Reducing Exposure to Environmental Tobacco Smoke in Communities and Health-Care Systems

August 1, 2001

In the United States, tobacco use is the leading cause of preventable death. Exposure to environmental tobacco smoke (ETS)

In the United States, tobacco use isthe leading cause of preventabledeath. Exposure to environmental tobacco smoke (ETS) is a preventable cause ofsignificant morbidity and death among nonsmokers. Reducing tobacco use andreducing exposure to environmental tobacco smoke are essential community andpublic health objectives. As part of the Healthy People 2010 initiative, goalshave been developed to reduce tobacco-related morbidity and death by reducingexposure to ETS, decreasing tobacco-use initiation, and increasing tobacco-usecessation (Table 1).

By implementing interventions shown to be effective, policymakers and health-care and public health providers can help their communitiesachieve these goals while using community resources efficiently.


The independent, nonfederal Task Force on Community PreventiveServices (the Task Force) is developing the Guide to Community PreventiveServices (the Community Guide) with the support of the US Department of Healthand Human Services and in collaboration with public and private partners. TheCenters for Disease Control and prevention (CDC) and other federal agenciesprovide staff support to the Task Force for development of the Community Guide.However, the recommendations presented in this report were developed by the TaskForce and are not necessarily the recommendations of the CDC or the USDepartment of Health and Human Services.

This Morbidity and Mortality Weekly report is the second to becompleted for the Community Guide, a resource that will include multiplechapters, each focusing on a preventive health topic. The first chapter was onvaccine-preventable diseases. The information in this report will be part of asecond chapter on tobacco use. This report provides an overview of the processused by the Task Force to select and review evidence; it summarizes the TaskForce’s recommendations on community interventions to reduce exposure to ETSand tobacco use. A full presentation of the recommendations, supportingevidence, and remaining research questions will be published in the AmericanJournal of Preventive Medicine in 2001.


Methods used to conduct systematic reviews and link evidence torecommendations are described in another publication (Briss PA et al: Am J PrevMed 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 selectingthe interventions for review

Systematically searching for and retrieving evidence

Assessing the quality of the body of evidence ofeffectiveness for interventions and summarizing the strength of this body ofevidence

Summarizing information regarding other evidence (eg,applicability of the intervention to different populations and settings,additional benefits, potential harms, barriers to implementation, and economicevaluations)

Identifying and summarizing research gaps

For the chapter on tobacco use, the chapter development teamfocused on interventions to decrease exposure to ETS, reduce tobacco-useinitiation, and increase tobacco-use cessation. The chapter consultation teammembers generated a comprehensive list of strategies and created a priority listof interventions for review based on their perception of the importance and theextent to which the interventions were practiced in the United States. Time andresource constraints precluded review of some interventions (eg, community-widerisk factor screening and counseling).

Interventions reviewed were either single-component (ie, usingonly one activity to achieve desired outcomes) or multicomponent (ie, using morethan one related activity). Interventions were grouped together on the basis oftheir similarity. Some studies provided evidence for more than one intervention.In these cases, the studies were reviewed for each applicable intervention. Theclassifications or nomenclature used in this report were chosen to ensurecomparability in the review process, and these classifications sometimes differfrom those used in the original studies.

To be included in the reviews of effectiveness, studies had tomeet the following criteria:

They were limited to primary investigations of interventionsselected for evaluation.

They were published in English from January 1980 through May2000.

They were conducted in industrialized countries.

They compared outcomes in groups of persons exposed to theintervention with outcomes in groups of persons not exposed or less exposed tothe intervention (whether the comparison was concurrent or before-after).

For each intervention reviewed, the team developed an analyticframework indicating possible causal links between the intervention under studyand predefined outcomes of interest. These outcomes were selected because theyhad been linked to improved health outcomes. For example, the Task Forceconcluded the following:

Tobacco use is a cause of morbidity (illness and disability)and death.

Tobacco-use cessation reduces tobacco-related morbidity anddeath.

Delivery of advice by health-care providers to tobacco-usingpatients to quit has a small but significant impact on tobacco-use cessationamong patients.

The younger persons are when they begin to smoke, the morelikely they are to be current smokers as adults—an indication that postponingor preventing tobacco use among children and adolescents will decrease thenumber of adult tobacco users.

Exposure to ETS is a cause of morbidity and death; reducingexposure 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, reducingtobacco-use initiation, and increasing tobacco-use cessation (includingincreasing patient receipt of advice to quit from health-care providers).

