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Tobacco Prevention and Control
Evidence-based Recommendations from the Guide to Community Preventive
Services
Introduction
• Guide to Community Preventive Services• Tobacco chapter• Recommendations from the Task Force
• Smoking bans• Provider reminder systems• Interventions to reduce minors’ access• Preview: School-based interventions
The Community Guide
• A Task Force
• A Process– Systematic reviews of the literature– Assessments of study quality– Summary of outcomes
• A Product– Evidence-based recommendations– Book
Why Evidence Reviews?
Decision-making
Advocacy
Defense
Program buiding
Options
Methods
• Develop a conceptual framework
• Search for evidence
• Rate the quality of the evidence
• Summarize the information
• Translate the strength of evidence into
recommendations for use
The Tobacco Chapter
• Recruited 20 experts• Selected 10 intervention categories• Screened 16,000 citations• Reviewed 1300 papers• Evaluated 350 studies• Summarized evidence for 15 interventions
Prevention: Targets and Goals
Former Users (1m)
Current Users (1m)
Future Users (114k/yr)
Non Users (4m)
Increase Cessation
Reduce Initiation
Reduce ETS Exposure
Population
Tobacco Control Policies: Settings
Goal
Increase
Cessation
Reduce
Initiation
Reduce
ETS
CommunityHealth
Care System
Yes
Yes
Yes
Yes
(No)
(Yes)
Issues to Consider in Reviews
InterventionIntendedOutcomes
ReducedMorbidity
and/orMortality
AdditionalOutcomes
Benefits
Harms
Barriers
Recommendations from the Community Guide Task Force
Interventions to Reduce Tobacco Use and ETS Exposure in
Communities and Health Care Systems
In Communities
Goal Recommended Interventions
Increase
Cessation
Reduce
Initiation
Reduce
ETS Exposure
* When combined with other interventions
Increase the price (tax)
Mass media campaigns*
Telephone Quit lines*
Increase the price (tax)
Mass media campaigns*
Smoking bans
Smoking bans
In Communities
Goal Interventions with Insufficient Evidence
Increase
Cessation
Reduce
Initiation
Reduce
ETS Exp.
Smoking cessation contests
Broadcast smoking cessation series
Community-wide efforts to reduce ETS exposure in the home
In Health Care Systems
Goal Recommended Interventions
Increase
Cessation
Reduce
Initiation
Reduce ETS
* When combined with other interventions
Provider reminder systems*
Telephone Quit Lines*Reducing patient out-of-pocket costs (NRT)
Smoking bans (in effect)
In Health Care Systems
Goal Interventions with Insufficient Evidence
Increase
Cessation
Reduce
Initiation
Reduce ETS
Provider education programs (alone)
Provider feedback systems
(Provider counseling to reduce home ETS exposure)
Reviews in Progress
Goals Interventions under Evaluation
Increase
Cessation
Reduce
Initiation
Reduce
ETS
Youth access interventions
School-based interventions
Interventions to Reduce Exposure to Environmental Tobacco Smoke
Smoking Bans and Restrictions
Analytic Framework: Smoking Bans
ReducedMorbidity
andMortality
SmokingBans
Smoking Bans Might Result from Community Education Efforts
ReducedMorbidity
andMortality
SmokingBans
CommunityEducation
Pre-emption
Bans Might Reduce ETS Exposure
ReducedMorbidity
andMortality
SmokingBans
ReducedExposure to ETS
Bans Might Increase Smoking Cessation
ReducedMorbidity
andMortality
SmokingBans
ReducedExposure to ETS
FewerTobacco
Users
Change In
Attitudes
ReducedConsumption
IncreasedQuit
Attempts
IncreasedCessation
Bans Might Reduce Smoking Initiation
ReducedMorbidity
andMortality
SmokingBans
ReducedExposure to ETS
Change In
Attitudes
ReducedInitiation
FewerTobacco
Users
Change In
Attitudes
ReducedConsumption
IncreasedQuit
Attempts
IncreasedCessation
Bans Might Increase ETS in the Home
ReducedMorbidity
andMortality
SmokingBans
ReducedExposure to ETS
Change In
Attitudes
ReducedInitiation
FewerTobacco
Users
Change In
Attitudes
ReducedConsumption
IncreasedQuit
Attempts
IncreasedCessation
DivertedConsumption
IncreasedHome Exposure
Body of Evidence: Bans and Restrictions
• 56 studies reviewed
• ETS exposure: 10 of 17 studies qualified
• Tobacco use: 9 of 51 studies qualified
Study Measurements by Outcome
ReducedMorbidity
andMortality
SmokingBans
ReducedExposure to ETS
Change In
Attitudes
ReducedInitiation
FewerTobacco
Users
Change In
Attitudes
ReducedConsumption
