military commissaries, cigarettes sell for approximately 35 percent less than in civilian
stores (Blake 198.5). A 1985 survey of active duty military personnel found that near-
ly one-half smoked cigarettes, one-quarter smoked cigars or a pipe, and almost one-
fifth used chewing tobacco, snuff, or other smokeless tobacco (Bray et al. 1986; Her-
bold 1987). Cigarette use was more common among nonofficers and varied by pay
grades, with those at the lower end of the pay scale exhibiting a higher prevalence of
smoking. A 1986 Department of Defense (DOD) report estimated that smoking-related
health care costs to the military were 209 million dollars in 1984 (DOD 1986).

In March 1986, prompted by the medical evidence linking smoking with disease and
the high prevalence of smoking among military personnel, the Secretary of Defense in-
itiated an intensive antismoking campaign to be conducted at all levels of all services
(DOD 1987). In April 1986, a DOD smoking reduction framework defined three smok-
ing reduction goals for the military: (1) to reduce active duty smoking and other tobac-
co use by 10 percent per year, (2) to provide smoking reduction information and motiva-
tion and cessation assistance to DOD personnel, and (3) to specify designated places
and times where smoking can occur to minimize effects of smoking on nonsmokers
(DOD 1987).

Print and audiovisual materials for the campaign were obtained from voluntary and
Federal agencies. In addition, in 1986, DOD allocated 97,000 dollars for publications
and 324,Odollars for antismoking on military radio and television PSAs (DOD 1987).

Each branch of the service developed its own smoking control plan consistent with
the overall goals of DOD (DOD 1987). The U.S. Air Force (USAF) modified the cur-
ricula at the Basic Military Training School, the USAF Officer Training School, the
USAF Academy, and the Air Force Reserve Officers' Training Corps to include man-
datory classes on the hazards of using tobacco products. Similar course material was
included in all professional military education for all officers and enlisted personnel.

In June 1986, the Air Force Surgeon General directed that there be on-base smoking
cessation classes at every medical treatment facility in the Air Force. Nicotine-con-
taining chewing gum was made available in all pharmacies, and tobacco sales were dis-
continued at all Air Force medical treatment facilities. Smoking was banned in all
hospital and clinic facilities. Smoking was also prohibited on aeromedical evacuation
flights, and the Officer Training School banned smoking during duty hours.

In July 1986, the Army banned the use of tobacco products in basic training and
restricted smoking in other military courses. Army training centers and service schools
incorporated antitobacco information into the curriculum. Smoking cessation courses
were offered to soldiers, retirees, and family members. In November 1986, the Army
participated in GASO.

In March 1987, the Navy Medical Commander directed that all naval hospitals offer
group smoking cessation programs and prohibited the sale of tobacco in medical and
dental facilities. Curricula for all Navy personnel include information on the health
risks of tobacco use. Naval hospitals stock nicotine-containing gum for members in
formal cessation classes. The Navy participated in the 1986 GASO.
The Marine Corps smoking control program is similar to that offered by the Navy.
Guidance and smoking cessation materials are disseminated at all accession training
commands and formal schools. Family Service Centers and Alcohol Counseling

426


Centers provide cessation programs. Smoking is prohibited in all medical and dental
facilities.

To monitor the impact of the smoking control program, DOD conducts annual tobac-
co use surveys of military personnel (DOD 1987). Comparison of the 1982 and 1985
DOD worldwide surveys on alcohol and nonmedical drug use among military person-
nel revealed that the percentage of active duty smokers has dropped significantly from
53 percent in 1982 to 46 percent in 1985 (DOD 1987) (see Chapter 5). Between Novem-
ber 1986 and March 1987, the monthly dollar sales of tobacco products in military com-
missaries dropped by 18 percent (DOD 1987). The evidence available to date suggests
that the DOD antismoking campaign has been successful (DOD 1987; Institute for the
Study of Smoking Behavior and Policy 1988). The impact of the campaign is still being
monitored, and the issue of tobacco sales pricing policies is being reassessed.

State Health Departments

A 1987 survey of State and territorial health agencies found that 33 of 52 (61 per-
cent) reported having sponsored smoking cessation programs (CDC 1987). Most State
plans focus on prevention rather than smoking cessation.

Several States have established programs to encourage cessation by pregnant women.
New Jersey, Maryland, and Pennsylvania have developed protocols for use in State-
supported maternity clinics (Coye 1988; US DHHS 1986a). New York has conducted
a mass media education initiative, "Healthy Mothers, Healthy Babies," to encourage
pregnant women to refrain from alcohol and tobacco use (US DHHS 1986a). Many
local health departments also have established programs that provide cessation ac-
tivities although these are not consistently cataloged.

Three State health departments, Colorado, Maryland, and Missouri, in collaboration
with the Division of Reproductive Health of CDC, are developing and implementing a
Smoking Cessation in Pregnancy (SCIP) Project to be used in public prenatal clinics.
The purpose of the project is to reduce the incidence of low birthweight among women
using publicly funded prenatal care services. One of the interventions used will be
directed at helping the women to stop smoking. It is anticipated that approximately
4,000 women will be involved in the project and that 2,000 smokers will be exposed to
the smoking cessation intervention.

Commercial Ventures in Smoking Control

As the number of smokers attempting to stop has increased, so have commercial ven-
tures to develop and market cessation aids and services. Today, for-profit stop-smok-
ing programs can be found in almost all major cities in the United States (Schwartz
1987). This Section provides a brief review of commercial ventures in smoking cessa-
tion, focusing first on the development and marketing of pharmacologic aids, followed
by a discussion of nonpharmacologic aids and behavioral and motivational programs.
Pharmacologic aids have been reviewed in the 1988 Surgeon General's Report on
nicotine addiction (US DHHS 1988). The description of commercial ventures in smok-

427


ing control is selective. Those nonpharmacologic programs described were chosen be-
cause they provide a historical perspective and have well-used national networks.

Pharmacologic Cessation Aids

Smoking deterrent drug products have been available since the early part of this cen-
tury. Early drug treatments included herbs and spices and mouthwashes that altered
the taste of tobacco so that smoking was less pleasant (Schwartz 1969). In 1936, Dor-
sey (1936) developed lobeline sulfate capsules to minimize the craving for tobacco.
Lobeline sulfate is the active ingredient in Nikoban and Bantron, two popular non-
prescription cessation aids available in most drugstores today. In 1982, a Food and
Drug Administration (FDA) panel that reviewed smoking deterrent drug products con-
cluded that the data were insufficient to demonstrate the effectiveness of lobeline as a
smoking cessation aid (FDA 1982). A similar conclusion was reached regarding the
effectiveness of drug products such as chewing gums, mouthsprays, and tablets con-
taining silver acetate (FDA 1982). In its proposed monograph for over-the-counter
(OTC) smoking deterrent drugs (FDA 1985), FDA tentatively adopted this panel's con-
clusions, but FDA has not yet issued a final rule. Silver acetate when combined with
tobacco creates an unpleasant metallic taste in the mouth that presumably serves to dis-
courage smoking.

