HEALTH EDUCATION RESEARCH Vol.15 no.3 2000Theory & Practice Pages 353–366

Durability of tobacco control efforts in the 22Community Intervention Trial for Smoking Cessation

(COMMIT) communities 2 years after the end ofintervention

Beti Thompson, Edward Lichtenstein1, Kitty Corbett2, Linda Nettekoven1 andZiding Feng

Abstract

Funding organizations increasingly want toknow that successful interventions are continuedafter the end of a research project. Assessmentsof durability are rare and where done do notinclude the comparison communities. In thisstudy we ascertain what tobacco control activit-ies continued in intervention communitiesinvolved in the Community Intervention Trialfor Smoking Cessation (COMMIT), a random-ized, controlled community trial aimed at adultsmokers, and also assessed level of tobaccocontrol activities in the comparison communit-ies. A mailed survey of key informants includingpaid staff and community volunteers inthe 22 COMMIT communities was conducted.Approximately 79% of key informantsresponded to the survey. Although there wasevidence that tobacco control activities werecontinuing in the intervention communities,there was an equal amount of tobacco controleffort in the comparison communities. Withinthe specific tobacco control intervention areas,only the youth area showed more activity inintervention communities than comparisoncommunities. We conclude that despite a posit-ive trial outcome, differential durability was not

Fred Hutchinson Cancer Research Center, 1100 FairviewAvenue North, MP-702, PO Box 19024, Seattle, WA98109-1024, 1Oregon Research Institute, 1715 FranklinBoulevard, Eugene, OR 97403-1983 and 2University ofColorado at Denver, Anthropology Department, CampusBox 103, PO Box 173364, Denver, CO 80217-3364, USA

© Oxford University Press 2000 353

achieved. More work needs to be done to assistcommunities in maintaining proven interventionactivities. More study of methods to measuredurability is also needed.

Introduction

Many foundations and other funding agenciesexpect research projects to leave something behindin the communities in which successful behaviorchange interventions have been conducted (Tarlovet al., 1987; COMMIT Research Group, 1991;Altman, 1995; ASSIST Working Group on Durabil-ity, 1996). This expectation is often predicated onthe assumption that successfully addressing animportant community problem leads naturally intoa desire by the community to continue interventionactivities (Kelly, 1979; Green and McAlister, 1984;Wallack and Wallerstein, 1986; Tarlov et al., 1987;Altman et al., 1991; Jackson et al., 1994; Altman,1995). Mobilization of a milieu, whether it be aworksite (Sorensen et al., 1990; Abrams et al.,1994; Glasgow et al., 1996), an organization(DePue et al., 1987; Elder et al., 1989; Corbettet al., 1995), a school (Scheirer, 1990; Resnicowand Botvin, 1993) or an entire town (Carlaw et al.,1983; Farquhar et al., 1985; Elder et al., 1986;COMMIT Research Group, 1991), often involvesa partnership between members from the milieuand researchers. By the end of the research phase,if an intervention has been successful, partnersfrom the community setting often wish to have themeans for project durability (Altman et al., 1991;Lefebvre, 1992; Bracht et al., 1994; Lichtensteinet al., 1996). Unfortunately, many research organ-

B. Thompson et al.

izations simply remove themselves, leaving it up tothe community to find ways to maintain successfulprojects. Often, this leaves the community partnerswithout resources, capabilities or other avenues toaddress the original problem. Such an action onthe part of researchers is considered inconsistentwith the principles of community ownership andpartnership (Green and McAlister, 1984; Wallackand Wallerstein, 1986; Thompson and Kinne, 1990;Thompson et al., 1990/91).

There are many good reasons to encourageperpetuation of successful intervention results andsometimes even equivocal results. Population-levelchange often requires more time than is funded byan external agent; thus a small immediate changemay lead to a larger change in the long run(Puska et al., 1979, 1983; Henderson et al., 1995;Beresford et al., 1997). Long-lasting and wide-spread behavior changes require alterations in‘rules for living’ (i.e. social norms) so that anew behavior is thoroughly incorporated into thesociety. To accomplish such a task, however, isnot a trivial undertaking and often needs more timethan research projects allow. The North Kareliaproject, for example, did not see changes in smok-ing behavior until 10 years after the project wasinitiated (Puska et al., 1979, 1983). The Commun-ity Intervention Trial for Smoking Cessation(COMMIT) did not begin to see results in smokingcessation until 3 years after the communities wererandomized (COMMIT Research Group, 1995a).

