 1985. 

Lando, H.A., McGovern, P.G., Barrios, F.X.,Etringer, B.D. 

Comparative evaluation of American Cancer Society and 

American Lung Association smoking cessation clinics. American Journal of Public Health 80: 554-559, 1990. 

Levin, M.L., Goldstein, H., Gerhardt, P.R. Cancer and 

tobacco smoking: A preliminary report. Journal ofthe American 

Medical Association 143: 336-338, 1950. 

Lewit, E.M., Coate, D. The potential for using excise taxes 

to reduce smoking. Journal ofHeaIth Economics l(2): 121-145, 

1982. 

Lichtenstein, E. Social learning, smoking and substance 

abuse. In: Behavioral Analysis and Treatment of Substance Abuse, 

N.A. Krasnegor (Editor). U.S. Department of Health, Education, 

and Welfare; Public Health Service; Alcohol, Drug Abuse, and 

Mental Health Administration; National Institute on Drug 

Abuse. DHEW Publication No. (ADM) 79-839, 1979, pp. 114-

127 (NIDA Research Monograph 25). 

Lichtenstein, E., Brown, R.A. Current trends in the modification of cigarette dependence. In: International Handbook of 

Behavior Modification and Therapy, A.S. Bellak, M. Hersen, and 

A.E. Kazdin (Editors). New York: Plenum Press, 1983,pp. 575-

611. 

Lieb, C.W. Can the poisons in cigarettes be avoided? 

Reader’s Digest (December):45-47, 1953. 

Lublin, I., Joslyn, I. Aversive conditioning of cigarette addiction. Paper presented at the Annual Convention of the 

American Psychological Association, San Francisco, 1968. 

Lundberg, G.D. In the AMA, policy follows science: A 

case history of tobacco (Editorial). Journal ofthe American 

Medical Association 253: 3001-3003, 1985. 

Marlatt, G.A., Gordon, J.R. Determinants of relapse: Implications for the maintenance of behavior change. In: Behavioral Medicine: Changing Health Lifestyles, P.O. Davidson and 

S.M. Davidson (Editors). New York: Brunner/Mazel, 1980,pp. 

410-452. 

McCann, D. Tobacco use and oral health. Journal ofthe 

American Dental Association 118: 19-25, 1989. 

66 
Smoking and Tobacco Control Monograph No. 1 

McFall, R.M. Effects of self monitoring on normal smoking behavior. Iournal of Consulting and Clinical Psychology 35: 

135-142,1970. 

McFarland, J.W., Gimbel, H.W., Donald, W.A.J., Folkenberg, E.J. The five-day program to help individuals stop smoking: A preliminary report. Connecticut Medicine 28: 885-890, 

1964. 

McGuire, W.J. Public communication as a strategy for 

inducing health-promoting behavioral changes. Preventive 

Medicine 13: 299-319, 1984. 

Miller, L.M., Monahan, J. The facts behind the cigarette 

controversy. Reader’s Digest 65: 1-6, 1954. 

Minnesota Department of Health. The Minnesota Plan for 

Nonsmoking and Health: Report and Recommendations of the Technical Advisory Committee on Nonsmoking and Health. Minneapolis: Minnesota Department of Health, 1984. 

Mogielnicki, R.P., Neslin, S., Dulac, J., Balestra, D., Gillie, 

E., Corson, J. Tailored media can enhance the success of 

smoking cessation clinics. Journal of Behavioral Medicine 9: 

141-161,1986. 

National Association of Insurance Commissioners. NAIC 

model rule (regulation) permitting smokerhonsmoker mortality tables for use in determining minimum reserve liabilities 

and nonforfeiture benefits. Model Regulation Service 812.4-

812.7,January 1987a. 

National Association of Insurance Commissioners. Personal lines-Property and Casualty (C) Committee. NAIC 

Proceedings 19872: 769-771, 1987b. 

New Mexico Health and Environment Department. New 

Mexico Committee on the Public Health Impact of Smoking, Tobacco 

Free 1988 Plan. Santa Fe: New Mexico Health and Environment Department, 1988. 

Norr, R. Cancer by the carton. Reader’s Digest (December): 

7-8, 1952. 

Ockene, J.K. Physician-delivered interventions for smoking cessation: Strategies for increasing effectiveness. American 

Journal ofPreventive Medicine 16: 723-737, 1987. 

Omenn, G.S.,Thompson, B., Sexton, M., Hessol, N., 

Breitenstein, B., Curry, S., Michnick, M., Peterson, A. A randomized comparison of worksite-sponsored smoking cessation 

programs. American Journal of Preventive Medicine 4: 261 -267, 

1988. 

67 
National Cancer Institute 

Pechacek, T.F. Modification of smoking behavior. In: Behavioral Aspects of Smoking, N.A. Krasnegor (Editor). U.S. Department of Health, Education, and Welfare; Public Health 

Service; Alcohol, Drug Abuse, and Mental Health Administration;National Institute on Drug Abuse. DHEW Publication No. 

79-882, 1979, pp.127-188 (NIDA Research Monograph 26). 

Pechacek, T.F., McAlister, A.L. Strategies for the modification of smoking behavior: Treatment and prevention. In: 

Comprehensive Handbook of Behavioral Medicine (Volume 3), J.M. 

Ferguson and C.B. Taylor (Editors). Jamaica, NY: Spectrum 

Publications, 1980, pp. 257-298. 

Pennsylvania Department of Health. Pennsylvania Plan for 

Tobacco or Health: Pennsylvania Consensus Conference on Tobacco 

and Health Priorities. Harrisburg: Pennsylvania Department of 

Health, 1986. 

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. U.S. Department of Health and Human Services, Public 

Health Service, National Institutes of Health, National Cancer 

Institute. NIH Publication No. 90-479, 1989. 

Pomerleau, O.F., Adkins, D., Pertschuk, M. Predictors of 

outcome and recidivism in smoking cessation treatment. Addictive Behaviors 3: 65-70, 1978. 

Pomerleau, O.F., Pomerleau, C.S. Break the Smoking Habit: 

A Behavioral Program for Giving Up Cigarettes. Champaign, IL: 

Research Press, 1977. 

Pomerleau, C.S., Pomerleau, O.F., Majchrzak, M.J. Mecamylamine pre-treatment increases subsequent self-administration as indicated by changes in plasma nicotine level, Psychophamtacolo~91: 391-393,1987. 

Resnick, J.H. Effects of stimulus satiation on the overlearned maladaptive response of cigarette smoking. Journal of 

Consulting and Clinical Psychology 32: 501-505, 1968. 

Riis, R.W. How harmful are cigarettes? Reader’s Digest 

January: 1-11, 1950. 

Rose, J.E., Herskovik,J.E., Trilling, Y., Jarvik, M.E. 

Transdermal nicotine reduces cigarette craving and nicotine 

preference. Clinical Pharmacology and Therapeutics 38: 450-456, 

1985. 

Rosen, G.M., Lichtenstein, E. An employee incentive 

program to reduce cigarette smoking. Journal of Consulting and 

Clinical Psychology 45: 957, 1977. 

68 
Smoking and Tobacco Control Monograph No. 1 

Rosenberg, J. The AMA tackles smoking: “A strong stand.” 

New York StateJournal ofMedicine 83: 1363-1365, 1983. 

Ross, C.A. Smoking withdrawal research clinics. In: 

Studies, and Issues in Smoking Behavior, S.V. Zagona (Editor). 

Tucson: University of Arizona Press, 1967, pp. 111-113. 

Russell, M.A.H. Smoking addiction: Some implications for 

cessation. In: Progress in Smoking Cessation. Proceedings of the 

International Conference on Smoking Cessation, J.L. Schwartz 

(Editor). New York: American Cancer Society, 1987, pp. 206-

226. 

Russell, M.A.H., Jarvis, M.J., Sutherland, G., Feyerabend, C. 

Nicotine replacement in smoking cessation: Absorption of 

nicotine vapor from smoke-free cigarettes. journal of the American Medical Association 257: 3262-3265, 1987. 

Sachs, D.P.L. Cigarette smoking-health effects and 

cessation strategies. Clinics in Geriatric Medicine 2:33 7-362, 

1986. 

Schilling, R.F., Gilchrist, L.D., Schinke, S.P. Smoking in 

the workplace: Review of critical issues. Public Health Reports 

100: 473-479, 1985. 

Schneider, L., Klein, B., Murphy, K.M. Governmental 

regulation of cigarette health information. Journal ofLaw and 

Economics 24: 575-612, 1981. 

Schneider, N.G., Jarvik, M.E., Forsythe, A.B. Nicotine vs. 

placebo gum in the alleviation of withdrawal during smoking 

cessation. Addictive Behaviors 9: 149-156, 1984. 

Schrek, R., Baker, L.A., Ballard, G.P., Dolgoff, S. Tobacco 

smoking as an etiologic factor in disease. 1.Cancer. Cancer Research 10: 49-58, 1950. 

Schwartz,J.L. A critical review and evaluation of smoking 

control methods. Public Health Reports 84: 483-506, 1969. 

Schwartz,J.L. Smoking cures: Ways to kick an unhealthy 

habit. In: Research in Smoking Behavior, M.E. Jarvik, J.W. 

Cullen, E.R. Gritz, T. Vogt, and L.J. West (Editors). U.S. Department of Health, Education, and Welfare; Public Health Service; 

Alcohol, Drug Abuse, and Mental Health Administration; 

National Institute on Drug Abuse. DHEW Publication No. 

(ADM) 78-581, 1977, pp. 308-336 (NIDA Research Monograph 

17). 

Schwartz, J.L. Review and Evaluation of Smoking Cessation 

Methods: The United States and Canada, 1978-1985.U.S. Department of Health and Human Services, Public Health Service, 

National Institutes of Health, National Cancer Institute. NIH 

Publication No. 87-2940, 1987. 

69 
National Cancer Institute 

Schwartz,J.L., Dubitzky, M. Expressed willingness of 

smokers to try 10 smoking withdrawal methods. Public Health 

Reports 82: 855-861, 1967. 

Schwartz, J.L., Dubitzky, M. Requisites for success in 

smoking withdrawal. In: Smoking, Health, & Behavior, E.F. Borgatta and R.R. Evans (Editors). Chicago: Aldine Publishing, 

1968, pp. 231-247. 

Schwartz, J.L., Rider, G. Review and Evaluation of Smoking 

Control Methods: The United States and Canada, 1969-1977. US. 

Department of Health, Education, and Welfare; Public Health 

Service; Center for Disease Control, Bureau of Health Education. HEW Publication No. (CDC) 79-8369, 1978. 

Shewchuk, L.A., Dubren, R., Burton, D., Forman, M., Clark, 

R.R., Jaffin, A.R. Preliminary observations on an intervention 

program for heavy smokers. International Journal ofthe Addictions 12: 323-336,1977. 

Shiffman, S. Cognitive antecedents and sequelae of smoking relapse crises. Iournal ofApplied Social Psychology 14: 296- 

309,1984. 

Smith, M.C., Fincham, J.E. Role of Pharmacists in Smoking 

Cessation Counseling. University, MS: University of Mississippi, 

Department of Health Care Administration, 1989. 

Smoking Control Advocacy Resource Center. Summary of 

the Utica COMMITAlvin Ailey Protest. Washington, DC: The 

Advocacy Institute, Smoking Control Advocacy Resource 

Center, August 1989. 

Stitzer, M.L., Bigelow, C.E. Contingent reinforcement for 

reduced carbon monoxide levels in cigarette smokers. Addictive 

Behaviors 7: 403-412, 1982. 

Study Group on Smoking and Health. Smoking and 

health: Joint report of the Study Group on Smoking and 

Health. Science 125: 1129-1133, 1957. 

Suedfeld, P. Restricted environmental stimulation 

therapy (REST). In: Behavioral Health: A Handbook for Health 

Enhancement and Disease Prevention, J.D. Matarazzo, S.M. Herd, 

N.E. Miller, and S.W. Weiss (Editors). New York: John Wiley 

and Sons, 1984, pp. 755-764. 

Suedfeld, P., Best, A.J. Satiation and sensory deprivation 

combined in smoking therapy: Some case studies and unexpected side effects. International Journal ofthe Addictions 12: 

337-359, 1977. 

70 
Smoking and Tobacco Control Monograph No. 1 

Tennant, F.S., Tarver, A.L., Rawson, R.A. Clinical evaluation of mecamylamine for withdrawal from nicotine dependence. In: Problems of Dmg Dependence, 1983,S.J. Harris (Editor). U.S. Department of Health and Human Services; Public 

Health Service; Alcohol, Drug Abuse, and Mental Health Administration; National Institute on Drug Abuse, 1984,pp. 239-

246. Publication No. NTIS(PB)85-151553/AS(NIDA Research 

Monograph 49). 

Troyer, R.J., Markle, G.E. Cigarettes! The Battle Over Smoking. New Brunswick, NJ: Rutgers University Press, 1983. 

U.S. Department of Health and Human Services. No Smoking: A Decision Maker's Guide to Reducing Smoking at the 

Worksite. A Report to the Office of Disease Prevention and 

Health Promotion and Office on Smoking and Health, U.S. 

Department of Health and Human Services, Public Health 

Service, 1985. 

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

Health Consequences of Involuntary Smoking: A Report of the 

Surgeon General. U.S. Department of Health and Human 

Services, Public Health Service, Centers for Disease Control. 

DHHS Publication No. (CDC) 87-8398, 1986. 

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

Survey of Worksite Health Promotion Activities: A Summary. U.S. 

Department of Health and Human Services, Public Health 

Service, Office of Disease Prevention and Health Promotion, 

1987. 

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

Consequences of Smoking: Nicotine Addiction. A Report of the 

Surgeon General, 1988. U.S. Department of Health and Human 

Services, Public Health Service, Centers for Disease Control, 

Center for Health Promotion and Education, Office on Smoking and Health. DHHS Publication No. (CDC) 88-8406, 1988. 

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

the Health Consequences of Smoking: 25 Years of Progress. A 

Report of the Surgeon General. 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. DHHS Publication 

NO. (CDC) 89-8411,1989. 

U.S. Department of Health, Education, and Welfare. Smoking and Health: Report of the Advisory Committee to the Surgeon 

General of the Public Health Service. U.S. Department of Health, 

Education, and Welfare; Public Health Service; Center for 

Disease Control. PHS Publication No. 1103,1964. 

71 
National Cancer Institute 

U.S. Department of Health, Education, and Welfare. 

Smoker’s Self-Testing Kit. U.S. Department of Health, Education, 

and Welfare; Public Health Service; National Clearinghouse for 

Smoking and Health. PHS Publication No. 1904, 1969. 

U.S. Department of Health, Education, and Welfare. Forward Plan for Health FY 1978-82.U.S. Department of Health, 

Education, and Welfare; Public Health Service. Washington, 

DC: U.S. Government Printing Office, 1979. 

U.S. Department of Health, Education, and Welfare. Smoking and Health: A Report of the Surgeon General. U.S. Department 

of Health, Education, and Welfare; Public Health Service; Office 

of the Assistant Secretary for Health; Office on Smoking and 

Health. DHEW Publication No. (PHS) 79-50066, 1979. 

Warner, K.E. Cigarette smoking and media coverage of 

smoking and health. New England Journal ofMedicine 312: 384- 

380,1985. 

Warner, K.E. Clearing the airwaves: The cigarette ad ban 

revisited. Policy Analysis 5: 435-450, 1977. 

Warner, K.E. Smoking and health implications of a 

change in the Federal cigarette excise tax. Journal of the American Medical Association 255(8): 1028-1032, 1986. 

Whelan, E.M., Sheridan, M.J., Meister, K.A., Mosher, B.A. 

Analysis of coverage of tobacco hazards in women’s magazines. 

Journal ofpublic Health Policy 2: 28-35, 1981. 

Wilde, G.J.S. Behaviour therapy for addicted cigarette 

smokers. Behaviour Research and Therapy 2: 107-110,1964. 

Winett, R.A. Parameters of deposit contracts in the modification of smoking. Psychological Record 23: 49-60, 1973. 

Wynder, E.L., Graham, E.A. Tobacco smoking as a possible 

factor in bronchiogenic carcinoma: A study of six hundred and 

eighty-four proved cases. Journal ofthe American Medical Association 143: 329-336, 1950. 

72 
Chapter 3 

Smoking Prevalence and 

Lung Cancer Death Rates 

CONTENTS Introduction ............................................................................ 75 

Analysis of Smoking Behavior ................................................. 77 

Smoking Prevalence ................................................................ 80 

Lung Cancer Mortality ............................................................ 86 

Methodology.................................................................... 86 

Mortality Rates for Lung Cancer ...................................... 86 

Smoking Prevalence and Lung Cancer Mortality ............ 92 

Use ofBirth Cohort Smoking Behaviors 

To Predict Lung Cancer Death Rates .......................... 108 

A Discrete State Model of Health Intervention ..................... 109 

The Markov Assumption ................................................ 110 

Previous Forecast Methods ............................................. 111 

Building the Model ........................................................ 112 

Conclusions........................................................................... 122 

References .............................................................................. 125 

Appendix A. Data Points for Figures in Chapter 3...............127 

73 
BLANK PAGE 
Chapter 3 

Smoking Prevalence and 

Lung Cancer Death Rates 

INTRODUCTION The use of cigarettes, in contrast to other tobacco products, is a behavior that has developed relatively recently. 

Widespread use of cigarettes has been predominantly a 

20th century phenomenon, with per capita consumption of 

cigarettes rising from 54 in 1900 to a peak of 4,345 in 1963 and 

then declining (Shopland et al., 1990) (see Figure 1). [Note:

The data points used for plotting all figures in this chapter are 

listed in Appendix A.] 

Figure 1 

U.S. per capita cigarette consumption for adults, aged 18 and 

older (1900 to 1990) 

Ciaarettes Der Year 

Other chapters of this monograph address the social and 

environmental influences that have produced these changes in 

per capita consumption over time. This chapter describes the 

changes in smoking prevalence that occurred during this 

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National Cancer Institute 

century and links them to observed changes in lung cancer 

death rates. A model for predicting future lung cancer death 

rates is presented also. 

The prevalence of cigarette smoking is not spread uniformly across the U.S. population. There are marked differences in smoking prevalence across gender, racial, educational, 

and age groupings in the current population, and these differences have varied markedly across the first nine decades of this 

century. The risk of developing lung cancer is defined predominantly by past smoking exposure rather than by current 

smoking status. For these reasons, the data presented in this 

chapter are arranged by 10-year birth cohort. (A birth cohort is 

a group of individuals born during a specific span of calendar 

years.) 

By following the changes in smoking behavior and lung 

cancer occurrence in a cohort as it ages, one is able to construct 

an accurate picture of the cumulative smoking history of the 

cohort and compare it with the resultant lung cancer occurrence in the same cohort. The more traditional approach, 

presenting data from multiple cross-sectional surveys done in 

different calendar years by the age of the individual surveyed at 

the time of the survey, leads to a biased impression of the 

changes in smoking prevalence that occur with age and an 

underestimation of the past smoking behavior of the older segments of the current population. When age-specific rates from 

multiple cross-sectional studies are compared to one another, 

the implicit assumption is that attained age (rather than 

calendar year of birth) is the dominant determinant of the rate 

being measured. For smoking behavior, however, calendar year 

of birth has a major influence on the possibility that an individual will become a cigarette smoker and on the duration of 

that smoking behavior. The individuals who constitute a given 

age group in cross-sectional samples drawn many years apart 

will belong to different birth cohorts. To compare the crosssectional smoking prevalences at a given age without considering the peak prevalences of the birth cohorts that they represent distorts the true relationship between smoking behavior 

and age. 

The excess death rates in cigarette smokers compared to 

nonsmokers lead to a diminishing fraction of ever-smokers 

being measured in a birth cohort as the population ages. 

Current measures of current and former smokers in older age 

groups will then underestimate the true prevalence of smoking 

of the same birth cohort several decades earlier. Since past 

rather than current smoking behavior causes lung cancer, and 

since the bulk of the U.S. lung cancer deaths occur among 

those same older segments of the current population, an 

accurate description of their smoking behavior is essential to 

76 
Smoking and Tobacco Control Monograph No. 1 

ANALYSIS OF 

SMOKING 

BEHAVIOR 

the development of a model that relates smoking behavior to 

lung cancer death rates. 

This section characterizes smoking behavior in the United 

States between 1901 and 1987. Smoking prevalence is examined over time, by 10-year birth cohort, gender, and race. This 

information was produced from analyses of the National 

Health Interview Surveys (”IS) conducted in 1970, 1978, 

1979, 1980, and 1987. Because of its large sample size and 

high response rate (typically greater than 95 percent), the NHIS 

was used for estimates of smoking prevalence in the United 

States. The NHIS data sets used here are the only NHIS data 

sets available for computer analysis that include information 

regarding age of initiation and cessation of smoking-the two 

variables necessary to this analysis for constructing the past 

smoking behavior of a birth cohort from recent cross-sectional 

data. 

Similar analyses have been reported previously in the 

Surgeon General’s Reports (US DHHS, 1980 and 1985). The 

1980 report included an analysis of the 1978 NHIS, with 

prevalence estimates through 1978. The 1985 report included 

analysis of the 1978, 1979, and 1980 NHIS combined, and also 

reported prevalence through 1978. The current analyses 

update the previous analyses by providing estimates through 

1987 (an additional 9 years) and make use of the earlier 1970 

data, which are likely to provide more accurate estimates of 

smoking behavior prior to 1970. This greater accuracy may be 

most applicable to earlier birth cohorts (e.g., people born from 

1901 to 1910), which experienced significant mortality prior to 

1978 (see discussion below). In addition, of all the NHIS 

samples, the 1970 NHIS is the largest, with 116,466 cases 

overall, including smoking data for 76,675 of these cases. The 

total number of cases for the other surveys used for this analysis were as follows: 1978, 12,111; 1979, 26,271; 1980, 11,333; 

and 1987,22,043. 

The analyses reported here rely mainly on responses to 

three questions: “How old were you when you first started 

smoking cigarettes fairly regularly?”, “DOyou smoke cigarettes 

now?”, and “About how long has it been since you smoked 

cigarettes regularly?” The wording of these questions remained 

essentially identical across all surveys; however, the order of 

the questions and coding of responses may have resulted in 

slight differences in the categorization of smokers as regular 

versus occasional smokers. Occasional smokers typically are 

defined as those who volunteer that they never smoked cigarettes regularly, and thus they do not consistently report an age 

of onset and/or age of quitting. Because of the inconsistency of 

reporting, these respondents, when identifiable, were treated as 

never-smokersin these analyses. 

77 
National Cancer Institute 

Another difference among the'five NHIS data sets used 

here is the source of responses-that is, self or respondent 

proxy. Of those responding to the smoking questions, the 

proxy response rates among those over age 17 in the surveys 

are: 1970, 39.0 percent; 1978 to 1980, 0.5 percent; and 1987, 

22.2 percent. Proxy respondents typically are thought to 

report smoking status accurately but to underreport the number of cigarettes smoked per day and to be less knowledgeable 

about the age of onset and cessation of smoking (US DHHS, 

1990). 

Diagnostic analyses regarding the effects of using both 

proxy reports and self-reports in the 1970 NHIS demonstrate 

that estimates of age of initiation and age of cessation, by 

cohort and by cohort and gender, generally differ by less than 

1 percentage point when based on proxy versus self-reports. In 

most cases, proxy reports result in slightly higher ages of 

initiation and cessation. This suggests that proxy reporting 

does not substantially affect cohort trends in smoking over 

time as reported here. Use of only self-reports for estimates of 

smoking prevalence results in smoking rates for females that 

are generally less than 2 percentage points higher than those 

reported here for all respondents (self and proxy). Among 

males, for whom the proportion of proxy reports is considerably higher, the use of only self-reports results in smoking 

prevalences between 0 and 6.2 percentage points higher, 

depending on the cohort. While part of the discrepancy is 

likely attributable to underreporting of smoking behavior by 

proxy respondents, those who respond by proxy have been 

noted to be generally younger, employed, and never married or 

married (as distinguished from divorced, separated, or widowed), and to have higher incomes and fewer health problems 

(Crane and Marcus, 1986). These characteristics suggest that 

those responding by proxy may indeed have lower smoking 

rates; thus, part of the difference between self-reports and all 

reports may reflect real differences in smoking status. 

Because this analysis estimates smoking prevalence beginning in 1905, it relies on recall of smoking behavior many 

years before the surveys. In general, the data used are those 

collected closest to the year for which smoking prevalence is 

being estimated. Two assumptions guided this decision: First, 

recall of previous smoking behavior is likely to be better when 

the survey is conducted closer in time rather than further from 

the year being estimated; second, each cohort experiences 

mortality as time passes, with the earlier cohorts experiencing 

greater mortality. Using earlier data to estimate smoking 

behavior assures that more members of each cohort are available to provide a more accurate picture of the cohort's smoking 

behavior in years past. Since both current and former smokers 

78 
Smoking and Tobacco Control Monograph No. 1 

have higher age-specific mortality rates than nonsmokers 

overall, a birth cohort has a progressively lower percentage of 

smokers and former smokers and a higher percentage of neversmokers as the individuals in the cohort grow older. Therefore, 

measurements of smoking behavior made earlier in time for 

the oldest cohorts provide a more accurate picture of their 

smoking behaviors during the middle part of the century than 

do current measurements. 

In keeping with this, 1970 NHIS data were used for estimates of smoking prevalence for time points up to and including 1970; the 1978,1979, and 1980 NHIS data were combined 

for estimates of smoking prevalence in 1975; the 1979 and 

1980 NHIS data were combined for estimates of smoking 

prevalence in 1980 (with the assumption of no changes in 

smoking status in 1980 for those who responded in 1979); and 

the 1987 NHIS data were used for estimates of smoking prevalence in 1985 and 1987. There were two exceptions to this 

scheme. Because the 1951 to 1960 birth cohort includes 

members who were only 10 years of age in 1970 (and thus did 

not respond to the smoking questions), 1978 through 1980 

data were used for estimates of smoking for this cohort prior to 

and including 1970. Similarly, the 1987 data were used to 

provide estimates of smoking for all time points for the 1961 to 

1970 birth cohort. 

In the 1980 Surgeon General’s Report on smoking (US

DHHS,1980), there is an attempt to quantify the potential 

underestimation of smoking prevalence for earlier cohorts 

attributable to the differential mortality between smokers and 

nonsmokers. Applying the author’s line of reasoning to this 

case, the group for which the mortality bias would have the 

most effect is the 1901 to 1910 cohort, which was aged 60 to 

69 when surveyed in 1970. According to insurance life tables 

reported by Cowell and Hirst (1979), a male cigarette smoker at 

age 32 has an 80 percent chance of surviving to age 60, while a 

nonsmoker has a 93 percent chance. Data from the 1970 NHIS 

indicate that this cohort reached its peak smoking prevalence 

of 62 percent in 1940. Given the estimated mortality differences between smokers and nonsmokers, the actual smoking 

rate may have been as high as 66 percent. Thus, the estimated 

underreporting for this cohort is about 4percentage points. 

The underestimate would be less for younger cohorts. The 

estimated survival rates to age 60 for female smokers and 

nonsmokers are 91 percent and 93 percent, respectively (Hammond, 1966), which would result in a negligible underestimation (less than 1percentage point). These adjustments to the 

prevalence estimates assume that smokers remain continuous 

smokers and derive no survival advantage from cessation, 

which provides a worst-case estimate of bias. 

79 
SMOKING 

PREVALENCE 

National Cancer Institute 

As noted previously, the sample sizes of the data sets used 

for these analyses varied, so the confidence intervals for estimates vary. For most groups and time points reported, 95 percent confidence intervals are less than f 2 percentage points 

(assuming a simple random sample; i.e., not taking into account 

the complex sampling strategy of the NHIS). However, estimates for the years 1985 and 1987 used the 1987 NHIS and are 

based on considerably fewer respondents than other estimates. 

Confidence intervals for estimates in 1985 and 1987 are in the 

range off 2 to 4 percentage points for most groups. These generalizations hold for smoking estimates for all males, all females, 

white males, and white females. Sample sizes for blacks of both 

sexes are considerably smaller, and confidence intervals for 

estimates are consequently much larger, in the range off 4 to 

7 percentage points for time points prior to 1985, and in the 

range of f 5 to 9 percentage points for estimates of smoking in 

1985 and 1987. Sample sizes for the three major data sets-by 

cohort,~gender, and race-are presented in Table 1. 

Figures 2 through 7 show changes in prevalence of cigarette 

smoking over time among successive birth cohorts for all males, 

all females, white males, black males, white females, and black 

females in the United States. As shown in Figure 2, among 

males, the 1911 to 1920 and 1921 to 1930 birth cohorts 

achieved the highest peak prevalences, at 65.9 percent and 

66.1 percent, respectively. According to these data, the 1901 to 

1910 cohort reached a peak smoking rate of 61.8 percent, which 

should be adjusted upward somewhat because of the differential 

mortality likely to have occurred between smokers and nonsmokers prior to the survey in 1970. The overall exposure to 

cigarettes appears to be different for these three cohorts, however, because of differences in the rates of cessation. For example, when the 1901 to 1910 cohort was aged 55 to 64 in 

1965, its smoking rate was 45.0 percent. The comparable rate 

for the 1911 to 1920 cohort in 1975 was 39.8 percent, while for 

the 1921 to 1930 cohort, the rate in 1985 was 32.5 percent. 

Thus, although the three cohorts achieved similar peak rates, 

cessation was progressively greater for the later cohorts, resulting in fewer total years of exposure to cigarettes for the later 

cohorts at any given age. Birth cohorts after the 1931 to 1940 

cohort experienced successively lower peak prevalence 

(52.3 percent, 39.6 percent, and 32.4 percent, respectively). 

Figure 3 presents the smoking prevalence for successive 

birth cohorts of U.S. women and clearly demonstrates that 

women began to smoke in substantial numbers much later in 

the century than did men. The earliest birth cohort of men 

(1901 to 1910) showed marked initiation of smoking during 

adolescence (around 1915 to 1920) and had a high peak prevalence. In contrast, the same birth cohort of women took up 

smoking much more slowly (around 1925 to 1930) and had a 

80 
Smoking and Tobacco Control MononraPh No. 1 

Table 1 

Sample sizes for three major NHlS data sets, by birth cohort, 

gender, and race 

Male Female 

All White Black All White Black 

Birth Cohorts, 1970NHIS 

1901-1910 3,363 3,065 256 4,677 4,215 440 

1911-1 920 4,715 4,331 334 5,934 5,350 525 

1921-1 930 5,484 4,991 41 9 6,884 6,129 696 

1931-1 940 5,188 4,663 438 6,532 5,662 762 

1941-1 950 6,690 6,008 586 8,409 7,332 941 

Birth Cohorts, 1978-80NHlS 

1901-1 910 1,511 1,388 1 07 2,031 1,839 178 

1911-1 920 2,520 2,290 200 3,261 2,947 282 

1 921-1930 3,194 2,922 231 3,768 3,388 335 

1931-1940 3,048 2,734 265 3,739 3,260 41 2 

1941-1 950 4,185 3,765 342 4,866 4,249 51 2 

1951-1 960 5,172 4,572 509 6,137 5,284 747 

Birth Cohorts, 1987NHlS 

1901-1910 331 289 37 831 754 74 

1911-1 920 833 731 96 1,412 1,240 159 

1921-1 930 1,084 937 135 1,583 1,345 220 

1931-1 940 1,125 957 134 1,399 1,145 221 

1941-1 950 1,757 1,501 205 2,198 1,821 324 

1951-1 960 2,144 1,839 242 2,936 2,318 528 

1961-1 970 1,548 1,305 187 2,033 1,581 376 

Source: National Health Interview Survey (NHIS) 1970, 1978, 1979, 

1980, 1987 Public Use Data tapes, National Center for Health 

Statistics. 

very low peak prevalence. Clearly the increase in per capita 

consumption of cigarettes during the first part of the century 

was confined largely to males, while the rapid increase in per 

capita consumption that occurred just prior to and during 

World War I1 involved both men and women. The highest 

peak prevalence among women occurred for the 1931 to 1940 

cohort, with a rate of 43.9percent in 1965. The peak for the 

1921 to 1930cohort was only slightly lower (42.5percent in 

1960). Thus, the highest peak prevalence for women occurred 

about 10years behind the peak prevalence for men. Notable 

among females is the considerably lower prevalence of smoking 

81 
National Cancer Institute 

Figure 2 

Changes in prevalence of cigarette smoking among 

successive birth cohorts of U.S. males, 1900to 1987 

Percentage 

70 I I I I 

0 1901-1910

. 

I 

1911-1920 

1921-1930 

so-- 01931-1940 -

A 1941-1950 

A 195-1960 

X 1961-1970 

- 50 

40 

30 

- 20 

10 

o., , , 

1910 1 D 

in the 1901 to 1910cohort than in all other cohorts (with a 

peak of only 25.4percent in 1955). While the peak prevalence 

declined considerably for males among those cohorts after 

1931 to 1940,the decline has been more modest for females 

(the peak was 39.3percent for the 1941 to 1950 cohort, 

33.6 percent for the 1951 to 1960 cohort, and 29.2 percent for 

the 1961 to 1970 cohort). 

One impact of this difference in the smoking behavior of 

the same birth cohorts of men and women is a difference in 

the current and future lung cancer death rates. Lung cancer 

occurrence is roughly proportional to the cumulative smoking 

experience of a cohort (the area under the prevalence curve for 

the cohort), but lung cancer occurs predominantly in the older 

age groups of the population. Therefore, overall lung cancer 

death rates for the U.S. population reflect largely deaths among 

individuals from ages 50 to 80.The men who are in this age 

group currently include those cohorts that have the highest 

peak prevalence of smoking and the greatest cumulative 

exposure to smoking. The cohorts now entering the 50 to 80 

age range, when most lung cancers occur, have a lower peak 

82 
Smoking and Tobacco Control Monograph No. 1 

Percentage 

70 I 

0 1901-1910 

1911-1920 

1921-1930 

60 __ 0 1931-1940 -

A 1941-1950 

A 1951-1960 

X 1961-1970 

50 

40 

30 

20 

10 

A; 

1901-1910 

0 

and cumulative smoking exposure than the cohorts they are 

replacing. This should result in a decline in the number of 

lung cancers caused by smoking, and the timing of the projected decline is discussed later in this chapter. 

The picture for women is substantially different. Peak and 

cumulative smoking exposures are substantially lower for those 

birth cohorts that are currently in the 50 to 80 age range, and 

so are lung cancer death rates. However, the women who are 

entering this age range (those cohorts born after 1930) have 

substantially greater peak and cumulative smoking exposure 

than those women whom they are replacing (the cohorts born 

from 1901 to 1930), and overall lung cancer death rates for 

women are continuing to increase steeply and will not begin to 

decline until much later than those for men. 

Figures 4 and 5 present smoking data for the same cohorts 

of white and black males. There are several important differences between the smoking patterns for white males and black 

males that are evident from a comparison of these figures. 

First, the adoption of cigarette smoking in the early part of this 

century was somewhat slower among black males than among 

83 
h 

84 
Smoking and Tobacco Control Monograph No. 1 

white males. The peak prevalence of smoking for the oldest 

cohort of black males is dramatically lower than that for the 

same cohort of white males, and the peak prevalence for each 

of the next two birth cohorts is also lower for black males. The 

peak prevalences for the 1931 to 1940 cohorts are similar and 

the peak prevalences for the cohorts born after 1940 are higher 

for black males than for white males. It is not until the 1951 to 

1960 birth cohort that there is any evidence of a decline in 

peak prevalence. This suggests that the influences that drive 

the initiation of smoking occurred somewhat later in this 

century among the black male population; but among more 

contemporary cohorts, they have exerted a stronger influence 

on the black male population than on the white male population. 

A second major difference between these two patterns is 

the width of the prevalence peaks. The number of years that a 

birth cohort spends at or close to its peak before beginning to 

decline is much greater for black males than for white males, 

resulting in the black male cohorts’ having a greater cumulative smoking exposure than would be estimated from an 

examination of their peak prevalence alone. There appears to 

have been very little smoking cessation among black males 

until they reached a substantially greater age than their white 

birth-cohort peers. These two differences in the prevalence 

patterns are consistent with the lag in black male lung cancer 

death rates, compared to white male lung cancer death rates, 

that was observed early in this century, which has now reversed to produce current lung cancer death rates for black 

males that are substantially above those for white males. 

A third difference relates somewhat to the longer duration 

of peak prevalence for black males. White males in all of the 

older birth cohorts began to quit in significant numbers in the 

mid-l950’s, but cessation did not become evident among black 

male cohorts until the middle to late 1960’s. A steep decline is 

evident in each of the three oldest white male cohorts (those 

that had already reached their peak) by the mid-l950’s, and the 

onset of the steep part of the decline seems to be more closely 

related to the calendar year than to age. This timing coincides 

with the drop in per capita tobacco consumption that occurred 

during the mid-1950’s and which has been attributed by 

Warner (1981) and others to the widespread publicity on 

smoking-related disease risks that occurred after publication of 

the first major prospective mortality studies on smoking risks. 

The same three cohorts of black males do not show a similar 

decline in prevalence until the 1970 data point, where all three 

cohorts show a steep decline from 1965. This time point also 

coincides with a drop in per capita cigarette consumption that 

occurred from 1967 to 1970 and which has been attributed to 

85 
LUNG CANCER 

MORTALITY 

Methodology 

Mortality Rates for 

Lung Cancer 

National Cancer Institute 

the antismoking advertisements that were on television at that 

time to counter cigarette commercials. This difference in the 

timing of the decline in prevalence between white and black 

males suggests that the knowledge of the disease risks associated with smoking may not have effectively penetrated into 

the black community until much later than it reached the 

white community. 

Figure 6 shows smoking prevalence for white female 

cohorts and closely resembles Figure 3 (all females). Figure 7 

(black females) shows some general similarities to the pattern 

for white females. 

From 1950 to the present, the age-adjusted cancer mortality rate for all sites combined has been increasing. However, 

when these rates are calculated for “all other cancers” (excluding lung cancer) the overall cancer death rate has been constant or declining, as shown in Figures 8 through 13. This 

decline is evident for the total male and female populations 

(Figures 8 and 1l), and it is evident for the subgroups of white 

males, white females, and nonwhite females (Figures 9, 12, and 

13); however, the death rates for “all other cancers” among 

nonwhite males are still increasing slightly. [Note: For all 

analyses in this chapter, the designations “black” and “nonwhite” may be considered interchangeable, as black men and 

women constitute about 90 percent of the nonwhite population studied.] 

This section of Chapter 3 examines trends in mortality 

from primary cancers of the lung between 1950 and 1985. Its 

purpose is to review the changes in lung cancer death rates as a 

reflection of the changes in smoking prevalence described 

above. 

Data from the National Death Tapes, supplied by the 

National Center for Health Statistics, were used to calculate 

mortality rates. These rates were age-adjusted according to the 

direct method (Lilienfeld, 1967), with the 5-year age distribution of the total 1970 U.S. population as the standard. Except 

where noted, rates are presented as cases per 100,000 population. The analysis is based on the same birth cohorts as those 

used in the previous section on smoking prevalence. 

Lung cancer mortality rates, by 10-year birth cohort, 

gender, and race, are presented in Tables 2 through 7. Lung 

cancer mortality becomes measurable when a cohort reaches a 

minimum age of 35,and it rises sharply as age increases. One 

can compare age-specific lung cancer death rates for different 

birth cohorts by using these tables and matching the death rate 

for one birth cohort with the death rate recorded 10years 

earlier for the preceding birth cohort. Each birth cohort is 

10years younger than the preceding one, so the rates for the 

86 
I I I I t (0 

0 0 0 0m 

I 

0N : 

I 0 

c 

0 

F 

QI 

eo 

h 

a7 
250 

National Cancer Institute 

Figure 8 

Age-adjusted cancer mortality rates,* all males 

Rate 

Lung Cancer 

preceding cohort at a given age will have occurred 10 years 

earlier. The age-specific death rates are presented by birth cohort in Tables 8 through 13. Successive cohorts of males experienced higher age-specific mortality rates through the 1921 to 

1930 cohort. However, beginning with the 1931 to 1940 

cohort, the age-specific rates have been declining. This is a reflection of the downward trend in cigarette smoking that began 

with the 1931 to 1940 cohort of males in the United States. 

Table 4 shows the mortality rates for lung cancer among 

nonwhite males. The rates for nonwhite males born during the 

period from 1901 through 1910 are somewhat lower than those 

for all U.S. males and for white males. However, for each 

subsequent cohort, the nonwhite male death rates from lung 

cancer are considerably higher than those for all males. The 

higher rates among nonwhites may be explained in part by the 

longer maintenance of the smoking habit and higher rates of 

smoking during the critical older ages. 

The lung cancer death rates for women, first measurable at 

age 35, are considerably lower than those for males and rise 

more slowly with age in the older birth cohorts (Table 5). 

While the rates for males began to decline with the 1931 to 

1940 cohort, the rates continued to rise among women for 

successive cohorts through 1931 to 1940. 

88 
250 

Smoking and Tobacco Control Monograph No. 1 

Figure 9 

Age-adjusted cancer mortality rates,* white males 

Rate 

Lung Cancer 

All Other Cancers 

Year 

* Deathsper 100,000. 

Year 

* Deathsper 100,000. 

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National Cancer Institute 

Figure 11 

Age-adjusted cancer mortality rates,* all females 

*Deathsper 100,000. 

Year 

The U.S. white female lung cancer mortality rates (Table 6) 

are very close to those for all females (Table 5). The lung cancer 

mortality rates among the nonwhite female cohorts before 1921 

to 1930 (Table 7) were generally, though not consistently, lower 

than among the whites; however, at that point they seem to 

catch up and then slightly surpass the white females. Smoking 

prevalence data suggest that lung cancer mortality would be 

lower for nonwhites than for whites in the earliest two cohorts. 

Tables 8 through 13provide a retabulation of data from 

Tables 2 through 7, as age-specific rates with percentage of 

change between cohorts. This allows a ready comparisonbf the 

lung cancer experience of the different cohorts at the same ages. 

For example, when males in the 1911 to 1920 cohort were aged 

40 to 49, their lung cancer mortality rate was higher than that 

of the 1901 to 1910 cohort at the same age. The rates continued 

to rise as the 1921 to 1930 cohort reached age 40 to 49; however, the rates declined slightly for the 1931 to 1940 cohort. 

This pattern is seen for all males, regardless of race. At ages 50 

to 59, the rates rose considerably less between the 1911 to 1920 

and 1921 to 1930 cohorts than they did between the 1901 to 

1910 and 1911 to 1920 cohorts (for all males, 13 percent compared with 32 percent), suggesting a leveling off of lung cancer 

mortality among this age group. 

90 
Smoking and Tobacco Control Monograph No. 1 

Figure 12 

Age-adjusted cancer mortality rates,* white females 

Year . __ 

*Deathsper 100.000. 

Figure 13 

Age-adjusted cancer mortality rates,* nonwhite females 

Rate 

Lung Cancer 

175 r[z9 All Other Cancers 

Year 

* Deaths per 100.000. 

91 
National Cancer Institute 

Table 2 

Lung cancer mortality rates, 1950 to 1985, for all males born 1901 

through 1950, by birth cohort 

Lung Cancer Mortality,* by Birth Cohort 

1901-1910 1911-1920 1921-1930 1931-1940 1941-1950 

Year 

1950 17.0 

1955 47.6 

1960 91.1 24.0 

1965 159.3 58.7 13.2 

1970 259.7 120.1 35.4 

1975 363.4 200.5 74.3 14.0 

1980 470.7 308.2 135.3 33.9 

1985 543.0 415.9 220.3 67.0 9.9 

* Deaths per 700,000. 

Table 3 

Lung cancer mortality rates, 1950 to 1985, for white males born 

1901 through 1950, by birth cohort 

Lung Cancer Mortality,* by Birth Cohort 

1901-1910 1911-1920 1921-1930 1931-1940 1941-1950 

Year 

1950 17.1 

1955 46.9 

1960 90.2 22.6 

1965 159.4 56.8 12.2 

1970 259.9 1 15.2 32.7 

1975 365.2 193.9 69.3 12.6 

1980 473.5 301.1 128.4 30.9 

1985 546.4 409.5 21 1.9 62.2 9.0 

* Deaths per 700,000. 

SmokingPrevalence Figures 14through 33 offer a closer look at the effect of 

And Lung Cancer smoking and at trends in lung cancer mortality, by birth 

Mortality cohort. For each gender and race group by birth cohort, the 

figures show changes over time in the percentage of those 

currently smoking, percentage of those who have ever smoked, 

and rates of lung cancer mortality, expressed as number of 

deaths per 10,000population. 

92 
Smokinn and Tobacco Control MonoxraPh No.1 

Table 4 

Lung cancer mortality rates, 1950 to 1985, for nonwhite males 

born 1901 through 1950, by birth cohort 

Lung Cancer Mortality,* by Birth Cohort 

1901-1910 1911-1920 1921-1930 1931-1940 1941-1950 

Year 

1950 16.1 

1955 54.1 

1960 99.8 36.7 

1965 158.7 77.0 22.3 

1970 257.8 166.2 59.0 

1975 347.6 262.2 117.1 24.1 

1980 445.1 374.5 194.7 54.8 

1985 51 1.6 475.3 288.7 99.4 16.5 

* Deaths per 700,000. 

Table 5 

Lung cancer mortality rates, 1950 to 1985, for all females born 

1901 through 1950, by birth cohort 

Lung Cancer Mortality,* by Birth Cohort 

1901-1910 191 1-1920 1921-1930 1931-1940 1941-1950 

Year 

1950 3.5 

1955 7.2 

1960 12.0 6.1 

1965 21.9 13.9 4.4 

1970 40.0 30.1 12.1 

1975 65.8 54.4 26.6 7.0 

1980 101.6 91.5 52.1 16.9 

1985 133.3 141.8 91.2 34.8 5.6 

* Deaths per 700,000. 

Small sample sizes create some difficulty in interpreting 

findings in smoking behavior among the black male cohorts 

(Figures 15, 17, 19,21, and 23). For example, estimates for the 

1901 to 1910 cohort in 1985 and 1987 are based on only 

37 respondents. This results in a 95 percent confidence interval of approximately f 14 percentage points (assuming a 

random sample). Regardless, the following trends appear: For 

the four oldest cohorts (1901 to 1940), there is an apparent rise 

93 
National Cancer Institute 

Table 6 

Lung cancer mortality rates, 1950 to 1985, for white females born 

1901 through 1950, by birth cohort 

Lung Cancer Mortality,* by Birth Cohort 

1901-1910 1911-1920 1921-1930 1931-1940 1941-1950 

Year 

1950 3.5 

1955 6.8 

1960 11.8 6.0 

1965 21.7 13.8 4.2 

1970 40.5 30.1 11.7 

1975 64.7 55.4 26.5 6.8 

1980 103.4 92.8 51.6 16.5 

1985 136.4 145.6 91.7 35.1 5.5 

Deaths per 7 00,000. 

Table 7 

Lung cancer mortality rates, 1950 to 1985, for nonwhite females 

born 1901 through 1950, by birth cohort 

Lung Cancer Mortality: by Birth Cohort 

1901-1910 1911-1920 1921-1930 1931-1940 1941-1950 

Year 

1950 3.6 

1955 10.5 

1960 13.1 7.2 

1965 23.8 14.5 5.9 

1970 35.0 29.7 14.9 

1975 79.3 45.8 28.1 8.0 

1980 83.8 79.6 55.8 19.5 

1985 101.2 108.7 87.7 33.0 6.2 

* Deaths per 700,000. 

between 1970 and.1985 in the number who have ever smoked. 

In addition to the small sample size, slight changes in survey 

methodology over the different years of administration (as 

described previously) could cause these results. Still, these increases deserve further exploration. 

Also of note are the rates of lung cancer relative to white 

males. Although the prevalence of current smokers and eversmokers is lower among black males through the 1931 to 1940 

94 
Smoking and Tobacco Control Monograph No. 1 

Table 8 

Age-specific lung cancer death rates,* 1950 to 1980, for all males 

born 1901 through 1940, by birth cohort 

1901- 1911- 1921- 1931-

1910 1920 Percent 1930 Percent 1940 Percent 

Cohort Cohort Change Cohort Change Cohort Change 

Age

40-49 17.0 24.0 (41.2) 35.4 (47.5) 33.9 (-4.2) 

50-59 91.0 120.1 (31.8) 135.3 (12.7) 

60-69 259.7 308.2 (18.7) 

70-79 470.7 

*Per 700,000 population. 

Table 9 

Age-specific lung cancer death rates,* 1950 to 1980, for white 

males born 1901 through 1940, by birth cohort 

1901- 1911- 1921- 1931-

1910 1920 Percent 1930 Percent 1940 Percent 

Cohort Cohort Change Cohort Change Cohort Change 

Age

40-49 17.1 22.6 (32.2) 32.7 (44.6) 30.9 (-5.5) 

50-59 90.2 115.2 (27.7) 128.4 (11.5) 

60-69 259.9 301.1 (15.8) 

70-79 473.5 

*Per 100,000population. 

cohort, lung cancer death rates are similar between the races 

for the 1901 to 1910 cohort, and they are noticeably higher for 

black males in each successive cohort. For example, for the 

1921 to 1930 cohort (Figure 19) in 1985, the lung cancer death 

rate for black males was more than 36 percent higher than for 

white males, even though the peak prevalence of smoking 

among black males in that cohort never achieved that of white 

males, and the ever-smokers rate matched that of whites only 

since 1970 (see Figure 18). The reason for this disparity in lung 

cancer death rates is not clear. Differences in smoking behavior other than prevalence may play a role, such as the type of 

cigarette smoked and the amount of each cigarette smoked. 

However, consumption in terms of the number of cigarettes 

smoked is considerably lower among blacks (US DHHS, 1988). 

95 
National Cancer Institute 

Table 10 

Age-specific lung cancer death rates,* 1950 to 1980, for nonwhite 

males born 1901 through 1940, by birth cohort ~~ ~ 

1901- 1911- 1921- 1931- 1910 1920 Percent 1930 Percent 1940 Percent 

Cohort Cohort Change Cohort Change Cohort Change 

Age

40-49 16.1 36.7 (128.0) 59.0 (60.8) 54.8 (-7.1) 

50-59 99.8 166.2 (66.5) 194.7 (17.1) 

60-69 257.8 374.5 (45.3) 

70-79 445.1 

* Per 700,000population. 

Table 11 

Age-specific lung cancer death rates,* 1950 to 1980, for all females 

born 1901 through 1940, by birth cohort 

1901- 1911- 1921- 1931- 1910 1920 Percent 1930 Percent 1940 Percent 

Cohort Cohort Change Cohort Change Cohort Change 

Age 

40-49 3.5 6.1 (74.3) 12.1 (98.4) 16.9 (39.7) 

50-59 12.0 30.1 (150.8) 52.1 (73.1) 

60-69 40.0 91.5 (128.8) 

70-79 101.6 

Per 700,000population. 

Also to be considered is the shorter life expectancy of black 

males compared with white males-approximately 8 to 10 

years for males born between 1920 and 1950 (Hoffman, 1987). 

The mortality rate for black males in that age group may result 

in considerable underestimation of past smoking behavior of 

the earlier cohorts, more so than for white males, because 

estimates are based on the behavior of survivors only. Thus, it 

is possible that there were higher rates of smoking than those 

reported,for those cohorts, resulting in the observed lung 

cancer mortality rates. 

White females (Figures 24, 26, 28, 30, and 32) are similar 

to white males in that, in later cohorts, there is considerably 

more initiation of smoking after the peak prevalence than for 

earlier cohorts, as indicated by differences between the current 

smoker and ever-smoker curves. For white females, as with 

96 
Smoking and Tobacco Control Monograph No. 1 

Table 12 

Age-specific lung cancer death rates,* 1950 to 1980, for white 

females born 1901 through 1940, by birth cohort 

1901- 1911- 1921- 1931-

1910 1920 Percent 1930 Percent 1940 Percent 

Cohort Cohort Change Cohort Change Cohort Change 

Age

40-49 3.5 6.0 (71.4) 11.7 (95.0) 16.5 (41.0) 

50-59 11.8 30.1 (155.1) 51.6 (71.4) 

60-69 40.5 92.8 (129.1) 

70-79 103.4 

*Per 100,000population. 

Table 13 

Age-specific lung cancer death rates,* 1950 to 1980, for nonwhite 

females born 1901 through 1940, by birth cohort 

1901- 1911- 1921- 1931- 1910 1920 Percent 1930 Percent 1940 Percent 

Cohort Cohort Change Cohort Change Cohort Change 

Age

40-49 3.6 7.2 (100.0) 14.9 (106.9) 19.5 (30.9) 

50-59 13.1 29.7 (126.7) 55.8 (87.9) 

60-69 35.0 79.6 (127.4) 

70-79 83.8 

*Per 100,000population. 

white males, this becomes apparent for the 1941 to 1950 

cohort (Figure 32). The lower overall smoking rates for white 

females compared with white males for all cohorts shown are 

borne out in considerably lower lung cancer death rates for 

women. It can be expected, however, that as later cohorts (e.g., 

1951 to 1960) enter the ages at which lung cancer death rates 

increase rapidly, the lung cancer death rate differential between 

males and females will begin to disappear because of the 

narrowing gap in smoking behavior. 

Starting with the 1931 to 1940 cohort (Figure 31), the 

pattern of both current smokers and ever-smokers for black 

women is similar to that for white women. Prior to 1931 

(Figures 25,27, and 29), black women had lower rates of 

current smokers and ever-smokers than did white women, with 

one exception. In the 1921 to 1930 cohort (Figures 28 and 29), 

97 
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107 
Use of Birth 

Cohort Smoking 

Behaviors To 

Predict Lung 

Cancer Death 

Rates 

National Cancer Institute 

the percentages of ever-smokers reached comparable levels for 

black women and white women. Lung cancer death rates for all 

cohorts are approximately the same for white and black females, 

even though smoking rates are lower for black females in the 

earliest two cohorts. As smoking rates converged for white and 

black females in later cohorts, lung cancer death rates remained 

approximately equivalent for the two races. The equivalent lung 

cancer rates for white and black females in earlier cohorts, despite lower smoking rates among black females, may again 

suggest a lung cancer risk that is not attributable to smoking. 

Understanding the effects that shifts in the distribution of 

risk factors (such as smoking patterns) have on disease occurrence and associated health care costs is fundamental to evaluating trends and formulating public policy, In the public policy 

domain, the determination of which health care programs or 

projects receive what proportion of limited resources requires 

analysis of the future costs and benefits of those programs. In 

assessing health trend effects, changes in either risk factor 

exposure or the treatment of disease may affect the incidence of 

disease, the prevalence of chronic conditions, and/or the mortality rates. 

The efficacy of a health program in preventing a disease 

with a long latency period may not be quickly manifest by the 

usual morbidity and mortality estimates. Primary prevention 

programs are directed at reducing risk factor exposures, and for 

many diseases the benefits of altering a risk factor as measured 

by reductions in mortality or disability require time to emerge. 

Individuals who already have a disease, including those at 

preclinical stages, may not benefit from alteration of risk factors 

and will often continue to progress through the disease course. 

Thus, intervention studies frequently require 5 to 10years to 

show significantly reduced morbidity and mortality risks. 

During these lengthy periods, the demographic profile of the 

beneficiary population may shift (e.g., the population may 

become younger with time) or those with adverse risk factor 

values may die earlier. In such cases, some of the observed 

benefits are not the result of interventions but of population 

shifts in the distribution of risk factors. A health program may 

reduce the age-specific mortality rates, but this reduction would 

only partly offset the increase in death rates that accompanies 

the aging of individuals. Thus, determining the benefits of a risk 

factor management program requires separating benefits attributable to risk factor modification from benefits attributable to 

demographic shifts, changes in susceptibility, and mortality selection. 

To assess the effects of risk factor interventions on health 

trends, standard increment-decrement life-table models are generalized to “compartment” models (Le., discrete state-discrete 

108 
Smokinn and Tobacco Control Monoxraph No. 1 

Figure 34 

Compartment model schematic of morbiditymortality process with discrete risk states 

I 

time models of health processes) to represent movement 

between risk factor states. The states in the compartment 

model can represent death, disability, or an adverse (or beneficial) risk factor status. In the current analysis, the primary risk 

factor is duration of smoking. Interventions are represented by 

changes in risk factor states; that is, interventions modify 

transition rates between certain risk factor and mortality states 

and change the number of individuals in those states. For 

example, decreases in the initiation of smoking rates and/or increases in the smoking cessation rates could represent effects of 

a health intervention in the population. The benefits of this 

intervention are calculated from incidence and prevalence rates 

calculated for each compartment and summed across the population. 

A DISCRETE A compartment model of morbidity-mortality processes is 

STATE MODEL illustrated in Figure 34. An individual resides in only one risk 

OF HEALTH factor state, although he or she can move to any other state at 

INTERVENTION time t. The risk factor states can represent chronic illness, 

disability, and risk factor exposure (e.g., smoker versus nonsmoker, hypertensive versus not hypertensive). The “well” 

state is defined as the state with no risk factors. Though an 

individual can be in only one state at any time, the definitions 

of states need not be exclusive; e.g., an individual may be in a 

hypertensive state, a smoking state, or a hypertensive and 

smoking state. We define the following terms: 

t = time measured in years (t= 1,2, . . .,T). 

K = number of risk factor states (besides the well 

state). Risk factor state 0 is the “well” state. 

109 
The Markov 

Assumption 

National Cancer Institute 

L = 

a = 

nk(a,t) = 

qk,(a,t) = 

q,(a,t) = 

index for age groups. 

number of causes of death (1 = 1,2, . . .,L). 

number of individuals in age group a at beginning of t in state k. 

probability that a person in age group a state 

at twill die of cause 1 during the year. 

probability that a person in age group a at t 

dies of cause 1, 

= ZqQ(a,t)nk(a,t)/ Znk(a,t) (1) 

Multiple increment-decrement life tables are special cases 

of the compartment model seen in Figure 34. Consequently, 

methods to estimate multiple decrement life-table parameters 

are easily extended to the compartment model. However, 

applying those methods for many risk factor states and causes 

of death requires a huge quantity of data. Problems in evaluating mortality functions arise because (1)all possible pathways 

that result in the contingent event of interest must be determined, and (2) the probabilities associated with each of these 

pathways must be assessed. The problems are simplified if the 

model in Figure 34 can be assumed to be Markovian; i.e., the 

probability of changing states depends only on the two states 

(the state the individual is coming from and the state he or she 

is going to) and not on any previous states the individual has 

been in or length of time in the current state. 

The Markov assumption seems unreasonable, since a 

person’s age and the length of time he or she smoked are determinants of the risks of many causes of death and disease. The 

Markov assumption can be made more reasonable by defining 

risk factor states as length of time with a particular risk factor. 

For example, a person enters the “smoked 0 to 5 years” risk 

state when smoking begins. In 5 years, the individual moves to 

a “smoked 5 to 10 years” risk state if he or she still smokes and 

has not died. Or, the person may enter a “hypertensive and 

smoked 5 to 10 years” state if the blood pressure rises and he or 

she continues to smoke. Alternatively, the person who stops 

smoking may enter the “smoked only 5 years” state. Age can 

be treated similarly; that is, Figure 34 can be viewed as applicable to a specific age group with risk factor states defined for 

each subsequent age group. Individuals move between states 

as they age. 

Assuming that the Markov assumption holds for Figure 34, 

movement between states can be described by a matrix of 

transition probabilities. If nilis the probability of moving from 

state i to state j in a year, the transition matrix is 

110 
Smoking and Tobacco Control Monograph No. 1 

Previous Forecast 

Methods 

n= 

Jcoo no1 ... “‘1, 

[‘RO ... XRR 

where the total number of states is R + I =K + L + I, including 

the “well” and death states. The sc, are determined from nk(a,t) 

and q,,(a,t). To determine the popuiation in each state after m 

years, let n, be the number of individuals in state i at time 0. 