Each study that met the inclusion criteria was evaluated byusing a standardized abstraction form and was assessed for suitability of thestudy design and threats to validity. On the basis of the number of threats tovalidity, studies were characterized as having good, fair, or limited execution.The strength of the body of evidence of effectiveness was characterized asstrong, sufficient, or insufficient on the basis of the number of availablestudies, the suitability of study designs for evaluating effectiveness, thequality of execution of the studies, the consistency of the results, and theeffect size.

The Community Guide links evidence to recommendationssystematically. The strength of evidence of effectiveness corresponds directlyto the strength of recommendations (eg, strong evidence of effectivenesscorresponds to an intervention being strongly recommended; sufficient evidencecorresponds to an intervention being recommended). Other types of evidence alsocan affect a recommendation. For example, evidence of harms resulting from anintervention might lead to a recommendation that the intervention not be used,even if it is effective in improving some outcomes. In general, the Task Forcedoes not use economic information to modify recommendations.

A finding of insufficient evidence of effectiveness does notresult in recommendations regarding an intervention’s use but is important foridentifying areas of uncertainty and continuing research needs. In contrast,adequate evidence of ineffectiveness leads to a recommendation that theintervention not be used.


The systematic search identified 243 studies on tobaccointerventions that met the inclusion criteria. Of these 243 studies, 77 wereexcluded on the basis of limitations in their execution or design and were notconsidered further. The remaining 166 studies were considered qualifyingstudies. The 14 Task Force evaluations in this report are based on thesequalifying studies, all of which had good or fair execution.

On the basis of the evidence of effectiveness, the Task Forceeither strongly recommended or recommended nine of the 14 strategies evaluated (Tables2, 3, 4, and 5). These nine recommendations include one intervention to reduceexposure to ETS (smoking bans and restrictions) and two interventions to reducetobacco-use initiation (increasing the unit price for tobacco products andmulticomponent mass media campaigns). There were also six interventions toincrease cessation:

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 cessationtherapies.

In addition to the 14 completed evaluations, reviews for threemore tobacco prevention interventions—youth access restrictions, school-basededucation, and tobacco industry and product restrictions—are still under wayand will be included in the finished chapter.

Using the Recommendations

Given that tobacco use is the largest preventable cause of deathin the United States, reducing tobacco use and ETS exposure should be relevantto most communities. In selecting and implementing interventions, communitiesshould strive to develop a comprehensive strategy to reduce exposure to ETS,reduce initiation, and increase cessation. Improvements in each category willcontribute to reductions in tobacco-related morbidity and death, and success inone area might contribute to improvements in the other areas as well. Increasingtobacco-use cessation, for example, will reduce exposure to ETS. Smoking bans,effective in reducing exposure to ETS, also can reduce daily tobacco consumptionfor some tobacco users and help others quit entirely.

Choosing interventions that work in general and that arewell-matched to local needs and capabilities and then implementing thoseinterventions well are vital steps for reducing tobacco use and environmentaltobacco smoke exposure. In setting priorities for the selection of interventionsto meet local objectives, recommendations and other evidence provided in theCommunity Guide should be considered along with such local information asresource availability, administrative structures, and economic, social, andregulatory environments of organizations and practitioners. Informationregarding applicability can be used to assess the extent to which theintervention might be useful in a particular setting or population. Thoughlimited, economic information—to be provided in the full report in 2001—mightbe useful in identifying (a) resource requirements for interventions, and(b) interventions that meet public health goals more efficiently than otheravailable options. If local goals and resources permit, the use of stronglyrecommended and recommended interventions should be initiated or increased.

A starting point for communities and health-care systems is toassess current tobacco-use prevention and cessation activities. Current effortsshould be compared with recommendations in this report as well as other relevantprogram recommendations proposed by CDC, the National Cancer Institute, thePublic Health Service, the US Department of Health and Human Services, and theInstitute of Medicine. In addition to assessing overall progress toward meetinggoals and the current status of tobacco control efforts, health planners shouldalso consider how to eliminate health disparities related to tobacco use and ETSexposure. The identification and assessment of existing disparities are criticalin 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 ofclinical cessation programs or therapies for tobacco dependence, which are notpart 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 interventionsthat 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 PublicHealth Service report; both publications present a range of effective optionsfor increasing and improving programs to help patients quit using tobacco.

Adapted from A Report of the Task Force on Community PreventiveServices. Morbidity and Mortality Weekly Report 49(RR-12):1-11, 2000.