Clonidine, a drug used to treat high blood pressure, currently is being investigated as
an aid to help people stop smoking (Glassman et al. 1988). Interest in clonidine as a
smoking cessation aid was stimulated by Glassman and colleagues (1984) who
demonstrated a reduction in cigarette urges associated with its use. It is speculated that
clonidine may relieve nicotine withdrawal symptoms through its effect on the central
nervous system's adrenergic mechanism (Glassman et al. 1984.1988; US DHHS 1988).
Boehringer Ingelheim Pharmaceuticals, Inc., currently is conducting studies to evaluate
the effectiveness of a clonidine transdermal patch as a smoking cessation aid. Clonidine
is not currently approved for marketing as a smoking cessation aid by FDA.

To date, the most successful and effective drug product developed to assist smokers
in stopping is nicotine polacrilex gum, a nicotine-containing chewing gum (US DHHS
1988). It is marketed by Lakeside Pharmaceuticals, a Division of Merrell Dow.
Nicotine-containing gum was developed on the premise that nicotine is the primary
reinforcer of smoking. It was reasoned that a product that could deliver nicotine into
the body in a form with lower potential to produce dependence could aid smokers in
stopping (Femoe. Lichtneckert, Lundgren 1973).

Nicotine-containing gum was first developed and manufactured by A.B. Leo in
Sweden in 1971. Early studies with the gum showed poor results. However, a car-
bonate buffer added to improve absorption of nicotine improved cessation rates (Axel-
sson and Brantmark 1977).The main benefit associated with gum use is the alleviation
of withdrawal symptoms. Several studies have demonstrated the effect of nicotine-con-
taining gum in relieving irritability, anxiety, problems in concentrating, restlessness,
and hunger (Hughes and Miller 1984; Schneider, Jarvik, Forsythe 1984; US DHHS
1988). Studies suggest that the gum does not fully replace the nicotine provided by
cigarette smoke. Benowitz, Jacob, and Savanapridic (1987) reported that chewing 2-

428


mg nicotine gum on an hourly schedule for 10 hr yielded blood nicotine levels com-
parable to one-third that achieved while smoking. Use of a 4-mg nicotine gum causes
a greater increase in blood nicotine levels and may increase cessation rates (Tonnesen
et al. I988 j. However, only the 2-mg dose is approved for use in the United States (US
DHHS 1988).

Numerous studies have reported on the efficacy of nicotine polacrilex gum in achiev-
ing smoking cessation (Schwartz 1987; US DHHS 1988). Many of these studies are
well-controlled double-blind investigations comparing nicotine-containing gum with a
placebo gum (British Thoracic Society 1983; Campbell, Lyons, Prescott 1987;
Fagerstrom 1982: Fee and Stewart 1982: Hall et al. 1987: Hjalmarson 1984; Jamrozik
et al. 1984; Jarvis et al. 1982; Puska, Bjorkqvist. Koskela 1979; Schneider et al. 1983;
Tonnesen et al. 1988). No studies to date have compared nicotine-containing gum with
othercessation drug products, such as those containing lobeline orclonidine (US DHHS
1988). Not all studies have shown nicotine polacrilex gum to be effective (British
Thoracic Society 1983; Campbell, Lyons, Prescott 1987; Fee and Stewart 1982; Jam-
rozik et al. 1984). Long-term cessation rates (over l-year followup) vary widely from
3 to 49 percent (US DHHS 1988). Nicotine-containing gum has become an increas-
ingly popular adjunct to behaviorally based cessation programs. Studies suggest that
behaviorally based treatment in conjunction with nicotine polacrilex gum tends to be
more effective than the same program without gum, or compared with gum alone
(Fagerstrom 1982; Hall et al. 1987; Killen, Maccoby, Taylor 1984).

FDA approved the marketing of nicotine-containing gum in the United States as a
prescription smoking cessation aid in January 1984 (IMS 1984). The product became
available to the public in mid-March of that year. It retails for about I8 dollars for a
box of 96 pieces. A mailing piece introducing the gum was circulated to 77,000
physicians (IMS 1984). In the 4 months after FDA approval of nicotine polacrilex gum,
Merrell Dow spent more than 4 million dollars to launch the product (IMS 1984). Over
80 percent of promotion dollars was used for in-person promotion in physicians' of-
fices and other health care settings. The result of this massive promotional campaign
was one of the fastest selling prescription products ever introduced (IMS 1984). Sales
were 42 million dollars in 1984,46 million dollars in 1985,54 million dollars in 1986,
and 60 million dollars in 1987.

As part of its promotional campaign, Merrell Dow has supported many medical sym-
posia on smoking, underwritten the cost of a newsletter on smoking cessation sent to
over 40,000 physicians annually, and helped support the development and distribution
of training materials on smoking cessation for health professionals.

Since the gum was introduced in March 1984. an estimated 4 to 6 million smokers
(approximately one-tenth) have used it. Surveys of gum users show that two-thirds of
prescriptions are generated by the patient rather than the physician. Lakeside advertis-
ing in public media (which does not mention the product or brand name) encourages
smokers to ask their physicians for help in stopping smoking. The commercial success
of nicotine polacrilex gum is likely to encourage other pharmaceutical companies to
consider developing and marketing cessation drug products. Several nicotine-contain-
ing products are under investigation as cessation aids, including nasal nicotine solu-
tions, nicotine dermal patches, and nicotine aerosols (US DHHS 1988).

429


Nonpharmacologic Cessation Aids

A variety of nonpharmacologic aids have been produced over the years to assist
smokers in reducing or stopping smoking, including filter systems, smokeless ciga-
rettes, self-help books, audiotapes, and more recently, videos (Schwartz 1987).
Evidence regarding the effectiveness of these cessation aids is extremely limited or non-
existent. Many companies have developed cigarette filter systems to help people stop
smoking. The basic idea behind a filter system as a cessation aid is to reduce the amount
of nicotine taken in, allowing smokers to wean themselves from the chemical addiction
(Schwartz 1987). One of the most popular filter systems available, One Step at a Time,
manufactured by Teledyne Water Pik, was first marketed in 1977 and is sold primari-
ly through chain drugstores and advertised in conjunction with local retailers. The fil-
ter system consists of four reusable filters, each of which further reduces the amount of
tar, nicotine, and carbon monoxide from cigarette smoke. Each of the filters is to be
used for 2 weeks. The One Step at a Time filter system sells for about 10 dollars.
Teledyne Water Pik also markets a single filter system called Step Four, which is the
fourth filter in the filter system and sells for about 5 dollars. In the FDA's 1980 response
to a petition filed by Action on Smoking and Health for the regulation of cigarette fil-
ters as medical devices (FDA 1980), the agency concluded that some of the labeling
and advertising for detached cigarette filters established intended therapeutic uses for
One Step at a Time and certain other products. Thus, One Step at a Time and certain
other detached cigarette filters were considered as medical devices within the agency's
jurisdiction.