To facilitate long-lasting programs, sponsoringorganizations often state that their purpose infunding a particular project is to provide ‘seed’money until the effectiveness of a program can beassessed (Tarlov et al., 1987; COMMIT ResearchGroup, 1991; Altman, 1995; ASSIST WorkingGroup on Durability, 1996). In recognition that itis very costly to establish large-scale studies,sponsors typically provide initial resources whichgradually dwindle as the project draws to a close.Sponsors also believe the seed money should havegenerated other resources by then and that asuccessful program should be ongoing. In an eraof scarce resources, however, obtaining the

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resources to continue a successful program canbe difficult.

Public health researchers have a responsibility towork for maintenance of successful interventions.Altman et al. (Altman et al., 1991) summarize itbest when they note that research findings must beapplied to have a public health effect. Part of thatapplication is enabling communities to continue toconduct disease prevention or health promotioninterventions (Jackson et al., 1994).

Only recently have a handful of researchersinvestigated what happens to large communityprojects once the external funding has been with-drawn (Bracht et al., 1994; Jackson et al., 1994;Lichtenstein et al., 1996). Few data-based studieson maintenance have been published and theexisting literature focuses only on communitiesinvolved in the intervention arm of the trial andnot on comparison communities that also may havemade changes. For example, the Minnesota HeartHealth Study reported that 60% of interventionactivities were incorporated and continued in thethree intervention communities 3 years after theeducational intervention ended (Bracht et al.,1994). During the late 1980s and early 1990s,however, there was much emphasis on health andthe Minnesota investigators pointed to a strongsecular trend as the reason for reduction of riskfactors in the comparison communities. Thus, it isnot clear that the intervention activities maintainedin the three intervention communities were similarto or different from those of the comparisoncommunities which may have also implementedsimilar programs and activities. In a report oncapacity-building activities for the Stanford Five-City Project, process data indicate that individualsin one community attended training sessions, andwere successful in obtaining grants and becominga model test site (Jackson et al., 1994). Again, itis not clear how the non-intervention comparisoncommunities fared.

Previously, we reported evidence for consider-able durability of tobacco control activities in the11 intervention communities of the COMMIT trial12 months after the end of intervention activities(Lichtenstein et al., 1996). At that time, we did

Durability in the 22 COMMIT communities

not collect information on the comparison commu-nities. In this paper, we report on the level oftobacco control activities in all 22 COMMITcommunities (11 intervention and 11 comparison)2 years after the end of the intervention phase. Inthis study of durability, we are particularly interes-ted in learning whether, and to what extent, tobaccocontrol activities in COMMIT intervention com-munities are of a greater magnitude than thosein comparison communities where COMMIT-likeintervention activities were not conducted. Com-parison communities, however, were not prohibitedfrom conducting tobacco control activities and thevast majority of communities in the US have avariety of tobacco control activities taking placeregularly (Thompson and Hopp, 1991). However,we hypothesized that communities that were activeparticipants in a comprehensive tobacco controlproject would have more tobacco control activitiesafter a project ends than communities not particip-ating in a comprehensive project.

Background of COMMIT

COMMIT was a 7-year, multi-center, randomizedcontrolled trial designed to assess whether a com-prehensive community-oriented intervention couldassist smokers, especially heavy smokers, inachieving and maintaining long-term smoking ces-sation. Eleven pairs of communities (10 in the USand one in Ontario, Canada) participated in the trial.Each community pair was matched on demographiccharacteristics. After a baseline survey which deter-mined smoking prevalence for each communityand recruited evaluation cohorts of heavy, light tomoderate and ex-smokers, one community in thepair was randomized to an intervention conditionand one to a comparison condition (COMMITResearch Group, 1991). The 11 intervention com-munities established Community Advisory Boardsto guide the project activities and followed astandardized protocol which also permitted somecommunity-specific activities (COMMIT ResearchGroup, 1991). The National Cancer Institute (NCI)regarded the money it gave the communities as‘seed money’ and expected communities to contrib-

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ute resources in kind to the project (COMMITResearch Group, 1991). Over 4 years of interven-tion, activities were targeted to health care pro-viders, worksites, organizations, schools, mediaand cessation resources so that community smokerswould hear regular and repeated messages aboutsmoking cessation. The results of the trial showedthat the intervention had no effect on heavysmokers but that light to moderate smokers had astatistically significant greater quit rate in theintervention communities compared to the controls(COMMIT Research Group, 1995a,b). Further, thequit rate was higher among less educated light andmoderate smokers compared to their more educatedcounterparts. More detail on the trial’s organization,goals and outcomes have been presented elsewhere(COMMIT Research Group, 1991, 1995a,b).

