Task Force on Community Preventive Services
Caswell A. Evans, Jr., D.D.S, M.P.H.
National Institute for Dental
and Craniofacial Research
National Institutes of Health
Jonathan E. Fielding, M.D., M.P.H., M.B.A.
Los Angeles Department of Health Services
Los Angeles, California
Ross C. Brownson, Ph.D.
St. Louis University School of Public Health
St. Louis, Missouri
George J. Isham, M.D.
Patricia A. Buffler, Ph.D., M.P.H.
School of Public Health
University of California, Berkeley
Mary Jane England, M.D.
Washington Business Group on Health
David W. Fleming, M.D.*
Oregon Health Division
Department of Human Resources
Mindy Thompson Fullilove, M.D.
New York State Psychiatric Institute
and Columbia University
New York, New York
Fernando A. Guerra, M.D., M.P.H.
San Antonio Metropolitan Health District
San Antonio, Texas
Alan R. Hinman, M.D., M.P.H.
Task Force for Child Survival
Garland H. Land, M.P.H.
Center for Health Information Management and Epidemiology
Missouri Department of Health
Jefferson City, Missouri
Charles S. Mahan, M.D.
College of Public Health
University of South Florida
Patricia Dolan Mullen, Dr.P.H.
University of Texas-Houston
School of Public Health
Susan C. Scrimshaw, Ph.D.
School of Public Health
University of Illinois
Robert S. Thompson, M.D.
Department of Preventive Care
Group Health Cooperative of Puget Sound
* As of June 2000, Dr. Fleming is with CDC in Atlanta, Georgia, and no longer serves on the
The following CDC staff members prepared this report:
David P. Hopkins, M.D., M.P.H.
Peter A. Briss, M.D.
Jeffrey R. Harris, M.D., M.P.H.
Connie J. Ricard, M.P.H.
J. Niels Rosenquist
Kate W. Harris
Division of Prevention Research and Analytic Methods
Epidemiology Program Office
Corinne G. Husten, M.D., M.P.H.
Jeffrey W. McKenna, M.S.
Donald J. Sharp, M.D., D.T.M.&H.
Trevor A. Woollery, Ph.D.
Namita Sharma, M.A., M.P.A.
Terry F. Pechacek, Ph.D.
Office on Smoking and Health National Center for Chronic Disease Prevention and Health Promotion
in collaboration with
Jonathan E. Fielding, M.D., M.P.H., M.B.A.
Task Force on Community Preventive Services
Los Angeles Department of Health Services
University of California, Los Angeles School of Public Health
University of California, Los Angeles School of Medicine
Reducing tobacco-related morbidity and death is an ongoing challenge
for health-care providers, health-care systems, and public health
programs. Interventions are available that a) reduce exposure to environmental
tobacco smoke, b) reduce tobacco-use initiation,* and c) increase
tobacco-use cessation.**The Task Force on Community Preventive Services has
conducted systematic reviews on 14 selected interventions, which are appropriate
for communities and health-care systems, and has made
recommendations regarding use of these interventions. This report summarizes
the recommendations, identifies sources that offer full reviews of the
interventions and details about applying the interventions locally, and provides an update
of the Task Force's work.
In the United States, tobacco use is the leading cause of preventable death
(1--3), and exposure to environmental tobacco smoke (ETS) is a preventable cause
of significant morbidity and death among nonsmokers
(4--6). Reducing tobacco use and reducing exposure to environmental tobacco smoke are essential community
and public health objectives (7). As part of the
Healthy People 2010 initiative (7),
goals have been developed to reduce tobacco-related morbidity and death by
reducing exposure to ETS, decreasing tobacco-use initiation, and increasing
By implementing interventions shown to be effective, policy makers and
health-care and public health providers can help their communities achieve these goals
while using community resources efficiently. This report and other related
publications provide guidance from the Task Force on Community Preventive Services to
personnel in state and local health departments, managed care organizations, purchasers
of health care, persons responsible for funding public health programs, and others
who have interest in or responsibility for decreasing tobacco use and reducing exposure
to environmental tobacco smoke in all segments of the population.
The independent, nonfederal Task Force on Community Preventive Services
(the Task Force) is developing the Guide to Community Preventive
Services (the Community Guide) with the support of the U.S. Department of Health and
Human Services and in collaboration with public and private partners. CDC and other
federal agencies provide staff support to the Task Force for development of the
Community Guide. However, the recommendations presented in this report were developed by
the Task Force and are not necessarily the recommendations of CDC or the
U.S. Department of Health and Human Services.
This MMWR report is the second to be completed for the
Community Guide, a resource that will include multiple chapters, each focusing on a preventive health
topic. The first chapter was on vaccine-preventable diseases
(8--11), and the information in this report will be part of a second chapter, on tobacco use. This report provides
an overview of the process used by the Task Force to select and review evidence;
it summarizes the Task Force's recommendations on community interventions to
reduce exposure to ETS and tobacco use. A full presentation of the
recommendations, supporting evidence, and remaining research questions will be published in
the American Journal of Preventive Medicine in 2001.