Smokeless cigarettes that simulate the taste of tobacco smoke are another popular
cessation aid. E-Z Quit, a smokeless cigarette sold through a mail order company, con-
sists of a plastic cigarette with three menthol flavor capsules. The product sells for
about 10 dollars and is widely advertised in popular magazines and newspapers. E-Z
Quit was designed to deliver flavoring ingredients through inhalation, and was intended
and labeled for use as a smoking deterrent. Products so formulated and labeled are
regarded by the FDA as drugs and have been included in the agency's ongoing OTC
drug review. Under this review, in 1982 an Advisory Review Panel (FDA 1982) con-
cluded that the data are insufficient to demonstrate the effectiveness of such products
as smoking deterrents. In 1985 the FDA tentatively concurred with this conclusion in
its proposed monograph (FDA 1985). A final rule has not yet been issued.

Dozens of different how-to-quit-smoking books have been produced. Many of the
books are written by former smokers and psychologists who provide a wide range of
suggestions on how to stop smoking. Studies evaluating the efficacy of quit-smoking
books have reported mixed results (Cummings et al. 1988; Davis, Faust, Ordentlich
1984; Glasgow and Lichtenstein 1987; Glasgow and Rosen 1978; FDA 1982). In
general, the findings of studies comparing the effectiveness of different quit-smoking
books suggest that no one book appears to be better than any other. The addition of a
personal contact to the provision of written materials appears to enhance quitting be-
havior (Flay 1987b; Kottke et al. 1988). Many bookstores also sell audiotapes on how
to stop smoking. In 1985, ALA produced "In Control,"@ a smoking cessation video
program that smokers can use at home on a videocassette recorder. "In Control" runs
for 2 hr and consists of 13 segments that viewers are encouraged to see on different
days. Users also receive a 124-page viewer guide and a 20-min audiotape with motiva-
tional and relaxation messages. The package sells for 60 dollars. A recent evaluation
of the program, which did not use a control group, involved 100 smokers and found
that 53 completed the program, with 3 I verified abstinent by carbon monoxide testing
1 month after completion. Twenty-one of the 100 smokers who started the program

430


were not smoking 1 year after completing it and 16 of these reported total abstinence
during the l-year followup period (Marston and Bettencourt 1988). ACS recently
produced the ACS Freshstart video, a 2 1 -day program that focuses on maintaining ces-
sation (i.e., quit day is day I). The video sells for about 20 dollars.

Recently. Health Innovations, Inc., developed and began marketing a computer-as-
sisted smoking cessation program called "LifeSign. " "LifeSign" consists of a credit-
card-sized microcomputer and self-help booklet. The microcomputer is used to assist
smokers in designing a tailored, gradual cutdown program that helps the smoker
withdraw from the nicotine in cigarettes. Two studies of "LifeSign" show validated 6-
month cessation rates of 18 and 28 percent (Frederiksen et al. 1988). However, both
of these studies were based on small samples of self-selected smokers and did not in-
volve comparisons with other cessation interventions.

Stop-Smoking Programs

Hypnosis has long been advocated as an effective treatment for stopping smoking
(Schwartz 1987). A review of smoking cessation treatments listed in the telephone yel-
low pages of 47 U.S. cities found that hypnosis was the most frequently advertised ser-
vice (Schwartz 1987). Hypnotists accounted for 31 percent of all services listed. The
intent of hypnosis as a smoking cessation treatment is often to increase personal motiva-
tion to stop smoking (Spiegel 1970). This is usually done by posthypnotically suggest-
ing a link between smoking and unpleasant experiences (e.g., "smoking is a poison").
Many hypnosis techniques are similar to behavioral therapy methods (e.g., relaxation
training, increased awareness of smoking cues), making it difficult to distinguish the
specific effects of hypnosis. Spiegel ( 1970) suggests that hypnosis alone does not make
a person stop smoking, but when combined with motivation, helps the subject con-
centrate on changing his or her smoking behavior. Schwartz's review of 31 hypnosis
trials concluded that hypnosis, when used as the only cessation method, is ineffective
(Schwartz 1987).

More recently, acupuncture has been touted as an effective treatment for smoking
cessation (Schwartz 1987). Acupuncture involves the use of needles or staplelike at-
tachments placed in the nose or ear (Schwartz 1987). The mechanism by which
acupuncture may help a person stop smoking is not clear. Several investigators sug-
gest that acupuncture relieves smoking withdrawal symptoms, although there is little
evidence to support this claim (Fuller 1982; Schneidernan 1981). Others suggest that
the effect of acupuncture is psychological and depends on personal motivation to stop
smoking (Machovec and Man 1978; Martin and Waite 1981). Studies that evaluate
acupuncture as a smoking deterrent vary widely in the methods used and in the cessa-
tion rates reported (Schwartz 1987).

One of the oldest and most successful commercial cessation programs is Smok-
Enders, which was started by a former smoker, Jacquelyn Rogers, in 1969. Head-
quartered in New Jersey, SmokEnders has chapters or franchises in many U.S. cities
and in several foreign countries (Schwartz 1987). The program consists of six 2-hr ses-
sions held over a 6-week period. Classes are conducted by former smokers who are
graduates of the SmokEnders program. The program emphasizes motivation for stop-
ping and brand switching, as well as behavioral and cognitive skills for gradually reduc-
ing the amount smoked. In 1985. Comprehensive Care Corporation purchased the
license to operate SmokEnders. However, the program is basically the same as the one
developed by Rogers in 1969. The cost of the program varies by location, ranging from
225 to 300 dollars. Since SmokEnders was established in 1969, an estimated 600,000
smokers have completed the program.

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The Schick Stop Smoking program, started in 197 1, was the first well-known com-
mercial program to use counterconditioning techniques to help people stop smoking
(Smith 1988). The Schick Stop Smoking program includes three phases: a l-week
preparation phase, a l-week counterconditioning phase, and a support phase (Smith
1988). In the preparation phase, smokers are instructed to keep a record of each
cigarette smoked. The counterconditioning phase of the program consists of five I-hr
treatment sessions held on consecutive days. Two counterconditioning techniques-
mild electric shock to the wrist and quick puffing on a cigarette-are used to attach
negative experiences to common cues for smoking. In the support phase, clients return
to the center for group counseling, receive weekly telephone contacts, and have one ad-
ditional counterconditioning session. The program is run by trained nonmedical per-
sonnel and treats about 2,000 smokers annually. The cost of the program is 595 dol-
lars.

Worksite and Hospital Wellness Programs

Stimulated by both public and private initiatives, an increasing number of businesses
have adopted policies that either limit or ban smoking at work (Bureau of National Af-
fairs 1987; Orlandi 1986; US DHHS 1986b; Martin, Fehrenbach, Rosner 1986) (see
Chapter 7). This trend has resulted in an increased demand for smoking control
programs offered at worksites. Worksite programs have the advantage of having an
available defined population that can potentially be reached. Many organizations have
attempted to capitalize on the demand by developing and marketing smoking control
programs specifically for worksites (Newsweek, August 29, 1988). The efficacy of
worksite smoking programs was reviewed in the 1985 Surgeon General's Report (US
DHHS 1985a), which presented somewhat disappointing results. Since that review,
other outcomes have been somewhat more encouraging (e.g., Omenn et al. 1988).