Durability of tobacco control activities was notoriginally considered an important goal of COM-MIT; however, as the trial progressed, investigatorsand community members alike expressed interest inmaintaining at least some tobacco control activitiesafter the end of the research. The investigatorsand the NCI began facilitating planning for thedurability of COMMIT-like activities at the begin-ning of the final project intervention year. By theend of the project, all 11 intervention communitieshad established ‘transition committees’ to explorethe possibility of continuing tobacco control activit-ies after the research aspect of the project ended.Each transition committee wrote a plan detailingwhat tobacco control activities would continue andhow they would be done. One year after theexternally funded intervention activities ended,nine of the 11 intervention sites still had a coalitionor board directing tobacco control activities, ninehad dedicated funding for tobacco control and10 had paid staff to work on tobacco control(Lichtenstein et al., 1996). Overall, there weresuggestions of considerable durability of tobaccocontrol in the intervention communities.

Methods

Defining durabilityThere are many ways to define durability. Someresearchers have noted that durability is ‘institu-

B. Thompson et al.

tionalization’ of an intervention program into anexisting organization and have developed indic-ators for assessing institutionalization (Goodmanand Steckler, 1989; Goodman et al., 1993). Othershave measured the level to which various programparts of an intervention are retained by organiza-tions within a community and called that ‘incorp-oration’ (Bracht et al., 1994). Some researchersargue that diffusion of intervention programs to apolicy level (e.g. executive orders, legislation,school policy) is necessary for durability (Altman,1995). Yet others believe that durability requiresthat even more activity around a problem continueafter the project ends (ASSIST Working Groupon Durability, 1996). The words used to definedurability vary, and include institutionalization,incorporation, capacity-building and sustainability,each with its own nuances of meaning.

In this study, we use the term ‘durability’ tomean that some level of COMMIT-like tobaccocontrol activities existed within the interventioncommunities (Thompson and Winner, 1999).Because the kinds of tobacco control activities thatwere promoted by COMMIT can be found inmost US towns (Thompson and Hopp, 1991), wedeveloped instruments that could be applied toboth intervention and comparison communities toascertain whether any differences existed betweencommunities. The activities are described in moredetail below.

Key informants

It was necessary to identify persons who couldspeak for the community about tobacco controlactivities. Knowledge of tobacco control activitiesin a community is generally found among paidemployees or volunteers in specific organizations.A list of such types of organizations was developeda priori (see Table I). Informants who held occupa-tional positions assumed to be closest to tobaccocontrol activities (e.g. the health voluntary organ-izations; the health department; substance abuseprograms) in the organizations were consideredthe ‘experts’ about activities that were happeningin the community. Key informants were identifiedin all 22 communities. Many of the key informants

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were identified through the COMMIT communityanalysts, individuals who maintained regular con-tact with individuals in intervention and compar-ison communities during the COMMIT trial. Incases where an individual was not known for aspecific organization, telephone calls were madeto establish who in the organization would be mostlikely to know about tobacco control activities.

In addition to the experts, other informants werealso identified. These were individuals who hadpreviously been involved with the COMMIT pro-ject or who were other community spokespersons.Understandably, there were many more ‘other’informants in the COMMIT intervention commu-nities.

Questionnaire distributionMailed questionnaires were used to collect data.Reasoning that informants might know what washappening in their own area but not in others, threeseparate questionnaires were developed: one eachfor health care providers, worksite-related groups,and schools and substance abuse programs. Inaddition, an overall questionnaire was developedfor the key informants who were expected to knowabout general tobacco control activities in thecommunity. This fourth questionnaire includedquestions related to the following: (i) the existenceand characteristics of a tobacco control coalitionor group; (ii) where the latest information ontobacco control could be found; (iii) knowledge ofactivities of both pro- and anti-tobacco groups;(iv) tobacco control activities carried out by healthcare providers, worksites or health voluntarygroups; (v) whether information was available forsmokers on where they could get help in thecommunity; (vi) community-wide tobacco controlevents that occurred (e.g. Quit & Win contests);and (vii) youth tobacco control activities.

