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Ending the Tobacco Problem: A Blueprint for the Nation
ing Intervention Study (ASSIST). In 1991, the ASSIST program funded community-level interventions to prevent tobacco use in 17 states.
By the mid-1990s, every state in the United States had some funding for comprehensive tobacco control either from ASSIST or from the Centers for Disease Control and Prevention (CDC) Office of Smoking and Health’s (OSH) Initiatives to Mobilize for the Prevention and Control of Tobacco Use (IMPACT) program. Additional funding for tobacco control was available for some states, from 1994 to 2000, from the Robert Wood Johnson Foundation’s (RWJF) SmokeLess States (SSI) program (Gerlach and Larkin 2005; Tauras et al. 2005). In addition to educational and cessation programs, the funds from all three of these national programs— ASSIST, IMPACT and the SmokeLess States program—supported statewide coalitions of individuals and organizations that pursued action strategies toward strengthening tobacco control policies. The ASSIST program funded state health departments’ work with coalitions (NCI 1991). The IMPACT program required state health departments to establish state-level tobacco control coalitions and to build capacity for comprehensive tobacco control programs in the 33 state health departments that participated in this cooperative agreement (Federal Register 1993). SmokeLess States was the only program that funded state coalitions whose lead agencies were outside of state health departments (RWJF 1993).
The state tobacco control coalitions focused from the beginning on public policy advocacy as an important strategy. Their plans reflected the shift away from interventions aimed at individuals toward interventions to change social norms and environmental conditions. By the late 1980s, NCI staff were aware that most intervention research showed that individual approaches to tobacco use prevention were not effective in reducing smoking prevalence and were ready to sponsor social and environmental approaches (NCI 1991). The planners of the ASSIST program recognized that promoting changes in public policy was consistent with a population-based solution to a population-wide epidemic of tobacco use (NCI 2005). The shift in focus enabled tobacco control advocates to pursue population-based solutions to the tobacco epidemic on a national scale for the first time in U.S. history. It was a bold initiative on the part of two federal agencies, a private foundation, state health departments, and nonprofit health organizations that deserves recognition and analysis in any effort to formulate future initiatives.
The ASSIST program promoted three types of interventions: (1) program services, (2) policy, and (3) mass media. However, ASSIST guidelines stated that “efforts to achieve priority public policy objectives should take precedence over efforts to support service delivery” (NCI 2005). Mass media initiatives were intended to support those policy changes, which meant that media advocacy that engaged the news media in support of prevention policies was the focus of media initiatives rather than social marketing. The four ASSIST priority policy areas were: (1) eliminating environmental tobacco smoke, (2) higher tobacco taxes, (3) limits on tobacco advertising and promotion, and (4) reducing youth access to tobacco (NCI 2005).
Evaluation of Comprehensive State Programs
The evidence that the ASSIST, CDC, and SSI programs were effective must be based on whether change occurred in the priority policy areas listed above. The CDC OSH released a summary in 2005 of the literature on the evidence of the effectiveness of state tobacco control programs (Kuiper et al. 2005). Organized by major reviews and five outcome indicators (tobacco-related mortality, prevalence, consumption, cessation, and smoke-free legislation and policy), the results are presented generally by state. The evidence provided can be considered a guide for state health departments to measure the success of their comprehensive tobacco control