NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Task Force on Community Preventive Services. The Guide to Community Preventive Services. Atlanta (GA): Centers for Disease Control and Prevention; 1999-.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of The Guide to Community Preventive Services

The Guide to Community Preventive Services.

Show details

Evidence Reviews and Recommendations on Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke: A Summary of Selected Guidelines

, MD, MPH, , MD, MPH, , MD, MPH, MBA, , MS, and , MA, MPH.

Author Information

, MD, MPH, , MD, MPH, , MD, MPH, MBA, , MS, and , MA, MPH.*

From the Division of Prevention Research and Analytic Methods, Epidemiology Program Office, Centers for Disease Control and Prevention (Hopkins, Rosenquist, Westphal), Atlanta, Georgia; Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (Husten), Atlanta, Georgia; Los Angeles Department of Health Services, University of California Los Angeles School of Public Health, University of California Los Angeles School of Medicine (Fielding), Los Angeles, California.
*Address correspondence and reprint requests to: David P. Hopkins, MD, MPH, Coordinating Scientist, Epidemiology Program Office, MS K73, Centers for Disease Control and Prevention, 4770 Buford Highway, Atlanta, GA 30341. E-mail: dhh4@cdc.gov.

Published: February 2001.

Medical Subject Headings (MeSH): community health services; decision-making; evidence-based medicine; practice guidelines; preventive health services; public health practice; smoking cessation; meta-analysis; review literature; tobacco smoke pollution; tobacco use cessation.

Introduction

The reports in this supplement to the American Journal of Preventive Medicine by the Task Force on Community Preventive Services 1 (the Task Force) and Hopkins et al. 2 represent the work of the Task Force, an independent, nonfederal group of national, regional, and local public health and prevention services experts supported by public and private partners. These reports are the second published section of what will be the Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Methods (the Community Guide). The first published section was on vaccine-preventable diseases. 3, 4, 5

In addition to expanding the Community Guide, these reviews and evidence-based recommendations add to the growing body of guidelines that identify and document the effectiveness of interventions to reduce tobacco use and exposure to environmental tobacco smoke (ETS). The Task Force reports complement other recent efforts that provide information and guidance to health care providers, health care systems, and communities on strategies to reduce the annual tobacco-related toll of addiction, illness, disability, and death. This paper presents a summary of selected guidelines and evidence reviews available as of August 2000, and provides an accessible review of the current evidence of effectiveness of interventions to reduce tobacco use and exposure to ETS.

The first section of this article describes the focus and general content of selected evidence reviews and guidelines, and information on the organization of the summary tables. The second section presents the summary evidence tables, organized by type or category of intervention. The third section provides a brief discussion of the comparisons across evidence reviews.

Selected Evidence Reviews and Guidelines on Tobacco Use Prevention and Control

The primary objective of this article is to compare the evidence reviews and recommendations from the Community Guide with reviews and recommendations recently produced by other groups. The two reports most often cited are Clinical Practice Guideline: Treating Tobacco Use and Dependence 6 and Reducing Tobacco Use: A Report of the Surgeon General 7 Other guidelines are also included to provide an additional assessment of the strength of the evidence for an intervention, 8 another summary effect measurement, 9 or a specific implementation recommendation from another agency or group. 10, 11, 12

This section identifies and briefly describes the selected guidelines and evidence reviews included in this summary report. Each of these documents employed a different methodology for finding, evaluating, and translating the evidence of effectiveness into a summary effect measurement and/or a recommendation for use. As a result, the descriptions provided here cannot fully elaborate on the methods used or the target audience for each publication.

The Guide to Community Preventive Services: Strategies to Reduce Tobacco Use and ETS Exposure (Published in 2001)

The tobacco section of the Community Guide currently includes 14 evidence reviews on interventions to reduce tobacco use and ETS exposure, with three additional reviews in progress. Community Guide methods, which have been summarized elsewhere, 13 basically involve a systematic process of: (1) identifying and selecting interventions to review; (2) searching for published evidence (limited to studies published in the English language); (3) abstracting and evaluating the quality of each identified study; (4) summarizing the available body of evidence regarding effectiveness, other effects, applicability, economic evaluation, and barriers to implementation; (5) Task Force translation of evidence into recommendations, based on established rules; and (6) identifying remaining questions for future research. Methods specific to the tobacco section are summarized elsewhere in this supplement.2.2 Overall, for each selected intervention, the Community Guide report provides a range and median of effect measures from the included studies, and a practice recommendation from the Task Force based primarily on the strength of the evidence.

Clinical Practice Guideline: Treating Tobacco Use and Dependence (Published in 2000)

Released in June 2000 by the Public Health Service, The Clinical Practice Guideline: Treating Tobacco Use and Dependence 6 (CPG) updates and expands on the review of strategies and therapies for the clinical identification and treatment of tobacco use and dependence published in the original 1996 report. 14 The CPG update provides (1) a comprehensive review of interventions to treat patient tobacco use and dependence that are appropriate for health care providers, health care systems, and health care purchasers; (2) a standardized evaluation process for each identified study; (3) standardized inclusion criteria; (4) a pooled summary estimate using meta-analytic techniques when appropriate; (5) a standardized assessment and grade of the strength of evidence for each intervention; and (6) identification of areas for further research.

A product of the Tobacco Use and Dependence Guideline Panel (the Panel), the CPG update is the most recent and the most complete assessment of interventions to treat tobacco use and dependence. The evaluations provided in both editions were heavily referenced in the relevant sections of the Surgeon General's report, and provided the foundation of evidence of effectiveness for several health care system strategies evaluated in the Community Guide.

Reducing Tobacco Use: A Report of the Surgeon General (Published in 2000)

Released in August 2000, the Surgeon General's report on smoking and health 7 (SGR) updates the status of tobacco use in the United States, and is the first Surgeon General's report to offer a composite review of the various methods used to reduce and prevent tobacco use. 15 The Surgeon General's report is a comprehensive, narrative review of (1) current tobacco use in the United States and a historical review of efforts to reduce smoking; (2) effective educational strategies to prevent tobacco use among young people; (3) individual and clinical strategies to increase tobacco use cessation; (4) regulatory efforts to reduce tobacco use and ETS exposure; (5) economic approaches (such as taxation of tobacco products); and (6) comprehensive tobacco prevention and control programs at the community, state, and national levels. Narrative reviews of the evidence of effectiveness are provided for some interventions, usually without a summary effect measure, or a formal recommendation for use. Some interventions are reviewed only in the context of comprehensive programs at the community, state, or national levels.

