In the United States, tobacco use is
the leading cause of preventable
death. Exposure to environmental tobacco smoke (ETS) is a preventable cause of
significant morbidity and death among nonsmokers. Reducing tobacco use and
reducing exposure to environmental tobacco smoke are essential community and
public health objectives. As part of the Healthy People 2010 initiative, goals
have been developed to reduce tobacco-related morbidity and death by reducing
exposure to ETS, decreasing tobacco-use initiation, and increasing tobacco-use
cessation (Table 1).
By implementing interventions shown to be effective, policy
makers and health-care and public health providers can help their communities
achieve these goals while using community resources efficiently.
The independent, nonfederal Task Force on Community Preventive
Services (the Task Force) is developing the Guide to Community Preventive
Services (the Community Guide) with the support of the US Department of Health
and Human Services and in collaboration with public and private partners. The
Centers for Disease Control and prevention (CDC) and other federal agencies
provide staff support to the Task Force for development of the Community Guide.
However, the recommendations presented in this report were developed by the Task
Force and are not necessarily the recommendations of the CDC or the US
Department of Health and Human Services.
This Morbidity and Mortality Weekly report is the second to be
completed for the Community Guide, a resource that will include multiple
chapters, each focusing on a preventive health topic. The first chapter was on
vaccine-preventable diseases. The information in this report will be part of a
second chapter on tobacco use. This report provides an overview of the process
used by the Task Force to select and review evidence; it summarizes the Task
Force’s recommendations on community interventions to reduce exposure to ETS
and tobacco use. A full presentation of the recommendations, supporting
evidence, and remaining research questions will be published in the American
Journal of Preventive Medicine in 2001.
Methods used to conduct systematic reviews and link evidence to
recommendations are described in another publication (Briss PA et al: Am J Prev
Med 2000 18[suppl1]:35-43). In brief, for each Community Guide chapter,
multidisciplinary chapter development teams conduct reviews by:
Developing an approach to organizing, grouping, and selecting
the interventions for review
Systematically searching for and retrieving evidence
Assessing the quality of the body of evidence of
effectiveness for interventions and summarizing the strength of this body of
Summarizing information regarding other evidence (eg,
applicability of the intervention to different populations and settings,
additional benefits, potential harms, barriers to implementation, and economic
Identifying and summarizing research gaps
For the chapter on tobacco use, the chapter development team
focused on interventions to decrease exposure to ETS, reduce tobacco-use
initiation, and increase tobacco-use cessation. The chapter consultation team
members generated a comprehensive list of strategies and created a priority list
of interventions for review based on their perception of the importance and the
extent to which the interventions were practiced in the United States. Time and
resource constraints precluded review of some interventions (eg, community-wide
risk factor screening and counseling).
Interventions reviewed were either single-component (ie, using
only one activity to achieve desired outcomes) or multicomponent (ie, using more
than one related activity). Interventions were grouped together on the basis of
their similarity. Some studies provided evidence for more than one intervention.
In these cases, the studies were reviewed for each applicable intervention. The
classifications or nomenclature used in this report were chosen to ensure
comparability in the review process, and these classifications sometimes differ
from those used in the original studies.
To be included in the reviews of effectiveness, studies had to
meet the following criteria:
They were limited to primary investigations of interventions
selected for evaluation.
They were published in English from January 1980 through May
They were conducted in industrialized countries.
They compared outcomes in groups of persons exposed to the
intervention with outcomes in groups of persons not exposed or less exposed to
the intervention (whether the comparison was concurrent or before-after).
For each intervention reviewed, the team developed an analytic
framework indicating possible causal links between the intervention under study
and predefined outcomes of interest. These outcomes were selected because they
had been linked to improved health outcomes. For example, the Task Force
concluded the following:
Tobacco use is a cause of morbidity (illness and disability)
Tobacco-use cessation reduces tobacco-related morbidity and
Delivery of advice by health-care providers to tobacco-using
patients to quit has a small but significant impact on tobacco-use cessation
The younger persons are when they begin to smoke, the more
likely they are to be current smokers as adultsan indication that postponing
or preventing tobacco use among children and adolescents will decrease the
number of adult tobacco users.
Exposure to ETS is a cause of morbidity and death; reducing
exposure to ETS can be assumed to reduce ETS-associated morbidity and death.
The Focus of Evaluations
The evaluations of interventions in this report, therefore,
focus on evidence of effectiveness in reducing ETS exposure, reducing
tobacco-use initiation, and increasing tobacco-use cessation (including
increasing patient receipt of advice to quit from health-care providers).
Each study that met the inclusion criteria was evaluated by
using a standardized abstraction form and was assessed for suitability of the
study design and threats to validity. On the basis of the number of threats to
validity, studies were characterized as having good, fair, or limited execution.
