Evidence-Based Strategies for Reducing Cigarette Smoking

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The CDC’s “Best Practices for Comprehensive Tobacco Control Programs” details evidence-based, statewide tobacco control programs that have dramatically reduced smoking rates, and therefore tobacco-related diseases and deaths.

The main conclusion of the report is that states have identified certain initiatives as being most effective in discouraging people from beginning to smoke in the first place, and helping them quit once they’ve started. In the fifty years since the 1964 Surgeon General’s report declared cigarette smoking to be a health hazard, these approaches have directly contributed to reducing cigarette smoking from more than 42% of the U.S population, to less than 17%.

Evidence-based research has found that what works best is a comprehensive statewide approach that combines educational, clinical, regulatory, economic, and social strategies. Most often that means:

  • Transforming social norms to dissuade people from smoking cigarettes in the first place.
  • Increasing the price of tobacco products.
  • Implementing comprehensive smoke-free laws that prohibit smoking in most indoor areas.
  • Motivating tobacco users to quit, and giving them access to cessation medicines and techniques.
  • Limiting minors’ access to tobacco products.

Nearly 90% of adult smokers begin before the age of 18, so many of the proven strategies are aimed at young people. Also important is to target populations with high incidence of smoking, and intervening where they live and where they get treated for other issues. That includes public housing, substance abuse facilities, mental health facilities, correctional institutions, and community health centers.

Encouraging and helping tobacco users to quit is the quickest approach to reducing tobacco-related disease, death, and healthcare costs. Although quitting smoking at any age is beneficial, according to an article in the New England Journal of Medicine, smokers who quit by the time they are 35 to 44 years of age avoid most of the risk of dying from a smoking-related disease.

In the states doing the best job of reducing tobacco use, all patients are screened for tobacco use and their status is documented. Those who use tobacco are advised to quit. Insurance coverage is crucial. In 2006 when Massachusetts offered a Medicaid Cessation Benefit, the benefit was utilized by about 37% of Medicaid recipients who smoked, and the smoking rate among Medicaid enrollees fell from 38.3% to 28.3%. According to the peer review journal, PLOS Medicine, the benefit was found to generate a return on investment of $3.12 for every dollar spent from averted hospitalizations for acute cardiovascular events.

Electronic health records can make it easier for providers to refer patients to counseling. Well-funded, well-publicized quitlines have shown to be one of the most effective ways to provide follow through. The CDC’s Best Practices guide drills down to suggest some very specific ways to make quitlines most effective. They include ensuring that all callers receive at least one 10-minute call-back and that those enrolled in state insurance marketplaces and Medicaid are offered three proactive counseling calls and a free 2-week starter supply of nicotine patches or gum.

Reducing tobacco use is particularly challenging because tobacco products are so heavily marketed. According to a report by the Federal Trade Commission, in 2011 tobacco companies spent more than $8 billion, or nearly $23 million per day, to market cigarettes in the United States, mostly at the point of sale. An  anti-smoking media campaign on television, radio, and billboards can at least mitigate their impact.

For an overall anti-tobacco media campaign, the CDC estimates that advertisements should reach 75% to 85% of the target audience each quarter, with a minimum average per quarter of 1,200 gross rating points (GRPs) during the introduction of a campaign and a minimum average of 800 GRPs per quarter thereafter.

Evidence also suggests that securing free news placements in multiple media outlets can contribute greatly to the effectiveness of a counter-marketing campaign. Local and statewide earned media campaigns have been shown to influence smoking knowledge and attitudes, encourage changes to local tobacco control policies, and increase calls to state quitlines. At the same time, programs need to be flexible so they can quickly shift funding to address new and emerging products or trends. For example, the influx of electronic cigarette marketing and use may not have begun when a program was first developed.

All 50 states and the District of Columbia have tobacco control programs, funded through various revenue streams, including tobacco industry settlement payments, cigarette excise tax revenues, state general funds, and nonprofit organizations. States also have numerous places to go within the federal government for help. They can lower advertising development costs by using existing television, radio, print, and outdoor advertisements from CDC’s Media Campaign Resource Center (MCRC), and investigate funding opportunities, partnerships, and scientific research from a variety of federal agencies.

“Best Practices for Comprehensive Tobacco Control Programs” can be downloaded at https://stacks.cdc.gov/view/cdc/5628.

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