The row vector N = (no,n,, ...,nr) of these counts is called the 

state vector. The vector N(m)of counts in each state after t years 

is 

N(‘) = Nn‘ (3) 

where ntis the product of Ilwith itself t - 1times (i.e., the “tth” 

power of n). The vector N@), t = 1,2, .. . ,is the basis for all 

discrete survival functions where N(‘) = (No(t),N,(t),.. . ,NR(t)), 

The model is useful for forecasting future contingent outcomes 

and evaluating functions associated with morbidity and mortality outcomes under various interventions or changes in the 

population. 

Because the current model is more biologically plausible 

than simply “alive-dead” and “standard-substandard risk” classifications, forecast estimates will be more accurate. By selecting a sufficient number of risk factor and mortality states, one 

can model any finite combination of risk factors. A model 

representing the interactions of risk factors and chronic conditions is more defensible than risk scoring methods that do not 

represent those interactions (see Cummins et al., 1983). In this 

chapter, the above model is used to forecast lung cancer mortality patterns. 

Several researchers have presented models for forecasting 

mortality patterns for lung cancer. The simplest method is to 

assume that the age-specific mortality rates will remain constant and then predict the number of deaths in the future from 

the number of individuals expected in each age group. A 

sophisticated version of this model is given by Brown and 

Kessler (1988), in which the differential cohort effects and differential smoking patterns are included in estimating the agespecific lung cancer mortality rate. The Brown and Kessler 

model also used the number of cigarettes and the tar per cigarette as regressor variables for the period effects. The model 

does not explicitly include the length of time that people 

smoked. Forecasts are based on estimated effects of cohort, 

age, smoking status, and “dose” (as measured by twovariables, 

average cigarettes and tar levels). The model adjusts for smoking duration and for any competing risks of deaths only 

111 
Building the 

Model 

The Risk Factor 

States 

National Cancer Institute 

implicitly; that is, insofar as these two variables are reflected in 

the mortality risks of lung cancer in the observed data used to 

fit the model, this same relationship is maintained in the 

forecasting formula. 

Hakulinen and Pukkala (1981)use a similar method but 

make explicit adjustments for subjects’ length of smoking and 

time since they last smoked. Although this model is more sophisticated in the use of smoking duration, it does not estimate 

the cohort effects from observed lung cancer mortality over 

time as the Brown and Kessler model does. The model also 

adjusts for the competing risks implicitly, by assuming that the 

mortality risks used contained the appropriate adjustment. 

The model proposed in this chapter extends these models 

in two ways. First, explicit adjustment of the competing risks is 

taken into account. Because current and past smoking patterns 

have a differential effect on both lung cancer and other competing risks, forecasting the effects of changes in the smoking 

patterns over the last 10 years and the anticipated smoking 

patterns on future lung cancer mortality requires “unbundling” 

the different mortality risks. Second, the model uses the mortality risk explicitly as a function of smoking initiation and cessation rates in a Markov model. Explicit identification of these 

components provides the forecaster more freedom in altering 

the constituent parts of the model to examine the long-term 

effects of interventions and health promotion programs on 

mortality outcome. As in the models described above, the 

current model does provide a cohort-specific, smokingduration-based model. However, rather than examine the 

trends of the mortality risks over the last two decades, as Brown 

and Kessler have done, this model assumes that the underlying 

causes of these trends are represented by the risk factor and 

population dynamics used in the model. 

To build a model, estimates of the transition probabilities 

are required. Tolley and Manton (in press) have described how 

the various types of health statistics can be used to determine 

estimates. In this section, the estimation of these transition 

probabilities is briefly described, and the data sources for making the estimates are presented. 

The first step in the estimation is to determine the number 

of individualsdn each of the risk factor states. Naturally, the 

primary risk factor state here is smoking status: whether or not 

the individual is or has been a smoker and, if a smoker, the 

duration of smoking. The initiation and cessation rates over 

time for birth cohorts of black and white males and females 

can be estimated from the NHIS data presented in the first part 

of this chapter. From these estimates, estimates of the number 

of individuals who are current smokers with a smoking 

112 
Smoking and Tobacco Control Monograph No. 1 

Causes of Death 

Relative Risks 

duration of 5 years, 10years, and so forth, can be obtained for 

both races and sexes for the entire Nation. In addition, estimates of the number of individuals who have never smoked, 

and the number of ex-smokers who smoked 5 years, 10years,

and so on, can be obtained. All of these estimates of smoking 

duration are specific to various birth cohorts beginning with 

the 1901 to 1910 cohort and including birth cohorts up to the 

1951 to 1960 cohort. 

Table 14 gives the distribution of each cohort in terms of 

their current smoking status in 1980. Naturally, these three 

smoking states can be subdivided. For the current model, the 

risk factor states for smoking are “never smoked,” “current 

smoker” (divided into 5-year duration intervals up to “smoked 

over 70 years”), and “ex-smoker,” which also is divided into 

5-year duration intervals. This gives 31 smoking states. 

The data given in the first section of this chapter show 

different patterns of initiation and cessation in various birth 

cohorts; therefore, the model here is developed through separate treatment of each of the 10-year birth cohorts. The oldest 

cohort considered in this study is the 1901 to 1910 cohort, and 

the youngest is the 1951 to 1960 cohort. 

Although risk factors such as hypertension, elevated blood 

cholesterol, alcohol consumption, and obesity are also important in the assessment of the future mortality patterns, current 

data on these patterns and how these patterns are expected to 

change in the future are limited. Therefore, these risk factors 

are disregarded in the current model, reflecting an assumption 

that, whatever the current patterns are, they will remain unchanged in the next three decades. 

The reason for including causes of death other than lung 

cancer is to adjust for their competing effects. Those causes of 

death that have smoking as a major risk factor must be considered as separate states in the model. Changes in smoking 

patterns will then be adjusted for in each such competing risk. 

All causes of death that do not have smoking as a primary risk 

factor can be grouped together as a “death by all other causes” 

state. Table 15 lists all causes other than lung cancer that are 

assumed (in this model) to have smoking as a major risk factor. 

The second step is to determine the relative risk associated 

with each risk factor level. For all causes of death except lung 

cancer, this model assumes that the relative risk is independent 

of the length of time that subjects smoked. Models relating 

smoking duration to coronary heart disease death and chronic 

obstructive pulmonary disease death are less established; therefore, they have not been included. Relative risks for current 

smokers and ex-smokers, both males and females, have been 

given in the Surgeon General’s Report (US DHHS,1989). 

113 
National Cancer Institute 

Table 14 

Distribution of nonsmokers, smokers, and ex-smokers in 1980, 

by race, gender, and birth cohort ~ 

Never-Smokers Current Smokers Ex-Smokers 

Born 1901-1 910 

White male .36 .19 .45 

White female .72 .15 -13 

Black male -52 .22 .26 

Black female .82 .06 .12 

Born 1911-1 920 

White male .28 .30 -42 

White female .57 .26 .17 

Black male -34 -40 .26 

Black female .64 .23 -13 

Born 1921-1 930 

White male .24 -40 .36 

White female .54 .31 -15 

Black male .32 .47 .21 

Black female .52 -34 .14 

Born 1931-1 940 

White male .29 .42 .29 

White female .49 .35 .16 

Black male -33 .49 .18 

Black female .54 .36 .10 

Born 1941-1950 

White male .34 .43 -23 

White female -50 .34 .16 

Black male .37 .47 .16 

Black female .54 .37 .07 

Born 1951-1 960 

White male -49 -39 .12 

White female -56 -33 .11 

Black male -46 .45 .09 

Black female -62 .33 .05 

Estimates of relative risks, reproduced in Tables 15 and 16, are 

used here. Note that since these risks are not race-specific, the 

same relative risks are used for both blacks and whites, 

114 
Smoking and Tobacco Control Monograph No. 1 

Table 15 

Relative risks of death for current and former smokers (males) 

Current Former 

ICD Code” Age Smokers Smokers 

Cause of Deathb 

CHD (41 0-41 4) 35 - 64 2.81 1.75 

65+ 1.62 1.29 

Other heart (390-398,401-405) 1.85 1.32 

CVD (430-438) 35 - 64 3.67 1.38 

65+ 1.94 1.27 

Other vascular (440-448) 4.06 2.33 

COPD (490-492,496) 9.65 8.75 

Other pulmonary (01 0-01 2,480-489, 493) 1.99 1.56 

Oral cancers (1 40-1 49) 27.48 8.80 

Bladder cancer (188) 2.86 1.10 

Kidney cancer (1 89) 2.95 1.95 

Pancreatic cancer (1 57) 2.14 1.12 

Esophageal cancer (1 50) 7.60 5.83 

WD, International Classification of Disease. 

bCHD,coronary heart disease; CVD,cerebrovascular disease; COPD, 

chronic obstructive pulmonary disease. 

Several authors have posited models relating the mortality 

from lung cancer to age and duration of smoking. Peto (1986) 

proposed a model that related smoking duration to risk of lung 

cancer. Peto’s model included smoking dose in two ways: first, 

there is a specific model for heavy smokers and moderate 

smokers; second, the cumulative dose, as measured by smoking 

duration, is explicitly included in determination of the risk. 

The models by Gaffney and Altshuler (1988) and those by 

Moolgavkar et. a1 (1989) are more sophisticated in their use of 

dose in determining relative risks of lung cancer instantiation. 

Although this second set of dose-related models seems to offer 

many strengths, the data available from the NHIS set sample 

provide good information on duration of smoking only and 

not explicitly on dose. 

Because of data limitations, the model used here for determining risk of lung cancer is that given by Peto. The probability of death by lung cancer for a person aged “a” who has 

smoked for “y” years is given by 

Prob (of death by lung cancer) =10-11a4 + 10-9y4. 

115 
National CancerInstitute 

Table 16 

Relative risks of death for current and former smokers (females) 

Current Former 

ICD Code' Age Smokers Smokers 

Cause of Deathb 

CHD (41 0-41 4) 35 - 64 3.00 1.43 

65t 1.60 1.29 

Other heart (390-398,401-405) 1.69 1.16 

CVD (430-438) 35 - 64 4.80 1.41 

65t 1.47 1.01 

Other vascular (440-448) 3.00 1.34 

COPD (490-492,496) 10.47 7.04 

Other pulmonary (01 0-01 2,480-489,493) 2.18 1.38 

Oral cancers (140-149) 5.59 2.88 

Bladder cancer 

Kidney cancer 

Pancreatic cancer 

Esophageal cancer 

(188) 

(1 89) 

(1 57) 

(150) 

2.58 

1.41 

2.33 

10.25 

1.85 

1.16 

1.78 

3.16 

'ICD, international Classification of Disease. 

bCHD, coronary heart disease; CVD, cerebrovascular disease; COPD, 

chronic obstructive pulmonary disease. 

Before using the Peto model, we must modify it for several 

reasons: First, the aggregation of moderate and heavy smokers 

into the same group, necessitated by the NHIS data format, is 

problematic; we expect that the "average" probability of lung 

cancer death would be higher than predicted by the model. 

Second, since the model was derived from a subpopulation of 

smokers in Britain, the toxicity of the smoked material and the 

method of smoking may differ from those characteristics in the 

United States. Third, the more prevalent use of filters on 

cigarettes in the last two decades may cause the model to estimate incorrectly the likelihood of death for more recent birth 

cohorts. 

The adjustment of the Peto model is as follows: We 

assume that for each gender- and race-specific birth cohort, the 

model for the probability of lung cancer can be determined 

from the Peto model by a scaling equation (4) as follows: 

Prob(of death by lung cancer for nonsmoker) = SlOl1a4 

Prob(of death by lung cancer for a current smoker) 

= ~10-11~4 + s10-y 

Prob(of death by lung cancer for a former smoker) = SlOll~~+ 5S1O9~ 

116 
Smoking and Tobacco Control Monograph No. 1 

Calculating 

Transition 

Probabilities 

In these equations, the unknown parameter S is a scale parameter. This parameter is determined by calculation of the 

observed number of deaths by lung cancer in 1980 for each 

birth cohort-gender-race combination, and comparison to the 

number predicted from the above equations. The value of S for 

each cohort-gender-race combination is the value that equates 

the predicted with the observed number of deaths. 

The probability of transitioning to one of the cause-ofdeath states (except death by lung cancer) from the neversmoked state for a particular age group is given by the following equation: 

qO1(a,0) = mumber of observed deaths from cause 11

[n,(a,O) + R 1&,(a,o) + RZ#Qn,,(a,O)l 

In this equation, R 1is the relative risk of the current smokers 

for the particular cause of death, and R2 is the relative risk of 

the ex-smokers for the same cause of death. The indexes k 

and k refer to current smoker and ex-smoker states, respectively. The transition probabilities for the particular cause of 

death for current smokers and ex-smokers are given by 

ql@,O) = R 1 qo1(a,0) 

qz,(a,O)= R2 qol(a,O). 

Calculation of the probability of transition from the 

“never-smoked” state to death by lung cancer is calculated 

similarly; however, in this case, each of the smoking levels has 

a different relative risk, as calculated by the modified Peto 

model (above). 

The transition probabilities for transitioning from the 

“never-smoked” to the “smoked-5-years-or-less”state are 

determined from the past initiation patterns. These probabilities are assumed to be age-dependent and cohort-dependent; 

however, because forecasting what pattern the younger cohorts 

will follow in the future is difficult, a single table for all cohorts 

for future initiation as a function of age was estimated. 

Table 17 is estimated from the initiation rates of the oldercohorts and gives the estimated initiation rates, by age group. 

How current awareness of the detrimental effects of smoking 

will reduce these initiation rates can only be guessed. 

Future cessation patterns, like future initiation patterns, 

are affected by the recent health trends in the United States. 

The estimated cessation rates, as a function of duration of 

smoking, are given in Table 18. These rates are determined by 

the experience of older cohorts and modified by recent trends 

toward better health. 

117 
National Cancer Institute 

Table 17 

Probability of initiating smoking in future as a function of age 

(5-year rate) 

White White Black Black 

Male Female Male Female 

Age Group 

20- 24years .20 .05 .16 .09 

25 - 29 37 .20 30 .18 

30 - 34 30 .17 .25 .20 

35 - 39 .10 .08 .10 .08 

40- 44 .03 .05 .05 .07 

45 - 49 .02 .03 .04 .05 

50- 54 .01 .015 .02 .03 

55 - 59 .01 -015 .01 .01 

60- 64 ,005 .005 .005 .01 

65 + 0 0 0 0 

Table 18 

Probability of termination of smoking during 5-year period, 

by 5-year duration 

White White Black Black 

Male Female Male Female ~~~~ 

Durationof Smoking 

c 5years .05 .05 .05 .08 

5-10 .08 .10 .08 .07 

10-15 .10 .10 .08 .06 

15 - 20 .lo .08 .06 -05 

20 - 25 .10 .10 -05 -04 

25 - 30 .15 .08 .05 -04 

30 - 35 .15 .05 .04 .03 

35 - 40 .10 -05 .03 .03 

40- 45 .05 -05 .03 .03 

45 t .05 .05 .03 -03 

Results and The parameters estimated above can now be placed in the 

Forecasts model described previously, to forecast mortality outcomes for 

each race and gender. These forecasts are summarized in 

Tables 19 through 22 for each race and gender combination. 

Entries in the tables are the age-specific annual mortality rates 

per 100,000individuals. 

Examining the values in these tables, we see several important points. One point of interest is that, for white males and 

white females, the age-specific lung cancer mortality rate drops 

118 
Smoking and Tobacco Control Mononaph No. 1 

Table 19 

Forecast mortality rates* for select causes of death, white males, 

ages 55 to 84 

Lung Other Coronary Heart All 

Cancer Cancers Disease Other Causes 

Year 

Age group 55 - 64 

1980 208.76 78.98 585.48 858.48 

1985 181.34 81.56 602.48 873.1 9 

1995 100.69 74.89 563.55 854.46 

2005 26.91 70.62 536.02 831.36 

201 5 14.97 77.45 578.38 856.1 9 

Age group 65 - 74 

1980 375.79 162.06 1,384.57 2,088.08 

1985 385.37 169.00 1,412.82 2,124.37 

1995 321.03 175.53 1,443.87 2,163.87 

2005 178.69 162.94 1,399.21 2,115.59 

201 5 49.1 3 155.46 1,357.07 2,056.93 

Age group 75- 84 

1980 476.60 242.20 2,554.47 4,169.47 

1985 508.34 393.92 3,246.97 5,966.54 

1995 51 6.52 429.99 3,350.83 6,192.03 

2005 451.04 458.1 4 3,440.06 6,403.72 

201 5 254.08 421.76 3,348.47 6,195.09 

*Deaths per 700,000; 7980 data are actual, not forecast. 

rather quickly for the younger age groups because of the low 

peak prevalence rates in more recent cohorts. For older age 

groups, this reduction occurs much more slowly. Note that the 

forecast model begins with the actual data for 1980; however, 

the values for 1985 and subsequent years are predicted from 

1980 mortality rates combined with the estimated smoking 

rates and the relative risks-as calculated with the Peto model. 

Although the mortality risks from coronary heart disease 

and from cancers other than lung are notably higher for 

smokers, as evidenced in Tables 15 and 16, the observed 

mortality rates for these causes are forecast to change very little 

over the next 25 years. One reason for this is that the agespecific mortality rates for different years are determined by the 

experience of different birth cohorts. Although the age-specific 

mortality rate for the “never-smoked” individuals is constant 

over time, the percentage of the population in each smoking 

state differs for each cohort. As a consequence, the number of 

individuals who are current smokers and ex-smokers and the 

119 
National Cancer Institute 

Table 20 

Forecast mortality rates* for select causes of death, white females, 

ages 55 to 04 

Lung Other Coronary Heart AH 

Cancer Cancers Disease Other Causes 

Year 

Age group 55 - 64 

1980 71.29 34.62 177.87 591.89 

1985 77.82 35.74 185.10 601 -68 

1995 67.28 36.53 186.19 600.72 

2005 30.57 35.82 178.18 588.91 

201 5 14.80 38.80 193.10 605.65 

Age group 65 - 74 

1980 98.11 70.75 597.32 1,293.86 

1985 126.22 76.04 623.35 1,324.53 

1995 150.88 78.17 637.81 1,343.84 

2005 130.33 80.32 640.43 1,341.47 

201 5 60.00 79.60 624.12 1,313.48 

Age group 75- 84 

1980 104.40 106.11 1,410.84 2,571.OO 

1985 126.22 140.30 1,972.20 3,465.08 

1995 199.74 160.30 2,096.1 8 3,619.20 

2005 239.28 165.62 2,145.72 3,689.71 

2015 208.90 170.37 2,155.74 3,681.28 

*Deaths per 700,000;1980data are actual, not forecast. 

number in each duration state are different. Differential effects 

of lung cancer as a competing risk and the differences in the 

number of smokers both will alter the mortality rates for these 

other causes. 

The forecast of the overall lung cancer rate is given in 

Table 23, where the age-standardized rate per 100,000 population between the ages of 55 and 84 is given for each of the four 

general causes of death. The rates in this table are substantially 

higher than the overall age-adjusted death rates because they 

are only for those between the ages of 55 and 84 rather than 

being age-standardized for the entire population. The population used for age standardization is the 1980U.S. population. 

Note that although the lung cancer mortality rate for white 

males is forecast to increase through 2005 for older ages and 

decrease for younger ages, the age-standardized rate is forecast 

to decrease. However this decrease is relatively slower than 

age-specific decreases in younger ages, being almost constant 

120 
Smoking and Tobacco Control Monograph No. 1 

Table 21 

Forecast mortality rates* for select causes of death, black males, 

ages 55 to 84 

Lung Other Coronary Heart All 

Cancer Cancers Disease Other Causes 

Year 

Age group 55 - 64 

1980 314.76 168.86 588.33 1,794.73 

1985 328.73 170.68 597.34 1,810.84 

1995 259.30 165.37 580.66 1,790.37 

2005 113.31 162.05 564.10 1,756.58 

201 5 95.30 176.18 601.21 1,793.03 

Age group 65- 74 

1980 452.74 224.42 1,195.15 3,244.99 

1985 554.03 242.24 1,232.01 3,309.03 

1995 600.65 244.18 1,238.17 3,325.57 

2005 473.81 236.98 1,221.15 3,289.64 

201 5 21 5.75 233.29 1,202.22 3,226.78 

Age group 75- 84 

1980 488.59 239.95 1,956.85 5,409.63 

1985 523.15 394.34 2,438.00 6,794.00 

1995 759.31 471.70 2,575.20 7,104.08 

2005 823.01 475.54 2,589.97 7,142.38 

201 5 652.22 458.10 2,559.84 7,062.83 ~ 

* Deaths per 700,000; 1980 data are actual, not forecast. 

until 1995. For all other gender-race combinations, the agestandardized lung cancer mortality rates increase until around 

2000 and then decrease. Thus, the decreases in smoking 

patterns that have occurred prior to the current time will have 

little effect on decreasing age-standardized rates until 2005 for 

all but white males. 

Potential Reduction The mortality rates forecast by the model assume that 

In Lung Cancer current patterns of initiation and cessation will continue over 

the next 25 years. The impact of improved smoking control 

strategies can be estimated with this model. If one assumes 

that implementation of the comprehensive smoking control 

strategies described in this volume would double current rates 

of cessation, then the impact of these improvements can be 

calculated, as presented in Table 24. The lung cancer mortality 

estimates in Table 24 can be compared with those in the first 

columns of Tables 19 through 22. 

121 
National Cancer Institute 

Table 22 

Forecast mortality rates* for select causes of death, black females, 

ages 55 to 84 ~ 

Lung Other CoronaryHeart All 

Cancer Cancers Disease Other Causes 

Year 

Age group 55 - 64 

1980 73.32 62.40 31 5.95 1,102.76 

1985 94.79 67.65 339.88 1,126.56 

1995 95.99 68.35 343.61 1,129.22 

2005 38.66 70.55 349.36 1,125.35 

201 5 45.73 76.99 376.51 1,155.40 

Age group 65 - 74 

1980 85.69 99.60 729.56 2,140.22 

1985 11 5.24 1 15.82 779.26 2,217.30 

1995 183.92 127.46 806.21 2,238.60 

2005 186.36 128.32 807.08 2,239.14 

2015 77.84 132.42 808.50 2,217.33 

Age group 75 - 84 

1980 86.81 127.68 1,381.49 3,657.1 7 

1985 96.44 150.15 1,759.85 4,449.39 

1995 178.13 185.61 1,916.42 4,671.24 

2005 288.34 203.44 1,974.39 4,722.32 

201 5 292.83 205.21 1,977.33 4,727.77 

*Deaths per 700,000; 7980 data are actual, not forecast. 

For white males, there is a dramatic change in the predicted lung cancer mortality pattern, with approximately a 50 

percent reduction in age-specific lung cancer death rates for all 

age groups by the year 2015. It is important that this reduction 

is in addition to the benefits to be expected from current srnoking control efforts. 

The results for the other racial and gender groups are more 

modest but still impressive. The more modest reductions 

reflect the lower current rates of cessation in those groups and, 

therefore, dramatically underestimate the benefits that could 

be achieved if the cessation patterns occurring among white 

males can be replicated in the other racial and gender groups. 

CONCLUSIONS 0 Males born early in this century became cigarette smokers earlier in life and in greater percentages than females. 

The pattern of initiation and peak prevalence of smoking 

is similar for males and females born into the most 

recent birth cohorts. 

122 
Smoking and Tobacco Control Monograph No. 1 

Table 23 

Forecast age-standardized mortality rates,* based on 1980 

population 

Lung Other Coronary Heart Other 

Cancer Cancers Disease Causes 

Year 

White male 

1980 31 0.61 54 134.8752 1,192.714 1,841.91 4 

1985 305.7283 164.9100 1,331.260 2,174.659 

1995 245.9573 170.0526 1,340.338 2,217.751 

2005 150.9946 168.6916 1,327.521 2,227.296 

2015 67.95557 163.2606 1,318.622 2,183.843 

White female 

1980 88.1 8845 63.94307 616.6047 1,305.564 

1985 105.5464 74.50172 765.1922 1,537.934 

1995 127.0899 80.41 854 800.6575 1,581.471 

2005 1 14.2955 82.12020 810.1826 1,592.848 

2015 77.01 571 84.31 496 81 3.6352 1,588.735 

Black male 

1980 389.381 8 199.0883 1,016.1 76 2,874.051 

1985 435.8217 231.4099 1,112.363 3,131.886 

1995 455.4529 242.1545 1,128.678 3,178.280 

2005 350.4382 238.7241 1,117.134 3,155.673 

2015 227.2963 241.7119 1,124.491 3,139.918 

Black female 

1980 80.22296 88.1 6579 671.2568 1,970.01 2 

1985 102.0179 100.6025 775.6823 2,167.45 

1995 142.2724 1 12.0328 81 8.2055 2,220.809 

2005 139.0346 1 16.9478 832.8903 2,229.558 

2015 106.61 73 121.6528 846.461 9 2,237.143 

*Deaths per 700,000; 1980data are actual, not forecast. 

White males began to quit smoking in substantial 

numbers during the 195O’s,but black males, white 

females, and black females did not begin to quit in substantial numbers until the late 1960’s. 

In general, the birth cohort pattern of cigarette smoking 

closely matches the pattern of lung cancer death rates 

within each racial and gender grouping, but black males 

and females appear to have higher rates of lung cancer 

than white males and females, even after consideration 

of the differences in their smoking behaviors. 

123 
____ 

National Cancer Institute 

Table 24 

Forecast age-specific lung cancer mortality rates,* assuming 

cessation rates are doubled 

White White Black Black 

Male Female Male Female 

Year 

Age group 55 - 64 

1980 208.76 71.29 31 4.76 73.32 

1985 170.67 75.04 321.54 92.82 

1995 73.49 57.46 235.19 88.38 

2005 15.49 21.60 91.20 32.29 

201 5 7.30 8.58 65.24 33.26 

Age group 65 - 74 

1980 375.79 98.11 452.74 85.69 

1985 376.39 122.73 544.93 1 13.27 

1995 276.21 134.41 559.70 171.67 

2005 115.14 101.44 404.11 162.25 

2015 24.66 38.41 162.14 61.03 

Age group 75- 84 

1980 476.60 104.40 488.59 86.81 

1985 502.75 123.99 51 7.38 95.38 

1995 485.26 185.24 721.70 168.96 

2005 364.44 201.04 732.67 257.39 

201 5 150.83 152.14 525.41 242.49 ~ ~ 

*Deaths per 700,000; 1980 data are actual, not forecast. 

A model of future lung cancer death rates based on 

trends in smoking behavior presented in this chapter 

predicts that the lung cancer death rates for white males 

will begin to fall by 1995, with declines in lung cancer 

death rates occurring later among the other racial and 

gender groups. 

A doubling of the effectiveness of current smoking 

control programs could result, by the year 2015, in up to 

a 50 percent reduction in lung cancer death rates from 

those that will occur if current trends continue. 

124 
Smoking and Tobacco Control Monograph No. 1 

REFERENCES Brown, C.C., Kessler, L.G. Projections of lung cancer mortality in the United States: 1985-2025. Iournal ofthe National 

Cancer Institute 80: 43-51, 1988. 

Cowell, M.J., Hirst, B.L. Mortaliv Differences Between Smokers and Nonsmokers. Worcester, MA: State Mutual Life Assurance Company of America, October 22,1979. 

Crane, L.A., Marcus, A.C. Effects of proxy reports on the 

collection of health data in the 1985 Current Population 

Survey. Paper presented at the 115thAnnual Meeting of the 

American Public Health Association, Las Vegas, NV, September 

1986. 

Cummins, J.D., Smith B.D., Vance, R.N., Van Derkin, J.L. 

Risk Classification in Life Insurance. Boston: Kluwer-Nijhoff 

Publishing, 1983. 

Gaffney, M., Altshuler, B. Examination of the role of 

cigarette smoke in lung carcinogenesis using multistage 

models. Journal ofthe National Cancer Institute 80: 146-149, 

1988. 

Hakulinen, T., Pukkala, E. Future incidence of lung cancer: 

Forecasts based on hypothetical changes in the smoking habits 

of men. International Journal ofEpidemiology 10: 233-240, 1981. 

Hammond, E.C. Smoking in relation to the death rates of 

one million men and women. In: Study ofCancer and Other 

Chronic Diseases. Washington, DC: U.S. Government Printing 

Office, 1966, pp. 269-285 (National Cancer Institute Monograph 19). 

Hoffman, M.S. (Editor). World Almanac and Book ofFacts, 

1987. New York: Pharos Books, 1987. 

Lilienfeld, A.M. Cancer Epidemiology: Methods ofstudy. 

Baltimore: Johns Hopkins Press, 1967. 

Moolgavkar, S., Dewanji, A., Luebeck, G. Cigarette smoking and lung cancer: Reanalysis of the British doctors’ data. 

Journal of the National Cancer Institute 81: 415-420, 1989. 

Peto, R. Influence of dose and duration of smoking on 

lung cancer rates. In: Tobacco: A Major International Health 

Hazard, D.G. Zaridze and R. Peto (Editors). Lyons: International Agency for Research on Cancer, 1986. 

Shopland, D.R., Pechacek, T. F., Cullen, J.W. Toward a 

tobacco-free society. Seminars in Oncology 17: 402-412, 1990. 

Tolley, H.D., Manton, K.G.Intervention effects among a 

collection of risks. Transactions ofthe Society ofActuaries (in 

press). 

125 
National Cancer Institute 

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

Consequences of Smoking for Women: A Report of the Surgeon 

General. U.S. Department of Health and Human Services, 

Public Health Service, Office of the Assistant Secretary for 

Health, Office on Smoking and Health, 1980. 

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

Health Consequences of Smoking: Cancer and Chronic Lung 

Disease in the Workplace. A Report of the Surgeon General. U.S. 

Department of Health and Human Services, Public Health Service, Office on Smoking and Health. DHHS Publication No. 

(PHS) 85-50207, 1985. 

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

Consequences of Smoking: Nicotine Addiction. A Report of the 

Surgeon General, 1988. U.S. Department of Health and Human 

Services, Public Health Service, Centers for Disease Control, 

Center for Health Promotion and Education, Office on Smoking and Health. DHHS Publication No. (CDC) 88-8406, 1988. 

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

the Health Consequences of Smoking: 25 Years of Progress. A 

Report of the Surgeon General. 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. DHHS Publication 

NO. (CDC) 89-8411,1989. 

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

Health Benefits of Smoking Cessation: A Report of the Surgeon 

General. U.S. Department of Health and Human Services, 

Public Health Service, Centers for Disease Control, Center for 

Health Promotion and Education, Office on Smoking and 

Health. DHHS Publication No. (CDC) 90-8416, 1990. 

Warner, K.E. Cigarette smoking in the 1970's: The impact 

of the anti-smoking campaign on consumption. Science 211: 

729-731, 1981. 

126 
Appendix A 

Data Points for Figures in Chapter 3 

127 
BLANK PAGE 
Smoking and Tobacco Control Monograph No. 1 

Figure 1. US. per capita cigarette consumption for adults, aged 18 

and older (1900 to 1990) 

Year Per Capita Year Per Capita 

1900 54 1945 3,449 

1901 53 1946 3,446 

1902 60 1947 3,416 

1903 64 1948 3,505 

1904 66 1949 3,480 

1905 70 1950 3,522 

1906 86 1951 3,744 

1907 99 1952 3,886 

1908 105 1953 3,778 

1909 125 1954 3,546 

1910 151 1955 3,597 

1911 173 1956 3,650 

1912 223 1957 3,755 

1913 260 1958 3,953 

1914 267 1959 4,073 

1915 285 1960 4,171 

1916 395 1961 4,266 

1917 551 1962 4,265 

1918 697 1963 4,345 

1919 727 1964 4,195 

1920 665 1965 4,259 

1921 742 1966 4,287 

1922 770 1967 4,280 

1923 911 1968 4,186 

1924 982 1969 3,993 

1925 1,085 1970 3,985 

1926 1,191 1971 4,037 

1927 1,279 1972 4,043 

1928 1,366 1973 4,148 

1929 1,504 1974 4,141 

1930 1,485 1975 4,123 

1931 1,399 1976 4,092 

1932 1,245 1977 4,051 

1933 1,334 1978 3,967 

1934 1,483 1979 3,861 

1935 1,564 1980 3,851 

1936 1,754 1981 3,840 

1937 1,847 1982 3,753 

1938 1,830 1983 3,502 

1939 1,900 1984 3,461 

1940 1,976 1985 3,370 

1941 2,236 1986 3,274 

1942 

1943 

2,585 

2,956 

1987 

1988 

3,197 

3,096 

1944 3,039 1989 2,926 

1990 2,828 

129 
National Cancer Institute 

Figure 2. Changes in prevalence of cigarette smoking among successive birth cohorts of 

U.S. males, 1900 to 1987 

1901- 1911- 1921- 1931- 1941- 1951- 1961- XData 1910 1920 1930 1940 1950 1960 1 970 

1900 0 0 0 0 0 0 0 

1905 0 0 0 0 0 0 0 

1910 0.4 0 0 0 0 0 0 

1915 2.9 0 0 0 0 0 0 

1920 16.2 0.2 0 0 0 0 0 

1925 39.9 2.6 0 0 0 0 0 

1930 56.7 17.4 0.4 0 0 0 0 

1935 61.3 44.3 2.8 0 0 0 0 

1940 61.8 62.0 17.8 0.3 0 0 0 

1945 61-3 65.9 49.4 2.6 0 0 0 

1950 58.9 65.2 65.8 18.7 0.1 0 0 

1955 55.8 62.8 66.1 47.0 2.3 0 0 

1960 51.8 59.6 63.5 61.8 19.1 0.2 0 

1965 45.0 53.6 57.7 59.0 44.7 2.6 0 

1970 32.0 42.1 45.9 47.4 48.5 17.7 0.3 

1975 25.4 39.8 48.1 48.1 52.3 39.4 3.7 

1980 18.6 30.5 40.3 42.5 43.3 39.6 18.7 

1985 15.3 19.8 32.5 35.7 39.5 36.1 32.4 

1987 14.3 17.3 29.5 32.3 35.7 32.1 30.0 

Figure 3. Changes in prevalence of cigarette smoking among successive birth cohorts of 

U.S. females, 1900 to 1987 

1901- 1911- 1921- 1931- 1941- 1951- 1961- XData 1910 1920 1930 1940 1950 1 960 1970 

1900 0 0 0 0 0 0 0 

1905 0 0 0 0 0 0 0 

1910 0.4 0 0 0 0 0 0 

1915 0.1 0 0 0 0 0 0 

1920 0.9 0 0 0 0 0 0 

1925 5.7 0.2 0 0 0 0 0 

1930 13.0 4.0 0.1 0 0 0 0 

1935 18.0 15.8 0.4 0 0 0 0 

1940 21.5 28.2 5.4 0 0 0 0 

1945 23.9 33.5 23.1 0.8 0 0 0 

1950 25.1 35.9 37.2 9.4 0 0 0 

1955 25.4 36.8 41.8 28.9 0.6 0 0 

1960 25.4 37.2 42.5 42.9 10.1 0.1 0 

1965 24.3 36.0 41.6 43.9 30.5 1.1 0 

1970 20.7 31.8 37.3 38.0 35.8 12.0 0.3 

1975 15.4 28.5 35.5 40.0 39.3 32.7 3.2 

1980 13.6 24.9 30.5 34.9 33.6 32.7 20.1 

1985 7.6 17.6 27.5 30.7 32.0 33.6 29.2 

1987 7.3 16.3 24.7 28.8 29.4 30.5 25.9 

130 
Smoking and Tobacco Control Monograph No. 1 

Figure 4. Changes in prevalence of cigarette smoking among successive birth cohorts of 

white U.S. males, 1900 to 1987 

1901- 1911- 1921- 1931- 1941- 1951-' 1961- XData 1910 1920 1930 1940 1 950 1 960 1 970 

1900 0 0 0 0 0 0 0 

1905 0 0 0 0 0 0 0 

1910 0.4 0 0 0 0 0 0 

1915 3.0 0 0 0 0 0 0 

1920 16.5 0.2 0 0 0 0 0 

1925 40.8 2.6 0 0 0 0 0 

1930 58.0 17.5 0.5 0 0 0 0 

1935 62.6 45.0 2.9 0 0 0 0 

1 940 62.9 62.9 18.1 0.3 0 0 0 

1945 62.4 66.8 50.0 2.6 0 0 0 

1950 59.9 66.0 66.8 19.0 0.2 0 0 

1955 56.5 63.5 67.0 47.9 2.5 0 0 

1960 52.4 60.2 64.0 62.4 19.7 0.2 0 

1965 45.3 53.6 57.9 59.3 45.3 2.6 0 

1 970 31.8 41.9 45.5 47.1 48.0 18.3 0.4 

1975 24.8 39.3 47.7 47.7 51.6 39.6 4.2 

1980 18.0 29.7 39.5 42.0 42.9 39.0 ' 20.2 

1985 14.5 19.0 30.7 35.0 39.5 34.4 33.7 

1987 13.5 16.4 27.6 31.4 35.6 30.8 31.O 

Figure 5. Changes in prevalence of cigarette smoking among successive birth cohorts of 

black U.S. males, 1900 to 1987 

1901- 1911- 1921- 1931- 1941- 1951- 1961- XData 1910 1920 1930 1 940 1950 1960 1970 

1900 0 0 0 0 0 0 0 

1905 0 0 0 0 0 0 0 

1910 0.5 0 0 0 0 0 0 

1915 1.7 0 0 0 0 0 0 

1920 12.7 0.2 0 0 0 0 0 

1925 30.9 2.7 0 0 0 0 0 

1930 42.1 15.8 0.2 0 0 0 0 

1935 46.6 38.7 2.2 0 0 0 0 

1940 48.3 54.1 15.8 0.2 0 0 0 

1945 48.6 57.6 44.3 2.5 0 0 0 

1950 48.9 59.6 55.0 16.3 0 0 0 

1 955 47.8 55.8 57.2 39.4 1 .o 0 0 

1960 46.1 54.9 58.0 57.1 15.5 0.3 0 

1965 43.6 54.0 55.7 56.5 41.3 2.2 0 

1970 34.7 45.3 50.0 51 .O 55.0 14.1 0 

1975 33.9 47.8 51.1 55.3 57.9 39.2 1.5 

1980 24.8 40.4 46.9 47.8 47.0 44.6 12.0 

1985 25.3 29.4 42.3 47.8 45.5 46.1 28.5 

1987 25.3 28.3 39.3 45.5 41.6 40.3 28.4 

13 1 
National Cancer Institute 

Figure 6. Changes in prevalence of cigarette smoking among successive birth cohorts of 

white U.S. females, 1900 to 1987 

1901- 1911- 1921- 1931- 1941- 1951- 1961- XData 1910 1920 1930 1 940 1950 1960 1970 

1900 0 0 0 0 0 0 0 

1905 0 0 0 0 0 0 0 

1910 0 0 0 0 0 0 0 

1915 0.1 0 0 0 0 0 0 

1920 0.8 0 0 0 0 0 0 

1925 5.6 0.2 0 0 0 0 0 

1930 13.2 4.2 0.1 0 0 0 0 

1935 18.5 16.5 0.4 0 0 0 0 

1 940 22.2 29.5 5.4 0 0 0 0 

1945 24.6 34.9 23.5 0.8 0 0 0 

1950 25.9 37.4 38.0 9.6 0 0 0 

1955 26.2 38.2 42.7 29.5 0.6 0 0 

1960 26.2 38.8 43.3 43.7 10.3 0.1 0 

1965 25.0 37.4 42.2 44.2 31.2 1.1 0 

1970 21.2 33.0 37.7 37.9 35.9 12.4 0.4 

1975 16.1 29.2 35.9 40.3 39.5 33.6 3.6 

1980 14.5 25.3 30.5 35.0 33.7 33.0 22.0 

1985 7.5 17.9 28.0 31.9 31.8 33.4 30.4 

1987 7.5 16.6 25.3 30.0 29.1 30.1 26.9 

Figure 7. Changes in prevalence of cigarette smoking among successive birth cohorts of 

black US. females, 1900 to 1987 

1901- 1911- 1921- 1931- 1941- 1951- 1961- XData 1910 1920 1930 1940 1950 1960 1970 

1900 0 0 0 0 0 0 0 

1905 0 0 0 0 0 0 0 

1910 0 0 0 0 0 0 0 

1915 0.6 0 0 0 0 0 0 

1920 2.4 0 0 0 0 0 0 

1925 6.6 0.6 0 0 0 0 0 

1930 10.7 3.2 0.1 0 0 0 0 

1935 13.2 9.4 0.4 0 0 0 0 

1940 14.6 16.1 6.1 0 0 0 0 

1945 17.0 20.4 20.3 1 .o 0 0 0 

1950 17.3 23.1 31.7 8.4 0.1 0 0 

1955 17.0 24.6 35.0 25.9 0.5 0 0 

1960 17.3 24.1 37.4 39.4 9.3 0.2 0 

1965 16.7 23.3 37.4 44.3 26.6 0.9 0 

1970 14.5 21.6 35.2 41.3 37.9 9.8 0.1 

1975 8.1 23.8 33.6 41.O 41.3 28.5 1.7 

1980 6.2 22.9 32.7 36.0 36.9 32.7 12.7 

1985 9.7 12.7 28.3 26.7 37.8 37.4 23.5 

1987 8.9 12.2 23.3 24.1 35.7 35.4 22.3 

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Smoking and Tobacco Control Monograph No. 1 

Figure 8. Age-adjusted cancer mortality rates, all males 

X Data All Sites Combined Lung Cancer All Other Cancers 

1950 171.9 22.2 149.7 

1955 182.9 34.6 148.3 

1960 187.9 39.3 148.5 

1965 197.8 48.7 149.1 

1970 190.2 55.9 134.3 

1975 212.2 66.7 145.5 

1980 221.3 73.3 148.0 

1985 218.8 73.9 144.9 

1987 21 9.4 74.9 144.5 

Figure 9. Age-adjusted cancer mortality rates, white males 

X Data All Sites Combined Lung Cancer All Other Cancers 

1950 173.3 22.6 150.7 

1955 183.1 35.2 147.9 

1960 186.8 39.3 147.5 

1965 196.2 48.8 147.4 

1970 194.4 57.5 136.9 

1975 207.7 65.7 142.0 

1980 21 5.6 71.8 143.8 

1985 21 2.5 72.2 140.3 

1987 213.4 73.2 140.2 

Figure 10. Age-adjusted cancer mortality rates, nonwhite males 

X Data All Sites Combined Lung Cancer All Other Cancers 

1950 151.7 16.2 135.5 

1955 176.9 27.3 149.6 

1960 196.3 38.7 157.6 

1965 21 1.9 47.0 164.9 

1970 161.7 44.6 117.1 

1975 252.0 74.9 177.2 

1980 271.7 85.7 186.0 

1985 271.3 87.3 184.0 

1987 269.2 88.5 180.6 

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National Cancer Institute 

Figure 11. Age-adjusted cancer mortality rates, all females 

X Data All Sites Combined Lung Cancer All Other Cancers ~~ 

1950 151.7 5.06 146.7 

1955 145.6 5.92 139.7 

1960 140.0 5.83 134.2 

1965 136.4 7.78 128.7 

1970 143.2 11 -80 131.5 

1975 134.2 15.60 11 8.6 

1980 138.0 21 -40 1 16.6 

1985 139.3 26.40 112.9 

1987 139.5 28.20 111.3 

Figure 12. Age-adjusted cancer mortality rates, white females 

X Data All Sites Combined Lung Cancer All Other Cancers 

1950 151.2 5.0 146.1 

1955 145.1 5.8 139.2 

1960 138.6 5.8 132.8 

1965 135.1 7.6 127.5 

1970 148.0 12.2 135.8 

1975 132.3 15.6 116.6 

1980 136.4 21.5 115.0 

1985 138.2 26.8 111.4 

1987 138.1 28.5 109.6 

Figure 13. Age-adjusted cancer mortality rates, nonwhite females 

X Data All Sites Combined Lung Cancer All Other Cancers 

1950 150.4 4.10 146.4 

1955 144.1 6.10 137.9 

1960 149.6 6.10 143.5 

1965 145.2 7.50 137.7 

1970 110.1 8.82 101.2 

1975 156.5 16.00 140.5 

1980 149.0 20.50 128.5 

1985 146.9 23.20 123.7 

1987 148.6 25.50 123.1 

134 
Smoking and Tobacco Control Monograph No. 1 

Figure 14. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for white U.S. males born 1901 to 191 0 

X Data Current Ever Lung Death 

1900 0 0 0 

1905 0 0 0 

1910 0.4 0.4 0 

1915 3.0 3.0 0 

1920 16.5 16.7 0 

1925 40.8 41.4 0 

1930 58.0 59.2 0 

1935 62.6 64.5 0 

1940 62.9 66.1 0 

1945 62.4 66.9 0 

1950 59.9 67.1 1.7 

1955 56.5 67.2 4.7 

1960 52.4 67.4 9.0 

1965 45.3 67.7 15.9 

1 970 31.8 67.8 26.0 

1975 24.8 65.7 36.5 

1980 18.0 64.3 47.4 

1985 14.5 62.6 56.8 

1987 13.4 62.6 

Figure 15. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for black US. males born 1901 to 191 0 

X Data Current Ever Lung Death 

1900 0 0 0 

1905 0 0 0 

1910 0.5 0.5 0 

1915 1.7 1.7 0 

1920 12.7 12.7 0 

1925 30.9 31.5 0 

1930 42.1 43.3 0 

1935 46.6 48.2 0 

1940 48.3 50.3 0 

1945 48.6 51 .I 0 

1950 48.9 52.1 1.6 

1 955 47.8 52.3 5.4 

1960 46.1 52.7 10.0 

1965 43.6 53.0 15.9 

1970 34.7 53.0 25.8 

1975 33.9 52.1 34.8 

1980 24.8 48.4 44.5 . 

1985 25.3 70.8 51.2 

1987 25.3 70.8 

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National Cancer Institute 

Figure 16. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for white US. males born 191 1 to 1920 

X Data Current Ever Lung Death 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0 0 0 

1920 0.2 0.2 0 

1925 2.6 2.6 0 

1930 17.5 17.7 0 

1935 45.0 45.5 0 

1940 62.9 64.0 0 

1945 66.8 69.2 0 

1 950 66.0 70.7 0 

1955 63.5 71.I 0 

1960 60.2 71-3 2.3 

1965 53.6 71.5 5.7 

1970 41.9 71.6 11.5 

1975 39.3 73.8 19.4 

1980 29.7 72.2 30.1 

1985 19.0 72.3 41.O 

1987 16.4 72.3 

Figure 17. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for black US. males born 191 1 to 1920 

X Data Current Ever Lung Death ~~ ~ ~ ~ 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0 0 0 

1920 0.2 0.2 0 

1925 2.7 2.7 0 

1930 15.8 15.8 0 

1935 38.7 38.7 0 

1940 54.1 54.7 0 

1945 57.6 58.7 0 

1950 56.8 59.6 0 

1955 55.8 59.6 0 

1960 54.9 60.0 3.7 

1965 54.0 60.5 7.7 

1970 45.3 62.7 16.6 

1975 47.8 68.0 26.2 

1980 40.4 65.7 37.5 

1985 29.4 65.0 47.5 

1987 28.3 65.0 

136 
Smoking and Tobacco Control Monograph No. 1 

Figure 18. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for white U.S. males born 1921 to 1930 

X Data Current Ever Lung Death ~ 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0 0 0 

1920 0 0 0 

1925 0 0 0 

1930 0.5 0.5 0 

1935 2.9 2.9 0 

1940 18.1 18.2 0 

1945 50.0 50.6 0 

1950 66.8 69.0 0 

1955 67.0 71.5 0 

1960 64.O 72.0 0 

1965 57.9 72.3 1.2 

1970 45.5 72.5 3.3 

1975 47.7 75.7 6.9 

1980 39.5 75.8 12.8 

1985 30.7 73.8 21.2 

1987 27.6 73.9 

Figure 19. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for black U.S. males born 1921 to 1930 

X Data Current Ever Lung Death 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0 0 0 

1920 0 0 0 

1925 0 0 0 

1930 0.2 0.2 0 

1935 2.2 2.2 0 

1 940 15.8 15.7 0 

1945 44.3 44.8 0 

1950 55.0 56.4 0 

1 955 57.2 60.0 0 

1960 58.0 61.6 0 

1965 55.7 62.0 2.2 

1970 50.0 62.5 5.9 

1975 51.1 68.6 11.7 

1980 46.9 68.1 19.5 

1985 42.3 74.7 28.9 

1987 39.3 74.7 

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National Cancer Institute 

Figure 20. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for white U.S. males born 1931 to 1940 

X Data Current Ever Lung Death 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0 0 0 

1 920 0 0 0 

1925 0 0 0 

1930 0 0 0 

1935 0 0 0 

1940 0.3 0.3 0 

1945 2.6 2.6 0 

1950 19.0 19.2 0 

1955 47.9 48.9 0 

1960 62.4 65.4 0 

1965 59.3 67.8 0 

1970 47.1 68.5 0 

1975 47.7 69.9 1.3 

1980 42.0 70.9 3.1 

1985 35.0 69.8 6.2 

1987 31.4 69.8 

Figure 21. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for black U.S. males born 1931 to 1940 

X Data Current Ever Lung Death 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0 0 0 

1920 0 0 0 

1925 0 0 0 

1930 0 0 0 

1935 0 0 0 

1940 0.2 0.2 0 

1945 2.5 2.5 0 

1950 16.3 16.3 0 

1955 39.4 39.8 0 

1960 57.1 57.6 0 

1965 56.5 60.2 0 

1970 51.O 62.1 0 

1975 55.3 68.7 2.4 

1980 47.8 67.4 5.5 

1985 47.8 61.O 10.0 

1987 45.5 61.O 

138 
Smokina and Tobacco Control MononraDh No. 1 

Figure 22. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for white U.S. males born 1941 to 1950 

X Data Current Ever Lung Death ~ 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0 0 0 

1920 0 0 0 

1925 0 0 0 

1930 0 0 0 

1935 0 0 0 

1940 0 0 0 

1945 0 0 0 

1950 0.2 0.2 0 

1955 2.5 2.5 0 

1960 19.7 19.9 0 

1965 45.3 47.4 0 

1970 48.0 61.4 0 

1975 51.6 65.9 0 

1980 42.9 66.2 0 

1985 39.5 65.2 0.9 

1987 35.6 65.3 

Figure 23. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for black U.S. males born 1941 to 1950 

X Data Current Ever Lung Death 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0 0 0 

1920 0 0 0 

1925 0 0 0 

1930 0 0 0 

1935 0 0 0 

1940 0 0 0 

1945 0 0 0 

1950 0 0 0 

1955 1 1 0 

1960 15.5 15.6 0 

1965 41.3 42.4 0 

1970 55.0 60.3 0 

1975 57.9 64.7 0 

1980 47.0 63.1 0 

1985 45.5 64.1 1.7 

1987 41.6 64.1 

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National Cancer Institute 

Figure 24. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for white U.S. females born 1901 to 191 0 

X Data Current Ever Lung Death 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0.1 0.1 0 

1 920 0.8 0.9 0 

1925 5.6 5.7 0 

1930 13.2 13.4 0 

1935 18.5 18.8 0 

1940 22.2 22.8 0 

1945 24.6 25.6 0 

1950 25.9 27.5 0.35 

1955 26.2 28.4 0.68 

1960 26.2 29.4 1.2 

1965 25.0 29.8 2.2 

1970 21.2 30.2 4.1 

1975 16.1 27.9 6.5 

1980 14.5 27.5 10.3 

1985 7.5 20.1 13.6 

1987 7.2 20.1 

Figure 25. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for black U.S. females born 1901 to 191 0 

X Data Current Ever Lung Death 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0.6 0.6 0 

1920 2.4 2.4 0 

1925 6.6 6.6 0 

1930 10.7 10.7 0 

1935 13.2 13.2 0 

1940 14.6 14.6 0 

1945 17.0 17.2 0 

1950 17.3 18.9 0.4 

1955 17.0 19.7 1.1 

1960 17.3 20.5 1.3 

1965 16.7 20.6 2.4 

1970 14.5 21.3 3.5 

1975 8.1 17.0 7.9 

1980 6.2 18.1 8.4 

1985 9.7 17.2 10.1 

1987 8.9 17.2 

140 
Smoking and Tobacco Control Monograph No.1 

Figure 26. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for white U.S. females born 1911 to 1920 

X Data Current Ever LungDeath 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0 0 0 

1920 0 0 0 

1 925 0.2 0.2 0 

1930 4.2 4.2 0 

1935 16.5 16.6 0 

1940 29.5 30.0 0 

1 945 34.9 35.9 0 

1950 37.4 39.3 0 

1955 38.2 41.0 0 

1960 38.8 42.6 0.6 

1965 37.4 43.4 1.4 

1970 33.0 44.0 3.0 

1975 29.2 42.9 5.5 

1980 25.3 42.8 9.3 

1985 17.9 37.4 14.6 

1907 16.6 37.4 

Figure 27. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for black U.S. females born 1911 to 1920 

X Data Current Ever LungDeath 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0 0 0 

1920 0 0 0 

1925 0.6 0.6 0 

1930 3.2 3.2 0 

1935 9.4 9.6 0 

1940 16.1 16.5 0 

1945 20.4 20.9 0 

1950 23.1 24.0 0 

1955 24.6 25.9 0 

1960 24.1 26.7 0.7 

1965 23.3 26.8 1.5 

1970 21.6 27.7 3.0 

1975 23.8 33.7 4.6 

1980 22.9 36.1 8.0 

1985 12.7 26.0 10.9 

1907 12.2 26.0 

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National Cancer Institute 

Figure 28. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for white US. females born 1921 to 1930 

X Data Current Ever Lung Death 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0 0 0 

1920 0 0 0 

1925 0 0 0 

1930 0.1 0.1 0 

1935 0.4 0.4 0 

1940 5.4 5.4 0 

1945 23.5 24.1 0 

1950 38.0 39.4 0 

1955 42.7 44.8 0 

1960 43.3 46.8 0 

1965 42.2 48.2 0.4 

1970 37.7 48.8 1.2 

1975 35.9 47.3 2.7 

1980 30.5 46.3 5.2 

1985 28.0 47.5 9.2 

1987 25.3 47.5 

Figure 29. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for black US. females born 1921 to 1930 

X Data Current Ever LungDeath 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0 0 0 

1920 0 0 0 

1925 0 0 0 

1930 0.1 0.1 0 

1935 0.4 0.4 0 

1940 6.1 6.1 0 

1945 20.3 20.3 0 

1950 31.7 32.0 0 

1955 35.0 36.3 0 

1960 37.3 39.1 0 

1965 37.4 40.5 0.6 

1970 35.2 42.2 1.5 

1975 33.6 43.7 2.8 

1980 32.7 47.8 5.6 

1985 28.3 43.9 8.8 

1987 23.3 43.9 

142 
Smoking and Tobacco Control Monograph No. 1 

Figure 30. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for white US. females born 1931 to 1940 

X Data Current Ever Lung Death 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0 0 0 

1920 0 0 0 

1925 0 0 0 

1930 0 0 0 

1935 0 0 0 

1940 0 0 0 

1945 0.8 0.8 0 

1950 9.6 9.7 0 

1955 29.5 30.2 0 

1960 43.7 46.3 0 

1965 44.2 50.0 '0 

1970 37.9 51 -5 0 

1975 40.3 51.1 0.7 

1980 35.0 51.2 1.7 

1985 31.9 50.1 3.5 

1 987 30.0 50.1 

Figure 31. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for black U.S. females born 1931 to 1940 

X Data Current Ever LungDeath 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0 0 0 

1920 0 0 0 

1925 0 0 0 

1930 0 0 0 

1935 0 0 0 

1 940 0 0 0 

1945 1 .o 1 .o 0 

1950 0.4 8.5 0 

1955 25.9 26.0 0 

1960 39.4 39.9 0 

1965 44.3 46.4 0 

1970 41.3 49.t 0 

1975 41.O 47.8 0.8 

1980 36.0 45.7 2.0 

1985 26.7 39.5 3.3 

1987 24.1 39.5 

143 
National Cancer Institute 

Figure 32. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for white U.S. females born 1941 to 1950 

X Data Current Ever Lung Death 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0 0 0 

1920 0 0 0 

1 925 0 0 0 

1930 0 0 0 

1935 0 0 0 

1940 0 0 0 

1945 0 0 0 

1950 0 0 0 

1955 0.6 0.6 0 

1960 10.3 10.5 0 

1965 31.2 33.3 0 

1970 35.9 46.9 0 

1975 39.5 49.0 0 

1980 33.7 49.7 0 

1985 31.8 49.4 0.6 

1987 29.1 49.5 

Figure 33. Changes in current smokers, ever-smokers, and lung 

cancer deaths, for black U.S. females born 1941 to 1950 

X Data Current Ever Lung Death 

1900 0 0 0 

1905 0 0 0 

1910 0 0 0 

1915 0 0 0 

1920 0 0 0 

1925 0 0 0 

1930 0 0 0 

1935 0 0 0 

1940 0 0 0 

1945 0 0 0 

1950 0.1 0.1 0 

1955 0.5 0.5 0 

1960 9.3 9.3 0 

1965 26.6 26.9 0 

1970 37.9 41.8 0 

1975 41.3 44.4 0 

1980 36.9 46.0 0 

f 985 37.8 49.1 0.6 

1987 35.7 49.4 

144 
Chapter 4 

Approaches Directed to the Individual 

CONTENTS Introduction .......................................................................... 147 

Public Information Campaigns ............................................147 . Early Presentation of Smoking’s Hazards ....................... 148 

Counteradvertising in the 1960’s..................................149 

Persuasion Approaches of the 1970’sand 1980’s..........149 

EvoIution of School-Based Interventions .............................. 152 

Traditional Approaches .................................................. 152 

Development and Application of Psychosocial 

Approaches ................................................................. 153 

Clinical Approach to Smoking Control ................................ 170 

Historical Trends ........................................................... 170 

Effectiveness of Different Methods ................................172 

Importance of Clinical Interventions ............................177 

Self-Help Approaches ............................................................179 

Effectiveness of Self-Help Efforts .................................... 180 

Acceptability of Self-Quitting ........................................ 180 

Importance of Self-Quitting ........................................... 181 

Conclusions...........................................................................182 

References .............................................................................. 183 

145 
BLANK PAGE 
Chapter 4 

Approaches Directed to the Individual 

INTRODUCTION The goal of any smoking control strategy is to influence 

individuals to choose nonsmoking status. Early efforts attempted to promote changes within the individual that would 

allow people to alter their behavior regardless of the social and 

environmental influences promoting smoking. More recently, 

public health professionals have recognized the need to change 

the smoking environment to provide persistent messages to 

quit and to encourage those who have quit not to relapse. 

Regardless of the smoking control strategy adopted, however, 

change must begin with the individual’s choices. As a result, a 

major effort of any comprehensive smoking control strategy 

should be focused directly on the individual. 

Three major approaches to the individual can be identified: (1)The first consists of public information campaigns 

that inform the smoker of the disease risks associated with 

smoking and continually present this information as a motivation for smoking cessation. (2) The second is the delivery of 

school-based health education curricula designed to prevent 

initiation of tobacco use by adolescents. (3) The third is the 

development of programs and clinics that smokers can use 

individually or in groups to improve the likelihood of longterm success with cessation attempts. Each of these approaches 

has important effects on the social environment and contributes synergistically to other components of a comprehensive 

smoking control effort; however, their major focus is on the 

individual. 

PUBLIC The changing role of the media in portraying cigarettes 

INFORMATION reflects the evolution of mass communication. The severe 

CAMPAIGNS deleterious impact of smoking on health makes cigarette 

advertising a special concern. The past and present influence 

of tobacco companies, expressed through billions of advertising 

dollars, has both promoted tobacco use and effectively censored information on the adverse health consequences of 

tobacco use in most print media (Wallack, 1989; Warner, 1981 

and 1985). This section reviews the historical role of the mass 

media and describes how cigarettes have been portrayed to the 

public by both protobacco and antitobacco groups. Modem 

antismoking media campaigns also are analyzed and discussed. 