Cochrane Collaboration (various reports)

The Cochrane Collaboration is an international coalition of participating research centers conducting evidence reviews on a wide variety of clinical and public health topics. We have included 10 reports from the Cochrane Collaboration on tobacco use prevention and treatment in the summary tables. 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 These reports provide assessments of the effectiveness of interventions based on a systematic process including: (1) a search for evidence (not usually restricted to the English language); (2) standardized inclusion and exclusion criteria; (3) standardized evaluation and abstraction of information; (4) a pooled summary estimate using meta-analytic techniques when appropriate, and a narrative review when a pooled summary estimate could not be conducted; and (5) a process of updating reviews as new evidence is identified.

Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force (Published in 1996)

The U.S. Preventive Services Task Force (USPSTF) provides evidence-based recommendations for clinical practice on preventive interventions for a wide variety of conditions. 8 The USPSTF conducted evidence reviews using: (1) a standardized search for evidence of effectiveness of clinical preventive services; (2) standardized inclusion criteria; and (3) standardized evaluations of the evidence concluding with a narrative review and a recommendation based on the strength of the evidence of effectiveness.

Institute of Medicine: Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths (Published in 1994) Institute of Medicine & National Cancer Policy Board: Taking Action to Reduce Tobacco Use (Published in 1998)

These publications from the Institute of Medicine (IOM) present policy positions to reduce and prevent tobacco use in the United States that are informed by scientific evidence. 10, 11 The reports provide a pertinent review of tobacco use in the United States, and a set of recommendations for the implementation of specific policies and/or interventions at the national, state, and local levels.

Centers for Disease Control and Prevention, Office on Smoking and Health: Best Practices for Comprehensive Tobacco Control Programs-August 1999

Best Practices, a guidance document from the Office on Smoking and Health at CDC, presents recommendations and funding estimates for states "to establish tobacco control programs that are comprehensive, sustainable, and accountable." 12 The report identifies nine basic components of a "comprehensive" tobacco control program based on a review of published intervention studies, evaluations of two state programs (California and Massachusetts), and work with six other state programs (Oregon, Maine, Florida, Minnesota, Mississippi, and Texas). In addition to a narrative evidence review for each component, Best Practices provides budget estimates for the successful implementation of each component, and generates funding estimates for a model comprehensive program in every state.

Organization of the Summary Tables

Evidence reviews and recommendations are summarized on the following pages in tables, arranged as follows:

Table 1: Clinical interventions to identify and to treat tobacco use and dependence

Table 1: Clinical interventions to identify and to treat tobacco use and dependence-Recommendations and summary effect measurements from selected tobacco control guidelines and evidence reviews.

Table

Table 1: Clinical interventions to identify and to treat tobacco use and dependence-Recommendations and summary effect measurements from selected tobacco control guidelines and evidence reviews.

Table 2: Health care system interventions to identify and to treat tobacco use and dependence

Table 2: Health care system interventions to identify and to treat tobacco use and dependence-Recommendations and summary effect measurements from selected evidence reviews.

Table

Table 2: Health care system interventions to identify and to treat tobacco use and dependence-Recommendations and summary effect measurements from selected evidence reviews.

Table 3: Community interventions to reduce exposure to ETS

Table 3: Community interventions to reduce exposure to environmental tobacco smoke-Recommendations and summary effect measurements from selected tobacco control guidelines and systematic reviews.

Table

Table 3: Community interventions to reduce exposure to environmental tobacco smoke-Recommendations and summary effect measurements from selected tobacco control guidelines and systematic reviews.

Table 4: Community interventions to reduce tobacco use initiation by children and adolescents

Table 4: Community interventions to reduce tobacco use initiation by children and adolescents-Recommendations and summary effect measurements from selected tobacco control guidelines and systematic reviews.

Table

Table 4: Community interventions to reduce tobacco use initiation by children and adolescents-Recommendations and summary effect measurements from selected tobacco control guidelines and systematic reviews.

Table 5: Community interventions to increase tobacco use cessation

Table 5: Community interventions to increase tobacco use cessation-Recommendations and summary effect measurements from selected tobacco control guidelines and systematic reviews.

Table

Table 5: Community interventions to increase tobacco use cessation-Recommendations and summary effect measurements from selected tobacco control guidelines and systematic reviews.

Each intervention is displayed in a single row, with summaries of the contributing evidence reviews presented in the columns. Within each column, the evidence review is summarized from top to bottom in the following order: (1) a formal strength-of-evidence rating or recommendation, if provided; (2) narrative conclusion, if any; (3) summary effect measurements, if provided, with a brief description of the effect measure, and pertinent information (such as the period of follow-up for measurements of tobacco-use cessation).

With the exception of the evidence summaries provided in Table 1, the interventions identified and included follow the organization of the Community Guide. Interventions not evaluated in the Community Guide (e.g., provider counseling to reduce ETS exposure in the home; community-wide individual risk-factor screening and counseling) are not presented in these tables, but may have been evaluated in the other guidelines. The clinical interventions reviewed in Table 1 present evidence of effectiveness of several strategies that directly relate to the evaluations of effectiveness of health care system interventions reviewed in the Community Guide. For example, the evidence of effectiveness of provider counseling to tobacco-using patients, demonstrated in both the Guide to Clinical Preventive Services and the Clinical Practice Guideline, was referenced in the Community Guide in the evaluation of provider reminder systems. As a result, the Community Guide evaluated the evidence of effectiveness of provider reminder systems in increasing patients' receipt of counseling or advice to quit from their providers.

There is also some duplication of intervention summaries. For example, telephone cessation support is presented both in Tables 2 and 5 because it is an appropriate intervention for both health care systems and communities.

Recommendations

Three of the selected evidence reviews- Guide to Clinical Preventive Services, the Community Guide, and the Clinical Practice Guideline: Treating Tobacco Use and Dependence -present formal recommendations concerning the evidence of effectiveness for each intervention. In summarizing the recommendations from these reviews, the strength of evidence rating or recommendation is presented. In some cases, a brief quotation or statement is also presented. For several interventions, longer recommendation statements in the original document were abbreviated to fit the table format.

In all of the guidelines, readers were cautioned not to confuse an assessment of insufficient evidence of effectiveness with evidence of in effectiveness. In most cases, an assessment of insufficient evidence was based on an inadequate number of qualifying studies.

Guide to Clinical Preventive Services

A letter rating was assigned to denote the strength of the evidence of effectiveness supporting the Task Force recommendation for or against use of the intervention. Letter ratings range from A, "good evidence to support the recommendation to include" to E, "good evidence to support the recommendation to exclude." An evaluation of "insufficient evidence" is denoted by a letter rating of C.