In 1980, Control Data Corporation began marketing "Stay Well," a health promotion
program designed for businesses (Anderson and Jose 1987). The smoking control com-
ponent of the "Stay Well" program is called "How to Quit Smoking" and consists of
eight I-hr group sessions conducted over 7 weeks. The program emphasizes nicotine
fading and behavioral coping skills. When the program was first introduced in 1980,
classes were conducted by staff from Control Data. However, this proved to be costly
and limited the geographical reach of the program. In 1982, the "Stay Well" program
began licensing hospitals to deliver and market the program. Today, there are 50
licensed distributors located in most major population centers. More than 600 corpora-
tions have used the "How to Quit Smoking" program. The cost of the program varies
by distributor, ranging from 35 to 80 dollars per smoker.

Johnson and Johnson, Inc., has recently begun marketing *`Live for Life" (LFL), a
wellness program designed for the workplace (Wilbur 1983). The smoking cessation
component of LFL includes an annual health screen with medical advice on smoking,
environmental changes to support nonsmoking, and regularly scheduled stop-smoking
classes. Classes consist of 14 I-hr sessions held over a 3-week period. Smoke hold-
ing, group support, relaxation training, and behavioral coping skills are the primary ele-
ments of the program (Shipley et al. 1988). A recent report on the effectiveness of the

432


LFL stop-smoking program showed that in four companies exposed to the program, 23
percent of smokers were not smoking 2 years later compared with 17 percent in three
matchedcomparison companies (Shipley et al. 1988). Among smokers in the LFL com-
panies, 2 1 percent enrolled in the stop-smoking classes and 32 percent of these were
not smoking after 2 years (Shipley et al. 1988).

In 1976 the American Institute for Preventive Medicine began marketing a stop-
smoking program called "Smokeless." The program includes five 1 -hr sessions held
on consecutive days, plus three maintenance classes spread over 2 weeks (Powell and
McCann 198 I j. The program instructs smokers in a wide range of behavioral and cog-
nitive coping skills and includes some mild counterconditioning procedures (e.g.,
"pinky puffing" (puffing a cigarette while holding it between the pi&y and ring finger)),
loud white noise, filters dipped in anti-nail-biting solution). "Smokeless" has recently
been adapted into a self-help format that sells for 39 dollars. The self-help program is
packaged in an attractive kit with six booklets and a relaxation audiotape. The Institute
also markets a guide for establishing a smoking policy in the workplace. `Smokeless"
is licensed to hospitals or businesses to use and market program materials. Hospitals
in turn will offer the program to people in the community. Corporate affiliates offer
the program solely to their own employees. Each hospital affiliate is responsible for
marketing the program in a defined geographic region. Since 1983. 250 hospitals and
several large corporations have been licensed to conduct "Smokeless," although this
does not mean that they actually run the program. The Institute conducts a 3-day train-
ing seminar on how to run the program and provides each trainee with a set of materials.
The Institute also assists hospital affiliates in marketing the program. Program
materials are sold to the affiliate hospital or corporation for 30 dollars per person. The
fee for "Smokeless" varies by affiliate, ranging from 75 to 225 dollars per smoker.

Smoke Stoppers is another commercial stop-smoking program that licenses hospitals
and other outlets to use its materials. The program is marketed by the National Center
for Health Promotion in Ann Arbor, MI. The format of Smoke Stoppers is similar to
that of "Smokeless," with five classes in the first week, followed by three maintenance
sessions. Outlets certified to conduct Smoke Stoppers programs are given exclusive
rights to market the program in a defined geographical region. All Smoke Stoppers in-
structors are required to be former smokers and must attend a 40-hr training program.
Program materials are sold to affiliates at a cost of 39 dollars per person. The fee
charged to smokers varies by outlet, averaging about 150 dollars per person. Smoke
Stoppers was established in 1977 and has licensed over 3000utlets toconduct programs.

One of the 1990 Health Objectives for the Nation calls for at least 35 percent of all
workers to be offered employer/employee-sponsored or -supported smoking cessation
programs either at the worksite or in the community. While there are no national data
available to measure the percentage of all workers who have access to such a program,
a 1985 survey, the National Survey of Worksite Health Promotion Activities, gathered
data on smoking cessation programs in worksites with 50 or more employees, which is
reflective of approximately 58 percent of the U.S. workforce (US DHHS 1987).
Preliminary analyses indicate that approximately 36 percent offer some kind of smok-
ing cessation program. Due to the incompleteness of the data, evaluation of progress
toward achievement of the objective cannot be adequately accomplished.

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In addition to offering cessation programs, businesses are increasingly providing in-
centives to employees to encourage them to stop smoking (Orleans and Shipley 1982).
A small ambulance company in Oregon offered a 5 dollar monthly bonus to any
employee who did not smoke during work hours. As an added incentive, the accumu-
lated bonuses for the year were matched at Christmastime. After 1 year, 4 of the 16
smokers claimed abstinence from smoking at work (Rosen and Lichtenstein 1977).
Smokers employed at a hospital in upstate New York were offered the chance to win a
250 dollar cash prize if they stopped smoking for 1 month. Of all smokers, 14 percent
enrolled in the contest, and 36 percent of these enrollees were not smoking 3 months
after the contest ended (Cummings, Hellmann, Emont 1988). A common type of incen-
tive is the offer to pay part or all of the cost to attend a cessation program. Campbell
Soup Company splits the cost for employees to attend an onsite smoking cessation
program (Schwartz 1987). General Motors absorbed 75 percent of the fee for a smok-
ing cessation program offered to employees (Schwartz 1987). The evidence available
does suggest that incentives can serve as a useful adjunct to other cessation services in
the workplace (Klesges, Vasey, Glasgow 1986; US DHHS 1985b).

Summary

The Chapter 8 Appendix includes a chronology of key events that have influenced
smoking education and cessation activities over the past 25 years. The antismoking
campaign of the 1960s focused primarily on educating the public about the health
hazards of tobacco use (Warner 1986). An assumption underlying the early antismok-
ing efforts was that an informed public would discontinue smoking. This assumption
was not without merit in that cigarette consumption did fall significantly in response to
information about the dangers of cigarette use (Hamilton 1972; Warner 1977, 1981,
1986). However, the assumption that smokers merely needed to be motivated to stop
ignored the addictive nature of smoking and the fact that many found it extremely dif-
ficult to stop smoking (US DHHS 1988).

The 1970s saw an increased emphasis on devising methods to assist smokers in stop-
ping and staying off cigarettes (Schwartz 1987), with special attention to cognitively
based self-management approaches.

The 1980s have seena renewed emphasis on educating the public about the hazards
of tobacco use and increased efforts to recruit smokers to attempt cessation. Such an
emphasis seems appropriate given the fact that the vast majority of smokers need first
to be persuaded to stop before efforts are directed at offering assistance in stopping.

The national voluntary agencies, especially ACS. ALA, and AHA, have played a sig-
nificant role in educating the public about the hazards of tobacco use. This has been
achieved through a wide variety of interventions including the distribution of educa-
tional materials, sponsorship of cessation programs, and production and dissemination
of PSAs that carry an antismoking message. Although the smoking education efforts
of the national voluntary health agencies have been the most visible of any group, some
critics note that more might have been accomplished if a higher level of interagency
collaboration had existed. In 1978, a blue ribbon panel of experts commissioned by
ACS to study the problem of smoking and the effectiveness of antismoking activities

434


concluded that the major voluntary health organizations should actively pursue in-
creased coordination of their efforts and resources in producing materials to assist
smokers in quitting (ACS 1978).