IncreasedQuit
Attempts
IncreasedCessation
DivertedConsumption
IncreasedHome Exposure
12
6
4591
0*0*6
-10 0 10 20 30 40 50 60 70 80 90 100
Relative Percent Reduction Environmental
Self-reported
Study
Millar, 1988
Gottlieb, 1990
Borland, 1992
Brownson, 1995
Patten, 1995a
Etter, 1999
Becker, 1989
Mullooly, 1990
Stillman, 1990b
Borland, 1992
Broder, 1993
Patten, 1995a
Restrictions
Bans
Median = 60.5
Distribution of Observed Changes in ETS Exposure: (n=12 measurements from 10 studies)
Smoking Bans and Tobacco Use
• Consumption (cigarettes/day) – Decreased in 8 of 9 studies– Median: -1.3 cigs/day range: -4.3 to 0
• Cessation attempts– Increased in 3 of 5 studies– Median: +1.8 pct pt (+9%: range –3.4% to +175%)
• Prevalence of self-reported smoking– Decreased in 3 of 6 studies– Median: -0.9 pct pt (-4.2%: range –33% to +5%)
Additional Information
• Applicability – Public and private workplaces
• Additional Benefits– Reduced consumption
• Potential Harms– Refuted: Loss of revenue
• Barriers– Pre-emption
Task Force Conclusion
• Smoking Bans and Restrictions are Recommended (strong evidence)
Because they:• Reduce exposure to ETS in a variety of
public and private workplaces
Limitations
• Based on published research– Bans v. Restrictions
• Excluded cross-sectional evidence– Recent studies– Additional evidence of impact on tobacco use
• Preliminary link is important– Interventions to obtain smoking bans
Interventions to Increase Tobacco Use Cessation
Provider Reminder Systems when coordinated with additional
interventions
Provider Reminder Systems
• Prompts to health care providers– Identify patient tobacco use status– Discuss tobacco use cessation
• Search: 32 studies
• Evaluation: 27 studies– Reminder system alone: 7 studies– Combined with other interventions: 20 studies
Analytic Framework
ProviderKnowledge
Patient Smoking
Status
Advice toQuit
Attempts to Quit
Quit
DecreasedMorbidity/Mortality
ProviderReminder
Reported Outcomes(n=39 measurements from 20
studies)
ProviderKnowledge
Patient Smoking
Status
Advice toQuit
Attempts to Quit
Quit
DecreasedMorbidity/Mortality
ProviderReminders
0 3 15 7 14
Understanding Study OutcomesDifferences or Changes
Quit Rate in Intervention Arm
Quit Rate in Control Arm
Difference
15% 10%
15-10=
+5 pct. pts
Absolute percent
15% 10%
5%/10%=
+50%
Relative percent
-10 -5 0 5 10 15 20 25 30
Percentage Point Change
Study
Cohen 1989a
Cohen, 1989b
Strecher, 1991
Secker-Walker, 1998
Conger, 1987
Wilson, 1988
Cummings, 1989a
Cummings, 1989b
Petersen, 1992
Stevens, 1995
Wall, 1995
Hartmann, 1996
Morgan, 1996
Manfredi, 1999
Provider Reminder + Provider Education
Provider Reminder + Provider Education + Patient Education
Median = 4.7
(12m)
(12m)
(6m)
(12m)
(4m)
(12m)
(12m)
(12m)
(8m)
(8w)
(3m)
(<8m)
(6m)
(8w)
Differences in Patient Cessation in Studies of M ulticomponent Programs
ProviderKnowledge
Patient Smoking
Status
Advice toQuit
Attempts to Quit Quit
DecreasedMorbidity/Mortality
ProviderReminders
+13% +20% +8% +4.7%?
*Combined with additional interventions
Median Reported Differences in Outcomes in Studies Evaluating Provider Reminder Systems*
(n=20 studies)
(+8, +13) (+5, +60) (+1, +20) (-1, +26)
Additional Information
• Applicability– Settings (HMO, private practice, HD)– Provider populations (Medicine, OB, Dental)
• Additional Benefits– Prompts for other preventive services
• Potential Harms– None identified
• Barriers– Infrastructure– (Screening of adolescents)
Task Force Conclusion
• Multi-component programs that include: provider reminder system + provider education program + patient education materials Recommended (Strong Evidence)
Because they:
• Increase provider delivery of advice to quit to tobacco-using patients
• Increase patient tobacco use cessation
Interventions to Reduce Tobacco Use Initiation
Interventions to Restrict Minors’ Access to Tobacco Products
Efforts to Restrict Minors’ Access Combined Policies with Other Interventions
• Policies– Laws directed at retailers
• Bans, restrictions, licensing
– Laws directed at youth • purchase, use, possession
– Enforcement (intent, conduct, penalties)
• Interventions– Retailer education programs– Community Education
YouthAccessInterv.
ReducedYouth
TobaccoUse
Analytic Framework-Outcome
YouthAccessInterv.