Guide to Community Preventive Services

Recommendations for or against use of an intervention were based on the evidence of effectiveness and consideration of other effects (positive and negative). The three options are: (1) Strongly Recommended (for or against); (2) Recommended (for or against); and (3) Insufficient Evidence (no recommendation).

Clinical Practice Guideline: Treating Tobacco Use and Dependence

A letter rating was assigned to each intervention based on the strength of the evidence supporting the recommendation. A rating of A indicates "multiple well-designed randomized clinical trials, directly relevant to the recommendation, yielding a consistent pattern of findings." A rating of B indicates "some evidence from randomized clinical trials supporting the recommendation, but the scientific support was not optimal." A rating of C was "reserved for important clinical situations where the panel achieved consensus on the recommendation in the absence of relevant randomized controlled trials. The Panel declined to make recommendations when there was no relevant evidence or the evidence was too weak or inconsistent to support a recommendation.

Narrative Reviews

Some of the selected guidelines provided a narrative evaluation of the evidence of effectiveness of the intervention. For presentation in the summary tables of this article, pertinent sections of the text were quoted and identified. In most cases, the included text represents a summation or conclusion from an extended narrative evaluation of the studies providing evidence.

Summary Effect Measurements

Three of the evidence reviews- the Community Guide, the Clinical Practice Guideline, and the reports from the Cochrane Collaboration-provide summary effect measurements in evaluations of the evidence of effectiveness of the intervention. This information is provided in the tables with additional comments or information as needed. In all cases, the original document included a more detailed presentation and discussion of the summary effect measurements than is provided in these summary tables.

Guide to Community Preventive Service

For most interventions, the summary effect measurements were the range and median of absolute percentage differences in outcome between the intervention and comparison groups. The results are reported here as percentage point changes. For some intervention evaluations, the differences in outcome between the intervention and comparison groups were expressed as a relative percentage difference, with the results reported as the percentage change.

Clinical Practice Guideline: Treating Tobacco Use and Dependence

For interventions with an appropriate body of evidence, a pooled summary estimate of effect was determined using meta-analytic techniques. In these cases, the summary table presents the estimated odds ratio for the effect measurement and the 95% confidence interval. In some cases, the estimated abstinence rate (cessation outcomes) or the estimated provider intervention rate (for delivery of a measured activity such as counseling) was also reported.

Cochrane Collaboration

For interventions with an appropriate body of evidence, a pooled summary estimate of effect was determined using meta-analytic techniques. In these cases, the summary table presents the estimated odds ratio for the effect measurement and the 95% confidence interval. Several of the bodies of evidence reviewed on tobacco interventions, however, were not suitable for meta-analytic evaluation. In these cases, the summary tables present a quotation or conclusion from the narrative review.

Discussion

Comparison of the evidence summaries presented here reveals considerable general agreement on the effectiveness or ineffectiveness of the interventions reviewed, with only a few instances in which different reviews reached different conclusions.

There is uniform agreement on the effectiveness of the clinical interventions, although the magnitude of the effects differed slightly. Screening patients for tobacco use, delivering brief advice or more intense or frequent counseling to quit, and the use of pharmacologic treatments (nicotine replacement or bupropion as first-line therapies) were identified as effective in increasing patient tobacco use cessation. Self-help education materials were assessed as less effective or inconsistent.

The health care system interventions evaluated in these reviews primarily focused on increasing the delivery or use of effective clinical strategies. For most interventions, the assessment of effectiveness was consistent across the evidence reviews. Provider reminder systems (alone or in combination with other interventions), patient cessation support provided by telephone (when implemented with other interventions), and interventions to reduce patient out-of-pocket costs for effective cessation treatments were all identified as effective. The reviews differed slightly in the assessment of provider education programs. Two of the reviews, the Community Guide and the SGR, identified limitations in the evidence of effectiveness of provider education when implemented alone. The reviews were consistent, however, in identifying stronger evidence of effectiveness when provider education efforts were combined with other interventions, such as a provider reminder system.

The assessments of community interventions to reduce exposure to ETS, reduce tobacco use initiation, and increase tobacco use cessation were also consistent. Both the Community Guide and the SGR identified smoking bans and restrictions as effective in reducing exposure to ETS, and potentially effective in reducing tobacco use prevalence. Regarding community education efforts to reduce exposure to ETS in the home, the Community Guide found insufficient evidence to make a recommendation, whereas the SGR identified mass media messages included in the state campaigns in California and Massachusetts as effective in protecting children from exposure to ETS.

The evidence reviews of interventions to reduce tobacco use initiation in children and adolescents uniformly agreed on the effectiveness of increasing the unit price of tobacco products. The reviews differed slightly in the assessment of the evidence of effectiveness of mass media campaigns in reducing tobacco use among youth. All of the guidelines, however, identified effective campaigns characterized by a solid theoretical basis, use of formative research in designing the messages, and a broadcast campaign of reasonable intensity over an extended period of time. One reason for the stronger recommendation in the Community Guide is the addition of recent evaluations of effectiveness of state campaigns in Florida 26, 27 and Massachusetts, 28 which were not available for earlier reviews.

Evidence reviews of interventions to increase tobacco use cessation uniformly documented the effectiveness both of increasing the unit price of tobacco products and of mass media campaigns (when implemented with other interventions). Telephone cessation support, when implemented with other interventions, was also identified as effective in increasing tobacco use cessation. Regarding telephone support, these reviews all found greater evidence of effectiveness for proactive support (contact or follow-up initiated by a clinician or counselor) than for reactive (patient initiates all contact).

Conclusion

This article is unique in pulling together information from various tobacco control guidelines and summarizing evidence and recommendations for complementary tobacco prevention and control activities at the individual, health care system, and community levels. The included guidelines used many of the same studies and explicitly referred to one another. Their similarity, therefore, is not surprising. Nonetheless, the similarity of the findings and recommendations in these evidence reviews and guidelines, despite the widely varied methods used to select, appraise, and summarize evidence, provides considerable reassurance about the effectiveness of the recommended interventions. The cohesiveness and coherence of these reviews and recommendations provides additional support for the policy positions and suggests that these effective and recommended interventions should be implemented and funded. The summary tables presented in this article provide a useful starting point for clinicians, health care providers and purchasers, state and local health departments, and local, state, and national managers, funders, and advocates of tobacco prevention and control efforts. These brief evidence summaries cannot convey all of the important information provided in the original reviews. However, these tables provide a quick review of recent efforts, and can efficiently direct users to the original sources for additional information of interest.

