relapse-prevention interventions found that behavioral interventions were not effective although therapy that helps smokers to avoid smoking cues had the best results; long-term use of varenicline was most effective for prolonged prevention of relapse whereas long-term use of bupropion did not appear to be effective (Hajek et al., 2005). A study of 1,700 smokers randomized to receive a nicotine inhaler, bupropion, or both for 3 months found that the combination therapy increased abstinence rates but did not prevent relapse (Croghan et al., 2007). A variety of tobacco-cessation treatments—including cognitive-behavioral therapy, social support, pharmacotherapies, and cue avoidance—may be required to prevent relapse and maintain long-term abstinence (Carmody, 1992).

SURVEILLANCE AND EVALUATION

The comprehensive tobacco-control programs described in this chapter have features in common that increase their effectiveness. An important feature is surveillance mechanisms to assess whether tobacco-use restrictions and modifications of the retail environment are being enforced and are reducing tobacco consumption and also to determine whether the various tobacco-cessation interventions are assisting tobacco users to quit. CDC states that surveillance “is the process of monitoring tobacco-related attitudes, behaviors, and health outcomes at regular intervals” (CDC, 2007a). Mechanisms to monitor the effectiveness of interventions may require surveys of populations to assess specific health behaviors, analysis of medical records, inventories, or financial tracking. CDC recommends that states spend specific dollar amounts per user on tobacco control. Surveillance must be continuous; a snapshot of a program is not sufficient to indicate its effectiveness. Scheduled periodic evaluations are the best surveillance tools, but ad hoc information may also be useful in identifying trouble spots or anomalies. Surveillance information helps program leaders modify programs to meet changing needs or to address disparities. Surveillance can indicate whether policies are being enforced, whether medications are being correctly prescribed and taken, whether quitlines are being used, whether mass-media campaigns are reaching target audiences, and whether funds are being spent appropriately. Feedback information obtained through surveillance is critical for ensuring that a tobacco-control program is effective. Tobacco-control surveillance includes prevalence of tobacco use, its health and economic consequences, its sociocultural determinants and tobacco-control policy responses, and tobacco-industry activities.

There is evidence that performance measures work well and it is possible to relate them to program improvements (IOM, 2005; Perrin, 1998, 1999). Performance measures may take the form of metrics, such as the number of people who enroll in a smoking-cessation program, the



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