The four intervention community questionnaireswere revised for the comparison communities;specifically, questions asking about long-lastingeffects of COMMIT were not included becausethe comparison communities had not participatedin the interventions. Thus a total of eight question-naires was developed, four for the intervention andfour for the comparison communities.

Durability in the 22 COMMIT communities

Table I. Key informants’ organizations, positions, questionnaire portions and numbers in the 22 participating communities ofCOMMIT, with experts and others designated

Organization Position(s) Questionnaire Respondents (N)portion(s) asked

Intervention Comparison

Expert informantshealth department medical officer(s)/health education all portions 11 7

specialist(s)local newspaper(s) health editor(s) and writer(s) all portions 9 10health voluntaries

American Cancer Societya manager, appropriate volunteer(s) all portions 6 10American Heart Associationa manager, appropriate volunteer(s) all portions 6 7American Lung Associationa manager, appropriate volunteer(s) all portions 6 8

existing tobacco coalition manager, appropriate volunteer(s) all portions 6 18medical society chair, medical staff medical section only 7 6hospital(s) public education specialist(s) all portions 18 17health care (other) dental society, dental staff medical section only 3 7chamber(s) of commerce president, secretaries worksite section only 9 6wellness council(s) public education staff worksite section only 0 2school superintendent office curriculum advisor/policy enforcer youth section only 12 15substance abuse program(s) curriculum advisor/program leader(s) youth section only 4 4youth agency/group(s) program leader(s) youth section only 0 3

Total Expert Set 97 120Other informants prior COMMIT members/other 104 8

community spokespeopleTotal informants overall 201 128

aAdapted for Canadian communities.

After pre-testing, the cover letters and question-naires were sent to all key informants. Three weekslater a reminder postcard was sent. If no responsewas received, in another 3 weeks a new packetwas sent followed by a reminder postcard 3 weeksafter that. Telephone calls were made to non-respondents encouraging them to return their ques-tionnaires. If the non-responder desired, s/he couldprovide the information to the telephone inter-viewer. If key informants had left their positions,recipients of the questionnaire were asked to passit on to the person who would be best qualified tocomplete it.

The questionnaire required 20–40 min to com-plete. The questionnaire, cover letters and themethods were approved by the Public HealthSciences Clearance Officer and the Office of Man-agement and Budget. The study also was reviewedby Institutional Review Boards at the Fred Hutchin-

357

son Cancer Research Institute and the OregonResearch Institute. The introductory letter con-tained language telling recipients they were freeto participate if they chose; telephone respondentsgave verbal consent to participate.

Questionnaire content

The primary purpose of the questionnaire was toidentify tobacco control activities that would havebeen similar to those promoted by the COMMITproject. We began by asking whether or not atobacco control structure existed in the community,noting that such a structure could be a group,coalition or other entity. For those respondentswho replied ‘yes’, we ascertained the strength ofthe structure by combining several variables. First,we examined structures by looking at their inde-pendence or ability to set their own agenda, withindependent groups defined as being stronger than

B. Thompson et al.

those that were part of other organizations. Struc-tures that were funded were ranked stronger thanthose that were not funded. Groups with paid staffwere stronger than those without paid staff andstructures with larger target areas of tobacco controlwere stronger than those with smaller areas.Responses to these variables were re-coded toreflect correct direction, summed and divided by4 to obtain a single figure varying from 0.0 to 1.0to indicate strength of an existing structure.

Tobacco control activities in health care settings,worksites, cessation resources, public educationand with youth were examined in intervention andcomparison communities.

Health care

Activities in the health care area were assessed byasking respondents to rate on a scale of 1 (not atall) to 5 (extremely) how active each of groups ofhospitals, physicians, dentists, medical societiesand other health professionals in their communitieshad been around tobacco control. The individualresponses were summed and the mean calculated.In addition, respondents were asked to rate on afive-point scale (low to high) the frequency ofopportunities to be trained in tobacco control forphysicians, dentists, office staff of health careproviders and other health professionals in thecommunity. Respondents in the intervention com-munities only were asked to note on a scale of 1(none) to 5 (a great amount) how much impactCOMMIT had on tobacco control activities amonghealth care providers in the community.

Worksites

We developed a list of activities and asked respond-ents to rate how often each occurred (from 1 �never to 5 � regularly) within the community inthe past 2 years. The activities included passageof restrictive smoking policies in worksites, one-on-one worksite consultations for implementingsmoking policies, public recognition of smoke-free workplaces and institution of stop smokingprograms at workplaces. Responses to these vari-ables were summed and divided by 4 to obtain asingle mean.