References

1.
Task Force on Community Preventive Services. Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med. 2001;20(2S):10–15. [PubMed: 11173214]
2.
Hopkins DP, Briss PA, Ricard CJ, et al. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med. 2001;20(2S):16–66. [PubMed: 11173215]
3.
Task Force on Community Preventive Services. Recommendations regarding interventions to improve vaccination converage in children, adolescents, and adults. Am J Prev Med. 2000;18(1S):92–6. [PubMed: 10806981]
4.
Briss PA, Rodewald LE, Hinman AR, et al. Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services. Am J Prev Med. 2000;18(1S):97–140. [PubMed: 10806982]
5.
Shefer A, Briss P, Rodewald L, et al. Improving immunization coverage rates: an evidence-based review of the literature. Epidemiol Rev. 1999;21:96–142. [PubMed: 10520476]
6.
Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence. http://www.surgeongeneral.gov/tobacco. Accessed on July 13, 2000.
7.
US Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health, 2000. Stock no.: 017-001-00544-4.
8.
US Preventive Services Task Force. Guide to Clinical Preventive Services: report of the U.S. Preventive Services Task Force.2nd ed. Baltimore: Williams & Wilkins, 1996.
9.
The Cochrane Collaboration. The Cochrane Database of Systematic Reviews. http://www.updateusa.com.
10.
Institute of Medicine. Growing up tobacco free: Preventing nicotine addiction in children and youths.Washington, DC: National Academy Press, 1994.
11.
National Cancer Policy Board, Institute of Medicine and Commission on Life Sciences-National Research Council. Taking action to reduce tobacco use.Washington, DC: National Academy Press, 1998.
12.
Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs-August 1999. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1999.
13.
Briss PA, Zaza S, Pappaioanou M, et al. Developing an evidence-based Guide to Community Preventive Services-methods. Am J Prev Med. 2000;18(1S):35–43. [PubMed: 10806978]
14.
Agency for Health Care Policy and Research. Smoking Cessation: Clinical Practice Guideline (Number 18) Washington, DC: US Department of Health and Human Services, 1996. Pub. No. [AHCPR] 96-0692.
15.
Centers for Disease Control and Prevention. Notice to readers: Publication of Surgeon General's report on smoking and health. MMWR Morb Mortal Wkly Rep. 2000;49:718–27. [PubMed: 10958588]
16.
Silagy C. Physician advice for smoking cessation (Cochrane Review) The Cochrane Library, Issue 3. Oxford: Update Software, 2000.
17.
Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation (Cochrane Review) The Cochrane Library, Issue 3. Oxford: Update Software, 2000.
18.
Lancaster T, Stead LF. Self-help interventions for smoking cessation (Cochrane Review) The Cochrane Library, Issue 3. Oxford: Update Software, 2000.
19.
Silagy C, Mant D, Fowler G, Lancaster T. Nicotine replacement therapy for smoking cessation (Cochrane Review) The Cochrane Library, Issue 3. Oxford: Update Software, 2000.
20.
Gourlay SG, Stead LF, Benowitz NL. Clonidine for smoking cessation (Cochrane Review) The Cochrane Library, Issue 3. Oxford: Update Software, 2000.
21.
Lancaster T, Silagy C, Fowler G. Training health professionals in smoking cessation (Cochrane Review) The Cochrane Library, Issue 3. Oxford: Update Software, 2000.
22.
Thomson O'Brien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Audit and feedback: effects on professional practice and health care outcomes (Cochrane Review) The Cochrane Library, Issue 3. Oxford: Update Software, 2000.
23.
Serra C, Cabezas C, Bonfill X, Pladevall-Vila M. Interventions for preventing tobacco smoking in public places (Cochrane Review) The Cochrane Library, Issue 3. Oxford: Update Software, 2000.
24.
Sowden AJ, Arblaster L. Mass media interventions for preventing smoking in young people (Cochrane Review) The Cochrane Library, Issue 3. Oxford: Update Software, 2000.
25.
Stead LF, Lancaster T. Interventions for preventing tobacco sales to minors (Cochrane Review) The Cochrane Library, Issue 3. Oxford: Update Software, 2000.
26.
Centers for Disease Control and Prevention. Tobacco use among middle and high school students-Florida, 1998 and 1999. MMWR Morb Mortal Wkly Rep. 1999;48:248–53. [PubMed: 10220252]
27.
Florida Department of Health. Florida Tobacco Youth Survey. 2000. Available at www.state.fl.us/tobacco.
28.
Siegel M, Biener L. The impact of an antismoking media campaign on progressions to established smoking: Results of a longitudinal youth study. Am J Public Health. 2000;90:1–7. [PMC free article: PMC1446163] [PubMed: 10705855]
29.
Fiore MC. The new vital sign. Assessing and documenting smoking status [comment] [see comments] JAMA. 1991;266:3183–4. [PubMed: 1823545]
30.
Cohen SJ, Stookey GK, Katz BP, Drook CA, Smith DM. Encouraging primary care physicians to help smokers quit. A randomized, controlled trial. Ann Intern Med. 1989;110:648–52. [PubMed: 2930095]
31.
Ockene JK, Kristeller J, Goldberg R, et al. Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial [see comments] J Gen Intern Med. 1991;6:1–8. [PubMed: 1999742]
32.
Wells KB, Ware Jr JE, Lewis CE. Physicians' attitudes in counseling patients about smoking. Med Care. 1984;22:360–5. [PubMed: 6717116]
33.
Glynn TJ. Relative effectiveness of physician-initiated smoking cessation programs. Cancer Bulletin. 1988;40:359–64.
34.
Ockene JK, Aney J, Goldberg RJ, Klar JM, Williams JW. A survey of Massachusetts physicians' smoking intervention practices. Am J Prev Med. 1988;4:14–20. [PubMed: 3395485]
35.
Cummings SR, Coates TJ, Richard RJ, et al. Training physicians in counseling about smoking cessation. A randomized trial of the "Quit for Life" program. Ann Intern Med. 1989;110:640–7. [PubMed: 2930094]
36.
Duncan C, Stein MJ, Cummings SR. Staff involvement and special follow-up time increase physicians' counseling about smoking cessation: a controlled trial. Am J Public Health. 1991;81:899–901. [PMC free article: PMC1405179] [PubMed: 2053669]
37.
Manley M, Epps RP, Husten C, Glynn T, Shopland D. Clinical interventions in tobacco control. A National Cancer Institute training program for physicians [see comments] JAMA. 1991;266:3172–3. [PubMed: 1956107]
38.
Ockene JK, Quirk ME, Goldberg RJ, et al. A residents' training program for the development of smoking intervention skills [see comments] Arch Intern Med. 1988;148:1039–45. [PubMed: 3365074]
39.
Strecher VJ, O'Malley MS, Villagra VG, et al. Can residents be trained to counsel patients about quitting smoking? Results from a randomized trial [see comments] J Gen Intern Med. 1991;6:9–17. [PubMed: 1999752]
40.
Dietrich AJ, O'Conner GT, Keller A, Carney PA, Levy D, Whaley FS. Cancer: improving early detection and prevention. A community practice randomised trial. BMJ. 1992;304:687–91. [PMC free article: PMC1881551] [PubMed: 1571644]
41.
Carney PA, Dietrich AJ, Freeman DJ, Mott LA. A standardized-patient assessment of a continuing medical education program to improve physicians' cancer-control clinical skills. Acad Med. 1995;70:52–8. [PubMed: 7826445]
42.
Klein JD, Portilla M, Goldstein A, Leininger L. Training pediatric residents to prevent tobacco use. Pediatrics. 1995;96:326–30. [PubMed: 7630693]
43.
Schauffler HH, Parkinson MD. Health insurance coverage for smoking cessation services. Health Education Quarterly. 1993;20:185–206. [PubMed: 8491632]
44.
Eddy DM. Clinical decision making: from theory to practice. Cost-effectiveness analysis: will it be accepted? JAMA. 1992;268:132–6. [PubMed: 1608100]
45.
Kaplan RM, Orleans CT, Perkins KA, Pierce JP. Marshaling the evidence for greater regulation and control of tobacco products: A call for action. Ann Behav Med. 1995;17:3–14. [PubMed: 24203496]
46.
Rothenberg R, Koplan JP, Cutler C, Hillman AL. Changing pediatric practice in a changing medical environment: factors that influence what physicians do. [Review] [151 refs] Pediatr Ann. 1998;27:241–50. [PubMed: 9589504]
47.
Centers for Disease Control and Prevention. Guidelines for school health programs to prevent tobacco use and addiction. MMWR Morb Mortal Wkly Rep. 1994;43 (RR-2):1–18. [PubMed: 8145711]
48.
Flay BR, Gruder CL, Warnecke RB, Jason LA, Peterson P. One year follow-up of the Chicago televised smoking cessation program. Am J Public Health. 1989;79:1377–80. [PMC free article: PMC1350178] [PubMed: 2782506]
49.
Flay BR. Mass media and smoking cessation: a critical review. Am J Public Health. 1987;77:153–60. [PMC free article: PMC1646843] [PubMed: 3541650]

