www.ncbi.nlm.nih.gov Open in urlscan Pro
2607:f220:41e:4290::110  Public Scan

Form analysis
2 forms found in the DOM

GET /books/

<form method="get" action="/books/">
  <div class="search_form"><label for="database" class="offscreen_noflow">Search database</label><select id="database">
      <optgroup label="Recent">
        <option value="books" selected="selected" class="last" data-ac_dict="bookshelf-search">Books</option>
      </optgroup>
      <optgroup label="All">
        <option value="gquery">All Databases</option>
        <option value="assembly">Assembly</option>
        <option value="biocollections">Biocollections</option>
        <option value="bioproject">BioProject</option>
        <option value="biosample">BioSample</option>
        <option value="books" data-ac_dict="bookshelf-search">Books</option>
        <option value="clinvar">ClinVar</option>
        <option value="cdd">Conserved Domains</option>
        <option value="gap">dbGaP</option>
        <option value="dbvar">dbVar</option>
        <option value="gene">Gene</option>
        <option value="genome">Genome</option>
        <option value="gds">GEO DataSets</option>
        <option value="geoprofiles">GEO Profiles</option>
        <option value="gtr">GTR</option>
        <option value="ipg">Identical Protein Groups</option>
        <option value="medgen">MedGen</option>
        <option value="mesh">MeSH</option>
        <option value="nlmcatalog">NLM Catalog</option>
        <option value="nuccore">Nucleotide</option>
        <option value="omim">OMIM</option>
        <option value="pmc">PMC</option>
        <option value="popset">PopSet</option>
        <option value="protein">Protein</option>
        <option value="proteinclusters">Protein Clusters</option>
        <option value="protfam">Protein Family Models</option>
        <option value="pcassay">PubChem BioAssay</option>
        <option value="pccompound">PubChem Compound</option>
        <option value="pcsubstance">PubChem Substance</option>
        <option value="pubmed">PubMed</option>
        <option value="snp">SNP</option>
        <option value="sra">SRA</option>
        <option value="structure">Structure</option>
        <option value="taxonomy">Taxonomy</option>
        <option value="toolkit">ToolKit</option>
        <option value="toolkitall">ToolKitAll</option>
        <option value="toolkitbookgh">ToolKitBookgh</option>
      </optgroup>
    </select>
    <div class="nowrap"><label for="term" class="offscreen_noflow" accesskey="/">Search term</label>
      <div class="nowrap">
        <div class="jig-ncbiclearbutton-wrap ui-ncbiclearbutton-wrap"><input type="text" name="term" id="term" title="Search Books. Use up and down arrows to choose an item from the autocomplete." value=""
            class="jig-ncbiclearbutton jig-ncbiautocomplete" data-jigconfig="dictionary:'bookshelf-search',disableUrl:'NcbiSearchBarAutoComplCtrl'" autocomplete="off" data-sbconfig="ds:'no',pjs:'no',afs:'no'" aria-haspopup="true"
            aria-autocomplete="list" role="textbox"><a class="reset" href="#" style="visibility: hidden;"><img src="/core/jig/1.15.2/img/clear.png" alt="Clear input"></a></div>
      </div><button id="search" type="submit" class="button_search nowrap" cmd="go">Search</button>
    </div>
  </div>
</form>

GET /books/n/nap12632/

<form method="get" action="/books/n/nap12632/" id="bk_srch">
  <div class="bk_search"><label for="bk_term" class="offscreen_noflow">Search term</label>
    <div class="jig-ncbiclearbutton-wrap ui-ncbiclearbutton-wrap"><input type="text" title="Search this book" id="bk_term" name="term" value=""
        data-jig="ncbiclearbutton"><a class="reset" href="#" style="visibility: hidden;"><img src="/core/jig/1.15.2/img/clear.png" alt="Clear input"></a></div> <input type="submit" class="jig-ncbibutton ui-corner-all ui-ncbibutton ui-ncbibutton-gray"
      value="Search this book" submit="false" style="padding: 0.1em 0.4em;" id="ui-ncbibutton-7" role="button">
  </div>
</form>

Text Content

Warning: The NCBI web site requires JavaScript to function. more...

An official website of the United States government

Here's how you know

The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive
information, make sure you're on a federal government site.

The site is secure.
The https:// ensures that you are connecting to the official website and that
any information you provide is encrypted and transmitted securely.


Log in Show account info
Close

ACCOUNT

Logged in as:
username
 * Dashboard
 * Publications
 * Account settings
 * Log out

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation



BOOKSHELF




Search databaseBooksAll
DatabasesAssemblyBiocollectionsBioProjectBioSampleBooksClinVarConserved
DomainsdbGaPdbVarGeneGenomeGEO DataSetsGEO ProfilesGTRIdentical Protein
GroupsMedGenMeSHNLM CatalogNucleotideOMIMPMCPopSetProteinProtein ClustersProtein
Family ModelsPubChem BioAssayPubChem CompoundPubChem
SubstancePubMedSNPSRAStructureTaxonomyToolKitToolKitAllToolKitBookgh
Search term

Search
 * Browse Titles
 * Advanced
 * Help
 * Disclaimer

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

Institute of Medicine (US) Committee on Smoking Cessation in Military and
Veteran Populations; Bondurant S, Wedge R, editors. Combating Tobacco Use in
Military and Veteran Populations. Washington (DC): National Academies Press
(US); 2009.


COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS.

Show details
Institute of Medicine (US) Committee on Smoking Cessation in Military and
Veteran Populations; Bondurant S, Wedge R, editors.
Washington (DC): National Academies Press (US); 2009.
 * Contents
 * Hardcopy Version at National Academies Press

Search term

< PrevNext >


4TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES

Preventing tobacco use and helping those who use it to quit can have long-term
benefits for individuals and for public health in general. State and federal
government agencies, health-care organizations, and other groups that promote
public health have developed and implemented tobacco control programs to help to
prevent or reduce tobacco use. The programs use taxation, restrictions,
mass-media campaigns, and effective and easily accessible behavioral counseling
and tobacco-cessation medications. They provide services to varied target
audiences, including young people, people with comorbid health problems, those
of diverse ethnicities and socioeconomic status, and women.

Evidence-based best practices for tobacco control have been widely promoted and
have succeeded in reducing tobacco use in the United States. The committee
recognizes, however, that identifying the best practices for specific and
diverse populations can be challenging. Reducing tobacco use faces special
challenges because tobacco products are legal and easy to acquire, highly
addictive, and heavily promoted by a tobacco industry that spends billions of
dollars a year to promote tobacco as part of the American culture (CDC, 2007a).
Creating a tobacco-free culture will depend on developing an environment that
encourages abstinence and makes many types of effective assistance and
encouragement accessible to diverse populations. Maintaining a tobacco-free
culture will require a sustainable infrastructure for comprehensive programs.

The application of evidence-based best practices for tobacco control in military
populations under the jurisdiction of the Department of Defense (DoD) is the
subject of Chapter 5; Chapter 6 addresses the same issues for the population of
veterans who use the Department of Veterans Affairs (VA) health-care system. The
committee believes that well-designed tobacco-control programs can influence
tobacco use by military personnel from the time they enter the military until
they leave the service and beyond. For military personnel who enter the VA
health system, these practices can also influence their tobacco use as veterans.

This chapter summarizes what is known about evidence-based best practices for
tobacco-control programs in the general population with an emphasis on program
components that are or could be most applicable to DoD and VA. The committee
hopes that by implementing these practices, DoD will be able to prevent or
reduce tobacco use by military personnel in all phases of their military
service—from the time they enter the military until they leave the service or
retire. Implementing these practices in VA may also reduce tobacco use in
veterans. As discussed in the next two chapters, DoD and VA already have in
place some of the components and practices, including the infrastructure and
regulatory authority, for an effective tobacco-control program; in these
instances the committee highlights how the departments can take advantage of
current policies and procedures to increase their effectiveness and reach and
also emphasizes where additional opportunities for tobacco control may reside.

Go to:


COMPREHENSIVE TOBACCO-CONTROL PROGRAMS

Evidence supports the use of a comprehensive tobacco-control program to reduce
tobacco consumption (Warner, 2007). A comprehensive approach to tobacco control
results in changes that affect the entire population, from the individual to the
societal level, by addressing the political, social, cultural, economic, and
environmental factors that support the use or nonuse of tobacco. Tobacco-control
programs reduce tobacco use at the population level by creating tobacco-free
indoor and outdoor areas, restricting young people’s access to tobacco products,
limiting tobacco advertising, having sustained counteradvertising campaigns,
increasing the cost of tobacco products, and providing easily accessible
tobacco-cessation products and services. Comprehensive tobacco-control programs
for military and veteran populations could help to do the following:

 * Foster a tobacco-free culture and denormalize tobacco use in military
   personnel and veterans.
 * Prevent the initiation of tobacco use by military personnel and their
   dependents during active duty and prevent relapse to tobacco use by military
   personnel and veterans who have quit.
 * Eliminate exposure of military and veteran personnel, family, co-workers, and
   others to secondhand smoke and its health consequences.
 * Support and promote tobacco cessation in military personnel, veterans, and
   their dependents.
 * Identify and eliminate disparities in tobacco treatment between the general
   population and military personnel or veterans in high-risk populations,
   including those with mental-health disorders.

Numerous entities have developed and implemented successful tobacco-control
programs. They include the federal government, specifically the National Cancer
Institute (NCI) and the Centers for Disease Control and Prevention (CDC);
various state governments; and commercial entities, such as Kaiser Permanente.
California has been a leader in establishing a comprehensive tobacco-control
program. Its program began in 1988 and adult tobacco use in California decreased
from 22.7% to 13.3% by 2006 (CDC, 2007a). California served as the model for
Massachusetts, which also developed a comprehensive program that resulted in a
decrease in statewide tobacco consumption. California and Massachusetts were
among the states that participated in the NCI American Stop Smoking Intervention
Study (ASSIST) program and evaluation. See Appendix A for a detailed discussion
of effective federal and state comprehensive tobacco-control programs.

Comprehensive programs can provide the societal and organizational framework for
reducing tobacco use in a population. Although such programs and policies may
prevent young people from initiating tobacco use and reduce the exposure of the
general population to secondhand smoke, a comprehensive program must also be
applicable to people who are already using tobacco regularly. Interventions are
needed to assist individual tobacco users, each of whom has a particular level
of addiction, particular reasons for smoking and for trying to stop, and
possibly concurrent health problems that affect their interest in and ability to
quit.

The process of creating tobacco-free environments should include educational
campaigns to prepare the target communities and build support for the measures
to be implemented. Once public support has been garnered, government and
political support of tobacco-free policies must remain strong, including
enforcement and sanctions for violations to ensure compliance (WHO, 2008).

The comprehensive tobacco-control programs noted above and in Appendix A vary in
target audience, size, funding sources, and bureaucratic oversight, but they
share several key components that contribute to their success: the development
and implementation of a strategic plan, dynamic leadership, effective and
enforceable policies, communication interventions, adequate resources,
appropriate therapeutic interventions (including those for special populations),
surveillance, evaluation of effectiveness with feedback, and management
capability to bring about change.

CDC’s (2007a) Best Practices for Comprehensive Tobacco Control Programs and its
Tobacco: Guide to Community Preventive Services (CDC, 2009a) synthesize
evidence-based practices into a multidimensional approach to public-health goals
across the entire tobacco-use continuum from prevention to cessation. A
combination of educational, clinical, and social strategies are recommended to
denormalize tobacco use. In CDC’s Best Practices, the strategies are in five
broad categories: (1) policies (for example, establishing tobacco-free
facilities and increasing the price of tobacco products); (2) health promotion
and education, including communication interventions (for example, mass-media
antitobacco advertising campaigns and such innovative approaches as text
messaging); (3) cessation interventions (for example, health-care-system–based
cessation counseling and medications and population-based services, such as
toll-free quitlines); (4) surveillance and evaluation; and (5)
capacity-building, including administration and management procedures. Direct
interventions for individuals, including health promotion and cessation, are
important, but the other evidence-based strategies—such as price increases,
reduced access to tobacco products, tobacco-free environments, advertising bans,
and changes in social perceptions—all contribute to reducing tobacco use and
ultimately encourage tobacco cessation (CDC, 2007a). Together, those key
components can provide DoD and VA with the capacity to develop and implement a
tobacco-control program that can achieve the five categories of strategies cited
above. DoD and VA have established comprehensive programs for other
public-health goals, such as weight management.

In the following sections, the committee describes the key components of
comprehensive tobacco-control programs. The committee believes that those key
components, if implemented by DoD and VA, could help reduce and prevent tobacco
use in their populations. The committee stresses that in addition to the
components discussed in this chapter, a comprehensive program in either DoD or
VA must begin with strong leadership that has the political and administrative
will to effect changes in how the departments conduct their tobacco-control
activities. An engaged leadership is also critical for implementing each of the
program components presented in Table 4-1. Comprehensive tobacco-control
programs with committed leadership and adequate resources are most effective in
preventing tobacco use and helping tobacco users to quit. The sections below
summarize the best evidence to support the use of the key program components and
in the boxes provide a brief introduction to possible applications in military
and veteran populations. The applications are discussed in greater detail in
Chapters 5 (DoD) and 6 (VA) along with policy and program barriers to wider use
of the key components.

TABLE 4-1

Key Components of Tobacco Control Programs.

DoD and VA already have some of the policy and infrastructure capabilities,
similar to those of states, that would allow them to develop and implement
comprehensive tobacco-control programs. The capabilities include leadership, the
ability to develop and enforce policies that affect all their constituents, and
resources that may be dedicated for specific purposes such as tobacco control.

Go to:


COMMUNICATION INTERVENTIONS

No tobacco-control intervention will be effective if it does not reach its
target audience: tobacco users. Communication interventions must not only
educate tobacco users and others about the hazards of tobacco and provide
information on how to access tobacco prevention and cessation services but,
first and foremost, must focus on changing the social norm of tobacco use. CDC
(2007a) states that “an effective state health communication should deliver
strategic, culturally appropriate, and high-impact messages in a sustained,
adequately funded campaign integrated into the overall state tobacco program
effort.” There are many reasons why tobacco users do not seek assistance when
quitting tobacco use, one of which may be a lack of knowledge that such
assistance is available. Several approaches may be used to increase tobacco
users’ awareness of, and interest in, tobacco-cessation interventions. One
communication approach is a mass-media campaign that alerts consumers about the
hazards of tobacco use and informs them that assistance is available to help
them quit. Product advertising can also alert consumers to tobacco-cessation
medications or other programs, such as quitlines. In contrast, the advertising
of tobacco products, particularly to young adults, has an enormous effect on
increasing demand for tobacco products.


ADVERTISING AND PROMOTIONS

The tobacco industry has long understood that mass-media advertising and
communication shape attitudes toward its brand images. As a result, cigarettes
are one of the most heavily advertised US products, with advertising and
promotion expenditures from 1940 to 2005 totaling $250 billion (in 2006 dollars)
and reaching $13.5 billion in 2005 alone (in 2006 dollars) (NCI, 2008). Since
the 1971 federal ban on television advertising of cigarettes and similar
restrictions on the nature of advertising linked to the 1998 Master Settlement
Agreement,1 the rate of smoking among people 18–24 years old has steadily
declined (CDC, 2007b), but it continues to be a public-health problem as young
people initiate tobacco use.

Reports such as the Institute of Medicine’s (IOM’s) Ending the Tobacco Problem:
Blueprint for the Nation (IOM, 2007), NCI’s The Role of the Media in Promoting
and Reducing Tobacco Use (NCI, 2008), CDC’s Best Practices for Comprehensive
Tobacco Control Programs (CDC, 2007a) and Tobacco: Guide to Community Preventive
Services (CDC, 2009a), and other studies (Saffer and Chaloupka, 2000) have
summarized a large body of literature on the effect of advertising on smoking
behavior and concluded that the prevailing scientific opinion indicated a causal
relationship between tobacco advertising and increased tobacco use. Because of
the strong effect of visual advertising on tobacco use, the IOM report
recommended that all visual advertisements for tobacco products be limited to
black-and-white, text-only formats. It also recommended prohibiting all
advertising by tobacco companies to minors, regardless of purpose, inasmuch as
even ostensibly discouraging advertisements and information-gathering campaigns,
such as surveys, may encourage tobacco use.

A recent study by Slater et al. (2007) found that advertising and price
promotion contribute to the initiation of smoking (moving from one-time
experimenters, or “puffers,” to other, more established categories of smokers).
The tobacco industry has also strategically targeted such populations as young
men and women and racial and ethnic groups. It uses sophisticated advertising to
appeal to the demographic and lifestyle characteristics of targeted audiences,
such as social acceptance, athleticism, rewarded risk-taking, and masculinity or
femininity (NCI, 2008). The committee notes that all of those characteristics
are likely to appeal to a military audience that consists of young men and women
being asked to undertake arduous duties and possibly risk their lives. Such
conclusions have led the World Health Organization (WHO) Framework Convention on
Tobacco Control (FCTC) to call on nations to “undertake a comprehensive ban on
all tobacco advertising, promotion and sponsorship … in accordance with its
constitution or constitutional principles,” but the United States has yet to
ratify the FCTC.2 Studies of comprehensive tobacco-advertising bans in several
countries indicate that they have reduced consumption (Saffer and Chaloupka,
2000).