Hand-rolled, paper-wrapped cigarettes were first heavily 

marketed at the beginning of the 20th century, partly in 

response to public health campaigns against chewing tobacco. 

Such campaigns alleged that the practice of spitting tobacco 

147 
Early Presentation 

Of Smoking’s 

Hi3ZiWd.S 

National Cancer Institute 

juice and wads onto streets and into cuspidors was a major 

contributor to the spread of tuberculosis and other communicable diseases. During this time, a new strain of tobacco that 

was much milder than cigar tobacco appeared on the market. 

For economic reasons and to expand their markets, the tobacco 

companies promoted a new milder cigarette as an alternative to 

chewing tobacco and as a product that offered a lower dose of 

nicotine. The development of cigarette rolling machines made 

the mass production of cigarettes more efficient and the 

products more available (Consumers Union, 19 72). 

Anticigarette campaigns were sponsored by educators, reformers, business leaders, and respected public figures in 

reaction to the marketing of the new milder, paper-wrapped 

cigarettes. In particular, the campaigns were designed to 

prevent smoking by women and children (Diehl, 1969;Troyer 

and Markle, 1983). 

Although some groups opposed smoking for health reasons, others attacked smoking as a moral issue. They claimed 

that cigarette smoking affected the brain and therefore contributed to degeneracy. Ultimately, the campaigns resulted in 

legislation that prohibited or limited cigarette smoking in most 

states by the early 1920’s.The impact of the laws on behavior 

was negligible, however. By 1927,the few states that still had 

smoking prohibition laws simply restricted sales to minors. 

Medical evidence that linked the increasing number of 

lung cancer deaths to smoking began to emerge in the United 

States in the late 1930’s.Several researchers investigated the 

relationship between the tobacco industry’s expenditures on 

mass media and the media’s coverage of the risks of smoking. 

Even though the evidence linking smoking to lung cancer was 

newsworthy and was presented at press conferences, most 

newspapers and magazines censored the information, possibly 

because they feared the loss of advertising revenue (Bagdikian, 

1983;Cirino, 1972;Consumers Union, 1972). Two major New 

York daily newspapers that carried limited information about 

the evidence restricted their stories to a few paragraphs placed 

inconspicuously in the middle or back of the paper (Bagdikian, 

1983). 

The revenue provided by tobacco advertisers has continued to suppress the presentation of the strong empirical relationship between smoking and health problems (Warner, 

1985). Cirino (1972)reported that, from 1938 to 1955,only

limited coverage was given to scientific evidence of the suspected link between smoking and lung cancer. At that time, 

the tobacco industry was a leading advertiser in newspapers 

and magazines in the United States. The tobacco companies 

148 
Smoking and Tobacco Control MonographNo. 1 

Counteradvertising 

In the 1960’s 

Persuasion 

Approaches of 

The 1970’sand 

1980’s 

routinely screened magazines and newspapers prior to publication to find articles dealing with the relationship between 

smoking and health, and they withheld advertising from issues 

that contained information on the negative health effects of 

smoking (Warner, 1985). 

The publication of the Surgeon General’s Report in 1964 

was accompanied by substantial media exposure. The impact 

of the mass media coverage was a 15 to 20 percent fall in 

cigarette sales across the United States within a few weeks of 

the report’s release (Consumers Union, 1972); however, that 

impact was short-lived. 

Cigarette consumption returned almost to pre-1964 levels 

within 1 year after the release of the Surgeon General’s Report. 

Public health agencies launched several television-based antismoking campaigns between 1964 and 1970. The Consumers 

Union (1972) reported that mass media campaigns launched 

subsequent to the 1964 Surgeon General’s Report had the 

following objectives: (1)to increase awareness of the negative 

health effects of smoking, (2) to promote abstinence among 

teenagers, and (3) to motivate current smokers to quit. 

Several conclusions have been drawn from reviews of the 

early mass media campaigns against cigarettes and the influence of cigarette advertising (Consumers Union, 1972; Flay, 

1987; Warner, 1981). The consensus was that mass media 

campaigns enhanced awareness of the detrimental effects of 

smoking on health. Such campaigns were found to motivate 

nonsmokers to abstain from smoking, at least temporarily. 

However, the antismoking educational campaigns seemed to 

have little sustained effect on changing the behavior of habitual smokers. Cigarette advertising was suggested to have a 

substantial influence on a young person’s decision to start 

smoking. 

Cigarette advertising associates smoking with enjoyment 

of life. Specifically, the advertising connects smoking with 

popuIar music, enhanced sexuality, popularity, and general 

happiness-overall, a very appealing message to adolescents. 

Furthermore, low-tar, low-nicotine cigarettes have been promoted by tobacco companies as less harmful alternatives to 

brands that have higher tar and nicotine concentrations. 

These advertising campaigns were found to be effective in motivating individuals who are concerned about their health to 

switch brands rather than to quit smoking. Almost 15to 

20 years later, the earlier conclusions presented by the Consumers Union have been replicated by additional research on 

the mass media, the tobacco industry, and advertising (Flay, 

1987; Wallack, 1989; Warner, 1985; Warner et al., 1986). 

149 
National Cancer Institute 

To counter the financially and politically powerful tobacco 

industry, professionals in public health, communications, and 

education and political lobbying groups have conducted 

numerous mass media campaigns and interventions during the 

past 30 years. More sophisticated appeals, designed to promote 

abstinence or facilitate cessation, evolved from initial educational campaigns of the late 1960’sand early 1970’s. However, 

cigarette advertising and promotion expenditures also increased, from approximately $491 million in 1975 to more 

than $3 billion in 1988 in the United States (Centers for 

Disease Control, 1990). 

The results of the U.S. public health campaigns conducted 

from 1967 to 1970 suggested sustained counteradvertising did 

affect the smoking-related beliefs and behaviors of many cigarette smokers (Warner, 1981). The results also suggested a 

dose-response relationship: As counteradvertising was increased and maintained, smoking prevalence decreased (Flay, 

1987). 

Flay (1987) reviewed 40 mass media programs and campaigns conducted in the past 30 years, evaluating their relative 

effectiveness in changing smoking prevalence rates and in 

sustaining quit rates. Comparing the programs and campaigns, 

however, was problematic. Most evaluations utilized posttestonly or single-group designs without randomization, and 

quasi-experimental designs made it difficult to attribute 

changes in smoking status to the program or campaign. However, several criteria were noted to maximize the effects of 

media campaigns against cigarettes (Flay, 1987),including the 

presentation of several different messages over a short time, 

widespread dissemination of information among the target audience, frequent airing of the messages, and long-term implementation of the advertising campaign. 

Flay concluded that viewing a cessation program message 

on television was as effective for viewers as the American Lung 

Association self-help manuals were for requestors. The television programs, in combination with the manuals, were found 

to be more effective than the American Lung Association 

manuals alone. Moreover, the media viewing plus social 

support condition was found to be the most effective mass 

media condition in that study. 

Using their integration of prevailing theory, Flay and 

Burton (1988)proposed the following six necessary and interrelated conditions for a n effective campaign: (1)The campaign 

should include high-quality messages, information sources, 

and media channels. (2) The message must be disseminated to 

the target audience and presented frequently, with some 

variety, over a long duration and at optimal viewing times. 

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(3) The campaign must retain the audience’s attention by 

ensuring the quality of the message, providing appropriate and 

supportive media channels, and ensuring that the message 

corresponds to audience characteristics. (4) Interpersonal 

communication among members of the target audience should 

be encouraged. Groups with opposing viewpoints should be 

encouraged to exchange dialogue that might influence social 

norms. (5) The campaign should facilitate changes in individuals in the target audience. For example, dialogue between 

smokers and nonsmokers could enhance smokers’ awareness of 

their behavior’s undesirable effects on others. (6) The campaign should influence social norms against smoking. Social 

norms might also be influenced by dialogue between legislators 

and their constituents; voter support of an increase in the 

excise tax on cigarettes might be one example. 

A strategy often neglected in mass media campaigns has 

been to provide smokers with the requisite skills to quit smoking and to provide nonsmokers with the skills needed to 

remain abstinent (McAlister et al., 1989). Campaigns that have 

attempted to address these issues have done so primarily

through applications of Bandura’s social learning theory (Le., 

the concepts of modeling, self-efficacy, and social support; 

Bandura, 1977). Television has been a popular medium for 

demonstration programs in which celebrities or trained individuals serving as role models provide specific instructions and 

demonstrate skills that the audience is encouraged to emulate 

(Flay, 1987; McAlister et al., 1989). 

Three examples of such demonstration programs were discussed by McAlister and associates (1989). Each demonstration 

was a large-scale project, one of which was implemented on a 

national level throughout Finland. The remaining programs 

were community programs-one in the county of North Karelia, Finland, and the other in Houston, Texas. The results of the 

Finnish national program were reported in detail by Puska and 

colleagues (1979). In brief, the national project was a television-based program that featured a role model who was trained 

to facilitate successful coping strategies and who then guided a 

group of smokers through the stages of smoking cessation. The 

authors reported that, of the 30,000 to 40,000 smokers who 

participated in the televised series, approximately 10,000 

former smokers credited the first year of their nonsmoking 

status to the program. 

The community projects carried the mass media approach 

to smoking cessation a step further. In North Karelia, a comprehensive program for cardiovascular risk reduction included a 

smoking cessation component. In addition to a televised 

cessation series, the program included recruitment and training 

of 805 volunteers to provide social reinforcement to individuals 

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EVOLUTION OF 

SCHOOL-BASED 

INTERVENTIONS 

Traditional 

Approaches

Information Model 

National CancerInstitute 

trying to quit smoking. The volunteers were also given selfhelp manuals to distribute to those individuals, and they reported success in helping approximately 500 smokers to quit 

(McAlister et al., 1989). 

The Houston project ran concurrently with the American 

Cancer Society’s Great American Smokeout. The media outlets 

used included the most widely viewed television station in 

Houston and one of the two city newspapers. Trained role 

models, who volunteered to attempt to quit smoking, were 

presented in specific programs, news announcements, and 

public service announcements. The role models were videotaped not only during group counseling sessions but also as 

they went about their daily activities. As part of the project’s 

comprehensive approach, newspaper announcements featured 

motivational statements and specific instructions for cessation, 

and printed materials were distributed by local pharmacies and 

grocery stores (McAlister et al., 1989). Brief training and 

printed materials were also provided to community public 

schools and large businesses. The results indicated that 20,000 

to 40,000 individuals quit smoking as a result of this campaign. 

There have been a number of excellent reviews of schoolbased programs to prevent smoking published in the last dozen 

years (Bell and Battjes, 1985; Best et al., 1988; Botvin, 1986; 

Cleary et al., 1988; Flay, 1985; Flay et al., 1983; Glynn and 

Haenlein, 1988; Glynn et al., 1983; Goodstadt, 1978; Leventhal 

and Cleary, 1980; Schaps et al., 1981; Snow et al., 1985; Sussman, 1989; Thompson, 1978; Tobler, 1986; US DHEW, 1979; 

US DHHS, 1989). These reviews provide careful methodological critiques of published studies that must precede any attempt to draw general conclusions from such varied and 

extensive literature. Although they differ in their enthusiasm 

for the interventions tested to date, the reviewers agree that the 

so-called traditional approaches to smoking prevention are 

largely ineffective and that approaches based on the socialpsychological models are at least modestly effective across a 

variety of settings, times, and populations. 

The interventions reviewed here are presented in historical 

sequence and grouped by common concepts, and their similarities and differences are noted. Several of the intervention 

methods discussed here are now under study in projects too 

recent to have been included in previous reviews or to have 

published results. 

The information model presumes that teaching adolescents that smoking is harmful will modify their attitudes and 

beliefs, which in turn will alter their smoking behavior. Information programs use various methods, including films, lectures, discussions, posters, pamphlets, newspaper articles, and 

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Affective Model 

guest speakers, to provide factual information on what tobacco 

products consist of, how they are used, and what effect they 

have on health, especially long-term health outcomes (Goodstadt, 1978; Schaps et al., 1981; Thompson, 1978; US DHEW, 

1979). 

Although there is substantial evidence linking beliefs and 

attitudes with behavior (Fishbein, 1967; Fishbein and Ajzen, 

1975; Hovland et al., 1953; McGuire, 1964 and 1969), the 

information model presumes that knowledge is the major determinant of behavior and thereby ignores the many complex 

social and personal factors that play an important role in the 

development of smoking among adolescents. The twomajor 

reviews of the smoking prevention literature based on the information model concluded that it was largely ineffective 

(Goodstadt, 1978; Thompson, 1978). In spite of these findings, 

the information model continues to predominate in schoolbased programs for smoking prevention outside the research 

milieu (Murray et al., 1988). 

The affective model assumes that tobacco use is influenced 

largely by attitudes. Programs based on the affective model 

attempt to enhance self-esteem and self-image, to teach stress 

management and stress reduction, to clarify the student’s 

values and show that tobacco use is inconsistent with those 

values, to improve decisionmaking, and to encourage greater 

achievement through goal-setting. Such programs often do not 

include specific information about tobacco or drug use (Durell 

and Bukoski, 1984; Goodstadt, 1978). The affective model 

evolved as educators and researchers recognized that the 

information model was inadequate and that youth who became involved with smoking or drugs often had a negative selfimage, were poor achievers, had trouble making healthy 

decisions, and were under multiple stressors from their social 

environments. 

Although attitude change can be an important component 

of behavior change, there is substantial evidence that the 

individual must also possess the skills to carry out the desired 

behaviors and believe that he or she can successfully execute 

those behaviors and that the behaviors will have the desired 

effect (Bandura, 1977; Maiman and Becker, 1974). There is 

little evidence that programs based only on the affective model 

have any beneficial effect on behavior with respect to tobacco 

or drug use (Hansen et al., 1988; Schaps et al., 1981; Tobler, 

1986). 

Development and Three major social-psychological approaches have evolved 

Application of as alternatives to the traditional approaches described above. 

Psychosocial These psychosocial models are the social influences model, the 

Approaches cognitive behavioral model, and the life skills model. 

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The social influences model recognizes smoking in adolescence as primarily a social behavior. This model includes the 

following four components: (1) information on the negative 

social effects and short-term physiological consequences of 

tobacco use; (2)information on the social influences that 

encourage smoking among adolescents, particularly peer, 

parent, and mass media influences; (3) correction of inflated 

normative expectations of the prevalence of adolescent smoking; and (4) training, modeling, rehearsing, and reinforcing of 

methods to resist those influences and to communicate that 

resistance to others, particularly peers (Evans, 1976, 1983, and 

1984; Evans et al., 1978,1981, and 1984; Evans and Raines, 

1982). 

The initial effort also employed older peer leaders as 

facilitators and included a public commitment by the adolescent to not become a regular smoker (McAlister et al., 1979 and 

1980; Perry et al., 1980a;Telch et al., 1982) or employed sameage peer leaders to increase the utility and visibility of leaders 

outside the formal classroom sessions (Hurd et al., 1980; 

Luepker et al., 1983). Jason (1979) experimented with modeling and rehearsing of pressure resistance skills but did not 

include the other elements of the social influences model and 

involved a single focus group of ninth graders. Evans (1976, 

1982, 1984, and 1990) describes the social influences model as 

social inoculation. This model involves increasing children and 

adolescents’ resistance to social influences that promote smoking by “inoculating” youth with knowledge and social skills for 

resisting such pressures. Furthermore, social inoculation 

includes training to understand and cope with not only overt 

social influences to smoke but also more subtle influences, 

such as smoking models in cigarette advertisements or individual perceptions of peer group smoking norms. 

The cognitive behavioral model assumes that smoking is the 

result of both social and psychological factors, and therefore 

tobacco use is learned as an approach to meeting social needs 

(e.g., stress reduction, conversation supplement, transition 

marking). The cognitive behavioral model differs from the 

social influences model by including several intervention 

components that address belief-attitude-behavior structures 

that may increase adolescents’ risk for tobacco use, and by 

using other than tobacco-related examples and settings as part 

of its generic social skills training. The earliest examples drew 

heavily on problem behavior theory (‘Jessor and Jessor, 1977) 

and cognitive behavior therapy (Kendall and Hollon, 1979). 

The cognitive behavioral approach adopts the basic social 

influences model and adds role-playing, rehearsal, and reinforcement of pressure resistance skills. It includes problemsolving, decision-making, and self-control methods (Kendall 

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and Hollon, 1979) to teach adolescents how to recognize risks 

and manage initial impulses until they are able to evaluate 

options and select appropriate responses. It also includes selfreward methods (Bandura, 1977) to improve self-efficacy and 

to teach students to reward themselves for correct decisions. 

Early studies, like those based on the social influences model, 

showed positive results (Gilchrist et al., 1979; Schinke and 

Blythe, 1981; Schinke and Gilchrist, 1983) but were subject to a 

number of methodological limitations (for a discussion, see 

Flay, 1985). 

The rife skiZls model incorporates the four elements of the 

social influences model; the decision-making, problem-solving, 

self-control, and self-reward strategies from the cognitive 

behavioral model; and methods to develop greater autonomy, 

self-esteem, and self-confidence from the affective model. Even 

more than the cognitive behavioral model, the life skills model 

provides training to help adolescents cope with social challenges, including those that involve tobacco. 

The life skills training program used a social-psychological

approach and had promising results. A 10-session life skills 

training program reduced the incidence of new smoking by 

75 percent in one study involving 8th, 9th, and 10th graders 

(Botvin et al., 1980). Botvin and Eng (1982), in a 12-session 

life skills training program involving only seventh graders, 

showed students smoking less at l-year followup, reducing new 

smoking by a significant 58 percent. The 1Zsession life skills 

training program is described in Table 1. 

Table 2 presents a comparison of some psychosocial 

school-based interventions. Included are the intervention 

grades, frequency and number of sessions, the intervention 

administrator, and size of the study population. 

The following sections summarize subsequent work on the 

three psychosocial models, especially refinements and applications along the following four dimensions: (1)program variations, involving the type of instructor, the timing and spacing 

of the sessions, the targeted age group, and use of media 

supplements; (2)the addition of complementary delivery 

channels such as mass'media, community organizations, and 

parent involvement; (3) the addition of complementary target 

outcomes such as substance use, nutrition, physical activity, 

and other health behaviors; and (4) long-term followup studies. 

For each model, the concluding paragraphs describe current 

and planned activities. It is notable that, in the course of continued development, there has been a gradual merging of the 

components of three psychosocial models. 

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Table 1 

A 12-session life skills training program 

Session Topics 

Orientation General introduction, saliva collection, pretest questionnaires 

Smoking: myths and realities Common attitudes and beliefs about smoking, prevalence of 

smoking, reasons for and against smoking, process of becoming 

addicted, decreasing social acceptance of smoking 

Smoking and biofeedback Effects of smoking on carbon monoxide levels and heart rate 

Self-image and self-improvement Self-image and how it is formed, self-image and behavior, 

importance of positive self-image, improving self-image 

Decision-making and independent General decision-making strategies, sources of influence affecting 

thinking decisions, resisting persuasive tactics, importance of independent 

thinking 

Advertising techniques Use and function of advertising, ad techniques, identifying ad 

techniques in cigarette ads and how they affect consumers' 

behavior, alternate ways to respond to these ads 

Coping with anxiety Situations causing anxiety, demonstration and practice of techniques for coping with anxiety 

Communications skills Verbal and nonverbal communication, learning to communicate 

effectively, techniques for avoiding misunderstanding 

Social skills A Overcoming shyness, initiating social contacts, giving and 

receiving compliments, basic conversational skills 

Social skills B Boy-girl relationships, nature of attraction, conversing with the 

opposite sex, asking someone for a date 

Assertiveness Situations calling for assertiveness, reasons for not being assertive, verbal and nonverbal assertive skills, resisting peer pressure 

to smoke 

Conclusion Review, conclusions, saliva collection, posttest questionnaires 

Adapted from Bowin and Eng (1982).Sessions were 1 hour in length, and there was one session per 

week for 12 weeks. 

Social Influences Model Progum variations. Variations in the programs consist of 

changes in delivery of the instructional material, age of the students, use of media supplements, involvement of parents, and 

rewards for low smoking rates. Positive effects have been 

reported when the social influences model was delivered by 

project staff (rather than classroom teachers) (Coe et al., 1982; 

Dielman et al., 1985;Jason et al., 1982;Shaffer et al., 1983; 

Spitzzeri and Jason, 1979). Coe and colleagues (1982)used 

freshman medical students, who learned the intervention 

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Table 2 

A comparison of some psychosocial school-based interventions 

Intervention Number of Frequency of Intervention Booster Study 

Grades Sessions Sessions Administrator Sessions Population 

Investigators 

Social lnfluences Model 

Coe et al., 1982 7 or 8 8 Weekly or Program staff No 30-40 

twice weekly 

Jason et al., 1982 9 7 Weekly Program staff No 1 49 

Spittzeri and 9 10 Weekly Program staff No 61 

Jason, 1979 

Evans, 1976 7 4 Consecutive days Peers No 750 

Pentz et al., 1989b 6-7 10 Peers, parents, Yes 1,122 

and teachers 

Ellickson and Bell, 7-8 8 Weekly Health educators, Yes 3,852 

1990 peers, and teachers 

Best et al., 1984 6 6 Weekly Program staff Yes 654 

Flay et al., 1983 6 6 Weekly Program staff Yes 653 

Flay et al., 1987 7 5 Consecutivedays Teacher No 4,891 

Cognitive Behavioral Model 

Gilchrist et al., 5-6 8 Peers and program No 741 

1986 staff 

Schinke et al., 6 10 Weekly Program staff No 689 

1985a 

Schinke and 6 8 Semiweekly Program staff No 234 

Gilchrist, 1984 

Gilchrist et al., 6 10 Health educators No 882 

1989 

Life Skills Model 

Tell et al., 1984 5-7 10 Over 2 years Peers and No 298 

program staff 

Botvin et al., 1983 7 15 Weekly or daily Teachers Yes 902 

Bush et al., 1989 4-6 4 Over school year Teachers No 1,234 

Botvinet al., 1980 8-10 10 Weekly Program staff No 281 

Walter et al., 1989 4-9 Throughout Weekly Teachers Yes 1,105 

school year 

Botvin et a!., 1984 7 20 Weekly Older peers No 1,311 

and teachers 

Botvin and Eng, 7 12 Weekly Older peers No 426 

1982 

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NationaI Cancer Institute 

techniques in eight 1-hour sessions during regular school hours 

with the teacher present. The intervention strategies of Jason 

et al. (1982) were delivered by graduate psychology students in 

six weekly sessions lasting about 30 minutes each. Spitzzeri 

and Jason (1979) used clinical psychology graduate students, 

divided treatment classes into groups of 10, and engaged in 

role-playing scenes that lasted 5 to 10minutes and were 

followed by 15 to 20 minutes of discussion. 

A number of studies have used teachers to deliver the 

intervention program. Biglan et al. (1987a and 1987b) had 

science or health teachers present instruction sessions that ran 

for 3 or 4 consecutive days and were followed by a booster 

session, 2 weeks later, which emphasized refusal skills. 

Colquhoun and Cullen (1981) used a program of six 75-minute 

sessions conducted by teachers, with participation from local 

general practitioners. Colquhoun and Cullen reported smoking declines for 12-year-old boys from 11percent to 4 percent 1year later and, in 13-to 14-year-olds, declines from 20 percent to 14 percent in boys and 31 percent to 26 percent in girls. 

Flay and coworkers (1987) delivered a 5-day classroom curriculum that was taught the same week that a local television 

station aired five 5-minute smoking prevention segments. 

There were an additional five 5-minute television segments on 

smoking cessation the following week. Pentz and colleagues 

(1989a and 1989b) had teachers deliver the intervention 

program in health, science, or social studies classes and reinforced classroom instruction with 10 homework sessions 

involving interviews and role-playing with parents and families. 

A number of studies have combined staff or teacher 

delivery of program material with the assistance of a student 

peer. Arkin and colleagues (1981) involved all seventh grade 

classes of eight junior high schools (3,206 students at the 

program’s start). Each seventh grade class nominated classmates who they believed would be effective leaders. The peer 

leaders directed discussions, provided feedback, and helped students to develop counterarguments. Ellickson and Bell (1990) 

used health educators to deliver the program to seventh graders 

in 10schools, and teen leaders assisted adult teachers in 10 

other schools. Perry and coworkers (1989), in a study of 

strategies to promote cardiovascular health, used same-age peer 

leaders in a smoking cessation program aimed at seventh 

graders. Murray and colleagues (1984, 1987, 1988, and 1989) 

employed a combination of teacher-led and peer-led intervention sessions and then tracked the participants for 6 years. 

They reported a significant reduction of smoking onset at 1year, but the effect diminished with the passage of time. 

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Positive effects were reported also when the prevention 

program was delivered to elementary school students (Best et 

al., 1984; Dielman et al., 1985; Flay et al., 1983 and 1985). Best 

and colleagues (1984) included sixth graders from 22 schools in 

a social influences smoking prevention program. At the end of 

the eighth grade, 47 percent of never-smokers in the control 

group still had not tried smoking, and 60 percent of the treatment group never-smokers still had not smoked. 

Johnson et al. (1986) delivered a social approach curriculum and a health approach curriculum aimed at Los Angeles 

area high school students. They concluded that social influence resistance training helps to reduce transitions to higher 

use by smoking experimenters. Health education was most 

valuable in preventing initial experimentation among those 

who were nonsmokers prior to the study. 

Perry and coworkers (1980b), in the area of Stanford, California, examined a smoking prevention and cessation program 

delivered in regular 10th grade health education classes. On 

consecutive days during the fall semester, students received 

four 45-minute classes that covered handling social pressures to 

smoke, identifying and discussing the targets of cigarette advertisements, and brainstorming about how to help others remain 

nonsmokers or quit smoking. The students also measured their 

blood pressure, pulse rate, lung capacity, skin temperature, and 

carbon monoxide levels in breath. At the end of the semester, 

students in the program were more knowledgeable about the 

immediate physiological effects of smoking and about the best 

methods to quit and prevent others from smoking. 

In a similar study, Perry and colleagues (1983) had 

20 classes of 10th graders participate in a comparison of three 

treatment programs: the first was the social consequences of 

smoking; the second was the immediate and long-term physiological effects of smoking; and the third was the long-term 

health effects of smoking. The investigators cautioned that no 

single program appeared to be more effective than the other 

two,although the combined effect of all three programs was a 

23 percent reduction of regular weekly smoking at 2-month 

followup. 

Not all researchers have been able to replicate earlier 

reports (Best et al., 1988). Clarke and associates (1986) concluded that interventions led by program staff, which were 

“relatively light, short-term interventions,” had little effect in 

an environment filled with powerful prosmoking messages by 

media, older peers, and adult role models. 

Failure to achieve significant results in programs led by 

teachers have been reported by Lloyd et al. (1983), Clarke et al. 

(1986), and Burke et al. (1987). Lloyd and coworkers (1983) 

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surveyed teachers about their own smoking habits, attitudes 

toward smoking, and prior use of smoking prevention material. 

Teachers who rated lowest on this implementation scale had 

students whose test results for knowledge and behavior 

changes were similar to those for control students. Fisher et al. 

(1985), Clarke et al. (1986), and Burke et al. (1987) reported inconclusive results with programs that used a combination of 

teachers or program staff and peer leaders. 

Several investigators have used mass media to supplement 

the more typical delivery approaches. Arkin et al. (1981) 

followed students who had received a social pressures curriculum and were nonsmokers at baseline. At followup, the percentages of students who were still nonsmokers for the adultled sessions with media, peer-led with media, and peer-led 

without media were 82.1 percent, 81.0 percent, and 88.6 percent, respectively (students who received a standard curriculum 

were 69 percent nonsmokers). The addition of mass media did 

not provide a significant benefit in this study. 

Murray et al. (1984, 1987, and 1988) reported similar 

results, in that adding videotape supplements to the social 

influences curriculum provided no additional benefits. 

Johnson et al. (1986) used a social influences curriculum to test 

the effect of recognizable compared with unfamiliar media 

models and reported no effects of the media models for any 

onset category or for quitting. 

Complementary delivery channels. Biglan and associates 

(1987a) included a set of four messages mailed to the parents of 

seventh grade students. The object of the messages was to help 

reinforce refusal skills, health effects, and commitment to nonsmoking. The messages also tried to encourage parents to 

discuss their views of smoking with their children and to set 

family rules about smoking. The first message was mailed at 

the end of the school intervention, and subsequent messages at 

2,4, and 6 weeks thereafter. The investigators concluded that 

messages to and through parents did not affect the outcome. 

Positive effects have been reported, though, by some programs that included parent activities and mass media programming as complements to the school-based intervention (Flay et 

al., 1987; Pentz et al., 1989a and 1989b). Pentz and colleagues 

(1989a) included, as part of their intervention program, homework sessions that included interviewing parents and family 

members about family rules on drugs, techniques to avoid drug 

use, and how families can counteract media and peer influences. 

In a related study, Pentz and associates (1989b) included a 

parent program that consisted of three to six organizational 

meetings per year, support activities for the school, and an 

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educational seminar for all parents. In addition, there was a 

1-day workshop each year for school principals, parent group 

representatives, and student leaders. The training emphasized 

changing school policy toward prevention education, smoking 

in and around schools, and providing support skills for parentchild communication and prevention. Thirty-two parents were 

involved in delivering the parent components of this intervention program. 

Complementary target outcomes. Reductions in tobacco use 

have been reported by social influences model programs aimed 

at general substance use (Ellickson and Bell, 1990; Hansen et 

al., 1988; Pentz et al., 1989a and 1989b). These studies aimed 

to reduce adolescents’ use of drugs-tobacco, alcohol, and 

marijuana. In a study that focused on cardiovascular risk factors, Perry and colleagues (1989) reported that, after the fifth 

year of a school-based health education program, 13.1 percent 

of the educated group were current smokers, in contrast to 

22.7 percent of controls. 

In a study by Hansen and coworkers (1988), seventh grade 

students were provided with social pressure resistance training 

and were tested prior to training and at 12 and 24 months after 

training. The initiation of smoking was lower in trained 

students than among controls: 13.0 and 11.8percent versus 

18.2 and 17.8 percent at 12- and 24-month followup testing. 

The most significant effect was inhibition of the move to 

heavier smoking. At the level of five or more cigarettes in the 

preceding 30 days, the reduction was about two-thirds at 

12 months (1.7 versus 5.3 percent for controls) and threefourths at 24 months (1.4 versus 6.0 percent for controls). 

. Ellickson and Bell (1990) reported a reduction in the levels 

of cigarette use that signal heavier smoking. After eighth grade 

booster lessons, weekly smoking declined in one group by 

almost 50 percent. Ellickson and Bell suggest that booster 

lessons are important for maintaining and reinforcing earlier 

intervention efforts. However, they also suggest that early 

cigarette smokers “need a more aggressive program than that 

offered by the social influences model alone.” 

Long-term followup. The only long-term followup studies 

based on the social influences model reported no program 

effects enduring beyond high school (e.g., Murray et al., 1989), 

even if booster sessions were included (Flay et al., 1989). 

Observed effects were maintained, however, up to 4 years after 

the conclusion of a program with seventh graders (Murray et 

al., 1988). 

Current activities. Researchers at the Oregon Research 

Institute are involved in a large-scale study of a variation on 

the social influences model that includes a much stronger 

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behavior-analytic focus than previous efforts. It differs from 

many previous efforts in that (1)it is a multiple grade-level 

intervention; (2) it relies heavily on videotaped material to 

present information and prompt discussion and training in 

pressure resistance skills; and (3) it addresses a wider range of 

risk-taking activities, including alcohol and marijuana use and 

behaviors such as shoplifting (Biglan et al., 1988). Results at 

1 year were encouraging, at least among baseline ever-smokers 

(Ary et al., 1990). 

At the Fred Hutchinson Cancer Research Center in Seattle, 

researchers are involved in a large-scale study of a social influences model variation. It is delivered annually in grades 3 

through 10, is delivered by teachers, and includes a parent 

component; however, it remains focused solely on tobacco use 

(A. Peterson, telephone conversation). 

Researchers at the New England Research Institute are 

testing another variation in a Hispanic population. Their 

intervention focuses on family and advertising issues and 

includes a video and discussion component designed to involve family members and neighbors in the school-based prevention program (S.McGraw, telephone conversation). 

In Minnesota, researchers are testing the effectiveness of 

statewide legislation designed to encourage schools to adopt 

social-influences-based programs to prevent tobacco use. The 

state legislature is providing financial support to schools that 

adopt such programs, and the research will compare tobacco 

use by adolescents in Minnesota and in Wisconsin, to determine whether the smoking rate declines in Minnesota as a result of the legislation. The study also includes a randomized 

trial designed to evaluate the three programs that have been 

adopted most widely as a result of the 1985 legislation (Murray 

et al., 1988). 

Researchers at the University of Southern California and 

the University of Chicago are testing a combination of television, family involvement, and school-based programming for 

their effect on tobacco use (Flay et al., 1988). Researchers in 

Vermont also are evaluating a school-based versus a schoolplus-mass media program (Worden et al., 1988). Evans and 

colleagues at the University of Houston are attempting to 

construct a psychosocial profile of the quickly accelerated 

heavy smoker relative to the more slowly accelerated moderate 

or heavy smoker (Evans et al., 1991). They are applying the 

psychosocial model developed during their work on cigarette 

smoking to the problem of smokeless tobacco use (Evans and 

Raines, 1990), with Little League Baseball players as a study 

population. They are also evaluating the potential contributions to the psychosocial model of factors such as gender 

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(Evans et al., 1990), ethnicity (Getz and Evans, 1989), selfefficacy (Getz, 1988), and smoking by others, including parents, older siblings, and peers (Cardozo, 1989; Getz et al., 

1990). 

Evans and associates also have responded to feedback from 

teachers and administrators who suggest that many useful prevention programs demand more curriculum time and teacher 

training time than can be allotted. They are developing and 

testing a compact, 2-week program that requires minimal 

training and preparation time by classroom teachers. The 

“Little Red Notebook” program is based on the social influences model and includes exercises in decision-making, roleplaying, and rehearsal; self-control methods; reinforcement of 

pressure resistance skills; and learning to use relevant community service agencies. Each section includes a step-by-step 

teacher’s guide and copy masters for all materials used in the 

unit. Although more extensive evaluation is needed, there is 

some evidence of modest results related to decreased use of 

cigarettes, smokeless tobacco, and alcohol among seventh 

grade students (Cardozo, 1989; Evans, 1990; Evans et al., 1989). 

Cognitive Behavioral Program variations. Gilchrist and Schinke (1984), in a study 

Model with sixth grade students, used self-control skills for smoking 

prevention and reported that self-control students who reported ever smoking rose only 3.6 percent over baseline after 

1year; control condition students rose 39.3 percent in that 

same year. These students learned a problem-solving model 

called SODAS, which instructs students to do the following: 

Stop-think about what they are doing; 

Options-think about their choices; 

Deciderhoose the best option; 

Act-make that option happen; and 

Self-praise-reward themselves for making the right 

decision. 

Gilchrist and colleagues (1986) evaluated the self-control 

process with middle school subjects. At a 15-month followup 

survey, fewer self-control skills students than controls reported 

smoking one or more cigarettes for the previous week. 

Glynn and coworkers (1985), working with sixth through 

eighth graders, described the stage model, which states that becoming a smoker is a lengthy, complex process with four 

stages. The first stage is the preparatory stage, in which adolescents first develop attitudes toward cigarettes and smoking. In 

the second stage of initiation, the adolescent smokes between 

one and three cigarettes. In the third stage, becoming a 

smoker, smoking is irregular and adolescents do not define 

themselves as smokers. The final stage is maintenance, when 

regular smoking has begun and the image of a smoker has been 

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Table 3 

The stage model and smoking motives 

Smoking Motives 

Social Compliance Affect Regulation Self-Definition 

Stages 

Preparatory Need for social Use of foods, Needto rebel 

approval drinks,and overthe-counter 

medicationsto 

regulate emotional 

state 

Initiation Peer pressure, Curiosity about Need for 

social initiation, mood-altering impression 

nonspecific propertiesof management 

curiosity cigarettes ( Le., how one 

appears to 

others) 

Becoming Continuing social Positive evaluation Is an instant 

influences of sensations adopter and 

produced by skips this stage 

smoking 

Maintenance Continuing Establishmentof Satisfaction with 

social influences, a link between projected image, 

positive evaluation smoking and positive 

of sensations affective state of evaluation 

produced by sensations 

smoking produced by 

smoking 

Adapted from Glynnet a/. (1985). 

adopted. Table 3 shows how the stage model depicts factors 

that influence adolescents at different smoking stages. 

Schinke and associates (1985a) used graduate social workers to provide skills intervention and information intervention 

to sixth graders. At 6, 12, and 24 months after the intervention, the skills students had a lower percentage of smoking 

than did the information-only and the control students. A 

four-step chain in the skill-building interventions-stop, think, 

decide, and act-was used by Schinke and coworkers (1985b). 

Schinke and Gilchrist (1984,1985, and 1986) have conducted several studies that were led by project staff using the 

cognitive behavioral technique. In 1984, the investigators 

reported that students in the skills-building condition, when 

164 
Smoking and Tobacco Control Monograph No. 1 

compared with students in an attitude modification condition 

or with controls, had larger gains at followup testing for identifying healthy solutions, encouraging nonsmoking, and anticipating negative consequences of tobacco use. Pentz (1983) 

reported positive results with a combination of teacher and 

peer leader administration techniques. 

Beneficial effects were reported when the program was 

delivered to elementary school students, rather than the usual 

delivery of psychosocial prevention programs to seventh or 

eighth grade students (Gilchrist and Schinke, 1984; Gilchrist et 

al., 1986; Schinke et al., 1985a, 1985b, 1986a, 1986b, and 

1988a; Schinke and Gilchrist, 1984, 1985, and 1986). Schinke 

and colleagues (1986b), working with sixth graders, taught 

problem-solving, self-instruction, and communication skills. 

When compared with students in a health education program, 

students in this study had better knowledge scores and nonsmoking intentions. Schinke and coworkers (1986a and 1988a) 

reported that, in a study that began with students in the fifth 

and sixth grades, students showed lower rates for both smoking 

and smokeless tobacco use. 

Native American adolescents are a particularly vulnerable 

population for abuse of substances, including tobacco, according to results obtained by Schinke and colleagues (1988b). At 

6-month followup, the treatment group reported less use of 

both smoked and smokeless tobacco during the previous 

14 days. However, because of the small number of subjects 

(n= 61) and the short period of followup, the authors advise a 

cautious interpretation of their results. 

Failures to duplicate results of earlier studies have been 

reported for studies with high-risk girls (Gilchrist et al., 1989). 

Gilchrist and associates reported the following data for highand low-risk girls and boys at a 24-month followup survey. 

The percentage of weekly smokers in the high-risk girls category was 9.1 percent; for low-risk girls, weekly smokers were 

3.6 percent; for high-risk boys, 7.3 percent; and for low-risk 

boys, 4.8 percent. The weekly smoking rate for high-risk girls 

was significantly higher than for any other intervention 

category and was similar to the high-risk girls in the control 

group (10.2 percent reporting weekly smoking). 

Gilchrist and associates (1989) suggest that females begin 

and continue smoking for different reasons than do males. 

Young female smokers tend to be more socially competent and 

self-confident than their male counterparts and do not smoke 

for social coping purposes or to demonstrate assertiveness. 

Therefore, teaching refusal and social competence skills may be 

less useful and relevant for females than for males, and thus 

have less effect. 

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Life Skills Model 

National Cancer Institute 

A more appropriate technique may require less attention 

to skills training and more to self-definition and self-expression. In addition, tension reduction and information on 

weight control methods, because smoking is perceived to be 

valuable for weight control, could prove to be more relevant to 

young female smokers (Gilchrist et al., 1989). 

Complementary delivery channels. The programs based on 

the cognitive behavioral model have been exclusively schoolbased. Thus, there are no reports of investigation of complementary channels for program delivery. 

Complementary target outcomes. Positive effects of reducing 

tobacco use have been reported by programs aimed at general 

substance use (Pentz, 1983; Schinke et al., 1988b). Such programs have not targeted other health outcomes, however. 

Long-term followup. There have been no published reports 

from followup studies beyond 2 years for programs based on 

the cognitive behavioral model. 

Current activities. Researchers at Columbia University are 

testing a variation of the cognitive behavioral model in a highrisk population (S. Schinke, telephone conversation). Adolescents at high risk for smoking often have been unaffected by 

intervention efforts in the past, and this remains an important 

area for research. The Columbia group employs the basic 

cognitive behavioral model but has modified the role models 

and scenarios to be more appropriate for high-risk youth. The 

investigators also have added a component to address values 

on deviance. 

Progum variations. Positive effects have been reported 

when the life skills program was delivered by the project staff 

(Tell et al., 1984), by teachers (Botvin et al., 1983, 1989a, and 

1989b; Bush et al., 1989; Vartiainen et ai., 1983, 1986, and 

1990; Walter et al., 1986, 1988, and 1989), and by a combination of teachers or staff and peer leaders (Botvin et al., 1984; 

Tell et al., 1984; Vartiainen et al., 1983, 1986, and 1990). The 

smoking prevention curriculum for one cohort of the study by 

Tell and coworkers is shown in Table 4. Tell and associates 

provided this social skills training in a 10-session curriculum 

that began in September 1979 and ended in February 1981. 

Botvin and coIleagues (1989a) used a psychosocial approach with black junior high students. The study used 

12 intervention sessions of 45 minutes each. In addition, an 

internal review committee of black researchers (a psychologist 

and two health educators) reviewed the material to make 

certain that the language, reading level, examples, and underlying concepts were appropriate for black youth. An external 

review group of black seventh grade students and outside 

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Smoking and Tobacco Control Monograph No. 1 

Table 4 

A program variation of the life skills model 

Session 

September 1979 

September 1979 

November 1979 

March 1980 

May 1980 

October 1980 

November 980 

December 980 

January 1981 

February 1981 

Topics 

Personal commitment and discussion of social 

pressures. 

Pressure resistance training. Student-led roleplaying. 

Social pressures and arguments against smoking. 

Coping with social anxiety. 

Pressure resistance training. Student-led talks 

about the harmful effects of smoking. 

Smoking: self-pollution and waste of resources. 

Smoking as a form of self-pollution and growing 

tobacco as a waste of agricultural resources were 

discussed. 

Passive smoking. Second-hand smoke, parental 

smoking, peer pressure at youth clubs were 

discussed. 

1 

Long-teim effects of smoking and marketing of 

tobacco. Cancer and cardiovascular diseases 

relating to smoking and comparison of selling 

tobacco in Third World countries versus selling 

it in Norway were discussed. 

Social and health aspects of smoking. 

It is your choice. A film on alcohol consumption 

was shown, and drinking and parallel smoking 

pressures were discussed. 

Adapted from Tell et al. (1984). Sessions were 45 minutes in length. 

experts with expertise with black youth was also formed. The 

main purpose of the study was to explore the feasibility of 

applying the life skills training model, previously used with 

middle-class white youth, to urban black youth. The overall 

rate of smoking during the most recent month of the study was 

down by 56 percent, although regular smoking did not appear 

to be affected. 

167 
National Cancer Institute 

Bush and coworkers (1989) identified problems that may 

affect most intervention studies for urban black youth: meeting the parental consent requirement, lack of true controls, 

variations in teacher effectiveness, frequent student transfers, 

isolation of the program within schools, data collection procedures, and lack of teacher support for the program. For example, at the seventh grade level, all of the health teachers 

were smokers, and their effectiveness therefore came into 

question. In addition, it was difficult for the research team to 

judge the effect of teachers as role models because of incomplete attendance at teacher training sessions and because there 

was some question about whether the teachers adhered to the 

curriculum. 

Failures to duplicate results have been reported for studies 

with teacher-administered life skills programs (Botvin et al., 

1984), particularly when the teachers received inadequate 

training (Botvin et al., 1989b; Tortu and Botvin, 1989). Tortu 

and Botvin (1989) cautioned that poor implementation can be 

misinterpreted as program failure. Therefore, to help ensure 

proper implementation of programs, effective teacher training 

must accompany teacher-administered programs. The training 

must include the theory underlying the program, demonstrations of skills needed to administer the program, practice of the 

new skills, and feedback and coaching from project staff. The 

social skills programs stress that students learn decision-making 

skills, assertiveness, and anxiety reduction. These skills require 

classroom techniques that differ from traditional teaching 

methods, for example, the practice of adolescent skills through 

role-playing (Tortu and Botvin, 1989). 

Additional benefits have been reported when the initial 

intervention is followed by a booster program. Botvin et al. 

(1983), in an intervention program with seventh grade students, reported 60 percent fewer new regular smokers than 

when the same intervention program was used without booster 

sessions. Furthermore, the eight booster sessions, which took 

place in the second year of the program, resulted in 87 percent 

less regular new smoking than among controls. 

Positive effects have been seen also when the intervention 

continues over several years (Bush et al., 1989; Tell et al. 1984; 

Walter et al., 1986, 1988, and 1989). Walter and associates 

began a study of coronary heart disease prevention with a 

baseline population of fourth graders. Each year from the 

fourth to the ninth grade, students received a teacher-delivered 

curriculum that included material designed to prevent cigarette 

smoking. After 6 years, the rate of initiation of cigarette smoking was significantly less (by 73 percent) than in the nonintervention schools. 

168 
Smoking and Tobacco Control Monograph No. 1 

By comparison, in a condensed timeframe, Botvin and colleagues (1983) conducted the life skills training program on 

consecutive days and completed the program in about 1 month, 

in addition to carrying out the usual practice of weekly sessions 

delivered over the course of a semester or a full school year. 

They reported that smoking initiation rates were significantly 

lower in the intensive program than among control students 

(who received no special prevention activities), according to 

monthly, weekly, and daily measures. 

Complementary delivery channels. An intervention program 

that was delivered within a broad-based and communitywide 

heart disease prevention program produced positive results 

(Vartiainen et al., 1983, 1986, and 1990). The North Karelia 

Youth Project attempted to reduce the factors associated with 

cardiovascular disease risk, including smoking, serum cholesterol, dietary habits, and blood pressure. The program was 

begun with a group of students who were 13 years old. In two 

schools there was an intensive intervention program and in > nine others, less intensive intervention; the balance of schools 

in the community served as controls. The intervention strategy 

was applied over a 2-year period. 

In the first followup survey (Vartiainen et al., 1983), 

21 percent of the students were smoking at least monthly in the 

intensive intervention schools, 19 percent in the less intensive 

intervention schools, and 29 percent in the control schools. At 

the second followup survey, these figures were 24, 22, and 

34 percent, respectively. Four years after the program’s start, 

the reported rates were 27 percent for the intensive intervention 

group, 26 percent for the less intensive intervention group, and 

37 percent for the control group (Vartiainen et al., 1986). 

Eight-year followup results indicated that some of the intervention effect had been lost. Preventive effects seemed to have 

been beneficial only for those who were nonsmokers when the 

program began. 

Complementary target outcomes. Effects that reflect reduced 

use of tobacco have been reported by programs based on the life 

skills model and directed to general substance use (Botvin et al., 

1984) as well as those that aimed at cardiovascular risk factors 

(Tell et al., 1984; Vartianinen et al., 1983, 1986, and 1990; 

Walter et al., 1986, 1988, and 1989). Details of these studies are 

mentioned in previous sections. 

Long-term followup. Two studies reported followup for more 

than 2 years beyond the initial life skills intervention. Walter 

and colleagues (1988 and 1989) reported positive effects at the 

end of the ninth grade, in a study that included interventions 

each year from grades 4 through 9. Vartiainen (1986 and 1990) 

reported positive effects 2 and 6 years after a 2-year intervention 

was delivered to students in grades 7 through 9. 

169 
CLINICAL 

APPROACH 

TO SMOKING 

CONTROL 

Historical Trends 

National Cancer Institute 

Current activities. At the American Health Foundation, 

researchers are examining whether the comprehensive life 

skills model aimed broadly at cardiovascular risk reduction will 

be more effective for preventing tobacco use than will the targeted application of only those components aimed at substance use (M. Orlandi, telephone conversation). Researchers 

at Cornel1 University are exploring even broader applications 

of the life skills model that would seek to improve skills related 

to future employment or early sexual behavior (G. Botvin, 

telephone conversation). 

The major efforts in smoking control have been aimed at 

the individual smoker-trying to motivate smokers to quit and 

help them to do so. Such assistance has included formal 

cessation programs, usually delivered in small groups, and oneto-one direct advice or counseling from a health care provider. 

More recently, pharmacologic adjuncts (Grabowski and Hall, 

1985) have been added to the treatment mix in both settings. 

This section briefly reviews the research on the effectiveness of 

clinical approaches and appraises their potential contribution 

to a comprehensive program to reduce tobacco use. 

Research on smoking cessation was initially driven by a 

clinical perspective. The aim was to develop effective methods 

that cessation clinics could use with motivated smokers who 

referred themselves for “treatment,” or that physicians and 

other health providers could use with their patients. Serious 

smoking cessation research and service programs have a rather 

short history, only about 30 years. Even early on there were 

proponents of both pharmacological approaches and educational-psychological approaches. The early pharmacological 

strategies were rather primitive by current standards. Although 

the role of nicotine in the maintenance and cessation of 

smoking was poorly understood, the notion of replacing or 

mimicking nicotine’s action was seen as plausible. Much of the 

early pharmacological research focused on lobeline, presented 

in over-the-counter products like Bantron and occasionally by 

injection. Placebo studies yielded fairly convincing demonstrations of lobeline’s lack of efficacy (Kozlowski, 1984). 

Cigarette smoking quickly attracted the attention of 

workers in behavior therapy. Behavioral approaches to smoking cessation tended to reflect current practices or the zeitgeist 

in behavior therapy rather than deriving from an analysis or 

understanding of smoking behavior (Lichtenstein, 1982). 

Smoking was considered to be a learned habit; pharmacological 

and biobehavioral processes were neglected. Earlier behavioral 

approaches to smoking featured conditioning methods followed by self-control strategies and tactics that represented 

behavioral thinking in the 1960’s and early 1970’s. Behavioral 

approaches in the 1980’s had major cognitive components, 

170 
Smoking and Tobacco Control Monograph No. 1 

reflecting the interest in cognitive behavioral strategies. 

Within this general trend, however, behavioral workers generally maintained an empirical attitude and became increasingly 

sensitive to the developing body of knowledge about both 

psychosocial and pharmacological processes in smoking 

behavior. For example, behavioral researchers evolved 

nicotine-fading (Foxx and Brown, 1979) or brand-switching 

strategies to deal with pharmacological processes and tended to 

be sympathetic to nicotine chewing gum as an adjunct toor even a major component of-cessation programs (e.g., Goldstein et al., 1989). 

Another trend in the late 1970’s and 1980’s was the shift 

in emphasis from smoking cessation to maintaining abstinence 

and preventing relapse. The change was sparked by repeated 

observations that most participants in cessation programs 

either quit or greatly reduce their smoking, but the majority 

subsequently relapse-most of them soon after the program 

ends. Although early programs tended to focus on smoking 

cessation by the end of the program, considerable program 

time is now devoted to relapse prevention. Marlatt and Gordon’s (1985) book on relapse prevention epitomized this trend. 

Both behavioral and pharmacological strategies are employed 

to achieve maintenance and relapse prevention. Smoking 

cessation now is recognized as a process that encompasses 

several identifiable stages-from precontemplation to maintenance or relapse (Prochaska et al., 1988). The importance of 

tailoring cessation materials to the smoker’s stage of readiness 

to change is increasingly recognized, although not yet empirically supported. 

Two other noteworthy trends in clinical intervention are 

interrelated. One is the renewed and vigorous interest in pharmacologic intervention, especially nicotine replacement 

therapies (Grabowski and Hall, 1985). This thrust is fueled by 

advances in knowledge about the critical role of nicotine in 

maintaining smoking behavior and in the quitting or relapse 

process (US DHHS, 1988), which have paved the way to growing literature on the effectiveness of nicotine polacrilex-both 

when used with relatively minimal advice and support and 

when combined with behavioral counseling and group support. The final trend noted is toward briefer clinical interventions delivered in the context of usual medical care (Glynn, 

1988; Ockene, 1987a; Russell et al., 1983). This strategy capitalizes on the credibility of physicians (American Cancer 

Society, 1977), the teachable moments in medical transactions 

(Vogt et al., 1989), and the possibility for physicians to use 

pharmacological adjuncts, a familiar treatment modality. 

171 
National Cancer Institute 

Effectivenessof 

Different Methods 

There are different cessation methods, and it is possible to 

categorize them in different ways. Schwartz (1987) lists 

21 different approaches in his summary table. With the exception of pharmacological strategies and physician advice or counseling approaches-where there has been much activity in the 

last 5 years-Schwartz’s review of specific clinical cessation 

methods remains valid. 

It is also possible to organize cessation methods into general 

strategies, for example, self-management strategies, aversive 

strategies, pharmacological strategies, relapse prevention strategies, combined behavioral-pharmacological approaches, and 

multicomponent strategies (Kamarck and Lichtenstein, 1988). 

In fact, nearly all clinical interventions are now multicomponent 

to a significant degree. Table 5, adapted from Lichtenstein and 

Mermelstein (1984), lists and briefly describes the typical elements in a multicomponent program, which are organized 

around three program phases: preparation for quitting, initial 

quitting, and the maintenance of quitting. No one program is 

likely to use all of these elements. Given the large number of 

different kinds of studies, the fact that some methods have been 

evaluated extensively and some very little, and the differences in 

evaluation criteria, it is difficult to identify the most effective 

interventions. However, the following conclusions seem defensible. 

The research literature generally indicates that more intensive and extensive interventions are more effective than singlestrategy or single-session methods. For example, single-strategy 

interventions have yielded weak results, whereas multicomponent programs (e.g., Lando, 1986; Ockene et al., 1982) have 

shown the highest quit rates. Good multicomponent programs 

can yield long-term (1-year) confirmed quit rates of 30 to 40 

percent. The intensity of the intervention or number of contacts 

also seems important. For example, Lando’s (1986) 15-session 

program is among the most effective intervention reported, and 

the high quit rates reported by Ockene et al. (1982) for the 

Multiple Risk Factor Intervention Trial are consistent with that 

conclusion. With respect to physician advice, a meta-analysis 

reveals that more frequent contacts are associated with higher 

quit rates (Kottke et al., 1988). Some research in the self-help or 

minimal assistance realm also indicates that additional prompts, 

for example, supportive phone calls, enhance effectiveness 

(Glynn et al., 1990; Orleans et al., 1988). 

It is difficult to empirically determine and demonstrate the 

specific efficacious elements of multicomponent programs. 

There is undoubtedly a large nonspecific effect in smoking 

cessation programs. The commitment to attend regular sessions, 

expectations of help, group or counselor support, and engagement with therapeutic activities (e.g., homework assignments) 

172 
Smoking and Tobacco Control Monograph No. 1 

Table 5 

Methods used by cessation programs 

Program Phase Typical Elements 

Preparation Mobilizing client motivation and commitment 

Deposits contingent on attendance 

Review reasons for quitting and benefits of stopping 

Self-monitoring; increase awareness of smoking patterns 

by keeping records* 

Setting target quit date 1 to 3weeks ahead* 

Self-management raining 

Use self-monitoring to identify typical cues for 

smoking 

Identifying substitutes for smoking and alternative 

nonsmoking behaviors* 

Stress management training; relaxation or exercise 

Quitting (usually Aversive strategies 

one of typical Pairing smoking with electric shock 

elements listed) Rapid smoking-inhaling every 6 to 8seconds in 

the clinic until nausea is imminent or satiationdoubling or tripling at-home smoking 

Nonaversive strategies 

Nicotine fading (switching successively to brands 

with increasingly lower nicotine content) 

Target date contract 

Pharmacological-Using nicotine replacement methods 

(e.g., gum, patches) as a temporary substitute 

Maintenance Followup sessions or phone calls 

Coping skills training* 

Transfer self-management skills to maintenance by 

avoiding cues to smoke and using substitutes (e.g., 

cinnamon sticks, water, deep breathing) 

Cognitive behavioral coping: anticipating high-risk 

situations; planning coping strategies 

Coping with slips or lapses; learning from mistakes 

Social support 

Buddy systems 

Involving significant others (e.g., Spouse) 

Pharmacological-Continuing to use nicotine 

replacement to cope with withdrawal 

*Found inmost programs 

173 
Cessation Clinics 

National Cancer Institute 

are known to have powerful effects on any behavior problem, 

including smoking. Attempts at component analysis-determining efficacious and nonefficacious elements-have generally 

failed (e.g., Lando, 1986); such studies are markedly lacking in 

statistical power (Glasgow and Lichtenstein, 1987). Similarly, 

attempts to identify the value of individual components by 

adding a single behavioral strategy such as spouse or partner 

support to a basic multicomponent program have also been 

unsuccessful (e.g., Lichtenstein et al., 1986). 

The addition of pharmacological adjuncts, notably nicotine 

chewing gum, to multicomponent cessation programs yields a 

more consistent and positive picture. Combining nicotine gum 

and behavioral counseling tends to produce better results than 

either approach by itself (Goldstein et al., 1989; Hall et al., 1987; 

Killen et al., 1984). 

Both clinical experience and research support the importance of focusing attention on the maintenance or relapse 

prevention phase of intervention (see Table 5). Although there 

are some notable examples of the effectiveness of relapse prevention components (Hall et al., 1984; Stevens and Hollis, 1989), 

there are as many failures (for a summary, see Glasgow and 

Lichtenstein, 1987). Nevertheless, there remains a consensus 

that attention to relapse prevention is important. It is plausible, 

however, that environmental factors, including other people’s 

smoking, are critical to maintenance (Glasgow and Lichtenstein, 

1987). 

For the individual smoker, conscientious attendance at a 

multicomponent, small-group, cessation program (including 

nicotine replacement strategies) is the best possible move toward 

becoming an ex-smoker. Such a program is likely to produce a 

30 percent quit rate at 1-year followup. Although far from the 

sure thing advertised by some proprietary programs and private 

practice providers, this is a good result compared with a single 

attempt at self-quitting (Cohen et al., 1989) or even quitting 

with the advice and assistance (e.g., prescription of a nicotine 

chewing gum) of a primary care physician (Glynn, 1988). 

Limitations of cessation clinics. Two extensively researched 

cessation programs illustrate the strengths and weaknesses of the 

cessation clinic approach. In the 1970’s, many programs employed rapid smoking (Lichtenstein et al., 1973; Schmahl et al., 

19 72), typically accompanied by considerable behavioral counseling and support. Rapid smoking is an aversive procedure 

wherein the smoker puffs and inhales every 6 to 8 seconds until 

nausea begins. It is the most frequently studied clinical strategy, 

accounting for 49 of the 416 trials summarized in Schwartz’s 

comprehensive summary (1987), and its close cousins-satiation 

174 
Smoking and Tobacco Control Monograph No. 1 

and regular-paced aversive smoking-account for another 

39 trials. Quit rates, although quite variable, are often 

30 percent or more at followup, which is considered good for 

cessation programs. 

However, the procedure is used sparingly today for several 

reasons. The accelerated nicotine intake from rapid smoking 

requires screening and safeguards (Lichtenstein and Glasgow, 

1977) and leads to the exclusion of many patients who need 

assistance. The method also requires close supervision either in 

one-to-one or in small group settings to monitor possible side 

effects. Concern about risks with the use of aversive methods 

makes many providers and consumers wary. Rapid smoking 

remains a reasonably powerful strategy, but it has a narrow 

range of application (Lichtenstein, 1982). 