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Cessation resources

Respondents were asked to rate how often on afive-point scale (1 � never to 5 � regularly)community agencies offered smoking cessationsessions. Seven organizations were named includ-ing the American Cancer Society, the AmericanLung Association, the American Heart Association,a local hospital, Nicotine Anonymous, SeventhDay Adventist and the Health Department.Responses were summed and divided by 7 for amean response. Informants were asked about theavailability of a cessation resource guide in theircommunity.

Public education

Respondents were asked about a number of publiceducation activities, including local media cover-age of tobacco control activities. This was meas-ured by asking the respondent’s opinion as to howactive the local media had been in covering tobaccocontrol. Level of activity was rated for newspapers,radio and television, and was ranked from never(1) to regularly (5).

Another part of public education addressed com-munity-wide activities called ‘magnet events.’ Allrespondents were asked how visible activitiesaround the Great American SmokeOut had beenin the previous year. Responses could range from1 � not at all visible to 5 � extremely visible.Respondents were also asked if other public eventsaround tobacco control occurred in the past 2 years.

Youth

Level of activities among youth was assessed inlocal schools, school-based groups, school admin-istrators and school-based youth groups. In allcases, informants rated whether the level of activitywas from very low (1) to extremely active (5).Participants were also asked the level to which thecommunity had been active (from 1 � not at allto 5 � extremely) in enforcing policies restrictingyouth access to tobacco. Finally, an index wascreated of three activities that are commonly doneto promote tobacco control among youth; theseinclude a poster contest about the dangers of

Durability in the 22 COMMIT communities

tobacco, compliance checks around sales to minorsand lobbying efforts to strengthen tobacco control.

Statistical analysis

The unit of randomization and analysis was thecommunity. A permutation test was used to com-pare differences between intervention and compar-ison communities in durability measures. For eachmeasure, a community mean was computed andthe difference between means in the matched pairswas calculated. The permutation of positive andnegative signs for the 11 differences forms thepermutation distribution and P values are obtainedby examining the observed mean differencebetween the two groups against a permutationdistribution (Edgington, 1987). In three measures,there were two communities without data andmeans were imputed by using the mean valueof the community means within the particulartreatment arm. In this way, communities did nothave to be dropped from the analysis.

Results

Responses were received from 329 of the 418informants surveyed for an overall response rateof 79%. Because former COMMIT staff were someof the informants in intervention communities, themedian number of people interviewed was higherfor intervention (median N � 18; range � 16–24)than comparison (median N � 11; range � 4–19)communities. Intervention communities had aslightly higher response rate (80%; range � 67–95%)than comparison communities (75%; range � 50–90%). The number of respondents in the ExpertSet was 97 in combined intervention communitiesand 120 in combined comparison communities.

Respondents were asked whether or not atobacco control structure existed in their commun-ity; if respondents said ‘yes,’ they were asked toassess the strength of that structure. In 18 of thecommunities (nine intervention and nine compar-ison), there was agreement by more than 50% ofthe Expert Set that a tobacco control structureexisted. As shown in Table II, there was littledifference between intervention and comparison

359

communities in the overall percentage of respond-ents who agreed that a structure existed, whetherexamining the responses given by all individualssurveyed or by the Expert Set respondents. In theintervention communities, there was good agree-ment between the entire set of respondents and theExpert Set, except for pairs ‘F’ and ‘H’, where theentire set of respondents were more likely than theExpert Set respondents to state that a structureexisted. In the comparison communities, generaland Expert Set respondents exhibited more dis-agreement than the intervention group. In pair ‘A’,less than half of all respondents thought that astructure existed, while all of the set experts werepositive in their responses. Pairs ‘F’ and ‘I’ alsohave substantial discordance. When examining thetwo groups overall, the range of percentages aroundthe grouped mean is similar for all respondentsand Expert Set respondents in the interventioncommunities (range � 31.5–95.2 and 0.0–100.0,respectively) and the comparison communities(range � 42.9–100.0 and 0.0–100.0, respectively).

In both arms of the trial, the evaluation of thestrength of the structure is relatively high (seeTable II). Both arms of the trial showed goodagreement among all respondents and the ExpertSet respondents regarding the strength of the struc-ture, with all respondents in the intervention com-munities indicating higher strength (0.61) than theExpert Set respondents (0.56). The comparisoncommunities had a slightly lower overall strengthreported by all respondents (0.54) than by theExpert Set (0.58).

