Tobacco Documents Online

I 1208 American Joumal!of Public Health Annotation Smoking Control in the 1990s: A National Cancer Institute Model for Change The geat obstacle to prevention is the devebpment of methods for complete application of the knowledge and mea- StnCSRY tIGW d~Fa`A~es of application affect both research and ptactioe. What is now known is not be- ing fiilty applied. -teona.dA. SdteelS MD Stogeon Genem; 1956 We need to transfer our current re- seairh hnowletige into common medical and personal health practices sooner. I'm disappointed by the waywe use, or I should saythewaywe don't use, what is already known. -7ames O. Masort,l4ID .i==nt Soatwary forHealth, 1992 January 11, 1994, marks the 30th an- II1vCtsaty of the Surgeon GCAC[al's Adv6S- ory Committee Report,l which unequivo- cally concluded that "tagarette smoking is a health hazard of sufficaent importance in the United' States to warrant appvprate . ranedial actiat"-wA (emphasis added). Most people consider that report to be the starting point of the smoking control movement in this country. But despite near annual reports since, each doc.ument- mg a longer list of fatal diseases, we still lack a cohesive, integrated, national pub- lic health strategy for reducing what Pres- ident Ronald Reagan's Council of Eco- nomic Advisers labeled "the greatest „ avoidable risk'." to .. health an :~American. _, . . - sodety.2(pt54) For decades, in fact, our country's national institutions, including those charged with protecting the public health, have not provided the leadership or the fiscal resources to support a level of remedial action commensurate with solv- ing this natiori's No: I cause of prematuie ' death and disability. At the National Cancer Institute (NCI), fortunately, this situation began to change following release of Dr. C. Everett Koop's first report as SurgeoroGeneral'in 1982. After The Health Consequatces of Smoldng: Cancer clearly identified cagarette smoking as the "major singie cause of cancer mortality in the United States,"-Xwi the leadership of the NQ re- sponded by making the reduction of smoking prevalence the cornerstone of a renewed and invigorated cancer preven- tion and control strategy. To help guide this effort, the NQ adopted a muitiphased rescanch plan to develop, test, and dissem- inate effectrve smoking prevention and cessation iateiveatioas.4 To achieve a sig- nificant reduction in smoldng rates as quickly as possibk, the plan particularly emphasizod the public health application of those methods that were proven to be effective. Between 1984 and 1993, nearly 100 smoldng inteivendott trials were funded at a oost oooetding $300 mt7lion--mone than S60 mtllion this year alone. So~ trials focused on the study of intervention channels such as schools, health care settings, self-help techt»qttes, and the mass media; others ex amiaed 'mttxvendoos that target gttixtps at high risk.suchasmmoiitiGS,youdt,women, and heavy smofaass To assess the oom- bined effecxiveness of these and other sttat: egies when- integrated into a community framework, the NQ launched the C'.otnmu- nity Interventiort..Trial for Smoldng,C'.essa•.. , .. : <. tioa (QOrIIvITI) 6 CD1tiIlVIIT, with a popu- lation of more than 1 million people in 11 cities, is the largest such randomized trial ever atteatpted and has provided the NQ with years of practical ettpetienoe in work N ing with real conuntmities in the implemen- Q tatioti and * maiiagement of a coutprehen- ~ sive, multichanneled tobaeco use reduction effort.54 M Im Editor's Note. See related editoriall by ~ Wynder (p 1204) in this issue_ ~ September 1991 Vol. 83, Na, 9

