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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences
In 1989, the National Cancer Institute (NCI), building on methods used in cardiovascular disease studies, launched the Community Intervention Trial (COMMIT) for Smoking Cessation (COMMIT, 1991). The trial used 11 matched pairs of communities across North America, and it was designed to test the effectiveness of a multifaceted, 4-year community intervention to encourage smokers, particularly heavy smokers, to achieve and maintain cessation (COMMIT, 1991, 1995a,b). A significant effect was observed among light-to-moderate smokers, and it appeared to be greater among a less-educated subgroup of participants (COMMIT, 1995a). There was no effect among heavy smokers (COMMIT, 1995a,b).
Although not a randomized, controlled intervention trial, the American Stop Smoking Intervention Study (ASSIST) was a large-scale, 7-year demonstration project building on randomized community-wide intervention trials. The intervention was implemented in 17 states through a partnership among NCI, the American Cancer Society, state health departments, and other organizations. The primary goal was to reduce smoking prevalence and cigarette consumption. To assess the results, investigators compared data from ASSIST and non-ASSIST states. Comprehensive tobacco control programs emphasized policy interventions, including indoor air, pollution, youth access, advertising, and tobacco taxes, as well as mass-media interventions and program services such as cessation classes (Manley et al., 1997a,b). Per capita consumption of cigarettes was comparable in ASSIST and non-ASSIST states before the beginning of the 1993 intervention. By 1996, smokers in ASSIST states were smoking 7% fewer cigarettes per capita. The intervention also included guidelines for raising cigarette excise taxes as a means of reducing consumption. Inflation-adjusted cigarette prices were nearly identical in both groups of states before 1993. Although the tobacco industry reduced prices during this period, in 1994 the average price was more than $0.12/pack higher in intervention than in control states (Manley et al., 1997a,b).
Small-scale studies. Several recent community-wide studies have borrowed principles from the early large cardiovascular disease prevention trials, but they have been implemented on a smaller scale and with smaller budgets. It might be difficult for such studies to achieve the necessary intensity and reach to show significant intervention effects. The Bootheel Heart Health Project, for example, was conducted in a six-county area in southeastern Missouri (Brownson et al., 1996). This rural area has the largest African American population in Missouri, and it is characterized