Current activity levels in the areas targetedby COMMIT (e.g. health care, worksites, publiceducation) are shown in Table III. The level ofactivity is similar across the community pairs.Intervention communities show slight gains inthe areas of ‘availability of smoking cessationinformation through a cessation resources guide’and ‘combined youth events’. ‘Presence of othercommunity cessation events’ and ‘enforcement ofprohibitions against youth smoking’ were signific-antly higher in the intervention communities. Onthe other hand, comparison communities have

B. Thompson et al.

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360

Durability in the 22 COMMIT communities

Table III. Activities by treatment arm 2 years post-intervention in COMMIT communities as reported by the Expert Set

Intervention area Activitiesa Intervention Comparisoncommunities communities

Nb Mean (SD) Nb Mean (SD)

Health care general health care activities 81 2.8 (0.35) 80 2.9 (0.56)opportunities for training health care providers 51 2.5 (0.67) 49 2.5 (0.60)

Worksite worksite activities 63 3.5 (0.35) 64 3.6 (0.56)Cessation resources smoking cessation activities 51 3.1 (0.75) 53 3.3 (0.59)

availability of smoking cessation informationc 51 0.95 (0.17) 47 0.85 (0.31)Public education media focus on tobacco 52 3.0 (0.54) 58 3.1 (0.59)

visibility of the Great American SmokeOut 45 3.1 (0.47) 43 3.3 (0.60)presence of other community cessation eventsc 41 0.56 (0.36)d 41 0.28 (0.33)

Youth activities in tobacco control addressing youth 61 3.1 (0.49) 71 3.0 (0.68)combined youth eventsc 67 0.89 (0.08) 74 0.87 (0.10)enforcement of prohibitions against youth smoking 52 3.1 (0.53) d 69 2.7 (0.68)

aRange of all activities is from 1 (low) to 5 (high) unless otherwise noted.bNumber in Expert Set varies by number of key informants qualified to respond to the specific tobacco control activities.cRange � 0.0 (activity not present) to 1.0 (activity present).*P � 0.05.

small advantages in ‘smoking cessation activities’and ‘visibility of the Great American SmokeOut’.

Durability also was assessed by examiningknowledge about availability of current tobaccocontrol information and the presence of active anti-tobacco groups in the community. Both interven-tion and comparison communities gave similarresponses to a question asking where the respond-ent would go to obtain current tobacco controlinformation (see Table IV). However, the compar-ison communities placed more emphasis on receiv-ing information from the three health care voluntaryagencies: American Cancer Society, the AmericanLung Association and the American Heart Associ-ation. In addition, comparison communities weremore likely to obtain information from their healthdepartments. Other anti-tobacco groups in all ofthe communities were sparse. Doctors Ought toCare had double the visibility in interventioncommunities, while Action on Smoking and Healthand Americans for Non-smokers’ Rights weremore visible in the comparison communities.

Finally, intervention community respondentsonly were asked to assess the overall communityimpact remaining from COMMIT. The overall

361

mean response was 3.4 on a scale of 1 to 5 where1 meant ‘no impact’ and 5 meant ‘a great amount’.That question was not asked of respondents in thecomparison communities.

Discussion

The COMMIT trial showed a significant increasein smoking cessation rates among light-to-moderatesmokers in intervention communities. The majorityof the COMMIT intervention communities dis-played strong interest in continuing tobacco controlactivities. To estimate the breadth and intensityof tobacco control efforts after COMMIT, keyinformants within the 22 communities that particip-ated in the COMMIT project were surveyed 2 yearsafter the project intervention phase ended. Thisproduced a snapshot of ongoing tobacco controlactivities both in the intervention and the compar-ison towns.