Until the 198Os, the voluntary health agencies focused their efforts on educating the
public about the facts on smoking and health and did little to initiate political and legal
challenges to the tobacco industry (,Patterson 1987). The formation of the Tri-Agency
Coalition on SmokingORHealth in1982 represented a major shift in the smoking con-
trol focus of the voluntary health agencies. The Coalition was formed primarily to
promote cooperation in obtaining legislation on smoking control issues.

Government smoking control efforts have been characterized by some observers as
modest (ACS 1978). OSH, the only Federal agency devoted exclusively to the smok-
ing issue, today has a budget that, in real dollars, is roughly one-half of the budget in
1966 when its predecessor, the National Clearinghouse, was established. (See Chapter
7.) Federal spending on smoking control has increased over the years, with the majority
of funds supporting research rather than interventions. In recent years, there has been
a shift away from supporting biomedical research on the hazards of tobacco to support-
ing studies on the behavioral aspects of smoking, including smoking cessation.
However, there is little evidence of transfer of research findings to community settings,
and some observers have questioned whether limited public health resources should be
disproportionately expended on treating smokers individually or in small groups, to the
exclusion of mass media and public relations efforts aimed at changing the social,
economic, and political environment that supports smoking (Chapman 1985). NC1 now
emphasizes support of studies that investigate effective application and dissemination
of smoking programs (Fanning 1988;NCI 1986b)and NHLBI is supporting large com-
munity programs of applied research that include smoking (US DHHS 1984, 1986a).

The opportunity to develop and market cessation aids and programs has expanded in
the past decade as more smokers have attempted to stop. The use of pharmacologic
therapies to aid cessation increased markedly with the introduction of nicotine
polacrilex gum in 1984. Alternative methods of nicotine replacement are currently
under investigation along with other pharmacologic cessation approaches (e.g.,
clonidine) (US DHHS 1988). In addition to pharmacologic aids, behaviorally oriented
cessation programs, particularly those targeting worksites, have increased in the past
decade. Likewise, greater efforts are now being made to increase involvement of
physicians and other health care professionals in smoking intervention.

In general, different types of smoking cessation strategies (e.g., condition- or cogni-
tion-based) have been emphasized during different time periods, new strategies have
been added, and some specific behaviorally oriented smoking cessation strategies ap-
pear to have changed relatively little in the past 25 years. The packaging and market-
ing of these programs have also become more sophisticated, with an increased emphasis
on targeting specific groups of smokers (e.g., pregnant women, Hispanics, blacks).
There has been a gradual shift in the way cessation interventions are promoted from
approaches that largely require smokers to seek assistance on their own to more aggres-
sive strategies that actively recruit smokers to seek help and stop. Examples of active
recruitment strategies include televised stop-smoking clinics (Flay 1987b) and contests
and competitions to promote abstinence behavior (Cummings, Hellmann, Emont 1988;

435


King et al. 1987; Klesges, Vasey, Glasgow 1986). The level of smoking cessation ac-
tivity has increased in recent years, spurred by regulatory decisions restricting smok-
ing (Chapter 7) and changing public perceptions and attitudes regarding tobacco use
(Chapter 4).

A significant event in terms of promoting smoking cessation activities of the nation-
al organizations was the 1967 FCC ruling applying the Fairness Doctrine to broadcast
cigarette advertising. This policy prompted organizations to become involved in ac-
tivities such as production of PSAs. The next chapter will cover this and other policy
activities. Evidence indicates that the resulting increase in the volume of antismoking
messages helped contribute to a substantial decline in cigarette consumption (Hamil-
ton 1972; Warner 1977. 1981, 1986).

The last 25 years have seen an increase in smoking cessation research and the im-
plementation of numerous public health approaches designed to help people stop smok-
ing. Working toward an integrated approach of policies and programs in the available
community networks seems to be a direction in which the smoking-and-health cam-
paign is moving (US DHHS 1986b).

PART III. ANTISMOKING ADVOCACY AND LOBBYING

Nature and Objectives of Advocacy and Lobbying

Individual citizens and organized groups have played an active role in the develop-
ment of public and private policies affecting smoking and the cigarette product. Their
activities range from efforts to inform and educate individuals and the public at large
about the health consequences of smoking to advocacy and lobbying to influence
policies and legislation to prevent or reduce smoking. The latter are considered in this
concluding part of the present chapter as a bridge between voluntary antismoking ac-
tivities and mandated activities (Chapter 7). Advocacy and lobbying are undertaken
voluntarily by private citizens and organizations, but with the intent of influencing
smoking-related laws and regulations.

Development and implementation of health information and education strategies are
oriented toward providing or imparting information to teach or instruct, often with a
view toward influencing thought and behavior. Earlier parts of this Chapter and other
sections of this Report address information and education activity as a component of
health education efforts designed to provide antismoking messages. As discussed in
this Chapter, several such efforts incorporate advice and instruction on how to remain
or become a nonsmoker.

Advocacy encompasses efforts to shape opinion in support of public policy. Lobby-
ing, in its strictest sense, means directly attempting to influence legislators, especially
in favor of a special interest. Frequently, lobbying also is used to mean directly trying
to influence officials to take desired action, or to influence the political process toward
a specific outcome. Despite these definitions, advocacy and lobbying activities often
overlap and their distinction is not always clear.

436


A primary purpose of these pursuits is to shift perceptions and attitudes about smok-
ing: to change from viewing smoking as a matter of personal choice toward viewing
smoking as a significant public health problem requiring adoption of public health
policy interventions. Antismoking advocacy and lobbying both recognize and act on
the fact that smoking is a political as well as a health, social. and economic issue.

Few antismoking advocacy and lobbying efforts have been studied systematically,
making it difficult to attribute changes in policy or public opinion to a specific group
or activity. Furthermore, little exists in the published literature on smoking that
describes the advocacy and lobbying activities of groups or individuals or evaluates the
impact of those activities on public awareness or public and private policies regarding
smoking. For example, the available data show that public support for restrictions on
smoking in public and at work has increased substantially in recent years (Chapter 4).
A temporal relationship can be demonstrated between this increasing support and the
growth of antismoking advocacy and lobbying activities targeted at these same issues.
It is not clear, however, to what extent changing public attitudes led to or followed ad-
vocacy efforts.

Analyses of the relationship between legislative lobbying activities and the enact-
ment of legislation have been predominantly qualitative. For example, an analysis of
lobbying efforts for the introduction and subsequent passage of the Comprehensive
Smoking Education Act of 1984 (Public Law 98-424) concluded that the Coalition on
Smoking OR Health, a group representing ACS. AHA, and ALA, significantly
influenced passage of the Act.  The analysis also concluded that the "woeful
miscalculations of the tobacco 1obbyists"made a significant contribution to the outcome
(Pertschuk 1986).

