cessation. It includes a combination of educational, clinical, and social strategies that support the broad goal of denormalization of tobacco use (CDC, 2007). The recommended strategies fall into five categories: (1) policies; (2) health promotion and education, including communication interventions (for example, mass-media–based antitobacco advertising campaigns and innovative approaches, such as text messaging); (3) cessation interventions (for example, cessation counseling based on the health-care system, Food and Drug Administration–approved tobacco-cessation medications, and population-based services, such as toll-free quitlines that are able to provide nicotine-replacement therapy); (4) surveillance and evaluation; and (5) capacity-building, including the administration and management procedures. Direct interventions on an individual level, including health promotion and cessation, are important, but the other strategies—including the implementation of evidence-based policies such as price increases, reduced access to tobacco products, tobacco-free environments, advertising bans, decreases in out-of-pocket costs of treatment, and countermarketing campaigns to change social norms around tobacco use—all encourage cessation. Therefore, cessation policies and programs should be considered as essential for creating the supportive environment necessary for quitting (WHO, 2007).

STATE TOBACCO-CONTROL PROGRAMS

States with the longest history of such programs have served as models, particularly California and Massachusetts. The first such program in California was funded by the 1988 California Tobacco Tax and Health Promotion Act. Its passage led to a $0.25/pack increase in the tax on cigarettes; 20% of the revenues were earmarked for a health-education campaign (Hu et al., 1994a, 1994b). That included pioneering an antismoking multimedia campaign and prevention and cessation initiatives (Hu et al., 1994a, 1994b). Specific messages targeted minority populations, and free tobacco quitlines featured services in multiple languages. Studies documented a reduction in cigarette sales by 232 million packs from the end of 1990 to the end of 1992 (Hu et al., 1994a, 1994b) and a 6% decline in lung-cancer incidence, equating to 11,000 fewer cases (Barnoya and Glantz, 2004). Smoking rates in California adults declined from 22.7% in 1988, when the tobacco control program was implemented, to 14.0% in 2005 (California Department of Health Services, 2006).

Massachusetts, the second state to initiate such a program after a successful tobacco-tax ballot initiative in 1992, launched a coordinated effort to denormalize tobacco use. The Massachusetts Tobacco Control Program (MTCP) featured a number of key dimensions with the goals of prevention of smoking by young people, increased cessation



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