The second multicomponent program probably represents 

the best that formal cessation programs have to offer while 

again illustrating some inherent limitations. Over a span of 

15 years, a multicomponent, nonaversive, a-week, 15-session 

program was empirically developed and evaluated (Lando, 

1986). (The program originally included satiation smokingdoubling or tripling at-home smoking for a specific period-a 

cousin of rapid smoking that provokes concerns about similar 

risk and screening; however, recent research indicates that 

nicotine fading effectively replaces satiation.) One-year abstinence rates were consistently 30 percent or better. Most 

importantly, the research team developed a partnership with 

the Iowa Lung Association, in which association volunteers 

were trained to deliver the program while the research team 

continued evaluation and monitoring. The Iowa Lung Association offered nearly 70 such clinics in 1year (Lando et al., 

1989). Thus, an empirically validated cessation clinic was 

given away to the public sector and disseminated at low cost 

statewide. However, the intensive nature of the program15 sessions of 1hour each-plus the need for trained volunteer 

leaders limit its applicability. Most smokers will not or cannot 

make such a behavioral commitment to any cessation clinic. 

Acceptance of cessation clinics. Cessation clinics are often 

the initial strategy of antismoking efforts, and they are a 

tangible resource and an important component of any comprehensive program. It is worthwhile to encourage smokers to 

attend such clinics, and most cities have clinics that are 

underused (e.g., offered through local hospitals); however, cessation clinics are not accepted by and will not reach the great 

majority of smokers. There are several lines of evidence that 

support this assertion. (1)The great majority of ex-smokers 

quit or try to quit without the aid of formal programs (Fiore et 

al., 1990; US DHHS, 1982). (2) Data from surveys indicate that 

175 
Health Care Provider 

Interventions 

National Cancer Institute 

most smokers prefer self-help or other assistance (e.g., from 

physicians) in preference to cessation clinics (Gallup Opinion 

Index, 1974; Owen and Davies, 1990; Schwartz and Dubitzky, 

1967). (3)The demand for cessation clinics does not appear 

great, judging from anecdotal reports of various program 

recruitment efforts. According to one market research survey, 

about 1.7 million smokers, a little more than 3 percent of the 

smoking population, attended some kind of cessation clinic in 

1988 (Pierce, 1990). Also, even if the demand increased, there 

would be many places, for example, rural areas and inner cities, 

where the supply of cessation clinics would always be inadequate. (4) Stop-smoking programs have not been nearly as 

successful commercially as their weight-loss counterparts. 

Schwartz (1987) notes that three national programs established 

between 1968 and 1971-Smoke Watchers, SmokEnders, and 

Schick-had reduced operations by 1985. 

Clinical intervention through health providers offers 

greater potential to reach smokers. It is estimated that physicians have contact with at least 70 percent of all smokers each 

year (Ockene, 1987a) and that approximately 38 million of the 

53 million adult smokers in the United States could be reached 

by physicians in the normal course of their medical care. 

Physicians are seen as a credible source of cessation advice 

(American Cancer Society, 1977). At the time of a consultation 

with a physician, patients are sensitized to their health and 

vulnerability, thus creating a teachable moment that could be 

used by health providers (Vogt et al., 1989). One NIH publication refers to these as “clinical opportunities” for smoking 

intervention and provides materials to promote physician involvement in smoking cessation (US DHHS,1986). 

These considerations have given rise to a sizeable body of 

literature on the effects of physician advice (see reviews by 

Glynn, 1988; Ockene, 1987b; Pederson, 1982). Compliance 

with physician advice to quit smoking has been addressed in 

more than 40 studies. Although the studies vary considerably 

in focus and methodological rigor, the evidence from randomized trials suggests that physicians who intervene with smokers 

have a small but measurable impact on public health. Studies 

of the effectiveness of physician smoking interventions indicate that advice or brief counseling alone can result in patient 

quit rates of 5 to 10 percent, an outcome of enormous public 

health significance (US DHHS,1986). Furthermore, the data 

suggest that even higher cessation rates can be achieved when 

physician-patient contacts are more intensive and frequent and 

when nicotine gum is used also (Fagerstrom, 1984; Glynn, 

1988; Wilson et al., 1987). As with most interventions, shortterm (1-to 3-month) quit rates tend to be higher; by l-year 

followup, significant relapse has occurred. 

176 
Smoking and Tobacco Control Monograph No.1 

Importance of 

CllniCal 

Interventions 

One cautionary note here is that most placebo-controlled 

trials indicate that nicotine gum is not effective when prescribed in routine outpatient settings (Hughes et al., 1989; 

Jamrozik et al., 1984; Lam et al., 1987). It is possible that 

instruction in the proper use of the gum (S.R. Cummings et al., 

1988) has been insufficient. Nicotine gum is effective, however, if accompanied by counseling and support and if careful 

instructions for using the gum are given (Glynn, 1988). Nicotine replacement via transdermal patches is another promising 

strategy that both physicians and patients may find convenient. Preliminary data from patch trials are promising. 

Surveys indicate that most physicians accept responsibility 

for dispensing cessation advice (Wechsler et al., 1983) and 

report that they do dispense such advice (Wechsler et al., 1983; 

Wells et al., 1986). Although some survey data reflect physicians’ pessimism about their efficacy and indicate financial and 

organizational obstacles (Orleans et al., 1985), several studies 

have demonstrated that physicians can be motivated to deliver 

a cessation protocol, at least during the course of a study (e.g., 

Fagerstrom, 1984; Janz et al., 1987; Wilson et al., 1987). 

Whether the majority of physicians can be induced to advise or 

counsel smokers consistently when not motivated and monitored by a research staff remains to be demonstrated. Nevertheless, from a public health perspective, physician interventions have the potential to reach large numbers of smokers. 

Clinical cessation interventions have made substantial 

contributions to antismoking efforts. Although it is difficult to 

provide accurate quantitative estimates, cessation clinics have, 

over the past 25 years, helped several million smokers quit. 

The American Cancer Society has sponsored cessation clinics 

based on its own program and materials; the American Lung 

Association has also sponsored clinics on a more limited basis. 

Evaluation of these programs (Schwartz, 1987) indicates 1-year 

quit rates averaging about 20 to 25 percent. 

Hospitals, health plans, and health departments are 

offering cessation programs in increasing numbers. Schwartz 

(1987) reported a major increase in these programs from 1980 

to 1985, and the trend appears to continue. At least two 

standardized, commercial programs, SmokeLess and Smoke 

Stoppers, are now licensed to hospitals that offer the services to 

the community. An estimated 600,000 smokers have completed the SmokEnders program (USDHHS, 1989). Adding in 

the other major commercial programs, Schick and Smoke 

Watchers, along with the numerous private practitioners who 

work with smokers-psychologists, psychiatrists, and hypnotherapists-one can see the significant aggregate impact of 

such services. They continue to provide a resource for motivated smokers who are unable to quit without help. 

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National Cancer Institute 

Besides individual and group cessation services, clinical 

interventions in the context of medical care probably have a 

significant impact on smoking cessation. Many of the selfquitters noted in the 1982 Surgeon General’s Report may have 

been prompted by a physician’s advice or warning. National 

surveys indicate that most physicians accept responsibility for 

helping patients stop smoking and many provide advice 

(Ockene, 1987a), although far fewer provide tangible assistance. Survey data from both America (Ockene et al., 1990- 

1991) and Australia (Owen and Davies, 1990) indicate that 

smokers see physicians as a major resource. 

Another indicator of medical provider impact on smoking 

cessation comes from prescription sales of nicotine-containing 

chewing gum. Since nicotine gum was introduced in 1984, an 

estimated 4 to 

6million smokers, according to one source, 

have received prescriptions for it (US DHHS, 1989). An industry spokesperson places the estimated number at 8 million and 

estimates that 95 percent of primary care physicians have prescribed nicotine polacrilex (Nicorette) (Rongey, 1990). Surveys 

indicate that about two-thirds of these prescriptions are patient 

initiated. These data also reflect the potential for health care 

providers to reach far more smokers than can cessation clinics. 

The availability of nicotine gum and other pharmacologic 

adjuncts that may be developed can prompt physicians and 

patients to engage in quitting attempts. 

Because clinical interventions reach moderate numbers of 

smokers and because they are a resource and a source of hope 

for many dependent smokers, these interventions must be an 

integral part of any comprehensive plan. Policy and other 

environmental strategies may shift social norms and change 

attitudes toward smoking such that some people will quit (or 

not start) with their own resources; however, many people, 

especially heavy smokers, will need the assistance of some kind 

of clinical service. Most smokers will not require a full-service 

cessation clinic but could profit from advice and support (e.g., 

a prescription) from a health care provider, a worksite incentive 

program, or some measure of individual prompting and assistance. 

Clinical interventions also have a subtle but important byproduct. They help to develop and maintain experts on 

smoking behavior, who in turn may have influence on public 

opinion. This influence operates at both local and national 

levels. A comprehensive community program needs credible 

spokespersons, and a physician who actively advises and 

counsels smoking patients becomes such a resource. Similarly, 

leaders of cessation clinics also develop expertise and credibility as spokespersons. 

178 
Smoking and Tobacco Control Monograph No. 1 

SELF-HELP 

APPROACHES 

There is a final contribution of the clinical approach that 

may be as important as the number of quitters produced. 

Clinical interventions have been the vehicle for developing 

knowledge about the process of quitting, understanding the 

nature of tobacco addiction, and developing useful quitting 

strategies. For example, cessation clinics have provided information about the effectiveness of nicotine chewing gum (e.g., 

Russell et al., 1983), the efficacy of combining behavioral and 

pharmacological strategies (Killen et al., 1990), and the usefulness of nicotine fading or brand switching (Foxx and Brown, 

1979). Most of the strategies and tactics embodied in the selfhelp materials described below were developed in cessation 

clinics. As new knowledge about smoking develops and spawns 

new intervention technologies (e.g., nicotine patches), cessation 

clinics and health providers will provide settings within which 

they may be evaluated and refined. 

Most of the estimated 37 million people who have stopped 

smoking since the Surgeon General’s first report on smoking 

and health have done so without the aid of formal cessation 

programs (Fiore et al., 1990). Survey data indicate that about 

one-third of current smokers made a quit attempt within the 

last year (Harris, 1980), and they express a preference for quitting without the aid of formal cessation programs (Gallup 

Opinion Index, 1974; Owen and Davies, 1990; Schwartz and 

Dubitsky, 1967). In recent years, growing recognition of the 

importance of unaided quitting (US DHHS, 1982) and the 

relative limitations of clinic-based cessation programs in dealing 

with what is a public health problem (Epstein et al., 1989) have 

given rise to substantial literature on unaided or minimally 

assisted quitting. 

Emerging studies suggest that unaided quitting is not a 

unitary concept, but rather one that requires definition (Lichtenstein and Cohen, 1990). There is no solid line separating 

clinical cessation from self-help efforts. It is probably more 

useful to construe a continuum ranging from an intensive, 

structured clinic to a smoker’s making a New Year’s resolution 

and quitting without any materials whatsoever. Self-help 

studies have reported on the effects of materials received 

through the mail (Jeffrey et al., 1982), community-wide quitting 

contests (Glasgow et al., 1985), New Year’s resolution quitting 

(Gritz et al., 1988; Marlatt et al., 1988), persons requesting selfhelp manuals (K.M. Cummings et al., 1988; Davis et al., 1984), 

and computer-assisted self-quitting programs (Prue et al., 1990). 

Unaided quitting efforts have two major defining characteristics: first, the smoker initiates the self-quitting attempt on his 

or her own initiative or with minimal prompting from a health 

care provider or health educator; and second, the effort involves 

no face-to-face counseling or advice from a health professional. 

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National Cancer Institute 

Effectiveness of 

Self-Help Efforts 

Acceptability of 

Self-Quitting 

Not surprisingly, unaided quitting tends to result in somewhat lower quit rates than those achieved with clinical interventions, although the differences are not large. Point-prevalence quit rates at l-year followup tend to be in the 10to 

20 percent range (Cohen et al., 1989;Davis et al., 1984; 

Schwartz, 1987). For continuous quitting, a less frequent but 

more conservative criterion is used; then, abstinence rates at 1-

year followup tend to be in the range of 3 to 5 percent (Cohen 

et al., 1989;Davis et al., 1984). Cohen and colleagues (1989) 

included several samples from different areas of the United 

States and found no differences at 12-month followup between 

quitters receiving materials (self-help booklets) from the 

investigator and those who quit completely on their own. 

Although self-quitting rates are lower than those for more 

intensive interventions, their cost-effectiveness is probably 

higher since there is little or no professional time involved 

(Epstein et al., 1989). 

Self-help materials are often used in concert with media or 

community programs. The media may be used to promote selfhelp products, as when a volunteer organization uses public 

service spots to encourage viewers to request a pamphlet or 

when proprietary companies use media to advertise products 

such as LifeSign or Cigarrest. The use of telephone cessation 

hotlines also can be increased through publicity (Ossip-Klein et 

al., 1984). 

Community campaigns have typically made extensive use 

of self-help approaches. One particularly effective method is a 

mediated, community-wide, cessation program. Through 

publicity about a quitting program via television or newspapers, significant numbers of smokers can be induced to make 

serious quitting attempts (Cummings et al., 1987). Quitting 

strategies may be provided to participants also through written 

self-help materials, and prizes for selected quitters (via lottery) 

may be offered. Self-help materials can also be joined with 

nicotine polacrilex to increase quit rates (Fortmann et al., 1988; 

Killen et al., 1990). Finally, physicians prescribing nicotine 

gum (or pharmacists dispensing it) can provide written materials to help patients deal with the behavioral aspects of 

smoking. 

Surveys have found that most smokers prefer indirect or 

self-help methods rather than formal cessation clinics (Gallup 

Opinion Index, 1974;Schwartz and Dubitsky, 1967). A recent 

probability sample from Australia (Owen and Davies, 1990) 

confirms the lack of interest in cessation groups (6.7percent) 

but found considerable interest in “a program through your 

doctor” (23.7percent) and “a program through [anlother 

health professional” (12.5percent). Unpublished survey data 

from the Community Intervention Trial for Smoking Cessation 

180 
Smoking and Tobacco Control Monograph No. 1 

Importance of 

Self-Quitting 

also suggest strong interest in assistance from physicians. This 

shift toward an interest in more direct or personalized cessation 

services may be an Australian phenomenon; however, it also 

may reflect historical changes in smokers. Today’s smokers 

may better recognize their dependency and need for external 

assistance. 

Nevertheless, there is a considerable consumer demand for 

take-home services or aids. Although no smoking cessation 

book has reached the nonfiction best seller lists-as is common 

for diet books-the public consumes millions of free brochures 

and pamphlets published by the Federal Government and the 

major voluntary organizations. One Government agency 

reported distributing over 2.5 million smoking-related items in 

1989. It has been estimated that Government and voluntary 

agencies combined produce 100 new smoking and health items 

each year. The brisk market for commercial products such as 

Cigarrest and LifeSign also attests to the public’s willingness to 

try promising methods in the privacy of their own homes and 

offices. 

Several considerations make self-help materials a critical 

element in any comprehensive smoking intervention. Their 

acceptance by many smokers is a major factor; another factor is 

their availability, as Government agencies and major voluntary 

organizations have already created many useful products. For 

the voluntary organizations, both their mission and their selfinterest dictate that they create, update, and disseminate good 

materials bearing their names; a shortage of good self-help 

materials is not likely. The great majority of these self-help 

materials either are free or cost very little. The problem is 

disseminating or deploying them effectively. A parallel motive 

drives the private sector; as long as there is the potential to 

make a profit, self-help products such as LifeSign and Cigarrest 

will be marketed. 

Because self-help materials are acceptable to many smokers, are relatively inexpensive, and can be distributed in settings where smokers naturally are found (medical offices, 

worksites, stores), they have the potential to reach many more 

smokers than do clinical interventions. They also offer the 

opportunity to tailor messages to particular subgroups of 

smokers in a cost-effective way. Market segmentation can 

focus on smokers along the lifespan trajectory, such as written 

materials aimed specifically at adolescents, pregnant women, 

or mothers of newborns. Alternatively, self-help materials can 

be focused on various demographic groups or on smokers at 

different points on the readiness-to-change continuum (Prochaska et al., 1988). 

181 
National Cancer Institute 

Finally, the presence and publicizing of both nonprofit 

and proprietary self-help materials increase public awareness of 

the smoking problem. For example, media advertising and 

store displays of commercial materials (e.g., Lifesign, Cigarrest) 

contribute to an environment that reflects public concern 

about smoking and support for those trying to quit. In summary, specific self-help materials or methods are likely to have 

only weak effects by themselves, but in combination with 

media or community programs, they can reach various populations of smokers and are a critical part of any comprehensive 

smoking reduction program. 

CONCLUSIONS 0 Public information campaigns have been successful in 

increasing awareness of the disease risks associated with 

smoking and have motivated some smokers to quit; 

however, they do not create substantial change in the 

behavior of regular smokers when used as an isolated 

smoking control strategy. 

School-based education methods have been demonstrated to reduce the prevalence of smoking for several 

years among adolescents receiving the curricula. This 

benefit in reduced or delayed initiation of smoking has 

been demonstrated for programs that treat smoking in 

conjunction with other drug-use behavior as well as for 

curricula that deal with smoking alone. 

The best school-based curricula include skills training in 

dealing with the social environment, and programs that 

include parent and community involvement are more 

successful than those that do not. 

Formal cessation clinics have the highest rate of successful long-term cessation of any smoking control strategy, 

but only a limited number of smokers will participate in 

such programs. 

Formal cessation clinics, brief personalized interventions 

by health providers, and the gamut of self-help materials 

constitute a continuum of services aimed at the individual smoker. When properly integrated in community 

programs such as the Community Intervention Trial for 

Smoking Cessation (Pechacek, 1987), they complement 

one another and offer attractive options for smokers 

with varying needs and interests. 

182 
Smoking and Tobacco Control Monograph No. 1 

REFERENCES American Cancer Society. A survey concerning cigarette 

smoking, health check-ups, cancer detection tests: A summary

of the findings. Survey conducted by the Gallup Organization, 

January 1977. 

Arkin, R.M., Roemhild, H.F., Johnson, C.A., Luepker, R.V., 

Murray, D.M. The Minnesota smoking prevention program: A 

seventh-grade health curriculum supplement. Journal ofSchool 

Health 51: 611-616, 1981. 

Ary, D.V., Biglan, A., Glasgow, R., Zorief, L., Black, C., 

Ochs, L., Severson, H., Kelly, R., Weissman, W., Lichtenstein, 

E., Brozovsky, P., Wirt, R., James, L.E. The efficacy of socialinfluence prevention programs vs. “standard care”: Are new 

initiatives needed? Journal ofBehaviora2 Medicine 13: 281-296, 

1990. 

Bagdikian, B.H. TheMedia Monopoly. Boston: Beacon 

Press, 1983. 

Bandura, A. Social Learning Theory. Englewood Cliffs, NJ: 

Prentice-Hall, 1977. 

Bell, C.S., Battjes, R. (Editors). Prevention Research: Deterring Drug Abuse Among Children and Adolescents. Washington, 

DC: U.S. Government Printing Office, 1985. DHHS Publication No. (ADM) 87-1334 (NIDA Research Monograph 63). 

Best, J.A., Flay, B.R., Towson, S.M., Ryan, K.B., Perry, C.L., 

Brown, K.S., Kersell, M.W., D’Avernas, J.R. Smoking prevention and the concept of risk. Journal ofApplied Social Psychology 

14(3): 257-273, 1984. 

Best, J.A., Thomson, S.J., Santi, S.M., Smith, E.A., Brown, 

K.S. Preventing cigarette smoking among school children. 

Annual Review ofpublic Health 9: 161-201, 1988. 

Biglan, A., Glasgow, R., Ary, D., Thompson, R., Severson, 

H., Lichtenstein, E., Weissman, W., Faller, C., Gallison, C. How 

generalizable are the effects of smoking prevention programs? 

Refusal skills training and parent messages in a teacheradministered program. Journal ofBehavioral Medicine lO(6): 

613-628,1987a. 

Biglan, A., Severson, H., Ary, D., Faller, C., Gallison, C., 

Thompson, R., Glasgow, R., Lichtenstein, E. Do smoking prevention programs really work? Attrition and the internal and 

external validity of an evaluation of a refusal skills training 

program. Journal ofBehaviural Medicine lO(2): 159-171, 1987b. 

Biglan, A., James, L.E., Lachance, P., Zorief, L., Joffe, J. 

Videotaped materials in a school-based smoking prevention 

program. PreventiveMedicine 17: 559-584, 1988. 

183 
National Cancer Institute 

Botvin, G.J. Substance abuse prevention research: Recent 

developments and future directions. Journal of School Health 

56: 369-386,1986. 

Botvin, G.J.,Baker, E., Renick, N.L., Filauola, A.D., Botvin, 

E.M. A cognitive-behavioral approach to substance abuse 

prevention. Addictive Behaviors 9: 137-147, 1984. 

Botvin, G.J., Batson, H.W., Witts-Vitale, S., Bess, V., Baker, 

E., Dusenbury, L. A psychosocial approach to smoking prevention for urban black youth. Public Health Reports 104(6): 573- 

582,1989a. 

Botvin, G.J., Dusenbury, L., James-Ortiz, S., Kerner, J. A 

skills training approach to smoking prevention among Hispanic youth. Journal ofBehaviorul Medicine 12:279-296, 1989b. 

Botvin, G.J., Eng, A. The efficacy of a multicomponent approach to the prevention of cigarette smoking. Preventive 

Medicine 11:199-211, 1982. 

Botvin, G.J., Eng, A., Williams, C.L. Preventing the onset 

of cigarette smoking through life skills training. Preventive 

Medicine 9: 135-143, 1980. 

Botvin, G.J., Renick, N.L.,Baker, E. The effects of scheduling format and booster sessions on a broad-spectrum psychosocial approach to smoking prevention. Journal of Behavioral 

Medicine 6(4): 359-379, 1983. 

Burke, J.A., Naughton, M.J., Becker, S.L., Arbogast, R., 

Lauer, R.M., Krohn, M.D. The short-term effects of competition and rewards in an adolescent smoking prevention 

program. Health Education Quarterly 14(2): 141-152, 1987. 

Bush, P.J., Zuckerman, A.E., Theiss, P.K., Taggart, V.S., Horowitz, C., Sheridan, M.J., Walter, H.J. Cardiovascular risk factor 

prevention in black schoolchildren: Two-year results of the 

“know your body“ program. American Journal ofEpidemiology 

129(2): 466-482,1989. 

Cardozo, S.R. Multiple substance use by adolescents and 

the influence of peer and adult modeling. Unpublished master’s thesis, University of Houston, Houston, TX, 1989. 

Centers for Disease Control. Cigarette advertising-United 

States, 1988. Morbidity and Mortality Weekly Report 39(16): 261- 

265,1990. 

Cirino, R. Don’t Blame the People. Los Angeles, CA: Diversity Press, 1972. 

Clarke, J.H., MacPherson, B., Holmes, D.R., Jones, R. Reducing adolescent smoking: A comparison of peer-led, teacherled, and expert interventions. Journal of School Health 56: 102- 

106, 1986. 

184 
Smoking and Tobacco Control Monograph No. 1 

Cleary, P.D., Hitchcock, J.L., Semmer, N., Flinchbaugh, 

L.J., Pinney, J.M. Adolescent smoking: Research and health 

policy. Milbank Quarterly 66: 137-171, 1988. 

Coe, R.M., Crouse, E., Cohen, J.D., Fisher, E.B., Jr. Patterns 

of change in adolescent smoking behavior and results of a oneyear follow-up of a smoking prevention program. Journal of 

School Health 52: 348-353, 1982. 

Cohen, S., Lichtenstein, E., Prochaska, J.O.,Rossi, J.S., 

Gritz, E.R., Carr, C.R., Orleans, C.T., Schoenbach, V.J., Biener, 

L., Abrams, D., DiClemente, C., Curry, S., Marlatt, G.A., Cummings, K.M., Emont, S.L., Giovino, G.,Ossip-Klein, D. Debunking myths about self-quitting: Evidence from 10 prospective studies of persons quitting smoking by themselves. American Psychologist 44: 1355-1365, 1989. 

Colquhoun, J., Cullen, K. Improved smoking habits in 

12-to-14-year-old Busselton children after antismoking 

programmes. Medical Journal ofAustralia 1: 586-587, 1981. 

Consumers Union. Licit and Illicit Drugs. Boston, MA: 

Little, Brown, 1972. 

Cummings, K.M., Emont, S.L.,Jaen, C., Sciandra, R. Format and quitting instructions as factors influencing the impact 

of a self-administered quit smoking program. Health Education 

Quarterly 15: 199-216, 1988. 

Cummings, K.M., Sciandra, R., Markello, S. Impact of a 

newspaper mediated quit smoking program. American Journal 

ofpublic Health 77(11): 1452-1453, 1987. 

Cummings, S.R., Hansen, B., Richard, R.J., Stein, M.J., 

Coates, T.J. Internists and nicotine gum. Journal of the American Medical Association 260: 1565-1570, 1988. 

Davis, A.L., Faust, R., Ordenlich, M. Self-help smoking cessation and maintenance programs: A comparative study with 

12-month follow-up by the American Lung Association. American Journal ofpublic Health 74: 1212-1217, 1984. 

Diehl, H.S. Tobacco and Your Health: The Smoking Controversy. New York: McGraw-Hill, 1969. 

Dielman, T.E., Lorenger, A.T., Leach, S.L., Lyons, A.L., Klos, 

D.M. Fifteen-month followup results of an elementary school 

based smoking prevention project. International Journal of 

Health Education 4: 28-35, 1985. 

Durell, J., Bukoski, W. Preventing substance abuse: The 

state of the art. Public Health Reports 99(1): 23-31, 1984. 

Ellickson, P.L., Bell, R.M. Drug prevention in junior high. 

A multi-site longitudinal test. Science 247: 1299-1305, 1990. 

185 
National Cancer Institute 

Epstein, L.H., Grunberg, N.E., Lichtenstein, E., Evans, R.1, 

Smoking research: Basic research, intervention, prevention, 

and new trends. Health Psychology 8: 705-722, 1989. 

Evans, R.I. Smoking in children: Developing a social psychological strategy of deterrence. Preventive Medicine 5: 122-127, 

1976. 

Evans, R.I. Deterring smoking in adolescents: A case study 

from a social psychological research program. In: Contemporary Health Services: Social Science Perspectives, A.W. Johnson, 0. 

Grusky, and B.H. Raven (Editors). Boston: Auburn House Publishing, 1982, pp. 205-219. 

Evans, R.I. Deterring smoking in adolescents: Evolution 

of a research program in applied social psychology. International Review ofApplied Psychology 32: 71-83, 1983. 

Evans, R.I. A social inoculation strategy to deter smoking 

in adolescents. 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 and Sons, 1984, pp. 765-774. 

Evans, R.I. Development of the social inoculation strategy 

to deter smoking and related health threatening behaviors in 

adolescents: Review and an update. Paper presented at the 

International Workshop on Prevention of Drug Addictions, 

Santa Pola, Alicante, Spain, December 1990. 

Evans, R.I., Getz, J.G., Sharp, M.J. A demographic-psychosocial-behavioral comparison between accelerating vs. infrequent vs. never-smokers among adolescents. Paper presented 

at the annual meeting of the Cardiovascular Behavioral Medicine, Epidemiology, and Biostatistics Training Session; National 

Heart, Lung, and Blood Institute; Orlando, FL; March 1991. 

Evans, R.I., Raines, B.E. Control and prevention of smoking in adolescents: A psychosocial perspective. In: Promoting

Adolescent Health: A Dialog on Research and Practice, T.J. Coates, 

A.C. Petersen, and C. Perry (Editors). New York: Academic 

Press, 1982, pp. 101-136. 

Evans, R.I., Raines, B.E. Applying a social psychological 

model across health promotion interventions: Cigarettes to 

smokeless tobacco. In: Social Influence Processes and Prevention: 

Social Psychological Applications of Social Issues, J. Edwards, R.S. 

Tindale, L. Heath, and E.J. Posavac (Editors). New York: Plenum Press, 1990, pp. 143-147. 

Evans, R.I., Raines, B.E., Hanselka, L.L. Developing databased communications in social psychological research: Adolescent smoking prevention. lournal of Applied Social Psychology 

14: 289-295, 1984. 

186 
Smoking and Tobacco Control Monograph No. 1 

Evans, R.I., Raines, B.E., Owen, A.E. Formative evaluation 

in school-based health promotion investigation. Preventive 

Medicine 18: 229-234, 1989. 

Evans, R.I., Rozelle, R.M., Maxwell, S.E., Raines, B.E., Dill, 

C.A., Guthrie, T.J., Henderson, A.H., Hill, P.C. Social modelling 

films to deter smoking in adolescents: Results of a three year 

field investigation. Journal ofApplied Psychology 66(4): 399-414, 

1981. 

Evans, R.I., Turner, S.H., Ghee, K.L., Getz, J.G. Is androgynous sex role related to cigarette smoking? Journal ofApplied 

Social Psychology 20:495-505, 1990. 

Fagerstrom, K.O. Effects of nicotine chewing gum and 

follow-up appointments in physician-based smoking cessation. 

Preventive Medicine, 13: 517-527, 1984. 

Fiore, M.C., Novotny, T., Pierce, J., Giovino, G., Hatziandreu, E., Newcomb, P., Surawicz, T. Methods of smoking 

cessation in the United States: A population-based epidemiologic study. Paper presented at the Seventh World Health Conference on Smoking and Health, Perth, Australia, April 1990. 

Fishbein, M. (Editor). Readings in A&*tude Theory and Measurement. New York: John Wiley and Sons, 1967. 

Fishbein, M., Ajzen, I. Belief, Aftitude, Intention and Behavior: An Introduction to Theory and Research. Reading, MA: 

Addison-Wiley, 1975. 

Fisher, D.A., Armstrong, B.K., de Klerk, N.H. A randomized-controlled trial of education for prevention of smoking in 

12-year-old children. In: Proceedings ofthe Fifth World Conference on Smoking and Health, W.F. Forbes, R.C. Frecker, and D. 

Nosbakken (Editors). Ottawa: Canadian Council on Smoking 

and Health, 1985, pp. 263-270. 

Flay, B.R. Psychosocial approaches to smoking prevention: 

A review of findings. Health Psychology 4(5): 449-488, 1985. 

Flay, B.R. Mass media and smoking cessation: A critical 

review. American Journal of Public Health 77(2): 153-160, 1987. 

Flay, B.R., Brannon, B.R., Johnson, C.A., Hansen, W.B., 

Ulene, A.L., Whitney-Saltiel,D.A., Gleason, L.R., Sussman, S., 

Gavin, M.D., Glowacz, K.M., Sobol, D.F., Spiegel, D.C. The 

television, school and family smoking prevention and cessation project. Preventive Medicine 17: 585-607, 1988. 

Flay, B.R., Burton, D. Effective mass communications campaigns for public health. Paper presented at the Conference for 

Mass Communications and Public Health: Complexities and 

Conflict, Rancho Mirage, CA, September 1988. 

187 
National Cancer Institute 

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. Firestone (Editors). New York SpringerVerlag, 1983. 

Flay, B.R., Hansen, W.B., Johnson, C.A., Collins, L.M., 

Dent, C.W., Dwyer, K.M., Hockstein, G., Grossman, L., Rauch, 

J., Sobol, D.F., Sobel, J.L., Sussman, S., Ulene, A. Implementation effectiveness trial of a social influences smoking prevention program using schools and television. Health Education 

Research 2: 385-400, 1987. 

Flay, B.R., Koepke, D., Thomson, S.J., Santi, S., Best, J.A., 

Brown, K.S. Six-year follow-up of the first Waterloo school 

smoking prevention trial. American Journal ofPublic Health 

79(10): 1371-1376, 1989. 

Flay, B.R., Ryan, K.B., Best, J.A., Brown, K.S., Kersell, M.W., 

d'Avemas, J.R., Zanna, M.P. Are social-psychological smoking 

prevention programs effective? The Waterloo study. Journal of 

Behavioral Medicine 8(1): 37-59, 1985. 

Fortmann, S.P., Killen, J.D., Telch, M.J., Newman, B. 

Minimal contact treatment for smoking cessation. A placebo 

controlled trial of nicotine polacrilex and self-directed relapse 

prevention: Initial results of the Stanford Stop Smoking 

Project. Journal of the American Medical Association 260: 1575- 

1580,1988. 

Foxx, R.M., Brown, R.A. Nicotine fading and self-monitoring for cigarette abstinence or controlled smoking. Journal of 

Applied Behavior Analysis 12: 111-125, 1979. 

Gallup Opinion Index. Public Pufs On Afrer 10 Years of 

Warnings. Princeton, NJ: Gallup Opinion Index, Report No. 

108, 1974, pp. 20-21. 

Getz, J.G. Personality mediators of adolescent smoking 

behavior: The construct of self-efficacy. Paper presented at the 

meeting of the Society for the Study of Social Issues, Atlanta, 

GA, August 1988. 

Getz, J.G., Evans, R.I. Can psychosocial mechanisms 

account for racial differences in smoking frequency? Paper 

presented at the annual meeting of the Cardiovascular Behavioral Medicine, Epidemiology, and Biostatistics Training Sessions; National Heart, Lung, and Blood Institute; San Francisco, 

CA; March 1989. 

Getz, J.G., Evans, R.I., Sharp, M.H. Relative influence of 

smoking parents, older siblings, and peers on adolescent 

smoking. Paper presented at the annual meeting of the Cardiovascular Behavioral Medicine, Epidemiology, and Biostatistics 

188 
Smoking and Tobacco Control Monograph No. 1 

Training Session; National Heart, Lung, and Blood Institute; San 

Diego, CA; March 1990. 

Gikhrist, L.D., Schinke, S.P. Self-control skills for smoking

prevention. In: Advances in Cancer Control 1983, P.F. Engstrom,

P.N.Anderson, and L.E. Mortenson (Editors). New York: Alan 

R. Liss, 1984,pp. 125-130. 

Gilchrist, L.D., Schinke, S.P., Blythe, B.J. Primary prevention services for children and youth. Children and Youth Services 

Review 1: 379-391,1979, 

Gilchrist, L.D., Schinke, S.P., Bobo, J.K.,Snow, W.H. Selfcontrol skills for preventing smoking. Addictive Behaviors 11: 

169-174, 1986. 

Gilchrist, L.D., Schinke, S.P., Nurius, P. Reducing onset of 

habitual smoking among women. Preventive Medicine 18: 235- 

248,1989. 

Glasgow, R.E., Klesges, R.C., Mizes, S.M., Pechacek, T.F. 

Quitting smoking: Strategies used and variables associated with 

success in a stop-smoking contest. Journal ofConsuZting and 

CZinical PsychoIogy 53: 905-912,1985. 

Glasgow, R.E., Lichtenstein, E, Long-term effects of behavioral smoking cessation interventions. Behavior Therapy 18: 297- 

324,1987. 

Glynn, K.G., Leventhal, H., Hirschman, R. A cognitive developmental approach to smoking prevention. In: Prevention 

Research: Deterring Drug Abuse Among Children and Adolescents, 

C. Bell and R. Battjes (Editors). Washington, DC: U.S. Government Printing Office, 1985,DHHS Publication No.(ADM) 87-

1334 (NIDA Research Monograph 63). 

Glynn, T.J. Relative effectiveness of physician-initiated 

smoking cessation programs. Cancer Bulletin 40: 359-364, 1988. 

Glynn, T.J. Essential elements of school-based smoking 

prevention programs. journal of School Health S9(5): 181-188, 

1989. 

Glynn, T.J., Haenlein, M. Managing adolescent behaviors 

at school: Implications for families, In: The Family Context of 

Adolescent Drug Use. New York: Haworth, 1988,pp. 225-243. 

Glynn, T.J., Boyd, G.M., Gruman, J.C. Essential elements 

of self-help/minimal intervention strategies for smoking 

cessation. Health Education Quarterly 17(3): 329-345, 1990. 

Glynn, T. J., Leukefeld, C.G.,Ludford,J.P. (Editors). Preventing Adolescent Drug Abuse: Intervention strategies. Washing 

ton, DC: U.S. Government Printing Office, 1983,DHHS Publication No. (ADM) 83-1280(NIDA Research Monograph 47). 

189 
National Cancer Institute 

Goldstein, M.G., Niaura, R., Follick, M.J., Abrams, D.B. 

Effects on behavioral skills training and schedule of nicotine 

gum administration on smoking cessation. American Journal of 

Psychiatry 146: 56-60, 1989. 

Goodstadt, M.S. Alcohol and drug education: Models and 

outcomes. Health Education Monographs 6(3): 263-279, 1978. 

Grabowski, J., Hall, S.M. (Editors). Phamzacological Adjuncts 

in Smoking Cessation. Washington, DC: U.S. Government 

Printing Office, 1985 (NIDA Research Monograph 53). 

Gritz, E.R., Can, C.R., Marcus, A.C. Unaided smoking cessation: Great American Smokeout and New Year’s Day quitters. 

Psychosocial Oncology 6: 217-234, 1988. 

Hall, S.M., Rugg, D., Tunstall, C., Jones, R. Preventing 

relapse to cigarette smoking by behavioral skill training. Journal of Consulting and Clinical Psychology 52: 372-382, 1984. 

Hall, S.M., Tunstall, C., Ginsberg, D., Benowitz, N.L., Jones, 

R.T. Nicotine gum and behavioral treatment in smoking 

cessation. Journal of Consulting and Clinical Psychology 55: 603- 

606,1987. 

Hansen, W.B., Johnson, C.A., Flay, B.R., Graham, J.W., 

Sobel, J. Affective and social influences approaches to the 

prevention of multiple substance abuse among seventh grade 

students: Results from Project SMART. Preventive Medicine 17: 

135-154, 1988. 

Harris, J.E. Patterns of cigarette smoking. In: The Health 

Consequences of Smoking for Women: A Report of the Surgeon

General. U.S. Department of Health and Human Services, 

Public Health Service, Office of the Assistant Secretary for 

Health, Office on Smoking and Health, 1980, pp. 25-42. 

Hovland, C.I.,Janis, I.L., Kelly, H.H. Communication and 

Persuasion. New Haven, CT: Yale University Press, 1953. 

Hughes, J.R., Gust, S.W., Keenan, R.M., Fenwick, J. W., 

Healy, M.L. Nicotine vs. placebo gum in general medical 

practice. Journal ofthe American Medical Association 261: 1300- 

1305,1989. 

Hurd, P.D., Johnson, C.A.,Pechacek, T., Bast, L.P., Jacobs, 

D.R., Luepker, R.V. Prevention of cigarette smoking in seventh 

grade students. Journal ofBehavioral Medicine 3(1): 15-28, 1980. 

Jamrozik, K., Fowler, G., Vessey, M., Wald, N. Placebo controlled trial of nicotine chewing gum in general practice. 

BritishMedical Journal 289: 794-797,1984. 

Janz, N.K., Becker, M.H., Kirscht,.JP., Eraker, S.A., Billi, J.E., 

Wolliscroft, J.O. Evaluation of a minimal-contact smoking 

190 
Smoking and Tobacco Control Monograph No. 1 

cessation intervention in an outpatient setting. American 

Journal ofpublic Health 77: 805-809, 1987. 

Jason, L.A. Preventive community'interventions: Reducing school children's smoking and decreasing smoke exposure. 

Professional Psychology 10: 744-752, 1979. 

Jason, L.A., Mollica, M., Ferrone, L. Evaluating an early 

secondary smoking prevention intervention. Preventive Medicine 11: 96-102, 1982. 

Jeffrey, R.W., Danaher, B.G., Killen, J., Farquhar, J.W., 

Kinnier, R. Self-administered programs for health behavior 

change: Smoking cessation and weight reduction. Addictive Behaviors 7: 57-63, 1982. 

Jessor, R., Jessor, S.L. Problem Behavior and Psychosocial 

Development-A Longitudinal Study of Youth. New York: Academic Press, 1977. 

Johnson, C.A., Hansen, W.B., Collins, L.M., Graham, J. W. 

High-school smoking prevention: Results of a three-year longitudinal study. Journal ofBehaviora1 Medicine 9(5): 439-452, 

1986. 

Kamarck, T.W., Lichtenstein, E. Program adherence and 

coping strategies as predictors of success in a smoking treatment program. Health Psychology 7(6):55 7-5 74, 1988. 

Kendall, P.C., Hollon, S.D. Cognitive-BehavioralIntewentions: Theory, Research and Practice. New York: Academic Press, 

1979. 

Killen, J.D., Fortmann, S.P., Newman, B., Varady, A. 

Evaluation of a treatment approach combining nicotine gum 

with self-guided behavioral treatments for smoking relapse 

prevention. Journal of Consulting and Clinical Psychology 58: 85- 

92, 1990. 

Killen, J.D., Maccoby, N., Taylor, C.B. Nicotine gum and 

self-regulation training in smoking relapse prevention. Behavior Therapy 15: 234-238, 1984. 

Kottke, T.E., Battista, R.N., DeFriese, G.H., Brekke, M.L. 

Attributes of successful smoking cessation interventions in 

medical practice: A meta-analysis of 39 controlled trials. 

Journal of the American Medical Association 259: 2883-2889, 

1988. 

Kozlowski, L.T. Pharmacological approaches to smoking 

modification. In: Behavioral Health: A Handbook of Health 

Enhancement and Disease Prevention, J.D. Matarazzo, J.A. Herd, 

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

John Wiley and Sons, 1984, pp. 713-728. 

191 
National Cancer Institute 

Lam, W., Sze, P.C., Sacks, H.S., Chalmers, T.C. Metaanalysis of randomized controlled trials of nicotine chewinggum. Lancet 2: 27-30, 1987. 

Lando, H.A. Long-term modification of chronic smoking 

behavior: A paradigmatic approach. Bulletin of the Society of 

Psychologists in Addictive Behaviors 5: 5-17, 1986. 

Lando, H.A., McGovern, P.G., Sipfle, C.L. Public service 

application of an effective clinic approach to smoking 

cessation. Health Education Research 4: 103-109, 1989. 

Leventhal, H., Cleary, P.D. The smoking problem: A 

review of the research and theory in behavioral risk 

modification. Psychological Bulletin 88(2): 370-405, 1980. 

Lichtenstein, E. The smoking problem: A behavioral 

perspective. Journal of Consulting and Clinical Psychology 50: 

804-819, 1982. 

Lichtenstein, E., Cohen, S. Prospective analysis of two 

modes of unaided smoking cessation. Health Education Research 

5: 63-72, 1990. 

Lichtenstein, E., Glasgow, R.E. Rapid smoking: Side 

effects and safeguards. Journal of Consulting and Clinical Psychology 45: 815-821, 1977. 

Lichtenstein, E., Glasgow, R.E., Abrams, D.B. Social 

support in smoking cessation: In search of effective 

interventions. Behavior Therapy 17:607-619, 1986. 

Lichtenstein, E., Harris, D.E., Birchler, G.R., Wahl, J.M., 

Schmahl, D.P. A comparison of rapid smoking, warm, smoky 

air, and attention-placebo in the modification of smoking 

behavior. Journal of Consulting and Clinical Psychology 40:93-

98, 1973. 

Lichtenstein, E., Mermelstein, R. Behavior modification 

strategies. In: Behavioral Health: A Handbook of Health Enhancement and Disease Prevention, J. Matarazzo, S.M. Weiss, J.A. 

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

Wiley and Sons, 1984,pp. 695-712. 

Lloyd, D.M., Alexander, H.M., Callcott, R., Dobson, A.J., 

Hardes, G.R., O’Connell, D.L., Leeder, S.R. Cigarette smoking 

and drug use in schoolchildren: 111-Evaluation of a smoking 

prevention education programme. International Journal of Epidemiology 12(1): 51-58, 1983. 

Luepker, R.V., Johnson, C.A., Murray, D.M., Pechacek, T.F. 

Prevention of cigarette smoking: Three-year follow-up of an 

education program for youth. Journal of Behavioral Medicine 

6(1): 53-62, 1983. 

192 
Smoking and Tobacco Control Monograph No. 1 

Maiman, L.A., Becker, M.H. The health belief model: 

Origins and correlates in psychology theory. In: The Health 

Belief Model and Personal Health Behavior, M.H. Becker (Editor). 

Thorofare, NJ: C.B. Slack, 1974. 

Marlatt, G.A., Curry, S., Gordon, J.R. A longitudinal

analysis of unaided smoking cesssation. Journal of Consulting 

and Clinical Psychology 56: 715-720, 1988. 

Marlatt, G.A., Gordon, J.R. Relapse Prevention: Maintenance 

Strategies in the Treatment of Addictive Behaviors. New York: 

Guilford Press, 1985. 

McAlister, A., Perry, C., Killen, J., Slinkard, L., Maccoby, N. 

Pilot study of smoking, alcohol and drug abuse prevention. 

American Journal ofPublic Health 70: 719-721, 1980. 

McAlister, A., Perry, C., Maccoby, N. Adolescent smoking: 

Onset and prevention. Pediatn’cs 63: 650-658, 1979. 

McAlister, A., Rameriz, A.G., Galavotti, C., Gallison, C. 

Antismoking campaigns: Progress in the application of social 

learning theory. In: Public Communication Campaigns (2nd 

edition), R.E. Rice and C. Atkins (Editors). Newbury Park, CA: 

Sage, 1989, pp. 291-307. 

McGuire, W.J. Inducing resistance to persuasion. In: Advances In Experimental Social Psychology (volume l),L. Berkowitz 

(Editor). New York: Academic Press, 1964, pp. 192-229. 

McGuire, W.J. The nature of attitudes and attitude 

change. In: Handbook of Social Psychology (2nd edition, volume 3), G. Lindzay and E. Aronson (Editors). Reading, MA: 

Addison-Wesley, 1969. 

Murray, D.M., Hearn, M.D., Goldman, A.I., Pirie, P., 

Luepker, R.V. Four- and five-year follow-up results from four 

seventh-grade smoking prevention strategies. Journal of Behavioral Medicine ll(4): 395-405, 1988. 

Murray, D.M., Johnson, C.A., Luepker, R.V., Mittelmark, 

M.B. The prevention of cigarette smoking in children: A 

comparison of four strategies. Journal of Applied Social Psychology 14: 274-288, 1984. 

Murray, D.M., Pirie, P., Luepker, R.V., Pallonen, U. Fiveand six-year followup results from four seventh-grade smoking 

prevention strategies. Journal of Behavioral Medicine 12(2):207-

218,1989. 

Murray, D.M., Richards, P.S., Luepker, R.V., Johnson, C.A. 

The prevention of cigarette smoking in children: Two- and 

three-year follow-up comparisons of four prevention strategies. 

Journal ofBehaviora1 Medicine lO(6): 595-61 1, 1987. 

193 
National Cancer Institute 

Ockene, J.K. Physician-delivered interventions for smoking cessation: Strategies for increasing effectiveness. Preventive 

Medicine 16: 723-737, 1987a. 

Ockene, J.K. Smoking intervention: The expanding role 

of the physician. American Journal of Public Health 77: 782-783, 

1987b. 

Ockene, J.K., Hymowitz, N., Sexton, M., Broste, S.K. Comparison of patterns of smoking behavior change among smokers in the Multiple Risk Factor Intervention Trial (MRFIT). 

Preventive Medicine 11: 621-638, 1982. 

Ockene, J.K., Lindsay, E., Berger, L., Hymowitz, N. Health 

care providers as key change agents in the Community Intervention Trial for Smoking Cessation. International Quarterly of 

Community Health Education ll(3): 223-237, 1990-1991. 

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. 

Orleans, C.T., Schoenbach, V.J., Salmon, M.A., Wagner, 

E.H., Pearson, D.C., Fiedler, J., Quade, D., Kaplan, B., Porter, C. 

Effectiveness of self-help quit smoking strategies: Long-term 

results of a randomized controlled trial. Paper presented at the 

annual meeting of the American Public Health Association, 

Boston, MA, November 1988. 

Ossip-Klein, D.J., Shapiro, R.M., Stiggins, J. Freedom Line: 

Increasing utilization of a telephone support service for exsmokers. Addictive Behaviors 9: 227-230, 1984. 

Owen, N., Davies, M.J. Smokers’ preferences for assistance 

with cessation. Preventive Medicine 19: 424-43 1, 1990. 

Pechacek, T. A randomized trial for smoking cessation. In: 

Smoking and Health, 1987. Proceedings of the Sixth World Conference on Smoking and Health, Tokyo, November 9-12, 1987. 

Pederson, L.L. Compliance with physician advice to quit 

smoking: A review of the literature. Preventive Medicine 11: 71-

84, 1982. 

Pentz, M.A. Prevention of adolescent substance abuse 

through social skill development. In: Preventing Adolescent 

Drug Abuse: Intervention Strategies, T.J. Glynn, C.G. Leukefeld, 

and J.P. Ludford (Editors). Washington, DC: U.S. Government 

Printing Office, 1983, DHHS Publication No. (ADM) 83-1280, 

pp. 195-232 (NIDA Research Monograph 47). 

Pentz, M.A., Dwyer, J.H., MacKinnon, D.P., Flay, B.R., 

Hansen, W.B., Wang, E., Johnson, C.A. A multicommunity

trial for primary prevention of adolescent drug abuse. Journal 

of the American Medical Association 261(22): 3259-3266, 1989a. 

194 
Smoking and Tobacco Control Monograph No. 1 

Pentz, M.A., MacKinnon, D.P., Flay, B.R., Hansen, W.B., 

Johnson, C.A., Dwyer, J.H. Primary prevention of chronic 

diseases in adolescence: Effects of the midwestern prevention 

project on tobacco use. American Journal ofEpidemiology 130(4): 

713-724, 1989b. 

Perry, C., Killen, J., Slinkard, L.A., McAlister, A.L. Peer 

teaching and smoking prevention among junior high students. 

Adolescence 15: 277-281, 1980a. 

Perry, C.L., Killen, J., Telch, M., Maccoby, N. Modifying 

smoking behavior of teenagers: A school based intervention. 

American Journal ofpublic Health 70: 722-725, 1980b. 

Perry, C.L., Klepp, K.I., Sillers, C. Community-wide 

strategies for cardiovascular health: The Minnesota Heart 

Health Program youth program. Health Education Research 4(1): 

87-101, 1989. 

Perry, C.L., Telch, J.J., Killen, J., Burke, A., Maccoby, N. 

High school smoking prevention: The relative efficacy of 

varied treatments and instructors. Adolescence 18(71): 561-566, 

1983. 

Pierce, J.P. Review of morning presentations. In: Smoking

Cessation: The Organization, Delivery, and Financing of Services. 

Hollis, NH: Puritan Press, 1990, pp. 77-99. 

Prochaska, J.O., Velicer, W.F., DiClemente, C.C., Fava, J. 

Measuring processes of change: Applications to the cessation 

of smoking. Journal of Consulting and Clinical Psychology 56: 

520-528, 1988. 

Prue, D.M., Riley, A.W., Orlandi, M.A., Jerome, A. Development of a computer-assisted smoking cessation program: A 

preliminary report. Journal of Advancement in Medicine 3(2): 

131-139, 1990. 

Puska, P., Koskela, K., McAlister, A., Pallonen, U., Vartiainen, E., Homan, K. A comprehensive television smoking 

cessation campaign program in Finland. International Journal of 

Health Education 22 (Suppl.):1-26, 1979. 

Rongey, C. Provider perspectives on cessation services 

(comment). In: Smoking Cessation: The Organization, Delivery, 

and Financing of Services. Hollis, NH: Puritan Press, 1990, 

p. 139. 

Russell, M.A.H., Merriman, R., Stapleton, J., Taylor, W. 

Effect of nicotine gum as an adjunct to general practitioners’ 

advice against smoking. British Medical Journal 287: 1782-1 785, 

1983. 

195 
National Cancer Institute 

Schaps, E., DiBartolo, R., Moskowitz, J., Palley, C., 

Churgin, S. Primary prevention evaluation research: A review 

of 127 impact studies. Journal OfDrugIssues 11: 17-43, 1981. 

Schinke, S.P., Bebel, M.Y., Orlandi, M.A., BoMn, G.J. Prevention strategies for vulnerable pupils. School social work 

practices to prevent substance abuse. Urban Education 22(4): 

510-519,1988a. 

Schinke, S.P., Blythe, B.J. Cognitive-behavioral prevention 

of children’s smoking. Child Behavior Therapy 3(4): 25-42, 

1981. 

Schinke, S.P., Botvin, G.J., Trimble, J.E., Orlandi, M.A., 

Gilchrist, L.D., Locklear, V.S. Preventing substance abuse 

among American-Indian adolescents: A bicultural competence 

skills approach. Journal of Counseling Psychology 35(1):87-90, 

1988b. 

Schinke, S.P., Gilchrist L.D. Primary prevention of tobacco 

smoking. Journal of School Health 53(7): 416-419, 1983. 

Schinke, S.P.,Gilchrist, L.D. Preventing cigarette smoking 

with youth. Journal of Primary Prevention 5(1): 48-56, 1984. 

Schinke, S.P., Gilchrist, L.D. Preventing substance abuse 

with children and adolescents. Journal of Consulting and Clinical 

Ps~c~oZO~ 53(5): 596-602, 1985. 

Schinke, S.P., Gilchrist, L.D. Preventing tobacco use 

among young people. Health and Social Work ll(1): 59-65, 

1986. 

Schinke, S.P., Gilchrist, L.D., Schilling, R.F., Senechal, V.A. 

Smoking and smokeless tobacco use among adolescents: 

Trends and intervention results. Public Health Reports lOl(4): 

373-378, 1986a. 

Schinke, S.P., Gilchrist, L.D., Schilling, R.F., Snow, W.H., 

Bobo, J.K. Skills methods to prevent smoking. Health Education 

Quarterly 13(1): 23-27, 1986b. 

Schinke, S.P., Gilchrist, L.D., Snow, W.H. Skills intervention to prevent cigarette smoking among adolescents. American Journal ofpublic Health 75: 665-667, 1985a. 

Schinke, S.P., Gilchrist, L.D., Snow, W.H., Schilling, R.F. 

Skills-building methods to prevent smoking by adolescents. 

Journal ofAdolescent Health Care 6: 439-444, 1985b. 

Schmahl, D.P., Lichtenstein, E., Harris, D.E.Successful 

treatment of habitual smokers with warm, smoky air and rapid 

smoking. Journal of Consulting and Clinical Psychology 38: 105- 

111,1972. 

196 
Smoking and Tobacco Control Monograph No. 1 

Schwartz,J.L. Review and Evaluation of Smoking Cessation 

Methods: The United States and Canada, 1978-1985. U.S. Department of Health and Human Services, Public Health Service, 

National Institutes of Health, National Cancer Institute. NIH 

Publication No. 87-2940,1987. 

Schwartz, J.L., Dubitzky, M. Expressed willingness of 

smokers to try 10 smoking withdrawal methods. Public Health 

Reports 82: 855-861, 1967. 

Shaffer, H., Beck, J.C., Boothroyd, P. The primary prevention of smoking onset: An inoculation approach. Journal of 

PsychoactiveDrugs 15(3): 177-184,1983, 

Snow, W.H., Gilchrist, L.D.,Schinke, S.P. A critique of 

progress in adolescent smoking prevention. Children and Youth 

Services Review 7: 1-19, 1985. 

Spitzzeri, A., Jason, L.A. Prevention and treatment of 

smoking in school age children. Journal of Drug Education 9: 

315-327,1979. 

Stevens, V.J., Hollis, J.F. Preventing smoking relapse, using 

an individually tailored skills-training technique. Journal of 

Consulting and Clinical Psychology 57: 420-424, 1989. 

Sussman, S. Two social influence perspectives of tobacco 

use development and prevention. Health Education Research 

4(2): 213-223, 1989. 

Telch, M.J., Killen, J.D., McAlister, A.L., Perry, C.L., Maccoby, N. Long-term follow-up of a pilot project on smoking 

prevention with adolescents. Journal of Behavioral Medicine 

5(1):1-8, 1982. 

Tell, G.S., Klepp, K., Vellar, O.D., McAlister, A. Preventing

the onset of cigarette smoking in Norwegian adolescents: The 

Oslo Youth Study. Preventive Medicine 13:256-275, 1984. 

Thompson, E.L. Smoking education programs, 1960-1976. 

American JournalofPublic Health 68: 250-257, 1978. 

Tobler, N.S. Meta-analysis of 143 adolescent drug prevention programs: Quantitative outcome results of program 

participants compared to a control or comparison group. 

Journal ofDrug Issues 16(4): 537-567, 1986. 

Tortu, S., Botvin, G.J. School-based smoking prevention: 

The teacher training process. Preventive Medicine 18: 280-289, 

1989. 

Troyer, R.J., Markle, G.E. Cigarettes: The Battle Over Smoking. New Brunswick, NJ: Rutgers University Press, 1983. 

197 
National Cancer Institute 

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

Health Consequences of Smoking: Cancer. A Report of the Surgeon 

General. Rockville, MD: U.S. Public Health Service, Office on 

Smoking and Health. DHHS Publication No. (PHS) 82-50179, 

1982. 

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

Opportunities for Smoking Intervention. A Guide for the Busy

Physician. U.S. Department of Health and Human Services; 

Public Health Service; National Institutes of Health; National 

Heart, Lung, and Blood Institute. PHS Publication No. (NIH) 

86-21 78, 1986. 

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

Health Consequences of Smoking: Nicotine Addiction. A Report of 

the Surgeon General, 1988. U.S. Department of Health and 

Human Services, Public Health Service, Centers for Disease 

Control, Center for Health Promotion and Education, Office on 

Smoking and Health. DHHS Publication No. (CDC) 88-8406, 

1988. 

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

the Health Consequences of Smoking: 25 Years of Progress. A 

Report ofthe Surgeon General, 1989. 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. DHHS Publication 

NO.(CDC) 89-8411, 1989. 

U.S. Department of Health, Education, and Welfare. Srnoking and Health. A Report ofthe Surgeon General. U.S. Department 

of Health, Education, and Welfare; Public Health Service; Office 

of the Assistant Secretary for Health; Office on Smoking and 

Health. DHEW Publication No. (PHS) 79-50066, 1979. 

Vartiainen, E., Pailonen, U., McAlister, A., Koskela, K., 

Puska, P. Effect of two years of educational intervention on 

adolescent smoking (the North Karelia Youth Project). Bulletin 

ofthe World Health Organization 61(3): 529-532, 1983. 

Vartiainen, E., Pallonen, U., McAlister, A., Koskela, K., 

Puska, P. Four-year follow-up results of the smoking prevention program in the North Karelia Youth Project. Preventive 

Medicine 15: 692-698, 1986. 

Vartiainen, E., Pallonen, U., McAlister, A., Puska, P. Eightyear follow-up results of an adolescent smokingprevention 

program: The North Karelia Youth Project. American Journal of 

Public Health 80(1): 78-79, 1990. 

Vogt, T.M., Lichtenstein, E., Ary, D., Biglan, A., Danielson, 

R., Glasgow, R.E., Hollis, J.F., Hornbrook, M.C., Lando, H., 

Severson, H., Stevens, V. Integrating tobacco intervention into 

198 
Smoking and Tobacco Control Monograph No. 1 

a health maintenance organization: The TRACC Program. 

Health Education Research 4: 125-135, 1989. 

Wallack, L. Social Marketing and Media Advocacy: Two 

Approaches to Health Promotion. School of Public Health, University of California, Berkeley, June 1989. 

Walter, H.J., Hofman, A., Barrett, L.T. Coronary heart 

disease prevention in childhood: One-year results of a randomized intervention study. American Journal of Preventive Medicine 

2: 239-245, 1986. 

Walter, H.J., Hofman, A., Vaughan, R.D. Modification of 

risk factors for coronary heart disease: Five-year results of a 

school-based intervention trial. New England Journal ofMedicine 

318: 1093-1100, 1988. 

Walter, H.J., Vaughan, R.D., Wynder, E.L. Primary prevention of cancer among children: Changes in cigarette smoking 

and diet after six years of intervention. Journal of the National 

Cancer Institute 81(13): 995-999, 1989. 