As findings from this research base emerged in the early 1990s, the program began plans to implement a large-scale detrtonstration project that could contnb- ute to a national'reduction in smoldng by the turn of the century. This process cul- minated' in ASSIST-the American Stop Smohing Intervention Study for Cancer prevention.s ASSIST is the largest, most cotnpre- hensivt public health-based stnoldng con- trol project ever undertaken in the United States. In October 1991, following a year- long national competition involving 37 states, 17 state health departments were awarded ASSIST conttacts. These 17 AS- SIST states (see Figure 1) have a com- bined population of 91 million people, or slightly more than a third of the total US pop ttation; 'n r.n!iion are chtld_*en and ad- olescents, and nearly 20 miAion are regu- lar tobacco users. Tbese states also con- tain significant minority representation; more than 10 mtllion in their populations are African American and 7 million are Hispanic or other ethnic group. ASSIST represents a national part- nership involving not only the NQ and 17 state health departments, but also the na- tional and state divisions of the American Caneer Society and thousautds of oommtN nityhealthand social service agencies and organizations that have joined state and local tobacco control coalitions. Total NQ outlays will exceed $120 mt7lion, and the American Cancer Societywdl oontrib- ute an additional SZ5 to 30 miilion for local smoking control plan. In the intervention phase, starting in October 1993 and con- tinuing at least through 1998, sites will im- plement their plans. State programs will use proven interventions in work sites, health care settings, schools, community groups, and the mass media. Detailed guidelines and extensive training has been provided to assis<the states in their efforts and to make sure that ASSIST internn- tions are oonsistent witlt current scieatific latowledge. While prevention and cessa tion intervention services are an integral component of the project, ASSIST places the most emphasis on the strategic use of staff, matet•iaLs, volunteers, and in-Idnd media and the adoption and implementa support. And because ASSIST is a dein- tion of'those tobacco'control policies that onstration project and not a controlled support nonsmoking as the accepted com- otial, the vast majority of fiscal resourres munity norm. being provided to the states is to be used To date, more than a thousand orga- in direct support of smoking control inter- nizations have joined ASSIST coalitions, ventions at the state and local levels, and this number will grow as ASSIST The scientific basis for the ASSIST moves ftom a planning to an intervention approach is ckarty detailed in the NQ's mode later this year. When ASSIST fund- first Stnoldng and Tobacxo Conu+ol Mono- ing ends, these organizations may provide gaph.9 Titied Stmtegies to Control To- the long-term oommunity-based smoking baccct •(Ise jn the.U.nited. conttnl infrasnucxure that to date has been print for Public Healih Action in the so lacldctg in this effort; atid they cau ac=' 1990's, the monograph provides a detailed complish this at a fracxion of what it would; summary of what has been learned' over cost the federal government. Further- the last 40 years of the public health effort tttore. ASSIST is expected to have signif- against smoking, and why comprehen- icant spin-off potential by providing the sive, community-based smoldng control impetus for other localities to adopt a strategies are now iteeded to reduce smok=. '. sttvttger -tobacoo control focus. ing prevalence nationwide. During the fust24 months of the proj- ect (its planning phase), each state con- ducted a detailed site analysis and needs assessment; then, following a careful re- view of these findings, each state devel- oped its own comprehensive, 5-year In effect, ASSIST represents a rna-. jor, science-tested intervention model ca- pable of contributing to a significant re- duction in smoking prevalence in support of the year 2000 health goals for the na- tion_10 'Drawing upon this modeC; as well as upon others, the Centers for Disease Control and Prevention's Office on Smok ing and Health recently announced a $3 million program to help non-ASSIST states incze.ase teir capacity for smoking control with the possibility of additional funding next year. Resonrces for smoking control pales, however, when compared with the $3.9 btllion that the major cigarette manttfac- tttrers spend annually to advertise aad promote their deadly producar.u To put this in perspective, during the entire 7 year life of ASSIST, slightly more than $1 will be spent per capita to convince people not to smoke whereas industry per capita spending will average $100. Unless substantial resouroiis can be aommitted too help redress this imbalance, the goal of a smoke-fnee society will remain years, if not generations, away. p Dcnald R ShopdmAd The author is with the Smoking and Tobaooo Control Progtam, Nationat Caacer Ittst:Mue. Bethesda, lvm. Requests for reprints should be sent to Doaald R. Shopland, National Cancer Instt- tqte, EPN-241, 9000 Rockville Py7ce, Bethesda, Cj References 1. Smolmtg and Health. RepoK of the.4dvis- oty Corrvnittee to the Sargeon Gateml of 1, alu PuLllc F7erldt Savicea W ivashington, DC: US Dept of Health, Education and ~ Welfare; 1964: DHEW pubVicatiott u03. .