The tobacco industry has changed its approach to tobacco promotion in response
to changing regulatory environments. After implementation of the ban on
television advertising, the tobacco industry used outdoor advertising,
magazines, point-of-sale advertising, and direct mail to appeal to consumers
(IOM, 2007). Point-of-sale advertising is associated with encouraging youth to
try smoking (CDC, 2007a). With prices increasing as a result of higher state and
federal taxes, the tobacco industry now spends $10 billion a year to provide
price-discount promotions to merchants (Pierce, 2007). Price promotions play an
important role in tobacco consumption because they counteract the effect of
increased cigarette prices.

The military services have enacted regulations that restrict or ban the
advertising of tobacco products on military installations. VA does not have
venues that advertise or sell tobacco products.

The independent military newspaper, Stars and Stripes, does not carry tobacco
advertising, but installation papers that are commercially owned may have such
advertising. VA does not have advertising in its newsletters.


COUNTERADVERTISING AND PUBLIC EDUCATION

Offsetting the tobacco industry’s mass-media influence through
counteradvertising is critical for achieving a nonsmoking public norm, including
the military or, indeed, any segment of society (CDC, 2007a, 2009a; IOM, 2007;
NCI, 2008). Strategies to counter advertising by the tobacco industry include
advertising bans and counteradvertising with the goal of preventing smoking
initiation, promoting cessation, and changing social norms associated with
tobacco use (CDC, 2007a). Strategies to change social norms include tailored,
engaging messages for specific audiences. Mass-media campaigns involving
television, radio, newspapers, billboards, posters, leaflets, and booklets that
deglamorize and denormalize tobacco use have been used successfully as
tobacco-control interventions alone and in combination with other program
components, such as increased prices for tobacco products and community-based
education programs (CDC, 2007a; IOM, 2007; NCI, 2008). Newer communication tools
to disseminate counteradvertising information include Web-based advertising,
text messaging to personal communication devices, and on-line Web logs (blogs)
(CDC, 2007a). Media campaigns should have sufficient reach, frequency, and
duration (at least 6 months and preferably 18–24 months) to influence behavior
(CDC, 2007a).

Many of the mass-media counteradvertising campaigns have focused on preventing
or reducing tobacco use by youth and reducing exposure to secondhand smoke (CDC,
2009a). The American Legacy Foundation’s “truth©” antitobacco campaign and the
Phillip Morris Company’s “Think. Don’t Smoke” campaign are aimed at adolescents.
The American Legacy Foundation’s campaign, particularly its negative
advertising, was found to be effective in encouraging antitobacco sentiments in
adolescents and in reducing tobacco-use initiation among youth (Farrelly et al.,
2009), but the Phillip Morris campaign was not (Apollonio and Malone, 2009). NCI
(2008) found that, in general, tobacco-industry youth smoking prevention
campaigns have been ineffective and may even have resulted in increased smoking
among some young people. CDC (2009a) found that the most effective mass-media
education campaigns for decreasing the number of young people and adults who use
tobacco, combined with other interventions, lasted at least 2 years. The
committee notes that most people entering the military are in their late teens,
therefore, antitobacco messages should be directed at those young adults,
particularly young men, who have the highest rates of tobacco use.

There is strong evidence that public-education campaigns via broadcast and print
media also increase tobacco cessation among both adults and youth (CDC, 2009a).
Mass-media campaigns, when combined with such other interventions as the
distribution of self-help materials, increased tobacco cessation by about 2
additional quitters per 100 people. Tobacco consumption was reduced by about
13%, and tobacco-use prevalence was reduced by about 3 people per 100 tobacco
users (CDC, 2009a). Antitobacco messages that included information about
accessing telephone quitlines significantly increased the number of people who
called them. The evidence of the effectiveness of mass-media education cessation
series (that is, broadcast instructional segments designed to recruit, inform,
and motivate tobacco users to try quitting and to succeed) and for cessation
contests is still insufficient (CDC, 2009a).

The mass media, particularly the news media, have been underused by
tobacco-control advocates; however, the use of counteradvertising is effective
in reducing smoking among targeted adult and youth populations (CDC, 2007a; IOM,
2007; NCI, 2008). Wakefield et al. (2008) found that antitobacco mass-media
campaigns were effective in reducing tobacco use if broadcast at regular
intervals. Strong negative messages about the health risks posed by tobacco use
are more effective than more neutral or humorous messages or negative messages
about the tobacco industry (NCI, 2008). Although the evaluation of mass-media
programs comes from heterogeneous studies of varied methodologic quality,
meta-analyses demonstrate that mass-media counteradvertising campaigns can be
effective in reducing smoking consumption and prevalence (Bala et al., 2008).

DoD has a strong mass-media presence both in recruiting and in promoting healthy
lifestyles among its military personnel. Such promotional activities can be
adapted to promote antitobacco messages. VA can access mass-media outlets—such
as newsletters, motivational materials for waiting rooms, and Web sites—to
encourage veterans to quit tobacco.

DoD has initiated a militarywide antitobacco campaign with the slogan “Quit
Tobacco. Make Everyone Proud” that targets military personnel 18–25 years old
and includes an interactive Web site.

Finding: Counteradvertising programs are effective in preventing tobacco
initiation and in increasing tobacco cessation in target audiences.

Go to:


TOBACCO-USE RESTRICTIONS

Tobacco-free policies have been shown to increase tobacco cessation (CDC, 2009a;
US Surgeon General, 2004). Policies and regulations restricting tobacco use
adopted outside the DoD and VA systems are described below. They point to
similar opportunities for DoD and VA to restrict tobacco use by their target
audiences. Such policies and regulations have the potential to affect tobacco
use by military personnel and their dependents, civilian employees on military
installations, and veterans.

Tobacco-use restrictions are most effective when they apply to a variety of
public and private settings. Smoking prevalence and annual per-capita
consumption are 4% and 14 packs higher, respectively, and quitting rates are 6%
lower in states without comprehensive clean-indoor-air laws (Bonta, 2007; Emont
et al., 1992). The effects on secondhand smoke, quitting rates, and consumption
are maximized when smoking is banned as opposed to restricted to designated
areas (Heironimus, 1992; Pizacani et al., 2003). It has been estimated that
clean-air laws can reduce smoking prevalence by 10% (Levy and Friend, 2003).
Smoking bans in public places and workplaces are generally supported by the
public, including smokers (Fong et al., 2006; RTI International, 2005; WHO,
2008).

Enforcement of tobacco-free laws and policies is critical for their
effectiveness. Comprehensive legislation establishing clear penalties for
violations needs to be paired with effective enforcement policies for smoking
restrictions to advance tobacco control. Fining the owners of establishments
where violations occur is the most effective way to enforce the law (WHO, 2008).
Those measures can be combined with penalties for tobacco users who break the
rules.


COMMUNITY SETTINGS

Community settings for tobacco restrictions include private and public
workplaces, restaurants and bars, and hospitals. By January 4, 2009, 23 states
had laws calling for 100% smoke-free public and private workplaces, 23 states
had laws calling for 100% smoke-free bars, and 28 states had laws calling for
100% smoke-free restaurants (ANRF, 2009a). As a result, over 70% of the US
population is protected by some type of 100% smoke-free law, and nearly 40% by a
law calling for 100% smoke-free workplaces, restaurants, or bars (ANRF, 2009b).
Many states and municipalities also have laws restricting smoking in prisons,
lodgings, malls, and hospitals and health clinics. In 1997, Executive Order
13058 required that all federal buildings be smoke-free. Those measures have
traditionally been framed as involving worker-safety issues, and this approach
has helped to build public support for smoking bans (WHO, 2008).

Research on the effects of workplace tobacco restrictions demonstrates that they
are effective in reducing exposure of all workers to secondhand smoke and in
promoting cessation by workers who smoke (Bonta, 2007; Brownson et al., 1995,
1997; Fichtenberg and Glantz, 2002; Fong et al., 2006; Glasgow et al., 1997;
Moskowitz et al., 2000). Furthermore, results of several studies suggest that
smoke-free legislation is associated with decreases in hospital admissions for
acute coronary problems (Pell et al., 2008; Sargent et al., 2004).

 * DoD Instruction 1010.15 states that DoD facilities must be smoke-free to
   protect civilian and military health, although there are areas that are
   exempt.
 * Veterans Health Administration Directive 2008-052 establishes a smoke-free
   policy for VA health-care facilities; it has effectively eliminated indoor
   smoking areas for patients and staff, although designated outdoor smoking
   areas remain.

In 1992, the Joint Commission on Accreditation of Healthcare Organizations (now
the Joint Commission) issued a mandate that all accredited hospitals except
psychiatric hospitals be smoke-free; a year later, 96% of hospitals in the
United States were complying with the mandate (Fee and Brown, 2004). At least 2
national hospitals and 1,594 local and state hospitals, health-care systems, and
clinics had adopted 100% smoke-free campus-grounds policies as of 2008 (ANRF,
2009c). Implementation of the Joint Commission’s smoke-free standards, although
initially aimed at protecting patients, has also had a favorable effect on the
smoking behavior of hospital workers (Fee and Brown, 2004; Longo et al., 1996,
2001).

There is some resistance to the adoption of tobacco-free restrictions in
psychiatric health-care settings. Although it has been argued that smoking helps
patients to manage their symptoms and that banning smoking may exacerbate mental
illness (Stage et al., 1996), evidence indicates that smoking restrictions can
be implemented in psychiatric health-care settings without adverse effects
(Alam, 2007; Prochaska et al., 2008; Ryabik et al., 1994; Smith et al., 1999;
Ziedonis et al., 2008).

Fears that smoking bans in restaurants and bars would translate into a loss of
revenues have been contested by research showing that such policies have no
negative economic effect on these establishments (Bartosch and Pope, 2002; Fong
et al., 2006; Howell, 2005; Huang and McCusker, 2004; Rabius et al., 2007; RTI
International, 2004; Scollo et al., 2003; Siegel, 1992; WHO, 2008).

Some employers, including WHO, have adopted policies that prohibit any tobacco
use by employees, including when they are not working. Those policies target the
individual rather than a geographic location. Numerous police departments have
implemented policies that prohibit smoking as a condition of employment (Holly
Deal, National Fraternal Order of Police, personal communication, November 20,
2008). Both firefighters and police officers are required to be smoke-free as a
condition of employment in Massachusetts. The effectiveness of policies that
prohibit employment of smokers has not been evaluated, and Houle and Siegel
(2009) note that although such policies may help tobacco users to quit, they may
also exacerbate economic disadvantages for people who smoke and are unable to
find employment, their families, the surrounding community, and the larger
society. They may also intensify stigma and its associated ill effects
(Schroeder, 2008; Stuber et al., 2008). “No-smoker” policies are controversial
because they raise concerns unrelated to health, including personal privacy and
employment discrimination (ACLU, 1998; Chapman, 2005; Gray, 2005; Warner, 1994).
More than half the states have statutes that prohibit employers from
discriminating in hiring, firing, or conditions of employment on the basis of an
employee’s lawful behavior outside work, including some that specify tobacco use
(Malouff et al., 1993). The committee acknowledges that such actions may have
unintended consequences that need further exploration.

Neither DoD nor VA requires that employees be tobacco-free. Both departments
mandate smoke-free facilities in compliance with Executive Order 13058, which
requires federal buildings to be smoke-free.


EDUCATIONAL SETTINGS

In 2003, about half the public universities in the United States had banned
smoking in all residence halls and dormitories and within a specified distance
from building entrances (Halperin and Rigotti, 2003). By January 2009, 260
colleges and universities had enacted 100% smoke-free–campus policies with no
exemptions (ANRF, 2009d). Moreover, 68% of the public universities do not sell
tobacco products, and about half have written policies banning tobacco
advertising on campus (Halperin and Rigotti, 2003). Smoking prevalence is lower
among students living in smoke-free college housing than in housing without such
bans (Wechsler et al., 2001). Furthermore, nonsmoking students living in
smoke-free college housing are less likely to initiate smoking (Wechsler et al.,
2001).

DoD is in the unique position of already requiring that new recruits into all
the services be tobacco-free during basic training; the Air Force also mandates
that trainees be tobacco-free during some technical training.

All military services require that recruits not use tobacco during basic
military training. The military service academies do not require that students
be tobacco-free.


PRIVATE RESIDENCES AND VEHICLES

There has been a marked increase in personal smoking bans in the home over the
last few decades. Smoking bans in the home are associated with lower exposure of
adult and child residents to secondhand smoke (Biener et al., 1997; Brownson et
al., 1995; Martinez-Donate et al., 2003, 2007; Spencer et al., 2005; Wakefield
et al., 2000a), and they encourage smoking cessation (Farkas et al., 2000; Longo
et al., 2001; Siahpush et al., 2003; Wakefield et al., 2000b), reduce smoking
levels, and increase the average time to the first cigarette of the day among
continuing smokers (Borland et al., 2006; Pizacani et al., 2004). Home smoking
bans are also effective in reducing smoking initiation, promoting cessation, and
lowering cigarette consumption by adolescents and young adults (Borland et al.,
2006; Clark et al., 2006a; Farkas et al., 2000; Hill et al., 2005; Lotrean et
al., 2005; NIH, 2006; Thomson et al., 2005; Wakefield et al., 2000b). The
potential effect of home smoking bans on smoking prevalence has been estimated
to surpass that of smoke-free workplaces (Bonta, 2007). Some municipalities have
taken steps toward promoting smoke-free housing (Older Americans Report, 2005;
Smokefree Apartment House Registry, 2007). As noted above, the concept of
smoke-free housing has already been implemented by the hospitality industry.
Over 8,300 lodgings in the United States were smoke-free in 2008, and 23 states
and over 500 municipalities had laws specifying the minimum percentage of
smoke-free rooms in hotels and motels (ANRF, 2009e; Stoller, 2008).

There is evidence that the increasing prevalence of smoking restrictions in
public places has translated into smokers and nonsmokers adopting smoking bans
in their cars. A 2002–2003 survey indicated that 57.1% of US smokers do not
smoke in their cars when nonsmokers are present (Borland et al., 2006). Several
states and jurisdictions have adopted legislation to ban or limit smoking in
private vehicles while children are present (American Lung Association, 2009;
IOM, 2007; OTRU, 2006). In California, 85% of daily smokers support a ban on
smoking in cars when children are present (Al-Delaimy et al., 2008). In a review
of public attitudes toward laws for smoke-free private vehicles when children
are present, more than 77% of smokers in California, New Zealand, and Australia
supported such laws (Thomson and Wilson, 2009).

DoD has no requirement for designated smoke-free housing for military personnel
and their families.


OUTDOOR SPACES

An increasing number of outdoor venues (such as parks and beaches) are becoming
smoke-free, especially in states with strong tobacco-control efforts, such as
California. By January 2009, Hawaii and Iowa prohibited smoking in outdoor
dining areas, and 149 municipalities had enacted laws for 100% smoke-free
outdoor dining areas (ANRF, 2009f). Moreover, 76 municipalities and Puerto Rico
had smoke-free–beach laws (ANRF, 2009g), and a total of 399 municipalities
required all city parks or specifically named city parks to be smoke-free (ANRF,
2009h). Aside from potential protective effects for nonsmokers, smoking bans in
outdoor spaces contribute to the denormalization of tobacco use, reduce smoking
rates, and prevent future initiation of smoking by children and adolescents.
More important, there is evidence of strong public support in California for
smoking bans in such outdoor public spaces as children’s playgrounds, parks,
beaches, golf courses, and sports stadiums (Gilpin et al., 2004).

 * DoD has no requirement for smoke-free outdoor areas. The Air Force does not
   permit personnel to smoke while walking in uniform, and this ban includes
   outdoor areas.
 * VA cannot have smoke-free campuses because of the congressional requirement
   that there be outdoor smoking areas for patients.

Several interactive mechanisms might explain the effectiveness of smoking
restrictions to achieve tobacco control (Hovell et al., 2002). Restrictions
legitimize the right of nonsmokers not to be exposed to secondhand smoke and
establish explicit economic, legal, and social penalties for people who violate
them. Smoking bans also reduce the number of areas where smoking is possible,
making smoking more inconvenient. By requiring smokers to leave other activities
and go to designated smoking areas, smoking bans increase the cost of smoking
and result in lower levels of smoking and more cessation attempts by those who
continue to smoke. Furthermore, restrictions limiting smoking to fewer and more
specific outside areas reduce exposure to smoking social models and can
contribute to the prevention of smoking initiation by young people and the
prevention of relapse by former smokers. Limits on where and when smoking takes
place, decreased exposure to smoking models, and changes in the social function
of smoking all work to denormalize tobacco use and reduce the glamour
traditionally associated with it. In combination, the legal, economic, and
social contingencies established by smoking restrictions change social
sentiments regarding smoking and secondhand smoke, transform public perceptions
of tobacco, and ultimately reduce smoking at the population level (Hovell et
al., 2002).

Finding: Tobacco-free policies have been effective in increasing tobacco
cessation among youth and adults. Workplaces, including medical facilities,
restaurants, and hotels; colleges and universities; parks and recreational
areas; and even private residences and vehicles have implemented tobacco-free
policies.

