We Know What Works

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It is no longer a secret. Smoking cigarettes will kill you. It says so right on the package. I suppose it could say, “Smoke these and you will die,” but the current warnings are pretty straightforward: “smoking causes lung cancer, heart disease, emphysema, and may complicate pregnancy.”

Nevertheless, more than 40 million adults in the United States still smoke cigarettes, nearly 500,000 will die prematurely, and another 16 million suffer from a life-threatening disease caused by tobacco. You don’t even have to smoke to be impacted. Each year, primarily because of exposure to secondhand smoke, the CDC estimates that more than 7,000 nonsmoking Americans die of lung cancer and more than 33,000 die of heart disease.

That’s the bad news. Fortunately, there is also good news. In the fifty years since the Surgeon General’s report declared cigarette smoking to be a health hazard, smoking is down from more than 42 percent of the U.S population, to less than 17 percent. The other good news is that we know what works; we know which strategies have been most effective in discouraging people from smoking in the first place, and helping them quit once they start. What works best is a comprehensive statewide approach that combines educational, clinical, regulatory, economic, and social strategies.

Nearly 90% of adult smokers begin before the age of 18, so many of the proven strategies are aimed at young people. Effective actions are those that reinforce one another, and are most effective when they work together to produce the synergistic effects of a comprehensive statewide program. No one strategy works as well by itself as it does as part of a multipronged effort. For example, while there is little evidence of the long-term effectiveness of school-based programs to prevent smoking, we know that they are most effective when part of an approach that includes school policies, community-wide strategies, and mass media.

None of this happens by accident, so states establishing a strategic plan for comprehensive tobacco control is crucial. That means coordinating with the appropriate partners, including elected officials, other decision-makers, local businesses, and community-based organizations. Integrating cessation efforts into the healthcare system is also crucial. That includes providing insurance coverage of evidence-based tobacco cessation treatments, but also interventions during visits to the doctor or hospital, even if for an unrelated reason. Experience shows that most smokers want and expect their physician to talk to them about quitting smoking and are receptive to their physician’s advice. The best approach is what many states call the “Five A’s” – Ask about tobacco use, Advise to quit, Assess willingness to make a quit attempt, Assist in the quit attempt, and Arrange follow-up.

Hard hitting mass-media campaigns that include paid media in print and on television, radio, and billboards, have been proven effective, but so has earned media. Although paid media benefits from the ability to control the message, news media coverage is important because it helps set the public agenda, influence what people are talking about, and further broadens and add credibility to paid messages. Examples of earned media tactics include establishing relationships with journalists, issuing press releases, scheduling editorial board briefings, holding events that generate media coverage, writing letters to the editor, and training spokespeople for interviews.

Evidence suggests that one of the most successful cessation strategies is to develop a robust, widely publicized quitline. Quitlines have the benefit of being inexpensive to set up and maintain, but at the same time they can reach broad, diverse populations. State quitlines are typically the most visible component of a state’s cessation efforts, and frequently serve as a hub or centerpiece of the entire program.

While we know what has worked in the past, programs need to be flexible in shifting funding to address new and emerging trends of. For example, recent increases in the use of electronic cigarettes may not have been recognized if a plan was developed several years ago.

Let’s not kid ourselves. These efforts take money, but in this case money well spent. The CDC reports that states that have made the largest investments in comprehensive tobacco control programs have seen the largest declines in cigarettes sales. Research also shows that the longer states invest in such programs, the greater and quicker the impact. For example, in California, the nation’s first and longest-running comprehensive state tobacco control program, the prevalence of smoking among adults was cut in half, from 22.7% in 1988 to 11.9% in 2010.

So urge your state to learn what works by taking a good look at the CDC’s comprehensive document called “Best Practices for Comprehensive Tobacco Control Programs” available free of charge at https://stacks.cdc.gov/view/cdc/5628. It spells out in detail evidence-based, statewide programs that have been shown to reduce smoking rates and tobacco-related diseases and deaths. The document also provides plenty of tips on how to tap the numerous federal programs that offer funding opportunities, research results, and help with messaging and free materials, like ad copy, sample press releases, and even radio and TV spots that can be adapted to local communities.

For many decades we’ve known that tobacco use is the single most preventable cause of disease and death in the United States. Now we know how to act on all the knowledge we’ve accumulated during the past 50 years. Take a look at the CDC’s Best Practices document and join in the ongoing evidence-based campaign to even further reduce deaths from cigarette smoking.

Keith Vensey, MPH, MBA
Director of Geographic Health Equity Alliance

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