Article
Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke1

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Abstract

Overview: This report presents the results of systematic reviews of effectiveness, applicability, other effects, economic evaluations, and barriers to use of selected population-based interventions intended to reduce tobacco use and exposure to environmental tobacco smoke. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis of recommendations by the Task Force on Community Preventive Services (TFCPS) regarding the use of these selected interventions. The TFCPS recommendations are presented on page 67 of this supplement.

Introduction

Tobacco use is the largest cause of preventable morbidity and mortality in the United States.1, 2, 3 Recognized as a cause of multiple cancers, heart disease, stroke, complications of pregnancy, and chronic obstructive pulmonary disease,4 tobacco use is responsible for 430,000 deaths per year among adults, and direct medical costs are in the range of $50 billion to $73 billion per year.5, 6

Exposure of nonsmokers to environmental tobacco smoke (ETS) is another entirely preventable cause of significant morbidity and mortality associated with tobacco use.7, 8, 9 Exposure to ETS is a recognized cause of heart disease and accounts for an estimated 3000 lung cancer deaths per year in adults.8 In infants and children, exposure to ETS causes middle ear infections and effusions, exacerbates 400,000 to 1 million cases of asthma annually, and causes 150,000 to 300,000 cases of lower respiratory tract infections each year.5, 7

Cigarette consumption, the dominant form of tobacco use, peaked in the United States in 1963, and the prevalence of tobacco use among adults in 1964 was 40.3%.4 The beginning of a steady but slow decline in tobacco use by adults followed the release and dissemination of the 1964 report of the advisory committee to the Surgeon General on smoking and health, which summarized more than a decade of research on the adverse health effects of tobacco use.10 The effect of subsequent education and tobacco control efforts (led at various times by government, public and private groups, and individuals) has been considerable, with an estimate of 200,000 premature deaths avoided in the period from 1964 to 1978 alone.11

Despite 36 years of policies, regulations, educational efforts, the increasing information on the negative health effects of tobacco use, and the positive health benefits of cessation, tobacco use remains unacceptably high. In 1998, there were 47.2 million adult smokers in the United States. Smoking prevalence among adults aged 18 years and older was 24.1% (men 26.4%; women 22.0%).12 There are regional, educational, socioeconomic, racial, and ethnic variations in tobacco use and disparities in tobacco-related morbidity and mortality.4, 13 Individuals below the poverty line, for example, are more likely to smoke than individuals at or above the poverty line (32.3% compared with 23.5%). People with 16 or more years of education are less likely to smoke than people with 9 to 11 years of education (11.3% compared with 36.8%).12 The prevalence of smoking among American Indians and Alaska natives (40%) is higher than in other racial and ethnic groups.12

Tobacco use results in true drug dependence in most users, making attempts to quit difficult and relapses common.14 Many users make multiple attempts to quit.15 In 1998, an estimated 15.2 million current smokers (39.2%) had stopped smoking for at least 1 day during the preceding 12 months because they were trying to stop smoking entirely.12 Although cessation significantly reduces the immediate and subsequent risks of tobacco-related morbidity and mortality,3, 16 most tobacco users do not receive assistance in quitting.14

Rather than treating tobacco use cessation as a single event, recent reviews of cessation strategies have stressed recognition of tobacco use as a chronic disease in implementing and maintaining programs to support users in their extended efforts to quit.14, 15 Despite knowledge of the health benefits of tobacco use cessation and the availability of effective treatments and therapies, many health care providers and health care systems fail to assess and to treat tobacco use consistently and effectively.14

Preventing the acquisition of this costly, chronic dependence is clearly desirable. However, tobacco use initiation and the transition from experimentation to addiction are not easy to prevent because they occur primarily in adolescence, when individuals are more susceptible to influences from family, friends, peers, society, and the tobacco industry, which encourage tobacco use.17 Among high school students in the United States, current smoking prevalence rose significantly between 1991 and 1999, from 27.5% to 34.8%.18 Recent increases in smoking prevalence among young adults aged 18 to 24 years (27.9% in 1998), in addition to reflecting the aging of the cohort of high school students among whom current smoking rates were high during the 1990s, may also indicate an increase in tobacco use initiation in this segment of the population.12

The health effects of exposure to ETS have prompted the increasing implementation of public and private policies restricting smoking.4 Although ETS exposures in some settings, such as hospitals and transportation systems in the United States, have been reduced or eliminated, nearly 9 of 10 nonsmokers still have some exposure to ETS.5 ETS exposure continues to occur in workplaces and public areas without smoking bans or effective restrictions as well as in households in which smoking is allowed.