Go to:


TOBACCO RETAIL ENVIRONMENT

The tobacco retail environment can affect the sale and use of tobacco products
favorably or unfavorably. The retail environment encompasses the financial and
nonfinancial costs of tobacco products, the accessibility of tobacco products
(access restrictions based on age or through physical barriers at the point of
purchase), and the promotion of tobacco products at the point of sale and
through advertising in periodicals, promotional events, coupons, and other
means. Increased tobacco costs and restricted access to the products are
associated with reduced consumption and increased cessation (CDC, 2009a). As
tobacco restrictions have increased along some dimensions, such as cigarette
taxes and smoke-free legislation, manufacturers have responded with increasingly
innovative tobacco products, particularly varieties of smokeless tobacco. As
elaborated below, tobacco prices remain among the most effective public-policy
levers available both to reduce tobacco use and to fund tobacco-control efforts,
such as counteradvertising.


TOBACCO PRICES AND TAXES

Higher prices reduce tobacco consumption by affecting initiation (Slater et al.,
2007), cessation (IOM, 2007), and the intensity of smoking (IOM, 2007). Research
has shown that the use of taxes to combat tobacco consumption is one of the most
effective tobacco-control policies (Warner, 2007). Tobacco prices are usually
raised through increases in state excise taxes; however, in 2009, the federal
government increased the federal tax3 on cigarettes from $0.39 to $1.0066 per
pack to pay for the expanded State Children’s Health Insurance Program (NCI,
2009). The most relevant evidence on tobacco prices and taxes that is applicable
to DoD is summarized below. DoD sells tobacco products at its commissaries and
exchanges, typically below the prices of the same products sold commercially
outside military installations. VA no longer sells tobacco products in its
canteens or at its facilities.

Overwhelming evidence demonstrates that people are less likely to smoke and to
smoke fewer cigarettes when cigarette prices are high (Chaloupka and Warner,
2000; Gallet and List, 2003; IOM, 2007; NIH, 2006). Econometric analyses show
consistently that a 10% rise in cigarette prices reduces consumption by 3–5%
(Chaloupka, 1999; Chaloupka and Warner, 2000; Gallet and List, 2003). Given high
rates of smoking relapse and initiation in military personnel after basic
training (Klesges et al., 2001, 2006), the evidence on the smoking behavior of
young adults is particularly relevant. For example, one study suggests that
older youths (17–20 years old) are more responsive to price than younger youths
(Gruber and Zinman, 2001). A mounting body of rigorous evidence indicates that
smoking behavior is more responsive to price among young adults than among older
adults (Chaloupka and Warner, 2000; Chaloupka and Wechsler, 1997; Gruber and
Zinman, 2001). In particular, Harris and Chan (1999) demonstrate declining
responsiveness to price with age among people 15–29 years old. Recent research
also demonstrates that the effect of price on youth and young-adult smoking
occurs both directly in response to price and indirectly through response to the
lower prevalence of smoking among peers (Powell et al., 2005).

Smoking initiation and tobacco use are more common among junior enlisted
military personnel. Those personnel tend to be young adults who are more
susceptible to tobacco pricing than older adults. Thus, tobacco-price increases
in DoD commissaries and exchanges could result in marked changes in tobacco use
in the military populations that use the most tobacco.

Results of several studies suggest that price increases facilitate smoking
cessation. Adult smokers are more likely to attempt cessation when faced with
increasing prices (Levy et al., 2005a; Reed et al., 2008), and higher prices
facilitate successful smoking cessation among young adults (Tauras, 2004).
However, some evidence shows that recent price increases may be less likely to
affect smoking prevalence even though higher prices can lower the intensity of
smoking (Sheu et al., 2004). That is true particularly in such populations as
low-income people and pregnant women (Franks et al., 2007; Levy and Meara,
2006).

The evidence on whether price affects smoking initiation is somewhat mixed: some
studies show that price does not affect whether youths have “ever smoked a
cigarette,” and others show that price influences the initiation of smoking (Jha
et al., 2006; Levy et al., 2005b; Thomas et al., 2008). The discrepancy can be
reconciled when viewed in the context of research that distinguishes
experimentation from established smoking. In a study of adolescents that
distinguished isolated experimentation (moving from nonsmoker to having ever
smoked “even a puff”) from more established smoking patterns, price had a
significant effect on initiation (Emery et al., 2001). In the aggregate, the
evidence is strong that higher prices lower the consumption of cigarettes along
all dimensions: initiation, cessation, and intensity.

One concern with raising local or state taxes is that people can evade higher
prices by purchasing tobacco through the mail, through the Internet, or by using
coupons (Hyland et al., 2004). Ribisl et al. (2007) note that the number of
Internet vendors and sales of tobacco products are increasing, particularly in
states with high excise taxes, possibly offsetting some of the reduction in
tobacco consumption associated with higher taxes (Ribisl et al., 2007). However,
studies of tobacco smuggling, usually focused on interstate or cross-country
smuggling, suggest that higher prices reduce the effect of smoking even in the
presence of opportunities for smuggling (Chaloupka and Warner, 2000; IOM, 2007).

 * Military exchanges and commissaries sell tobacco products at a discount
   compared with civilian retail outlets.
 * VA no longer sells tobacco products at its facilities.


ACCESS TO TOBACCO PRODUCTS

The effectiveness of barriers to the purchase of cigarettes on adolescent
smoking behavior is supported by reports from IOM (2007) and NCI (2005). The
2007 IOM report Ending the Tobacco Problem: Blueprint for the Nation called for
licensing of retail sellers of tobacco. Such licensing prohibits self-service
sales of cigarettes by unlicensed retailers. Although this licensing policy
targets youth, such restrictions could apply to a broader population. However, a
recent study examining stores that required clerk assistance to obtain tobacco
products showed no significant effect of licensing on smoking behavior among
youth (Slater et al., 2007).

There are many reasons to believe that small measures, such as requiring clerk
assistance or requiring people to make an extra effort to purchase cigarettes in
commissaries and exchanges, may work to reduce smoking. As described in Chapter
3, a robust literature in behavioral economics suggests that people can change
their behavior dramatically in response to relatively small changes in their
environment.

Conversely, the number of tobacco products or other nicotine-delivery products
that can be used in tobacco-free areas is increasing. There are now several
varieties of smokeless cigarettes that manufacturers advertise can be legally
used in no-smoking areas because they do not emit smoke, but they still deliver
a high dose of nicotine. Those products include snus (a moist tobacco powder for
oral use), “dissolving” nicotine, and smokeless or electronic cigarettes, all of
which allow smokers to maintain their nicotine concentrations in situations
where they are unable to smoke.

Surveys of military personnel indicate that the use of smokeless tobacco is on
the rise, particularly among deployed personnel (DoD, 2006). Although some
military installations restrict access to tobacco products in commissaries and
exchanges, others promote such products with large, prominent displays—so-called
power walls—near checkout counters.

Finding: Increasing the price of tobacco products is one of the most effective
interventions to prevent tobacco use and promote tobacco cessation. The funds
generated from increased prices could be used to expand other tobacco-control
efforts.

Go to:


TOBACCO-CESSATION INTERVENTIONS

The vast majority of smokers (80%) report that they want to quit, and over half
of smokers will make a serious attempt to quit in any given year (Kaiser Family
Foundation, 2009), but only about 4–7% succeed in quitting in any one try (Fiore
et al., 2008). Studies show that the rate and duration of tobacco abstinence are
increased, generally doubled, when cessation treatments are used (CDC, 2007a;
Fiore and Jaen, 2008; Fiore et al., 2008). National surveys, however, indicate
disappointingly low rates of use of tobacco-cessation treatment by the general
public. For example, the 2005 National Health Interview Survey found that less
than 5% of smokers who made a serious attempt to quit used both behavioral and
pharmacologic treatment (Curry et al., 2007). A similar pattern is evident in
the 2003 Current Population Survey (Shiffman et al., 2008).

In addition to the evidence-based interventions discussed below, the committee
considered harm reduction as a possible intervention for tobacco use by military
and veteran populations. A previous IOM report (2001) found that there was
insufficient evidence on the health effects of smokeless or modified tobacco
products, although the International Agency for Research on Cancer has found
that smokeless tobacco use causes cancer (IARC, 2007). The IOM report also
recommended that “harm reduction be implemented as a component of a
comprehensive national tobacco control program that emphasizes
abstinence-oriented prevention and treatment.” A recent strategic dialogue
reached the conclusion that “significant tobacco harm reduction can be achieved
over the long term only in a world where virtually no one uses combustible
tobacco products” (Zeller et al., 2009). The evidence base on smokeless-tobacco
products is not sufficiently robust to determine what health hazards other than
cancer and periodontal disease are associated with smokeless or modified tobacco
products. Furthermore, the committee is concerned that such products may serve
as starters or supplements for the use of smoked tobacco products. This dual use
is a substantial concern as demonstrated by the number of military personnel who
use both (see the section on dual use in Chapter 5). The committee has
insufficient evidence to make any recommendations with respect to the use of
smokeless tobacco as an alternative to smoked tobacco. There is an evidence base
that supports the use of nicotine-replacement therapies (NRTs) on an extended
basis as a form of harm reduction if a person is trying to quit or has made a
quit effort and is sustaining abstinence. The Public Health Service (PHS)
Clinical Practice Guideline—Treating Tobacco Use and Dependence: 2008 Update
(Fiore et al., 2008) indicates that prolonged use of NRTs (for more than 14
weeks) is effective in increasing abstinence.

In the sections below, the committee examines the evidence base on various
tobacco-cessation interventions, including medications and behavioral therapies.
It then identifies the most effective practices for providing those treatments
to the targeted audiences.


EVIDENCE-BASED INTERVENTIONS

Tobacco users today have access to a variety of evidence-based interventions
that, if used appropriately, can significantly increase the likelihood that they
will achieve long-term abstinence. There is abundant evidence on effective
tobacco-cessation interventions, and numerous groups have provided detailed and
consistent recommendations for individual-level interventions. For example, the
2008 PHS guideline (Fiore et al., 2008), the Task Force on Community Preventive
Services Recommendations Regarding Interventions to Reduce Tobacco Use and
Exposure to Environmental Tobacco Smoke (Hopkins, 2001), and the 2007 IOM report
Ending the Tobacco Problem: A Blueprint for the Nation all conclude that the
most effective way to achieve smoking cessation is to combine behavioral
interventions that include person-to-person treatment with Food and Drug
Administration (FDA)–approved pharmacologic treatments. Effective behavioral
interventions include brief advice and assistance from a health-care provider
during routine health-care visits, multisession outreach telephone counseling,
and face-to-face group and individual counseling. Although all those
interventions are effective, there is a dose–response relationship in behavioral
treatments: multisession intensive treatments achieve significantly higher quit
rates than minimal-contact interventions. The use of FDA-approved
tobacco-cessation medications, alone or in conjunction with behavioral
interventions, is effective in maintaining long-term abstinence.

BEHAVIORAL INTERVENTIONS

Behavioral interventions focus on providing tobacco users with specific skills
and supports to modify their tobacco use. Building from theoretical models of
the determinants of tobacco use and cessation, the interventions typically have
five key components: (1) self-monitoring, including systematic observation and
recording of behavior; (2) cognitive restructuring, which involves identifying
and altering thoughts and beliefs that may undermine quit efforts; (3)
goal-setting focused on specific, quantifiable, and reasonable short-term (such
as 1–2 weeks) and long-term (such as 6 months) goals; (4) problem-solving to
identify and cope with high-risk situations that may lead to relapse; and (5)
social support, seeking support from others and informing them of the types of
support desired (NRC, 2003). Those interventions can be offered in different
formats (such as face to face, over the telephone, and by computer) with
different numbers and lengths of contact. Meta-analyses show that even a
behavioral intervention contact as brief as 3 minutes improves the odds of
quitting by as much as 40% compared with no treatment. Abstinence rates increase
as the length of counseling sessions increases from minimal (under 3 minutes) to
longer than 10 minutes, as the number of sessions increases, and as the total
contact time increases from 1–3 minutes to 91–300 minutes; however, contact time
in excess of 300 minutes does not appear to increase abstinence rates (Fiore et
al., 2008).

TOBACCO-CESSATION MEDICATIONS

Seven medications have been approved by FDA for smoking cessation and are
recommended by the 2008 PHS guideline alone or in combination as first-line
medications (Fiore et al., 2008). The first-line medications include several
forms of NRTs—gum, lozenges, and patches are available over the counter, and
nasal sprays and inhalers are available by prescription—and bupropion
sustained-release (SR) and varenicline, which are available by prescription.
Each of these medications has been shown to increase the likelihood of smoking
cessation significantly (Fiore et al., 2008). Nicotine gum, patches, and
lozenges should be used for 6–14 weeks for both highly dependent and regular
smokers. In addition to recommending the use of the nicotine patch as a single
medication, the guideline recommends several medications in combination with it,
including nicotine gum or spray, bupropion SR, and inhaled nicotine. Kornitzer
et al. (1995) found a significant increase in abstinence rates in those who
added gum use to patch use. In an effort to assess the comparative effectiveness
of the FDA-approved medications, various cessation medications were compared to
the nicotine patch—the most commonly used cessation medication. The
meta-analysis identified two medication regiments that were more effective than
the nicotine patch: varenicline used alone and the combination of a long-term
nicotine patch with NRT gum or spray (Fiore et al., 2008). The guideline also
recommends two second-line medications, defined as medications that FDA has not
approved for tobacco-dependence treatment and about which there are more
concerns for potential side effects than in the case of first-line medications:
clonidine and nortriptyline.

Interactions between tobacco smoke and various medications have been identified
(Zevin and Benowitz, 1999), and clinicians should not only be aware of their
patients’ smoking status but also should monitor patients to ensure that their
medications are acting as prescribed. Because former smokers may relapse and
current smokers may decide to quit smoking, it is important to ascertain smoking
status at each office visit and to inform patients of the need to be aware of
possible changes in their response to any medication, whether prescription or
over the counter and whether used for tobacco cessation or for other conditions.

COMBINED BEHAVIORAL INTERVENTIONS AND MEDICATIONS

The guideline concludes that “the combination of counseling and medication is
more effective for smoking cessation than either intervention alone. Therefore,
whenever feasible and appropriate, both counseling and medication should be
provided to patients trying to quit smoking” (Fiore et al., 2008). A
meta-analysis of 9 studies showed a 70% increase in the likelihood of quitting
when medication was added to counseling alone, and a meta-analysis of 18 studies
showed a 40% increase in the likelihood of quitting when counseling was added to
medication alone (Fiore et al., 2008). With behavioral counseling alone, there
was a dose–response relationship between the number of counseling sessions and
rates of cessation. Two or more sessions significantly increased cessation
rates; the highest abstinence rates were observed with more than eight
counseling sessions (32.5% abstinence rate at 6 months). Furthermore, among
patients who used multiple tobacco-cessation medications in combination with
individual or group counseling, the cessation rates at 6 months increased with
the number of medications. Patients who continued to use medications at 6 months
had a greater abstinence rate than those who quit using them in less than 6
months (82% vs. 52%) (Steinberg et al., 2006).

OTHER INDIVIDUAL INTERVENTIONS

Although other tobacco-cessation interventions are available—such as self-help
materials, rapid smoking, acupuncture, and hypnosis—results are inconclusive
with regard to their effectiveness in helping tobacco users achieve long-term
abstinence. The 2008 PHS guideline states that rapid smoking (also called
aversive smoking) was more effective than no psychosocial counseling or therapy,
but it is not a recommended treatment (Fiore et al., 2008). A Cochrane review on
aversive smoking suggested that although it may be effective, more research was
needed (Hajek and Stead, 2001). Self-help materials, such as brochures and
videos, as either the only interventions or in combination with other
interventions, do not significantly increase abstinence rates (Fiore et al.,
2008). Acupuncture has also been assessed in both the guideline and a Cochrane
review; the Cochran review found a slight positive effect (White et al., 2006),
but the guideline did not.

Neither the 2008 PHS guideline nor the Cochrane review found sufficient studies
to assess the use of hypnosis for tobacco-use cessation. One study in veterans
found that hypnosis increased abstinence at the 6-month and 12-month follow-ups
(Carmody et al., 2008).

The use of financial incentives for tobacco-use cessation has also been
explored. A Cochrane review found that the use of financial incentives increased
the rate of participation in smoking-cessation programs but did not increase
long-term abstinence rates (Cahill and Perera, 2008). Volpp et al. (2006)
studied the use of financial incentives in a group of veterans attending a VA
medical center, paying some smokers to attend smoking-cessation classes and for
remaining abstinent for 30 days. The financial incentives were useful for
enrolling veterans in the program, but the 6-month quit rates between the
incentive and no-incentive groups were not significantly different (p > 0.2).
However, in a later study of employees at a large company, financial incentives
for enrolling in and completing the smoking-cessation program and for
maintaining abstinence for up to 12 months resulted in significantly higher
abstinence rates compared with employees who did not receive such incentives (p
< 0.001) (Volpp et al., 2009).

Other interventions that have been studied include telling smokers about their
decreased lung function, or lung “age,” as a result of smoking; the
effectiveness of this intervention is uncertain (Kotz et al., 2008; Parkes et
al., 2008; Wilt et al., 2007).