Warner, K.E. Cigarette smoking in the 1970’s: The impact 

of the anti-smoking campaign on consumption. Science 211: 

729-731,1981. 

Warner, K.E. Cigarette advertising and media coverage of 

smoking and health. New England Journal ofMedicine 312: 384- 

388,1985. 

Warner, K.E., Ernster, V.L., Holbrook, J.H., Lewit, E.M., 

Pertschuk, M., Steinfeld, J.L., Tye, J.B., Whelan, E.M. Promotion of tobacco products: Issues and policy options. Journal of 

Health Politics, Policy, and Law 11: 367-392, 1986. 

Wechsler, H., Levin, S., Idelson, R.K., Rothman, M., Taylor, 

J.O. The physician’s role in health promotion-A survey of 

primary care practitioners. New England Journal ofMedicine 308: 

97-100, 1983. 

Wells, K.B., Lewis, C.E., Leuke, B., Schleiter, M.K., Brook, 

P.H. The practices of general and subspecialty internists in 

counseling about smoking and exercise. American Journal of 

Public Health 76: 1009-1013, 1986. 

Wilson, D.M.C., Lindsay, E.A., Best, J.A., Gilbert, J.R., 

Willms, D.G., Singer, J. A smoking cessation intervention for 

family physicians. Canadian Medical Association Journal 137: 

613-619, 1987. 

Worden, J.K., Flynn, B.S., Geller, B.M., Chen, M., Shelton, 

L.G., Secker-Walker, R.H., Solomon, D.S., Solomon, L.J., 

Couchey, S., Costanza, M.C. Development of a smoking 

prevention mass media program using diagnostic and formative research. Journal of Preventive Medicine 17: 531-559, 1988. 

199 
BLANK PAGE 
Chapter 5 

Approaches Directed to the 

Social Environment 

CONTENTS Public Opinion and Tobacco Use ..........................................203 

Intervention Channels .......................................................... 205 

Mass Media .................................................................... 205 

Health Care Providers .................................................... 210 

Worksites........................................................................ 213 

Schools...........................................................................215 

Community Mobilization ..................................................... 218 

Community Analysis ..................................................... 221 

Planning ......................................................................... 223 

Implementation ............................................................. 223 

Maintenance .................................................................. 224 

Restrictive Legislation ........................................................... 225 

Federal Actions ............................................................... 226 

State Legislation ............................................................. 227 

Local Legislation ............................................................228 

Public Opinion ...............................................................229 

Effects of Restrictions on Smoking Prevalence ..............229 

Employee Attitudes ........................................................230 

Impact of Worksite Restrictions ..................................... 230 

Impact of Smoking Bans ................................................ 231 

Effect on Continuing Smokers .......................................232 

Elements Needed for Worksite Restrictions ...................232 

Preventing Tobacco Sales to Minors ..................................... 233 

Minors’ Access to Tobacco ............................................. 234 

Action at the Community Level ....................................237 

A Public Policy Agenda ..................................................238 

Economic Incentives ............................................................. 239 

Excise Taxes on Tobacco Products ................................. 240 

Preferential Hiring and Promotion ...............................245 . Differential Insurance Premiums ...................................249 

An Overview of Economic Incentives ............................251 

Conclusions........................................................................... 253 

References ...........................................................................254 ...

201 
BLANK PAGE 
Chapter 5 

Approaches Directed to the 

Social Environment 

PUBLIC OPINION The addictive nature of tobacco notwithstanding, tobacco 

ANDTOBACCO USE use appears to be largely a socially mediated practice that is susceptible to change in the social environment. Changes in 

cigarette consumption in the United States seem to mirror 

shifts in public attitudes and opinions about smoking (Warner, 

1986a). Figure 1demonstrates a correspondence between the 

per capita cigarette consumption of adults and the timing of 

major public events related to smoking and health. Increasing 

consumption between 1900 and 1950 can be related to application of newly developed marketing and advertising techniques 

by the tobacco industry and the impact of World Wars I and 11, 

when millions of men were introduced to cigarettes in the 

armed forces (Warner, 1986a; Whelan, 1984). 

Most studies of seminal events that affected public awareness and knowledge about smoking, such as publication of the 

first Surgeon General’s Report in 1964, have shown significant 

decreases in cigarette consumption in the year of the event 

(Hamilton, 1972; Warner, 1977 and 1989). Several studies 

have found the events to have a cumulative downward influence on demand for cigarettes. Warner, projecting from 

prevalence rates and trends of the rnid-l960’s, found that 1985 

smoking rates for every age and sex cohort were significantly 

lower than expected, with the greatest decreases from the 

projected rates in the younger cohorts (Warner, 1989). He 

estimated that in 1985 there were 35 million fewer smokers 

than expected, a 38 percent decline in anticipated prevalence. 

Warner attributes this difference to changes in the social 

environment spawned by scientific and social interest in the 

hazards of smoking (Warner, 1986a and 1989). 

As social beings, humans are subject to a desire to conform, to adopt the social conventions, customs, and norms of 

the majority (Wrightman, 1977). To the extent that individuals perceive their actions as deviant, there will be pressure to 

conform to the dominant public opinion. The history of 

tobacco use traced in Figure 1can be seen in these terms, 

initially reflecting increasing social sanction of smoking (first 

by men and then by women), then growing disapproval of 

smoking as a practice dangerous to the smoker and, later, to 

others. 

203 
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Smoking and Tobacco Control Monograph No. 1 

Perception and internalization of social norms arise from a 

process in which the individual observes the distribution of 

opinion and behavior in the environment. The environment 

consists of both primary and secondary social networks (e.g., 

family, friends, and workplace) and impressions of society at 

large, derived largely from the mass media (Noelle-Neuman, 

1974). In this light, an important function of tobacco advertising and promotion is to fill the environment with messages 

reinforcing the perception of smoking as a socially approved, 

accepted, and even desirable behavior (Davis, 1987; Tye et al., 

1987; Warner, 1986a). 

Efforts to control tobacco use, then, should focus on 

creating a social environment that provides persistent and inescapable cues to smokers to stop smoking and to nonsmokers 

not to start. Such an approach assumes that the best way to 

change individual behavior is to intervene through the social 

structures in a community that help shape an individual’s 

opinions and attitudes (Warner et al., 1986). 

INTERVENTION The primary targets for tobacco control interventions are 

CHANNELS not individuals but the social networks that shape the attitudes 

of individuals (both smokers and nonsmokers) toward tobacco. 

For smoking control, the most relevant networks are the media, 

health care providers, worksites, and schools. Additional 

efforts to alter the environment in which the smoker smokes 

and the adolescent begins to smoke have been made through 

legislation, restriction on where smoking is allowed, restriction 

of access to cigarettes by adolescents, and increases in the 

economic costs of tobacco use. The following paragraphs 

review the nature of these intervention channels and provide 

suggestions about how each may be employed in a populationwide smoking control program. 

Mass Media The mass media play a critical role in influencing what 

society knows, believes, and does with respect to tobacco use 

(Tye et al., 1987; Warner, 1986a). In 1988, U.S. cigarette

manufacturers spent $3.27 billion on advertising and promotion (Centers for Disease Control, 1990a). Few popular models 

rival the “Marlboro man” for familiarity; this and other images 

from cigarette advertisements are seen daily by virtually every 

American. Moreover, the presence of tobacco advertisements 

reinforces the perception that “smoking must be acceptable, 

otherwise the Government would ban it” (Warner, 1986). 

Although the tobacco industry has used them to encourage tobacco consumption, the mass media have played and 

will continue to play an important role in tobacco control 

efforts (Flay, 1987; US DHHS, 1989a; Warner, 1986a). Media 

coverage of the tobacco and health issue over the past quartercentury is credited with improving public awareness of 

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smoking’s hazards, shifting attitudes about smoking, and 

lowering the percentage of smokers in the population (US 

DHHS, 1989a). However, the public’s understanding of tobacco’s hazards is still remarkably superficial, particularly 

among those segments of the population at greatest risk of 

smoking-the poorly educated, minorities, and teenagers 

(Warner, 1986a). 

In a comprehensive tobacco control effort, the mass media 

serve a number of important functions, including (1)providing 

information to the public about facts and issues rela’ting to 

tobacco use; (2) alerting citizens and policymakers to injurious 

public policies that promote tobacco use; (3) motivating people 

to stop or not start using tobacco; (4) recruiting smokers into 

treatment programs; and (5)conducting smoking cessation 

programs. 

Those who control the media do not necessarily view any 

of these tasks as their responsibility. To the contrary, a substantial body of evidence indicates that, because they depend 

on tobacco advertising revenue, the media often evade the 

topic of tobacco and health (Dagnoli, 1990; Warner, 1985). 

Tactics Tobacco control activities directed at the media should 

seek to accomplish two goals: (1)increase the public’s exposure to prohealth, antitobacco messages; and (2) limit the 

public’s exposure to protobacco messages. The following 

sections briefly discuss tactics for accomplishing these goals. 

Cuunterudvertising. Perhaps the most visible use of the 

mass media for tobacco control has been antitobacco campaigns sponsored by the major voluntary health organizations 

and Government agencies (Flay, 1987; US DHHS,1989a; 

Warner, 1988 and 1989). For the most part, these campaigns 

have relied on donated air time and advertising space. 

One of the most significant periods of antismoking advertising occurred between 1967 and 1970, when the Federal 

Trade Commission ruled that, under the Fairness Doctrine, 

television and radio broadcasters were required to donate air 

time to antismoking messages as a balance to cigarette commercials (O’Keefe, 1971; US DHHS, 1989b; Warner 1977, 

1986a, and 1989). At their peak, antismoking messages were 

given about 1minute of air time (much of it in prime time) for 

every 3 minutes of cigarette advertisements (Whiteside, 1971). 

Several studies support the conclusion that the antismoking 

messages aired during the Fairness Doctrine era markedly discouraged smoking (O’Keefe, 1971; Warner, 1989). Cigarette 

consumption declined each year during the campaign (Figure 

1)and rose again after removal of cigarette advertising and the 

antismoking advertisements from the broadcast media in 1970. 

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This experience supports the idea that a public service announcement campaign can be effective in certain circumstances 

(Flay, 1987). After reviewing 56 evaluated antitobacco campaigns, Flay concluded that the key element in the success or 

failure of an antismoking campaign is its intensity. The more 

intensive the campaign-that is, the greater its reach, frequency, 

and duration-the greater the impact on behavior. The disappointing results of many health promotion campaigns delivered 

through the mass media can be traced directly to inadequate 

exposure of campaign messages (Bettinghaus, 1986; Flay, 1987; 

McGuire, 1984; Wallack, 1981). 

Reliance on public service announcements most often 

results in campaign messages being seen infrequently (Flay, 

1987; Wallack, 1981). In an evaluation of a 6-month antismoking television campaign conducted in media markets in 

New York and Pennsylvania, Cummings and colleagues reported 

that half of donated advertisements were aired between 12 midnight and 7 a.m. Airing of the same messages in purchased time 

significantly improved response, as measured in calls to a 

hotline (K.M. Cummings et al., 1989). 

Several states, including Minnesota, Michigan, and California, have funded antitobacco media campaigns with revenue 

earmarked from cigarette excise taxes (Johnson, 1990; US DHHS, 

1989a). In California, excise taxes are funding a $28.6 million, 

18-month advertisement campaign against smoking (Johnson, 

1990). The campaign, launched in April 1990, includes paid advertisements in newspapers and magazines, on billboards, and 

in prime time on television and radio. 

Public relations events. Creating events that will be of 

interest to large segments of the population is an effective and 

economical way to gain media coverage for tobacco control 

issues (US DHHS, 1989b). The best known national public 

relations event for smoking cessation is the American Cancer 

Society’s Great American Smokeout, which has been held 

annually since 1977 (Flay, 1987; US DHHS, 1989a). The Smokeout is a multimedia event carried out each November throughout the United States. In most communities, it constitutes an 

8-day media blitz leading up to Smokeout Day, when smokers 

are urged to give up cigarettes for at least 24 hours. Public 

awareness and participation in the Smokeout has been high for 

years (Flay, 1987; US DHHS, 1989a). A Gallup poll of adult 

smokers taken after the 1989 Smokeout showed that 85 percent 

of smokers were aware of the event and 10.5 percent abstained 

from smoking on Smokeout Day. 

In 1987, the American Lung Association began sponsoring 

Non-Dependence Day, the 5th of July, as a way to bring attention to the problem of nicotine addiction and to offer assistance 

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to smokers trying to stop. National events such as the Smokeout and Non-Dependence Day can be used to spin off media 

events such as television and radio cessation clinics (Flay, 

1987)’ newspaper stories profiling former smokers (Cummings 

et al., 1987), and cornmunitywide stop-smoking contests 

(Cummings et al., 1990; King et al., 1987; Pechacek et al., 

1985). 

Government agencies frequently designate specific times 

of the year to highlight specific prevention and disease control 

initiatives (e.g., high blood pressure control week). The State of 

New York designated the first week of January 1990 as “Tobacco Awareness Week” and granted $5,000to county health 

departments to create local tobacco control events. Those 

events varied across the state and included poster contests for 

schoolchildren, stop-smoking contests, smoking policy workshops for businesses, and training programs for health care 

providers. Local media coverage of events was heightened by 

the fact that local events were conducted as part of a statewide 

initiative. 

Presentation of research findings is another way to gain 

access to the media (American Cancer Society, 1987; Davis, 

1988a; US DHHS, 1989b). The media’s desire for health stories 

is so strong that even familiar health information can be recycled or repackaged in such a way as to be of interest to media 

gatekeepers. The best example of such an event is the annual 

release of the U.S. Surgeon General’s Reports on smoking and 

health. These reports usually contain little new scientific 

information, but their presentation by the Surgeon General in 

a high-profile news conference generates extensive media coverage (US DHHS,1989a). Having a highly visible and credible 

spokesperson or group deliver the information will often generate media coverage, even when the message is familiar. 

Tailoring information for local news media can be an 

effective way to extend the life of a national news story or 

create a new media event (American Cancer Society, 1987; US 

DHHS, 1989b). After a news release on the medical costs 

associated with treating smoking-related diseases in the United 

States, several state health departments issued cost information 

specific to their individual states, which resulted in a new wave 

of media coverage on the burden of smoking. 

Advocacy. Media advocacy is the strategic use of the mass 

media to promote public policy initiatives (US DHHS, 1989b; 

Wallack, 1990). Media advocacy does not attempt to directly 

change individual smoking behavior but uses the media to 

promote public debate about the tobacco issue. It shifts attention from smoking as solely an individua1 problem to the role 

of public policy in shaping individual health choices. Media 

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Smoking and Tobacco Control Monograph No. 1 

Regulations on 

Advertising 

advocacy stimulates community involvement in defining 

public policy initiatives that influence the social environment 

in which consumers make choices about tobacco use. 

In contrast to a planned information campaign or public 

relations effort, a media advocacy campaign is more like a 

political campaign in which competing forces continually react 

to unexpected events, breaking news, and opportunities (US 

DHHS, 1989b; Wallack, 1990). When tons of imported Chilean 

fruit were banned after the discovery of a small amount of 

cyanide in two grapes, smoking control advocates alerted the 

media to the fact that there is more cyanide in one cigarette 

than was found in the grapes. The Chilean grapes incident was 

thus used as a vehicle to raise the issue of Government's failure 

to regulate the tobacco industry. 

Specific kinds of knowledge are essential for effective 

media advocacy: knowing the media, knowing the relevant 

tobacco policy issues, and knowing how to frame an issue for 

public debate (US DHHS, 1989b). Tobacco control advocates 

need to understand how the different media work, that is, what 

types of stories are deemed newsworthy, how editors decide 

what stories get covered, and what deadlines and logistical 

issues might influence coverage. There are several excellent 

guides available that illustrate media advocacy skills specifically 

for tobacco control (American Cancer Society, 1987; US DHHS, 

1989b). 

Providing media advocacy training to interested persons is 

one way to encourage and enhance the use of news media for 

control of tobacco use. A communication network among advocates sharing information on local and national activities 

will promote media advocacy efforts. As noted earlier, local 

news coverage of smoking control issues is enhanced when 

local stories spin off from current issues in the national news 

media (American Cancer Society, 1987; US DHHS, 1989b).

Newsletters and computer bulletin board systems provide ways 

to facilitate timely communications among national, state, and 

local advocates. The Smoking Control Advocacy Resource 

Center sponsors an electronic communications network 

(SCARCNET, 1990). 

Because tobacco advertising is nearly ubiquitous, several 

medical and public health groups have argued that stronger 

regulatory actions are needed to curb the influence of protobacco messages delivered through the media (American 

Medical Association Board of Trustees, 1986; Warner, 1986a). 

Currently, the Federal Government bans tobacco advertising in 

the broadcast media and regulates the content of tobacco 

advertisements by Federal Trade Commission action (US 

DHHS, 1989a). 

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A number of proposals to further restrict tobacco advertising and promotion are now under consideration by public 

health groups, state and local governments, and Congress 

(Colford, 1990; Myers et al., 1989). One such proposal would 

limit the imagery and graphics of tobacco advertisements to 

permit only "tombstone ads,'' with no models, slogans, scenes, 

or colors. Other proposals that would restrict tobacco advertising and promotion range from a total ban on all tobacco 

advertising, to limited restrictions, such as disallowing certain 

types of promotion (e.g., tobacco company sponsorship of 

sporting and cultural events, brand advertising in movies, and 

distribution of free samples). 

Most of the proposed legislation to regulate tobacco 

advertising is designated for action at the Federal level because 

of laws that preempt states and localities from regulating 

cigarette advertising (Myers et al., 1989; US DHHS, 1989a). 

However, state and local communities do have jurisdiction in 

regulating the location of tobacco advertising when the medium is not national in scope. For example, several metropolitan areas (Denver, San Francisco Bay Area, and Amherst, 

Massachusetts) have prohibited tobacco advertisements on 

their mass transit systems (US DHHS, 1989a). In Minnesota, 

the state's Sports Commission banned tobacco advertising in 

the Hubert H. Humphrey Metrodome (US DHHS, 1989a). The 

City of Detroit banned tobacco advertisements on billboards 

(McMahon and Taylor, 1990). The City of New York passed an 

ordinance prohibiting tobacco advertisements on city-owned 

property. Numerous cities and two states (Minnesota and 

Utah) have passed laws prohibiting the distribution of free 

tobacco product samples (US DHHS, 1989a). 

Tobacco control efforts directed at the health care sector 

should seek to accomplish the following goals: (1)establish 

routine counseling on tobacco as a minimum standard of 

practice for all health care settings (i.e,, physicians' offices, 

hospitals, public health clinics); (2) make all health care facilities smoke-free; (3) increase the number of pharmacies and 

other health care facilities that will not sell tobacco products; 

(4) increase the number of health insurance companies that 

offer financial incentives that discourage tobacco use (e.g., 

lower premiums for nonsmokers, payment for cessation services); and (5) increase the number of health care providers 

actively involved in promoting tobacco control initiatives in 

other sectors of the community, such as in schools, through 

the media, and in worksites. Intervention activities to achieve 

these goals fall into three categories: education, economic 

incentives, and regulation. 

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Education Antitobacco counseling efforts by health professionals 

appear to have great potential in encouraging patients to stop 

or reduce their tobacco use (Glynn et al., 1990). The strength 

of this approach lies in the large number of smokers who can 

be reached by credible sources in environments where health is 

a salient topic. Estimates show that if “stop smoking” messages 

were routinely delivered to patients by physicians, 38 million 

smokers could be reached and the number who stop smoking 

each year could be doubled. Despite the fact that most physicians believe it is their responsibility to encourage their patients to abstain from using tobacco, many fail to do so routinely with all patients (Anda et al., 1987). 

A number of barriers to more active involvement in 

tobacco cessation counseling have been cited. Among them 

are insufficient time, training, and backup materials to provide 

effective help (Orlandi, 1987; Orleans et al., 1985). In an effort 

to address these barriers, several health provider groups have 

developed training materials and programs to assist health care 

providers in becoming more proficient in providing tobacco 

cessation assistance (Davis, 1988b). In 1989, the National 

Cancer Institute and the American Cancer Society initiated a 

national program to recruit and train physicians from around 

the United States who will in turn provide training in tobacco 

counseling to health providers on a statewide or regional basis. 

The establishment of a core group of health care providers who 

are capable of training other providers will in time result in 

more training opportunities and, presumably, more effective 

tobacco counseling by all health care providers. 

Insufficient time is an important barrier that affects attendance at training programs. Too often those who voluntarily 

attend training programs are already predisposed and knowledgeable about counseling their patients to abstain from 

tobacco. To recruit other providers, some groups have advocated visiting health care offices to provide on-site training, 

much like the pharmacy company sales representatives who 

make regular visits to health care providers (Kottke et al., 

1988). Such an approach has the advantage of involving the 

provider’s office staff in training and provides the opportunity 

to disseminate relevant tobacco control materials (e.g., selfhelp guides, labels for patients’ charts, list of community 

cessation services). 

Because influential health care providers in a Community

are often asked to comment on the tobacco issue, providing 

them with training on effective use of the media is important 

to ensure that the prohealth message is heard (American 

Cancer Society, 1987; US DHHS,1989b). The tobacco control 

movement has demonstrated that concerned community 

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leaders, in spite of limited media experience, can be effective 

media advocates. Experience has also demonstrated that such 

community-based advocacy can be greatly enhanced if tobacco 

control advocates are introduced to some basic lessons of 

media advocacy (US DHHS, 1989b). In the United States, 

Doctors Ought to Care, a concerned group of physicians and 

other health professionals, has created satirical media events to 

publicize the problem of tobacco use and promotion, a prominent example being its sponsorship of the Emphysema Slims 

tennis tournament as a counterpoint to the Philip Morrissponsored Virginia Slims tournament (Doctors Ought to Care, 

1989). 

Economic Incentives Convincing pharmacists to stop selling a profitable product like cigarettes is not easy (Richards and Blum, 1985). 

However, the number of tobacco-free pharmacies is increasing, 

and the American Pharmaceutical Association has endorsed the 

position that pharmacists should not sell tobacco products (US 

DHHS, 1989a). In Nevada, a local pharmacist made national 

news when he built a tobacco “bonfire” to publicize the fact 

that his store would no longer sell tobacco products. In Erie 

County, New York, the American Cancer Society urged community pharmacies to stop selling tobacco during the Great 

American Smokeout. In New Jersey, one advocacy group 

compiles and publicizes a list of tobacco-free pharmacies (New 

Jersey Group Against Smoking Pollution, 1988). Pharmacists 

have been encouraged also to be more involved in counseling 

their clients on ways to stop using tobacco, In 1982, the 

National Cancer Institute in collaboration with the American 

Pharmaceutical Association produced and distributed over 

25,000 copies of the “Pharmacist’s Helping Smokers Quit Kit” 

(NCI, 1982). 

Regulation Two-thirds of the states now require hospitals to restrict 

smoking to designated areas (Pertschuk and Shopland, 1989; 

US DHHS,1989a). Minnesota was the first state to pass a law 

that requires all hospitals to be smoke-free. 

There are many compelling reasons for health care facilities, especially hospitals, to adopt strong smoking restrictions 

(Knapp et al., 1986). Permitting smoking in the facility may 

undermine physicians’ advice to stop smoking. Nonsmoking 

patients in the facility may be adversely affected by exposure to 

environmental tobacco smoke. The majority of hospital fires 

are caused by smoking in bed. Finally, other sectors of the 

community look to actions in the health care sector to model 

their response to the tobacco issue. 

One strategy that has been used effectively to help promote the establishment of stronger smoking policies is to . 

survey patients and staff about their attitudes about restricting 

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Worksites 

smoking (Kottke et al., 1988). Population surveys have demonstrated strong public support for tough smoking restrictions in 

health care facilities (US DHHS, 1989a). Getting local medical 

and public health organizations to endorse smoking restrictions can pressure administrators to institute stronger smoking 

restrictions (American Cancer Society, 1988; Knapp et al., 

1986). Finally, publicly acknowledging health care facilities 

that have strong antismoking policies may help pressure others 

to adopt similar restrictions (Kottke et al., 1985). There are 

several comprehensive guides available that describe strategies 

for implementing voluntary no-smoking policies (American 

Hospital Association, 1988; Burtaine and Slade, 1988; Hurt et 

al., 1989; Knapp et al., 1986). 

Licensure requirements for health care facilities could be 

changed to mandate that tobacco prevention and cessation 

services be offered. The New York State Health Department is 

currently considering a regulation that would require hospitals 

to include plans for cardiovascular disease prevention programs 

(including prevention of tobacco use) in their application for a 

“certificate of need” to build a coronary care unit. Similarly, 

funding for state and local health departments could be made 

contingent on their providing certain types of tobacco control 

services. 

Worksites are an important channel for tobacco control 

because they constitute a setting in which large numbers of 

smokers can be reached with programs to encourage and 

support cessation efforts (Fielding, 1984; US DHHS, 1985). 

Worksites are also an important channel for involving nonsmokers in tobacco control efforts, particularly through the 

promotion of no-smoking policies (American Cancer Society, 

1988). 

Tobacco control activities for worksites should seek to accomplish the following goals: (1)increase the number of 

worksites that provide tobacco control programs for their 

employees and (2) increase the number of worksites that adopt 

policies that discourage tobacco use (e.g., no smoking indoors, 

lower health insurance premiums for nonsmokers, hiring of 

nonsmokers only). Intervention activities to accomplish these 

goals fall into the same above-mentioned categories: education, 

economic incentives, and regulation. 

Stimulated by both public and private initiatives, an increasing number of businesses are adopting policies that limit 

smoking at work. A 1987 national survey conducted by the 

Bureau of National Affairs found that 54 percent of the businesses responding to the survey had policies limiting smoking 

at work (Bureau of National Affairs, 1987). The 1986 Adult Use 

213 
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National Cancer Institute 

of Tobacco Survey showed that 45 percent of employed adults 

in the survey reported having some smoking restrictions at 

their workplace (Centers for Disease Control, 1988). 

Policies limiting smoking at work have resulted in an 

increased demand for worksite tobacco education and cessation 

programs (Martin et al., 1986; Newsweek, 1988). Community 

organizations such as the American Lung Association, the 

American Heart Association, and the American Cancer Society 

have all developed educational programs and materials to assist 

worksites in providing tobacco education for their employees 

(LaRosa and Haines, 1986). A number of commercial stopsmoking programs have created programs and marketing 

strategies specifically for worksites (Newsweek, 1988; US DHHS, 

1989a). 

In addition to offering educational programs, some businesses offer their smoking employees incentives to stop smoking (Schwartz, 1987; US DHHS, 1985). A common type of 

incentive is the offer to pay part or all of the cost to attend a 

cessation program. General Motors absorbs 75 percent of the 

fee for a smoking cessation program offered to its employees 

(Schwartz, 1987). Some employers have offered a cash bonus 

to employees who abstain from smoking (Rosen and Lichtenstein, 1977). Recently, a company in Houston began charging 

smokers an extra $10 a month to pay for higher health care 

benefit costs associated with smoking (Winslow, 1990). 

A strong policy against smoking is the cornerstone of a 

successful workplace tobacco control effort (Emont and Cummings, in press; Fielding, 1986). The most common barrier to 

adopting a restrictive smoking policy is a perceived absence of 

employee demand (Bureau of National Affairs, 1987; Emont 

and Cummings, 1989). In a 1987 survey, two-thirds of cornpanies without policies cited insufficient employee demand as the 

reason for not adopting a policy (Bureau of National Affairs, 

1987). In addition, many employers fear a negative reaction 

from smoking employees, including possible legal action and 

grievances (Bureau of National Affairs, 1987). However, surveys of smokers and nonsmokers consistently show support for 

smoking restrictions at work (US DHHS, 1986 and 1989a). 

Conducting workshops to educate employers about the rationale and tactics for implementing smoking restrictions is 

one approach to encouraging worksites to implement nosmoking poIicies. Publicizing surveys that demonstrate support 

for worksite smoking restrictions can be an effective way to 

make employers aware of employee demand for such policies. 

In the same vein, actively marketing tobacco control services to 

worksites, rather than just reacting to requests for such assistance, can substantially increase the number of worksites 

214 
Smoking and Tobacco Control Monograph No. 1 

voluntarily implementing tobacco control policies and programs for their employees. 

Economic Incentives A growing body of evidence shows that health care costs 

are greater for smokers than for nonsmokers (Kristein, 1983; 

Winslow, 1990). This information is particularly relevant to 

employers, because a large share of health insurance is purchased by employers as a benefit for employees. The issues 

related to insurance as an economic incentive are covered later 

in this chapter. 

The courts have established that it is the employer’s common law duty to provide a safe workplace. In several cases employers have been held legally and financially responsible for 

smoking-related illnesses and disability caused by exposure to 

environmental tobacco smoke at work (Myers and Arnold, 

1987). As evidence about the health hazards posed by environmental tobacco smoke continues to mount, the concern about 

liability for allowing unrestricted smoking at work will probably stimulate more employers to institute restrictive smoking 

policies (US DHHS, 1986). 

Regulation Government efforts to regulate smoking restrictions for 

private and public worksites have increased markedly in the 

past decade (Pertschuk and Shopland, 1989; US DHHS, 1986 

and 1989a). As of 1990, 14 states and nearly 300 cities and 

counties had mandated the adoption of workplace smoking 

policies (Pertschuk and Shopland, 1989). There has been little 

evaluation of the adequacy of implementation or level of 

compliance with smoking laws. The available evidence does 

not support the tobacco industry claim that smoking laws in 

workplaces are expensive and unenforceable (US DHHS, 

1989a). 

Schools Most smokers begin using tobacco before the age of 18; 

only a small percentage take up smoking after age 21 (US 

DHHS, 1989a). Most health professionals agree that the reduction of tobacco-caused disease can best be achieved through 

preventing children from initiating tobacco use (American 

Academy of Pediatrics, 1987; American Medical Association, 

1987; Blum, 1986; Colorado Department of Health, 1986; 

Coye, 1988; Maine Department of Human Services, 1983; 

Minnesota Department of Health, 1984; Pennsylvania Plan for 

Tobacco or Health, 1986; Warner et al., 1986). Schools are important for tobacco control efforts also because they are significant community ins ti tu tions. 

School activities to control tobacco use should seek to accomplish the following two goals: (1)increase the number of 

schools that implement state-of-the-art tobacco prevention 

curricula and (2) increase the number of schools that are 

tobacco-free. Intervention activities to accomplish these goals 

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fall into two broad categories: information dissemination, 

which includes activities to encourage voluntary actions by 

schools, and regulation, which mandates that schools take 

specific actions. Examples of each of these intervention strategies are given below. 

Since the mid-l960’s, tobacco education has been a common element of school health programs. However, the nature 

of tobacco education efforts and their designated targets have 

changed over time (US DHHS, 1989a). There has been a shift 

away from information-oriented programs to psychosocial 

curricula designed not only to address youth’s motivations to 

smoke but also to impart skills for resisting influences to smoke 

(Flay, 1985; US DHHS,1989a). There has also been a shift in 

the target group from high school and college students to 

middle school and elementary schoolchildren (US DHHS, 

1989a). Although evaluations of school-based tobacco prevention programs indicate that no single program can be relied on 

to deter adolescents’ tobacco use across the board, evidence 

does point to certain key features of school-based programs 

that have been consistently associated with positive preventive 

effects. These include multiple sessions over many grades; 

information about the social consequences and short-term 

physiological effects of tobacco use; information about social 

influences on tobacco use, especially peer, parent, and media 

influences; and training in refusal skills (Glynn, 1989). 

The extent to which state-of-the-art curricula for prevention of tobacco use have been adopted and are used by schools 

has not been systematically documented, although anecdotal 

evidence suggests that few school systems provide truly substantial curricula (Best et al., 1988; Cleary et al., 1988; US 

DHHS, 1989a). Barriers to widespread adoption of tobacco 

prevention programs within schools include demands on 

teacher time, cost of materials for specific programs and 

teacher training, and competing educational and health 

priorities (Best et al., 1988; Cleary et al., 1988). Packaging 

program materials so that they are easy for teachers to use will 

facilitate their adoption. Recruiting and training influential 

representatives from school systems to serve as local smoking 

control resources will help ensure that teachers stay current 

with program materials and will develop advocates for tobacco 

prevention within school systems (Glynn, 1989). 

School-based no-smoking policies are important because 

the school environment should be free of tobacco smoke, and 

teachers and school staff are influential role models for children. Evidence suggests that the rules about smoking at school 

influence the efficacy of tobacco prevention programs. Tobacco education programs implemented in schools that 

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Smoking and Tobacco ControlMonograph No. 1 

Regulation 

prohibit smoking appear to be more effective than identical 

programs in schools with less restrictive policies (Best et al., 

1988). 

Conducting workshops to educate school administrators 

and board members about the rationale and tactics for implementing no-smoking policies is one approach to encourage 

schools to implement such policies. Conducting and publicizing surveys that demonstrate support for tobacco-free schools 

can be used to pressure school boards to consider implementing stronger tobacco use policies (National School Boards 

Association, 1987). 

School education about the health consequences of 

tobacco use is mandated by law in 20 states (US DHHS, 1989a).

Several states also require teacher training about the effects of 

tobacco use. In Connecticut, to be certified to teach in public

school, a person must pass an exam on the effects of nicotine 

and tobacco use (US DHHS,1989a). 

Little is known about the level of compliance with state 

regulations. As noted previously, the nature and scope of 

tobacco education efforts appear to vary widely across school 

districts. Regulatory actions that fail to stipulate the nature 

and scope of tobacco curricula will likely be ineffective. Moreover, standards should be established to guide implementation 

and evaluation of curricula. Standards should address the 

curricula that should be used, teacher training, and minimum 

number of hours devoted to tobacco education at each grade 

level. 

By 1990, 15 states had prohibited smoking by secondary 

school students, and another 17 states had laws that restrict 

students’ smoking to designated areas (US DHHS,1989a). Most 

secondary schools have written policies that prohibit or restrict 

smoking by students (National School Boards Association, 

1987; US DHHS,1989a). Smoking by school faculty and staff 

members is generally permitted, but only in areas away from 

students. Three states, New Jersey, Wisconsin, and Utah, have 

passed laws that prohibit smoking by anyone on school property. Although most schools have policies regulating smoking, 

fewer than 5 percent are totally smoke-free (National School 

Boards Association, 1987). An important barrier to adoption of 

a tobacco-free policy is concern about opposition from the 

teacher’s union. Union contracts often negotiate smoking 

areas for teachers, even though the vast majority of teachers do 

not smoke. Thus, legislation that mandates schools to be 

tobacco-free is probably necessary. In general, public support is 

greater for laws restricting smoking in schools than for other 

locations such as private worksites and restaurants (US DHHS, 

1989a). If additional evidence can be produced to demonstrate 

217 
COMMUNITY 

MOBILIZATION 

National CancerInstitute 

a link between school smoking policies and smoking initiation, 

it is probable that measures to prohibit tobacco use on school 

grounds will become more common. 

Table 1 summarizes the tobacco control activities discussed 

in this section and identifies groups and organizations that 

may assume responsibility for each. These interventions may 

have a greater synergistic effect when combined, compared to 

the sum of individual effects. The key to a community-based 

approach lies in assuring that the intervention is broad-based 

and permeates the social networks. 

Although national and statewide initiatives are critical 

components of a comprehensive smoking control plan, many 

of the most effective interventions will be individually applied 

in thousands of cities and towns across the United States. To 

achieve behavior change in a community, the target population must be involved in identifying the problem, planning 

and undertaking steps to correct the problem, and creating 

structures in the community that assure the change is maintained. An underlying assumption is that the community must 

be empowered to control the intervention and must accept 

“ownership” of it, This approach has been tested in several 

community health promotion initiatives, including the Stanford Five-City Project (Farquhar, 1978;Farquhar et al., 1985), 

the Minnesota Heart Health Program (Blackburn and Pechacek, 

1984),and COMMIT-the Community Intervention Trial for 

Smoking Cessation (Pechacek, 1987). There are two practical 

ways to implement tobacco control interventions that provide 

community ownership. These may be described as “social 

action” and “locality development” (Rothman, 1979). 

Social action implies grassroots organizing of disadvantaged and disaffected groups who demand change in the social 

structure. An excellent example of social action in the tobacco 

control field is in the formation of local groups (e.g., Group 

Against Smoking Pollution) to lobby for restrictions on public 

smoking. Such groups often can be strong advocates for rapid 

change. The strength of the social action approach is also its 

weakness: because they are confrontational, grassroots groups 

provoke conflict and may sometimes inhibit the adoption of 

consensus. 

Locality development maximizes local participation in the 

intervention by including more than only the most committed 

groups in the change process. Essentially everyone is invited to 

.join in identifying and solving the problem. An important 

advantage of this approach is that it expedites participation by 

established community organizations and increases participation by community leaders. 

218 
Smoking and Tobacco Control Monograph No. 1 

Table 1 

Examples of tobacco control activities, by channel and group responsible for performance 

Channel Tobacco Control Activities 

Media Sponsor antitobacco informational campaigns 

Sponsor smokeout days and/or communitywide 

cessation events (e.g., TV clinics, contests) 

Advertise cessation services 

Hold press conferences to release relevant tobacco 

research findings to the media 

9 Create events to dramatize the problem of tobacco use in 

the community (e.g., satirize tobacco promotions) 

Conduct and publicize surveys to document support for 

tobacco control policies 

Conduct advocacy training for community leaders 

Establish a communications network among tobacco 

control advocates 

Lobby politicians to earmark government funds for counteradvertising and to regulate tobacco ads and promotions 

Health Disseminate materials to assist health care providers in 

Care counseling patients who smoke 

Sector Sponsor seminars to train health care providers on ways to 

counsel patients to stop smoking 

Recruit and train influential health care providers in media 

advocacy 

Sponsor a program to encourage community pharmacies 

to become tobacco-free 

Conduct surveys of patients, staff, and visitors to document 

support for tobacco-free health care facilities 

Sponsor seminars to promote tobacco-free health care facilities 

Include tobacco education in medical/health professional 

school curricula 

Reimburse providers for treating tobacco addiction 

Gather data to support health insurance premium discounts for 

nonsmokers 

Lobby politicians to mandate smoke-free health care facilities; 

mandate insurance coverage for cessation services, and premium 

discounts for nonsmokers; and mandate performance of tobacco 

control services by health departments, hospitals, and other 

health care facilities 

Groups Responsible* 

All groups 

A, B, C, D 

A, B, C, D, E 

B,C, H 

B, C, E,H 

A, B, C, D, E, H 

B, C, D, E 

C, E 

I 

A, C, E, I 

All groups 

219 
National Cancer Institute 

Table 1 (continued) 

Channel Tobacco Control Activities Groups Responsible* 

Worksite Disseminate information to support establishment of smoke-free 

workplace A, B, C, H, 1, J 

Sponsor seminars to promote no-smoking policies In the workplace A, 8, C, H,1, J 

Conduct surveys of employees to document support for no-smoking 

policies and cessation services A, B, E, H, I,J 

Gather data to support health insurance coverage of tobacco 

cessation services A, E,I, J 

Gather data to support health Insurance premium discounts for 

nonsmokers A, E, I. J 

0 Lobby politicians to mandate smoking restrictions inworksites All groups 

Lobby politicians to mandate insurance coverage for cessation services 

and premium discounts for nonsmokers and to provide tax incentives to 

worksites that offer cessation assistance to their employees All groups 

Support employee litigation against employers who fail to implement 

meaningful smoking policies B, C, H, I 

Schools Disseminate state-of-the-art curricula to schools A, B, E 

Sponsor workshops to train teachers to implement tobacco 

education curricula A, B, E, F 

Make presentations on tobacco-free schools to school boards, PTAs B, C, H 

0 Conduct stydent surveys to document the need for tobacco education A, 8, F 

Conduct surveys of students, faculty, and school staff to document 

support for tobacco-free schools A, 8, F 

Mandate that all teachers receive tobacco education training A, B, E 

Lobby politicians to mandate tobacco-free schools All groups 

* Key 

A Government health agencies 

B Health voluntaries 

C Health professlonal associations (e.g., medical societies) 

D Hospitals and other health care facilities 

E Universities, including medical schools 

. F Elernentarylsecondary schools 

G Community organizations (e.g., youth groups, service clubs) 

H Activist groups (e.g., Group Against Smoking Pollution, Doctors Ought to Care) 

I Insurance industry 

J Business organizations (e.g., Chamber of Commerce) 

220 
Smoking and TobaccoControl Monograph No. 1 

Community

Analysis 

Coalition building is a form of locality development. 

Coalitions encourage local organizations and groups to adopt 

tobacco control as their own project. Networking among 

coalition members fosters sharing of resources and reduces 

conflict, It lends instant credibility to the program because it 

involves recognized community leaders and tends to isolate 

opponents. 

Involving organizations encourages them to divert their resources to tobacco control, in itself a change in norms. Because Community organizations network with each other, this 

change diffuses throughout the community and affects the 

membership of every organization. Seen from a systems 

perspective, change in organizations leads to change in the 

entire community. 

The role of the tobacco control interventionist in a 

locality development approach is to catalyze and coordinate 

action by the wide cross-section of organizations and individuals recruited to the effort. Under a broad, communitywide 

strategy, small task-oriented groups within the coalition pursue 

specific, manageable goals. Maintaining communication 

among organizations and promptly resolving disputes is an 

important function of leadership, and a democratic structure of 

coalition governance is critical to building a true sense of 

ownership by all the members. 

There are four major steps in the coalition-building process: community analysis, planning, implementation, and 

maintenance. Each is critical to the development of a lasting 

tobacco control intervention that will permanently change 

community structures and norms. 

Community analysis provides an accurate, in-depth understanding of the community’s needs, resources, social structures, 

and values. At the same time, it provides an opportunity to 

begin involving the community in the problem-solving process. 

The first task is to define the community geographically. 

A community may be as small as a neighborhood or as large as 

a major metropolitan area. The important factors in defining a 

community are interdependence among important social 

groups and a sense of shared values and norms that lead to 

individual identification with the community. Because of the 

importance of major media in determining such identity and 

in changing norms, consideration should be given to defining 

the scope of the community as widely as the area of dominant 

influence of the local broadcast and daily print media. In any 

case, such a definition should be undertaken in consultation 

with the leadership of important community sectors, including 

health, education, business, labor, and government, 

221 
National Cancer Institute 

Once the community is defined, the next step is to identify the community resources and structures that are potentially available to focus on the tobacco control effort. A large 

body of quantitative and interpretive data is collected from 

both secondary sources (e.g., census data, economic reports, 

histories) and primary sources (leaders and members of the 

various community sectors). Information should be gathered 

on the demographic makeup of the population, smoking 

patterns, and the levels of illness and disability in the community, It should assess the economic structure and well-being of 

the community, identify business leaders, and tabulate major 

employers. Political activity and the level of citizen participation should be appraised. 

The analysts should carefully assess the level of health promotion and treatment programs available. What resources and 

skills already exist, and what is the level of service being provided? How ready are providers to join in a tobacco control 

effort? 

The important public and private educational systems 

should be identified, and the content of the health curriculum 

appraised. In addition, an effort should be made to identify 

important social, fraternal, and community improvement organizations and to characterize their memberships. Important 

religious denominations and major and minor media outlets 

also must be identified and analyzed. A calendar of major 

community events should be compiled. 

The community leadership structure, because it is likely to 

affect the intervention, is as important as a list of community 

resources. What organizations and groups are currently involved in tobacco control? Who are the groups and individuals likely to help or hinder the project? Who are the important 

leaders who could make a significant contribution? What are 

competing community priorities, and who are their advocates? 

How do people want to participate? 

This information should be gathered in interviews with 

community Ieaders, beginning with those most likely to be 

interested in the intervention, such as the leadership of major 

volunteer health organizations and those in charge of health 

promotion at the local health department and hospitals. From 

these interviews, influential community leaders will be identified. These leaders in turn should be interviewed to identify 

additional community leaders and important organizations. 

This process should be pursued as long as profitable. 

The point of the analytic exercise is to determine how the 

community makes decisions and to begin involving the community in the task of solving the tobacco problem. At the end 

of the process, the analysts should be able to determine the 

222 
Smoking and Tobacco Control Monograph No. 1 

Planning 

Implementation 

community’s readiness for change. Are the various elements of 

the community able to work together to identify and solve common problems? Can they achieve consensus on goals and priorities? Who are the key players who must be part of that consensus? Is there a history of collaboration to build on or must trustbuilding and conflict resolution be an early component of the 

tobacco control intervention? To what extent is tobacco control 

a community priority? 

At this point the process of planning the intervention 

begins. A small group of influential individuals willing to commit the time and energy needed to plan and begin implementing 

the project should be selected. An important consideration in 

choosing members for this initial group is that major stakeholders be included, that is, those with a preexisting commitment to 

tobacco control. In many communities this will include representatives of the major voluntary health agencies and other 

health promotion organizations. Other important community 

sectors, such as education and business, should be represented if 

possible. 

This planning group will determine the structure and initial 

membership of the coalition and will begin recruiting members. 

It will set overall goals for the program and will determine 

staffing structure, office location, and similar needs. If resources 

are available to pay a staff, the program director should be hired 

at this point, and the planning group should have a significant 

role in writing the job description and screening candidates. 

Staff support is vital to the success of the intervention. If funds 

are not available to pay for a staff, individuals employed by 

health agencies may be reassigned from current activities. In 

either case, clear role definitions are important. 

The program director should be someone familiar with the 

target community (preferably a member of it) and should be acquainted with local resources, values, and decision-making processes. The most important skill is the ability to “network,” preferably on a communitywide level. 

The coalition should be as broad as possible and divided into 

task forces according to members’ interests. Obvious choices for 

task forces would be media, public policy, health care, worksites, 

youth and education, and cessation services, though there may 

be others. A scheme for coalition governance should be devised 

early. Some type of board or executive group is needed to make 

important management decisions, but care should be taken to 

ensure that interventions are planned and implemented by the 

task forces. An important board function may be allocating 

resources among the task forces, so it is important that the board 

be responsive to the coalition’s membership, possibly through 

election to fixed terms. 

223 
Maintenance 

National Cancer Institute 

Training and education of board and task force members 

are important and continuing aspects of the community mobilization process. Most members will not be experts in tobacco 

control and may approach the problem with strategies that are 

ineffective or incomplete. They will benefit from further 

education on the smoking problem, nationally and as it exists 

in their community, and they should be exposed to strategies 

established as effective in previous interventions. Many will 

bring important skills to the program that can be enhanced by 

training in other areas, but some will benefit from learning 

new skills. For example, physicians trained in media advocacy 

can be a powerful addition to the project’s efforts. 

A strategic tobacco control plan presents the coalition’s 

overall goals and a series of specific objectives toward meeting 

those goals. It is important both in guiding rational, sequential 

implementation of the intervention and as a tool for mobilizing the community to recognize tobacco use as an important 

public health problem. The plan should be a product of the 

task forces, which will set priorities, identify resources, and 

plan activities. In developing the plan, the community begins 

to assume ownership of the project. 

Above all, the tobacco control plan should represent a 

comprehensive, communitywide approach employing multipIe, integrated interventions. Coordination among task 

forces and intervention activities is vital and is the primary 

responsibility of the program staff. Rather than providing 

interventions themselves, the staff will identify others in the 

community to undertake the intervention activities and to 

coordinate those efforts. A number of state and local tobacco 

control plans have been produced and are available for guidance (Colorado Department of Health 1986;Coye, 1988; 

Minnesota Department of Health, 1984). 

Maintenance of the intervention is necessary to its success. 

Smoking will not disappear from a community in months or in 

a few years, and changes in community norms will probably 

occur over the course of a generation. Any outside financial 

support for a community intervention will be restricted in 

amount and duration. More fundamentally, ownership of the 

intervention will not be complete until the community redirects its resources to smoking control. This action will, in itself, 

constitute a significant normative change. 

Planning for transfer to the community should be an 

integral part of the intervention. Activities should be structured to elicit the greatest possible participation from community organizations and structures. The strategic use of seed 

money grants and contracts can build a constituency for 

tobacco control within organizations and ensure a continuing 

interest in addressing the problem. 

224 
Smoking and Tobacco Control Monograph No. 1 

RESTRICTIVE 

LEGISLATION 

In addition to broadening the group of stakeholders who 

believe in the importance of tobacco control and have actively 

worked at it, this approach gives individuals and organizations 

the experience of successfully implementing programs they 

might otherwise not have attempted. Selecting low-cost 

activities, or at least demonstrably cost-effective activities, will ‘ 

increase the sense of self-sufficiency. 

Only by letting the members of the community implement the tobacco control program can it continue after outside 

funding is exhausted. Staff members must not become service 

providers. Rather, they are facilitators, coordinators, and 

trainers. It is recognized that the community will make mistakes, but it will learn from these mistakes and, given time, will 

institutionalize an effective tobacco control program. 

Restrictions on smoking for fire and safety reasons have 

existed for much of this century, but restrictions based on 

health and annoyance have been implemented largely over the 

last two decades (US DHHS, 1986). The major motivations for 

this new wave of restrictions have been the irritation and 

annoyance of the nonsmoker caused by environmental tobacco 

smoke and the evolving understanding of the disease risks 

associated with exposure to environmental tobacco smoke. 

Now these motivations are blending to produce a social climate 

in which cigarette smoking is increasingly unacceptable. 

Much of the credit for changes in the social acceptability 

of smoking has focused on recent events such as the call for a 

smoke-free society by the year 2000 as well as reports on the 

scientific evidence by the Surgeon General (US DHHS, 1986), 

the National Academy of Sciences (1986), and most recently 

the U.S. Environmental Protection Agency (in press). However, 

this kind of social shift occurs slowly, gathering momentum 

with time. The understanding of the risks associated with 

environmental tobacco smoke began in 1970 when the Surgeon General at that time, Jesse L. Steinfeld, M.D., recognized 

the clear biological plausibility of a significant public health 

risk from environmental tobacco smoke. Addressing the 

National Interagency Council on Smoking and Health, he 

stated, “Evidence is accumulating that the nonsmoker may 

have untoward effects from the pollution his smoking neighbor forces upon him.” Dr. Steinfeld called for a bill of rights 

for the nonsmoker (Steinfeld, 1972), and he directed the 

National Clearinghouse for Smoking and Health to conduct a 

complete assessment of scientific evidence on the topic for 

inclusion in the next Surgeon General’s Report (US DHEW, 

1972). 

225 
Federal Actions 

National Cancer Institute 

Those documented concerns, coupled with nonsmokers’ 

annoyance at being exposed to tobacco smoke, ignited the 

nonsmokers’ rights movement. By the mid-l970’s, the change 

in social acceptability of smoking was well under way and has 

been credited with the downturn in per capita cigarette consumption that began in 1974 (Warner, 1981). 

Federal Government efforts to restrict smoking have not - been as extensive as those of state and local governments. 

Outside the tobacco belt, state and local governments are less 

subject to lobbying efforts by the tobacco industry and therefore have passed more laws restricting smoking. 

The only area in which Congress has acted to restrict 

smoking has been aboard commercial airline flights. Until 

recently, most of the regulation of smoking on airlines was the 

responsibility of the Civil Aeronautics Board (CAB). In 1971, 

the CAB mandated that all commercial airline flights provide 

nonsmoking sections large enough to accommodate every 

passenger who desired to sit in them, and in 1983 it issued new 

regulations that banned smoking on flights of 2 hours or less. 

However, within hours of its announcement, the ban was 

reversed at the insistence of lobbyists and powerful members of 

Congress (Walsh and Gordon, 1986). 

Nevertheless, public pressure for a smoking ban continued 

to mount, and as a result, Congress passed legislation in 1987 

doing exactly what the CAB had tried to do in 1983-ban 

smoking on all commercial airline flights of 2 hours or less. 

This included about 80 percent of all flights within the continental United States (US DHHS, 1989a). In spite of concerns to 

the contrary, the airlines have found the law to be an easy one 

to enforce. Flight crews found it necessary to initiate enforcement actions against only 1out of approximately every 

4 million airline passengers in 1988 (Hensley, 1989). 

in 1989, Congress again considered the issue of smoking 

on commercial air flights because the law dictating the 2-hour 

smoking ban was about to expire. The Senate wanted a total 

ban on all flights, whereas the House voted only to continue 

the 2-hour ban. A compromise was reached, whereby the ban 

on smoking was increased to 6 hours, effectively eliminating 

smoking on all flights except those to Alaska, Hawaii, and 

foreign locales, as well as on charter flights (Phillips, 1990). 

Most other Federal action regulating smoking has been by 

agencies restricting smoking at Government worksites. The 

General Services Administration, which is responsible for onethird of all Federal buildings, prohibits smoking except in 

designated areas. The Department of Health and Human 

Services completely bans all smoking in its buildings. In 1986, 

226 
Smoking and Tobacco Control Monograph No. 1 

the Department of Defense established a new policy to curtail 

smoking among Armed Forces personnel. As part of the policy, 

smoking is permitted only in designated areas (US DHHS, 

1989a). 

State Legislation In 1973, Arizona became the first state to restrict smoking 

in a number of public places because environmental tobacco 

smoke is a public health hazard. This was done in response to 

the 1972 Surgeon General’s Report, which for the first time 

identified involuntary smoking as a health risk. The passage of 

the Arizona law marked a shift in the content of laws regulating smoking. Instead of restricting smoking because it is a fire 

hazard, likely to contaminate food, or morally wrong, legislatures started restricting smoking because it endangers the 

health of nonsmokers (US DHHS, 1989a). 

Throughout the 1970’s, the regulation of smoking in 

public places became a major issue for state legislatures. In 

1974, Connecticut became the first state to pass a law restricting smoking in restaurants, and in 1975, Minnesota passed its 

Clean Indoor Air Act. This was the first law to use the approach that smoking would be prohibited everywhere except 

where specifically permitted, thereby making nonsmoking the 

norm. It was also the first law to extend smoking restrictions to 

worksites, both public and private. Continuing until today, this 

law has served as a model for other state legislatures seeking to 

pass comprehensive smoking legislation (US DHHS, 1989a; 

Kahn, 1983). 

The growth of state smoking legislation was rapid throughout the 1970’s and 1980’s. Two years that particularly stand 

out are 1975, in which 13 states enacted smoking laws, and 

1987, in which a record 20 states passed such laws. The flurry 

of activity in 1987 reflected the 1986 publication of reports 

from the Surgeon General and the National Academy of Sciences, both of which documented the health risks of involuntary smoking (Rigotti, 1989; US DHHS, 1989a). As of August 1, 

1990, 45 states and the District of Columbia had passed laws 

restricting smoking in public places in some manner (TobaccoFree America, 1990). 

The laws that were passed were also more restrictive. Previously, laws restricted smoking only in public places such as 

elevators or buses, but the new laws began increasingly to 

regulate smoking in restaurants and private worksites (Rigotti, 

1989; US DHHS, 1989a; Warner, 1981). As of August 1,1990, 

27 states regulated smoking in restaurants and 18states restricted smoking at private worksites (Tobacco-Free America, 

1990). 

227 
Local Legislation 

National Cancer Institute 

The restrictiveness of state smoking laws varies in different 

regions of the country. In particular, southern states have fewer 

smoking laws, and they are less comprehensive. Of the five 

states that have no laws whatsoever to restrict smoking in 

public places, two-Tennessee and North Carolina-are major 

tobacco producers (Rigotti, 1989; Tobacco-Free America, 1990; 

US DHHS, 1989a). 

No-smoking laws passed by the states are generally implemented by the state health departments with minimal burden 

(US DHHS, 1989a). For example, for the 3 years after the passage of the Minnesota Clean Indoor Air Act, the cost to the 

Minnesota Department of Health was only about $4,600 per 

year (Kahn, 1983). 

During the 1980’s, efforts to control cigarette use spread 

to the local level-towns, cities, and counties (US DHHS, 

1989a). During the period between 1986 and 1990, a more 

than fourfold increase occurred in the number of communities 

with smoking ordinances, from 89 in 1986 (US DHHS, 1989a) 

to 468 in 1990 (Tobacco-Free America, 1990). 

Although state smoking laws are generally called clean 

indoor air acts, smoking laws at the local level are usually 

referred to as smoking ordinances (Pertschuk and Shopland, 

1989). With few exceptions, these local ordinances are 

stronger and more comprehensive than corresponding state 

laws and are often enacted because of difficulties in passing 

stronger state laws (Rigotti, 1989). A legislative response by the 

tobacco industry has been to promote state legislation that 

preempts the right of local communities to pass laws restricting 

tobacco use. As a result, seven states have passed laws preventing the passage of more stringent ordinances at the local level. 

In Florida, the law not only prevents the passage of future local 

smoking ordinances but also preempts all existing ones (Tobacco-Free America, 1990). 

The most complete records on local smoking ordinances 

have been kept for California, which has been a leader in the 

passage of these laws. The first were passed in 1979, and in 

1982, San Diego became the first large California city to enact 

an ordinance regulating smoking in the workplace (US DHHS, 

1989a). In 1983, the San Francisco Board of Supervisors passed 

an ordinance regulating smoking in private worksites, which 

later was brought before the voters in the form of a proposition. In spite of heavy opposition from tobacco interests, it 

passed, and the publicity generated by the campaign stimulated other communities around the country to pass similar 

ordinances (Martin and Silverman, 1986). 

Laws restricting smoking are often called “self-enforcing” 

because few complaints of violations are filed, and so it is 

228 
Smoking and Tobacco Control Monograph No. I 

Public Opinion 

Effects of 

Restrictions 

On Smoking 

Prevalence 

assumed that most people are obeying the law (Rigotti, 1989). 

In San Francisco, only 1out of approximately 60 Department 

of Public Health inspectors was assigned to enforce that city’s 

Smoking Pollution Control Ordinance. The percentage of time 

he spent doing that job declined during the first year until, 

during the last 4 months, only 21 percent of his time was spent 

on the program. No additional funds were needed to enforce 

the law (Martin and Silverman, 1986). Similarly, New York’s 

Health Department reported receiving only a few complaints 

after that the city’s no-smoking law restricted smoking in 

restaurants (US DHHS, 1989a). 

An effort to actively measure compliance with Iaws restricting smoking, rather than just counting the number of 

complaints received by a health department, was made in 

Cambridge, Massachusetts. Researchers asked city residents 

whether they had recently noticed smoking in places where it 

was not permitted 3 months after the passage of a city smoking 

ordinance. One-third, it turned out, had noticed illegal smoking. Asked what their response was, most people said that they 

had ignored the violation (US DHHS, 1989a). 

Rigotti (1989) makes the point that public support for 

smoking restrictions was present long before either the passage 

of no-smoking laws or the publication of most of the evidence 

that passive smoke could be damaging to one’s health. As early 

as 1964, most nonsmokers felt that smoking should be allowed 

in fewer places, and by 1975, a majority of both nonsmokers 

and smokers felt that way. In 1987, a Gallup poll found, for 

the first time, that a majority of all adults (55 percent) favored 

a complete ban on smoking in all public places (US DHHS, 

19 89a), 

In 1982, the government of Hong Kong began making a 

concerted effort to reduce smoking in that city. Smoking was 

restricted in public places, a fourfold increase in the duty paid 

on tobacco was instituted, public health education was increased, and an antismoking publicity campaign launched. As 

a result, 16 percent of the population quit smoking between 

1982 and 1984, and the number of regular smokers between 

the ages of 15 and 19 was cut in half. When ex-smokers were 

asked in surveys which factors were influential in causing them 

to quit, respondents identified two main ones-ost and health 

concerns (Mackay and Barnes, 1986). 

A similar effort to decrease smoking was instituted by the 

U.S. Department of Defense starting in 1986. Between 1985 

and 1987, smoking prevalence decreased in all branches of the 

Armed Forces, particularly in the Army, which was the branch 

most active in getting its personnel to eliminate smoking 

(Hagey, 1989; Rigotti, 1989; US DHHS, 1989a). 