Appendix B-1Studies of Effectiveness of Smoking Bans and Restrictions on Reducing Exposure to Environmental Tobacco Smoke (ETS)

Appendix B-1 Studies of Effectiveness of Smoking Bans and Restrictions on Reducing Exposure to Environmental Tobacco Smoke (ETS)

Author & Year (study period) Design suitability: design Quality of execution (# of Limitations) Evalution settingIntervention and comparsion elementsStudy population description

Sample size
Results
Effect MeasureReported baselineReported effectValue used in summaryFollow-up time
Studies measuring the impact of Smoking Restrictions
Becker 1989b 1 (1987)

Least: Before-After
Good (1)
Hospital
Location: USA; Baltimore, MD

Components: Smoking ban implemented in the Medical Center + employee education

Comparison: Before-After
N=9 randomly selected locations within the Medical Center
(several locations were tested; results here for lounge areas)
1) Average nicotine vapor concentrations in tested lounge areas (7 day collections ug/m3)13.010.48-12.53 ug/m3
p=0.03
(-96%)
6months
Borland 1992 2 (1990)

Least: cross-sectional survey
Good (1)
Workplace
Location: USA, California

Components: Workplace smoking policies (smoke-free; work area ban only; other; none)

Comparison: Worksites without smoking policies/restrictions
Employed, non-smoking, adult respondents to the 1990 California Tobacco Survey n=7002 (analysis)1) Self-reported work area ETS exposure
Note: Logistic regression analysis for nonsmokers' work area exposure to ETS
51.4% (no policy)9.3%(smoke-free)



23.2%(work area ban only)

Smoke-free vs Area ban only
-42.1 pct pt(-82%)
Adj OR =8.46 a
95%CI(5.51,12.9)

-28.2 pct pt(-55%)

-13.9 pct pt(-60%)
Adj OR =2.81
95%CI(1.92, 4.12)
NA

NA



NA
Broder 1993b 3 (1989-1990)

Least: Before-After
Good (1)

Workplace (public sector)
Location: Canada; Toronto

Components: Workplace smoking ban

Comparison: Before-After
Study buildings n=3,
8-12 sampled worksite sectors of each floor
1) Mean measurements of environmental air samples (units differ)
Volatiles (V)
Carbon dioxide(CD)
Carbon monoxide(CM)
Particulates (Pa)

V=1.6



CD=491
CM=0.003
Pa=0.023

V=0.9



CD=481
CM=0.004
Pa=0.014
-0.7 (-44%)
p=0.0007
-10 (-2%) p=0.03
+0.001(+33%) NS
-0.009 (-39%) NS
12 months
Brownson 1995 4 (1992-1993)

Moderate: Time series
Fair (2)
Workplace; Community
Location: USA, Missouri

Components: Smoking restrictions and community education

Comparison: Before-After
BRFSS sample n=6052 (resp rate 73%)
Adult, employed, never or former smokers
n=(not reported)
1) Self-reporting exposure to environmental tobacco smoke in the workplace44.2 %(± 2.6)Post 1: 33.2 % (± 6.3)

Post 2: 34.7 % (± 4.1)
-11 pct pt
(-24.9%) p=0.01
-9.5 pct pt
(-21.5%) p<0.001
1-4 months

5-16 months
Etter 1999 5 (1995-1996)

Greatest: Other design with a concurrent comparison group
Fair (4)
School; workplace
(University of Geneva)
Location: Switzerland; Geneva

Components: University smoke free program: Smoking restrictions + smoking cessation services

Comparison: Participants less exposed to smoking restrictions
Probability sample of University students, faculty, and staff, n=2908 eligible
Baseline
n= 2237 (77%)
I=833
C=1023
4m f/u (cohort)
n=1856 (64%)
1) Scale response of self- reporting exposure to environmental tobacco smoke on campus ("Never"=0; "Very often"=100)I=53.3
C=51.2
I=49.3
C=45.1
overall +2.1 pts (+3.9%) p=0.134months
Gottlieb 1990 6 (1987-1988)