Finding: Behavioral therapies are effective in increasing long-term tobacco
cessation. Cognitive strategies and problem-solving are particularly effective
when offered in a multisession format. Available over-the-counter and
prescription medications, when used appropriately, also improve the likelihood
of long-term tobacco cessation. A combination of the tobacco-cessation
pharmacotherapies and behavioral therapies described above is most effective in
achieving long-term tobacco cessation. Other interventions—such as hypnosis,
acupuncture, and financial incentives—have been assessed in a few studies, but
there is insufficient information on their effectiveness in achieving long-term
tobacco cessation.

Go to:


DELIVERY OF INTERVENTIONS

An integral aspect of tobacco control is generating a desire and willingness in
people to quit using tobacco. Motivation to quit may spring from encouragement
from family and friends, increased awareness of the hazards of tobacco use
because of public-education campaigns, in response to increased prices for
tobacco products or restrictions to areas where they may be used, or advice from
a healthcare provider. A comprehensive tobacco-control program ensures that many
sources of encouragement and support are made available.

Individual interventions to promote tobacco-use cessation are effective and can
help many people achieve and maintain abstinence, but if tobacco users are not
aware of the treatments, cannot easily access them, cannot afford them, or do
not use them when they are available, the effectiveness of the treatment is
irrelevant. All of these barriers may prevent tobacco users from seeking or
receiving treatment when they are motivated to quit. Inasmuch as most people who
make a quit attempt relapse within 48 hours, removing barriers to treatment is
paramount to maintaining abstinence. Provision of tobacco-cessation services can
occur in many settings and formats. Health-care providers can inform patients
about the health effects of tobacco use and counsel them about treatment options
for quitting, patients can be referred to proactive or reactive telephone
quitlines that provide cessation counseling and often medications, and patients
can access computer-based cessation programs that offer counseling, support, and
medications—although the evidence base on the latter is lacking. In this
section, the committee considers the evidence base on those approaches for
delivering tobacco-cessation services and the training needs of health-care
professionals that provide them.

The committee finds that a combination of in-person and other forms of
program-delivery formats are likely to be the most effective in reaching the
largest audience. A number of tobacco-cessation programs are used by health-care
organizations (see Box 4-1), but they have not all been evaluated formally for
their effectiveness.

BOX 4-1

Some Smoking-Cessation Programs. BecomeAnEx, sponsored by the National Alliance
for Tobacco Cessation (made up of the American Legacy Foundation and numerous
other groups, government and nongovernment), is a three-step plan. It allows for
personalizing (more...)


CLINICAL SETTINGS

The PHS Clinical Practice Guideline—Treating Tobacco Use and Dependence: 2008
Update outlines an evidence-based algorithm for addressing tobacco use and
dependence as part of routine health-care delivery (Fiore et al., 2008). Known
as the 5 A’s, it begins with a patient’s presentation in a health-care setting
and uses a decision tree to help the health-care provider to do the following:

1.

Ask all patients about tobacco use.

2.

Advise all current users to quit.

3.

Assess smokers’ willingness to quit.

4.

Assist smokers willing to quit by providing appropriate tobacco-dependence
treatments.

5.

Arrange follow-up for smokers who are making a quit attempt.

Using the 5 A’s should require only about 3 minutes of a clinician’s time with a
patient and other health professionals such as medical assistants can ask the
patient about their tobacco-use status and include the information on the
patient’s chart for the clinician. The guideline also includes specific
recommendations for program intensity, the type of counseling, and the inclusion
of medications. It states that in some clinical settings it may be more
effective to deliver the 5 A’s in a different format or order, such as Ask,
Advise, and Refer (Fiore et al., 2008). Schroeder and Cooper (2005) found that
many clinicians may not be aware of, or take the time to use, the 5 A’s;
therefore, the brief approach of Ask, Advise, and Refer patients to a quitline
or other counseling service may be more acceptable to some clinicians.

The guideline recognizes that not all patients are willing or able to quit and
provides interventions for these patients. Health-care providers can use
motivational interviewing for patients unwilling to quit and to encourage future
quit attempts, (Fiore et al., 2008; Rubak et al., 2005). The 5 R’s provide a
framework for conducting motivational interviewing:

1.

Relevance—encourage patient to explain why quitting is relevant to them.

2.

Risks—ask patients to explain adverse effects of tobacco use.

3.

Rewards—ask patients to identify the benefits of quitting.

4.

Roadblocks—determine the barriers to a patient’s quitting.

5.

Repetition—use a motivational intervention each time a patient is seen.

Feedback loops help providers to motivate tobacco users who are unwilling to
quit and encourage former users or newly quitting users to prevent relapse.
Although a meta-analysis (Burke et al., 2003; Butler et al., 1999) and a
randomized trail (Burke et al., 2003; Butler et al., 1999) suggest that
motivational interviewing does not increase long-term cessation rates, recent
analyses have found it to be effective in promoting quit attempts and abstinence
(Fiore et al., 2008; Soria et al., 2006; Van Schayck et al., 2008).

DoD and VA have developed the VA/DoD Clinical Practice Guideline for the
Management of Tobacco Use, modeled on the PHS guideline; it provides
evidence-based advice on many aspects of treatment of military personnel, their
dependents, and veterans for tobacco use.

A 1999–2000 survey of the use of the 5 A’s by health-care providers in 9
health-maintenance organizations found that 90% of the 2,325 smokers were asked
about their smoking status, 77% were advised to quit, 63% were assessed for
willingness to quit, 35% were offered self-help materials (assist), 41% were
offered or referred to classes or counseling (assist), 33% were offered
pharmacotherapy (assist), and 13% had follow-up arranged. Thus, it seems that
the health-care providers were more likely to advise smokers to quit than to
assist in cessation, or especially, to arrange cessation treatments, in spite of
the fact that all of the health plans in the study provided comprehensive
coverage for tobacco-cessation counseling and medications. Those who were
offered and used tobacco-cessation medications or counseling were significantly
more likely be abstinent for 30 days at 12 months than those who did not (odds
ratio [OR], 2.23; 95% confidence interval [CI], 1.56–3.20, and OR, 1.82; 95% CI,
1.16–2.86). The use of self-help materials alone (OR, 0.71; 95% CI, 0.47–1.08)
or having a health care provider only advise the patient to quit smoking were
not effective (OR, 0.84; 95% CI, 0.56–1.25) (Quinn et al., 2009).

The 2002 National Ambulatory Medical Care Survey found that participating
physicians were as likely to ask their male patients as their female patients,
in all age categories, about tobacco use (65.1–73.2% of all patients). About
17–27% of the men and women who used tobacco received counseling when visiting
their physicians regardless of age, except for men over 75 years old, who were
counseled only 5.6% of the time (Wallace et al., 2006).

In some medical facilities, a variety of health-care providers (such as nurses,
psychologists, counselors, and physicians) may be responsible for the delivery
of tobacco-cessation interventions. In a meta-analysis examining the
effectiveness of tobacco-cessation interventions by various health-care
providers with or without NRTs, interventions without NRTs were most effective
when delivered by a psychologist or physician. Counselors and nurses were also
effective, but the difference compared with the placebo (usual care) was not
statistically significant. When NRTs were combined with provider intervention,
the effectiveness of most providers increased up to twofold (Mojica et al.,
2004).

PRIMARY-CARE PROVIDERS

The 2008 PHS guideline found evidence that tobacco-cessation interventions
offered by both physicians and nonphysicians (such as nurses, psychologists,
dentists, and counselors) were more effective in increasing abstinence rates
than no intervention. Compared with no advice, brief advice from a primary-care
physician was effective in increasing 6-month quit rates, and intensive
interventions were slightly more effective than brief counseling (Stead et al.,
2007).

NURSES

In a Cochrane review of nursing interventions for smoking cessation, Rice and
Stead (2008) conducted a meta-analysis of 31 studies and determined that
nurse-provided interventions were more effective in reducing 6-month smoking
rates than no intervention or usual care. High-intensity interventions, such as
an initial counseling session of 10 minutes or more with additional materials
and at least one follow-up contact, were more effective than low-intensity
interventions. Nursing intervention was most effective for inpatients in a
hospital and to a smaller extent for nonhospitalized patients. Interventions
offered during a screening health check were less effective. The use of
additional materials (such as leaflets) by a nurse did not appear to promote
smoking cessation (Rice and Stead, 2008).

OTHER HEALTH-CARE PROVIDERS

Health-care providers other than primary-care clinicians and nurses have been
considered as resources for tobacco-cessation counseling. Pharmacists are
frequently associated with medical facilities, particularly hospitals and large
outpatient clinics. In addition to their obvious role in providing
tobacco-cessation medications, including such over-the-counter medications as
NRTs, some pharmacists have been trained to offer counseling and literature to
their patients who use tobacco. In a Cochrane review of two studies conducted in
the United Kingdom, only one study showed a significant association between
pharmacist-provided counseling and record-keeping and self-reported 12-month
abstinence rates (Sinclair et al., 2004). A more recent review by Dent et al.
(2007) of 15 studies of tobacco-cessation services provided by pharmacists found
a statistically significant difference in abstinence rates between the
pharmacist-intervention groups and control groups (Dent et al., 2007). A later
randomized controlled study of pharmacist intervention for tobacco cessation in
a VA community-based outpatient clinic showed that patients who received three
face-to-face group counseling sessions from the pharmacist in addition to
tobacco-cessation medication had a biochemically confirmed 6-month abstinence
rate that was greater than that in patients who received one 5- to 10-minute
call from the pharmacist in addition to medication (28% vs. 11.8%; p < 0.041)
(Dent et al., 2009).

Dentists are also well situated to counsel patients about tobacco use,
particularly smokeless-tobacco use, which is associated with increased oral
cancer and periodontal disease (see Chapter 2). At 12 months, smokeless-tobacco
users who had received tobacco-cessation counseling from their oral-health
professional (dentist or oral hygienist) had greater abstinence rates than those
who did not receive such counseling (Carr and Ebbert, 2006).

Finding: Multiple-session counseling in a health-care setting, preferably on an
individual basis, is effective in achieving long-term tobacco cessation and may
be provided by a variety of health-care providers in addition to physicians,
such as nurses, dentists, and pharmacists.

DoD and VA both have large, complex health-care systems that should strive to
offer barrier-free access to tobacco-cessation services (both counseling and
medications) that reflect current evidence on effective programs. Programs
should be available to all members of the target populations regardless of
place, time, and status (for example, active duty, deployed, reservist, at home)
and be offered by a variety of health-care professionals.


TOBACCO QUITLINES

There is ample evidence that tobacco quitlines are efficacious (Borland et al.,
2001; Stead et al., 2006; Zhu and Anderson, 2004), particularly when combined
with other interventions (CDC, 2009b). Quitlines offer the advantage of
generally being available when needed and free of charge for counseling. No
appointments are necessary to access them, and patients can call them for
individual counseling in privacy. Quitlines also help patients to overcome
barriers to treatment, such as living at a considerable distance from a clinic
or other treatment locations, being unable to attend counseling sessions because
of work or social commitments, and waiting for the next tobacco-cessation
program to begin.

The statewide use of a quitline as part of a comprehensive tobacco-use cessation
program began in California in the early 1990s and was followed in
Massachusetts. Now all 50 states and the District of Columbia have tobacco
quitlines (http://www.smokefree.gov/). Any adult in need of tobacco-use
cessation services can call a national telephone number (1-800-QUIT-NOW), which
will route the caller to his or her state tobacco quitline; this referral
service is sponsored by NCI. NCI also has a toll-free quitline at 1-877-44U-QUIT
that has a smoking-cessation counselor available during the day for help in
quitting and to provide answers to smoking-related questions in English or
Spanish.

Although quitline access is available to all adults across a broad demographic
spectrum, quitlines vary greatly in quality, intensity, and duration. Three
factors increase their efficacy: proactive quitlines (participant may initiate
call with proactive follow-up by quitline or a telephone counselor may initiate
the call to the participant) rather than reactive quitlines (the participant
initiates all calls to the quitline) (Stead et al., 2006); counseling that lasts
longer (for example, at least four sessions) and that includes booster sessions
(Hollis et al., 2007; Stead et al., 2006); and quitlines that provide NRTs
(Fiore et al., 2008; Rabius et al., 2007).

Cummins et al. (2007) surveyed 62 publicly available quitlines in North America
(all 50 states, the District of Columbia, Puerto Rico, and 10 Canadian
provinces) in 2004–2005. Most of the US quitlines had trained counselors
available for a mean of 85 hours/week, many of them offering counseling in 2
languages, and a few offering as many as 8 languages. All the quitlines offered
multisession (generally 5 sessions) proactive telephone counseling, and some
offered follow-up reactive sessions; the first session was usually 30 minutes
long, and the follow-up sessions were shorter. In addition to their telephone
counseling services, about 50% of the quitlines offered Internet-based services,
including general quitline information, cessation information, self-directed
quit plans, automated e-mail messages, chat rooms, and interactive counseling.
About one-third of the quitlines mailed free medications to callers, and 23%
provided vouchers for medications. Although many of the quitlines had
specialized protocols for pregnant women, smokeless-tobacco users, ethnic
populations, and people 12–17 years old, far fewer offered protocols for
multiple addictions, people 18–24 years old, those with mental illness, or older
adults. Most of the quitlines had some criteria for receiving free medications,
such as lack of insurance coverage.

The North American Quitline Consortium (NAQC) was established to help federal
and state health departments, quitline service providers, researchers, and
service providers, such as the American Cancer Society, to improve quitline
services. In addition to the state quitlines and the service providers, NAQC
members include CDC, the Robert Wood Johnson Foundation, the American Legacy
Foundation, ClearWay Minnesota, and several Canadian organizations. NAQC is one
resource for information about current quitline services, improving quitline
quality, and assessing quitline efficacy and research.

Although quitlines are acknowledged to be effective in reaching a large number
of tobacco users and can be tailored to reach specific audiences, they do have
limitations. Quitlines typically reach only a small proportion of their target
populations and are chronically underfunded. The 2003 National Action Plan for
Tobacco Cessation (Fiore, 2003) recommended that state quitlines use at least
four person-to-person proactive calls, that there be no cost to insurers for the
use of the quitline by eligible tobacco users, and that all NRTs be made
available to quitline users free of charge or that users receive vouchers for
prescription medications. The plan also called for states to receive earmarked
grants to maintain their quitlines and for quitlines to meet national
performance standards. Zhu and Anderson (2004) noted that the promotion of a
quitline may prompt tobacco users to attempt to quit on their own even if they
did not contact the quitline (Zhu and Anderson, 2004). Quitlines therefore may
reach a broader audience than only tobacco users who are seeking counseling,
including their friends and family who may call to request information on how to
support or initiate quit attempts by tobacco users.

The national action plan specifically states that military personnel and their
families should be eligible to use the national quitline and that a toll-free
number should be available for military personnel and their families stationed
overseas.

DoD and VA populations live in a variety of locations including small and remote
communities and overseas, where in-person tobacco-cessation services may be
scarce or nonexistent. Veterans, in particular, may find it difficult to access
VA tobacco-cessation services if they are disabled or otherwise disadvantaged.

Finding: Quitlines, particularly proactive quitlines, are effective in reaching
a large number of tobacco users and increasing abstinence rates over those
achieved with usual care. Evidence indicates that a quitline should be proactive
(counselor-initiated) and should provide four to six sessions and follow-up
sessions as necessary.


COMPUTER-BASED PROGRAMS

Several studies have assessed the effectiveness of computer-based
tobacco-cessation interventions, but there is insufficient information on their
effectiveness. Nevertheless, the committee considered these programs as more
people, both civilian and military, turn to computers for a variety of health
information, assistance, and support. Many computer-based interventions have the
advantage of being tailored to individual participants on the basis of their
responses to questions, and they can be used to reach a large audience,
including people who may not be contemplating quitting. Counseling may be
conducted by telephone or e-mail with additional individualized resources, such
as chat rooms, videos, graphics, journals, and action plans (Etter, 2002);
computer-based programs can also be combined with medication. The efficacy of
tailored computer-based tobacco-cessation programs is varied (Strecher and
Velicer, 2003). Etter (2006) surveyed current and former smokers about the
quality and helpfulness of 133 tobacco-cessation Web sites. Two of the most
frequently visited sites were run by tobacco companies and were not considered
helpful by participants. Two sites were ranked above average for quality and
were nonprofit (Anti-smoking.com and Smokefree.gov), and the one ranked highest
for helpfulness (Quitsmoking.About.com) was a for-profit Website. Strecher et
al. (2008) found that a Web-based behavioral smoking-cessation program was less
effective for participants who were younger, male, and had less formal education
(Strecher et al., 2008). Feil et al. (2003) designed a Web-based cessation site
and studied recruitment approaches, use patterns, retention incentives,
satisfaction, and cessation rate. The program included social support and
cognitive–behavioral coping skills. Of the 370 subjects followed for 3 months,
the 7-day point-prevalence abstinence rate was 18% on the basis of
intent-to-treat analysis (Feil et al., 2003).