For more information about this report, please call the Office on Smoking and
Health (OSH) press line at 770-488-5493. Copies of this report may be obtained through
OSH's Web site at <http://www.cdc.gov/tobacco> or by calling 770-488-5705 (press 3 to talk
to an information specialist).
Methods used to conduct systematic reviews and link evidence
to recommendations have been described elsewhere
(12). In brief, for each Community
Guide chapter, multidisciplinary chapter development teams conduct reviews by
- developing an approach to organizing, grouping, and selecting the
interventions for review;
- systematically searching for and retrieving evidence;
- assessing the quality of the body of evidence of effectiveness for
interventions and summarizing the strength of this body of evidence;
- summarizing information regarding other evidence (e.g., applicability of
the intervention to different populations and settings, additional benefits,
potential harms, barriers to implementation, and economic evaluations); and
- identifying and summarizing research gaps.
For the chapter on tobacco use, the chapter development team focused
on interventions to decrease exposure to ETS, reduce tobacco-use initiation, and
increase tobacco-use cessation. The chapter consultation team members*** generated
a comprehensive list of strategies and created a priority list of interventions for
review based on their perception of the importance and the extent to which the
interventions were practiced in the United States. Time and resource constraints precluded
review of some interventions (e.g., communitywide risk factor screening and
Interventions reviewed were either single-component (i.e., using only one
activity to achieve desired outcomes) or multicomponent (i.e., using more than one
related activity). Interventions were grouped together on the basis of their similarity.
Some studies provided evidence for more than one intervention. In these cases, the
studies were reviewed for each applicable intervention. The classifications or
nomenclature used in this report were chosen to ensure comparability in the review process,
and these classifications sometimes differ from those used in the original studies.
To be included in the reviews of effectiveness, studies had to meet these criteria:
a) they were limited to primary investigations of interventions selected for evaluation;
b) they were published in English from January 1980 through May 2000; c) they
were conducted in industrialized countries; and d) they compared outcomes in groups
of persons exposed to the intervention with outcomes in groups of persons not
exposed or less exposed to the intervention (whether the comparison was concurrent or
For each intervention reviewed, the team developed an analytic
framework indicating possible causal links between the intervention under study and
predefined outcomes of interest. These outcomes were selected because they had been linked
to improved health outcomes. For example, the Task Force concluded the following:
- Tobacco use is a cause of morbidity (illness and disability) and death
- Tobacco-use cessation reduces tobacco-related morbidity and death
- Delivery of advice by health-care providers to tobacco-using patients to quit
has a small but significant impact on tobacco-use cessation among patients
- The younger persons are when they begin to smoke, the more likely they are
to be current smokers as adults --- an indication that postponing or
preventing tobacco use among children and adolescents will decrease the number of
adult tobacco users (17).
- Exposure to ETS is a cause of morbidity and death
(4--6), and reducing exposure to ETS can be assumed to reduce ETS-associated morbidity and death.
The evaluations of interventions in this report, therefore, focus on evidence
of effectiveness in reducing ETS exposure, reducing tobacco-use initiation,
and increasing tobacco-use cessation (including increasing patient receipt of advice to
quit from health-care providers).
Each study that met the inclusion criteria was evaluated by using a
standardized abstraction form and was assessed for suitability of the study design and threats
to validity. On the basis of the number of threats to validity, studies were characterized
as having good, fair, or limited execution
(12). The strength of the body of evidence
of effectiveness was characterized as strong, sufficient, or insufficient on the basis of
the number of available studies, the suitability of study designs for
evaluating effectiveness, the quality of execution of the studies, the consistency of the
results, and the effect size (12).
The Community Guide links evidence to recommendations systematically
(12). The strength of evidence of effectiveness corresponds directly to the strength
of recommendations (e.g., strong evidence of effectiveness corresponds to
an intervention being strongly recommended, and sufficient evidence corresponds to
an intervention being recommended). Other types of evidence also can affect
recommendation. For example, evidence of harms resulting from an
intervention might lead to a recommendation that the intervention not be used, even if it is
effective in improving some outcomes. In general, the Task Force does not use
economic information to modify recommendations.
A finding of insufficient evidence of effectiveness does not result
in recommendations regarding an intervention's use but is important for
identifying areas of uncertainty and continuing research needs. In contrast, adequate evidence
of ineffectiveness leads to a recommendation that the intervention not be used.
The systematic search identified 243 studies on tobacco interventions that met
the inclusion criteria. Of these 243 studies, 77 were excluded on the basis of limitations
in their execution or design and were not considered further. The remaining 166
studies were considered qualifying studies.**** The 14 Task Force evaluations in this
report are based on these qualifying studies, all of which had good or fair execution.
On the basis of the evidence of effectiveness, the Task Force either
strongly recommended or recommended nine of the 14 strategies evaluated.
These nine recommendations include one intervention to reduce exposure to ETS
(smoking bans and restrictions), two interventions to reduce tobacco-use initiation
(increasing the unit price for tobacco products and multicomponent mass media campaigns),
and six interventions to increase cessation (increasing the unit price for tobacco
products; multicomponent mass media campaigns; provider reminder systems; a
combined provider reminder plus provider education
with or without patient education program; multicomponent interventions including telephone support for persons
who want to stop using tobacco; and reducing patient out-of-pocket costs for
effective cessation therapies). In addition to the 14 completed evaluations, reviews for
three more tobacco prevention interventions --- youth access restrictions,
school-based education, and tobacco industry and product restrictions --- are still under way and
will be included in the finished chapter.