An earlier study conducted only within theCOMMIT intervention communities found that agreat deal of the tobacco control activity instigatedby COMMIT was continuing (Lichtenstein et al.,1996). That study focused on tobacco control

B. Thompson et al.

Table IV. Sources of tobacco control information as reported by all respondents

Intervention Comparisoncommunities communities(N � 201) (%) (N � 128) (%)

Source of current tobacco control information (multiple responses possible)local coalition 25.3 24.8regional coalition 11.3 7.3American Cancer Society 49.4 57.1American Lung Association 38.0 41.0American Heart Association 18.1 24.0local health department 29.8 29.3state health department 20.5 27.2

Active anti-tobacco agencies in community (multiple responses possible)Doctors Ought to Care 21.3 10.5Action on Smoking and Health 2.9 9.2Group Against Smoking Pollution 13.9 14.4Americans for Non-smokers’ Rights (ANR) 6.5 8.3

12–16 months post-intervention and before theCOMMIT outcome data were reported. Despitenot knowing whether the trial had been successful,nine of the 11 intervention communities had coali-tions or boards in place, nine had dedicated fundingand 10 had some paid staff time. There was alsoevidence of activities focused on youth, who wereonly a minor target in the original project becauseof the emphasis on heavy smokers. The findingsof that study supported other findings of large-scale community studies that suggest that durabilitycan be attained (Bracht et al., 1994; Jacksonet al., 1994).

Data from this study substantiated the earlierfindings in the intervention communities. Twoyears after the intervention ended, nine of the 11intervention communities had coalitions or boards.Respondents from six of the communities scoredstrength of the coalition (resources, paid staff, andreach of activities) as 0.75 or higher on a scalethat ranged from 0.0 to 100.0. Taken by itself,this might be considered similar to the durabilityidentified in intervention communities in the Min-nesota Heart Health Program (Bracht et al., 1994)and the Stanford Five-City Study (Jackson et al.,1994). We had the opportunity to evaluate the datarelative to data from the comparison communities.There are few differences in scores between the

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intervention and comparison communities. Thedifferences that do appear are small. Only twoactivities, ‘presence of other community cessationevents’ and ‘enforcement of prohibitions againstyouth smoking’, showed significant differencesbetween intervention and comparison commu-nities.

There are a number of potential explanationsfor this overall outcome. As with other large-scalecommunity trials, COMMIT saw a large seculartrend that affected tobacco control activitiesthroughout the country. California had passed itsproposition increasing tobacco taxes and dedicatingthose taxes to tobacco control activities.Massachusetts was ready to do the same. Both ofthose states had COMMIT sites.

Another explanation might lie in the AmericanStop Smoking Intervention Study for Cancer Pre-vention (ASSIST). ASSIST is a collaborationbetween state health departments and the AmericanCancer Society designed to build coalitions in 17states that will conduct tobacco control activitiesin specified channels of intervention to reducesmoking prevalence. The ASSIST project beganbefore the COMMIT project was completed andsome of the COMMIT communities workedintensely to become an ASSIST site. That mayhave affected results of this durability study in two

Durability in the 22 COMMIT communities

ways. Comparison communities in ASSIST statesmight have received tobacco control funds and sowere able to develop their own tobacco controlinfrastructure. On the other hand, COMMIT com-munities not awarded ASSIST funds may havestruggled with maintaining even a low level oftobacco control when their communities were notawarded ASSIST funds.

Another explanation may be that COMMIT didnot spend enough time planning for durability. Thetopic of durability was raised only in the last 18months of the trial. At that time, many of thecommunity Boards were concerned with the endingof COMMIT and wanted help in planning forthe future. The communities received little or notraining or technical assistance in generating plansfor the future or in finding funds to sustain someactivities. Some communities did hold workshopsor retreats to plan for the future, but appearedto be overwhelmed by the difficulty of findingadditional funding to establish a long-term infra-structure. Further, although a goal of COMMITwas to increase the community capacity to conducttobacco control activities, the project emphasizedthat it was not taking over activities from existingtobacco control organizations; rather, its goal wasto increase the abilities of those organizations towork together with other community groups in aneffective and coordinated manner. This may havecaused confusion as to long-term goals and plan-ning for life after COMMIT. It was not untilmidway through the intervention that researchersand community members agreed that durabilitymight be an important feature to include in COM-MIT. This did not leave sufficient time to engagein trial-wide planning to keep tobacco controlactivities going.

Typically the organizations that deal with canceror smoking-related diseases in communities arethe health voluntary groups (American CancerSociety, American Lung Association and AmericanHeart Association) and, to some extent, healthdepartments, and the assumption was that theseorganizations would build capacity to providesmoking-related services and information. Interes-tingly, when asked where information could be

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obtained, the major differences between interven-tion and comparison communities was less use ofthe health voluntary groups in the interventioncommunities. In retrospect, this is not so surprising.Health voluntary agencies have limited resources.COMMIT had the funds to advertise its presencespecifically for tobacco control; thus, it acquiredthe reputation for being the place to go for tobacco-related information. In the meantime, the healthvoluntary agencies saw COMMIT as being able tofree the organizations to pursue other cancer-relatedactivities. When the COMMIT project ended, thevoluntary health groups may not have taken upthe activities again.