Moderate: Time Series
Fair (3)
Workplace
Location: USA; Texas,

Components: Worksite smoking restriction (Texas Dept of Human Services)


Comparison: Before-After
Survey sample of employees
Pre: n=2158
82.2% resp rate
Post 6m: n=2205
52.7% resp rate
1) Self-reported exposure to coworkers smoke ("never bothered by")41.3%80.1%
(p<0.001)
+38.8pct pt (94%)6months
Millar 1988b 7 (1986-1987)

Least: Before-After
Good (1)
Workplace
Location: Canada, Ontario

Components: Workplace smoking restrictions

Comparison: Before-After
Workplace locations
n=12
1) Mean respirable suspended particulate levels (ug/m3) at each location;
(By location)
1)A-7th floor,
2) A-9th floor
3) B-3rd floor
4) B-15th floor
1)30 ug/m3

2)28 ug/m3

3)35 ug/m3

4)47 ug/m3
22 ug/m3

22 ug/m3

18 ug/m3

25 ug/m3
-8 ug/m3 (-27%)p<0.001
-6 ug/m3 (-21%)p<0.05
-17 ug/m3(-48%)p<0.01
-22 ug/m3 (-47%)p<0.001
1 year
Mullooly 1990 8 (1985-1987)

Moderate: Time series
Fair (2)
Workplace; HMO
Location: USA, Oregon

Components: Worksite smoking ban (some facilities in 1985 and the rest in 1986)

Comparison: Before-after (including a comparison with expected outcomes based on projected trends 1976-1984)
Employees n=13,736 overall;

1985 facilities ban n=5590
(resp rate 70%)

1986 facilities ban n=8146
(resp rate 70%)
1) Self-reported presence of smoke in the workplace:
Overall = (Obs post-Obs pre) -- (Exp pre-Exp post)
1985 : observed 31% expected 30%
1986 : observed 53% expected 43%

NR

1985: obs 23.5% exp 23%

1986 obs 19% exp 22%
1985: obs 10% exp 20%
1986: obs 18% exp 42%

NR

1985: obs 22% exp 19%
1986: obs 20% exp 22%
Overall: -11pct pt(-35%) (p<0.05)
Overall: -34pct pt(-64%) (p<0.05)

No significant change observed Overall +2.5 pct pt (+10.6%) NS
Overall +1 pct pt(+5.2%) NS
2 years

1 year



2 years

1 year
Patten 1995a 9 (1990-1993)

Moderate: Time series
Fair (3)
Workplaces (statewide)
Location: USA, California

Components: Smoke-free workplace

Comparison: Lesser or no work area restrictions; Work area ban only (restriction)
Nonsmoking, adult indoor workers responding to the California Tobacco Surveys of 1990, 92, 93.
YrResp#nonsm
90(75%)8580
92(73%)2177
93(70%)12946
1) % nonsmokers self-reported exposure to environmental tobacco smoke in the work area by workplace smoking policy1993
67.5 (±7.3)%
No work area ban



41.1(±6.8)%
Work area ban
1993
11.2 (±2.1)%
Smoke-free worksite

-56.3 pct pt
(-83%)
Adj OR=15.09
95%CI (9.8,23.2)

Smoke-free vs work area ban (restriction)
-29.9 pct pt (-73%) NR
3 years
Stillman 1990b 10 (1988)

Least: Before-After
Good 1
Hospital
Location: USA; Baltimore, MD

Components: Medical center smoking ban ; Smoking cessation program offered to employees


Comparison: Before-After
7-day nicotine vapor measures (environmental sampling)
Randomly selected locations within the Medical Center;
lounge areas n=4, cafeterias n=2 of 3
1) Av. 7-day nicotine vapor concentrations (ug/m3) in sampled locations
Cafeteria

Waiting area

Staff lounges

Restrooms

Corridors/elevators


7.06 ug/m3

3.88 ug/m3

2.43 ug/m3

17.71 ug/m3

2.28 ug/m3


0.22 ug/m3

0.28 ug/m3

0.12 ug/m3

10.0 ug/m3

0.20 ug/m3


-6.84 ug/m3(-97%) p=0.0007
-3.6 ug/m3(-93%) p=0.0003
-2.31 ug/m3(-95%) p=0.003
-7.71 ug/m3 (-44%) NS
-2.08 ug/m3 (91%)
8months










p=0.02

aAbbreviations: BRFSS = Behavioral Risk Factor Surveillance System; C = comparison group; CI = confidence interval; Exp = expected; f/u = follow-up; I = intervention group; m = months; NS = not significant; Obs = observed; OR = odds ratio; pct pt = percentage point

References

1.
Becker DM, Conner HF, Waranch HR, et al. The impact of a total ban on smoking in the Johns Hopkins Children's Center. JAMA. 1989;262:799–802. [PubMed: 2746836]
2.
Borland R,Pierce JP, Burns DM, Gilpin E, Johnson M, Bal D. Protection from environmental tobacco smoke in California: The case for a smoke-free workplace. JAMA. 1992;268:749–52. [PubMed: 1640575]
3.
Broder I, Pilger C, Corey P. Environment and well-being before and following smoking ban in office building. Can J Public Health. 1993;84:254–8. [PubMed: 8221499]
4.
Brownson RC, Davis J, Jackson-Thompson J, Wilkerson J. Environmental tobacco smoke awareness and exposure: impact of a statewide clean indoor air law and the report of the US Environmental Protection Agency. Tob Control. 1995;4:132–8.
5.
Etter J, Ronchi A, Perneger TV. Short-term impact of a university based smoke free campaign. J Epidemiol Community Health. 1999;53:710–5. [PMC free article: PMC1756808] [PubMed: 10656100]
6.
Gottlieb NH, Eriksen MP, Lovato CY, Weinstein RP, Green LW. Impact of a restrictive work site smoking policy on smoking behavior, attitudes, and norms. J Occup Med. 1990;32:16–23. [PubMed: 2324839]
7.
Millar WJ. Evaluation of the impact of smoking restrictions in a government work setting. Can J Public Health. 1988;79:379–82. [PubMed: 3179907]
8.
Mullooly JP, Schuman KL, Stevens VJ, Glasgow RE, Vogt TM. Smoking behavior and attitudes of employees of a large HMO before and after a work site ban on cigarette smoking. Public Health Rep. 1990;105:623–8. [PMC free article: PMC1580168] [PubMed: 2124362]
9.
Patten CA, Pierce JP, Cavin SW, Berry C, Kaplan R. Progress in protecting non-smokers from environmental tobacco smoke in California workplaces. Tob Control. 1995;4:139–44.
10.
Stillman FA, Becker DM, Swank RT, et al. Ending smoking at the Johns Hopkins Medical Institutions. An evaluation of smoking prevalence and indoor air pollution. JAMA. 1990;264:1565–9. [PubMed: 2395198]