229 
Employee Attitudes 

Impact of Worksite 

Restrictions 

National Cancer Institute 

Data collected by the Wisconsin Department of Health 

and Social Services show the effects of the antismoking campaign in that state. Per capita sales of cigarettes in Wisconsin 

started dropping off sharply from a peak in 1981. Coincident 

with this dropoff were two cigarette tax increases, one state and 

one Federal, and the 1983 passage of Wisconsin’s Clean Indoor 

Air Act (Centers for Disease Control, 1989). 

Worksite smoking restrictions are gaining acceptance 

among workers, including smokers (Becker et al., 1989; Biener 

et al., 1989a; Sorensen and Pechacek, 1989). Sorensen and 

Pechacek found support for no-smoking policies among smokers who were interested in quitting, those who were concerned 

about the health effects of smoking, those who indicated a 

high level of support from coworkers for previous quit attempts, and those who had a high number of nonsmoking 

coworkers. This may help to allay the fears of employers who 

believe that smoking restrictions will lead to dissension or low 

morale among employees. In most situations, smoking restrictions can be implemented without significant conflict. 

A study that included a survey of smokers outside office 

buildings in Pasadena showed similar support from smokers for 

smoking restrictions. Pasadena citywide smoking regulations 

require restrictions in all indoor places, including worksites. In 

the study by Sussman et al. (in press), a majority of smokers 

interviewed thought it was important to stop smoking and had 

positive feelings about the nonsmokers’ rights movement. In 

addition, about three-quarters of the smokers had made at least 

one quit attempt, with those subject to no-smoking policy reportedly putting more effort into quitting smoking. The researchers caution that “little is known about attitude-behavior 

relationships and smoking policy effects” (Sussman et al., in 

press). 

Millar (1988), in a government work setting, found a continuous quit rate of 3.5 percent at 1year after smoking restrictions went into effect. Two hundred registrants for a smoking 

cessation course were surveyed at 6 weeks, 6 months, and 

1year after smoking restrictions began. The overall smoking 

prevalence in the year after restrictions declined from 29 to 

24 percent. 

A recent study analyzed the impact of a strict smoking 

policy at the Texas Department of Human Services (Gottlieb et 

al., 1990). The policy limited smoking to break rooms or 

lounges and cafeteria smoking sections. Regional administrators were given the authority to declare a worksite smoke-free if 

no appropriate room was available, and smoking was banned 

outright in 4 of the 12 regions. Again, most of the departments 

studied had some restrictive policy in effect prior to implementation of the new policy and before the study began. 

230 
Smoking and Tobacco Control Monograph No. 1 

Impact of 

Smoking Bans 

The Texas study showed that the reduction in smoking 

prevalence at 6 months after policy implementation was 

greater in the work areas with smoking bans than in those with 

smoking restrictions. Consumption of cigarettes at work decreased in work areas with both types of policies. However, the 

authors concluded that although daily consumption of cigarettes at work decreased significantly, “no significant change 

was detected in smoking prevalence.” 

The authors of the Texas study summed up in this way: 

the “failure to find changes in smoking rates may also have 

been due to an insufficient follow-up period. Quitting smoking has been conceptualized as a process of change, with 

smokers moving through the stages of precontemplation, 

contemplation, action, and maintenance. It is possible that 

the smokers had increased their readiness to quit but not yet 

taken action” (Gottlieb et al., 1990). 

The Australian Public Service used a sample of 2,113 employees who were surveyed 2 to 4 weeks before a complete 

workplace smoking ban was implemented and again 5 to 

6 months later (Borland et al., 1990). Fifty-seven employees 

who were smoking at the time of the initial survey were not 

smoking at the time of the followup surveys. However, 

36 previous nonsmokers reported starting smoking; it was not 

noted whether the 36 were relapsing ex-smokers or new smokers. Including the 36 employees who took up smoking brought 

the reduction findings to a 1percent reduction in prevalence 

over the 6-month period, which was not considered significant 

by the study authors. However, because it is unlikely that 

these employees took up smoking as a result of the workplace 

smoking ban, including them in the equation reduced the drop 

of prevalence that might have been found. 

An additional indicator that the reported drop in prevalence might be low is that the work settings in which this study 

was conducted had various levels of restrictions on smoking 

prior to the mandated ban. It is therefore possible that some 

smokers had already quit as a result of a smoking control policy 

prior to the ban and that this reduction in prevalence was not 

captured in the study. 

The study reached its conclusions on smoking prevalence 

by conducting pre- and postpolicy surveys on workplace 

smoking consumption. The smokers were asked to estimate 

the number of cigarettes they usually smoked on both workdays and nonworkdays and to recall the number of cigarettes 

they smoked in the previous 24 hours, divided into seven time 

periods. The study showed that moderate and heavy smokers 

231 
Effect on 

Continuing 

Smokers 

Elements Needed 

For Worksite 

Restrictions 

National Cancer Institute 

had fewer cigarettes during the day, with the greatest change 

among heavy smokers. Small increases in smoking rates 

outside the work environment did not compensate for the 

enforced reduction at work. 

In a more recent study at the Johns Hopkins University, 

however, a significant reduction in smoking prevalence was 

found to result from implementation of a total ban on smoking 

(Stillman et al., 1990). As of July 1, 1988, smoking was banned 

in all areas of the Johns Hopkins Hospital complex involving 

24buildings in an area covering 12 square blocks. The previous policy had allowed smoking in designated areas of cafeterias, waiting areas, and lounges. The new policy was announced on January 1,1988, and the announcement was 

followed by an extensive internal media campaign. A healthoriented campaign that emphasized the effects of passive 

smoking and included free screening for exhaled carbon monoxide was launched. Educational programs to ensure policy 

enforcement were offered to the staff, and four smoking 

cessation options were offered free to all employees. In addition to these efforts, discreet observations of visitor and employee smoking were performed monthly beginning 8 months 

prior to the ban and at 1month and 6 months after the ban 

started. 

The initial survey of 8,742 full- and part-time employees 

was distributed 6 months prior to the ban, thereby allowing for 

inclusion of smokers who ceased in anticipation of the ban. 

One year after the initial survey and 6 months after the ban, 

respondents who were still actively employed (4,480) were 

mailed a followup survey. A significant decrease in employee 

smoking prevalence was found (21.7 percent before the ban to 

16.2 percent after the ban). 

There is no consensus whether smoking restrictions encourage smokers to quit or the extent to which restrictions alter 

behavior. Some researchers have suggested that, over time, 

smokers may adapt smoking behavior to smoking restrictions, 

rather than using the restrictions as an incentive to quit (Biener 

et al., 1989b). Others suggest that worksite no-smoking 

policies encourage smokers to put more effort into quitting 

(Sussman et al., in press). Although restricting the areas in 

which smoking may occur might reduce the cues that encourage smoking, it is also suggested that the smoking area itself 

could become a cue to smoke (Glasgow, 1989). Additional 

research may provide more insight about this area. 

A number of investigators have made suggestions for the 

important elements to successfully introduce worksite smoking 

restrictions and make them as effective as possible. Announcing the restriction or ban well in advance is essential. This will 

232 
Smoking and Tobacco Control Monograph No. 1 

PREVENTING 

TOBACCO SALES 

TOMINORS 

allow time for smokers to prepare for quitting or to make 

adjustments. Rosenstock and colleagues (1986) recommended 

introducing new policies gradually, offering smokers an opportunity to express their dissatisfaction, and making clear the 

limitations of employee influence over the new policy. Millar 

(1988) suggested that, in designated smoking areas, smokers be 

separated from nonsmokers and that smoke be vented to the 

outside and not through the building’s ventilation system. 

Finally, smokers’ efforts to quit should be aided by available 

cessation classes, coworker support, publicity regarding adverse 

health effects, and ex-smoker support groups. 

In conclusion, there is some evidence that worksites that 

eliminate smoking completely, offer cessation clinics and other 

incentives to encourage smoke-free lifestyles, and implement 

comprehensive health promotion measures will experience a 

measurable drop in smoking prevalence. 

In the United States today, more than 3 million children 

under the age of 18 regularly smoke cigarettes or use smokeless 

tobacco. More than 2 million others are actively experimenting with tobacco use and are at high risk for becoming regular 

users. Tobacco companies collect more than $1.25 billion 

annually from the sale of their products to minors (DiFranza, 

1989). 

More than half of all smokers begin before the age of 14, 

and 90 percent begin by the age of 19. Tobacco use by young 

people is a problem easily understandable in terms of economic 

demand and supply. A major factor in creating demand for 

tobacco within young age groups is tobacco industry advertising and promotion. Inadequate and unenforced laws assure 

that this demand is met with a readily available supply. In the 

6 years following the introduction of Virginia Slims and other 

“feminine” cigarettes in 1968, the number of teenage girls who 

regularly smoke more than doubled. During the late 1970’s, 

the rate of smoking among teenage boys decreased, whereas 

female smoking remained high. 

Although 45 states and the District of Columbia prohibit 

the sale of tobacco to minors, most often defined as anyone 

under the age of 18,youngsters who want to obtain cigarettes 

find it easy to do so. An estimated 1billion packs of cigarettes 

are sold to minors under the age of 18 every year, usually in 

violation of the law (DiFranza and Tye, 1990). The National 

Adolescent Student Health Survey of 12,000 students found 

that 86 percent of respondents believed it would be easy for 

them to obtain cigarettes (American School Health Association, 

1989). 

233 
Minors’ Access 

To Tobacco 

Sales by Retail Stores 

National Cancer Institute 

There are many reasons to prevent minors from obtaining 

tobacco products. First, easy availability conveys a message 

that the substance is not really very harmful. Second, illegal 

tobacco sales to minors foster disrespect for the law and may 

help young people toward illegal purchases of alcohol or use of 

illicit drugs. Third and most obvious, the harder it is for young 

people to obtain tobacco, the fewer will use the substance. 

By 1990, 45 states had some legislation preventing minors’ 

access to tobacco products. Only three, however (Indiana, 

Utah, and Idaho), are considered to meet the standards for 

even “basic” coverage, based on criteria established by the U.S. 

Office on Smoking and Health, meaning that in addition to 

establishing a minimum age for sale, there are penalties for 

merchants selling tobacco to minors and some restrictions on 

the placement of cigarette vending machines. Six states have 

no minimum age law whatsoever (Montana, Wyoming, New 

Mexico, Missouri, Louisiana, and Kentucky). No state law is 

considered to be “comprehensive,” which in addition to the 

basic category’s requirements would include a requirement for 

warning signs at the point of purchase, provision to revoke 

merchant licenses for violation, and a ban on the distribution 

of free tobacco products (Centers for Disease Conrol, 1990b). 

A DHHS study of enforcement of laws prohibiting the sale 

of tobacco to minors was able to document only 32 instances 

of those laws having been enforced outside of Utah, which has 

a relatively good record (Office of the Inspector General, 1990). 

In his 1989 report, the Surgeon General stated: 

In marked contrast to the trends in virtually all other areas 

of smoking control policy, the number of legal restrictions 

on children’s access to tobacco products has decreased 

over the past quarter-century. Studies indicate that compliance with minimum-age-of-purchase laws is the exception rather than the rule (US DHHS, 1989a). 

In studies across the country, it has been shown that, on 

average, 75 percent of retail stores sell tobacco to minors as 

young as age 12. In one Massachusetts community, an 

11-year-old girl was successful in purchasing cigarettes at 75 

out of 100 attempts (DiFranza et al., 1987). In the largest trial 

of this type, in Santa Clara County, California, 18minors aged 

14 to 16 visited 412 stores and 30 vending machines with the 

intent of purchasing cigarettes. They were successful at 74 

percent of the stores and 100 percent of the vending machines 

(Altman et al., 1989). In Erie County, New York, minors purchased cigarettes in 77 percent of stores that had received a 

special mailing about the law prohibiting tobacco sales to 

minors, and in 88 percent of stores that did not receive the 

mailing (Skretny et al., 1990). 

234 
Smoking and Tobacco Control Monograph No. 1 

Table 2 

Survey of Minnesota 10th graders 

Percentage of 

Location Yes Responses* 

Drug Store 42 

Grocery Store 53 

Convenience Store 68 

Vending Machine 71 

Gas Station 80 

*Question: Have you purchased tobacco at these places? 

Attempts to purchase tobacco products in at least 18 different communities have yielded similar results: On average, three 

of four retail stores will sell tobacco to minors, in violation of 

the laws of their state (Tobacco and Youth Reporter, 1989a). 

Researchers asked 10th graders in two Minnesota communities “Have you ever purchased cigarettes from any of these 

places?,” with the results shown in Table 2. Most teens thought 

it would be “very easy” (55 percent) or “fairly easy” (31percent) 

to obtain cigarettes. Among teenage smokers, 90 percent 

thought it was “very easy” to obtain cigarettes (Forster et al., 

1989). 

Vending Machine As mentioned above, when minors aged 14 to 16 attemptSales ed to purchase cigarettes from 30 vending machines in Santa 

Clara County, California, they were successful in all 30 attempts. 

Even after a massive community education program had reduced illegal over-the-counter cigarette sales to minors by 50 

percent, followup tests showed vending machine sales allowed 

minors to purchase cigarettes 100 percent of the time. 

In a major study covering the three-state area surrounding 

Washington, D.C., Davis and colleagues escorted minors to 

120 cigarette vending machines (twice each, for a total of 

240 attempts). The children were successful in 100percent of 

attempts to buy cigarettes (Davis et al., 1989). Davis concluded 

that “teenagers have easy access to cigarette vending machines 

in three different jurisdictions in the Washington, D.C., area. 

There is every reason to believe that this reflects the situation 

across the country’’ (Tobacco and Youth Reporter, 1989b). Identical results were obtained when minors were escorted to cigarette vending machines in New York, Colorado, and New Jersey. 

235 
Free Cigarette 

Samples 

National Cancer Institute 

A study by the National Automatic Merchandising Association, the trade association for the cigarette vending machine 

business, confirms the impression that vending machines are 

the source of cigarette supply for many very young teenagers 

when they first begin to experiment with smoking. The study 

found that, while only 16 percent of teens regularly obtained 

their cigarettes from vending machines (which still represents 

more than half a million teenagers), vending machines are a 

key source of supply for young teens. Among the study’s 

conclusions were: 

Thirteen-year-olds are 11 times as likely as 17-year-olds 

to buy cigarettes from vending machines (22 percent vs. 

2 percent). 

Most teens (56 percent) say they use vending machines 

“because no one will stop me from buying cigarettes this 

way.“ 

Whereas virtually all teenage smokers (96 percent) had 

been stopped from buying cigarettes over the counter, 

only about 1 in 10 had ever been stopped from buying 

cigarettes from a vending machine. 

A growing trend is to sell cigarettes and candy from the 

same vending machines, which is likely to further 

encourage and facilitate cigarette sales to minors. 

Tobacco companies spent $265 million giving away 

cigarette samples through direct distribution or coupons during 

1988, the most recent year for which data are available (Centers for Disease Control, 1990). One of the key functions of 

tobacco company giveaways is to provide young people with 

their first experimental packs of cigarettes or smokeless tobacco 

products at no cost and little risk of being caught. That young 

people are the target for many free cigarette distribution 

campaigns was made clear by a recent Camel advertisement 

that included a coupon with the encouragement to get a friend 

or a “kind-looking stranger” to redeem the pack for you if you 

are uncomfortable, an obvious come-on to underage youth. 

Sean Marsee, the Oklahoma youth who died at age 18 of 

mouth cancer caused by using smokeless tobacco, got started 

when a tobacco company representative gave him a free pack 

of snuff at a rodeo. Indeed, giving free samples to young 

nonusers has been a foundation of the growth strategy of the 

U.S.Tobacco Company (makers of Skoal, Copenhagen, Happy 

Days, and other smokeless tobacco products). The company 

has run advertisements in youth-oriented magazines offering 

free samples, complete with instructions for use, and gives free 

samples to young people at music, sports, and other events. 

Davis and colleagues asked a large number of young 

people if they had personally been given free tobacco samples; 

236 
Smokingand Tobacco Control Monograph No. 1 

Action at the 

CommunityLevel 

14 percent of the total and 20 percent of the high school 

students responded in the affirmative. Approximately half 

reported having seen other teenagers being given free cigarette 

samples (Davis and Jason, 1988). 

DiFranza organized a group of young people to send 

coupons in response to tobacco company solicitations for free 

tobacco samples being sent through the mail. Fifteen of 

twenty were mailed free tobacco samples at home, in violation 

of Massachusetts state law (DiFranza, 1989). 

Over the past several years, there has been a flurry of 

activity to prevent the sale of tobacco to minors. Much of this 

action has been at the community level. For example, in Santa 

Clara County, California, a major communitywide education 

campaign resulted in a 50 percent reduction in the number of 

stores selling tobacco to minors (from 74 percent to 38 percent), although there was no impact on the rate of sale by 

vending machines, which remained at 100 percent (US DHHS, 

1989a). 

In Woodridge, Illinois, police officer Bruce Talbott successfully pushed for enactment of a local ordinance requiring 

tobacco merchants to obtain a license and providing for fines 

and licensure revocation for violation of the law prohibiting 

sale of tobacco to minors under age 18. Compliance is monitored by means of “sting” operations in which a minor is 

escorted to stores. If cigarettes are sold to the minor, the store 

owner must pay a fine. Since enactment and enforcement of 

the law, the proportion of stores in Woodridge selling tobacco 

to minors has declined from 92 percent to 0. 

In Minnesota, the town of White Bear Lake outlawed 

cigarette vending machines in 1989. Since that time, 8 other 

communities have followed suit, 11have imposed more 

limited restrictions, and 10others are considering restrictions. 

A tobacco company effort to enact state legislation that would 

preempt these local ordinances failed (Jean Forster, Ph.D., 

personal correspondence). The State of Utah, using evidence 

that lockout devices on cigarette vending machines in that 

state failed to prevent access by minors, outlawed cigarette 

vending machines from all areas accessible to minors. The law 

was upheld by the Supreme Judicial Court of Utah against a 

challenge from the vending machine industry. 

A number of jurisdictions have outlawed the distribution 

of free tobacco samples. They are totally prohibited in Minnesota and Utah; it is illegal to distribute smokeless tobacco 

samples in Nebraska. Eight communities in Massachusetts 

prohibit giveaways of tobacco samples. 

237 
A Public Policy 

Agenda 

National Cancer Institute 

Another step that is being taken by an increasing number 

of jurisdictions is to post signs that warn against tobacco sales 

to minors. This may be effective not only at warning would-be 

underage tobacco purchasers but also at reminding store 

personnel of the law. 

A growing number of activists, impatient with the sometimes slow progress of enacting controls over the sale of tobacco to minors-often in the face of determined tobacco 

industry resistance-have taken to direct action against cigarette vending machines. For example, one antismoking organization published instructions for disabling cigarette vending 

machines, including the use of bent paperclips and coins 

dipped in Superglue. Another produces “out of order” stickers 

that can be placed over the coin slot of cigarette vending 

machines. f 

Stop Teenage Addiction to Tobacco (STAT) is a nonprofit 

educational organization that was founded in 1985 to eliminate tobacco addiction of adolescents by raising public awareness of how tobacco companies use sophisticated marketing 

campaigns to attract young people and how ready access 

increases tobacco consumption among young people. STAT 

has prepared model legislation that has served as the basis for 

legislative efforts in a number of communities around the 

country. Its “Position Paper on Tobacco-Free Schools” has 

helped many jurisdictions eliminate school smoking. STAT is 

forming a national network of community organizers to 

implement strategies that will reduce the sale of tobacco to 

minors. 

Eliminating the sale of tobacco to minors is an essential 

step if we are to achieve the national public health goal of a 

smoke-free society. Based on research and review of what has 

been effective at the state and community levels, the following 

steps are probably necessary. 

All free distribution, “sampling” in tobacco industry 

parlance, must be outlawed. The offer of free cigarettes 

and smokeless tobacco products is reminiscent of the 

drug pusher who gives the first sample free to get his 

customer hooked. 

Legislation at either the state or local level should 

establish that any merchant must obtain a license prior 

to selling tobacco products. There must be a provision 

that repeated violation of the law prohibiting tobacco 

sales to minors will result in meaningful monetary fines 

and/or extended revocation of that license. There 

should be provision that enforcement will be ensured by 

means of sting operations conducted by either the police 

or health department of the jurisdiction (the Tennessee 

238 
Smoking and Tobacco Control Monograph No. 1 

ECONOMIC 

INCENTIVES 

state law explicitly provides that it is not entrapment for 

a youth under official supervision to attempt to purchase 

cigarettes to monitor compliance with the law). 

In light of their potential to start young people on the 

course of tobacco addiction, cigarette vending machines 

must be outlawed. The Nation’s 374,000 cigarette 

vending machines are an open invitation to addiction 

for the Nation’s young people. A vast majority are 

located in areas where they cannot be effectively supervised. With the proliferation of 24-hour convenience 

stores over the past several decades, cigarette vending 

machines can no longer be justified. 

Signs should be required providing notice of the 

minimum-age-of-purchase law and of the store’s intent 

to abide by the law. 

The legal age for sale of tobacco should be raised to 21, 

making it consistent with the age for legal sale of alcohol. This will send an important message that tobacco is 

just as hazardous as alcohol. It will also make it simpler 

for merchants to monitor identification for sale of 

products that are legal for adults but not for minors by 

establishing a consistent age for both tobacco and 

alcohol. Perhaps most important, because relatively few 

high school students are friendly with 21-year-olds 

(though many know 18-year-olds), this would reduce 

access to tobacco products for high school students. 

Smoking by students should be prohibited in schools. In 

addition, smoking by adults should be prohibited on 

school campuses, establishing teachers as appropriate 

role models. 

Tobacco prices should be increased by means of taxation 

because young people are price sensitive in their demand 

for tobacco products. Ideally, revenue generated by increased taxes should be used for health education, as has 

been done with Proposition 99 tax revenues in California. 

This section describes environmental manipulations based 

on the application of economic incentives. Economic incentives serve to reduce consumption of tobacco products by 

increasing, either directly or indirectly, the costs of using these 

products. In this section, three economic incentive policies are 

examined: (1)higher excise taxes on cigarettes, (2) preferential

hiring and promotion of nonsmokers, and (3) insurance 

premium differentials for smokers and nonsmokers. An attempt is made here to present some of the conceptual linkages 

between economic incentives and smoking and to describe the 

development and current status of each of the three strategies. 

239 
Excise Taxes on 

Tobacco Products 

Past and Current Status 

National Cancer Institute 

The excise tax is an administratively simple mechanism 

through which public policy can influence the price of tobacco 

products. The chief purpose of excise taxes has always been 

generation of revenues, although recently these taxes are 

receiving increased interest and support as a public health 

measure. 

A Federal excise tax on cigarettes has existed since 1864 

and was an especially important source of Federal revenues 

before the enactment of the Federal income tax in 1913. Since 

1951, the tax rate has been raised twice. In 1982, it was 

doubled from 8 cents to 16 cents per pack; and in 1990, it was 

raised 8 cents to be implemented in two stages. 

In 1921, Iowa became the first state to implement an 

excise tax on cigarettes. By 1960, all but four states had enacted cigarette excise tax policies, and in 1969 North Carolina 

was the last state in the Nation to do so. Currently, 396 city 

and county governments also impose an excise tax on cigarettes. These local governments are largely concentrated in just 

a few states, and in 1988 they were responsible for 2 percent of 

all excise taxes collected on cigarettes (Tobacco Institute, 1990). 

One of the largest single-year increases ever in a state 

excise tax on cigarettes occurred recently in California. In 

January 1989, Proposition 99 raised the tax from 10to 35 cents 

per pack, boosting the California tax to one of the highest in 

the Nation. There is now substantial variability in the excise 

tax rate among states. 

An important historical perspective on cigarette excise 

taxes is gained by considering the relative contribution of the 

tax to the overall price of Cigarettes. Table 3 shows the percentage of the average price of cigarettes accounted for by Federal 

and state taxes from 1954 to 1988. This table shows that the 

Federal tax is declining as a proportion of the total cost of 

cigarettes. Even with the 8-cent increase in 1983, the relative 

impact is quickly being eroded by inflation toward the pre1983 level. The overall relative decline in Federal revenues also 

holds when compared with either the consumer price index or 

gross national product. As a percentage of the total Fedexal tax 

base, revenues from cigarette excise taxes have declined from 

3 percent in 1950 to 0.5 percent in 1987. Since the early 

1970’s, state revenues as a percentage of the total price of 

cigarettes have also declined appreciably. Without constant readjustment of the rate, real revenues from excise taxes will 

continue to decline as long as a unit rate is used. Annual 

adjustments to the Federal tax based on a cost-of-living index 

have been proposed. Alternatively, an ad valorem tax would 

index the tax rate to the price of cigarettes. As of 1988, Hawaii 

was the only state to use this method. 

240 
Smoking and Tobacco Control Monograph No. 1 

Table 3 

Excise taxes as percentage of cigarettes' total cost to consumers 

Federal and State 

Taxes" Federal Taxes State Taxes 

Yea+ 

1955 48.7% 36.7% 12.0% 

1956 47.4 34.9 12.5 

1957 48.8 35.4 13.4 

1958 48.0 36.1 11.9 

1959 46.6 32.9 13.7 

1960 48.9 32.2 16.7 

1961 48.6 31.6 17.0 

1962 48.3 30.6 17.7 

1963 49.4 31.1 18.3 

1964 49.3 30.1 19.2 

1965 49.8 29.9 19.9 

1966 51.4 28.4 23.0 

1967 50.8 27.7 23.1 

1968 49.2 25.2 24.0 

1969 48.9 24.0 24.9 

1970 47.7 21.7 26.0 

1971 46.8 20.9 25.9 

1972 47.7 20.0 27.7 

1973 48.4 19.9 28.5 

1974 47.6 19.9 27.7 

1975 44.5 17.9 26.6 

1976 41.4 16.9 24.5 

1977 40.5 15.8 24.7 

1978 37.1 14.4 22.7 

1979 35.5 13.8 21.7 

1980 34.5 14.0 20.5 

1981 33.1 12.8 20.3 

1982 29.9 11.4 18.5 

1983 26.8 12.0 14.8 

1984 33.2 17.3 15.9 

1985 32.3 16.2 16.1 

1986 30.8 15.2 15.6 

1987 29.9 15.1 14.8 

1988 28.8 13.7 15.1 

1989 26.5 12.0 14.5 

1990 26.4 11.2 15.2 

aSource: Tobacco institute (7990). 

bFiscal year ending June 30. 

241 
Anticipated Effects 

Of a Tax Increase 

National Cancer Institute 

How much reduction in smoking might we expect in 

response to increasing the price of cigarettes? The quantitative 

relationship between price and demand is described by economists as price elasticity, which is defined as the change in 

demand for a product relative to the change in price. For 

example, a price elasticity of -0.5 implies that a 10 percent 

increase in the price of a product will result in a 5 percent 

decrease in the quantity demanded. Note that a given tax 

increase must first be translated into the percentage increase in 

the retail price before its effect can be estimated. 

Studies on the price elasticity for cigarettes in the United 

States were summarized in the 1989 Surgeon General’s Report 

(US DHHS, 1989a). Thirteen studies conducted since 1980 

were identified. Overall price elasticity estimates varied from - 0.14 to -1.23. However, there was a clustering of short-term 

elasticity estimates in the -0.4 to -0.5 range, and the mean 

estimate was -0.43. These estimates are similar to those obtained in European studies, as summarized by Pekurinen and 

Valtonen (1987) and Godfrey and Maynard (1988). Considering the differences in cultural attitudes toward smoking, 

varying levels of government involvement in antismoking 

health education, and substantial variations in the real price of 

cigarettes, the overall level of agreement between the American 

and European studies adds a degree of confidence to the 

general findings of these studies. 

Overall price elasticities convey no information regarding 

which groups and types of smokers are more sensitive to price 

changes. However, by analyzing survey-based data rather than 

aggregate consumption data, Lewit and colleagues have attempted to answer several critical questions about differential 

impacts. Using a sample of nearly 20,000 adults surveyed in 

the 1976 National Health Interview Survey, Lewit and Coate 

(1982) found that the consumption response to a price increase 

occurs primarily through reduction of smoking prevalence, 

rather than reduction of the average number of cigarettes 

smoked per smoker. The elasticity for participation, that is, the 

number of smokers, was found to be -0.26. The elasticity for 

the number of cigarettes per smoker was only -0.10. Thus, it 

would appear that the primary impact of an increase in the 

cigarette excise tax would be to encourage some smokers to 

quit, but the majority of smokers would continue to smoke 

about the same amount. 

Studies that have examined age-specific responses to the 

price of cigarettes are of particular interest to public health professionals because they assess the potential impact of price 

policy on teenage smoking. It is well known that most adult 

smokers started before the age of 20, and thus a high priority 

for smoking control efforts is the reduction of teenage smoking 

242 
Smoking and Tobacco Control Monograph No. 1 

Table 4 

Age-specific estimates of the price elasticity of demand 

for cigarettes 

Elasticities 

Overall Participation Quantity per Smoker 

Age Group 

12-1 7 yr -1.40 -1.20 -0.25 

25 -0.89 -0.74 -0.20 

26-35 -0.47 -0.44 -0.04 

36-74 -0.45 -0.15 -0.15 

All adults -0.42 -0.26 -0.10 

All ages -0.47 -0.31 -0.11 

Adapted from US DHHS (1989a,p. 537),and US GAO (1989, p.30). 

rates (DiFranza et al., 1987). The first study (Lewit et al., 1981) 

found the price elasticity for youths aged 12 to 17 to be -1.40, a 

substantially higher figure than for adults. Similar to adults, 

adolescents also respond to price primarily through participation, rather than the quantity smoked per smoker. The price 

elasticity estimates for participation and quantity smoked were 

-1.20 and -0.25, respectively. A second study, by Grossman 

and colleagues (1983), used data from four smaller, more recent 

samples provided by the National Surveys on Drug Abuse. The 

estimated price elasticities for participation were all less than 

the figure obtained in the earlier study. To obtain their summary estimate of -0.76 for these studies, the authors excluded 

the highest and lowest figures and averaged the remaining two. 

The authors of a General Accounting Office report on teenage

smoking suggest relying on this lower elasticity estimate, rather 

than the -1.20 figure, because of the recency of the data used in 

the second study (US GAO, 1989). A summary of the elasticity 

estimates provided by these studies is shown in Table 4. 

The participation elasticity estimates provided in Table 4 

may be used to project the decrease in smoking prevalence 

related to a given tax rate change. The current price of cigarettes is needed to convert the tax increase into the percentage 

change in the retail price of cigarettes. Also necessary are 

estimates of current prevalence of smoking. For example, 

Warner (1986b) projected the reduction in prevalence in adult 

cigarette smoking for three specific values of possible tax rate 

changes. In 1986, a 16-cent-per-pack increase in the excise tax 

would have raised prices 15.1 percent. Based on 1982 prevalence data, this would be expected to reduce the number of 

adult smokers by over 2.5 million (3.9 percent). More recently, 

243 
National Cancer Institute 

Cummings and Sciandra (1989) have used similar methods to 

estimate the response in overall smoking prevalence in New 

York State to a scheduled 12-cent increase in the state excise 

tax. 

The US GAO report (1989) employed analogous procedures 

to estimate the effect of a tax increase on teenage smoking. 

Using the more conservative estimate for participation elasticity of -0.76 and the most recently available prevalence estimates, the GAO predicted that a 21-cent tax increase would 

result in a reduction of more than one-half million teenage 

smokers. Because deterrence in the teen years may result in 

lifelong abstinence from smoking, the health impact on this 

group is especially significant. 

Projected responses to excise tax increases are subject to a 

number of potentially distorting influences, and estimates 

should be interpreted with caution. The level of uncertainty 

increases as we seek to generalize the results of previous studies 

to changing social and normative environments, varying levels 

of tax increases, and long-term impact on smoking. Recent 

empirical data on cigarette consumption trends may be helpful 

in validating short-term price response estimates. Several 

conceptual issues regarding the use of results from elasticity 

studies in forecasting price response are also summarized 

below. 

Significant increases in the cigarette excise tax have occurred recently in the United States, Canada, and the State of 

California. From 1981 through 1984, the real price of cigarettes in the United States increased 27 percent, while per 

capita consumption declined 10 percent (Harris, 1987). In 

Canada, the real price of cigarettes rose 66 percent from 1982 

to 1988, with an attendant 24 percent drop in per capita 

consumption (Canadian Council on Smoking and Health, 

1990). Finally, preliminary data from California suggest that 

overall sales in California in the third quarter of 1989 dropped 

10.5 percent from that in the third quarter of 1988 uames 

Howard, personal communication, 1990). The 25-cent-perpack state tax increase implemented in January 1989 raised the 

price of cigarettes in California about 20 percent. 

These declines in cigarette consumption reflect a substantially accelerated decline over the rate for previous years and 

are consistent with a price elasticity in the range of -0.36 to 

-0.50. However, the extent to which the declines may be 

attributed purely to the price increases cannot be precisely 

determined. The Canadian Council on Smoking and Health 

attributes only about half of the decline in consumption to the 

effect of the increase in cigarette prices. 

244 
Smoking and Tobacco Control Monograph No. 1 

Preferential Hiring 

And Promotion 

Relationship to 

Other Policies 

Recent consumption trends, and how they have been 

interpreted, point to several of the difficulties involved in 

accurately measuring and predicting responses to price increases. There are many influences on smoking behavior that 

operate concurrently with changing levels of price, making it 

difficult to isolate specific effects. It is possible that more of the 

recent decline in smoking than is generally recognized is due to 

general societal trends. On the other hand, Harris (1987) 

suggests that the decline in smoking prevalence, particularly 

among lower income groups, might have been substantially 

greater if the real price of cigarettes had not declined during 

the 1970’s. 

Recent experience suggests that tax increases are not 

simply passed directly to consumers but may be accompanied 

by an additional percentage increase by the manufacturers, 

thus “multiplying” the impact of the tax increase (Harris, 

1987). There has also been increased marketing and sales of 

low-cost generic and discount brand cigarettes (Adler and 

Freedman, 1990), a trend that may serve to partially offset the 

influence of a tax increase. The long-term impact of tax 

increases on consumption is less clear than the short-term 

response. It is also uncertain whether large increases in price

have the proportionately equivalent effect of small increases. 

A range of worksite policies and programs may potentially 

influence smoking behaviors. Rigotti (1989) outlines a continuum of worksite smoking policies that includes (1)no explicit 

policy, (2) environmental alterations, (3) designated smoking 

and nonsmoking areas, (4) total smoking bans, and (5) preferential or exclusive hiring of nonsmokers. This section considers only the fifth and most restrictive category. This does not 

imply that less restrictive policies do not also generate economic incentives for reducing cigarette consumption. Job opportunities may be constrained for those who resist applying 

for positions where restrictions are imposed. Among the costs 

of noncompliance with established worksite smoking policies is 

the threat of losing one’s job-certainly an economic incentive. Some worksites have also developed financial incentive 

programs as part of their overall effort to facilitate smoking 

cessation among employees. These incentives typically involve 

small monetary rewards to employees who successfully maintain abstinence from smoking (Orleans and Shipley, 1982). 

Variations of this approach include the use of contests, prizes, 

and lotteries to increase the program’s visibility and appeal. A 

number of programmatic approaches to worksite incentives are 

described in a workbook published by the National Cancer 

Institute (US DHHS, 1989~). 

245 
Prevalence and 

Current Trends 

National Cancer Institute 

Walsh and McDougall(l988) identify several motivational 

concerns that underlie company smoking policies. The reasons 

for preferential hiring and promotion of nonsmokers appear 

somewhat different and more situation-specific than those 

given for on-site restrictions. Protection of the health and 

rights of nonsmokers in the workplace is a key component of 

worksite restrictions (Rigotti, 1989). However, the extension of 

policies to personal behaviors away from the worksite may be 

motivated more by economic considerations (Walsh and 

McDougall, 1988). Employers defend the practice of preferentially hiring nonsmokers because smokers incur higher costs to 

both the business and society (Action on Smoking and Health, 

1989). Some occupations involve environmental exposures 

where employees who smoke are at a much greater health risk 

and thus not hired for this reason. Hiring restrictions have 

been imposed also for jobs that require high levels of physical 

fitness, such as for firefighters and police officers. Additionally, 

for occupations where respiratory functional decline caused by 

tobacco use can be confused with compensable occupational 

injury, employers have hired only nonsmokers to limit disability costs. 

Recent surveys of employers suggest that the practice of 

hiring only nonsmokers is uncommon, occurring in only 1to 

2 percent of the businesses surveyed (Bureau of National 

Affairs, 1987; Peterson and Massengill, 1986; Swart, 1988). The 

Bureau of National Affairs report found little evidence that 

exclusive hiring practices are becoming more prevalent, despite 

growing implementation and acceptance of worksite restrictions. However, a more recent report (Action on Smoking and 

Health, 1989) cited evidence to suggest that the frequency of 

these practices is increasing. Hiring preferences, as opposed to 

absolute hiring restrictions, are more common. The Bureau of 

National Affairs survey found that 5 percent of the organizations surveyed gave companywide preference to nonsmoking 

applicants, and another 10 percent allowed individual supervisors to preferentially hire nonsmokers. It is possible that 

informal preferential hiring practices are substantially more 

widespread than the policy survey suggests. A poll by a New 

York recruiting firm found that 46 percent of the executives of 

large firms would choose a nonsmoker over an equally qualified smoker (Bureau of National Affairs, 1987). 

Such informal preferences may also apply to promotion 

and firing decisions. Although Peterson and Massengill (1986) 

found that none of the companies surveyed indicated that they 

preferentially promoted nonsmokers, anecdotal evidence , 

suggests such practices exist, although discreetly (Freedman, 

1987). A similar situation may exist with regard to demoting 

or firing employees who smoke, even though companies that 

246 
Smoking and Tobacco Control Monograph No.1 

hire only nonsmokers do not as a rule dismiss smokers employed prior to implementation of the hiring policy (Action on 

Smoking and Health, 1989). 

Any increase in the prevalence of nonsmoker hiring 

policies is expected to be gradual. When businesses were asked 

to project whether they would have such a policy in place in 

the future, 3.8 percent predicted they would by 1990, and 

6.6 percent by 1995 (Swart, 1988). There are several reasons for 

reluctance on the part of employers to implement preferential 

hiring policies. There is a perception that less restrictive 

measures are working well and that hiring restrictions are 

intrusive and go beyond normal employment practices. Businesses may not want to restrict their pool of available employees. Also, verification of smoking status of current and potential employees and decisions on how to respond to infractions 

are problematic and potentially costly. Guidelines by Action 

on Smoking and Health (1989) suggest that employers clearly 

state their policy to all applicants and that consequences of 

infractions be stipulated. Some employers have implemented 

biochemical or physiological testing to verify smoking status. 

Influence of Hiring Although several formal evaluations of the effect of 

And Promotion worksite smoking policies on smoking have been conducted, 

Preferences none have specifically examined the impact of preferential or 

exclusive hiring practices. Clearly, one potentially important 

contribution that such policies make is the message they 

convey about the changing social acceptability of smoking. 

Formal policies against hiring smokers are still relatively uncommon but may be highly visible and attract considerable 

media attention. The more direct impact of such policies is 

expected to occur through the economic incentive to quit 

smoking provided by the policy. If employment is contingent 

on quitting smoking, some potential applicants might be 

motivated to quit smoking rather than settle for some other 

job. Whether or not this happens depends on a number of 

considerations, including the availability of other employment 

opportunities and the strength of the individual’s propensity to 

smoke. 

Legal Issues The legal right of employers to preferentially or exclusively 

hire nonsmokers is generally recognized. Federal and state 

statutes prohibit discrimination on the basis of race, religion, 

national origin, and, in most circumstances, age and sex. In 

some situations, it is also unlawful to discriminate on the basis 

of sexual orientation, political affiliation, marital status, citizenship, and physical or mental handicap (Myers, 1990). Aside 

from these attributes, employers in most situations have’the 

right to make hiring decisions on whatever basis they choose, 

including smoking status. 

247 
National Cancer Institute 

On the forefront of occupations experiencing establishment of nonsmoker hiring policies are emergency services. A 

firefighter in Oklahoma who was dismissed from his job when 

observed smoking off duty challenged his dismissal, but the 

employment policy of the fire department was upheld in 

Federal court in 1987. Another challenge to a nonsmokersonly hiring policy occurred when the application of a New 

York woman for employment in a jewelry store was rejected. 

In this case, the applicant claimed that she was discriminated 

against on the basis of a handicap, namely an addiction to 

smoking. Although New York state law classifies addicts of 

certain drugs as handicapped, no mention is made of tobacco. 

Even so, the case is proceeding after it was determined by a 

state board that there was probable cause to suspect that 

unlawfuI discrimination had occurred. 

Additional legal challenges to preferential hiring policies 

are probable. The American Civil Liberties Union opposes such 

practices except where the smoking status of applicants or employees can be shown on a case-by-case basis to interfere with 

job performance. However, no actions by the American Civil 

Liberties Union to date have been initiated against employers 

who refuse to hire smokers. Additional challenges to nonsmoker hiring practices may be brought on the basis that they 

are discriminatory to blacks, because of a higher smoking 

prevalence among blacks. One other potential focus of legal 

debate on preferential hiring practices is the invasion of privacy issue, although this aspect of such policies has so far gone 

unchallenged. 

Two additional caveats may apply to employment policies 

that favor nonsmokers. The first applies to any workplaces that 

are covered by collective bargaining agreements with labor unions. Most cases in which unions have confronted rnanagement on smoking policies have focused on workplace restrictions. However, collective bargaining agreements may also 

pertain to restrictions on eligibility for employment. Efforts by 

the Manville Corporation, a Texas asbestos manufacturer, to 

hire onIy nonsmokers and ban workplace smoking have been 

stymied by litigation instigated by the International Machinists 

Union. Although in some cases management has successfully 

defended its nonsmoker-hiring policies, the general recommendation for employers is to develop and impose hiring policies 

and smoking restrictions in consultation with the unions 

involved and in accordance with current collective bargaining 

agreements (Action on Smoking and Health, 1989). 

The second situational limitation on the legal right of employers to hire only nonsmokers occurs when state or local 

laws prohibit such practices. In 1989 legislation was passed in 

Virginia that prohibits state agencies from requiring employees 

248 
Smoking and Tobacco Control Monograph No. 1 

Differential 

Insurance 

Premiums 

Current Status 

to be nonsmokers. Private employers are not affected by the 

legislation, nor are agencies prevented from implementing 

workplace smoking restrictions. A similar bill in the State of 

Maryland, applicable to both public and private employers, was 

defeated in 1989. 

Substantial evidence that smoking is firmly associated with 

reduced longevity, health care costs, and damage to property 

has accumulated over the past 45 years. This evidence has 

elicited varying degrees of response from the corresponding 

major components of the insurance industry-life, health, and 

property. Before the release of the 1964 Surgeon General’s 

Report, no major insurer of any type offered premium reductions to nonsmokers. Now almost all life insurance companies 

provide nonsmoker discounts, whereas only a small but growing 

number of health and property insurers do so. This section 

examines the development and current status of differential 

premium rates for smokers and nonsmokers for each of the 

three major arms of the insurance industry. To the extent that 

these differentials are visibly passed on to individual consumers, 

they may provide an economic incentive not to smoke. Premium differentials could be labeled as either nonsmoker discounts or smoker surcharges; the net premium costs to smokers 

and nonsmokers would be the same. However, for both historical reasons and marketing purposes, the term “nonsmoker discount” is generally used. 

Although life insurance companies began to introduce nonsmoker discounts as early as 1965, adoption proceeded slowly 

until 1979. In that year, a definitive actuarial study by State 

Mutual Life Assurance revealed a substantial and statistically 

significant mortality difference between smokers and nonsmokers. Collaborative evidence provided by other companies soon 

followed. By 1984, the National Association of Insurance 

Commissioners had developed formal guidelines for setting 

differential premium rates for smokers and nonsmokers, which 

were subsequently incorporated into practice in most states. 

Currently, the vast majority of companies provide nonsmoker 

discounts on individual policies. The size of the discounts 

varies across ages and gender; average discounts are in the range 

of 12 to 22 percent (US DHHS, 1989a). 

The situation for health insurance, where providers have 

been slower to adopt nonsmoker discounts, is considerably 

more complicated. Most health insurance is purchased as group 

coverage, where the health status and risk factors of individuals 

typically are not considered. Furthermore, actuarial data on the 

health care cost differentials of smokers and nonsmokers have 

not been as complete and readily available as for mortality 

differentials (US DHHS, 1989a). Administrative costs and the 

problem of verifying the smoking status of individuals covered 

249 
National Cancer Institute 

by group policies may also contribute to the reluctance of the 

industry to provide discounts. Despite a National Association 

of Insurance Commissioners resolution (1985) supporting premium differentials in both group and individual policies and 

an Action on Smoking and Health (1987) special report that 

questioned the legality of not differentiating, only about 15 

percent of individual policies offer nonsmoker discounts. Even 

fewer group plans do. Individual policies carry discounts that 

range from 3 to 15 percent. Group plan differentials are 

usually provided on the basis of the percentage of nonsmokers 

in the group and offer discounts of a few percentage points to 

groups below a specified smoking prevalence level. 

Nonsmoker discounts in property and casualty insurance 

are also relatively uncommon. This situation exists despite 

solid evidence that smoking materials are responsible for a significant percentage of house fire property damage and firerelated deaths and that smokers have more vehicular accidents 

than nonsmokers (US DHHS, 1989a). The Farmer’s Insurance 

Group was the first company to offer nonsmoker discounts and 

as of 1987 was still the only major insurer to offer them on 

both homeowner and automobile policies. Discounts on 

homeowner policies range from 3 to 7 percent and on automobile policies from 10 to 25 percent. Recently the Hanover 

Insurance Company increased its nonsmoker discount for 

automobile policies from 5 to 10 percent. The difficulty of 

verifymg smoking status, as well as prohibitory regulations in 

certain states, have deterred more companies from adopting 

discount policies. 

State insurance commissions and legislatures have prohibited certain practices that offer premium differentials 

because they were deemed discriminatory. However, the 

National Association of Insurance Commissioners has actively 

sought to encourage state governments to remove legal barriers 

to nonsmoker discounts and has facilitated the collection of 

actuarial data to help justify the practice. In the future, a 

willingness on the part of state legislatures and insurance 

commissions to require the availability of differentially priced 

policies may result from these efforts. 

One additional insurance industry practice that indirectly 

offers a financial incentive to quit smoking is the coverage of 

costs for smoking cessation programs. This coverage is currently uncommon, and the future growth of such policies is 

uncertain. Only 11percent of carriers surveyed in 1985 provided benefits for smoking cessation programs (US DHHS, 

1989a). Employers have absorbed some of the burden for 

providing cessation resources, and more may be expected to do 

so if discounts for group health insurance policies continue to 

become more widely available. 

250 
Smoking and Tobacco ControlMonograph No. 1 

Effects of Premium 

Differentials 

An Overview 

Of Economic 

Incentives 

Similar to the situation regarding preferential hiring, no 

empirical studies have assessed the impact of differential 

insurance premiums on smoking. Until such studies are 

conducted, expectations must remain speculative. Premium 

differentials may reduce smoking by providing both economic 

incentives and social or educational influences. For several 

reasons, premium differentials will probably provide less 

economic incentive for not smoking than direct increases in 

the price of cigarettes. Their impact is acute only at the time 

the policies are paid, and even then it may not be made clear 

to consumers that smokers are paying more. In many circumstances, smokers will have the option of simply switching to 

another policy or provider that does not differentiate. Health 

insurance premiums are often paid entirely by employers, 

although increasing efforts by employers to reduce their health 

insurance costs may result in more smokers having to pay extra 

for health insurance. 

The role of the insurance industry in providing additional 

awareness and support for the declining social acceptability of 

smoking may be just as powerful as any economic incentives it 

provides. Being asked about one’s smoking status when completing insurance forms is yet another reminder of the potential personal health and economic consequences of smoking. 

Health maintenance organizations may be especially inclined 

to provide educational reminders and resources for smoking 

cessation, although adoption of such efforts is also advocated 

for the larger community of health care providers (S.R. Cummings et al., 1989). 

There are several aspects of the use of economic incentives 

to discourage smoking that have raised ethical concerns about 

their fairness and appropriateness. The regressivity issue 

concerning excise taxes has surfaced repeatedly and is a basis 

for opposition to proposals to increase taxes on cigarettes. A 

regressive tax is defined as one where the proportion of individual’s income consumed by the tax is inversely related to 

income level (Fusfeld, 1982). Cigarette taxes appear to be 

highly regressive (Citizens for Tax Justice, 1988; Toder, 1985), 

although Harris (1985) suggests that the regressivity issue has 

been exaggerated. Proponents of increasing excise tax rates, 

although aware of the regressivity issue, weigh this concern 

against the expected improvements in health status and 

longevity resulting from the reduced prevalence of smoking. 

They also note that the lower income groups, ,where the 

burden of smoking-related disease is greatest, are also expected 

to show the greatest response to a price increase (Townsend, 

1987). 

251 
National Cancer Institute 

Many other elements have been introduced into the 

debate over the fairness of economic incentives. Among these 

are ethical concerns about paternalism, victim blaming, and 

fair distribution of costs. The current racial and socioeconomic 

disparities between smokers and nonsmokers has elicited 

charges that economic incentive policies are racist and elitist. 

The accuracy of projected effects of a tax increase has been 

questioned, and little empirical evidence is available on the 

effects of the other economic incentive strategies. Potential 

consequences include a lack of employment opportunities and 

affordable insurance for those who are unwilling or unable to 

stop smoking. 

Despite the numerous arguments raised in opposition to 

economic incentive policies, there is broad support for these 

approaches. Increases in the cigarette excise tax are advocated 

by numerous health organizations, including the American 

Heart Association, American Lung Association, American 

Cancer Society, American Public Health Association, and 

American and Canadian Medical Associations. Several proposals have been offered to mitigate at least some of the previously 

raised ethical concerns. These suggestions merit serious consideration and further reflect the importance of a coordinated, 

multifaceted approach to smoking and tobacco control. For 

example, Toder (1985) and Warner (1986b) argue that potentially negative effects of excise tax regressivity could be offset 

by making other aspects of the tax structure more progressive. 

Earmarking of tobacco tax revenues for health care and tobacco 

cessation and education programs may reduce the perception 

that smokers are being victimized or exploited. A 1987 American Medical Association poll (Harvey and Shubat, 1987) 

showed that a majority of smokers support an increase in the 

cigarette excise tax if the revenues are earmarked for Medicare 

costs. In California, 75 percent of the estimated $600 million 

generated in the first year of the Proposition 99 tax increase is 

designated for health care, drug education, and research. 

Increased affordability and availability of smoking cessation 

resources and programs help remove economic and logistical 

barriers to quitting and also contribute to an atmosphere of 

positive support and reinforcement for those trying to quit. 

The economic incentive strategies examined here focus on 

methods that increase the cost of smoking for consumers. 

Another approach is to apply economic inducements and 

policies to the supply side of the smoking problem, which includes agricultural practices and policies, cigarette manufacturing and distribution, and advertising (Walsh and Gordon, 

1986). Initiatives that may reduce smoking by affecting this 

side of the smoking equation include (1) elimination of the 

tobacco support program (Warner, 1988), (2) agricultural 

252 
Smoking and Tobacco Control Monograph No. 1 

CONCLUSIONS 

policies that promote and subsidize alternative crops (Milio, 

19SS), (3) elimination of tax deductions for tobacco advertising 

(US DHHS, 1989a), (4) further restrictions on advertising 

(Warner et al., 1986), and (5) tighter controls on the distribution and sale of tobacco products (DiFranza et al., 1987). The 

political influence of the tobacco industry has undoubtedly 

impeded the implementation of these initiatives, but the increasing political influence of the antismoking movement 

enhances the opportunity for a broad spectrum of antismoking 

legislation. The potential impact of policies to restrict advertising and actively support the agricultural transition to other 

crops extends beyond their direct impact by complementing 

and reinforcing other antismoking efforts. For example, 

economic inducements and educational efforts might be even 

more effective when seen as part of a broader and more congruous Federal policy to reduce smoking and improve health. 

The targets of recent interventions to control tobacco 

use are social networks that shape the attitudes of 

individual smokers and nonsmokers, including media, 

health care providers, worksites, and schools. 

The use of media in tobacco control includes providing 

information on the risks of tobacco use and dangers of 

policies that promote tobacco use, motivating smokers 

to stop and others to not start, and conducting cessation 

programs or recruiting smokers into treatment programs. 

Health care providers should not only intervene with 

their smoking patients but also be agents for social 

change.

Restrictions on smoking in the worksite and other locations change the social acceptability of smoking and 

may increase the number of individuals who try to quit 

and who have long-term success after cessation. 

Comprehensive smoking control strategies are best implemented at the local level and can be implemented 

through formation of coalitions of established community groups. 

Most adolescent smokers have little difficulty in purchasing cigarettes, even when these purchases violate local 

laws. Increasing the barriers to cigarette purchases by 

minors is important in strategies to prevent the initiation of regular tobacco use. 

Economic incentives that may reduce the consumption 

of cigarettes include increasing the excise tax on tobacco 

products; preferential hiring and promotion of nonsmokers; and increasing the cost of life, health, and 

other forms of insurance for smokers. 

25 3 
REFERENCES 

National Cancer Institute 

Action on Smoking and Health. Charging smokers more 

for health insurance is fair and legal. ASHRwiew (May): 7-12, 

1987. 

Action on Smoking and Health. Employment Policies 

Against Hiring Smokers. Washington, DC: Action on Smoking 

and Health, October 1989. 

Adler, S.J., Freedman, A.M. Smoked out-Tobacco suit exposes ways cigarette firms keep the profits fat. Wall Street 

Journal, March 5, 1990,p. 1. 

Altman, D., Foster, V., Rasenick-Douss, L., Tye, J. Reducing 

the illegal sale of cigarettes to minors. Journal of the American 

MedicaZ Association 261:80-83, 1989. 

American Academy of Pediatrics. Tobacco use by children 

and adolescents. Pediatrics 79: 479-481, 1987. 

American Cancer Society. Smoke Signals: The Smoking 

Control Media Handbook. New York: American Cancer Society, 

1987. 

American Cancer Society. Where There’s No Smoke: Helping 

to Create a Smoke-pee Environment. New York: American 

Cancer Society, 1988. 

American Hospital Association. Smoking and Hospitals ... Are a Bad Match! Policy Development and Implementation Strategies for a Smokeftee Environment. Chicago: American Hospital 

Association, 1988. 

American Medical Association. Creating a Tubacco-Free 

Society: A Physician Leadership Kit. Chicago: American Medicd 

Association, 1987. 

American Medical Association Board of Trustees. Media 

advertising for tobacco products. Journal ofthe American 

Medical Association 255: 1033, 1986. 

American School Health Association. National Adolescent 

Student Health Survey, 1989. 

Anda, R.F., Remington, P.L., Sienko, D.G., Davis, R.M. Are 

physicians advising smokers to quit? The patient’s perspective. 

Journal of the American Medical Assuciation 257:1916-1919, 

1987. 

Becker, D.M., Comer, H.F., Waranch, H.R., Stillman, F., 

Pennington, L., Lees, P.S., Oski, F. The impact of a total ban on 

smoking in The Johns Hopkins Children’s Center. Journal of 

the American Medical Association 262: 799-802, 1989. 

Best, J.A., Thomson, S.J., Santi, S.M., Smith, E.A., Brown, 

K.S. Preventing cigarette smoking among school children. 

Annual Review ofPublic Health 9: 161-201, 1988. 

254 
Smoking and Tobacco Control Monograph No. I 

Bettinghaus, E.P. Health promotion and the knowledgeattitude-behavior continuum. k&mtive Medicine 15: 475-491, 

1986. 

Biener, L., Abrams, D.B., Follick, M.J., Dean, L. Acomparative evaluation of a restrictive smoking policy in a general 

hospital. American Journal ofhblicHealth 79: 192-195, 1989a. 

Biener, L., Abrams, D.B., Emmons, K., Follick, M.J. Evaluating worksite smoking policies: Methodological issues. New 

York State Journal of Medicine 89: 5-10, 1989b. 

Blackburn, H., Pechacek, T. Smoking cessation and the 

Minnesota Heart Health Program. In: Proceedings ofthe Fiflh 

World Conference on Smoking and Health, Winnipeg, Canada, 

July 1984. 

Blum, A. Strategies to reduce cigarette sales: Excise taxes 

and beyond. Journal of the American Medical Association 255: 

1049-1050, 1986. 

Borland, R., Chapman, S., Owen, N., Hill, D. Effects of 

workplace smoking bans on cigarette consumption. American 

Journal of Public Health 80: 178-180, 1990. 

Bureau ofNational Affairs. Where There’s Smoke: Problems 

and Policies Concerning Smoking in the Workplace (2nd edition). 

Washington, DC: Bureau of National Affairs, 1987. 

BurtaineJ., Slade, J. The smoke-free hospital. New Jersey

Medicine 85: 143-145, 1988. 

Canadian Council on Smoking and Health. Tobacco Tax 

Policy in Canada. A Health Perspective, Ottawa: National Campaign for Action on Tobacco, January 1990. 

Centers for Disease Control. Passive smoking: Beliefs, attitudes, and exposures-United States, 1986. Morbidity and 

Mortality Weekly Report 37: 239-241, 1988. 

Centers for Disease Control. Trends in cigarette smokingWisconsin, 1950-1988. Morbidity and Mortality Weekly Report 

38(44): 752-754, 1989. 

Centers for Disease Control, Cigarette advertising-United 

States, 1988. Morbidity and Mortality Weekly Report 39(16):261-

265,1990a. 

Centers for Disease Control. State laws restricting minors 

access to tobacco. Morbidip and Mortality Weekly Report 39: 

349-353,1990b. 

Citizens for Tax Justice. Nickels and Dimes:How Sales and 

Excise Taxes Add Up in the 50 States. Washington, DC: Citizens 

for Tax Justice, March 1988. 

255 
National Cancer Institute 

Cleary, P.D., Hitchcock, J.L., Semmer, N., Flinchbaugh, 

L.J., Penney, J.M. Adolescent smoking: Research and health 

poky. Milbank Quarterly 66: 137-171, 1988. 

Colford, S.W. Ad-bashing is back in style. Adweek, 

April 30, 1990. 

Colorado Department of Health. Report ofthe Technical Advisory Committee on Tobacco and Health for CoZorado. Colorado 

Department of Health, July 1986. 

Coye, M.J. Preventing tobacco dependence: The New 

Jersey Commission on Smoking or Health. New Jersey Medicine 

85:151-155, 1988. 

Cummings, K.M., Kelly, J., Sciandra, R., DeLoughry, T., 

Francois, F. Impact of a community-wide stop smoking 

contest. American Journal of Health Promotion 4:429-434, 1990. 

Cummings, K.M., Sciandra, R. The public health benefit of 

increasing tobacco taxes in New York State. New York State 

Journal of Medicine April: 174-175, 1989. 

Cummings, K.M., Sciandra, R., Davis, S., Rimer, B. Response to 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 

ofPublicHealth 77(11): 1452-1453, 1987. 

Cummings, S.R., Rubin, S.M., Oster, G. The cost-effectiveness of counseling smokers to quit. Journal ofthe American 

Medical Association 261: 75-79, 1989. 

Dagnoli, J. Spoof ad gets da ax. Adweek, March 26, 1990, 

p. 45. 

Davis, R.M. Current trends in cigarette advertising and 

marketing. New England journal of Medicine 316(2): 725-732, 

1987. 

Davis, R.M. Health education on the six o’clock news. 

JoumaIof the American Medical Association 259: 1036-1038, 

1988a. 

Davis, R.M. Uniting physicians against smoking: The 

need for a coordinated national strategy. Journal ofthe American Medical Association 259: 2900-2901, 1988b. 

Davis, R.M. Tobacco Issues (Part I): Hearings Before the Subcommittee on Transportation and Hazardous Materials of the Committee on Energy and Commerce, House ofRepresentatives, One 

Hundred First Congress. Washington, DC: U.S.Government 

Printing Office, 1989,pp. 68-74(Serial No. 101-85). 