-N 2 Eeonorrtie report of the president risk and ~ responsibility. In: 77w Annual Reporr of ~ the Presrdent's Council of Economic Ad- visers. Washington, DC: President's CounV,- cil of Eoonomic Advisers; 1987: ~ 3. The Health Consequences of Smolwtg: Cancer. A Report of the Sargron Genetn! -148Z Rockvillt, Md: US Dept of N

Anwtatlun Health and Human Services; 1982- DHHS publication PHS 82-50179. 4. Cullen JW. Cancer prevention and the Smoking. Tobacco, and Cancer Program of the National Cancer institute. In: Mizell M, /` Correa P, eds. Cancer Causes and Ptr- ( entiorL New York, NY: Verlag Chemie International, lnc; 1984. 5. Shopland DR, Massey M, eds. Stteoldttg Tobacco, and Cattcer Ptngrrtm: 198.5-1 AB9 Status Reporr. Washington, DG US Dept of Health and Human Services, Public Health Service; 1990. NIH publication 90- 3107. 6. Lichtenstein E, Wallack L, Pechacek T, eds. The Community Intetvcntion Trial for Smoking Cessation (COMMIT). 1nt Q Cor.tmunity Health Educ. 1990-1991;11: 169-309: Special issue. 7. Thompson B, Wallack I., Lichtcnstein E, Pechaeeic T. Principles of community or- ganization and partnership for smoking cessation in the Community Intervention Trial for Smoking Cessation (COMMIT): Int QCornmtntiryHealtlt Edue 1990-1991;'. 11:187-204. 8. McKenna J, Carbone E. Huge tobacco control project begun by NCt, ACS:JNatl Cancer Inst 1989;8193-94. 9. Strategies to Corutvl Tobacco Use in the Planning Themes in the Journal: A Call for Papers United States: A Blueprint for Public HealtltAcrioa in the 1990's. Bethesda, Md- National Cancer Institute; 1991. Smoking and Tobacco Control Monograph 1. NIH publication 92-3316. 10. Healthy Peoplc National Health Pronto- tion and Disease Pteventiott Objectiucc Washington, DC US Dept of Health and Huntan Services, Public Health Service; 1991. DHHS publication PHS 91-50213: 11. Federal Trade Commission Report to Gxt- gnss: Pusttont to the Federal Cegatette LabeGng and Advrrtiting Act- Washing- ton, DC: US Federal Trade Commission; 1992. We are engaged in a small experiment. For three upcoming issues, we have announced the featured theme ahead of time. To ensure the submission of a sufficient number of papers, we invite potential authors among our readers to submit paperss relevant to the chosen topics by the dates announced. In recent volumes, Journal editors have successfully assembled themes out of the material on hand. Reader response has been positive. Theme issues announced in advancewill bemorecoherentthanthosectratedfrom random submissionsifthey attract the number of authors we hope for. They will also enable us to indicate the Journal's intett*st in neglected areas that authors may not see as high on our agenda now. Our first call for papers, announcing three topics, was published in the November 1992 issue of the Journal. Papers submitted for the first theme. "Children: Societal and Individual Violence, Injury, and Abuse" (deadline was April 1, 1993), have been reviewed; those revised and,accepted will be published together. Papers submitted forthe . and second theme,"Age and Aging: Epidemiology, Health Care, and General Public Health" (deadline was August 1,1993), are now under review. (Please note tha6submissions on these two themes are welcome at any time.) The third theme and its deadline for submission is as follows: Pr3tna "ry Care and Public Health Submissiorts due February 1, 1994 Before sending us your manuscript, please consult "WhatAJPH Authors Should Know; " published:ia each.issue; pf 4he Journal and,wailabl.e~ hom the offtx,.foz,$landa~d.s.of ., submission and address. 1210 American Joumal of Public Health Se Septnmtx-r 1993, Vol. 83. No. 9