Appendix B2: Studies of the Effectiveness of Smoking Bans and Restrictions on Tobacco Use Behaviors

Appendix B2: Studies of the Effectiveness of Smoking Bans and Restrictions on Tobacco Use Behaviors

Author & year (study period) Design suitability: design Quality of execution (# of Limitations) Evaluation setting Intervention and comparison elementsStudy population description

Sample size
Results
Effect MeasureReported baselineReported effectValue used in summaryFollow-up time
Studies measuring the impact of Smoking Restrictions
Biener 1989 1 (1985-1986)

Greatest: Other design with a concurrent comparison group
Fair (2)
Hospital
Location: USA, Rhode Island

Components: Hospital smoking restriction

Comparison: Hospital with fewer smoking restrictions
Hospital Employees
Int: a
Pre: n= 82
Post: n=110
Comp:
Pre: n=83
Post: n=104
1) Self-reported consumption of cigarettes (cigs/day): b At work
At home

2) Self-reported smoking cessation attempt in the 6 months prior to interview c


3) Self-reported smoking prevalence d
Int 8.4+2.5
Comp 7.6+2.6
Int 12.8+2.5
Comp 13.3+4.1

Int 4% +8
Comp 30%+21

Int 34.1%
Comp 27.7%
Int 4.5+1.4
Comp 6.9+2.0
Int 10.6+3.1
Comp 9.2+2.6

Int 0%+2
Comp 19% +17

Int 20.0%
Comp 25.0%

Work: -3.2 cigs/dy
Home:+1.9cigs/dy
Overall:-1.3cigs/dy


+7 pct pt NS
(+175%)

-11.4 pct pt
(-33%)

12 months




12 months


12 months
Brigham 1994 2 (1989)

Greatest: Group non-randomized trial
Fair (4)
Hospital
Location: USA; Baltimore, MD

Components: Hospital smoking ban

Comparison: Hospitals without smoking restrictions
Recruited smoking employees
n=92
n=67 (73%)
completed
Int=34
Comp=33
1) Self-reported consumption during working hours: cigs/shift (SD) b


2) Self-reported cessation e
Inter: 7.57(4.7) cigs/shift
Comp:10.02(2.9) cigs/shft


0%
I: 3.64 (4.9) c/s
C: 9.53 (4.8) c/s


0%
-3.44 cigs/shift
F(1,65)=15.9 p<0.0001

0 pct pt (0%) NS
4 wks



4 wks
Etter 1999 3
(1995-1996)

Greatest: Other design with a concurrent comparison group
Fair (4)
School; Workplace (University of Geneva)
Location: Switzerland; Geneva

Components: University smoke free program: Smoking restrictions + smoking cessation services

Comparison: Participants less exposed to smoking restrictions
Probability sample of University students, faculty, and staff, n=2908 eligible
Baseline
n= 2237 (77%)
I=833
C=1023
4m f/u (cohort)
n=1856 (64%)
1) Self-reported consumption (cigs/day) by smokers b

2) Self-reported smoking cessation attempts in the last 4 months c

3) Self-reported current smoker status e
I=11.4 cigs/day
C=11.4 cigs/day

I=2.0%
C=3.5%

I=24.8%
C=27.2%
I=11.7 cigs/day
C=12.0 cigs/day

I=3.8%
C=3.5%

I=25.1%
C=26.7%
overall -0.3 cigs/dy (-2.6%) p=0.53

overall +1.8 pct pt (+90%) p=0.048

overall +0.8 pct pt (+3.2%) p=0.47
4months


4months


4months
Gottlieb 1990 4 (1987-1988)

Moderate: Time Series
Fair (3)
Workplace
Location: USA; Texas

Components: Worksite smoking restriction (Texas Dept of Human Services)


Comparison: Before-After
Survey sample of employees
Pre: n=2158
82.2% resp rate
Post 6m: n=2205
52.7% resp rate
1) Self-reported cigarette consumption
of 25+ cigarettes/day b
2) Self-reported smoking cessation attempts by current smokers in the last 6 months c 3) Self-reported current smoker d
41.3%

19.4%

30.7%

22.9 %
80.1%
(p<0.001)
16.7%
(p<0.001)
30.0%
NS
19.5%
NS
+38.8pct pt (94%)

-2.7 pct pt (-14%)

-0.7pct pt (-2.3%)

-3.4 pct pt (-15%)
6months

6months

6months

6months
Jeffery 1994 5 (1987-1990)

Greatest: Prospective cohort
Fair (4)
Workplace
Location: USA; Minneapolis-St. Paul
Components: Worksite smoking restrictions (Companies that implemented restrictions in the study period)

Comparison: No worksite smoking restrictions (companies without restrictions at baseline and at f/u )
Recruited companies (n=32)

Random samples of employees (n=200 at each company)
1) Mean cigarette consumption self-reported by smoking employees (cigs/day) b

2) Mean proportion of employees self-reporting cessation attempt(s) in the last 3 months c

3) Mean smoking prevelance (self-reported) d
I=20.6
C=20.4


I=26.6%
C=25.8%

I=26.1
C=26.1
I=18.3
C=20.2


I=21.3%
C=21.4%

I=23.9
C=23.5
-2.1 (-11.5%)
(p=0.01)


-0.9 pct pt (-4%)
(p=0.91)

+0.4 pct pt
(+1.5%)
(p=0.97)
2 years



2 years


2 years
Longo 1996 6 (1994)

Greatest: Other design with a concurrent comparison group
Fair (4)
Hospitals; Workplace
Location: USA; Communities in 21 states

Components: Mandated hospital smoking ban

Comparison: Worksites in the community without a smoke-free policy
Communities containing a study hospital, n=26

Random survey samples of employed adult current+former smokers
(response rate)
Inter: 1469 (84%)
Comp: 920 (64%)
1) Self-reported average daily cigarette consumption b

2) 1 year post-ban quit ratio e
quit ratio = #former smokers
#current+#former
NR


0.038
95%CI (0.025, 0.052)
-1.1 cigs/day
p=0.01

0.066
95%CI
(0.05, 0.082)
-1.1 cigs/day (NA)