256 
Smoking and Tobacco Control Monograph No. 1 

Davis, R.M., Jason, L.A. The distribution of free cigarette 

samples to minors. American Journal of Preventive Medicine 4: 

21-26, 1988. 

DiFranza, J. Project “Bandit Buster.” University of Massachusetts Medical School, press release, September 6, 1989. 

DiFranza, J.R., Norwood, B.D., Garner, D.W., Tye, J.B. Legislative efforts to protect children from tobacco. Journalof the 

American Medical Association 257: 3387-3389, 1987. 

DiFranza, J.R., Tye, J.B. Who profits from tobacco sales to 

children? Journal of the American Medical Association 263: 2784- 

2787,1990. 

Doctors Ought to Care. Counter promotion-Tennis 

elbows tobacco company sponsorship at sports. DOC News and 

Views, Summer 1989,pp. 4-5. 

Emont, S.L., Cummings, K.M. Adoption of smoking 

policies by automobile dealerships. Public Health Reports 104: 

509-514,1989. 

Emont, S.L., Cummings, K.M. Worksite-level predictors of 

participation and cessation in a smoking control program. 

American Journal ofHealth Promotion (in press). 

Farquhar, J.W. The community-based model of lifestyle 

intervention trials. American Journal ofEpidemiology 108: 103- 

111,1978. 

Farquhar, J.W., Fortmann, S.P., Maccoby, N., Haskell, W.L., 

Williams, P.T., Flora, J.A., Taylor, C.D., Brown, B.W., Jr., Soloman, D.S., Hulley, S.D. The Stanford Five-City Project: Design 

and methods. American Journal of Epidemiology 122: 323-324, 

1985. 

Fielding,J.E. Health promotion and disease prevention at 

the worksite. Annual Reviews ofpublic Health 5:257-265, 1984. 

Fielding, J.F. Banning worksite smoking (editorial). American Journal ofpublic Health 76: 957-959, 1986. 

Flay, B.R. Psychosocial approaches to smoking prevention: 

A review of the findings. Health Psychology 4(5): 449-488, 1985. 

Flay, B.R. Selling the Smokeless Society: 56 Evaluated Mass 

Media Programs and Campaigns Worldwide. Washington, DC: 

American Public Health Association, 1987. 

Forster, J., Kunt-Inge, K., Jeffrey, R. Source of cigarettes for 

tenth graders in two Minnesota cities. Health Education Research 4:45-50, 1989. 

Freedman, A.M. Harmful habit: Cigarette smoking is 

growing hazardous to careers in business. Wall Street Journal, 

April 23, 1987, p. 1. 

257 
National Cancer Institute 

Fusfeld, D.R. Economics, Principles of Political Economy. 

Glenville, IL: Scott, Foresman, 1982. 

Glasgow, R.E. Assessment of smoking behavior in relation 

to worksite smoking policies. New York State Journal of Medicine 

89: 31-34, 1989. 

Glynn, T.J. Essential elements of school-based smoking 

prevention programs. Journal ofschool Health 59(5): 181-188, 

1989. 

Glynn, T.J., Manley, M.W., Pechacek, T.F. Physician- . 

initiated smoking cessation program: The National Cancer 

Institute trials. Progress in Clinical Biology Research 339: 11-25, 

1990. 

Godfrey, C., Maynard, A. Economic aspects of tobacco use 

and tobacco policy. British Medical Journal 297: 339-343, 1988. 

Gottlieb, N.H., Eriksen, M.P., Lovato, C.Y., Weinstein, R.P., 

Green, L.W. Impact of a restrictive work site smoking policy on 

smoking behavior, attitudes, and norms. Journal ofOccupationa1 

Medicine 32: 16-23, 1990. 

Grossman, M., Coate, D., Lewit, E. Economics and other 

factors in youth smoking. In: Teenage Smoking: Higher Excise 

Tax Should Significantly Reduce the Number of Smokers. Washington, DC: General Accounting Office, June 1989. GAO Publication No. HRD-89-119. 

Hagey, A. Implementation of a smoking policy in the 

United States Army. New York State Journal of Medicine 89(1): 42-

44, 1989. 

Hamilton, J.L. The demand for cigarettes: Advertising, the 

health scare, and the cigarette advertising ban. Review of Economics and Statistics 54: 401-411, 1972. 

Harris, J.E. On the fairness of cigarette excise taxation. In: 

The Cigarette Excise Tax. Cambridge, MA: Institute for the Study 

of Smoking Behavior and Policy, John F. Kennedy School of 

Government, Harvard University, 1985, p. 106. 

Harris, J.E. The 1983 increase in the Federal cigarette excise 

tax. In: Tux Policy and the Economy (volume l),L.H. Summers 

(Editor). Cambridge, MA: Massachusetts Institute of Technology Press, 1987, pp. 87-111. 

Harvey, L., Shubat, S. Public opinion on health care issues. 

In: AMA Surveys ofphysicians and Public Opinions on Health Care 

Issues, 1987. Chicago: American Medical Association, April 

1987. 

Hensley, T. Airplane smoking ban to expire; extension 

debated. Journal of the National Cancer Institute 81(16): 1213- 

1214,1989. 

258 
Smoking and Tobacco Control Monograph No. 1 

Hurt, R.D., Berge, K.G., Offord, K.P., Leonard, D.A., Gerlach, D.K., Larson-Renquist, C., O’Hara, M.R. The making of a 

smoke-free medical center. Journal of the American Medical 

Association 261: 95-97, 1989. 

Johnson, B. Anti-smoke torch flickers. Adweek, April 16, 

1990. 

Kahn, P.L. The Minnesota Clean Indoor Air Act: A model 

for New York and other states. New York State Journal ofMedicine 83(13): 1300-1301, 1983. 

King, A.C., Flora, J.A., Fortmann, S.P., Taylor, C.D. Smokers’ challenge: Immediate and long-term findings of a community cessation contest. American Journal ofPubZic Health 77: 

1340-1341, 1987. 

Knapp, J., Silvis, G., Sorenson, G., Kottke, T.E. Clean Air 

Health Care. Minneapolis, MN: Doctors Helping Smokers, University of Minnesota, 1986. 

Kottke, T.E., Battista, R.N., Defriese, G.H., Brekke, M.L. 

Attributes of successful smoking cessation interventions in 

medical practice. A meta-analysis of 39 controlled trials. 

Journal of the American Medical Association 259: 2883-2889, 

1988. 

Kottke, T.E., Hill, C., Brekke, M. Smoke-free hospitals: Attitudes of patients, employees, and faculty. Minnesota Medicine 

68:53-55, 1985. 

Kristein, M. How much can business expect to profit from 

smoking cessation? Preventive Medicine 12: 358-381, 1983. 

LaRosa, J.H., Haines, C.M. It’s Your Business: A Guide to 

Heart and Lung Health at the Workplace. U.S. Department of 

Health and Human Services; Health Education Branch; Office 

of Prevention, Education, and Control; National Heart, Lung, 

and Blood Institute. Publication No. (NIH) 86-2210,September 

1986. 

Lewit, E., Coate, D. The potential for using excise taxes to 

reduce smoking. Journal ofHealth Economics l(2): 121-145, 

1982. 

Lewit, E.M., Coate, D., Grossman, M. The effect of government regulation on teenage smoking. Journal ofLaw and Economics 24: 545-569, 1981. 

Mackay, J.M., Barnes, G.T. Effects of strong government 

measures against tobacco in Hong Kong. British Medical Journal 

292: 1435-1437, 1986. 

259 
National Cancer Institute 

Maine Department of Human Services. Smoking in Maine. 

A Report on the Health and Economic Consequences of Cigarette 

Smoking in Maine. Maine Department of Human Services, 

Bureau of Health, Division of Health Education, February 1983. 

Martin, M.J., Fehrenback, A., Rosner, R. Ban on smoking 

in industry (letter). New England Journal ofMedicine 215: 647- 

648,1986. 

Martin, M.J., Silverman, M.F.The San Francisco experience with regulation of smoking in the workplace: The first 

twelve months. American Journal ofPublic Health 76(5): 585- 

586,1986. 

McGuire, W.J.Public communication as a strategy for 

inducing health-promoting behavioral changes. Preventive 

Medicine 13:299-319,1984. 

McMahon, E.T., Taylor, P.A. Citizen’s Action Handbook on 

Alcohol and Tobacco Billboard Advertising. Washington, DC: 

Center for Science in the Public Interest and Scenic America, 

1990. 

Millar, W.J. Evaluation of the impact of smoking restrictions in a government work setting. Canadian Journal of Public 

Health 79: 379-382, 1988. 

Milio, N. Health policy and the emerging tobacco reality. 

Social Science and Medicine 21:603-613, 1985. 

Minnesota Department of Health. The Minnesota Plan for 

Nonsmoking and Health. Report and Recommendations of the 

Technical Advisory Committee on Nonsmoking and Health. Minneapolis: Minnesota Department of Health, 1984. 

Myers, M. Is there a legal right to smoke? (policy statement). Washington, DC: Tobacco-Free America Project, Legislative Clearinghouse, January 1990. 

Myers, M., HoIlar, J., Synar, M. Tobacco marketing and 

promotion. In: Tobacco Use in America Conference: Final Report 

and Recommendations from the Health Community to the lOlst 

Congress and the Bush Administration. Chicago: American 

Medical Association, 1989. 

Myers, M.L., Arnold, S.L. The Policy Implications of Involuntary Smoking as a Public Health Risk. Cambridge, MA: Institute 

for the Study of Smoking Behavior and Policy, Harvard University, May 1987. 

National Academy of Sciences. Environmental Tobacco 

Smoke: Measuring Exposures and Assessing Health Effects. Washington, DC: National Academy Press, 1986. 

260 
Smoking and Tobacco Control Monograph No. 1 

National Association of Insurance Commissioners. Resolution on financial incentives. December 1984. NAIC Proceedings 

1: 638, 1985. 

National Cancer Institute. Utilizing Physicians, Dentists, 

and Pharmacists as Health Exemplars to Help Smokers Quit-A 

Case Study. National Cancer Institute, Office of Cancer Communications, April 1982. 

National School Boards Association. No Smoking: A Board 

Member’s Guide to Nonsmoking Policies for the Schools. Alexandria, VA: National School Boards Association, June 1987. 

New Jersey Group Against Smoking Pollution. New Jersey 

GASP salutes New Jersey’s tobacco-free pharmacies. New Jersey

Medicine 85: 107, 1988. 

Newsweek. The kick-the-habit business. Corporations pay 

big money to help smokers quit. Newsweek, August 29, 1988. 

Noelle-Neuman, E. The spiral of silence: A theory of 

public opinion. Journal of Communication 24: 43-51, 1974. 

Office of the Inspector General. Youth Access to 

Cigarettes. OEI, 02-90-02310, May 1990. 

O’Keefe, M.T. The anti-smoking commercials: A study of 

television’s impact on behavior. Public Opinion Quarterly 35: 

242-248, 1971. 

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. 

Orleans, C.T., Shipley, R.H. Worksite smoking cessation 

initiatives: Review and recommendations. Addictive Behaviors 

7: 1-16, 1982. 

Pechacek, T. A randomized trial for smoking cessation. In: 

Smoking and Health, 1987. Proceedings of the Sixth World Conference on Smoking and Health, Tokyo, November 9-12, 1987. 

Pechacek, T., Mittelmark, M., Freutel, J., Pirie, P., Luepker, 

R., Blackburn, H. Promotion of community-wide smoking 

cessation. Circulation 72: 345, 1985. 

Pekurinen, M., Valtonen, H. Price, policy, and consumption of tobacco: The Finnish experience. Social Science and 

Medicine 25(8): 875-881, 1987. 

261 
National Cancer Institute 

Pennsylvania Plan for Tobacco or Health. Pennsylvania

Consensus Conference on Tobacco and Health Priorities. Pennsylvania Department of Health, Pennsylvania Interagency Council 

on Tobacco and Health, Statewide Coordinating Council, 1986. 

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

Public Health Service, National Institutes of Health, National 

Cancer Institute. NIH Publication No. 90-479, 1989. 

Peterson, D.J., Massengill, D. Smoking regulations in the 

workplace: An update. Personnel (May): 27-31, 1986. 

Phillips, D. 48-State airline smoking ban nears reality. 

Washington Post, February 21, 1990, pp. Al, A4. 

Richards, J.W., Blum, A. Pharmacists who dispense cigarettes: With reference to drug store chains and pharmaceutical 

companies. New York State Journal of Medicine 85: 350-353, 

1985. 

Rigotti, N.A. Trends in the adoption of smoking restrictions in public places and worksites. New York State Journal of 

Medicine 89(1): 19-26, 1989. 

Rosen, G.M., Lichtenstein, E. An employee incentive 

program to reduce cigarette smoking. Journal of Consulting and 

Clinical Psychology45: 957, 1977. 

Rosenstock, I.M., Stergachis, A., Heaney, C. Evaluation of 

smoking prohibition policy in a health maintenance 

organization. American Journal ofPublic Health 76: 1014-1015, 

1986. 

Rothman, J. Three models of community organization 

practice. In: Strategies of Community Organization. Itasca, IL: 

Peacock, 1979, pp. 86-102. 

SCARCNET. Smoking Control Advocacy Resource Center. 

Washington, DC: The Advocacy Institute, 1990. 

Schwartz,J.L. Review and Evaluation of Smoking Cessation 

Methods: United States and Canada, 1978-1985. U.S. Department of Health and Human Services, Public Health Service, 

National Institutes of Health, National Cancer Institute. Publication No. (NIH) 87-2940, April 1987. 

Skretny, M.T., Cummings, K.M., Sciandra, R., Marshall, J. 

An intervention to reduce the sale of cigarettes to minors. New 

York State Journal ofMedicine 91: 54-55, 1990. 

262 
Smoking and Tobacco Control Monograph No. 1 

Sorensen, G., Pechacek, T.F. Implementing nonsmoking 

policies in the private sector and assessing their effects. New 

York State Journal ofMedicine 89:11-15,1989. 

Steinfeld,J.L. 11. The public’s responsibilty: A bill of rights 

for the non-smoker. Rhode Island Medical Journal 55(4): 124- 

126,138,1972. 

Stillman, F.A., Becker, D.M., Swank, R.T., Hantula, D., 

Moses, H., Glantz, S., Waranch, H.R. Ending smoking at the 

Johns Hopkins Medical Institutions: An evaluation of smoking 

prevalence and indoor air pollution. Journalof the American 

Medical Association 264: 1565-1569, 1990. 

Sussman, S., Pentz, M., Hahn, G. The relationship of a 

worksite no-smoking policy to employee smoking behavior and 

attitudes. In: Advances in Cancer Control VII. New York: Alan 

R. Liss, in press. 

Swart, J.C. Corporate smoking policies: Today and 

tomorrow. Personnel: August: 61-66, 1988. 

Tobacco-Free America. State Legislated Actions on Tobacco 

Issues. Washington, DC: Tobacco-Free America, 1990. 

Tobacco Institute. The Tax Burden on Tobacco: Historical 

Compilation (volume 25). Washington, DC: Tobacco Institute, 

1990. 

Tobacco and Youth Reporter. Ending tobacco sales to 

teens. Tobacco and Youth Reporter 4(2):5, 1989a. 

Tobacco and Youth Reporter. Vending machines must go. 

Tobacco and Youth Reporter 4(2):7, 1989b. 

Toder, E.J. Issues in the taxation of cigarettes. In: The 

Cigarette Excise Tax. Cambridge, MA: Institute for the Study of 

Smoking Behavior and Policy, John F. Kennedy School of Government, Harvard University, 1985,p. 3. 

Townsend, J. Cigarette tax, economic welfare and social 

class patterns of smoking. Applied Economics 19: 355-365, 1987. 

Tye, J., Warner, K., Glantz, S. Tobacco advertising and 

consumption: Evidence of a causal relationship. Journalof 

Public Health Policy 8(4): 492-508, 1987. 

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

Health Consequences of Smoking: Cancer and Chronic Lung 

Disease in the Workplace. A Report of the Surgeon General. U.S. 

Department of Health and Human Services, Public Health Service, Office on Smoking and Health. Publication No. (PHS) 85-

50207,1985. 

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

Health Consequences of Involuntary Smoking: A Report of the 

263 
National Cancer Institute 

Surgeon General. U.S. Department of Health and Human 

Services, Public Health Service, Centers for Disease Control. 

Publication No. (CDC) 87-8398, 1986. 

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

the Health Consequences of Smoking: 25 Years of Progress. A Report

ofthe Surgeon General. US.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. DHHS Publication No. (CDC) 

89-8411,1989a. 

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

Strategies for Smoking Control: Guidelines. U.S. Department of 

Health and Human Services, National Cancer Institute. Publication No. (NIH) 89-3013, 1989b. 

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

Programs Workbook. Prepared for Community Intervention 

Trial for Smoking Cessation (COMMIT). U.S. Department of 

Health and Human Services, National Institutes of Health, 

National Cancer Institute, 1989c. 

U.S. Department of Health, Education, and Welfare. The 

Health Consequences of Smoking: A Report of the Surgeon General, 

1972. U.S.Department of Health, Education, and Welfare; 

Public Health Service; Health Services and Mental Health Administration. DHEW Publication No. (HSM) 72-7516, 1972. 

U.S. Department of Health, Education, and Welfare. The 

Health Consequences ofSrnoking. U.S. Department of Health, 

Education, and Welfare; Public Health Service; Office of the Assistant Secretary for Health; Center for Disease Control. DHEW 

Publication No. (PHS) 75-8704, 1975. 

U.S. Department of Health, Education, and Welfare. 

Smoking and Health: A Report of the Surgeon General. U.S. Department of Health, Education, and Welfare; Public Health 

Service; Office of the Assistant Secretary for Health; Office on 

Smoking and Health. DHEW Publication No. (PHS) 79-50066, 

1979, 

U.S. Environmental Protection Agency. Health Effects of 

Passive Smoking: Lung Cancer in Adults and Respiratory Disorders 

in Children (in press). 

U.S. General Accounting Office. Teenage Smoking. Higher 

Excise Tax Should Significantly Reduce the Number of Smokers. 

Washington, DC: General Accounting Office, GAO Publication 

No. HRD-89-119. June 1989. 

Wallack, L.M. Mass media campaigns: The odds against 

finding behavior change. Health Education Quarterly 8: 209-260, 

1981. 

264 
Smoking and Tobacco Control Monograph No. 1 

Wallack, L.M. Social marketing and media advocacy: Two 

approaches to health promotion. World Health Forum 11:143-

154,1990. 

Walsh, D.C., Gordon, N.P. Legal approaches to smoking 

deterrence. Annual Review of Public Health 7: 127-149, 1986. 

Walsh, D.C., McDougall, V. Current policies regarding 

smoking in the workplace. American Journal of Industrial Medicine 13: 181-190, 1988. 

Walsh, D.C., Gordon, N.P. Legal approaches to smoking 

deterrence. Annual Review ofpublic Health 7: 127-149, 1986. 

Warner, K. Selling Smoke: Cigarette Advertising and Public 

Health. Washington, DC: American Public Health Association, 

October 1986a. 

Warner, K.E. The effects of the anti-smoking campaign on 

cigarette consumption. American Journal ofPublic Health 67: 

645 -650,19 77. 

Warner, K.E. State legislation on smoking and health: A 

comparison of twopolicies. Policy Sciences 13: 139-152, 1981. 

Warner, K.E. Cigarette advertising and media coverage of 

smoking and health. New England Journal of Medicine 312: 384- 

388,1985. 

Warner, K.E. Smoking and health implications of a 

change in the Federal cigarette excise tax. Journal of the American Medical Association 255(8): 1028-1032, 1986b. 

Warner, K.E. The tobacco subsidy: Does it matter? Journal 

of the National Cancer Institute 80: 81-83, 1988. 

Warner, K.E. Effects of the anti-smoking campaign: An 

update. American Journal ofPublic Health 79: 144-151, 1989. 

Warner, K.E., Ernster, V.L., Holbrook, J.H., Lewit, E.M., 

Pertschuk, M., Steinfeld, J.L., Whelan, E.M. Public policy on 

smoking and health: Toward a smoke-free generation by the 

year 2000. Circulation 73: 381a-395af 1986. 

Whelan, E.M. A Smoking Gun. How the TobaccoIndustry 

Gets Away WithMurder. Philadelphia: George F. Stickley, 1984. 

Whiteside, T. Selling Death: Cigarette Advertising and Public 

Health. New York: Liveright, 1971. 

Winslow, R. Will firms shift costs to smokers? Wall Street 

Journal, March 6, 1990. 

Wrightman, L.S. Social Psychology (2nd edition). Monterey, CA: Brooks/Cole Publishing, 1977. 

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Chapter 6 

Interdependence and synergy 

Among Smoking Control Activities 

CONTENTS Introduction .......................................................................... 269 

Conceptual Framework ......................................................... 270 

Studies of Environmental Change ........................................ 272 

Synergistic Effects Among Selected Interventions ................272 

Media Coverage of Antitobacco Activities ..................... 273 

Worksite Policies for Smoking Control ......................... 274 

Physician Actions for Tobacco Control ......................... 275 

Current Intervention Research ...................................... 276 

Approaches to Tobacco Companies’ Targets ........................ 276 

Smoking Among Women .............................................. 277 

Smoking Among Blacks ................................................. 278 

Smoking Among Hispanics ............................................ 285 

Conclusions........................................................................... 289 

References.............................................................................. 290 

267 
BLANK PAGE 
Chapter 6 

Interdependence and Synergy 

Among Smoking Control Activities 

INTRODUCTION Efforts to control tobacco use have employed a wide range 

of tactics and techniques to reduce the prevalence of smoking. 

Traditional approaches to smoking control have focused on the 

individual, with less attention to the broad social context 

within which the individual acts. 

More recently, a number of researchers have recognized 

that local values, norms, and behavior patterns are significant 

in shaping an individual’s attitudes and behaviors (Abrams et 

al., 1986; Farquhar et al., 1977; McAlister et al., 1982; Puska et 

al., 1985). Rather than emphasizing changes by individuals, 

the newer approach argues that permanent, large-scale behavioral change is best achieved through changing standards of 

acceptable behavior; that is, through adoption of different 

norms for health-related behavior (Abrams et al., 1986; Farquhar, 1978; Farquhar et al., 1985a; Syme and Alcalay, 1982; 

Van Parijs and Eckhardt, 1984). 

In the past 15 years, a number of major health-promotion 

initiatives have used a community approach to change behavior (Abrams et al., 1986; Elder et al., 1986; Farquhar et al, 

1985b; McAlister et al., 1982; Mittelmark et al., 1986; Puska et 

al., 1985; Tarlov et al., 1987). Most of these efforts addressed 

multiple risk factors in cardiovascular disease, with goals of 

changing individual subjects’ behavior with regard to smoking, 

diet, and screening for health problems. The majority of such 

projects reflected the need to change the social context of their 

communities, recognizing that the environment has a significant role in facilitating or inhibiting the adoption of new 

behaviors (Farquhar et al., 1977; Farquhar et al., 1985b; McAlister et al., 1982; Puska et al., 1985). Some researchers also have 

discussed the importance of changing community norms. 

Planning interventions that capitalize on the inherent interdependence and synergy of a system is likely to yield a maximum 

effect. 

In this chapter, (1)a conceptual framework for a comprehensive, synergistic approach to smoking control is presented;

(2) pertinent data in support of such an approach are reviewed; 

(3) examples are presented to illustrate how interventions have 

built and can build on the interdependence and synergy 

269 
CONCEPTUAL 

FRAMEWORK 

National Cancer Institute 

among them; and (4) synergistic approaches for three specific 

target populations-women, black Americans, and Hispanic 

Americans-are reviewed. 

Individuals do not act in a vacuum; rather, they are greatly 

influenced by the social environment in which they act. A 

smoker often responds to environmental cues when deciding 

to smoke or not smoke. For instance, a work break, the end of 

a meal, and exiting from a no-smoking faciIity are situations 

that provide the smoker with cues to smoke; while attending a 

religious service and working in designated no-smoking areas 

are examples of cues that inhibit the smoker’s behavior. Many 

cues have their origins in rules about acceptable behaviorsnorms (Robertson, 1977). Changing the environment that 

surrounds the smoker involves changing the prevailing norms. 

In concept, the social environment may be considered a 

system with related and interdependent parts that serve to 

maintain the whole. The system includes many components, 

or subsystems, that carry out the activities required to keep the 

system viable; among these subsystems are the political, 

economic, and educational institutions that ensure governance 

of, resources for, and socialization into the system. The system 

is not a simple aggregation of its component parts; rather, it is 

a unique structure that includes all the parts and the interdependencies that connect the parts (von Bertalanffy, 1962). The 

system also provides the context for all activities, including 

making choices about behaviors. The social environment 

system is based on some degree of cooperation and consensus 

on social norms (Ashby, 1958; Boulding, 1978), and individuals 

generally act within the parameters of the system. 

Social norms change aIong with the system to provide new 

rules of conduct to help maintain the reformed system 

(Robertson, 1977). An example of this can be seen in the 

emerging norms related to tobacco use. Technical changesrecognition of the dangers of smoking cigarettes and of inhaling secondhand smoke-have led to restrictions on public 

smoking, and as this secular trend accelerates, smokers find it is 

no longer appropriate to light up in all settings. 

Factors that promote continued tobacco use are still found 

at many levels in the system, though. The political subsystem 

provides price supports for tobacco growers and thus affects the 

economic subsystem. Together, the political and economic 

subsystems contribute to the development of public and 

private resources that expand the tobacco industry’s capability 

to further promote its products. In addition, tobacco industry 

representatives are adept at using the communication subsystem to relay messages that promote acceptability for tobacco 

use (Leventhal et al., 1987; Tye et al., 1987; Warner, 1986a; 

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White, 1988). An important factor is the addictive nature of 

tobacco (US DHHS, 1988), which helps to maintain a high level 

of demand for the product. 

Conversely, there are system factors that inhibit the use of 

tobacco. The political sector has publicly endorsed and supported some restrictions on certain tobacco industry activities, 

most notably in the area of distribution and promotion of 

products to minors (DiFranza et al., 1987; Tobacco-Free America Project, 1988; US DHHS, 1989). Excise taxes on tobacco 

products have some effect in the economic sector. When 

cigarette taxes are portrayed as “sin” taxes (Harris, 1982; 

Tobacco Institute, 1988), a message about smoking behavior is 

disseminated through the system. The economics of such taxation also may affect the prevalence of smoking: estimates 

indicate a drop of about 2 percentage points in the prevalence 

of adult smoking for every 8-cent increase per package of 

cigarettes (Harris, 1982; Lewit and Coate, 1982; Warner, 

1986b). Another subsystem, the scientific sector, has published 

thousands of studies linking ill effects to tobacco use, thereby 

providing yet another force against smoking. 

The net environmental effect of the forces influencing 

tobacco use has been a gradual move away from the free use of 

tobacco and toward restrictions on its use. In the past 20 years, 

tobacco advertising has been restricted to media other than 

radio and television (Whiteside, 1971); 41 states have implemented restrictions on smoking in public places (US DHHS, 

1986);all states have enacted cigarette taxes (US DHHS, 1989); 

and many other restrictions on tobacco sales and use have 

been legislated (Pertschuk and Shopland, 1989). 

There is little doubt that environmental changes have an 

effect on the smoking habits of individuals. The 1964 Surgeon 

General’s Report, for example, led to a significant change in 

smoking prevalence (US DHEW, 1964; Warner, 1985). A 

similar effect was seen when the Federal Communications 

Commission required “equal time” for antismoking messages 

on radio and TVto match the time allotted for cigarette commercials (Warner, 1985). “Clean air” laws, enacted recently 

around the country, also may have had an effect on prevalence 

as smokers find it more difficult to smoke in public places. 

As the forces working toward restrictions on tobacco use 

multiply, a type of synergy-beneficial cooperation among 

various sectors of the system-develops. To the extent that 

relations among the sectors are harmonious and oriented 

toward a common goal, the synergy that develops produces a 

net effect of the combined forces that is greater than the sum 

271 
STUDIES OF 

ENVIRONMENTAL 

CHANGE 

SYNERGISTIC 

EFFECTS AMONG 

SELECTED 

INTERVENTIONS 

National Cancer Institute 

of their separate effects. Ultimately, the synergy of multiple

forces supporting tobacco restrictions should lead to a societal 

norm in which tobacco use is not acceptable. 

Empirical research addressing how various changes in 

tobacco control relate to the social environment and to the 

prevalence of tobacco use has been largely retrospective and 

observational. Few experiments have been conducted in which 

the multiple social forces that promote tobacco restrictions 

have been manipulated. 

The Stanford Three-Community Study (Farquhar et al., 

1977) used the communication sector (media) to deliver 

messages about smoking cessation. Although success was 

limited, there appeared to be some synergy between the media 

messages and intensive assistance with smoking cessation 

provided to individuals at high risk for cardiovascular disease 

(Meyer et al., 1980). In another community, media messages 

alone were used, and the observed effect was not significantly 

greater than the change seen in a control community that 

received neither media messages nor face-to-face intervention 

(Farquhar et al., 1981). 

Investigators of the Australian North Coast study found 

significant smoking reduction among all smokers through a 

combination of media programs with community programs 

(Egger et al., 1983); again, that effect was not seen in a community that received only media interventions. Similarly, the 

Finnish North Karelia Project showed a significantly greater 

decrease in smoking in a community that received multichannel stop-smoking activities than in a control community that 

received no intervention (Puska et al., 1983). A Swiss national 

study used media, public policy changes, and a community 

organization approach to achieve significantIy higher rates of 

smoking cessation in intervention communities than in the 

control communities (Gutzwiller and Schweizer, 1983). Three. 

ongoing community studies-the Minnesota Heart Health 

Project (Jacobs et al., 1986),the Pawtucket Heart Health Program (Elder et al., 1986),and the Stanford Five-City Project 

(Farquhar et al., 1985)-are projects similar to those above; 

however, their results have not yet been reported. 

Additional examples of the effectiveness of multiple intervention subsystems and the effects of synergy can be seen in at 

least three specific areas: media coverage of antitobacco events, 

policy changes at worksites, and antismoking messages conveyed by physicians. The following paragraphs briefly describe 

the interactions and interdependencies that lead to a presumably synergistic result. 

272 
Smoking and Tobacco Control Monograph No. 1 

Media Coverage 

Of Antitobacco 

Activities 

Several advocacy techniques have been used in efforts to 

obtain media coverage of antitobacco events in two major 

areas: promotional activities and cessation activities. A small 

but influential group of advocates has developed simple techniques to attempt to gain media attention. A common tactic is 

to borrow some aspect of a prosmoking promotion and endow 

it with an antismoking message; for example, the “Emphysema 

Slims” tennis tournament was hosted to counter a “Virginia 

Slims” tournament (US DHHS, 1988). Similarly, the media are 

attracted to conflicts. In a “monster truck” rally, one of the 

drivers chose to decorate her truck with no-smoking symbols; 

she was prevented from driving her decorated truck because 

the event was sponsored by a tobacco company (Doctors 

Ought to Care, 1990). 

The media also respond to the positioning of an issue 

around another extant issue. Several recent news events, for 

example, were amenable to reframing in terms of tobacco information. When cyanide was found in Chilean grapes in 

March 1989, news releases related the fact that cyanide is 

present in tobacco smoke (DeNelsky, 1989). Advocates of 

smoking control also noted the apparent contradiction in a 

tobacco company’s support of a dance troupe (Smoking Control Advocacy Resource Center, 1989). Similarly, a number of 

editorials pointed out that the amount of benzene in Perrier 

water taken off the market was only a fraction of the amount 

of benzene in tobacco (Smoking Control Advocacy Resource 

Center, 1990). 

It is difficult to determine whether such media coverage 

has any effect on smokers. It is likely, however, that such 

coverage reinforces and helps to solidify a nonsmoking norm 

that already has substantial support. 

It is easier to draw conclusions from media coverage of 

cessation activities. Some investigators (Bettinghaus, 1988; 

Flay, 1987) have examined the efficacy of media promotions 

for use of a smoking cessation hotline (Anderson et al., 1989), 

use of self-help cessation materials (Jason et al., 1988), and participation in other smoking cessation programs (Cummings, 

1987; Danaher et al., 1984). Although the results vary, there is 

a strong trend for increased participation in smoking cessation 

activities when media messages are available; similarly, evidence suggests that smokers are more likely to stop smoking 

when the two activities are combined than when each activity 

is presented alone (Flay, 1987). 

Media control and smoking control activities are interdependent in that media cannot operate without activities and 

events to cover, and cessation activities and motivation messages to stop smoking make significant news only rarely (e.g., 

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Workslte Policies 

For Smoking 

Control 

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when new research findings are released). When tobaccorelated issues are framed in a newsworthy manner, both media 

and smoking control groups benefit. Furthermore, smokers 

benefit because they are made aware not only of their habit 

and the opportunity for changing that habit but also of the 

ways in which they are manipulated into tobacco use. Such 

insights may motivate them to look more carefully at their 

smoking. 

Over time, the antismoking messages may be adopted into 

the normative structure of society, and notions about the impropriety of tobacco vendors’ promoting cultural, political, 

sporting, and other events will become norms. 

Restrictive smoking policies are being implemented increasingly in both public and private workplaces. All Federal 

workplaces are now subject to poIicies that restrict smoking to 

designated areas (US DHHS, 1989). In addition, 31 states have 

laws restricting smoking in public workplaces, and many other 

states have similar restrictions through executive actions (US 

DHHS, 1989). The numbers are equally impressive for private 

workplaces: almost 300 cities and counties have mandated 

formal policies about smoking in public and private 

workplaces. Surveys reported in 1986 (Bureau of National 

Affairs) and 1987 (US DHHS) placed the prevalence of restrictive smoking policies in private workplaces at 30 percent and 

rising rapidly, since the majority of workplaces surveyed that 

did not have a policy had at least a plan to institute one in the 

near future (US DHHS, 1986 and 1989). 

The effect of worksite smoking policies on the attitudes of 

smoking employees provides important information on the acceptance or nonacceptance of this normative change. Results 

from a number of studies (Brown et al., 1988; Thompson et al., 

1987; US DHHS,1987) showed that smokers as well as nonsmokers responded well to smoking restrictions at work. Both 

groups reacted more favorably to the policy after it was implemented than before (Petersen et al., 1988; Rigotti et al., 1986; 

Rosenstock et al., 1986), suggesting that conversion to the new 

norm was accomplished easily. 

Although data are somewhat equivocal, experts are becoming more convinced that worksite smoking policies have some 

effects on employees’ smoking (Petersen et aI., 1988; Rosenstock et al., 1986). Studies of employee participation in 

workplace smoking cessation programs that are offered along 

with implementation of a smoking control policy indicate that, 

for at least some workplaces, policy implementation increases 

enrollment in cessation activities (Martin, 1982; Walsh and 

McDougall, 1988). 

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Physician Actions 

For Tobacco 

Control 

The interdependence of worksite policies and smoking cessation activities is clear: when workplace policies restrict 

smoking, smokers will reduce the amount they smoke during 

the workday. Employers benefit in the long run by increased 

productivity and decreased costs for cleaning and insurance. 

Nonsmoking employees benefit by reduced exposure to environmental tobacco smoke, whereas smokers benefit in terms of 

health (if they achieve cessation) and support in stopping their 

habit, Where restricted smoking policies are implemented, 

worksite norms are likely to change to advocate nonsmoking, 

thus offering smokers an ongoing incentive to quit and to stay 

abstinent. 

The synergistic effect between worksite policies and the 

smoker is that the employer action may propel the smoker 

toward cessation. Nonsmoking employees are also likely to 

support nonsmoking and may provide repeated and continuing impetus for smokers to quit. Smokers may benefit because 

some of the cues for smoking are controlled, making it easier 

for them to avoid the practice. Over time, the new nonsmoking norm may become entrenched in the workplace, providing 

smokers with yet another prompt to stop smoking. 

Physicians have regular, recurring opportunities to offer 

smoking cessation messages to their patients, because most 

smokers (70 percent) visit a physician annually (Ockene, 1987). 

Smokers listen to their physicians, and a sizeable number of 

smokers report that their physicians have advised them to stop 

smoking (Ockene et al., 1987). 

The advice of a physician is particularly effective when it is 

part of a general office system that provides regular messages 

about quitting smoking and offers assistance with cessation 

efforts (Ockene, 1987; Wilson et al., 1987). Chart identification, use of an office coordinator who asks about smoking 

status, and a regular plan for advising the patient on the 

specifics of smoking cessation are more effective in helping 

patients achieve cessation than simply asking about smoking. 

The regular physician messages may be enhanced also by the 

environment of health care offices: a no-smoking office policy, 

amplified by posters, cessation information, and other cues €or 

nonsmokhg, provide strong normative support for cessation. 

In addition to physicians’ having an ability to affect individual smokers, they are powerful lobbyists for smoking control activities. Through their professional associations (American Medical Association, American Academy of Family Physicians, and others), physicians present a formidable lobby to 

persuade policymakers to control the use of tobacco. Historically, the professional associations have worked toward tobacco 

275 
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Intervention 

Research 

APPROACHES TO 

TOBACCO 

COMPANIES’ 

TARGETS 

National Cancer Institute 

control in a number of areas, especially in smoke-free environments and control of advertising directed to youth. Physician 

organizations such as Doctors Ought to Care provide regular 

lobbying at the national, state, and local levels to restrict 

tobacco use. 

As with the other examples, the synergistic effect of physicians’ messages and other smoking control activities is found 

in the repeated and pervasive messages to smokers to modify 

their behavior. In addition, the health care environment for 

the smoker promotes nonsmoking as the acceptable behavior. 

In each of the three examples above, there appears to be 

an interdependence and synergy between the sector employed 

for control of tobacco use and the other societal subsystems. In 

addition, each sector seems to be contributing toward the development of increasingly stronger nonsmoking norms. Although empirical substantiation for such assertions is weak, a 

number of current research efforts in smoking control (for 

example, the Community Intervention Trial for Smoking 

Cessation [COMMITJ and the American Stop Smoking Intervention Study for Cancer Prevention [ASSIST]) are expecting 

synergy in planning interventions, and they may provide more 

information on the empirical validity of this approach. 

While the overall prevalence of smoking has gone down 

significantly over the past 20 years, the prevalence is still high 

among those in our society who are most disadvantagedwomen of all races, black people, and Hispanics who have the 

lowest education leve1 and incomes. This is not accidental. 

The cigarette industry spends $2.5 billion per year to convince 

minority groups, women, and young people that nicotine-an 

addictive drug-is their ticket to “elegance, power, confidence, 

maturity, and desirability” (Tuckson, 1989). Tobacco companies spend $1.4million per year on advertising in Hispanic 

communities, and in black communities they spend $5 million 

per year on billboards alone (Davis, 1987). Surveys in lowincome communities have shown that they are saturated with 

billboards promoting cigarettes (Tuckson, 1989). 

The presence of the tobacco industry in the lives of minorities and women of all races goes well beyond advertising. 

The industry is an important funder of minority organizations, 

publications, and events, and it has even managed to ally itself 

with civil rights issues by equating freedom to smoke with the 

civil freedoms guaranteed by the Bill of Rights. The National 

Cancer Institute has funded projects that aim directly at these 

groups, and communities are beginning to build coalitions to 

combat the cigarette companies when their targeting of particular populations becomes apparent. 

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Smoking and Tobacco Control Monograph No. 1 

Following are discussions of the magnitude of the problem 

for each of three groups (women, blacks, and Hispanics), as 

well as a consideration of barriers that racial minority groups 

and women must confront in smoking cessation. 

Smoking Among

Women 

Magnitude of the 

Problem 

Barriers to 

Smoking Cessation 

Before World War 11, smoking was primarily a male’ behavior. In the late 1930’s and 1940’s, women began to take up 

cigarette use until the prevalence of smoking among women 

peaked at 32 percent from the mid-sixties to the mid-seventies 

(US DHHS, 1989). Since that time, smoking rates have declined for both sexes, but the rate of decline among women has 

been slower than that among men. In 1986, 28 percent of 

adult women smoked compared with 33 percent of adult men 

(Morbidity and Mortality Weekly Report, 1987). If the differential rate of decline among men and women continues, by the 

end of the century more women than men may be smokers. 

While fewer males have taken up smoking in recent years, 

the rate of initiation has remained fairly constant among 

females (Fiore et al., 1989). The situation among disadvantaged women, however, is even worse. From 1979 to 1985, the 

smoking prevalence among women who were less educated 

and had lower socioeconomic status (SES)actually increased 

from 40 percent to 44 percent. 

Women tend to underestimate the health risks that they 

incur because of cigarette smoking (Sorenson and Pechacek, 

1987). It has been speculated that the more rapid decline in 

smoking among men relative to women in the 1960’s was due 

to the Surgeon General’s Report linking smoking with lung 

cancer and heart disease. At the time, these diseases were seen 

as more relevant for men than for women. Since that time, the 

disease rates for women have increased markedly. While 

mortality from breast cancer has not changed in recent years, 

mortality from lung cancer among women has risen dramatically. Lung cancer now exceeds breast cancer as the largest 

cause of cancer deaths among women (American Cancer 

Society, 1990). 

Concern about physical appearance may be another barrier 

to smoking cessation by women. Quitting smoking is often accompanied by significant weight gain (Rodin and Wack, 1984), 

and women are more likely than men to report that fear of 

weight gain keeps them from giving up cigarettes (US DHHS, 

1980; Waldron, 1988). 

Female adolescents who smoke have been shown to be 

more self-confident, socially skilled, and outgoing than those 

who do not. Girls seem to adopt smoking not because they are 

pressured to, but because they seek to identify themselves as independent, successful, and glamorous-precisely the image 

277 
Channels for 

Reaching Women 

Content of Messages 

SmokingAmong 

Blacks 

Magnitude of the 

Problem 

National Cancer Institute 

projected by cigarette advertisers. Finally, smoking is one of 

the significant ways that women cope with stress, particularly 

the stress of being a mother of small children (Biener, 1987). 

The health care system is a good channel for smoking cessation efforts, as women tend to be high utilizers of health 

services. The fact that many women quit smoking during 

pregnancy suggests that the prenatal period provides a good 

opportunity for intervention. Public health clinics and neighborhood health centers that serve disadvantaged groups should 

make a special effort to convey the importance of quitting to 

their clients. 

There are many magazines directed to women specifically. 

Counteradvertising (Le., advertising designed to undermine the 

goals of tobacco advertising) in such magazines and/or convincing them to refuse to advertise cigarettes would reduce the 

association between attractiveness and smoking that is so 

prevalent in the media. At least two magazines, Ms.and Good 

Housekeeping,refuse to take cigarette advertisements. When 

tobacco companies are found to be targeting women, as in the 

recently revealed campaign to market Dakota cigarettes to a 

specific subgroup of women, influential groups such as the 

National Organization of Women may be willing to mobilize 

to counter the tobacco industry’s promotional activity. 

Many supermarkets and food stores have become involved 

in efforts to promote healthy choices by labeling foods that are 

low in cholesterol and/or high in fiber. These stores are often 

willing to disseminate information about the health risks of 

smoking (Hunkeler, et al., 1990). Efforts could be made by 

community organizers to discourage sales of cigarettes by food 

stores and sales of cigarettes to minors. 

Three messages about smoking may be particularly relevant in campaigns directed to women: (1)smoking is as much 

of a health risk for women as it is for men; (2) quitting smoking promotes the health of children; and (3) the possibility of 

being slimmer is not important enough to risk the health 

dangers of smoking. Messages about how to acquire social 

support from family members, friends, and coworkers may also 

help women to quit smoking. 

Black Americans have the highest smoking prevalence 

rates: 35.4 percent of black adults smoke-40.6 percent of 

black men and 31.5 percent of black women (Fiore et al., 1989; 

US DHHS,1988). Blacks suffer the Nation’s highest rates of 

morbidity and mortality from smoking-related diseases, including cardiovascular disease and lung cancer (Cooper and Simmons, 1985; US DHHS,1985 and 1988). Cigarette smoking is a 

major contributor to the short life expectancy of inner-city 

black men (McCord and Freeman, 1990; Rivo et al., 1989). 

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Smoking and Tobacco Control Monograph No. 1 

Sociodemographic factors associated with smoking among 

black people are similar to those for the U.S. population as a 

whole. They include lower income, less education, blue-collar 

occupations, unemployment, male gender, and unmarried 

status (Orleans et al., 1989b; US DHHS, 1988; Warnecke et al., 

1978.) 

Although the rate of smoking initiation is decreasing, and 

the ratio of quitting is increasing at similar rates for blacks and 

whites, blacks currently have a lower quit ratio (defined as the 

proportion of smokers who have quit). Quit ratio estimates 

range from 32.9 percent to 38.8 percent for blacks and from 

47.1 percent to 49.3 percent for whites (Fiore et al., 1989; US 

DHHS, 1990). Past survey data suggest that black smokers may 

try to quit as often as whites, but they succeed less often (US

DHHS, 1985). 

Among blacks, several high-risk groups deserve special attention: (1)black women, because of the unique risks associated with smoking during childbearing years, and because their 

smoking rate is declining more slowly than that of black men 

(Fiore et al., 1989; Marcus and Crane, 1987); (2)smokers with 

less than a high school education because they are quitting at 

the slowest rates (Pierce et al., 1989); and (3) black men in bluecollar and service occupations because their smoking rates may 

exceed 50 percent (US DHHS, 1985). Special efforts are needed 

also to reach the chronically unemployed, who have high rates 

of smoking and may not be active in church and community 

groups (Lemann, 1986). 

Barriers to For black people, barriers to quitting smoking include 

Smoking Cessation reliance on cigarettes as a way of coping with the life stress and 

social disadvantage related to low SES and pervasive discrimination, limited access to health care in general and to smokingrelated services and resources in particular, and limited confidence in their ability to quit (Hunkeler et al., 1990). A study of 

smoking among black people in Richmond, California, showed 

that more than 90 percent knew that smoking was harmful to 

health, but only 27 percent thought they could quit within the 

year (Hunkeler et al., 1990). Norms in black communities may 

actually encourage smoking. Many blacks regard other problems such as drugs, unemployment, and crime as having a 

higher priority than smoking. Powerful advertising tailored to 

black consumers not only glamorizes and legitimizes smoking 

but also downplays the health risks (Blum, 1989). 

Fewer blacks (54 percent) than whites (70 percent) report a 

physician’s office as their usual source of care. Twice as many 

blacks as whites say they receive their regular medical care from 

hospitals, public health clinics, and emergency rooms. Fewer 

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Channels for Reaching 

Black Smokers 

National CancerInstitute 

blacks than whites receive medical advice to stop smoking 

(Marcus and Crane, 1987; US DHHS, 1985). 

Stronger smoking norms and tobacco advertising influences in black communities help to sustain a high smoking 

rate. Black-targeted tobacco advertising has become increasingly predatory and pervasive. The tactics include extensive 

cigarette advertising in black print media; increased billboard 

and point-of-purchase cigarette advertising in inner-city

neighborhoods; tobacco company sponsorship of sports, civic 

events, and entertainment and cultural events important to the 

black community; and well-publicized philanthropic support of 

black causes and organizations (Blum, 1989; Cummings et al., 

1987; Tuckson, 1989). 

Lasting change in individual smoking behavior requires 

changing the social and cultural context in which smoking 

occurs by integrating program components into many existing 

communication channels (Hunkeler et al., 1990). These 

communication channels include the health care system, 

black-focused mass media, churches, voluntary health organizations, fraternal and mutual aid organizations, workplaces, 

unemployment offices, job training programs, retail establishments, families, and neighborhood and tenants' organizations 

(Orleans et al., 1989b). 

These channels include two types of organizations that 

might be mobilized to reduce black smoking-those that reach 

black populations easily, such as black churches, black fraternal 

and mutual aid organizations, and neighborhood and tenants' 

organizations; and those that have health and smoking on 

their agendas already, but are not focused on the black population, such as voluntary health organizations (e&, American 

Cancer Society, American Heart Association, American Lung 

Association). To involve both types of organizations in the 

reduction of smoking among black people requires convincing 

black organizations to take up smoking as an issue (despite 

their other pressing priorities) and convincing the voluntary 

health organizations to produce materials that focus on blacks. 

Any successful effort to reduce smoking among blacks requires 

strong black leadership. Unfortunately, at this time many of 

the organizations in black communities do not have the 

resources to add smoking to their list of priorities. Enlisting 

the aid of those organizations requires time. Many of the 

organizations that deal with smoking, such as the lung association and the cancer society, are just beginning to focus more 

heavily on low-income and minority smokers. 

If quitting smoking can be linked to other difficult problems faced by black communities, such as unemployment, 

quitting smoking might be more of a priority. For example, if 

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Smoking and Tobacco Control Monograph No. 1 

it could be shown that nonsmokers are more attractive job 

candidates, people might be more motivated to quit. If job 

training programs and unemployment offices distributed selfhelp materials and/or offered a smoking cessation component 

to their training, unemployed black smokers might be more 

interested in quitting. 

Health professionals can play a key role in educating 

individual smokers and community groups about the hazards 

of smoking (Ockene, 1987), but they should be practitioners in 

emergency rooms and public health clinics as well as regular 

physicians so that the low-SES groups with the highest proportion of smokers are reached. Medical-based programs should 

be offered in the hospital and public health clinics and emergency rooms where black smokers receive a disproportionate 

amount of their medical care (Orleans et al., 1989b). The 

National Medical Association could play a critical role by 

training its members to offer brief counseling and self-help 

materials as part of routine medical care (e.g., Glynn and 

Manley, 1989). 

Influential members of important nonmedical organizations also should be involved to raise consciousness about 

smoking as a health and social issue in black communities. 

The key spokespersons in Philadelphia’s successful campaign 

against Uptown cigarettes included health professionals, public 

health officials, political leaders, and clergy from the black 

community (Robinson et al., 1990). 

Communications aimed at black children and adolescents 

should include peer education. Recent focus groups indicate 

that information about smoking risks for blacks may be more 

credible coming from black than from white sources, and that 

information about other quitting benefits may be most convincing when the sources are “everyday” people instead of 

celebrities (James et al., 1990). Communications aimed at 

families and social networks have the potential to increase 

social support for quitting smoking and to mobilize efforts to 

curtail cigarette use among black children and adolescents. 

Widespread community concern to protect black children from 

a lifetime of nicotine addiction was a major tactic in the 

successful grassroots campaign against Uptown cigarettes in 

Philadelphia (Robinson et al., 1990). Interventions that target 

youth may reach both young people and their families; for 

instance, the making of a rap video, “Stop Before You Drop,” 

by the Richmond Quits Smoking Project in Richmond, California, was a mobilization tactic that reached families as well as 

over 300 young people involved in the production at various 

levels. 

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National Cancerinstitute 

Many effective health education campaigns combine 

formal and informal interpersonal communications, such as 

personal medical advice and social support from one’s primary 

social group (McDill, 1975; Warnecke et al., 1978). This may be 

especially true within the black community because of its strong 

self-help tradition. Recruiting and training volunteers from 

churches, neighborhood councils, and community organizations to talk with family members, friends, coworkers, and 

neighbors about smoking was one strategy used by the 

Richmond project to extend formal programming to informal 

social networks (Hunkeler et al., 1990). 

Community-based motivation or education campaigns 

should employ black-focused media (e.g., newspapers, magazines, and radio) to the greatest extent possible. The need to 

reach blacks with the lowest SES and educational levels requires 

that print materials be suitable for low-literacy populations 

(Doak et al., 1987) and that alternative audiovisual media also 

be available. 

Videotaped or televised quit-smoking programs are useful 

complements to print materials, especially to reach low-literacy 

groups. Minimal counseling might be provided to smokers 

using self-help materials by means of toll-free telephone 

quitlines, like the nationwide Cancer Information Service 

(1-800-4-CANCER), although few black smokers may avail 

themselves of this service. 

Briefly trained lay leaders (Lando et al., 1990) can provide 

quit-smoking assistance through organizations and institutions 

already established in the black community. The project in 

Richmond, California, recruited volunteers through churches, 

neighborhood councils, and community organizations to 

encourage, support, and assist quitters. Schoenbach and colleagues (1988) trained life insurance agents to deliver self-help 

quitting guides to interested policyholders nationwide. 

Interventions aimed at groups and organizations, not just 

individuals, are needed. Self-help programs, workshops, and 

clinics can be offered in churches, medical settings, schools, 

workplaces, and community organizations. The Richmond 

project distributed stop-smoking materials in more than 

100community sites, including restaurants, barber shops, youth 

organizations, recreational centers, senior centers, grocery 

stores, churches, the public library, and unemployment offices 

(Hunkeler et al., 1990). 

Voluntary health organizations, particularly the American 

Cancer Society and the American Lung Association, are the 

major providers of self-help materials and quit-smoking clinics 

in the United States (US DHHS,1989). Their multiracial quitting guides are designed for wide appeal to blacks and other 

282 
Smoking and Tobacco Control Monograph No.I 

minorities and are written at reading levels suitable for lowliteracy smokers (American Cancer Society, 1988; Strecher and 

Rimer, 1987). The community and worksite-based clinics of 

both organizations achieved similar, relatively modest outcomes 

(Lando et al., 1990). Both programs can be led by facilitators 

recruited and trained from the target community. 

An issue at present is the role of generic stop-smoking materials versus black-focused materials. Both have their place. The 

experience of the Richmond project was that blacks were very 

receptive to both black-focused motivational materials and 

black-focused quit-smoking guides. Examples of black-focused 

,stop-smoking literature include A Guide to Quim’ngSmoking, 

created by the Richmond project, and North Carolina Mutual 

Insurance Company’s Quitfor Life guide, designed as a companion to the multiracial guide, Freedom /?om Smoking for You and 

Your Family, from the American Lung Association (Strecher and 

Rimer, 1987). 

It is noteworthy that offers of standard counseling, groups, 

and self-help materials will reach only a small group of black 

smokers. However, the experience of the Richmond project was 

that, while the program had to offer these services to gain 

credibility and to accommodate the few who used them, most 

black smokers who were interested in cessation needed more 

innovative approaches to quitting. 

Content of Messages Messages about smoking for black Americans should contain clear information about the health consequences of smoking, the health benefits and other potential gains from quitting 

smoking, suggestions for how to quit smoking, and information 

to combat the cigarette companies’ message that smoking is 

glamorous. Information about the health risks of secondhand 

smoke exposure should be included to exploit the altruistic 

quitting motives commonly cited by black ex-smokers (Orleans 

et al., 1989a). 

Because health is the primary motivation for quitting 

among black smokers, as among all U.S. smokers (Orleans et al., 

1989a) and because blacks do not receive messages about the 

health risks of smoking as often as do whites (US DHHS, 1987), 

black-focused antismoking campaigns should clearly state the 

health risks and the benefits of not smoking. Messages should 

emphasize the fact that while quitting smoking is not easy, it 

can be done, and that there are individuals interested in helping 

others quit. Other benefits, not strictly health-related, such as 

freedom from addiction and inconvenience, saving money, 

greater self-esteem, and more social acceptability, should be 

stressed. Reassurance about overcoming common quitting 

barriers, for example, concerns about weight gain and the loss of 

smoking as an all-purpose coping tactic, also is important, 

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The smoking issue should be framed in ways relevant to 

the concerns of blacks, particularly with regard to family life, 

for instance, emphasizing the economic burden of smokingrelated illness for black families and the hazardous effects of 

secondhand smoke on children (Hunkeler et al., 1990; James et 

al., 1990). Family themes like these are emphasized in the 

American Lung Association’s new motivational brochure 

(1990) developed specifically for black smokers. These messages are similar to those meant for all other racial or ethnic 

groups, but there is a difference in tone and emphasis. Many 

blacks are already well aware of the problems they face (unemployment, higher mortality rates, drug abuse, etc.), including 

smoking. What is needed is more information on how blacks 

can combat smoking personally, in their families, and in the 

wider community by organizing to decrease the advertising of 

cigarettes (Hunkeler et al., 1990). 

Counteradvertising has become an essential antismoking 

strategy in minority communities. Its goals are to expose the 

tactics used by the tobacco industry to recruit new smokers, 

especially minority women, children, and adolescents. Counteradvertising can deglamorize smoking through images and 

slogans that mock the themes of power, attractiveness, escape, 

popularity, and pleasure that are used now to promote cigarettes (Blum, 1989; Tuckson, 1989). One of the successful 

tactics in the campaign against the new Uptown cigarettes was 

to expose the tobacco industry strategy of marketing more 

highly addictive, high-nicotine and high-menthol cigarettes to 

black smokers (Robinson et al., 1990). 

Counteradvertising strategies can involve everyone, nonsmokers and smokers alike. Recently, the City Council of the 

predominantly black city of Richmond, California, in a preliminary vote, passed an ordinance that prohibits billboard advertising of alcohol and cigarettes within 500 feet of each school. 

Thus, whole communities can be mobilized against smoking. 

The community-based project in Richmond portrayed 

smoking as “unhip,” “uncool,” and socially undesirable behavior (Hunkeler et al., 1990). Counteradvertising can also include 

(1)political action and legislation to regulate the billboard 

cigarette advertising that is two to three times more prevalent 

in black than in white communities; (2) strategies to reduce 

point-of-purchase advertising and curtail minors’ access to 

tobacco products in community retail establishments and to 

prohibit the distribution of free samples of cigarettes; (3) stopping patronage of events sponsored by tobacco companies; and 

(4) the refusal of philanthropy from tobacco companies 

(Tuckson, 1989). 

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Smoking Among The proportion of current smokers among Hispanic men 

Hispanics varies from 31 percent to 41 percent, and among Hispanic 

Magnitude of the women from 21 percent to 33 percent, in national and regional 

Problem surveys (Escobedo and Remington, 1989; Escobedo et al., 1990; 

Marcus and Crane, 1985). Rates for Hispanic men are similar 

to or greater than those for white men, but a substantially 

lower proportion of Hispanic women than white women are 

smokers. Smoking rates for the three major Hispanic subgroups, Mexican Americans, Cuban Americans, and Puerto 

Ricans, were compared in the Hispanic Health and Nutrition 

Examination Survey (HHANES) conducted between 1982 and 

1984 (Escobedo and Remington, 1989). Similar gender differences were observed among Mexican Americans and Cuban 

Americans, but the gap was much less striking among Puerto 

Ricans. Puerto Rican women report smoking at a much higher 

rate than either of the other Hispanic subgroups examined as 

part of HHANES. In addition, birth cohort analyses based on 

HHANES data estimated that, although the prevalence of 

smoking appears to be decreasing among Hispanic men, 

smoking rates actually increased among successive cohorts of 

Hispanic women (Escobedo and Remington, 1989). 

Barriers to Acculturation to the U.S. mainstream is a complex, multiSmoking Cessation dimensional phenomenon that has an important but poorly 

understood role in many health-related behaviors. In a telephone survey of smoking behavior, completed with 1,669 

Hispanic residents of San Francisco in 1986-1987 (Marin et al., 

1989b), smoking rates were higher for the more acculturated 

Hispanic women but lower for the more acculturated men. 

These data suggest that smoking behavior among Hispanics 

becomes more like that of whites with increasing levels of acculturation and, as a consequence, smoking may become an increasingly serious problem for Hispanics as they merge with 

mainstream U.S. society. 

A consistent finding in surveys (Marcus and Crane, 1985; 

Marin et al., 1989b) has been that Mexican-American smokers 

report smoking fewer cigarettes per day than the average reported by white or black smokers. Although a lower proportion of highly acculturated men smoke, they report a greater 

number of cigarettes per day than less acculturated men. 