In addition to these difficulties in planning fordurability, staff and volunteers had to turn theirattention from intervention activities to fund raisingfor any durability to occur. Fund-raising is anarduous task at best and the COMMIT staff hadnumerous project-related close-out activities toconduct. This may have led to reduced energy todeal with durability of tobacco control activities.

The COMMIT project required that funds givento the communities be spent annually on tobaccocontrol activities. It was not possible, under theconditions of the contract, to save money forcontinuing tobacco control activities after the trialwas over. Some communities were able to obtaindonated space from a hospital, voluntary healthorganization, health department or other source;however, the majority of the communities had fewresources remaining from COMMIT. Given thisconstraint, it may be understandable that fewdifferences existed between intervention and com-parison communities 2 years after the trial.

This study focused on a quantitative assessmentof activities; therefore, it is not clear that thequality of tobacco control activities was the samein intervention and comparison communities. Amore qualitative assessment might have identifieddifferences in activities between the communities.For example, the cessation resource guides inthe intervention communities were comprehensive,colorful and had numerous self-help instructionson quitting, compared to a list of where one couldgo to get help on quitting commonly seen in the

B. Thompson et al.

comparison communities. Qualitatively, this couldhave a different impact on smokers. Future researchmay wish to include qualitative examinations ofdurability.

The two significant differences in durabilityactivities were ‘presence of other community cessa-tion events’ and ‘enforcement of prohibitionsagainst youth smoking’. The other communityactivities were overwhelmingly ‘Quit & Win’ con-tests. Those contests had been an active part ofCOMMIT and many intervention communitiesfound ways to continue them by linking up withother groups in the community.

The emphasis on youth prevention in the inter-vention communities increased substantially afterthe intervention ended. From the beginning of thetrial, researchers and community members wereencouraged to target heavy smokers and since fewyouth fell into that category, little emphasis wasplaced on them initially. As the trial planningprogressed, activities directed at youth or withyouth were added to the protocol. The protocol ofyouth activities, however, was later downsizedbecause of budget consideration. By the end of thetrial, many communities, recognizing that preven-tion now could decrease the need for cessationlater, wanted to focus on youth. The data likelyreflect this interest as the intervention communitiesexceed the comparison communities in all threeareas of youth activities, although only enforcementis significant.

This study on durability, although breakingnew ground by examining comparison as wellas intervention communities, has a number oflimitations. The sample for this survey wasselected on the basis of occupational positionsin each of the 22 communities. It is possiblethat by using the positional approach, someother key individuals may have been missed.Respondents in our intervention communitiesmay have been more knowledgeable aboutactivities that were going on in the communitybecause their level of awareness of tobaccocontrol had been raised by COMMIT. This mayhave been particularly true in the area of youthwhere the issue of prevention became clear as

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the trial went on and where many interventioncommunities focused their energies once the trialwas over. Being more aware about tobaccocontrol could have led to reporting more tobaccocontrol activities than the comparison communit-ies. Alternatively, tobacco control activities couldhave been under-reported as respondents inintervention communities compared current activ-ities with the past COMMIT years where therehad been a much higher rate of activity.

Conclusion

This study contributes to the growing body ofliterature on the durability of intervention activitiesinstigated during community trials. It is the firststudy to compare ongoing activities in both inter-vention and comparison communities after aresearch study has ended. We found considerableevidence for durability in the intervention commu-nities, with the overwhelming majority of themhaving coalitions or advisory groups to conducttobacco control activities. There were, however,only small differences between intervention andcomparison communities in the level of tobaccocontrol activities after the funding period ended.

A number of lessons can be gleaned fromthis study. First, the time to establish a solidinfrastructure for durability probably requires morethan the last few months or the last year of aproject. Durability planning should begin whenproject activities are implemented so that theirmaintenance will be natural when the externalfunds decrease. Secondly, communities in generalwant their project activities to continue and shouldbe encouraged to do so when a trial has a successfuloutcome. Finally, to translate research data to thereal world, we must understand durability and thefactors related to durability so that other communit-ies can benefit from research projects.

Acknowledgements

This study was supported by contract no. CN64100from the National Cancer Institute.

Durability in the 22 COMMIT communities

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