Objectives

Smoking-and-health advocacy and lobbying efforts during the 25 years since the first
Surgeon General's Report have centered on a number of specific objectives, including:
broader and more effective dissemination of information on the hazards of smoking;
provision of increased resources for research, public education, and prevention; reduc-
tion in consumption and encouragement of cessation by smokers; prevention of uptake
by children and adolescents; creation of public support for policies to restrict or prevent
smoking; protection of nonsmokers from exposure to environmental tobacco smoke;
regulation of the contents and emissions of the cigarette; regulation of the marketing,
promotion, and advertising practices related to tobacco products; limitation on access
through restriction of the sale and distribution of cigarettes (e.g., through vending
machines and free samples); increase in the price of smoking through taxation of
cigarettes; and stimulation or creation of public demand for political action on a specific
policy or issue, Many of the advocacy and lobbying groups active since 1964 have pur-
sued a variety of these objectives with varying degrees of activism and political
involvement.

The origin and objectives of the National Interagency Council on Smoking and
Health, the first major organization created in response to the 1964 Surgeon General's
Report, provide an illustration of the variety of purposes diverse groups may want to
achieve, individually or jointly.

437


Following the release of the Report, Surgeon General Luther Terry called together
representatives from the major national voluntary health agencies to discuss what ac-
tions might be taken in response to the Report. One result of this meeting was the crea-
tion of the National Interagency Council on Smoking and Health, which included
among its members the voluntary health agencies, a variety of medical and health
professions groups, organizations such as the National Congress of Parents and
Teachers, and Federal agencies such as the Public Health Service and the Veterans Ad-
ministration. By 1969, the Council's membership included 25 national organiza-
tions and 3 Government agencies.

The purpose of the Council was "( 1) to use its professional talents to bring to the na-
tion-particularly to the young-an increasing awareness of the harmfulness of
cigarette smoking; (2) to encourage, support and assist national,State,and local smok-
ing and health programs; and (3) to generate and coordinate public interest and action
related to this area of health" (Diehl 1969). The Council's statement of purpose reflects
an early perception that stimulating some form of public interest and action would be
necessary to achieve other Council purposes related to smoking and health.

The Council did not initiate its own programs of education or intervention, however,
and operated on a very small budget contributed by the member organizations. Its ac-
tivities in the area of advocacy were extremely limited, although it spawned much ac-
tivity at the State and local levels that has carried over into the present. The Interagen-
cy Council became the principal national forum for the exchange of information and
coordination of efforts among the many groups concerned about smoking.

In addition to the National Interagency Council, there were 40 State and many city
interagency councils in operation with the primary function of coordinating and
stimulating action by member groups (Diehl 1969). These State and local interagency
councils consisted, in large part, of the State and local affiliates of the national groups
represented in the National Interagency Council.

Troyer and Markel (1983) analyzed the announcements and proposed actions of
health groups regarding smoking as reported in the press during the period 1954-78.
They found that through 1973, the overwhelming majority of announcements and ac-
tions (26 of 29) were targeted toward education and persuasion, while during the period
1974-78, almost all (9 of 10) were focused on laws and regulations restricting smok-
ing. The reasons for the initial apparent prioritization of information and education ac-
tivities are not known, but it is clear that during the early period of antismoking efforts,
the major groups considered their primary contributions to be made by informing the
public and testifying before legislative groups, not by lobbying for specific regulations
or motivating the public to political action. For example, AHA stated in 1967 that "its
`proper responsibility' involved testimony on the health hazards of smoking, not legal
action" (Troyer and Markel 1983).

Over the years, the national voluntary agencies and other significant organizations
have continued their critical information and education activities, as described in Parts
I and II of this Chapter. More recently, many of these organizations have begun to sup-
plement their more traditional educational campaigns with more active efforts in sup-
port of specific heath policy outcomes. Accordingly, they have emerged as strong ad-
vocates in support of antismoking policies. In addition, as part of a health strategy,

438


some have developed specific components within their organizations, and sometimes
have fostered special coalitions to advocate or lobby for specific purposes on behalf of
their organizations.

A significant example is the Coalition on SmokingORHealth, an organization formed
in 1982 to initiate and coordinate antismoking lobbying activity on behalf of ACS,
AHA. and ALA, and to supplement the more traditional information and education ap-
proaches of these three organizations. The Coalition's statement of purpose reflects its
emphasis on political action in support of smoking and health issues:

To more effectively bring tobacco and health issues to the attention of federal legislators,
administrators and other public officials; to work with legislators and other government
officials to enact policies which will discourage tobacco use, further educate the public about
the hazards of tobacco use, and limit the demand for and marketing of this deadly product
in the future (AC.5 1988).

Organizational Characteristics

Five relatively distinct types of groups operating at the national, State, or local level
carry out smoking control advocacy and lobbying activities. The first group, and per-
haps the largest and most visible, is composed of the three major national voluntary
health agencies (ACS, ALA, and AHA) and their State and local affiliates. Each of the
three agencies concentrates primarily on research and public education related to the
diseases of interest to the agencies, and delivery of services to those affected by such
diseases. In addition to forming the Coalition on Smoking OR Health, each also has
become more focused on leadership in health policy development, and has increased
its level of interest and participation in advocacy and lobbying. Much of what the
voluntary health agencies are allowed to do in this regard may be affected by both their
Internal Revenue Code status as nonprofit agencies and the Tax Reform Act of 1976,
which specifies permissible lobbying activites by nonprofit groups.

The second group is made up of special focus or special population organizations that
have targeted their efforts on a particular aspect of the smoking problem or a specific
approach. This group includes such organizations as Action on Smoking and Health
(ASH), which has pursued a legal action campaign to force legislators and regulatory
bodies to address a variety of aspects of the smoking problem; Stop Teenage Addiction
to Tobacco (STAT), which focuses on teenage tobacco issues; the Tobacco Products
Liability Project (TPLP), which, as a public health strategy, supports efforts to bring
product liability lawsuits against cigarette manufacturers; and Doctors Ought to Care
(DOC), founded to provide physicians with a rallying point for health promotion and
antismoking advocacy, especially through counteradvertising. These groups are more
involved in advocacy than in lobbying.

The third group is composed of health and health professions organizations such as
the American Medical Association, American Public Health Association, American
Dental Association, American Academy of Pediatrics, American College of Chest
Physicians, American Medical Women's Association, American Academy of Family
Physicians, American Society of Internal Medicine, American College of Obstetricians
and Gynecologists, and American Association for Respiratory Care. These groups in-

439


creasingly have promoted a role for their members as advocates for smoking control in
their respective communities, in addition to engaging, as organizations, in advocacy
and lobbying activities at the Federal level.

Organizations devoted to the rights of and protections for nonsmokers make up the
fourth group. This would include organizations such as Americans for Nonsmokers'
Rights, the only national antismoking group devoted solely to clean indoor air legisla-
tion. Other examples would be the numerous State and local groups that have formed
independent chapters of Group Against Smoking Pollution (GASP) or that focus on
nonsmoker protection and nonsmokers' rights. There are approximately 85 such groups
at the State and local level (unpublished data, OSH).

The fifth group is made up of antismoking coalitions (groups of organizations) operat-
ing at the national, State, and local levels. Such coalitions have formed increasingly as
the voluntary health agencies and other organizations have become more active in ad-
vocacy and lobbying and have found common interests. The National Interagency
Council on Smoking and Health, referred to earlier, was the first major antismoking
coalition formed, but, as discussed, it did not engage in advocacy or lobbying. The Na-
tional Interagency Council no longer is active, but a number of State interagency coun-
cils remain active (US DHHS 1986d).