RetailerKnowledge
RetailerPerceptions
RetailerBehaviors
(Sales)
YouthTobacco
Use
Interventions Might Affect Retailers
YouthAccessInterv.
RetailerKnowledge
RetailerPerceptions
RetailerBehaviors
(Sales)
YouthTobacco
Use
Interventions Might Affect Youth
YouthKnowledge
YouthPerceptions
YouthTobacco
Purchases
YouthAccessInterv.
RetailerKnowledge
RetailerPerceptions
RetailerBehaviors
(Sales)
YouthTobacco
Use
Interventions Might Affect the Community
YouthKnowledge
YouthPerceptions
YouthTobacco
Purchases
CommunityNorms
Enforcement
YouthAccessInterv.
RetailerKnowledge
RetailerPerceptions
RetailerBehaviors
(Sales)
YouthTobacco
Use
Youth Have Other Sources
YouthKnowledge
YouthPerceptions
YouthTobacco
Purchases
CommunityNorms
Enforcement
Other SourcesOf Tobacco
YouthAccessInterv.
RetailerKnowledge
RetailerPerceptions
RetailerBehaviors
(Sales)
YouthTobacco
Use
The Key Outcomes
YouthKnowledge
YouthPerceptions
YouthTobacco
Purchases
CommunityNorms
Enforcement
Other SourcesOf Tobacco
YouthAccessInterv.
RetailerKnowledge
RetailerPerceptions
RetailerBehaviors
(Sales)
YouthTobacco
Use
YouthKnowledge
YouthPerceptions
YouthTobacco
Purchases
CommunityNorms
Enforcement
Other SourcesOf Tobacco
5
13
32
0 1
0
1
1 0
26 Measurements from 13 Studies
Five Studies Measured Changes in Youth Tobacco Use
Study
Com.
Mobiliz.
Ret.
Edu
Law Active
Enfrcmt
Other
Altman 1999 Yes Yes
Biglan 2000 Yes Yes S Edu
Forster 1998 Yes Yes Yes
Jason 1996 Yes Yes Yes Yes
Rigotti 1997 Yes Yes
-15 -10 -5 0 5
Absolute percentage change
Changes in Self-Reported Tobacco Use: Multicomponent Interventions (n=5)
Median = - 5 pct pointsRange: -11 pct points , +2 pct points
Study
Altman 1999
Biglan 2000
Forster 1998
Jason 1996a
Rigotti 1997
Task Force Conclusion
Number of Studies
Consistent Effect?
Sufficient Effect Size?
Strength of Evidence
4 Yes Yes Sufficient
Community mobilization when combined with additional interventions such as local laws, active enforcement of
illegal sales to minors, and community-directed education of retailers are effective in restricting minors’
access to tobacco products
Task Force Assessment: Recommended
(sufficient evidence)
There is No Evidence that Single Interventions are Effective
• Sales laws directed at retailersInsufficient Evidence
• PPU laws directed at youthInsufficient Evidence
• Active enforcement of sales lawsInsufficient Evidence
• Retailer EducationInsufficient Evidence
• Community educationInsufficient Evidence
Pitfalls
• Preemption
• Enforcement responsibility
• “Knowingly” / “Intentionally”
• Clerk vs owner
• Criminal penalties (judicial nullification)
Pitfalls
• Youth purchase, possession, or use laws
– Normative diversion
“Penalize kids, not retailers”
– Resource diversion
– Compliance checks barrier
School-Based Interventions
Interventions Selected for Review
• Tobacco-free policies• School-based education• Smoking cessation programs• Multi-component programs that include a
school-based component• Student delivered community education
– SWAT programs
OrganizedStudent
Advocacy
CommunityEvents or
Efforts
MassMedia
Exposure
Change in Community
Attitudes
Change in Community
Policies
ReducedTobacco
Use Initiation Fewer
TobaccoProductUsers
ReducedMorbidity
&Mortality
SchoolEvents
Change in Student
Attitudes*
Reduced/DelayedInitiation
Of TobaccoUse
Increased Tobacco
UseCessation
FewerStudent
Tobacco Users
Change inSchool Policies
StudentParticipation
Change inParticipantAttitudes*
ReducedParticipantTobacco
Use
FewerParticipantTobacco
Users
Analytic Framework: Student-delivered Community Education
*Includes changes in knowledge and skill development or enhancement
Content of Recent Evidence Reviews
TobaccoUser
ProviderHealthCare
SystemCommunity
Community Guide Clinical Guide
PHS: Clinical Practice Guidelines
CDC Best Practices
SGR: Reducing Tobacco Use
NCI: Population Based Smoking Cessation
Conclusions
• Evidence on effectiveness is one tool for decision-making
• There are effective interventions– For Communities– For Health Care Systems
• Building blocks of a comprehensive tobacco control program