Among women, a high proportion smoke and report smoking 

more cigarettes as acculturation increases. Among a sample of 

547 Mexican-American smokers participating in HHANES, 

comparison of self-reported smoking behavior with levels of 

serum cotinine (a specific metabolite of nicotine) showed that 

approximately 20 percent of men and 24 percent of women 

reported smoking fewer than 10 cigarettes per day, and that 

estimated underreporting of cigarette consumption ranged 

from 2 to 17 cigarettes per day (Perez-Stable et al., 1990). These 

285 
Channels for 

Reaching Hispanics 

National Cancer Institute 

observations have important implications for cessation strategies, because light smokers are much more likely to successfully 

quit smoking on their own with appropriate motivational 

messages and self-help methods. 

Unemployment, little education, and little or no awareness of cessation services also contribute to the barriers that 

Hispanics face in attempting to quit smoking. Less educated 

persons are more likely to smoke and less likely to quit, and 

Hispanics have the fewest average years of education of any 

ethnic group in the United States. Up to 50 percent of adolescents from all subgroups do not graduate from high school. In 

addition, many Hispanic immigrants have little formal education and at least 25 percent speak little or no English; thus, 

smoking prevention and cessation services are less accessible to 

them. 

With regard to barriers at the individual level, cigarette 

smoking remains a socially acceptable behavior among Hispanics. Few Hispanics question whether it is permissible to smoke 

at a private home and many consider offering a cigarette a 

polite gesture (Marin et al., 1989a). Smokers attempting to quit 

may confront situations in which they must politely refuse a 

cigarette in a culturally appropriate manner. Smoking among 

Hispanic men is perceived also as part of the machismo culture. 

The tobacco industry has exploited these culturaI traits in *

advertising campaigns aimed at Spanish-speaking people. 

Providing services to Hispanic Americans, whether at the 

individual level, in a clinical setting, or for an entire community, requires a working knowledge of social and cultural issues. 

Financial access to health care, immigrant documentation 

status, reasons for emigration from Latin America, and SES in 

the United States are all essential issues that persons planning 

to work with Hispanics must recognize. Because the proportion of Hispanic health professionals in the United States does 

not come close to the proportion of Hispanics in the population, non-Hispanics will be providing a substantial number of 

services; awareness of specific cultural issues may help to 

reduce the known barriers. 

On average, Hispanics are younger, less educated, and 

have an SES level intermediate between that of whites and 

blacks who are not Hispanic. More than 80 percent of Hispanics reside in urban areas and nearly 90 percent live in New 

York, Florida, Illinois, New Jersey, and five Southwestern states 

(California, Texas, New Mexico, Arizona, and Colorado). 

Although Hispanics are a racially diverse group, with each 

country of origin imparting unique characteristics, there are 

more similarities than differences among Hispanic subgroups 

in this country, For example, Spanish is the language preferred 

286 
Smoking and Tobacco Control Monograph No. 1 

for use at home by 60 percent of Hispanic adults, which creates 

a bonding among subgroups (Perez-Stable, 1987). 

To promote smoking cessation and prevent smoking 

initiation among Hispanics, interventions must incorporate 

culturally appropriate information about why and how to quit 

smoking. Standard use of broadcast Spanish that avoids 

regional idioms should be used in all of the media components. Hispanic physical types that represent the national 

groups in the area also should be used as models and communicators. 

The Spanish-language media can play an important role in 

promoting nonsmoking. Television and radio public service 

announcements can be produced at low cost and aired on the 

major Spanish-language stations in a specific area. These 

public service announcements can include culturally appropriate messages about smoking and how to quit, with community 

leaders talking about the disadvantages of smoking and former 

smokers talking about why they quit and what benefits they 

have gained. Less acculturated Hispanics are more likely to 

listen to radio, and discussions of smoking and health by 

Hispanic experts on locally popular radio talk shows can be an 

effective way of reaching Hispanics. The call-in talk show 

format allows for listener participation, lively discussions, and 

testimonials by former smokers. 

There are Spanish-language newspapers publishing weekly 

or monthly in most U.S. areas that have a significant Hispanic 

population. In some urban areas (e.g., Los Angeles, Miami, and 

New York), a prominent daily newspaper is widely read by 

Hispanics, but in many areas the absence of a daily newspaper 

in Spanish means that Hispanics read English language newspapers (Alcalay et al., 1987-1988). Newspapers and magazines 

are susceptible to influence by the tobacco industry’s advertising dollars and thus may be less amenable than radio and 

television to promoting nonsmoking; however, other printed 

media in Spanish may have an important role in promoting 

smoking cessation. For example, posters showing a family 

quitting cigarettes, flyers with motivational messages, pamphlets with information on how to help a smoker quit, and 

billboards promoting the no-smoking message can all be part 

of a Hispanic-focused program of smoking control. The messages in printed media should be aimed at nonsmoking family 

members as well as smokers, in order to make the most of the 

powerful characteristic of familial regard among Hispanics. 

Content of Messages Hispanics tend to have a collective loyalty to the extended 

family that ranks higher than individual needs (furniliulisrno), 

and this quality may be useful in an effort to change smoking 

behavior. For example, motivating fathers or mothers to quit 

28 7 
National Cancer Institute 

smoking in order to prevent their children’s smoking and to 

decrease the likelihood of harm to their children is an appropriate and effective strategy to use among Hispanics. The 

extended family network remains much more intact among 

Hispanics in general when compared with whites, even after 

several generations have passed since immigration (Sabogal et 

al., 1987). The family network can be used also to persuade 

smokers to quit. An example of a vignette related to real-life 

issues in the community is a television public service announcement showing a delighted Hispanic mother reading a 

letter from her son, who writes that he has quit smoking on 

Mother’s Day because of his children. 

Hispanic people often will establish relationships with 

health professionals and other authority figures out of a paternalistic dependence. Because of this cultural trait of respect for 

authority figures, physicians and other health professionals in 

a clinical setting may be especially effective in counseling

Hispanic smokers about quitting. Physicians need to implement a more authoritative style, use standard counseling 

techniques to promote cessation, and order adjunctive pharmacologic methods as needed. Authoritative experts have enhanced credibility in promoting nonsmoking among Hispanics 

both at an individual encounter and through a public health 

campaign. This relationship, however, depends on maintenance of respect for the individual regardless of social standing, 

and it can disintegrate if non-Hispanics are not aware of these 

cultural scripts. For example, Triandis and colleagues (1984) 

described the cultural script of simpatia that differentiates 

Hispanics from whites; this script means that Hispanics are 

more likely than whites to expect a high frequency of positive

social interaction and a low frequency of neutral or negative 

social interactions. Inattention to the presence of this script 

may lead to misunderstandings when Hispanics and people of 

other cultures interact in any social setting. 

Although Hispanics report having less awareness than that 

of other groups about where to obtain information on smoking 

cessation services, they state also that they need less help in 

quitting and feel more capable of quitting on their own. In 

fact, the most frequently cited method by Hispanic smokers in 

helping them to quit is voluntudpropia, or willpower. Promotion of willpower with self-help methods, such as the Guia para 

Dejar de Fumar (Sabogal et al., 1988),is an effective strategy to 

use among Hispanic smokers. 

Compared to white smokers, Hispanics perceive their 

smoking to be less dependent on situational cues and more 

dependent on social cues. The importance of cigarette smoking with a group of friends or at a social gathering is greater for 

Hispanics than for whites. Thus, antismoking messages must 

288 
Smoking and Tobacco Control Monograph No. 1 

CONCLUSIONS 

include culturally appropriate ways to resist social pressures to 

smoke, Hispanics were more concerned also about the effects 

of smoking on interpersonal relationships and about smoking 

making their clothes and their breath smell bad. This also 

should be incorporated into antismoking messages. Finally, 

Hispanics report a greater concern about the effects of smoking 

on their health and the health of their children. Thus, graphic 

presentations of the adverse health effects of smoking on 

smokers and their loved ones may be effective if presented

within a context that offers ways to quit smoking. 

Helping smokers quit with the more traditional cessation 

group approach has not been widely accepted by Hispanic 

smokers, even when offered free of charge at convenient hours 

and locations. Use of a series of Spanish-language audiotapes 

that include professionally enacted vignettes to illustrate the 

principles of relapse prevention, relaxation techniques, and 

assertiveness when coping with social temptations to smoke 

may be widely applicable through radio programs. One approach to complement the standard group cessation is to offer 

counseling sessions for smokers over the telephone. It has the 

advantage of being time-efficient, allows for a much wider 

dissemination of quitting techniques, and should be costeffective. 

In the limited number of settings where interactions 

between the multiple components of a smoking control 

program have been examined, there appears to be a 

synergistic effect. 

Interaction between the multiple components of the environmental system and the multiple message channels 

that compose a comprehensive strategy for smoking 

control is expected, in light of current social behavior 

theory, and the anticipated interaction has been incorporated into most recent comprehensive, communitybased, smoking control approaches, such as COMMIT 

and ASSIST. 

The targeting of women by tobacco advertising has been 

associated with a dramatic rise in the number of women 

who smoke and who develop smoking-related diseases. 

Approaches toward blacks include programs to counter 

targeted advertising within black neighborhoods, increasing the priority and resources available for smoking 

control within black groups, and encouraging the 

dissemination of programs and materials developed for 

use in the black community. 

The recognition of the importance of acculturation and 

Hispanic social and cultural issues is essential in implementing smoking control programs in Hispanic communities. Approaches that emphasize family impact may be 

particularly useful. 

289 
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REFERENCES Abrams, D.B., Elder, J.P., Carleton, R.A., Lasater, T.M., Artz, 

L.M. Social learning principles for organizational health 

promotion: An integrated approach. In: Health and Industry: A 

Behavioral Medicine Perspective, M.F. Cataldo and T.J. Coates 

(Editors). New York: Wiley-Interscience Publications, 1986, pp. 

28-51. 

Alcalay, R., Sabogal,F., Marin, G., PQez-Stable, E., Marin, 

B.V., Otero-Sabogal, R. Patterns of mass media use among 

Hispanic smokers: Implications for community interventions. 

International QuarterZy ofCornmunity Health Education 8(4): 341-

350,1987-1988. 

American Cancer Society. Cancer Facts Sr Figures--1990. 

New York: American Cancer Society, 1940. 

American Cancer Society. Special Delivery. New York: 

American Cancer Society, 1988. 

American Lung Association. Don’t Let Your Dreams Go Up 

in Smoke. New York: American Lung Association, 1990. 

Anderson, D.M., Meissner, H.I., Portnoy, B. Media use and 

health information acquisition process: How callers learned 

about the NCI’s Cancer Information Service. HeaZth Education 

Research: Theory and Practice 4(4): 419-427, 1989. 

Ashby, W.R. General systems theory as a new discipline. 

General Systems 3: 1-6,1958. 

Bettinghaus, E.P. Using the mass media in smoking 

prevention and cessation programs: An introduction to five 

studies. Journal of Preventive Medicine 17: 503-509, 1988. 

Biener, L. Gender differences in the use of substances for 

coping. In: Gender and Stress, R. Barnett, L. Beiner, and G. 

Baruch (Editors). New York: The Free Press, 1987. 

Blum, A. The targeting of minority groups by the tobacco 

industry. In: Minorities and Cancer, L.A. Jones (Editor). New 

York: Springer-Verlag, 1989, pp. 153-163. 

Boulding, K.E. General systems theory-The skeleton of 

science. In: Classics of Organization Theory, J. Shafritz and P. 

Whitbeck (Editors). Oak Park, IL: Moore, 1978, pp. 121-131. 

Brown, E.R., McCarthy, W.J., Marcus, A., Baker, D., 

Froines,J.R., Dellenbaugh, C., McQuiston, T. Workplace

smoking policies: Attitudes of union members in a high-risk

industry. Journalof Occupational Medicine 30(4): 312-320,1988. 

Bureau of National Affairs. Where There’s Smoke: Problems 

and Policies Concerning Smoking in the Workplace. Washington, 

DC: Bureau of National Affairs, 1986. 

290 
Smoking and Tobacco Control Monograph No. 1 

Cooper, R., Simmons, B.E. Cigarette smoking and ill 

health among Black Americans. New York StuteJoumal of 

Medicine 85: 344-350, 1985. 

Cummings, K.M., Sciandra, R., Markello, S. Impact of a 

newspaper mediated quit smoking program. American Journal 

ofPublicHealth 77(11): 1452-1453,1987. 

Danaher, B.G., Berkanovic, E., Gerber, B. Mass media 

based health behavior change: Televised smoking cessation 

program. Addictive Behaviors 9: 245-253, 1984. 

Davis, R.M. Current trends in cigarette advertising and 

marketing. New England Journal ofMedicine 316(2): 725-732, 

1987. 

DeNelsky, G.Y. Letter to the editor. Los Angeles Times, 

March 14, 1989. 

DiFranza, J.R., Norwood, B.D., Garner, D.W., Tye, J.B. Legislative efforts to protect children from tobacco. Journal ofthe 

American Medical Association 257(24): 3387-3389, 1987. 

Doak, C.C., Doak, L.G., Root, J.J. TeachingPutients with 

Low Literacy Skills. Philadelphia: J.B. Lippincott, 1987. 

Doctors Ought to Care. Washington-DOC sponsors

monster truck momma with a message. DOC News and Views, 

Spring 1990. 

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 

communitywide prevention of heart disease: The first two 

years of the Pawtucket Heart Health Program. Preventive Medicine 15: 107-117, 1986. 

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 ofthe American Medical Association 

264: 1550-1555, 1990. 

Escobedo, L.G., Remington, P.L. Birth cohort analysis of 

prevalence of cigarette smoking among Hispanics in the United 

States. Journal ofthe American Medical Association 261(1): 66-69, 

1989. 

Farquhar,J.W. The community-based model of life style 

intervention trials. American Journal ofEpidemiology 108: 103-

111,1978. 

29 1 
National Cancer Institute 

Farquhar, J.W., Fortmann, S.P., Maccoby, N., Haskell, W.L., 

Williams, P.T., Flora, J.A., Taylor, C.D.,Brown, B.W., Jr., Soloman, D.S., Hulley, S.D. The Stanford Five-City Project: Design 

and methods. American Journal ofEpidemiology 122: 323-334, 

1985b. 

Farquhar, J.W., Wood, P.D.,Breitrose, H., Haskell, W.L., 

Meyer, A.J., Maccoby, N., Alexander, J.K., Brown, B.W., McAlister, A.L., Nash, J.D., Stern, M.P. Community education for 

cardiovascular health. Lancet l(8023): 1192-1 195, 1977. 

Farquhar, J.W., Magnes, P.F., Maccoby, N. The role of 

public information and education in cigarette smoking 

controls. Canadian Journal of Public Health 72(6): 412-420, 

1981. 

Farquhar, J.W., Maccoby, N., Wood, P.D. Education and 

communication studies. In: Oxford Textbook ofPublic HeaZth 

(volume 3), W.W. Holland, R. Detels, and G.Knox (Editors). 

Oxford, UK: Oxford University Press, 1985a, pp. 207-221. 

Fiore, M.C., Novotny, T.E., Pierce, J.P., Hatziandreu, E.J., 

Patel, K.M., Davis, R.M. Trends in cigarette smoking in the 

United States: The changing influence of gender and race. 

Journalof the American Medical Association 261(1): 49-55, 1989. 

Flay, B.R. Mass media and smoking cessation: A critical 

review. American Journal ofPublic Health 77(2): 153-160,1987. 

Glynn, T., Manley, M. W. How to Help Your Patients Stop

Smoking: A National Cancer Institute Manual for Physicians. U.S. 

Department of Health and Human Services, Public Health 

Service, National Institutes of Health, National Cancer Institute. NIH Publication No. 90-3064, 1989. 

Gutzwiller, F., Schweizer, W. Intervention on smoking: 

An individual and collective challenge. In: Atherosclerosis: Proceedings ofthe Sixth International Symposium, F.G. Schettler, A.M. 

Getto, G. Middethoff, A.J.R. Haberniehr, and A.R. Jurutlea 

(Editors). New York: Springer-Verlag, 1983. 

Harris, J.E. Increasing the federal excise tax on cigarettes. 

Journal ofHealth Economics 1: 117-120, 1982. 

Hunkeler, E.F., Davis, E.M., McNeil, B., Powell, J.W., Polen, 

M.R. Community mobilization for smoking cessation: Program development in a predominantly black city. In: Health 

Promotion at the Community Level, N.J. Bracht (Editor). Newbury 

Park, CA: Sage Publications, 1990. 

Jacobs, D.R., Jr., Leupker, R.V., Mittelmorle, M.B., Folsom, 

A.R., Pirie, P.L., Macsioli, S.R., Hannan, P.J., Pechacek, T.F., 

Bracht, N.S., Carlaw, R.W., Kline, F.G., Blackburn, H. Community-wide prevention strategies: EvaIuation design of the 

292 
Smoking and Tobacco Control Monograph No. 1 

Minnesota Heart Health Program. Journal of Chronic Diseases 

39: 775-788, 1986. 

James, D., Robinson, R., Orleans, C.T. Summary of focus 

groups conducted with African-American smokers, ex-smokers 

and never smokers. Unpublished paper, Fox Chase Cancer 

Center, Philadelphia, PA, 1990. 

Jason, L.A., Tait, E., Goodman, D., Buckenberger, L., 

Gruder, C.L. Effects of a televised smoking cessation intervention among low-income and minority smokers. American 

Journal of Community Psychology 16(6): 863-876, 1988. 

Lando, H.A., McGovern, P.G., Barrios, F.X., Etringer, B.D. 

Comparative evaluation of American Cancer Society and 

American Lung Association smoking cessation clinics. American Journal of Public Health 80: 554-559, 1990. 

Lemann, J. The origins of the underclass. Atlantic 258: 54- 

66, 1986. 

Leventhal, H., Glynn, K. Fleming, R. Is the smoking 

decision an informed choice? Effect of smoking risk factors on 

smoking beliefs. Journal ofthe American Medical Association 

257(24): 3373-3376,1987. 

Lewit, E., Coate, D. The potential for using excise taxes to 

reduce smoking. Journal ofHealth Economics l(2): 121-145, 

1982. 

Marcus, A.C., Crane, L.A. Smoking behavior among U.S. 

Latinos: An emerging challenge.for public health. American 

Jourrial ofpublic Health 75: 169-172, 1985. 

Marcus, A.C., Crane, L.A. Current estimates of adult 

cigarette smoking by race/ethnicity. Invited paper presented at 

the Interagency Committee on Smoking and Health, Washington, DC, 1987. 

Marin, G., Marin, B.V., Otero-Sabogal, R., Sabogal, F., 

Perez-Stable, E.J. The role of acculturation on the attitudes, 

norms, and expectancies of Hispanic smokers. Journal of CrossCultural Psychology 20(4): 399-415, 1989a. 

Marin, G., Perez-Stable, E.J., Marin, B.V. Cigarette smoking 

among San Francisco Hispanics: The role of acculturation and 

gender. American Journal ofPublic Health 79: 196-199, 1989b. 

Martin, M.J. Smoking control-Policy and legal methods 

(letter). WesternJournal ofMedicine 148(2): 199, 1982. 

McAlister, A,, Puska, P., Salonen, J.T., Toumilehto, J., 

Koskela, K. Theory and action for health promotion: Illustrations from the North Karelia Project. American Journal ofPublic 

Health 72: 43-50, 1982. 

293 
National Cancer Institute 

McCord, C., Freeman, H.P. Excess mortality in Harlem. 

NewEngland Journal ofMedicine 322: 173-177, 1990. 

McDill, M.S. Structure of social systems determining 

attitudes, knowledge, and behavior toward disease. In: Applying Behavioral Science to Cardiovascular Risk, A. Enelow and J. 

Henderson (Editors). New York American Heart Association, 

1975, pp. 18-33. 

Meyer, A.J., Nash, J.D.,McAlister, A.I., Maccoby, N., Farquhar, J.W. Skills training in a cardiovascular health education 

campaign. Journal of Consulting and Clinical Psychology 48(2): 

129-142, 1980. 

Mittelmark, M., Luepker, R.V., Jacobs, D., Bracht, N.F., 

Carlaw, R.W., Crow, R.S., Finnegan, J., Kline, F.G.,Mullis, R.H., 

Murray, D.M., Pechacek, T.F., Perry, C.L., Pirie, P.L., Blackburn, 

H. Education strategies of the MHHP. Preventive Medicine 15: 1-

17, 1986. 

Morbidity and Mortality Weekly Report. Progress in 

chronic disease prevention: Cigarette smoking in the United 

States, 1986. Journal of the American Medical Association 258: 

1877-1881, 1987. 

Ockene, J.K. Physician-delivered interventions for smoking cessation: Strategies for increasing effectiveness. Preventive 

Medicine 16: 723-737, 1987. 

Ockene, J.K., Hosmer, D.W., Williams, J.W., Goldberg, R.J., 

Ockene, I.S., Biliouris, T., Dalen, J.E. The relationship of 

patient characteristics to physician delivery of advice to stop 

smoking. Journal of General Internal Medicine 2: 337-340, 1987. 

Orleans, C.T., Schoenbach, V.J., Salmon, M.A., Strecher, 

V.J., Kalsbeek, W., Quade, D., Brooks, E.F., Konrad, T.R., 

Blackmon, C., Watts, C.D. A survey of smoking and quitting 

patterns among black Americans. American Journal of PubZic 

Health 79(2): 176-181, 1989a. 

Orleans, C.T., Strecher, V.J., Schoenbach, V.J., Salmon, 

M.A., Blackmon, C. Smoking cessation initiatives for black 

Americans: Recommendations for research and intervention. 

Health Education Research 4: 13-25, 1989b. 

PQez-Stable, E.J. Issues in Latino health care. Western 

Journal ofMedicine 146: 213-218, 1987. 

Pkrez-Stable, E.J., Marin, B.V., Marin, G., Brody, D.J., 

Benowitz, N.L. Apparent underreporting of cigarette consumption among Mexican-American smokers. American Journal of 

Public Health 80(9): 1057-1061, 1990. 

294 
Smoking and Tobacco Control Monograph No. 1 

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

Public Health Service, National Institutes of Health, National 

Cancer Institute. NIH Publication No. 90-479, 1989. 

Petersen, L.R., Helgerson, S.D., Gibbons, C.M., Calhoun, 

C.R., Ciacco, K.H., Pitchford, K.C. Employee smoking behavior 

changes and attitudes following a restrictive policy on worksite 

smoking in a large company. Public Health Reports 103(2): 115- 

120,1988. 

Pierce, J.P., Fiore, M.C., Novotny, T.E., Hatziandreu, E.J., 

Davis, R.M. Trends in cigarette smoking in the United States: 

Educational differences are increasing. Journal of the American 

Medical Association 261(1): 56-60, 1989. 

Puska, P., Nissinen, A., Salonen, J.T., Twomilehto, J. Ten 

years of the North Karelia Project. Results with communitybased prevention of coronary heart disease. Scandinavian 

Journal of Social Medicine ll(3): 65-68, 1983. 

Puska, P., Nissinen, A., Toumilehto, J., Salonen, J.T., 

Koskela, K., McAlister, A., Kottke, T.E., Maccoby, N., Farquhar, 

J.W. The community-based strategy to prevent coronary heart 

disease: Conclusions from the ten years of the North Karelia 

Project. Annual Review ofPublic Health 6: 147-193, 1985. 

Rigotti, N.A., Hill Pikl, B., Cleary, P., Singer, D.E., Mulley, 

A.G. The impact of banning smoking on a hospital ward: 

Acceptance, compliance, air quality and smoking behavior. 

Clinical Research 34(2): 833, 1986. 

Rivo, M.L., Kofie, V., Schwartz,E., Levy, M.E., Tuckson, 

R.V. Comparisons of black and white smoking-attributable 

mortality, morbidity and economic costs in the District of 

Columbia. Journal of the National Medical Association 81: 1125- 

1130,1989. 

Robertson, I. Sociology. New York: Worth Publishers, 

1977. 

Robinson, R.G., Brown, J., Mansfield, C. Victory over 

Uptown: The Philadelphia experience. Paper presented at the 

Annual Meeting of the American Public Health Association, 

New York, 1990. 

Rodin,J., Wack, J.T. The relationship between cigarette 

smoking and body weight: A health promotion dilemma? 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: Wiley, 1984. 

295 
National Cancer Institute 

Rosenstock, I.M., Stergachis, A,, Heaney, C. Evaluation of 

smoking prohibition policy in a health maintenance 

organization. American Journal ofPublic Health 76(8): 1014- 

1015,1986. 

Sabogal, F., Marh, B., Marin, G., Otero-Sabogal, R., PkrezStable, E.J. Guia para Dejar de Fumar. U.S. Department of 

Health and Human Services, Public Health Service, National 

Institutes of Health. NIH Publication No. 88-3001,1988. 

Sabogal, F., Marin, G., Otero-Sabogal, R., Marin, B.V., 

Perez-Stable, E.J. Hispanic familisrn and acculturation: What 

changes and what doesn't? Hispanic Journal of Behavioral 

Sciences 9(4): 397-412, 1987. 

Schoenbach, V.J., Orleans, C.T., Salmon, M.A. A self-help 

quit smoking program for Black Americans. Paper presented at 

the 116th Annual Meeting of the American Public Health Association, Boston, 1988. 

Smoking Control Advocacy Resource Center. Summary of 

the Utica COMMITAIvin Ailey Protest. Washington, DC: The 

Advocacy Institute, Smoking Control Advocacy Resource 

Center, August 1989. 

Smoking Control Advocacy Resource Center. Action Alert: 

The Perrier Benzene Scare. The Advocacy Institute, Smoking 

Control Advocacy Resource Center, Washington, DC, February 14,1990. 

Sorenson, G., Pechacek, T.F. Attitudes toward smoking 

cessation among men and women, Journal of Behavioral Medicine 19: 129-137, 1987. 

Strecher, V.J., Rimer, B. Freedom porn Smoking for You and 

Your Family. New York: American Lung Association, 1987. 

Syme, L.S., Alcalay, R. Control of cigarette smoking from a 

social perspective. Annual Review ofPubZicHealth 3: 179-199, 

1982. 

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 ofHealth Promotion Fall: 74-80, 1987. 

Thompson, B., Sexton, M., Sinsheimer, J. Smoking policy 

at the worksite: Employee reactions to policy changes. In: 

Advances in Cancer Control: The War on Cancer-1 5 Years of 

Progress. New York Alan R. Liss, 1987. 

Tobacco-Free America Project. State Legislated Actions on 

TobaccoIssues. Washington, DC: Tobacco-Free America 

Project, 1988. 

296 
Smoking and Tobacco Control Monograph No. 1 

Tobacco Institute. The Tax Burden on Tobacco (volume 23). 

Washington, DC: Tobacco Institute, 1988. 

Triandis, H.C., Marin, G., Lisansky, J., Benacourt, H. 

Simpati’a as a cultural script of Hispanics. Journal of Personality

and Social Psychology 47: 1363-1375, 1984. 

Tuckson, R. Race, sex, economics and tobacco advertising. 

Journal of the National Medical Association 81: 1119-1124, 1989. 

Tye, J., Warner, K., Glantz, S. Tobacco advertising and 

consumption: Evidence of a causal relationship. Journal of 

Public Health Policy 8(4): 492-508, 1987. 

US.Department of Health and Human Services. The 

Health Consequences of Smoking for Women: A Report of the 

Surgeon General. U.S. Department of Health and Human 

Services, Public Health Service, Office on Smoking and Health, 

1980. 

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

the Secretary’s Task Force on Black and Minority Health (volume 1). U.S. Department of Health and Human Services, 

Public Health Service, National Institutes of Health, 1985, p. 

239. 

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

Health Consequences of Involuntary Smoking. A Report of the 

Surgeon General. U.S. Department of Health and Human 

Services, Public Health Service, Centers for Disease Control. 

DHHS Publication No. (CDC) 87-8398, 1986. 

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

Prevention Awareness Survey Wave11: Management Summary. 

U.S. Department of Health and Human Services, Public Health 

Service, National Institutes of Health, National Cancer Institute. NIH Publication No. (NIH) 87-2908, 1987. 

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

Health Consequences of Smoking: Nicotine Addiction. A Report of 

the Surgeon General, 1988. 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. DHHS Publication 

NO. (CDC) 88-8406,1988, 

US.Department of Health and Human Services. Reducing

the Health Consequences of Smoking: 25 Years of Progress. A Report

ofthe Surgeon General. 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. DHHS Publication No. (CDC) 

89-8411,1989. 

29 7 
National Cancer Institute 

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

Health Benefits of Smoking Cessation: A Report of the Surgeon 

General. U.S. Department of Health and Human Services, 

Public Health Service, Centers for Disease Control, Center for 

Health Promotion and Education, Office on Smoking and 

Health. DHHS Publication No. (CDC) 90-8416, 1990. 

U.S. Department of Health, Education, and Welfare. 

Smoking and Health: Report of the Advisory Committee to the 

Surgeon General ofthe Public Health Service. U.S. Department of 

Health, Education, and Welfare; Public Health Service; Center 

for Disease Control. PHS Publication No. 1103, 1964. 

Van Parijs, L.G., Eckhardt, S. Public education in primary 

and secondary cancer prevention. Hygie 3(3): 1984. 

Von Bertalanffy, L. General systems theory: A critical 

review. General Systems 7: 1-20, 1962. 

Waldron, I. Gender and health related behavior. In: 

Health Behavior: Emerging Research Perspectives, D.S. Gochman 

(Editor). New York Plenum Press, 1988. 

Walsh, D.C., McDougall, V. Current policies regarding 

smoking in the workplace. American Journal of Industrial 

Medicine 13: 181-190, 1988. 

Warnecke, R.B., Graham, S., Rosenthal, S., Manfredi, C. 

Social and psychological correlates of smoking behavior among 

black women. Journal ofHealth and Social Behavior 19: 397- 

410,1978. 

Warner, K.E. Cigarette advertising and media coverage of 

smoking and health. New England Journal of Medicine 312: 384- 

388,1985. 

Warner, K.E. Selling Smoke: Cigarette Advertising and Public 

Health. Washington, DC: American Public Health Association, 1986a. 

Warner, K.E. Smoking and health implications of a 

change in the Federal cigarette excise tax. Journal of the American Medical Association 255(8): 1028-1032, 1986b. 

White, L. Merchants of Death: The American TobaccoIndustry. New York: Beech Tree Books, William Morrow, 1988. 

Whiteside, T. Selling Death: Cigarette Advertising and Public 

Health. New York: Liveright, 1971. 

Wilson, D.M.C., Lindsay, E.A., Best J.A., Gilbert, J.R., 

Willms, D.G., Singer, J. A smoking cessation intervention 

program for family physicians. Canadian Medical Association 

JOUIYIU~ l(7): 613-619, 1987. 

298 
Smoking and Tobacco Control Monograph No. 1 

Index 

abstinence 39,48-50, 149, 171 

Action on Smoking and Health 246, 250 

acupuncture 38,41 

addiction vi, 25, 47, 248, 271 

adolescents 11,233-234,271 

advertising aimed at v-vi, 21, 24, 50-51, 149, 205, 

233,236,275,276 

age of initiation 8, 22-23, 215 

antismoking campaigns aimed at xi, xx, 148 

black 281 

education of 24, 281 

(see also school-based interventions) 

effects of smoking 234 

female 50-51, 165-166 

given free product samples 24, 52, 210, 236-237, 

238,284 

minimum age law 234 

Native American 165 

prevalence of smoking iv, 8 

preventing sales to 234, 237, 238, 253 

price elasticity for 24, 239, 243-244 

sale of tobacco to 51, 53, 233, 235, 278 

smokeless tobacco use 51-52, 233, 236 

socialization into the workforce 25 

use of vending machines 20, 234-236 

Adult Use of Tobacco Survey (1986) 213-214 

advertising, antismoking 

billboards 207 

counteradvertising 14, 86, 206-207 

directed to specific audiences 24, 50, 275, 284 

effects 150 

equal time for 206,271 

Fairness Doctrine ix, x 

public service announcements 36, 207, 287 

advertising, tobacco 

aimed at adolescents v-vi, 21, 24, 50-51, 149, 205, 

233,236,276 

aimed at blacks 50-51, 276, 279, 280 

aimed at Hispanics 276, 286, 287 

aimed at women 50-51, 277-278, 289 

and consumption 203 

ban 210 

billboards vi, 210, 276, 280 

broadcast ban 36 

concealment of health problems 5-6, 37, 147-149 

expenditures v-vi, 150 

health warnings required for 36 

prohibitions 210 

refusal of magazines to accept 278 

restrictions 12, 24, 36, 51, 209-210, 253, 271, 284 

tax deductions for 253 

(see also advertising, antismoking) 

airline smoking regulations 20, 53-54,226 

American Academy of Family Physicians 275 

American Academy of Pediatrics 215 

American Cancer Society 

advocation of tax increases 252 

blacks, cessation materials 280 

cessation materials 38, 47, 282-283 

cessation clinics 39, 177 

educational materials 36, 214 

First World Conference on Smoking and 

Health 38 

Freshstart 39 

Great American Smokeout 26,55, 59, 152, 207 

public service announcements 36 

recruitment and training of physicians 211 

“Special Delivery” 59 

tobacco sales by pharmacies 212 

American Civil Liberties Union 248 

American Dental Association 58 

American Health Foundation 170 

American Heart Association 36, 55, 59,214, 

252,280 

American Lung Association 

advocation of tax increases 252 

blacks, cessation materials 280-284 

cessation clinics 39, 177 

educational materials 36, 214 

Freedom from Smoking manuals 39, 47, 57, 59, 283 

Non-Dependence Day 55, 59, 207-208 

public service announcements 36 

self-help materials 150, 282-283 

American Medical Association 58,252, 275 

American Pharmaceutical Association 

58,212 

American Public Health Association 252 

American Stop Smoking Intervention Study 

for Cancer Prevention (see ASSIST) 

Americans for Nonsmokers’ Rights 59 

anticholinergics 4 1 

anticonvulsants 41 

-Y see Department of Defense 

assertiveness training 24 

associations, societies 

see individual organization names, e.g., 

American Cancer Society, American 

Medical Association 

ASSIST ix, xi-xii, 276, 289 

Australian North Coast Study 272 

Australian Public Service 231-232 

aversion therapy 

aversive conditioning 40-41 

299 
National Cancer Institute 

cessation clinics, in 174-175 

covert sensitization 43 

mulicomponent programs 48 

rapid smoking 43 

satiation 43 

smoke-holding 44 

Bantron (nicotine replacement) 170 

behavioral approaches 170-1 71 

(see also cessation program strategies) 

behavior change 218,269 

behavior modification 

see cessation program strategies 

behavior, smoking 

cues 232,277 

current smokers, black women 97 

effect on lung cancer death rates 82-83 

ever-smokers, black women 97, 108 

lung cancer occurrence, relation to 76, 82, 83 

role in lung cancer death 95 

(see also addiction; cessation, smoking; 

consumption, tobacco; initiation, 

smoking; prevalence, smoking) 

benzene 273 

billboards 

see advertising, antismoking; advertising, 

tobacco 

blacks 

advertisements aimed at 50-51, 276, 279-280 

antismoking advertisements 50 

cessation, smoking 13-15, 123, 279-280, 283-284 

channels for reaching 280-283 

consumption, tobacco 4 

discrimination against 248 

health care 279-280 

initiation of smoking 85, 112 

mortality rates 93-107, 121-122, 135-144, 278 

prevalence, smoking iv, 9, 84, 87, 131-132, 

278-279 

youth 166-168, 281 

bladder cancer 115, 116 

booster lessons (inschool-based 

programs) 161 

breast cancer 277 

Brown and Kessler model (lung cancer 

mortality patterns) 111-112 

Brown and Williamson Tobacco Corp. vi 

Bureau of National Affairs 213,246 

CAB (Civil Aeronautics Board) 226 

California 

cigarette consumption 18-20, 244 

Hispanic population 286 

local smoking ordinances 228 

Proposition 99 240, 252 

research 54 

(see also tax, taxes) 

Camel cigarettes v-vi, 236 

Canadian Council on Smoking and 

Health 244 

Canadian Medical Association 252 

cancer 

see specific sites, e.g., lung cancer 

(see also health risks) 

Cancer Information Service 282 

cerebrovascular disease (CVD) 115,116 

cessation, smoking 3, 13-15, 122 

and cost of cigarettes 17-20 

as function of duration of smoking 117-118 

barriers to 277-280, 285-286 

by females 14, 16, 112, 123, 165-166, 277-278 

clinics 37, 38, 174-176 

counseling 21 1 

efforts 278 

health trends 117 

methods 37-51, 172-177 

participation 9 

patterns 117 

physicians 275 

precontemplation 16 

process 14, 16, 22, 25-26 

programs 37-38, 171, 174-175, 177 

(see also cessation program strategies; 

clinical approaches; commercial stopsmoking programs; comprehensive 

control strategies) 

promotion of 273, 287 

rates 8, 15-16, 112-113, 117-118 

relapse prevention 171 

worksite 55, 274-275 

cessation program strategies 14-16 

behavorial modification 42-46 

costs 17 

Five-Day Plan 40 

medication 41-42 

multiple component (multicomponent) programs 

43, 48, 172, 174-175 

self-help strategies 46-48 

withdrawal clinics 17, 38-41 

(see also aversion therapy; intervention; 

nicotine gum) 

CHD (coronary heart disease) 115, 116,119-123 

chemical smoking deterrents 

see cessation program strategies; nicotine 

gum; pharmacologic intervention 

chewing tobacco 

see smokeless tobacco 

children 

see adolescents 

chronic obstructive pulmonary disease 

(COPD) 115,116 

cigarettes 

cigarette advertising 

see advertising, tobacco 

cigarette consumption 

see consumption, tobacco 

cigarettes, marketing/promotion of 

see advertising, tobacco; free tobacco 

samples; vending machines 

Cigarrest (commercial self-help product) 180, 

181,182 

300 
Smoking and Tobacco Control Monograph No. I 

Civil Aeronautics Board (CAB) 226 

Clean Indoor Air Act 

Minnesota 227, 228 

Wisconsin 230 

clinical approaches 173, 182 

cessation clinics 174-1 76 

effectiveness 17, 172, 174 

health care provider interventions 176-177 

historical trends 170-171 

importance 177-179 

clinical intervention 176-1 79 

(see also dcothe gum; physicians) 

clonidine (to reduce the urge to smoke) 42 

cognitive behavioral model 166 

cognitive behavioral technique 164 

cognitive recognition 49 

commercial stop-smoking programs 

worksites 214 

Schick Centers for the Control of Smoking 40-41, 

176, 177 

SmokEnders 40, 176, 177 

SmokeLess 40-41, 177 

Smoke Stoppers 40-41, 177 

Smoke Watchers 40,44, 45, 176, 177 

COMMIT (Community Intervention Trial for 

Smoking Cessation) 180-182, 218,276, 289 

communication sector xxi, 57-58,282,287,278 

community-based intervention xx,218,221 

community analysis 221-223 

implementation 223 

maintenance 224-225 

planning 223 

(see also COMMIT) 

community campaigns 38,180,237-238 

Community lntervention Trial for Smoking 

Cessation (see COMMIT) 

comprehensive control strategies x-xi, 7, 9,21- 

23, 25-26, 253 

communication sector 57-58 

(see also media; advertising, antismoking) 

economic sector 54-56 

(see also price elasticity; tax, taxes; hiring; 

insurance) 

education sector 56-57 

(see ah schools; school-based 

interventions) 

health professional sector 58-59 

(see also physicians; pharmacists) 

health voluntaries sector 59-60 

(see also American Cancer Society, 

American Heart Association, American 

Lung Association) 

political sector 53-54 

(see also restrictions, smoking; 

advertising, tobacco) 

ConsumerReports 35 

Consumers Union 149 

consumption, tobacco iv-v, 4,11, 17, 75,129, 

204,244 

and antismoking advertisements 85-86 

and mortality studies 85 

and nonsmokers’ rights movement 226 

and price elasticity 242-245 

by blacks 4, 131-132 

by females 4, 130, 132 

by males 4, 130, 131 

cigarette consumption, per capita 11-12, 17, 18, 

36, 75, 81 

current iv-v 

in 1950’s 12, 36, 85-86 

in 1960’s ix,12, 36 

in 1970’s 12, 36, 85-86, 226 

increase after discontinuation of broadcast ads 36 

peak 75 

rates in 1985 203 

related to smoking and health events 203 

trends 244 

World War I 203 

World War I1 81, 203 

(see also behavior, smoking; California; 

prevalence, smoking) 

COPD (chronic obstructive pulmonary 

disease) 115, 116 

coping responses 49 

Cornel1 University 170 

coronary heart disease (CHD) 115,116, 

1 19-123 

cost, effect of cigarettes’ 

see price elasticity; tax, taxes 

covert sensitization 43 

Cuban Americans 

see Hispanics 

CVD (cerebrovascular disease) 115,116 

cyanide 209,273 

Dakota cigarettes 278 

demonstration programs 

see North Karelia Youth Project 

(see also ASSIST) 

Department of Defense 229 

Department of Health and Human Services 

(DHHS) 226,234 

Doctors Ought to Care 59,212,276 

drug therapy 

see cessation program strategies; 

pharmacologic intervention 

economic incentives 239,251-253 

(see also hiring; insurance; tax, taxes) 

education campaigns 3,282 

education sector 56-57 

educational interventions 

see schools; school-based interventions 

Emphysema Slims tennis tournament 212 

environmental effect 271 

environmental influences 52 

environmental interventions 271-272 

media coverage 273-274 

physician actions 275-276 

worksite policies 274-275 

301 
National Cancer Institute 

Environmental Protection Agency (U.S. 

EPA) 225 

environmental tobacco smoke 20,212,215, 

225,227 

esophageal cancer 115, 116 

excise tax 

see tax, taxes 

ex-smokers 

see smokers, former 

ever-smokers 

see smokers, current; smokers, former 

Fairness Doctrine ix, x, 204, 206 

Farmer's Insurance Group 250 

FDA (Food and Drug Administration) 41-42 

Federal Communications Commission ix, 27 1 

Federal Trade Commission 206,209 

females 

adolescent 50-51, 165-166 

advertising aimed at 50-51, 278, 289 

antismoking messages aimed at xi, xx, 148, 278 

barriers to cessation 277-278 

cessation, smoking 14, 16, 112, 123, 277-278 

channels for reaching 278 

consumption, cigarette 4 

content of messages 278 

Hispanic 285 

initiation, smoking 50, 112, 122, 277 

mortality rates 90, 91, 93, 94, 96, 97, 103-107, 

118, 120, 122, 134, 140-144, 277 

pregnant 59,278 

prevalence, smoking iii, iv, 9, 10, 83, 87, 97, 108, 

114, 130, 132,277 

filters 6, 37-38, 45, 47, 48, 116 

Finland (national demonstration 

program) 151 

Five-Day Plan 

see cessation program strategies; SeventhDay Adventist Church 

Florida 

Hispanic population 286 

smoking law 228 

Food and Drug Administration (FDA) 41-42 

Fred Hutchinson Cancer Research Center 162 

free tobacco samples 24,52,210,236-237,284 

Fresh Air for Nonsmokers 59 

Freshstart 

see American Cancer Society 

Gallup poll (on public smoking) 229 

General Accounting Office (GAO) 243-244 

General Motors (cessation program for 

employees) 214 

General Services Administration (GSA) 226 

Good Housekeeping(refused cigarette 

advertising) 278 

Great American Smokeout 

see American Cancer Society 

Group Against Smoking Pollution 212,218 

GSA (General Services Administration) 226 

Hakulinen and Pukkala model (lung cancer 

mortality patterns) 112 

Hanover Insurance Company 250 

Hawaii (use of ad valorem tax) 240 

health care costs vi, 215 

(see also insurance) 

health care providers 58-59,210 

economic incentives for 212 

education 21 1 

regulation of 212-213 

training of 211-212 

(see also physicians, pharmacists) 

health education program 159-161 

health educators 51 

health risks 3-4, 20, 148-149 

(see also bladder cancer; breast cancer; CHD; 

COPD; CVD; kidney cancer; lung cancer; 

oral cancer; pancreatic cancer) 

HHANES (Hispanic Health and Nutrition 

Examination Survey) 285 

high school programs 159 

(see also school-based interventions) 

hiring 239, 245-249, 253 

Hispanics 

acculturation 285, 287, 289 

barriers to smoking cessation 285-286 

channels for reaching 50, 286-287 

content of messages 287-289 

school-based prevention program directed to 162 

tobacco company advertising targeting 276 

Hispanic Health and Nutrition Examination 

Survey (HHANES) 285 

hospitals 212-213,232 

hypnosis programs 38,41 

individual-centered cessation approaches 

see clinical approaches; public information 

campaigns; self-help cessation 

approaches; school-based interventions 

information campaigns 

see public information campaigns 

initiation, smoking iv, 3; 51 

age of 8, 22-23, 96-97, 233 

by females 50, 112, 122, 277 

decreasing 279 

prevention 50-51 

probability of 118 

process of 22-25 

rates of 112-113, 117 

stage model 163-164 

insurance 

cessation efforts, coverage of 250, 282-283 

Costs 56, 108, 215, 239, 249-251, 253 

health 210,249,250 ~ 

life 249-250 

premiums 239, 249-251 

property 249-250 

interagency councils on smoking and 

health 36 

302 
Smoking and Tobacco Control Monograph No. 1 

International Machinists Union (litigation 

against workplace policies) 248 

intervention 

aimed at groups and organizations 282 

antitobacco counseling 21 1 

booster program 168 

channels 205-218 

components 223-224 

during pregnancy 278 

in schools 

see school-based interventions 

information dissemination 216-217 

studies 167-168 

(see also ASSIST; behavior, smoking; 

cessation, smoking; COMMIT) 

tobacco control 205,218,221 

Iowa Lung Association 175 

James I, King 3 

Joe the Camel v-vi 

kidney cancer 115,116 

Kool cigarettes vi 

Lakeside Pharmaceuticals 42 

licensing tobacco merchants 237-238 

life insurance 

see insurance 

life skills 

intervention 155-156, 169 

program 156, 167 

training model 167 

life expectancy 96-97 

LifeSign (commercial self-help product) 

180-182 

Little League Baseball (in smokeless tobacco 

study) 162 

Little Red Notebook program 162 

lobeline (nicotine replacement) 170 

lung cancer 

death rate projections 4, 108-124 

death rates from iv, 3-4, 82-83, 85, 97, 108, 

123,277 

incidence 83, 121-122 

mortality 86i108, 111, 115, 118-124, 133-144 

relation to smoking behavior 76-77, 148 

retrospective studies 35 

(see also health risks) 

m'aintenance strategies 

cognitive restructuring 49 

coping skills 49-50 

social support 49 

males 

cancer mortality iv, 88-89, 92-96, 98-102, 133, 

135-139 

cessation, smoking x, 12-15, 112, 123 

consumption, cigarette 4, 130, 131 

forecast mortality 118-121 

former smokers 13 

Hispanic 285 

initiation, smoking 112, 122 

smoking prevalence iii, iv, 8-10, 82, 84, 114 

Manville Corporation (workplace smoking 

policies) 248 

Markov assumption 110-1 12 

Marlboro Man 205 

mecamylamine (to maintain abstinence) 42 

media 

advocacy 208-209,211-212 

antismoking campaigns using 21,26, 149- 

152,253 

(see also advertising, antismoking) 

black-focused 282 

cessation programs 38 

constraints 57-58, 147-149, 287 

coverage of antitobacco messages 206-207, 

272-274 

influenced by tobacco companies 147-149, 287 

information dissemination ix-x, 12, 57-58, 212 

public relations events 207-208 

restrictions 

see advertising, tobacco 

Spanish-language 287 

Medicare 252 

MerrellDow 42 

Mexican Americans 

see Hispanics 

Minnesota Heart Health Program 218,272 

mortality 

forecast rates 118-123 

from cancer 88-91 

functions evaluating 110 

processes 109 

prospective study 35 

rates for smokers 76, 250 

(see also specific diseases, e.g., coronary heart 

disease; lung cancer) 

mouthwashes (smoking deterrents) 41 

morbidity and mortality 109,278 

Ms.(refused cigarette advertising) 278 

multicomponent programs 

see cessation program strategies 

Multiple Risk Factor Intervention Trial 172 

Natiohal Academy of Sciences 225,227 

National Adolescent Student Health 

Survey 233 

National Association of Insurance 

Commissioners 249-250 

National Automatic Merchandising 

Association 236 

National Cancer Institute (NCI) iii-iv, vi, 

ix, 276 

funding for smoking cessation and 

prevention xix 

Helping Smokers Quit Kit 47 

Pharmacist's Helping Smokers Quit Kit 212 

Smoking and Tobacco Control Monographs 

xx-xxiii 

Smoking and Tobacco Control Program (STCP) 

x, xix-xxiii 

training of physicians 21 1 

303 
National Cancer Institute 

workbook on worksite incentives 245 

National Center for Health Statistics 86 

National Clearinghouse for Smoking and 

Health 36,38,235 

National Death Tapes 86 

National Health Interview Survey 77-80, 112, 

115,242 

National Interagency Council on Smoking 

and Health 38,225 

National Medical Association 281 

National Organization of Women 278 

National School Boards Association 217 

National Surveys on Drug Abuse 243 

Native Americans 165 

NCI 

see National Cancer Institute 

Nevada (tobacco bonfire) 212 

New England Research Institute 162 

New Jersey Group Against Smoking 

Pollution 212 

New York, City of (antitobacco ordinances) 

210,229 

New York State Health Department (hospital 

regulation) 213 

Nicorette 

see nicotine gum 

nicotine 

addiction 25 

replacement therapy 42, 55, 177 

self-help materials 180 

withdrawal 37 

nicotine gum 27, 38, 39, 42, 50, 59, 176-179 

and behavioral counseling 174 

and self-help approach efforts 180 

effectiveness 41, 171 

prescriptions 178 

requested by patients 178 

nicotine polacrilex (Nicorette) 

see nicotine gum 

Non-Dependence Day 

see American Lung Association 

nonsmoker discounts 

see insurance 

nonsmoker hiring practices 

see hiring 

no-smoking laws 

see restrictions, smoking 

nonsmokers’ rights movement 52,226,230 

North Carolina (laws, taxes) 228,240 

North Carolina Mutual Insurance 

Company 283 

North Karelia Youth Project 151,169,172 

Office on Smoking and Health 47,234 

Oklahoma (employment policy) 248 

oral cancers 115, 116 

ordinances, antismoking 

see restrictions, smoking 

Oregon Research Institute 161-162 

pancreatic cancer 115,116 

participation elasticity 243 

Pasadena, California (smoking 

restrictions) 230 

Pawtucket Heart Health Program 272 

peer education 165,281 

Pennsylvania (media market study) 207 

Pennsylvania Plan for Tobacco or Health 215 

Pet0 model (risk oflung cancer) 115-116, 119 

pharmacists 58, 211-212 

pharmacologic intervention 171 

(see also lobeline; mecamylamine; nicotine 

gum; transdermal patch) 

Philadelphia (campaign against Uptown 

cigarettes) 281 

physicians xix, 59, 253 

as activists 275 

cessation programs 39, 41 

cessation resource 178, 180 

counseling 25, 37, 182 

educating individual smokers 281 

prescription of nicotine gum 42 

relationships with Hispanics 288 

source of cessation advice 26, 176-1 77, 21 1, 

275-276 

preferential hiring policies 

see hiring 

pregnancy 

see females 

prevalence, smoking iii-v, 75-77, 80-86 

blacks 80, 83-86, 108, 278 

changes among birth cohorts 80 

conclusions 231-232 

declines 245, 277 

down significantly past 20 years 276 

effect of taxes 

see price elasticity 

estimates 79, 112, 115 

females iii, iv, 9, 10, 78-83, 86, 87, 97, 108, 114, 

130, 132,277 

high among disadvantaged 276 

high among those with the lowest education and 

income 276 

Hispanics 285 

in the United States 5 

lower income groups 245 

males 8, 10, 78-86, 130, 131, 277 

peak 80-86 

whites 80, 83-86, 97, 108 

worksites 229-230, 233 

price elasticity 17, 24, 26, 242-245, 253 

psychosocial cessation approaches 

see school-based interventions; socialpsychological models 

public information campaigns 147,182 

counteradvertising 149 

persuasion 149-152 

presentation of smoking hazards ix-x, 5-6, 11-12, 

14, 25, 148-149 

(see also advertising, antismoking) 

304 
Smoking and Tobacco Control Monograph No. 1 

public service announcements 36,207,287 

public smoking 20, 53, 55-56, 218, 225-229, 

270, 271 

Puerto Rims 

see Hispanics 

quit attempts 

see cessation, smoking 

quitting smoking 

see cessation, smoking 

rapid smoking 43,174-175 

(see also aversion therapy) 

Reader3 Digest 35 

regressive tax 

see tax, taxes 

relapse prevention 45,48-50 

(see also cessation, smoking; comprehensive 

control strategies; maintenance 

strategies) 

restaurants, smoking in 20,55-56 

restrictions, smoking 53, 212-215, 225 

airlines 226 

effects of 229-233 

encourage social influence programs 162 

Federal laws 53, 226-227 

in hospital 232 

in restaurants 20, 55-56, 227 

limited cigarette smoking 148 

local laws 53, 228-230, 238-239 

municipal laws 210, 234, 235, 237 

public opinion of 229 

public places 227 

schools 217 

State laws 53, 217, 227-230, 234, 238-239, 286 

violations 229 

worksite 53, 215 

(see also free tobacco samples; vending 

machines; worksite) 

Richmond, California (study among black 

people) 279,281,284 

Richmond Quits Smoking Project 281-283 

risk factor interventions 108-109, 112-113 

RJR Nabisco v-vi 

rolling machines, cigarette 3, 148 

Rolling Stone v 

San Francisco Board of Supervisors (worksite 

ordinance) 228 

satiation 

see aversion therapy 

Schick Center 

see commercial stop-smoking programs 

schools 

cessation classes 39 

curricula on tobacco 56-57, 217 

health education programs 14 

health programs 160-161 

information dissemination 56-57, 216-217 

link to smoking initiation 217-218 

regulation of 217-218, 239 

smoking policies 53, 57,216-218 

smoking prevention programs 39 

school-based interventions xix, 157, 182 

affective model 153 

cognitive behavioral model 153, 154-155, 

163-166 

delivered by health educator 158 

delivered by teacher 157-158 

information model 152-153 

life skills model 155, 166-170 

peer delivery 158, 160 

program staff delivery 159 

social influences model 154, 156-162 

social-psychological approaches 152-153 

sedatives 41 

self-esteem, self-worth 20, 21, 23,24 

self-help cessation approaches xix, 27 

acceptability 180-181 

effectiveness 6, 180, 182 

importance 181-182 

materials 46-48 

self-image 24 

self-management 44-46 

contingency contracting 44, 46 

nicotine fading 44-45, 48 

program differences 50 

restricted environmental stimulation therapy 

44,46 

self-monitoring 44 

stimulus control 44, 45, 48 

systematic desensitization 44, 46 

Seventh-Day Adventist Church 38-40 

Five-Day Plan 40 

silver acetate 41 

SmokEnders 

see commercial stop-smoking programs 

smoke-holding 

see aversion therapy 

SmokeLess 

see commercial stop-smoking programs 

smokeless tobacco 

health campaigns against xx, 147-148 

use by adolescents 51-52, 233, 236 

smokers, current iii-iv, 5, 11, 15, 16, 20, 23, 92, 

98-107, 113-116, 179, 232 

(see also adolescents; blacks; females; 

Hispanics; males; whites) 

smokers, former 12, 13, 14,48,49,113, 116, 179 

(see also adolescents; blacks; females; 

Hispanics; males; whites) 

Smoker’s Self-Test 40 

Smoker’s Self-Testing Kit 47 

Smoke Stoppers 

see commercial stop-smoking programs 

Smoke Watchers 

see commercial stop-smoking programs 

smoking 

see addiction; behavior, smoking; cessation, 

smoking: consumption, tobacco; 

initiation, smoking; prevalence, 

smoking; restrictions, smoking 

305 
National- Cancer Institute 

Smoking and Tobacco Control Monographs 

see National Cancer Institute 

Smoking and Tobacco Control Program 

(STCP) 

see National Cancer Institute 

Smoking Control Advocacy Resource 

Network 209 

smoking control interventions 

see media; intervention; physicians; 

school-based interventions; worksites 

smoking policies 212-213, 230, 274-275 

s,ocial acceptability ix, 17,20,225,251 

social influences model 161-162 

social learning theory, Bandura’s 151 

social norms 21,25,27,58,203,270 

social pressures to smoke 23,26,49, 159, 

288-289 

social workers 164 

social-psychological models 152 

sports, sponsorship of 273,280,284 

Stanford Five-City Project 218, 272 

Stanford Three-Community Study 272 

STAT (Stop Teenage Addiction to 

Tobacco) 238 

State Mutual Life Assurance 249 

STCP (Smoking and Tobacco Control 

program) 

see National Cancer Institute 

Steinfeld, Jesse L., M.D. 20,225 

Stop Teenage Addiction to Tobacco 

(STAT) 238 

students 

see adolescents; high school programs; 

schools; school-based interventions 

Surgeon General, Surgeon General’s Reports 

(see U.S. Surgeon General) 

SweetHeart Day 55,59 

(see also American Heart Association) 

sympathomimetics 41 

tax, taxes 

ad valorem 240 

California 17-20, 26, 54, 207, 240, 244 

excise 17, 19, 207, 239, 240, 241, 244, 251- 

253,271 

Federal 54, 230, 240-241 

funds for antitobacco research 54 

increases 18, 243,245 

influence on cigarette sales 17, 26, 52, 271 

local 54 

on tobacco products 53, 54, 230, 251-252, 271 

regressive 25 1 

“sin” tax 207 

state 54, 207, 230, 240-241 

teenagers, teens 

see adolescents 

Teledyne Water Pik (commercial self-help 

device) 47 

Terry, Luther ix 

Texas Department of Human Services (strict 

smoking policies) 230-231 

tobacco companies v 

(see also tobacco industry) 

tobacco control 219-220 

actively marketing 214-215 

enhanced with media training 211-212 

fivegoals 210 

groups and organizations 218 

interventions 205, 218, 221 

plan 224 

research, retrospective and observational 272 

tactics and techniques 269 

to focus on community resources 222 

twogoals 213 

worksites as an important channel 213 

(see also interventions; National Cancer 

Institute) 

tobacco industry v, vi, 17, 148-149,233,270, 

276,287 

Tobacco Institute 271 

tobacco prevention programs 

see comprehensive control strategies; 

intervention; school-based interventions 

tobacco use 

see behavior, smoking; consumption, 

tobacco; prevalence, smoking; smokeless 

tobacco 

tranquilizers 41 

transdermal patch (nicotine replacement) 

177 

unemployment offices (channel for self-help 

materials) 281 

Uptown cigarettes 281,284 

U.S. Surgeon General 225 

report on smoking and health (1964) ix, 12, 36, 

149,203, 249, 271 

report on smoking (1972) 225,227 

report on women and smoking (1980) 70, 77, 79 

report on cancer (1982) 178 

report on disease in the workplace (1985) 77 

report on involuntary smoking (1986) 225, 227 

report on 25 years of progress (1989) 113, 

234,242 

Surgeon General’s reports xxii, 36, 208 

(see also Steinfeld, Jesse L., M.D.; Terry, 

Luther) 

U.S. Tobacco Company 237 

vending machines 20,234-239 

Vipont Pharmaceuticals 48 

Virginia Slims 212,233,273 

whites 

cessation, smoking x, 13-16, 112, 122-123 

consumption rates, cigarette 4, 131-132 

initiation, smoking 112 

mortality 89-92, 94-107, 133-144 

mortality forecast 118-120 

prevalence, smoking iv, 9, 84, 87, 114 

306 
Smoking and Tobacco Control Monograph No. I 

Wisconsin Department of Health and Social 

Services (effects of antismoking 

campaign) 230 

withdrawal clinics 

see cessation program strategies 

worksites 

cessation programs 54-55, 214, 275 

involvement in smoking control 54-55 

nonsmoking requirements 249 

regulation of smoking 20-21, 213, 227-228, 230-

233, 253, 274-275 

smoking education 214-215 

(see also hiring) 

youth 

see adolescents 

307 
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