Interventions to reduce tobacco use and ETS exposure implemented and evaluated over the past 35 years provide considerable evidence on the effectiveness of clinical and community strategies. Given the massive burden of current addiction, premature death, and disability, as well as the implications for the future, efforts to identify, implement, and maintain or expand effective tobacco prevention and control efforts should be a priority at the national, state, local, and individual levels.

Section snippets

The Guide to Community Preventive Services

The systematic reviews in this report represent the work of the independent, nonfederal Task Force on Community Preventive Services (TFCPS). The TFCPS is developing the Guide to Community Preventive Services (the Community Guide) with the support of the U.S. Department of Health and Human Services (DHHS) in collaboration with public and private partners. The Centers for Disease Control and Prevention (CDC) provides staff support to the TFCPS for development of the Community Guide. A special

Conceptual approach

The methods used to conduct the systematic reviews and arrive at the evidence-based recommendations contained in this report are explained in Appendix A. Tables and figures that summarize effectiveness findings and tables that support our economic analyses are available at the website (www.thecommunityguide.org).

An illustration of the logic framework depicts our conceptual approach to the subject of tobacco use prevention and control (Figure 1). This figure portrays the relationships among the

Healthy People 2010 goals and objectives

The interventions reviewed in this report can be useful in reaching many of the tobacco control objectives in Healthy People 2010,19 a prevention agenda for the United States. These objectives identify the significant preventable threats to health and focus the efforts of the public and private sectors for addressing those threats. Many of the proposed Healthy People objectives in chapter 27, “Tobacco Use,” relate directly to goals for increasing cessation, for reducing initiation, and for

Part I: strategies to reduce exposure to ETS

Interventions to reduce exposure to ETS require or encourage the establishment of smoke-free areas in workplaces, in public areas, and in the home. Smoke-free workplaces, public areas, and homes can be effective in reducing tobacco-related morbidity and mortality in several ways. First, these policies can reduce exposure to ETS, contributing to a reduction in ETS-related morbidity and mortality.7, 8, 9 Second, smoke-free policies could change attitudes and behaviors of smokers and increase both

Part II. Strategies to reduce tobacco use initiation

Interventions that reduce tobacco use initiation are designed to change knowledge, attitudes, and tobacco use behaviors in children, adolescents, and young adults. Most smokers initiate tobacco use during adolescence, and nicotine addiction begins during the first few years of use.98 Major risk factors for tobacco initiation among children and adolescents are perceptions that tobacco use is a common and normative peer and adult behavior as well as the availability and accessibility of tobacco

Part III. Strategies to increase tobacco use cessation

Interventions to increase tobacco use cessation include strategies to increase the number of tobacco users who attempt to quit, strategies to improve the success rate of individual cessation attempts, and strategies to achieve both of these goals. Two interventions reviewed in this report are appropriate for communities: increasing the unit price for tobacco products and mass media education. The TFCPS also reviewed the following interventions appropriate for implementation in health care

Acknowledgements

We appreciate the contributions of the tobacco prevention evidence review team. The members are as follows: Coordination Team—JE Fielding, MD, MPH, MBA, Los Angeles Department of Health Services, University of California Los Angeles School of Public Health, University of California Los Angeles School of Medicine (TFCPS member); PA Briss, MD; VG Carande-Kulis, MS, PhD; DP Hopkins, MD, MPH, Division of Prevention Research and Analytic Methods, Epidemiology Program Office, Centers for Disease

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    The names and affiliations of the Task Force members are listed in the front of this supplement and at www.thecommunityguide.org.

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