USE OF THE RECOMMENDATIONS IN COMMUNITIES AND HEALTH-CARE SYSTEMS
Given that tobacco use is the largest preventable cause of death in the
United States, reducing tobacco use and ETS exposure should be relevant to
most communities. In selecting and implementing interventions, communities should
strive to develop a comprehensive strategy to reduce exposure to ETS, reduce initiation,
and increase cessation. Improvements in each category will contribute to reductions
in tobacco-related morbidity and death, and success in one area might contribute
to improvements in the other areas as well. Increasing tobacco-use cessation,
for example, will reduce exposure to ETS. Smoking bans, effective in reducing
exposure to ETS, also can reduce daily tobacco consumption for some tobacco users and
help others quit entirely.
Choosing interventions that work in general and that are well-matched to
local needs and capabilities and then implementing those interventions well are vital
steps for reducing tobacco use and ETS exposure. In setting priorities for the selection
of interventions to meet local objectives, recommendations and other evidence
provided in the Community Guide should be considered along with such local information
as resource availability, administrative structures, and economic, social, and
regulatory environments of organizations and practitioners. Information regarding
applicability can be used to assess the extent to which the intervention might be useful in
a particular setting or population. Though limited, economic information --- to
be provided in the full report in 2001 --- might be useful in identifying a)
resource requirements for interventions, and b) interventions that meet public health
goals more efficiently than other available options. If local goals and resources permit,
the use of strongly recommended and
recommended interventions should be initiated
A starting point for communities and health-care systems is to assess
current tobacco-use prevention and cessation activities. Current efforts should be
compared with recommendations in this report as well as other relevant
program recommendations proposed by CDC (18), the National Cancer Institute
(19), the Public Health Service (16), the U.S. Department of Health and Human Services
(17,20,21), and the Institute of Medicine
(22). In addition to assessing overall progress
toward meeting goals and the current status of tobacco control efforts, health planners
should also consider how to eliminate health disparities related to tobacco use and
ETS exposure. The identification and assessment of existing disparities are critical
in selecting and implementing interventions to assist populations at high risk, such
as low-socioeconomic populations and some racial/ethnic groups
This review did not examine the evidence of effectiveness of clinical
cessation programs or therapies for tobacco dependence, which are not part of the
Community Guide mandate but were addressed in an extensive, evidence-based review
recently updated by the Public Health Service
(16). However, evidence reviews conducted
for the Community Guide include several interventions that might be useful to
health-care providers and systems in identifying, advising, and assisting tobacco-using patients
in their efforts to quit. Recommendations in the
Community Guide complement those provided in the Public Health Service report
(16), and both publications present a range of effective options for increasing and improving programs to help patients
quit using tobacco.
ADDITIONAL INFORMATION ABOUT THE COMMUNITY GUIDE
During 2000--2001, Community
Guide chapters will be prepared and released
as each is completed. Upcoming chapters will focus on such topics as motor
vehicle occupant injury, oral health, sexual behavior, physical activity, cancer, and
the sociocultural environment. A compilation of the chapters will be published in
book form. Additional information regarding the Task Force and the
Community Guide is available on the Internet at <http://www.thecommunityguide.org>.
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*Tobacco-use initiation is defined as the onset, development, and establishment
of tobacco- use behavior.
** Tobacco-use cessation is defined as a process that begins with the decision
to stop using tobacco and ends with long-term maintenance of abstinence from tobacco.
***Consultants for the chapter on preventing tobacco use and exposure were Dileep
G. Bal, M.D., California Department of Health Services, Sacramento, California;
Anthony Biglan, Ph.D., Oregon Research Institute, Eugene, Oregon; Patricia A. Buffler,
Ph.D., M.P.H., University of California, Berkeley, California; Gregory Connolly, D.M.D.,
M.P.H., Massachusetts Tobacco Control Program, Boston, Massachusetts; K. Michael
Cummings, Ph.D., M.P.H., Roswell Park Institute, Buffalo, New York; Michael C. Fiore, M.D.,
M.P.H., University of Wisconsin Medical School, Madison, Wisconsin; David W. Fleming,
M.D., CDC, Atlanta, Georgia; Sally Malek, M.P.H., North Carolina Department of Health,
Raleigh, North Carolina; Patricia A, Mullen, Dr.P.H., University of Texas Health Sciences
Center, Houston, Texas; Cheryl L. Perry, Ph.D., University of Minnesota, Minneapolis,
Minnesota; John P. Pierce, Ph.D., University of California, San Diego, California; Helen H.
Schauffler, Ph.D., University of California, Berkeley, California; Randy H. Schwartz, M.S.P.H.,
Maine Bureau of Health, Augusta, Maine; and Mitchell Zeller, American Legacy
Foundation, Washington, DC.
****Additional information on the qualifying studies will be available at