One example of a computer-based service is QuitNet® that includes personalized
interactive materials for members, provides proactive telephone counselors, and
hosts an online support community of other smokers and ex-smokers (Cobb et al.,
2005). One version of the program is available free to the public, and the other
is an enhanced version available to commercial organizations. Other
computer-based tobacco-use cessation programs include Quit For Life, offered by
Free and Clear, Inc.; Freedom From Smoking®, developed by the American Lung
Association; and BecomeAnEX, sponsored by the National Alliance for Tobacco
Cessation. SmokeFree.gov offers an online smoking-cessation program that
includes text messaging with an NCI tobacco-cessation counselor. The
SmokeFree.gov site also contains a referral for military personnel to DoD’s
“Quit Tobacco. Make Everyone Proud” program. According to the National
Institutes of Health Web site (www.clinicaltrials.gov), formal assessments of
QuitNet and other online smoking-cessations programs are under way.

Finding: Computer-based tobacco-use cessation programs may be able to reach a
large audience of tobacco users, but there is insufficient evidence of their
effectiveness.


PROVIDER EDUCATION

Many people see a health-care professional (such as a primary-care physician or
dentist) at least once a year. Each visit can be an opportunity to ask patients
about their tobacco use and educate them about adverse health effects and
available interventions. But first, healthcare providers must themselves be
aware of tobacco-cessation interventions and be comfortable in providing advice
on these matters to their patients.

The use of evidence-based interventions may be enhanced by educating providers
on the 5 A’s to increase the rate of asking, advising, and assisting patients
with tobacco cessation. The National Ambulatory Medical Care Survey of
office-based physicians in the United States conducted by the National Center
for Health Statistics in 2001–2003 found that physicians identified smoking
status during 68% of office visits and counseled about 20% of smokers during
their visits. Pregnant women were most frequently asked about their smoking
status but were the least likely to receive smoking counseling. The use of
tobacco-cessation medication, primarily prescription bupropion, was recorded in
only 1.7% of visits (Thorndike et al., 2007). A Cochrane review found that
training of health-care providers increased the likelihood that they would offer
evidence-based cessation interventions during patient visits (Lancaster et al.,
2000).

Numerous training programs are available for health-care providers, some of them
free of charge. For example, the University of California, San Francisco, has a
program, Rx for Change: Clinician-Assisted Tobacco Cessation, that trains
health-professionals, students, and licensed clinicians in the 5 A’s or the
Ask-Advise-Refer model (accessible at http://www.rxforchange.ucsf.edu). The
2AandR online program, sponsored by the Washington State Department of Health
and run by Free and Clear, Inc., also offers training and resources to
healthcare providers based on the 2008 PHS guideline. The American Lung
Association’s Tobacco Cessation Resource Center has electronic resources for
health-care providers to use in their clinics and organizations; providers are
able to request additional assistance as needed (accessible at
http://www.tobaccoprc.org/page.cfm?id=9).

There is a lack of training among mental-health professionals, primary-care
providers, and tobacco-cessation specialists with regard to tobacco-cessation
interventions for patients with psychiatric disorders (Williams and Ziedonis,
2006). Training psychiatrists to provide cognitive-behavior therapy to
mental-health patients for tobacco cessation within the psychodynamic
therapeutic model taught in most psychiatric residencies may be challenging
inasmuch as only about half the psychiatry residencies require
cognitive-behavior therapy training (Prochaska et al., 2007).

Provider-level strategies for increasing patient use of cessation interventions
include electronic or written prompts and reminders on medical charts or records
such as the assessment and documentation of tobacco-use status as a vital sign
at every health-care visit (Fiore et al., 2008). For example, primary-care
physicians who used a computer report of their patients’ smoking status that
included tailored recommendations for discussing smoking cessation were more
likely to have abstinent patients at a 6-month follow-up than those who supplied
standard care (Smith et al., 2007; Unrod et al., 2007). Provider reminder
systems have been shown to be effective in increasing tobacco cessation,
particularly when combined with provider education (CDC, 2009a).

NCI has developed a Handheld Computer Smoking Intervention Tool (HCSIT), which
assists clinicians with smoking-cessation counseling during patient visits. The
software was developed in accordance with the current PHS guideline and includes
a handheld version of the Fagerstrom Test for Nicotine Dependence. The tool
guides clinicians through the appropriate questions and makes intervention
recommendations, including prescription information, on the basis of the level
of dependence. The HCSIT contains medication information, brief motivational
interventions for tobacco users, and evidence-based recommendations from the PHS
guideline. The easy-to-use program can be used with Palm®, SmartPhone, and
MicrosoftTM Pocket PC handheld computers. For more information, see
http://www.smokefree.gov/hphcsit.html.

VA initiated a preceptor training program to improve delivery of
tobacco-cessation treatment for veterans with mental disorders. The program uses
a train-the-trainer format to educate more than 160 VA mental-health and
substance-use disorder providers from every Veteran Integrated Service Network
about evidence-based clinical practices and mentors their progress in
integrating smoking cessation into routine psychiatric care.

Finding: The training of health-care providers in tobacco-cessation
interventions is effective in increasing the likelihood that a patient will be
asked about tobacco-use status, be advised to quit, and be assisted with
tobacco-cessation services. Computer-aided training and reminder systems help
health providers to discuss tobacco cessation with their patients.

Go to:


TOBACCO CESSATION IN SPECIAL POPULATIONS

The 2007 IOM report Ending the Tobacco Problem: A Blueprint for the Nation
acknowledges that some tobacco users will have a more difficult time in quitting
than others. Many populations of tobacco users may be reluctant to quit, find it
hard to do so, or be at risk for adverse health outcomes; these special
populations include “hard-core” smokers who have smoked for many years, people
with psychiatric and medical comorbidities, and people who have other
complicating conditions, such as homelessness. Those populations have not
traditionally been the focus of tobacco-control and cessation programs, and they
may require modified or innovative approaches to help them quit. This may have
particular relevance for DoD and VA: both treat tobacco users who have mental
illness and other comorbidities, and VA treats a homeless population. Other
populations served by the VA and military health systems that may require
different approaches for effective tobacco-cessation services include women,
pregnant women, minority-group members, hospitalized tobacco users, older
tobacco users, and smokeless-tobacco users. In the sections below, the committee
considers the evidence on tobacco-cessation interventions for special
populations with an emphasis on treating those with mental-health disorders.


TOBACCO USERS WITH MENTAL-HEALTH DISORDERS

Disproportionately higher rates of smoking (see Chapter 3 for specifics) are
related to an increased risk of tobacco-related illness among those with
psychiatric or mental disorders. For example, persons with chronic mental
illness die about 25 years earlier compared to those without—mortality is
primarily due to lung cancer and cardiovascular disease (Colton and
Manderscheid, 2006), and half of premature deaths in alcoholics are attributable
to cigarette smoking (Hurt et al., 1996). These statistics underscore the
importance of developing effective treatments for patients with psychiatric
comorbidities. Tobacco-cessation interventions in people with psychiatric
disorders have been the subject of much research and several reviews (Fagerstrom
and Aubin, 2009; Hagman et al., 2008; Ranney et al., 2006; Schroeder, 2009;
Ziedonis et al., 2008).

Barriers impede the application of cessation treatments in mental-health
populations, contributing to the high rates of tobacco use and low rates of
cessation in this population (Williams and Ziedonis, 2004). Foremost among these
barriers is a seeming reluctance on the part of mental-health professionals to
provide concurrent treatment for mental-health disorders and tobacco use. For
example, in mental healthcare settings, smoking-cessation treatment seems
neglected as psychiatric patients only receive cessation counseling during 38%
of their visits with physicians and 12% of their visits with psychiatrists
(Ziedonis et al., 2008). In the past, cigarettes have even been used as tokens
to reinforce positive behavior (Gustafson, 1992). Possible reasons for this
reluctance include the belief that nicotine withdrawal may exacerbate a
patient’s psychiatric symptoms, lack of training in tobacco-cessation treatment
and counseling, possible interactions between cessation medications and
medications prescribed for other psychiatric disorders, and the attitude that
tobacco use is a long-term problem and thus a lower priority than more immediate
psychiatric concerns (Ziedonis et al., 2006, 2007).

In spite of the 1996 publication of the American Psychiatric Association
guideline recommending that psychiatric patients receive routine treatment for
tobacco use (American Psychiatric Association, 1996), the proportion of
mental-health patients counseled about smoking by their primary-care physicians
(23%) or their psychiatrists (18%) is low (Thorndike et al., 2001). The National
Ambulatory Medical Care Survey found that psychiatrists offered
tobacco-cessation counseling to only 12.4% of their patients who smoked
(Himelhoch and Daumit, 2003). More counseling was offered to patients who were
over 50 years old, had diabetes, had hypertension, had obesity, lived in a rural
location, or were in their initial visit. A study of 250 hospitalized
psychiatric smokers found that only 105 were actually identified as current
smokers in their medical records and none had received a diagnosis of nicotine
dependence or withdrawal (the facility was smoke-free) or had cessation services
as part of their hospital treatment; however, NRT was prescribed for 56% of the
smokers, almost all of whom used it (Prochaska et al., 2004a). Ziedonis et al.
(2008) noted that mental-health providers may be ideal for delivering
tobacco-cessation treatment because there is a therapeutic alliance between
patient and provider; patients will return for treatment for their psychiatric
symptoms regardless of their cessation status, and the provider can use these
opportunities to encourage repeated attempts to quit; and it is relatively
cost-efficient in that tobacco-cessation treatment can be delivered during
planned visits to the provider (Ziedonis et al., 2008).

Although people with psychiatric disorders have higher rates of tobacco use than
people without these disorders, many of them are interested in quitting and will
attempt to quit. The National Comorbidity Survey found that smokers with history
of mental illness in the past month had a self-reported quit rate of 30.5%
compared with a quit rate of 42.5% for those without any mental illness (Lasser
et al., 2000). Patients with psychiatric disorders may use tobacco as a
self-medication for their symptoms (Fagerstrom and Aubin, 2009; Khantzian, 1997;
Lerman et al., 1998) because nicotine has been associated with improved
psychomotor function in people with depression (Malpass and Higgs, 2007) and has
been associated with enhanced attention, sensory gating, and working memory in
those with schizophrenia (Dalack and Meador-Woodruff, 1996; Strasser et al.,
2002; Ziedonis et al., 2007). However, as discussed in Chapter 3, nicotine
withdrawal may exacerbate some psychiatric symptoms if not properly controlled
(Fagerstrom and Aubin, 2009).

The best time to start tobacco-cessation treatment is not clear; some studies
indicate that it can be concurrent with treatment for psychiatric disorders, but
some evidence suggests that it is more effective if given when psychiatric
symptoms are less severe, particularly in those with alcohol dependence (Fiore
et al., 2008). Although quit rates and relapse rates are higher in populations
with psychiatric disorders, long-term abstinence can be achieved. In treating
psychiatric patients for tobacco use, it must be remembered that traditional
tobacco-cessation therapies may need modification to address issues specific to
a psychiatric population such as self-medication, the particular psychiatric
diagnoses, medications that the patients are already taking for their
psychiatric symptoms, and the need for modified psychotherapy. Furthermore, in
treating nicotine addiction, as in treating such other addictions as heroin
addiction, it may be necessary to provide treatment for longer periods than the
typical 12 weeks (Schroeder, 2009). The committee notes that treatment of
tobacco dependence in people who have psychiatric disorders requires a tailored
approach to meet individual needs, treatment can be enhanced through a
combination of medication and psychosocial therapy, and tobacco use can alter
the effectiveness of a variety of medications.

BEHAVIORAL INTERVENTIONS

Behavioral interventions have been applied for tobacco users with several
mental-health disorders, including schizophrenia (McChargue et al., 2002;
Ziedonis, 2004; Ziedonis et al., 2007), depression (Brown et al., 2001; Hitsman
et al., 2003), and substance-use disorders (Gulliver et al., 2006; Kodl et al.,
2006). The 2008 PHS guideline (Fiore et al., 2008) indicates that current
evidence is insufficient to determine whether smokers with mental-health
disorders are more likely to quit if they receive interventions tailored to
their disorders or symptoms or whether standard treatments are equally
effective. Ziedonis (2004) found that cessation interventions for psychiatric
patients may include telephone-based counseling, Internet-based approaches, and
face-to-face counseling, but more research is needed. They caution, however,
that the interventions may be most effective in those with less severe mental
illnesses, including addictions, because the interventions tend to be brief or
time-limited and are not tailored to a particular mental illness.

TOBACCO-CESSATION MEDICATIONS

In general, the FDA-approved tobacco-cessation medications that have been shown
to be effective for the general population—NRTs (gum, patch, spray, lozenge, and
inhaler), bupropion, and varenicline—have also been shown to be effective in
people with psychiatric disorders (Fiore et al., 2008; Stapleton et al., 2008).
However, as with patients with any comorbidity, treating tobacco dependence in
psychiatric patients requires an understanding of the specific condition, the
medications that are being used to treat the condition, and the severity of the
dependence. Clinicians and tobacco-cessation counselors may need to adjust or
combine tobacco-cessation medications to treat both the psychiatric symptoms and
the nicotine dependence most effectively (VA/DoD, 2004). For example, Richmond
and Zwar (2003) found that bupropion reduced withdrawal symptoms and was
effective for smoking cessation in people with and without a history of
depression or alcoholism. Heavier smokers may need higher doses of the cessation
medications and additional NRTs (Richmond and Zwar, 2003). Extra emphasis on the
use of NRTs or bupropion for treating nicotine dependence may be necessary in
those with more severe tobacco dependence (VA/DoD, 2004). Varenicline has been
associated anecdotally with changes in behavior, agitation, depressed mood,
suicidal ideation, and attempted and completed suicide in some tobacco users
(FDA, 2008); therefore, patients should be monitored closely for side effects,
including depression and suicidal ideation, while on the drug. More research on
the association between varenicline and suicide is needed (see the FDA website,
www.fda.gov, for updates on the status of varenicline).

A number of studies have found that the combination of medication and
psychosocial treatments may be more effective than either alone for patients
with mental illness (Fiore et al., 2008). For example, Evins et al. (2001)
studied the effect of bupropion SR and cognitive behavioral therapy on smoking
behavior in patients with schizophrenia. The authors found that bupropion SR
combined with cognitive behavioral therapy facilitated smoking reduction in some
schizophrenic patients and stabilized psychiatric symptoms during attempts to
quit (Evins et al., 2001). McFall et al. (2006) found that integrated
tobacco-cessation treatment consisting of cessation medication with behavioral
counseling and psychotherapy was effective in veterans with posttraumatic stress
disorder (PTSD). Similarly, preliminary studies of tobacco-dependence treatment
in PTSD patients indicated that behavioral treatments combined with medication
when offered by a patient’s mental-health provider were more effective than
referral to a tobacco-cessation clinic. Furthermore, repeat treatment delivered
in the context of a continuing therapeutic relationship was more effective than
brief, episodic treatment delivered by a specialist (Fu et al., 2007). Similar
results were seen in patients with diagnosed psychotic disorders: a combination
of NRT, motivational interviewing, and 8 sessions of individual
cognitive-behavior therapy resulted in point-prevalence abstinence rates at 3,
6, and 12 months that were 3 times higher in the treatment group than in the
group receiving routine care (Baker et al., 2006). There was a dose–response
relationship between abstinence and attendance at the treatment sessions.

An additional, potentially unexpected benefit of reducing or eliminating tobacco
use by patients with mental illness is lowering of psychotropic medication
dosages. Patients with serious mental illness, such as schizophrenia or bipolar
disorder, are commonly given antipsychotic medications, such as olanzapine or
clozapine. Smokers who receive those medications may need about twice the dosage
of nonsmokers, because of the effect of the polycyclic aromatic hydrocarbons in
tobacco smoke on medication metabolism (Desai et al., 2001). Other medications
that are affected similarly include haloperidol and fluphenazine (Desai et al.,
2001; Workgroup on Substance Use Disorders, 2006). Cigarette smoking may also
increase the clearance of benzodiazepines (Smith et al., 1983). Careful
monitoring of the side effects of psychiatric medications during changes in
tobacco use is necessary, particularly during the early abstinence period
(VA/DoD, 2004). Health-care providers should be actively involved in working
with patients to adjust medications and to inquire about side effects. Tobacco
users with mental illness may need to be treated for a longer period and with
more intensive treatments than nonusers (Collie et al. 2006).

In the section below, the committee assesses the evidence on tobacco-cessation
interventions for specific psychiatric disorders that may be seen in military
personnel returning from Iraq and Afghanistan and in veterans from those and
earlier conflicts: PTSD, major depressive disorder (MDD), alcohol abuse and
dependence, and schizophrenia.

POSTTRAUMATIC STRESS DISORDER

In a review by Fu et al. (2007), PTSD was strongly associated with tobacco use
and nicotine dependence; many studies reported smoking rates of over 50% in
those with the disorder. Although several observational studies have shown that
smokers with PTSD are less inclined to quit smoking than smokers without PTSD or
with other psychiatric disorders, several clinical studies have indicated that
smokers with PTSD or other mental disorders respond to tobacco-cessation
treatment at levels nearly equivalent to those in smokers without mental
disorders (Fu et al., 2007).

