Integrating population smoking cessation policies and programs

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This series of eight studies demonstrates that population cessation programs can produce important impacts on smoking cessation for purposes of disease prevention and disease management. These studies also suggest that increased impacts for chronic disease control can be produced by programs that intervene on multiple behavioral risks. Such intervention programs could also increase support for tobacco control policies. Stages of change and support for tobacco control policies: To assess population support for tobacco control policies, our center developed a Smoking Policy Inventory that reliably and validly assesses support for five types of tobacco control policies: (1) education, (2) controlling youth access, (3) increasing taxes, (4) advertising bans, and (5) smoking bans. One study that looked at six nations found support for tobacco control policies decreased as the policies became more restrictive. In each of the six nations, support for each type of tobacco control policy increased across the stages of change, with the least support among smokers in the precontemplation stage and the most support among former smokers in the maintenance stage. These data suggest that population cessation programs that help smokers progress through the stages of change could also increase support for different types of tobacco control policies. A reciprocal relationship could be generated in which cessation programs increase support for tobacco control policies, and tobacco control policies could help smokers succeed in cessation programs. In a 2000 National Cancer Institute (NCI) report on population smoking cessation, considerable concern was raised that population cessation rates did not increase in the U.S. during the 1990s, even though the application of tobacco control policies and programs increased dramatically. No improvements in cessation rates were found across any demographic group or type of smoker. There was no improvement in cessation rates in older or younger smokers, African American or non-Latino white smokers, smokers with higher or lower levels of education and income, or in heavier or lighter smokers. To increase the nation's cessation rates, NCI's report recommended that states and communities should increase the frequency, intensity, and/or quality of current tobacco control strategies. The NCI report discovered one other alternative, an individually tailored cessation innovation that has ". . . the potential to provide assistance to the general population of smokers. Interventions based on computer driven algorithms that tailor the intervention and counseling provided to the individual smoker have been developed." Our research suggests that not only could these tailored interventions provide assistance to the general population of smokers, they could also increase support for a broad range of tobacco control policies. As smokers progressed through the stages of change, their support for policies such as increased taxes and counter advertising could increase. They could appreciate how increased taxes could also increase their motivation to quit smoking. They could recognize how counter advertising could help them resist temptations to keep smoking. They could support smoking bans in public places as a strategy that could increase their smoke-free choices, when they are struggling to stay free from smoking. Increased availability of population cessation programs tailored to the needs of individual smokers and increased support for tobacco control policies have the potential to produce a synergy that could increase cessation rates across a variety of population groups. Research to test these hypotheses is currently under review. Future policies and programs: Here is an example of how national policy makers can progress toward programs designed to increase population impacts. The senior author had the honor of advising the Prime Minister of Great Britain on smoking cessation programs to prevent cancer and other chronic diseases. The author reported that there are smoking cessation programs available that could reduce smoking prevalence by 20% in two years, even though smoking has decreased in the United States by only about 2% in 12 years. The Prime Minister asked two key questions: (1) Are these cessation programs based on research with small samples that won't generalize to the real world? and, (2)Are these cessation programs so intensive that few smokers will participate? Here is the leader of a nation asking the most important empirical and practical questions: (1) Are these programs based on clinical trials with small, select samples? and (2) Are these programs that might have adequate efficacy but poor impacts? If policy makers and program sponsors continue to ask such tough questions, they can help raise the standard for health behavioral change theory, research, practice, and policy. The research reviewed here leads to the recommendation that policy makers support chronic disease programs that shift their primary emphasis: from clinical trials to population trials, from efficacy outcomes to population impacts, from reactive recruitment to proactive recruitment, from action-oriented interventions to stage-matched interventions, from clinician interventions to computer-based interventions, from interventions for a single behavior to interventions for multiple behaviors, and from policies that coerce change to programs that generate support for policy change. By shifting our emphasis to population-based interventions, we can build a more effective integration between population smoking cessation policies and programs.

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Public Health Reports