estimated that if the states had met the minimum CDC expenditure recommendation for tobacco control, there would have been more than 2 million fewer smokers by 2003 (Farrelly et al., 2008).

FEDERAL TOBACCO-CONTROL PROGRAMS

American Stop Smoking Intervention Study

The American Stop Smoking Intervention Study (ASSIST) was not a randomized trial but a large-scale, natural experiment to change the behavior of entire states (that is, the entire population and environment). The goal was to change social, cultural, economic, and environmental factors in the state that promote smoking behavior. That goal was accomplished primarily through interventions of four kinds: (1) promoting smoke-free environments, (2) countering tobacco advertising and promotion, (3) limiting youths’ tobacco access and availability, and (4) increasing tobacco prices by raising excise taxes.

An important component was building the capacity for tobacco control by recruiting and training a qualified workforce and by developing and implementing strategic plans of action. The statewide tobacco-control plans were carried out in the 17 ASSIST states by a network of state and local coalitions. The ASSIST evaluation was one of the largest evaluation efforts conducted by NCI and compared changes in tobacco-control policies, state per-capita cigarette consumption, and adult smoking prevalence in the 17 ASSIST states with those in the 33 non-ASSIST states and the District of Columbia. The authors also analyzed the effect of program components and tobacco-control policies on smoking prevalence and per-capita cigarette consumption and determined the cost effectiveness of ASSIST (Stillman et al., 1999, 2000, 2001, 2003).

ASSIST states had a greater decrease in adult smoking prevalence than non-ASSIST states. States that experienced greater improvement in tobacco-control policies had larger decreases in per-capita cigarette consumption. States (not including the District of Columbia) with higher policy scores also had lower smoking prevalence. The authors found that states with greater “capacity” (ability to implement tobacco-control activities)—such as states with tobacco-control infrastructure in the health department, staff experience, and strong interagency and statewide relationships—had lower per-capita cigarette consumption. Finally, there was evidence that policy interventions may be more effective in reducing women’s smoking than other types of interventions.

The ASSIST results showed that investing in tobacco-control programs that focus on strong tobacco regulations and policies is an



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