Adjusted relative risk 1.7 (1.2, 2.4)
1 year


1 year
Mullooly 1990 7 (1985-1987)

Moderate: Time series
Fair (2)
Workplace; HMO
Location: USA, Oregon

Components: Worksite smoking ban (some facilities in 1985 and the rest in 1986)

Comparison: Before-after (including a comparison with expected outcomes based on projected trends 1976-1984)
Employees n=13,736 overall;

1985 facilities ban n=5590
(resp rate 70%)

1986 facilities ban n=8146
(resp rate 70%)
1) Self-reported total daily consumption of cigarettes (cigs/day) b

2) % self-reporting current smoker status (prevalence) d

NR


1985: obs 23.5%
exp 23%
1986 obs 19%
exp 22%

NR


1985: obs 22%
exp 19%
1986: obs 20%
exp 22%

No significant change observed

Overall +2.5 pct pt
(+10.6%) NS
Overall +1 pct pt
(+5.2%) NS

1 and 2 years

2 years

1 year
Patten 1995b 8 (1990-1992)

Greatest: Other design with a concurrent comparison
Fair (4)
Workplaces (statewide)
Location: USA, California

Components: Workplace smoking policy (smoke-free)

Comparisons: Workplace smoking policy not smoke-free

Workplace policy changes 1990+1992
Group19901992
InterventionNSFSF
ComparisonNSFNSF

Note: 2 additional study groups not reported here
Respondents to the California Tobacco Survey, analysis on a subset n=1844 indoor workers employed in 1990 and 1992


Intervention n=157 smokers at baseline (1990)
Comparison n=217 smokers at baseline (1990)
1) Self-reported mean cigarette consumption (cigs/day) by smokers (quitters = 0 cigs) b





2) % Self-reporting smoking cessation at 1992 interview (95% CI) e

3) % Self-reporting smoking relapse at 1992 interview 95% CI)

3) Self-reported smoking prevalence, 1990 and 1992 d
Int 14.51 cigs/day

Comp 14.86 cigs/day






Comparison: 9.2 (+4.9)%


Comparison: 3.5 (+3.3)%

Int: 20.3%
Comp: 26.7%
13.11 cigs/day

14.41 cigs/day






Int: 18.8(+8.8)%


Int: 3.3 (+4.0)%

Int: 19.1%
Comp: 26.7%
-1.41 (+2.16) c/dy
NS
-0.45 (+1.42) c/dy
NS
Overall difference
-0.96 cigs/day
(-6.6%) NR (NS)




+9.6 pct pt
(+104%) NS


-0.2 pct pt NS


-1.4 pct pt
(-6.9%) NS
2 years










2 years



2 years


2 years
Stave 1991 9 (1988-1989)

Greatest Other design with a concurrent comparison group
Fair (4)
Wrokplace; Hospital clinics
Location: USA; North Carolina; Duke University Med. Ctr.

Components: Medical Center smoking ban

Comparison: University employees not subject to the Medical Ctr smoking ban
Random samples of employees,
Medical center n=400;
University
n=400;
(resp rate 91.2%)
1) Self-reported cigarette consumption (cigarettes/day) I=inter; C=Comp b

2) % self-reported smoking cessation attempts at 15m f/u c


3) % smoking cessation (validated) at 15m f/u e


4) % self-reported smoking cessation at 15m f/u e
I=18.7 (+13.9) cigs/day
C=18.7 (+12.2) cigs/day
(retrospective)


45.8%


2.9% (v)


6.9%
I=14.2 (+8.0)
C=18.5 (+10.6)




50%


10.8% (v)


22.5%
Overall:
-4.3 cigs/day
(-23%) (p<0.03)




+4.2 pct points
(+9.2%) NR

+7.9 (v) pct pt
(+272%) p<0.03

+15.6 pct pt
(+226%) p<0.01
15 months






15 months


15 months


15 months
a

Abbreviations: C or Comp = comparison group; c/s = cigarettes per shift; CI = confidence interval; exp = expected; F = f-test; f/u = follow-up; I, Int, or Inter = intervention group; m = months; NR = not reported; NS = not significant; NSF = not smoke-free; obs = observed; pct pt = percentage point; resp = response; SF = smoke-free

b

Measurements of cigarette consumption by smokers

c

Measurements of smoking cessation attempts by smokers

d

Measurements of tobacco use prevalence in the study populations

e

Measurements of smoking cessation

References

1.
Biener L, Abrams DB, Follick MJ, Dean L. A comparative evaluation of a restrictive smoking policy in a general hospital. Am J Public Health. 1989;79:192–5. [PMC free article: PMC1349932] [PubMed: 2913839]
2.
Brigham J, Gross J, Stitzer ML, Felch LJ. Effects of a restricted work-site smoking policy on employees who smoke. Am J Public Health. 1994;84:773–8. [PMC free article: PMC1615061] [PubMed: 8179047]
3.
Etter J, Ronchi A, Perneger TV. Short-term impact of a university based smoke free campaign. J Epidemiol Community Health. 1999;53:710–5. [PMC free article: PMC1756808] [PubMed: 10656100]
4.
Gottlieb NH, Eriksen MP, Lovato CY, Weinstein RP, Green LW. Impact of a restrictive work site smoking policy on smoking behavior, attitudes, and norms. J Occup Med. 1990;32:16–23. [PubMed: 2324839]
5.
Jeffery RW, Kelder SH, Forster JL, French SA, Lando HA, Baxter JE. Restrictive smoking policies in the workplace: effects on smoking prevalence and cigarette consumption. Prev Med. 1994;23:78–82. [PubMed: 8016037]
6.
Longo DR, Brownson RC, Johnson JC, et al. Hospital smoking bans and employee smoking behavior: Results of a national survey. JAMA. 1996;275:1252–7. [PubMed: 8601957]
7.
JP, Schuman KL, Stevens VJ, Glasgow RE, Vogt TM. Smoking behavior and attitudes of employees of a large HMO before and after a work site ban on cigarette smoking. Public Health Rep. 1990;105:623–8. [PMC free article: PMC1580168] [PubMed: 2124362]
8.
Patten CA, Gilpin E, Cavin SW, Pierce JP. Workplace smoking policy and changes in smoking behavior in California: a suggested association. Tob Control. 1995;4:36–41.
9.
Stave GM, Jackson GW. Effect of a total work-site smoking ban on employee smoking and attitudes. J Occup Med. 1991;33:884–90. [PubMed: 1941284]
PubReader format: click here to try

Views

  • PubReader
  • Print View
  • Cite this Page

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...