The most prominent coalition today is the Coalition on Smoking OR Health, also dis-
cussed earlier. The apparent successes of this Coalition and the growth of the
"nonsmokers' rights" movement have led to an increasing number of State-level coali-
tions formed to undertake a variety of public education and advocacy activities and to
pass specific antismoking legislation. In addition, goals such as the achievement of a
smoke-free society by the year 2000 have spurred the formation of additional coalitions
aimed at advocacy and lobbying activity in support of these broad goals.

The resources represented by and available to these five groupings are difficult to es-
timate. The large voluntary and professional organizations have many thousands of
members, but no data are available to determine what number are involved actively in
advocacy or lobbying or what resources may be directed to those purposes. The smaller
groups, such as ASH, have modest budgets and staffs, but collectively represent a sig-
nificant number of volunteers and dues-paying supporters.

The Tobacco Lobby

In discussing the nature and scope of antismoking lobbying, it is important to con-
sider the nature of the political environment in which this takes place. An influential
component of this environment has been the "tobacco lobby." The lobbying activities
of the tobacco lobby do not vary greatly from the activities of other groups on behalf
of other interests or causes, groups with vested economic or political interests using a
variety of approaches to influence the outcome of legislation (Pertschuk 1986).

The term "tobacco lobby" has been used throughout the past 25 years as a generic
description of those interest groups whose political activities have been directed toward
protecting tobacco and cigarette interests from adverse policies. The groups included
most often in this description are: the cigarette manufacturers and other commercial
firms involved in the manufacture, marketing, and sale of cigarettes; the Tobacco In-

440


stitute, the trade association representing the cigarette manufacturers; the tobacco
farmers and those commercial firms involved in the trading of unmanufactured tobac-
co; and the registered lobbyists representing these various interests.

As in the case of antismoking advocacy and lobbying, there is little in the published
literature on which to base a detailed analysis of the activities or impact of the tobacco
lobby. It is difficult to determine the precise composition of the lobby at any point in
time. and particularly at those points during which efforts of the lobby have been al-
leged to have had significant impact on the outcome of legislative or regulatory efforts
to control smoking or the cigarette product. The available data indicate that since 1964,
the cigarette manufacturers and the Tobacco Institute often have played the lead role
in developing strategies and initiating lobbying against antismoking legislation and
regulation.

The available historical record indicates that. unlike the voluntary health agencies,
the tobacco lobby and its constituent members have engaged in active lobbying
throughout the years. Among the legislative outcomes purportedly influenced by the
tobacco lobby at the national level are the following: negotiating provisions of
the Cigarette Labeling and Advertising Act of 196.5 to ensure that the Federal Trade
Commission would be precluded from regulating cigarette advertising for 3 l/2 years
(1965); negotiating provisions of the Public Health Cigarette Smoking Act of 1969 to
include preemption of State regulation of cigarette advertising (see Chapters 7 and 8;
see also Friedman 1975; Fritschler 1975); and precluding the Consumer Product Safety
Commission from exercising jurisdiction over cigarettes (1972). At the State level, in-
fluences attributed to the tobacco lobby relate to defeat of statewide nonsmokers' rights
legislation in California on two separate occasions (1978, 1980; Whelan 1984). There
are numerous anecdotal reports of tobacco lobby opposition to efforts to pass other State
and local ordinances restricting smoking. It is difficult to establish the extent of the
tobacco lobby's influence on these events, or to determine what combination of inter-
est groups and individuals was involved.

Antismoking Advocacy and Lobbying: 1964 to the Present

Early Efforts

A succession of legislative and regulatory actions aimed at labeling the cigarette as
dangerous and restricting the advertising and marketing practices of the cigarette
manufacturers marked the period following the 1964 Surgeon General's Report. (See
next chapter.) Throughout the period from 1964-69, the major national voluntary agen-
cies provided extensive expert medical testimony in support of these initiatives but did
not lobby actively for their passage. While the expert testimony contributed to the
decision process, more aggressive advocacy and direct lobbying that supplemented
these efforts undoubtedly influenced the process as well. One important example is the
citizen petition that John F. Banzhaf III filed, as an individual, with the Federal Com-

441


munications Commission (FCC) contending that smoking should be subject to the Fair-
ness Doctrine. This action led to the FCC ruling that the Fairness Doctrine applied to
cigarette advertising. As a result, stations broadcasting cigarette commercials were re-
quired to donate time to antismoking messages (see Chapter 7).

In the process of pursuing this legal course, Banzhaf founded ASH as a legal action
arm for the antismoking community and launched an ongoing series of legal challen-
ges to advance smoking control policies. ASH played a major role in establishing the
legal concept of the right of nonsmokers to be free from exposure to tobacco smoke.
A major component of that effort was pressure brought to bear on the Federal Aviation
Administration to require separate smoking and nonsmoking areas on commercial
flights. Through these and other initiatives, which other organizations also supported,
ASH introduced the principle of private legal activism to influence legislation and other
decisions on smoking and health issues.

Nonsmokers' Rights

The specific origin of concerns about the health hazards to nonsmokers of exposure
to environmental tobacco smoke is difficult to date. In 197 1, ASH already had targeted
restrictions on smoking on airliners and in public as major regulatory initiatives. Dr.
Jesse Steinfeld. U.S. Surgeon General from 1969-73, called official attention to the
hazards of ETS for the first time in the 1972 Surgeon General's Report (US DHEW
1972) and was outspoken throughout his public career on the need to protect non-
smokers.

During the mid-1970s groups concerned about nonsmokers' exposure to environ-
mental tobacco smoke began to appear around the United States. One of the largest,
California GASP, was the forerunner of Americans for Nonsmokers' Rights, the prin-
cipal national antismoking group devoted solely to clean indoor air legislation. Califor-
nia GASP was founded in 1976 as a nonprofit public interest group and became Califor-
nians for Nonsmokers' Rights (CNR) in 1978. That year, CNR succeeded in placing a
statewide proposition on the California ballot seeking restrictions on smoking in public.
Although defeated in a vote preceded by a well-funded campaign by the tobacco lobby
(Wong 1978), this initiative set the stage for repeated and increasingly successful smok-
ing ordinances at the community level in California and in other States and cities. As
Americans for Nonsmokers' Rights, the group reports having assisted in the passage of
scores of city and county ordinances (Americans for Nonsmokers' Rights 1988).

ALA also has played an important role in public education and advocacy on the issue
of protecting nonsmokers. Due in large part to its strong interest in promoting clean
air, ALA was the first of the three national voluntary health organizations to become
involved in the nonsmokers' rights issue. In fact, ALA did so early in the 1970s with
a campaign stressing the concept that nonsmokers objected to involuntary exposure to
tobacco smoke.

As it evolved, the nonsmokers' rights issue introduced a new element in the growth
of antismoking advocacy and lobbying: a basis for involving nonsmokers in activities
other than encouraging smokers to quit or discouraging initiation among teenagers.