For tobacco users with PTSD, there appears to be greater abstinence from tobacco
use when cessation interventions are integrated into standard mental health
care. In one study, 107 veterans with PTSD who smoked were encouraged to make
multiple attempts to quit (that is, repeated treatment) during a 6-month
treatment period. The 9-month, 7-day point-prevalence abstinence rate was 18% in
the integrated-care group and 3% in the standard smoking-cessation group
(difference not significant) (McFall et al., 2005, 2006). The sample was small,
but, given the effect size, the committee considers that this intervention
merits further study.

Collie et al. (2006) reported that cue-reactivity and coping-skills training may
be beneficial in cessation efforts in smokers who have PTSD, extrapolating from
the literature on preventing alcohol abuse. Other approaches that have been
found effective in increasing tobacco-cessation rates in people with PTSD
include supportive counseling and mood management, particularly before the quit
attempt begins. Unaided quit attempts result in higher relapse rates in the
first week after quitting in smokers with PTSD than in smokers without a mental
disorder (Zvolensky et al., 2008).

One small trial of bupropion SR in PTSD patients found it to be effective
compared with placebo (Hertzberg et al., 2001).

DEPRESSION

Research indicates that smokers with depression can be motivated to attempt to
quit smoking and, with formal assistance, accept and use tobacco-cessation
treatment (Acton et al., 2001; Haug et al., 2005; Prochaska et al., 2004a).
Acceptance was not correlated with chronicity of depression history, severity of
current depressive symptoms, severity of nicotine dependence, sex, age, or
education (Haug et al., 2005). Recent research has shown that people in
treatment for chronic depression can be treated for tobacco dependence with no
adverse effects on their mental-health functioning or compensation with other
substance use (Prochaska et al., 2008).

Meta-analyses of smoking-cessation trials published in 1988–2000 found that
smokers with a history of depression were as likely as those without such a
history to achieve short-term (up to 3 months) or long-term abstinence (at least
6 months) (Covey et al., 2006; Hitsman et al., 2003). Three randomized,
controlled trials indicate that smokers with MDD are capable of achieving
abstinence rates comparable with those of nondepressed smokers after similar
interventions (Hall et al., 2006; Muñoz et al., 1997; Thorsteinsson et al.,
2001). Several studies have compared standard smoking-cessation treatment (ST)
with the combination of ST and cognitive-behavioral therapy for depression
(CBT-D) in smokers with past MDD and recurrent MDD (Brown et al., 2001; Haas et
al., 2004; Hall et al., 1994, 1996, 1998). Contrary to expectation, CBT-D with
ST did not produce significantly higher abstinence rates than ST alone in
smokers with past MDD, perhaps because these smokers already fared well in
nonpharmacologic standard treatment. However, in smokers with recurrent MDD (two
or more past episodes), CBT-D with ST resulted in significantly higher
abstinence rates than ST alone (p = 0.02). In sum, adding CBT-D to usual
smoking-cessation treatment is efficacious in smokers with a history of
recurrent depression. Cognitive-behavioral therapy with an emphasis on group
cohesion and social support (Ait-Daoud et al., 2006) and mood management
combined with tobacco-cessation treatment and increased therapist time (Brown et
al., 2001; Collie et al., 2006) also appear to be effective in smokers with
recurrent depression.

Hall et al. (2006) conducted a comparison of a stepped-care intervention with a
brief-contact intervention in smokers with current depression recruited from
four mental-health outpatient clinics. The stepped-care intervention consisted
of a computerized expert system based on the stage-of-change model and the
option of receiving six 30-minute psychotherapy sessions that included
mood-management training and medication (nicotine patch and/or bupropion). The
brief-contact intervention included a smoking-treatment referral list and a
packet of educational materials at the first visit. Abstinence rates at 12 and
18 months were higher in depressed smokers who received the stepped-care
intervention than in the brief-contact controls (Hall et al., 2006).

An etiologic connection may exist between smoking and depression (Aubin, 2009;
Kotov et al., 2008). The variation in symptoms of MDD may affect
smoking-cessation outcomes (Burgess et al., 2002) in such a way that increasing
depressive symptoms are associated with poorer cessation outcomes. Smokers with
a history of MDD who were currently free from depression and not on
antidepressant medication and who stopped smoking were at a significantly
increased risk for a new episode of depression (OR, 7.17; 95% CI, 1.5–34.5)
compared with those who were not abstinent. The risk persisted during the
6-month follow-up period (Glassman et al., 2001).

ALCOHOL ABUSE AND DEPENDENCE

It has been estimated that 80% of people who abuse or are dependent on alcohol
are smokers (Sussman, 2002), and rates of tobacco use and nicotine dependence
increase with alcohol consumption (Falk et al., 2006). Of importance for DoD is
that the 2001–2002 National Epidemiologic Survey on Alcohol and Related
Conditions found that the co-use of alcohol and tobacco was highest in men and
women 18–24 years old (Falk et al., 2006). However, although most alcoholics are
interested in quitting tobacco at some point and some are concerned that doing
so will make them drink more (Joseph et al., 2003), treatment for tobacco
cessation is not routinely included in alcohol-treatment programs in spite of
evidence that tobacco-cessation treatment does not impede alcohol-use outcomes
(Burling et al., 2001; Gulliver et al., 2006).

Concurrent treatment for tobacco use and alcohol dependence or abuse has been
studied, but results are mixed. Some studies have shown that cessation rates
tend to increase with length of sobriety if the two treatments are delivered
concurrently (Heffner et al., 2007). Tobacco-cessation rates were about 3 times
as great in people with 3 months of sobriety or more as in people with shorter
sobriety, although both groups relapsed at about the same rate. At 3–6 months of
sobriety, tobacco-cessation rates resembled those of alcohol nonusers, and
1-year cessation rates were as high as 46% in people who had been sober for
several years (Sussman, 2002). Other studies of concurrent treatment found
greater participation rates in tobacco-cessation treatment; however, long-term
cessation rates did not differ significantly from those seen when smoking
intervention was delayed for 6 months after alcohol treatment indicating that
optimal timing has yet to be determined (Joseph et al., 2002). Sequential
treatments may be preferred for some people (Kodl et al., 2006). Ellingstad et
al. (1999) suggested that tobacco cessation may improve alcohol-treatment
outcomes because it removes a cue for alcohol use (Ellingstad et al., 1999).

In a study of outpatients in alcohol treatment, the longer the period of alcohol
abstinence, the more receptive to quitting smoking were those with low scores on
the Center for Epidemiologic Studies Depression Scale (Hitsman et al., 2002).
Patten et al. (2002) assessed the use of behavioral therapy alone or behavioral
therapy with cognitive-behavioral mood-management training for tobacco
abstinence in depressive smokers with a history of alcohol dependence.
Behavioral therapy alone was more effective in helping smokers with low scores
on the Hamilton Rating Scale for Depression to achieve short-term tobacco
abstinence, whereas the mood-management training was more effective in
increasing abstinence in smokers with high depression scores (Patten et al.,
2002). Those studies suggest that treating people who have both depression and
alcohol dependence for tobacco use requires assessing both disorders in addition
to nicotine addiction. Ait-Daoud et al. (2006) found that the preponderance of
evidence suggests that concurrent treatment for depression and tobacco use is
preferable to treating either disorder alone, even in people who have alcohol
dependence, and that a combination of pharmacotherapies and cognitive-behavioral
therapy was most advantageous (Ait-Daoud et al., 2006).

SCHIZOPHRENIA

Patients with schizophrenia are treated in a variety of intensive-treatment
settings (such as psychiatric hospitals, residential facilities, and
day-treatment programs), and these settings provide an opportunity to deliver an
intensive smoking-cessation treatment integrated with mental health care.
However, only recently have some psychiatric treatment settings begun to address
tobacco use. As with other psychiatric disorders, the percentage of people with
schizophrenia who are smokers is more than twice the percentage of smokers in
the general population (Kotov et al., 2008). People with schizophrenia appear to
be able to quit tobacco with the support of psychosocial treatment,
nicotine-dependence treatment medications, and social support (Workgroup on
Substance Use Disorders, 2006). Although many experience difficulties and can
relapse, some people with schizophrenia are interested in reducing their tobacco
consumption (Forchuk et al., 2002). Patients with schizophrenia who smoke appear
to be more severely ill than patients who do not smoke, although the severity of
specific symptoms does not appear to differ between smokers and nonsmokers
(Kotov et al., 2008). Clinical studies show that psychologic treatment
interventions of different intensity have been effective, including one-to-one
and group-based counseling using modified American Lung Association
interventions, cognitive-behavioral therapy, social-skills training, and
contingency monetary reinforcement. Much of the relevant literature on people
with psychotic disorders, such as schizophrenia, has focused on interactions
between antipsychotic medications and bupropion rather than on the efficacy of
psychologic treatments. Most of the studies in this population using NRT or
bupropion have included a psychologic-treatment component (Addington et al.,
1998; Goldberg et al., 1996; Ziedonis and George, 1997).


TOBACCO USERS WITH MEDICAL COMORBIDITIES

Smoking is the leading cause of morbidity in the general population and is
causally linked to the development of many cancers (particularly lung cancer),
chronic obstructive pulmonary disease (COPD), and cardiovascular disease (CVD)
(see Chapter 2). Smoking is also known to have an adverse effect on people who
have those diseases and other illnesses, such as diabetes, that are not commonly
linked to smoking. The 2006 National Health Interview Survey (NHIS) found that
36.9% of smokers with any smoking-related chronic disease continued to smoke,
including almost 49% with emphysema, 41% with chronic bronchitis, 21% with lung
cancer, 39% with other cancers, 29% with coronary heart disease, and 30% with
stroke; only 19% of those with no chronic disease smoked (CDC, 2007a). A
significant portion of veteran patients suffer from chronic diseases: in 2008,
over 2 million veterans had a diagnosis of hypertension, over 175,000 had a
diagnosis of heart failure, over 150,000 had peripheral vascular disease, over
400,000 had a diagnosis of COPD, over 65,000 had a stroke, and over 28,000 had a
diagnosis of lung cancer (James Schaeffer, VA, personal communication, February
26, 2009). Thus, this issue is of particular importance to DoD and VA with
regard to both the medical consequences of continued smoking and also
smoking-cessation treatment as they each treat large populations with comorbid
illnesses.

The prognosis of CVD in smokers can improve markedly with smoking cessation
(Burns, 2003). Continued smoking is associated with earlier age of disease
onset, disease progression, recurrent events, and higher mortality (Van Spall et
al., 2007). For example, the risk of myocardial infarction decreases within 1
year after smoking cessation, and 10-year survival after coronary-artery bypass
surgery increases from 68% to 84% (Cavender et al., 1992). Most studies of
tobacco-cessation intervention in patients with CVD have been conducted in
hospitalized male patients and compared usual care with more intensive programs.
The more intensive interventions included behavior therapy, telephone support,
and self-help materials, often in combination. Behavioral therapy and telephone
support were slightly more effective than self-help materials, but better 6- and
12-month abstinence rates were obtained with more intensive treatments of at
least 1-month duration; brief interventions were not effective (Barth et al.,
2008). When 12-week intensive behavior-modification therapy was combined with
individualized medication, long-term abstinence was significantly increased in
patients with CVD (33% vs. 9%; p < 0.0001), and patients had fewer
hospitalizations later and had reduced all-causes mortality (Mohiuddin et al.,
2007). Intervention intensity is related to increased treatment efficacy in the
2008 PHS guideline (Fiore et al., 2008). Medications—such as NRTs, bupropion SR,
and varenicline—for tobacco cessation in patients with CVD appear to be both
safe and effective (Fiore et al., 2008; Joseph and Fu, 2003; Tonstad et al.,
2003). Peripheral arterial disease is also associated with smoking, and current
management of peripheral arterial disease includes smoking-cessation
interventions (Aronow, 2008).

The Lung Health Study demonstrated that permanent abstinence from smoking can
reduce the progression from early COPD—mild to moderate airway obstruction—to
clinically serious lung disease (Anthonisen, 2004). Evidence indicates that
smoking cessation improves lung function and long-term survival in people with
COPD regardless of disease severity (Godtfredsen et al., 2008), and the risk of
COPD exacerbation diminishes as the length of abstinence increases (Au et al.,
2009). Nevertheless, the risk of death from COPD may remain increased even after
20 years of smoking abstinence; once lung disease is disabling, continued
abstinence may slow the decline, but symptom-related benefits may be fewer
(Burns, 2003). Sherman et al. (2003) reported that smokers attending a VA
hospital for COPD were more likely to receive smoking-cessation therapy than
smokers without COPD (Sherman et al., 2003). Smoking-cessation interventions in
those with COPD that combine behavioral and pharmacologic interventions were
more effective than behavioral interventions alone or no treatment (Fiore et
al., 2008; Hilberink et al., 2005; Wagena et al., 2004). A long-term cessation
program that included 2-week hospitalization, NRT, physical exercise, and group
counseling with a year of telephone follow-up by trained staff was found to be
significantly more effective in maintaining abstinence at 3 years than usual
care for patients with COPD (38% vs. 10%) (Sundblad et al., 2008). Other
programs with combined therapy have been effective in achieving long-term
smoking cessation (Jonsdottir et al., 2004). Bupropion has been shown to be both
safe and efficacious as a smoking-cessation medication for patients with COPD
(Tashkin et al., 2001; Wagena et al., 2004).

Cancer patients who smoke are at increased risk for recurrence of cancer, second
primary cancers, reduced cancer-treatment efficacy, increased medication
toxicity, and reduced survival and quality of life (Gritz et al., 2005, 2006,
2007). Smokers undergoing surgery for cancer or other health conditions
experience increased postsurgical complications of anesthesia, respiratory
infections, and wound healing (including healing after reconstructive plastic
surgery). Continued smoking can also compromise radiation-therapy outcomes,
increase toxicity, and exacerbate side effects. Although chemotherapy has not
been specifically studied with regard to continued smoking, compromised immune
function, weight loss, fatigue, and susceptibility to infection may all be
exacerbated by continued smoking. The efficacy of cancer-chemotherapy agents and
molecular treatments (such as tyrosine kinase inhibitors of epidermal
growth-factor receptors) may be reduced by induction of drug-metabolizing
enzymes due to tobacco smoke (Gritz et al., 2007; Toschi and Cappuzzo, 2007).

Up to 60% of patients with smoking-related tumors are current smokers at
diagnosis (McBride and Ostroff, 2003); although many patients may quit in
preparation for surgery or other treatments, the relapse rate is high (Gritz et
al., 2007; Walker et al., 2006). Duffy et al. (2006) showed that patients with
head and neck cancers who smoked and had alcohol abuse or depression had higher
6-month abstinence rates after a nurse-administered smoking-cessation
intervention consisting of cognitive-behavioral therapy combined with medication
than patients who received usual care (Duffy et al., 2006). As in patients with
CVD and COPD, smoking-cessation interventions for cancer patients must factor in
the medications that the patients are taking for the cancer (and other possible
comorbidities) and their psychologic status. Smoking-cessation intervention
studies of cancer patients have not shown a consistent effect, and more research
is needed. Future studies should use the evidence-based treatments set forth in
the 2008 PHS guideline (Fiore et al., 2008), combine behavioral counseling and
pharmacologic treatments, involve the provider treatment team, and validate
outcomes.

Two chronic diseases exacerbated by smoking are diabetes and asthma. Smoking
puts diabetic patients at higher risk for vascular disease, stroke, nephropathy,
neuropathy, lower-extremity morbidity, and premature death from CVD (Haire-Joshu
et al., 1999; Phisitkul et al., 2008). Smoking-cessation intervention trials
have had mixed findings, but in large trials, nurse-delivered interventions and
motivational interviewing have shown favorable results (Canga et al., 2000;
Davies et al., 2008; Persson and Hjalmarson, 2006). Further research on
motivational interviewing by a primary-care nurse is under way (Jansink et al.,
2009).

In people with asthma, symptoms may be triggered and aggravated by active
smoking and by secondhand smoke. Other adverse effects among asthmatic smokers
include increased frequency of attacks, increased symptom severity, higher
hospitalization rates, and rapid decline in lung function (Althuis et al., 1999;
Sippel et al., 1999; Siroux et al., 2000; Yun et al., 2006). Cigarette smoking
may reduce the effectiveness of steroid treatment for asthma (Tyc and
Throckmorton-Belzer, 2006). Smoking prevalence in adult asthmatics is similar to
that in the general population (Thomson et al., 2004), and intervention studies
in adults have not been reported. Adolescents with asthma are more likely than
nonasthmatic adolescents to have parents that smoke (Otten et al., 2005).


OTHER SPECIAL POPULATIONS OF TOBACCO USERS

The 2008 PHS guideline and some Cochrane reviews have assessed the efficacy of
tobacco-cessation treatments for several specific groups; some of the results
have particular relevance for the populations served by DoD’s TRICARE health
system and VA. The populations include hospitalized smokers, older smokers,
racial and ethnic minority populations, women, pregnant smokers, and
smokeless-tobacco users. In general, the literature on tobacco-cessation
treatments for those populations is sparse.