The strength of the body of evidence of effectiveness was characterized as
strong, sufficient, or insufficient on the basis of the number of available
studies, the suitability of study designs for evaluating effectiveness, the
quality of execution of the studies, the consistency of the results, and the
The Community Guide links evidence to recommendations
systematically. The strength of evidence of effectiveness corresponds directly
to the strength of recommendations (eg, strong evidence of effectiveness
corresponds to an intervention being strongly recommended; sufficient evidence
corresponds to an intervention being recommended). Other types of evidence also
can affect a recommendation. For example, evidence of harms resulting from an
intervention might lead to a recommendation that the intervention not be used,
even if it is effective in improving some outcomes. In general, the Task Force
does not use economic information to modify recommendations.
A finding of insufficient evidence of effectiveness does not
result in recommendations regarding an intervention’s use but is important for
identifying areas of uncertainty and continuing research needs. In contrast,
adequate evidence of ineffectiveness leads to a recommendation that the
intervention not be used.
The systematic search identified 243 studies on tobacco
interventions that met the inclusion criteria. Of these 243 studies, 77 were
excluded on the basis of limitations in their execution or design and were not
considered further. The remaining 166 studies were considered qualifying
studies. The 14 Task Force evaluations in this report are based on these
qualifying studies, all of which had good or fair execution.
On the basis of the evidence of effectiveness, the Task Force
either strongly recommended or recommended nine of the 14 strategies evaluated (Tables
2, 3, 4, and
5). These nine recommendations include one intervention to reduce
exposure to ETS (smoking bans and restrictions) and two interventions to reduce
tobacco-use initiation (increasing the unit price for tobacco products and
multicomponent mass media campaigns). There were also six interventions to
Increasing the unit price for tobacco products;
Multicomponent mass media campaigns;
Provider reminder systems;
A combined provider reminder plus provider education with or
without patient education program;
Multicomponent interventions, including telephone support,
for individuals who want to stop using tobacco;
Reducing patient out-of-pocket costs for effective cessation
In addition to the 14 completed evaluations, reviews for three
more tobacco prevention interventionsyouth access restrictions, school-based
education, and tobacco industry and product restrictionsare still under way
and will be included in the finished chapter.
Using the Recommendations
Given that tobacco use is the largest preventable cause of death
in the United States, reducing tobacco use and ETS exposure should be relevant
to most communities. In selecting and implementing interventions, communities
should strive to develop a comprehensive strategy to reduce exposure to ETS,
reduce initiation, and increase cessation. Improvements in each category will
contribute to reductions in tobacco-related morbidity and death, and success in
one area might contribute to improvements in the other areas as well. Increasing
tobacco-use cessation, for example, will reduce exposure to ETS. Smoking bans,
effective in reducing exposure to ETS, also can reduce daily tobacco consumption
for some tobacco users and help others quit entirely.
Choosing interventions that work in general and that are
well-matched to local needs and capabilities and then implementing those
interventions well are vital steps for reducing tobacco use and environmental
tobacco smoke exposure. In setting priorities for the selection of interventions
to meet local objectives, recommendations and other evidence provided in the
Community Guide should be considered along with such local information as
resource availability, administrative structures, and economic, social, and
regulatory environments of organizations and practitioners. Information
regarding applicability can be used to assess the extent to which the
intervention might be useful in a particular setting or population. Though
limited, economic informationto be provided in the full report in 2001might
be useful in identifying (a) resource requirements for interventions, and
(b) interventions that meet public health goals more efficiently than other
available options. If local goals and resources permit, the use of strongly
recommended and recommended interventions should be initiated or increased.
A starting point for communities and health-care systems is to
assess current tobacco-use prevention and cessation activities. Current efforts
should be compared with recommendations in this report as well as other relevant
program recommendations proposed by CDC, the National Cancer Institute, the
Public Health Service, the US Department of Health and Human Services, and the
Institute of Medicine. In addition to assessing overall progress toward meeting
goals and the current status of tobacco control efforts, health planners should
also consider how to eliminate health disparities related to tobacco use and ETS
exposure. The identification and assessment of existing disparities are critical
in selecting and implementing interventions to assist populations at high risk,
such as low-socioeconomic populations and some racial/ethnic groups.
This review did not examine the evidence of effectiveness of
clinical cessation programs or therapies for tobacco dependence, which are not
part of the Community Guide mandate but were addressed in an extensive,
evidence-based review recently updated by the Public Health Service. However,
evidence reviews conducted for the Community Guide include several interventions
that might be useful to health-care providers and systems in identifying,
advising, and assisting tobacco-using patients in their efforts to quit.
Recommendations in the Community Guide complement those provided in the Public
Health Service report; both publications present a range of effective options
for increasing and improving programs to help patients quit using tobacco.
Adapted from A Report of the Task Force on Community Preventive
Services. Morbidity and Mortality Weekly Report 49(RR-12):1-11, 2000.