442


Resulting initiatives provided a new rallying point outside the traditional focus of the
voluntary health agencies and at the same time appealed to and prompted greater ac-
tivity among those groups.

The effect of this element in the smoking control movement has yet to be fully
evaluated. Surveys of public attitudes about smoking and the need to restrict it to protect
nonsmokers show a widespread acceptance of these principles and an increasing con-
sensus that the social acceptability of smoking is declining (Chapter 4).

Coalition Building and the Growth of Advocacy

As mentioned previously, ACS, AHA, and ALA in 1982 formed a tripartite Coali-
tion on Smoking OR Health, primarily to coordinate their Federal legislative activities
related to smoking control. The creation of the Coalition came at the end of a long
period of gradual expansion in the public policy activities of the three voluntary or-
ganizations. The National Commission on Smoking and Public Policy, a study group
ACS established in 1976, added impetus to the concept of the Coalition by recommend-
ing the three voluntary health agencies do more to support public policy initiatives to
control smoking (ACS 1978). The Coalition has served as a mechanism for coordinat-
ing and implementing lobbying efforts of the three agencies. At the time the Coalition
was established, ACS, AHA, and ALA also increased the staffs and resources of their
individual public policy components.

Through the Coalition, the three voluntary health agencies have worked with other
organizations and coalitions with common interests in support of smoking control
policies, relating to health warning labels, tobacco advertising, smoking on airlines, the
tobacco excise tax, and the price support program. Successful antismoking efforts the
Coalition supported have included: passage of the Comprehensive Smoking Education
Act of 1984, which requires four rotating warning labels on cigarette packages and ad-
vertisements, as well as disclosure to the Secretary of Health and Human Services of
additives used in the manufacture of cigarettes; passage of the Comprehensive Smoke-
less Tobacco Health Education Act of 1986, banning advertising for smokeless tobac-
co in the electronic media and requiring warning labels on packages and advertisements;
permanent extension of the Federal excise tax at 16 cents per pack as a provision of the
Consolidated Omnibus Budget Reconciliation Act of 1985 (Public Law 99-272); and
banning of smoking on commercial domestic airline flights scheduled for flight time
of 2 hr or less as part of the fiscal year 1988 Department of Transportation appropria-
tions bill (see Chapter 7). One analyst has concluded that the Coalition has enabled the
three national voluntary health agencies to take the initiative in a variety of areas, plac-
ing the tobacco lobby in a reactive posture (Pertschuk 1986).

Other factors that have accompanied the Coalition's efforts are believed to have con-
tributed to the Coalition's success and to an apparent steady increase in the level of an-
tismoking advocacy and lobbying throughout the United States. One of these factors
is the recruitment of new allies and the energizing of old ones. In addition to the Coali-
tion, other groups and organizations have taken more aggressive positions. For ex-
ample, the American Council on Science and Health has been an aggressive advocate
on all aspects of smoking control. Another example is the American Medical Associa-

443


tion, which has become involved in a major effort to mobilize its members at the State
and local levels. in addition to using its considerable influence in Washington, in sup-
port of antismoking legislation (Lundberg 1985; AMA Council on Scientific Affairs
1984: American Medical Association 1987).

Another important factor is the growth in knowledge and sophistication of the advo-
cates and lobbyists themselves. Drawing on the experience and expertise of other
public interest groups, the antismoking interests have become significantly more profi-
cient at employing their resources. In addition, through its Smoking Control Advocacy
Resource Center, the Advocacy Institute, a public interest advocacy strategy and skills
training resource, has contributed new thinking and coordination to the effort to counter
the influence of the tobacco lobby (Advocacy Institute 1987a, 1987b).

One of the most important aspects of the growth of antismoking advocacy and lob-
bying has been the increase in State and local activity. The creation of coalitions and
the success of local antismoking ordinances appear to have encouraged more groups
and individuals to become politically active. Surveys and studies of trends in local and
State smoking control ordinances (US DHHS 1986d) indicate that the restrictiveness
of those ordinances is increasing, as is public support. (See also Chapter 7.)

CONCLUSIONS

Part I. Smoking Prevention Activities

1.  Diverse program approaches to the prevention of smoking among youth grew out
of antismoking education efforts in the 1960s. These approaches include media-
based programs and resources; smoking prevention as part of multicomponent
school health education; psychosocial prevention curricula; and a variety of other
resources developed and sponsored by professional and voluntary health or-
ganizations. Federal and State agencies, and schools and community groups.
2. Psychosocial curricula addressing youths' motivations for smoking and the skills
they need to resist influences to smoke have emerged as the program approach
with the most positive outcomes. Evolution in program content has been accom-
panied by a shift since the 1960s in prevention program focus from youths in high
school and college to adolescents in grades 6 through 8.
3.  Existing prevention programs vary greatly in the extent to which they have been
evaluated and used. Psychosocial prevention curricula have been intensively
developed over the last decade and have been the most thoroughly evaluated and
best documented; however, they are generally not part of a dissemination system.
More widely disseminated smoking prevention materials and programs, such as
those using mass media and brochures, have not always been as thoroughly
evaluated; however, they have achieved wider use in the field.
4. The model of stages of smoking behavior acquisition underlies current smoking
prevention programs and suggests new intervention opportunities, ranging from
prevention activities aimed at young children to cessation programs for adoles-
  cent smokers.

444


5. There has been and continues to be a lack of smoking prevention programs that
target youth at higher risk for smoking, such as those from lower socioeconomic
backgrounds or school dropouts.

Part II. Smoking Education and Cessation Activities

1. During the past 25 years, national volurltary health agencies. especially the
American Cancer Society, the American Heart Association, and the American
Lung Association, have played a significant role in educating the public about the
  hazards of tobacco use.
2. Individual and group smoking cessation programs evolved from an emphasis on
conditioning-based approaches in the 1960s to the cognitively based self-
management procedures of the 1970s. to the relapse prevention and pharmacologi-
tally based components of the 1980s.
3. There has recently been an increased emphasis on targeting specific groups of
smokers for cessation activities (e.g., pregnant women, Hispanics, blacks).
4. Packaging and marketing of self-help smoking cessation materials have become
more sophisticated and there is more of an emphasis on relapse prevention, while
  much of the content has changed relatively little over the years.
5. Mass-mediated quit-smoking programs have become an increasingly popular
strategy for influencing the smoking behavior of a large number of smokers.
6. The 1980s have seen an increase in the promotion of smoking control efforts in
the workplace in response to increasing demand and opportunity for worksite
wellness programs and smoking control policies.
7. In the last decade there has been an increasing interest in involving physicians and
other health care professionals in smoking control efforts. Medical organizations
have played a more prominent role in smoking and health during the 1980s than
they had in the past.

Part III. Antismoking Advocacy and Lobbying

1. Lobbying and advocacy efforts have expanded through the increasing commit-
ment of the national voluntary health agencies to political action and the forma-
tion of coalitions at the local, State, and national levels.
2. Antismoking advocacy and lobbying have evolved over the past 25 years and now
focus on a growing number of local, State, and national legislative and regulatory
initiatives designed to reduce smoking, regulate the cigarette product, and prevent
the uptake of smoking by children and adolescents.

445


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