WOMEN

In 2001, the US Surgeon General released a second major report on women and
smoking (US Surgeon General, 2001). The surgeon general emphasized that although
smoking is not the norm among women, those who use tobacco are at risk for
adverse health effects. If they are pregnant and smoke there is also an
increased risk to the fetus. The Department of Health and Human Services offers
a Web site with health information for women that contains information on
tobacco use and cessation, including information for pregnant smokers
(http://www.4woman.gov/QuitSmoking/index.cfm). The 2008 PHS guideline indicates
that women are responsive to the same smoking-cessation treatments as men,
specifically medication (bupropion SR, NRTs, and varenicline) and counseling
intervention, such as active telephone counseling, individually tailored
follow-up, and advice to quit aimed at children’s health (Fiore et al., 2008).
Croghan et al. (2009) found that among smokers who participated in an
individualized tobacco-cessation program in a large hospital, there was no
difference between men and women in outcomes although women were more likely to
receive a prescription for tobacco-cessation medication.

Female veterans with PTSD are twice as likely to smoke as those without PTSD
(Dobie et al., 2004). Female and male veteran smokers receiving care at VA
medical centers were equally likely to be advised to quit smoking and to be
referred to tobacco-cessation services, but women were less likely to be given
cessation medications and to have quit at the 1-year follow-up. When asked about
what would constitute an ideal smoking-cessation program for women, female
veterans indicated that support, particularly emotional support from peers,
would be an important component of any such program and that options for
individual and group support would be helpful (Katzburg et al., 2008).

SMOKELESS-TOBACCO USERS

Numerous forms of smokeless tobacco are available, and its use is on the rise in
military populations, particularly those deployed to Iraq and Afghanistan (Smith
et al., 2008); therefore, treatment for smokeless-tobacco use is an important
consideration for military health advisers. In addition, many military personnel
who use smokeless tobacco also smoke cigarettes, and this may increase the
complexity of cessation interventions for either form of tobacco use. Evidence
summarized in a Cochrane review of two randomized trials of pharmacotherapies
for smokeless-tobacco use with 6-month follow-up found that neither nicotine
replacement nor bupropion were effective (Ebbert et al., 2007a). Behavioral
interventions, such as counseling by a dentist or telephone counseling, might be
effective, but more study is needed (Carr and Ebbert, 2006; Ebbert et al.,
2007a; Klesges et al., 2006). The 2008 PHS guideline also indicates that
counseling is effective for smokeless-tobacco cessation, although the evidence
for cessation medications is insufficient (Fiore et al., 2008). A review of
behavioral and pharmacologic interventions for smokeless-tobacco use found
similar results (Severson, 2003). Cessation counseling during a dental visit was
more effective in increasing 12-month abstinence than group support sessions in
a tobacco-cessation clinic or self-help materials with brief counseling. The use
of NRT gum, NRT patch, or bupropion did not improve cessation in
smokeless-tobacco users.

HOSPITALIZED TOBACCO USERS

Several studies of tobacco cessation in hospitalized smokers are included in the
above discussion of tobacco users with comorbidities (Barth et al., 2008;
Prochaska et al., 2004b; Sundblad et al., 2008). In addition, a Cochrane review
assessed smoking-cessation treatments for hospitalized patients (Rigotti et al.,
2007). Hospitalized tobacco users benefit from tobacco-cessation treatments,
particularly intensive cognitive-behavioral therapy combined with NRT (Simon et
al., 2003). Smokers who received a multicomponent cessation intervention
consisting of face-to-face in-hospital counseling, a videotape, self-help
literature, NRT, and 3 months of telephone follow-up after noncardiac surgery
had higher biochemically confirmed abstinence rates at 12 months than those who
received only self-help literature and brief counseling (relative risk, 2.0; p =
0.04) (Simon et al., 1997). A meta-analysis of treatment of hospitalized
patients shows that intensive therapy begun in the hospital and continuing with
at least 1 month of follow-up after discharge appears to result in the best
cessation rate; the addition of cessation medications does not increase the rate
(Rigotti et al., 2007).

OTHER TOBACCO USERS

The 2008 PHS guideline assesses tobacco cessation in several special
populations, including those with low socioeconomic status (SES) and little
formal education, older smokers, and racial and ethnic minorities (Fiore et al.,
2008). There is a paucity of studies on the effectiveness of tobacco-cessation
treatments in each of those populations. Tobacco users with low SES and little
formal education benefit from the use of nicotine patches in combination with
counseling, including proactive telephone counseling and motivational messages
with or without telephone counseling (Fiore et al. 2008). Older smokers
typically do not receive adequate treatment for tobacco use (Doolan and
Froelicher, 2008), but they too benefit from a variety of tobacco-cessation
treatments, including those used for low-SES tobacco users. Buddy support,
tailored self-help materials, and physician advice are also effective (Fiore et
al., 2008). Effective interventions for racial and ethnic minorities include
medications (bupropion SR and nicotine patches), motivational counseling,
clinician advice, tailored self-help materials, telephone counseling, and
biomedical feedback (Fiore et al., 2008).

Heavy smokers are those who smoke more than 1 pack of cigarettes a day (20
cigarettes in a pack), typically 25–30 cigarettes/day. The number of cigarettes
smoked per day can be predictive of withdrawal symptoms. For people with severe
tobacco dependence, it may be necessary to increase the dose of cessation
medications to alleviate symptoms or to use combinations of treatments (Dale et
al., 1995)—perhaps three or more medications simultaneously (Ebbert et al.,
2007b). The committee recommends that health-care providers consider tailoring
the dose of NRT and the use of multiple NRTs or other combination medications in
these patients.

Finding: Although most studies have focused on treating tobacco users in the
general public, evidence suggests that special populations—such as those with
mental illness, women, and those with medical comorbidities—will benefit from
the same tobacco-cessation treatments, although some modifications may be
necessary to avoid medical complications. A combination of tailored behavioral
therapy and medication is effective for tobacco cessation in these populations.

Go to:


RELAPSE-PREVENTION INTERVENTIONS

The issue of relapse from tobacco abstinence is well known but not well studied.
As many as 75–80% of smokers who quit tobacco use will relapse within 6 months
(Carmody, 1992). Most people who quit without assistance relapse within the
first 8 days after quitting (Hughes et al., 2004). Studies of people who used
nicotine medications to quit suggest that long-term (1-year) abstinence rates
are about 10% and that the rate of relapse after 1 year is not significant
(Hughes et al., 2008). Several factors may be at play in relapse, including the
biologic nature of nicotine addiction, conditioned activities (such as smoking
when drinking alcohol or coffee), and cognitive-social learning factors. Men and
women may be concerned about gaining weight if they stop smoking (Carmody, 1992;
Clark et al., 2004, 2005, 2006b). A Cochrane review of relapse-prevention
interventions found that behavioral interventions were not effective although
therapy that helps smokers to avoid smoking cues had the best results; long-term
use of varenicline was most effective for prolonged prevention of relapse
whereas long-term use of bupropion did not appear to be effective (Hajek et al.,
2005). A study of 1,700 smokers randomized to receive a nicotine inhaler,
bupropion, or both for 3 months found that the combination therapy increased
abstinence rates but did not prevent relapse (Croghan et al., 2007). A variety
of tobacco-cessation treatments—including cognitive-behavioral therapy, social
support, pharmacotherapies, and cue avoidance—may be required to prevent relapse
and maintain long-term abstinence (Carmody, 1992).

Go to:


SURVEILLANCE AND EVALUATION

The comprehensive tobacco-control programs described in this chapter have
features in common that increase their effectiveness. An important feature is
surveillance mechanisms to assess whether tobacco-use restrictions and
modifications of the retail environment are being enforced and are reducing
tobacco consumption and also to determine whether the various tobacco-cessation
interventions are assisting tobacco users to quit. CDC states that surveillance
“is the process of monitoring tobacco-related attitudes, behaviors, and health
outcomes at regular intervals” (CDC, 2007a). Mechanisms to monitor the
effectiveness of interventions may require surveys of populations to assess
specific health behaviors, analysis of medical records, inventories, or
financial tracking. CDC recommends that states spend specific dollar amounts per
user on tobacco control. Surveillance must be continuous; a snapshot of a
program is not sufficient to indicate its effectiveness. Scheduled periodic
evaluations are the best surveillance tools, but ad hoc information may also be
useful in identifying trouble spots or anomalies. Surveillance information helps
program leaders modify programs to meet changing needs or to address
disparities. Surveillance can indicate whether policies are being enforced,
whether medications are being correctly prescribed and taken, whether quitlines
are being used, whether mass-media campaigns are reaching target audiences, and
whether funds are being spent appropriately. Feedback information obtained
through surveillance is critical for ensuring that a tobacco-control program is
effective. Tobacco-control surveillance includes prevalence of tobacco use, its
health and economic consequences, its sociocultural determinants and
tobacco-control policy responses, and tobacco-industry activities.

There is evidence that performance measures work well and it is possible to
relate them to program improvements (IOM, 2005; Perrin, 1998, 1999). Performance
measures may take the form of metrics, such as the number of people who enroll
in a smoking-cessation program, the number of people who are counseled to quit
using tobacco by their health-care providers, the number of people who quit at
some time after using an intervention, or the number and types of policies aimed
at achieving tobacco control.

Progress in tobacco-use cessation treatment at the population level can be known
because of metrics that are tied to resources (Curry et al., 2006, 2008). Some
metrics consist of straightforward information about investment in state and
national mass-media campaigns to promote smoking cessation and use of
evidence-based treatments, such as state quitlines. Other metrics are indicators
of the coverage of tobacco-cessation interventions in federal insurance plans
(such as Medicare and Medicaid) and employer-sponsored insurance (Bondi et al.,
2006). With support from the Robert Wood Johnson Foundation, several national
surveys of managed-care coverage for tobacco-cessation services have been
conducted (McPhillips-Tangum et al., 2006), but funding for those surveys has
ended. The National Committee for Quality Assurance (NCQA, 2008) report The
State of Health Care Quality 2007 states that counseling smokers to quit
increases the likelihood that they will do so and is a cost-effective
intervention. Interventions such as discussing tobacco-cessation strategies and
the use of NRTs increase the potential for smoking cessation. NCQA has a quality
measure for medical assistance with smoking cessation that consists of three
components: advising smokers to quit, discussing smoking-cessation medications,
and discussing smoking-cessation strategies. NCQA has recently proposed revising
the Health Plan Employer Data and Information Set measure for 2010 to include
other tobacco products, such as pipes, snuff, and chew (NCQA, 2008).

Those measures allow tracking of patients’ reports of whether their physicians
have advised them quit and offered behavioral and pharmacologic treatments.
Inpatient metrics derive from the Joint Commission accreditation measures of the
number of inpatients that receive advice or counseling for smoking cessation
during their hospital stays. These metrics are a core measure for assessing the
treatment of acute myocardial infarction, congestive heart failure, and
pneumonia. The National Quality Forum nursing-sensitive care measures include
nursing-centered interventions for smoking cessation (Robert Wood Johnson
Foundation, 2008). The Agency for Healthcare Research and Quality’s annual
National Healthcare Quality Report includes measures related to primary-care
provider advice to quit for all smokers over 18 years old during routine office
visits and post–myocardial infarction counseling to quit smoking (HHS, 2007).

Health-care system metrics related to front-line clinical practice are
complemented by individual-level data from national surveys, such as the NHIS.4
Although not part of the core items, information on healthcare provider advice
on, and assistance with, quitting and information on the use of evidence-based
treatments are available as part of the cancer-control supplement to the NHIS.
However, the NHIS surveys include only the civilian, noninstitutionalized US
population and exclude the military population, although dependents of
active-duty service members may be included.

With regard to the availability of effective behavioral treatment through a
national quitline network, the North American Quitline Consortium tracks the
number of services and types of telephone counseling available through state
quitlines. Members of the consortium also contribute information about quitline
use and the characteristics of quitline callers through their minimal dataset
(NAQC, 2008).

In addition to collecting specific information about tobacco-cessation services
offered by health-care providers, evaluation of comprehensive tobacco programs
has been undertaken and can serve as a model for future program evaluations. The
NCI reviewed the effectiveness of the state tobacco-control programs that had
participated in the federal ASSIST program described in Appendix A (Gilpin et
al., 2006). The Robert Wood Johnson Foundation has also assessed state
tobacco-control programs (http://www.rwjf.org/pr/product.jsp?id=21098). Public
dissemination of these evaluations can help to engage outside participants in
program improvement, encourage transparency in program processes, and permit
cross-program comparisons to determine best practices for tobacco control.
Program evaluations also help to identify needed policy changes and can support
leadership initiatives for program enhancements. CDC has developed a set of key
outcome indicators for evaluating comprehensive tobacco-control programs that
may be used by DoD and VA to monitor progress and determine the success of their
programs. Outcome indicators are presented for achieving three program goals
that are applicable to both DoD and VA populations: preventing tobacco-use
initiation, eliminating nonsmokers’ exposure to secondhand smoke, and promoting
quitting (CDC, 2009b).

Finding: Periodic and public evaluation of tobacco-control programs, based on
performance metrics and other surveillance tools help provide the necessary
information to modify tobacco-control programs to enhance their effectiveness.

Go to:


REFERENCES

 * ACLU (American Civil Liberties Union). 1998. Lifestyle Discrimination in the
   Workplace: Your Right to Privacy Under Attack. http://www
   .aclu.org/workplacerights /gen/13384res19981231 .html (accessed May 20,
   2009).
 * Acton, G. S., J. J. Prochaska, A. S. Kaplan, T. Small, and S. M. Hall. 2001.
   Depression and stages of change for smoking in psychiatric outpatients.
   Addictive Behaviors 26(5):621-631. [PubMed: 11676374]
 * Addington, J., N. El-Guebaly, W. Campbell, D. C. Hodgins, and D. Addington.
   1998. Smoking cessation treatment for patients with schizophrenia. American
   Journal of Psychiatry 155(7):974-976. [PubMed: 9659869]
 * Ait-Daoud, N., W. J. Lynch, J. K. Penberthy, A. B. Breland, G. R.
   Marzani-Nissen, and B. A. Johnson. 2006. Treating smoking dependence in
   depressed alcoholics. Alcohol Research and Health 29(3):213-220. [PMC free
   article: PMC6527046] [PubMed: 17373412]
 * Al-Delaimy, W. K., M. M. White, D. R. Trinidad, K. Messer, A. L. Mills, and
   J. P. Pierce. 2008. The California Tobacco Control Program: Can We Maintain
   the Progress? Results from the California Tobacco Survey, 1990-2005. La
   Jolla: University of California, San Diego.
 * Alam, F. D. 2007. Smoking has no place in psychiatric hospitals [4].
   Psychiatric Bulletin 31(4):154.
 * Althuis, M. D., M. Sexton, and D. Prybylski. 1999. Cigarette smoking and
   asthma symptom severity among adult asthmatics. Journal of Asthma
   36(3):257-264. [PubMed: 10350222]
 * American Lung Association. 2009. State of Tobacco Control 2008. Washington,
   DC: American Lung Association.
 * American Psychiatric Association. 1996. Practice guideline for the treatment
   of patients with nicotine dependence. American Journal of Psychiatry
   153(suppl):1- 31. [PubMed: 8831466]
 * ANRF (American Nonsmokers’ Rights Foundation). 2009. a. States,
   Commonwealths, and Municipalities with 100% Smokefree Laws in Workplaces,
   Restaurants, or Bars. http://www .no-smoke.org/pdf/100ordlist .pdf (accessed
   March 10, 2009).
 * ANRF. 2009. b. Percent of US State Populations Covered by 100% Smokefree Air
   Laws. hppt://www .no-smoke.org /pdf/percentstatepops.pdf (accessed March 4,
   2009).
 * ANRF. 2009. c. 100% Smokefree US Hospitals and Nursing Homes. http://www
   .no-smoke.org /pdf/smokefreehealthcare.pdf (accessed March 10, 2009).
 * ANRF. 2009. d. US Colleges and Universities with Smokefree Air Policies.
   http://www .no-smoke.org /pdf/smokefreecollegesuniversities .pdf (accessed
   March 10, 2009).
 * ANRF. 2009. e. State and Local Laws Restricting Smoking in Hotel and Motel
   Guest Rooms. http://www .no-smoke.org /pdf/tatelocallawshotelrooms.pdf
   (accessed March 4, 2009.
 * ANRF. 2009f. Municipalities with Smokefree Outdoor Dining Laws. http://www
   .no-smoke.org /pdf/SmokefreeOutdoorDining.pdf (accessed March 10, 2009).
 * ANRF. 2009. g. Municipalities with Smokefree Beach Laws. http://www
   .no-smoke.org /pdf/SmokefreeBeaches.pdf (accessed March 10, 2009).
 * ANRF. 2009. h. Municipalities with Smokefree Park Laws. http://www
   .no-smoke.org /pdf/SmokefreeParks.pdf (accessed March 10, 2009).
 * Anthonisen, N. R. 2004. Lessons from the Lung Health Study. Proceedings of
   the American Thoracic Society 1(2):143-145. [PubMed: 16113427]
 * Apollonio, D. E., and R. E. Malone. 2009. Turning negative into positive:
   Public health mass media campaigns and negative advertising. Health Education
   Research 24(3):483-495. [PMC free article: PMC2682642] [PubMed: 18948569]
 * Aronow, H. 2008. Peripheral arterial disease in the elderly: Recognition and
   management. American Journal of Cardiovascular Drugs 8(6):353-364. [PubMed:
   19159122]
 * Au, D. H., C. L. Bryson, J. W. Chien, H. Sun, E. M. Udris, L. E. Evans, and
   K. A. Bradley. 2009. The effects of smoking cessation on the risk of chronic
   obstructive pulmonary disease exacerbations. Journal of General Internal
   Medicine 24(4):457-463. E-published February 5, 2009. [PMC free article:
   PMC2659150] [PubMed: 19194768]
 * Aubin, H.-J. 2009. Management of emergent psychiatric symptoms during smoking
   cessation. Current Medical Research and Opinion 25(2):519-525. [PubMed:
   19193000]
 * Baker, A., R. Richmond, M. Haile, T. J. Lewin, V. J. Carr, R. L. Taylor, S.
   Jansons, and K. Wilhelm. 2006. A randomized controlled trial of a smoking
   cessation intervention among people with a psychotic disorder. American
   Journal of Psychiatry 163(11):1934-1942. [PubMed: 17074945]
 * Bala, M., L. Strzeszynski, and K. Cahill. 2008. Mass media interventions for
   smoking cessation in adults. Cochrane Database of Systematic Reviews
   1:CD004704. [PubMed: 18254058]
 * Barth, J., J. Critchley, and J. Bengel. 2008. Psychosocial interventions for
   smoking cessation in patients with coronary heart disease. Cochrane Database
   of Systematic Reviews 1:CD006886. [PubMed: 18254119]
 * Bartosch, W. J., and G. C. Pope. 2002. Economic effect of restaurant smoking
   restrictions on restaurant business in Massachusetts, 1992 to 1998. Tobacco
   Control 11:1138-1142. [PMC free article: PMC1766082] [PubMed: 12034980]
 * Biener, L., D. Cullen, Z. X. Di, and S. K. Hammond. 1997. Household smoking
   restrictions and adolescents’ exposure to environmental tobacco smoke.
   Preventive Medicine 26(3):358-363. [PubMed: 9144760]
 * Bondi, M. A., J. R. Harris, D. Atkins, M. E. French, and B. Umland. 2006.
   Employer coverage of clinical preventive services in the United States.
   American Journal of Health Promotion 20(3):214-222. [PubMed: 16422142]
 * Bonta, D. 2007. Clean air laws. Appendix B. In Ending the Tobacco Problem,
   edited by R. J. Bonnie, editor; , K. Stratton, editor; , and R. B. Wallace,
   editor. . Institute of Medicine. Washington, DC: The National Academies
   Press.
 * Borland, R., C. J. Segan, P. M. Livingston, and N. Owen. 2001. The
   effectiveness of callback counseling for smoking cessation: A randomized
   trial. Addiction 96(6):881-889. [PubMed: 11399219]
 * Borland, R., H. H. Yong, K. M. Cummings, A. Hyland, S. Anderson, and G. T.
   Fong. 2006. Determinants and consequences of smoke-free homes: Findings from
   the International Tobacco Control (ITC) Four Country Survey. Tobacco Control
   15(Suppl 3):III42-III50. [PMC free article: PMC2593064] [PubMed: 16754946]
 * Brown, R. A., C. W. Kahler, R. Niaura, D. B. Abrams, S. D. Sales, S. E.
   Ramsey, M. G. Goldstein, E. S. Burgess, and I. W. Miller. 2001.
   Cognitive-behavioral treatment for depression in smoking cessation. Journal
   of Consulting and Clinical Psychology 69(3):471-480. [PMC free article:
   PMC1832078] [PubMed: 11495176]
 * Brownson, R. C., J. R. Davis, J. Jackson-Thompson, and J. C. Wilkerson. 1995.
   Environmental tobacco smoke awareness and exposure: Impact of a statewide
   clean indoor air law and the report of the US Environmental Protection
   Agency. Tobacco Control 4:132-138.
 * Brownson, R. C., M. P. Eriksen, R. M. Davis, and K.E. Warner. 1997.
   Environmental tobacco smoke: Health effects and policies to reduce exposure.
   Annual Review of Public Health 18:163-185. [PubMed: 9143716]
 * Burgess, E. S., R. A. Brown, C. W. Kahler, R. Niaura, D. B. Abrams, M. G.
   Goldstein, and I. W. Miller. 2002. Patterns of change in depressive symptoms
   during smoking cessation: Who’s at risk for relapse? Journal of Consulting
   and Clinical Psychology 70(2):356-361. [PMC free article: PMC1808225]
   [PubMed: 11952193]
 * Burke, B. L., H. Arkowitz, and M. Menchola. 2003. The efficacy of
   motivational interviewing: A meta-analysis of controlled clinical trials.
   Journal of Consulting and Clinical Psychology 71(5):843-861. [PubMed:
   14516234]
 * Burling, T. A., A. S. Burling, and D. Latini. 2001. A controlled smoking
   cessation trial for substance-dependent inpatients. Journal of Consulting and
   Clinical Psychology 69(2):295-304. [PubMed: 11393606]
 * Burns, D. M. 2003. Epidemiology of smoking-induced cardiovascular disease.
   Progress in Cardiovascular Diseases 46(1):11-29. [PubMed: 12920698]
 * Butler, C. C., S. Rollnick, D. Cohen, M. Bachmann, I. Russell, and N. Stott.
   1999. Motivational consulting versus brief advice for smokers in general
   practice: A randomized trial. British Journal of General Practice
   49(445):611-616.
 * Cahill, K., and R. Perera. 2008. Competitions and incentives for smoking
   cessation. Cochrane Database of Systematic Reviews 3:CD004307. [PubMed:
   18646105]
 * Canga, N., J. De Irala, E. Vara, M. J. Duaso, A. Ferrer, and M. A.
   Martinez-Gonzalez. 2000. Intervention study for smoking cessation in diabetic
   patients: A randomized controlled trial in both clinical and primary care
   settings. Diabetes Care 23(10):1455-1460. [PubMed: 11023136]
 * Carmody, T. P. 1992. Preventing relapse in the treatment of nicotine
   addiction: Current issues and future directions. Journal of Psychoactive
   Drugs 24(2):131-158. [PubMed: 1506998]
 * Carmody, T. P., C. Duncan, J. A. Simon, S. Solkowitz, J. Huggins, S. Lee, and
   K. Delucchi. 2008. Hypnosis for smoking cessation: A randomized trial.
   Nicotine and Tobacco Research 10(5):811-818. [PubMed: 18569754]
 * Carr, A. B., and J. O. Ebbert. 2006. Interventions for tobacco cessation in
   the dental setting. Cochrane Database of Systematic Reviews 3: CD005084.
   [PubMed: 16437517]
 * Cavender, J. B., W. J. Rogers, L. D. Fisher, B. J. Gersh, C. J. Coggin, and
   W. O. Myers. 1992. Effects of smoking on survival and morbidity in patients
   randomized to medical or surgical therapy in the coronary artery surgery
   study (CASS): 10-year follow-up. Journal of the American College of
   Cardiology 20(2):287-294. [PubMed: 1634662]
 * CDC (Centers for Disease Control and Prevention). 2007. a. Best Practices for
   Comprehensive Tobacco Control Programs—2007. Atlanta, GA: National Center for
   Chronic Disease Prevention and Health Promotion, Office on Smoking and
   Health.
 * CDC. 2007. b. National Health Interview Surveys—United States, 1965–2006:
   Percentage of Young Adults Who Were Current, Former or Never Smokers,Overall
   and by Sex, Race, and Education. http://www .cdc.gov/tobacco /data_statistics
   /tables/adult/table_12.htm (accessed May 19, 2009).
 * CDC. 2009. a. Tobacco: Guide to Community Preventative Services. www
   .thecommunityguide.org/tobacco (accessed May 19, 2009).
 * CDC. 2009. b. The Community Guide: What Works to Promote Health. www
   .thecommunityguide.org (accessed May 28, 2009).
 * Chaloupka, F. J. 1999. Macro-social influences: The effects of prices and
   tobacco-control policies on the demand for tobacco products. Nicotine and
   Tobacco Research 1(Suppl 1):S105-S109. [PubMed: 11072413]
 * Chaloupka, F. J., and K. E. Warner. 2000. The economics of smoking. In
   Handbook of Health Economics. Vol. 1B, edited by A. J. Culyer, editor; and J.
   P. Newhouse, editor. . Amsterdam, The Netherlands: Elsevier. Pp.1539-1627.
 * Chaloupka, F. J., and H. Wechsler. 1997. Price, tobacco control policies and
   smoking among young adults. Journal of Health Economics 16(3):359-373.
   [PubMed: 10169306]
 * Chapman, S. 2005. The smoker-free workplace: The case against. Tobacco
   Control 14(2):144. [PMC free article: PMC1748013] [PubMed: 15791027]
 * Clark, M. M., P. A. Decker, K. P. Offord, C. A. Patten, K. S. Vickers, I. T.
   Croghan, J. T. Hays, R. D. Hurt, and L. C. Dale. 2004. Weight concerns among
   male smokers. Addictive Behaviors 29(8):1637-1641. [PubMed: 15451131]
 * Clark, M. M., J. T. Hays, K. S. Vickers, C. A. Patten, I. T. Croghan, E.
   Berg, S. Wadewitz, S. Schwartz, P. A. Decker, K. P. Offord, R. W. Squires,
   and R. D. Hurt. 2005. Body image treatment for weight concerned smokers: A
   pilot study. Addictive Behaviors 30(6):1236-1240. [PubMed: 15925132]
 * Clark, P. I., M. W. Schooley, B. Pierce, J. Schulman, A. M. Hartman, and C.
   L. Schmitt. 2006. a. Impact of home smoking rules on smoking patterns among
   adolescents and young adults. Preventing Chronic Disease 3(2):A41. [PMC free
   article: PMC1563982] [PubMed: 16539782]
 * Clark, M. M., R. D. Hurt, I. T. Croghan, C. A. Patten, P. Novotny, J. A.
   Sloan, S. R. Dakhil, G. A. Croghan, E. J. Wos, K. M. Rowland, A. Bernath, R.
   F. Morton, S. P. Thomas, L. K. Tschetter, S. Garneau, P. J. Stella, L. P.
   Ebbert, D. B. Wender, and C. L. Loprinzi. 2006. b. The prevalence of weight
   concerns in a smoking abstinence clinical trial. Addictive Behaviors
   31(7):1144-1152. [PubMed: 16137833]
 * Cobb, N. K., A. L. Graham, B. C. Bock, G. Papandonatos, and D. B. Abrams.
   2005. Initial evaluation of a real-world internet smoking cessation system.
   Nicotine and Tobacco Research 7(2):207-216. [PMC free article: PMC2885701]
   [PubMed: 16036277]
 * Collie, C. F., C. P. Clancy, B. P. Yeatts, and J. C. Beckham. 2006.
   Posttraumatic stress disorder and smoking cessation in veteran smokers.
   Journal of Trauma Practice 3(4):37-63.
 * Colton, C. W., and R. W. Manderscheid. 2006. Congruencies in increased
   mortality rates, years of potential life lost, and causes of death among
   public mental health clients in eight states. Preventing Chronic Disease
   3(2):A42. [PMC free article: PMC1563985] [PubMed: 16539783]
 * Covey, L. S., A. Bomback, and G. W. Y. Yan. 2006. History of depression and
   smoking cessation: A rejoinder [1]. Nicotine and Tobacco Research
   8(2):315-319. [PubMed: 16766424]
 * Croghan, I. T., R. D. Hurt, S. R. Dakhil, G. A. Croghan, J. A. Sloan, P. J.
   Novotny, K. M. Rowland, A. Bernath, M. L. Loots, N. A. Le-Lindqwister, L. K.
   Tschetter, S. C. Garneau, K. A. Flynn, L. P. Ebbert, D. B. Wender, and C. L.
   Loprinzi. 2007. Randomized comparison of a nicotine inhaler and bupropion for
   smoking cessation and relapse prevention. Mayo Clinic Proceedings
   82(2):186-195. [PubMed: 17290726]
 * Croghan, I. T., J. O. Ebbert, R. D. Hurt, J. T. Hays, L. C. Dale, N. Warner,
   and D. R. Schroeder. 2009. Gender differences among smokers receiving
   interventions for tobacco dependence in a medical setting. Addictive
   Behaviors 34(1):61-67. [PubMed: 18814974]
 * Cummins, S. E., L. Bailey, S. Campbell, C. Koon-Kirby, S. H. Zhu. 2007.
   Tobacco cessation quitlines in North America: A descriptive study. Tobacco
   Control 16(Suppl 1):i9-i15. [PMC free article: PMC2598516] [PubMed: 18048639]
 * Curry, S. J., C. T. Orleans, P. Keller, and M. Fiore. 2006. Promoting smoking
   cessation in the healthcare environment: 10 years later. American Journal of
   Preventive Medicine 31(3):269-272. [PubMed: 16905041]
 * Curry, S. J., A. K. Sporer, O. Pugach, R. T. Campbell, and S. Emery. 2007.
   Use of tobacco cessation treatments among young adult smokers: 2005 National
   Health Interview Survey. American Journal of Public Health 97(8):1464-1469.
   [PMC free article: PMC1931476] [PubMed: 17600243]
 * Curry, S. J., P. A. Keller, C. T. Orleans, and M. C. Fiore. 2008. The role of
   health care systems in increased tobacco cessation. Annual Review of Public
   Health 29:411-428. [PubMed: 18173387]
 * Dalack, G. W., and J. H. Meador-Woodruff. 1996. Smoking, smoking withdrawal
   and schizophrenia: Case reports and a review of the literature. Schizophrenia
   Research 22(2):133-141. [PubMed: 8958597]
 * Dale, L. C., R. D. Hurt, K. P. Offord, G. M. Lawson, I. T. Croghan, and D. R.
   Schroeder. 1995. High-dose nicotine patch therapy: Percentage of replacement
   and smoking cessation. Journal of the American Medical Association
   274(17):1353-1358. [PubMed: 7563559]
 * Davies, M. J., S. Heller, T. C. Skinner, M. J. Campbell, M. E. Carey, S.
   Cradock, H. M. Dallosso, H. Daly, Y. Doherty, S. Eaton, C. Fox, L. Oliver, K.
   Rantell, G. Rayman, and K. Khunti. 2008. Effectiveness of the Diabetes
   Education and Self Management for Ongoing and Newly Diagnosed (DESMOND)
   programme for people with newly diagnosed type 2 diabetes: Cluster randomised
   controlled trial. British Medical Journal 336(7642):491-495. [PMC free
   article: PMC2258400] [PubMed: 18276664]
 * Dent, L. A., K. J. Harris, and C. W. Noonan. 2007. Tobacco interventions
   delivered by pharmacists: A summary and systematic review. Pharmacotherapy
   27(7):1040-1051. [PubMed: 17594210]
 * Dent, L. A., K. J. Harris, and C. W. Noonan. 2009. Randomized trial assessing
   the effectiveness of a pharmacist-delivered program for smoking cessation.
   The Annals of Pharmacotherapy 43(2):194-201. [PubMed: 19193572]
 * Desai, H. D., J. Seabolt, and M. W. Jann. 2001. Smoking in patients receiving
   psychotrophic medications: A pharmacokinetic perspective. CNS Drugs
   15(6):469-494. [PubMed: 11524025]
 * Dobie, D. J., D. R. Kivlahan, C. Maynard, K. R. Bush, T. M. Davis, and K. A.
   Bradley. 2004. Posttraumatic stress disorder in female veterans: Association
   with self-reported health problems and functional impairment. Archives of
   Internal Medicine 164(4):394-400. [PubMed: 14980990]
 * DoD (Department of Defense). 2006. Department of Defense Survey of Health
   Related Behaviors Among Active Duty Military Personnel 2005. Research
   Triangle Park, NC: RTI International.
 * Doolan, D. M., and E. S. Froelicher. 2008. Smoking cessation interventions
   and older adults. Progress in Cardiovascular Nursing 23(3):119-127. [PubMed:
   19039892]
 * Duffy, S. A., D. L. Ronis, M. Valenstein, M. T. Lambert, K. E. Fowler, L.
   Gregory, C. Bishop, L. L. Myers, F. C. Blow, and J. E. Terrell. 2006. A
   tailored smoking, alcohol, and depression intervention for head and neck
   cancer patients. Cancer Epidemiology Biomarkers and Prevention
   15(11):2203-2208. [PubMed: 17119047]
 * Ebbert, J. O., V. Montori, K. S. Vickers, P. C. Erwin, L. C. Dale, and L. F.
   Stead. 2007. a. Interventions for smokeless tobacco use cessation. Cochrane
   Database of Systematic Reviews 4:CD004306. [PubMed: 17943813]
 * Ebbert, J. O., A. Sood, J. T. Hays, L. C. Dale, and R. D. Hurt. 2007. b.
   Treating tobacco dependence: Review of the best and latest treatment options.
   Journal of Thoracic Oncology 2(3):249-256. [PubMed: 17410050]
 * Ellingstad, T. P., L. C. Sobell, M. B. Sobell, P. A. Cleland, and S. Agrawal.
   1999. Alcohol abusers who want to quit smoking: Implications for clinical
   treatment. Drug and Alcohol Dependence 54(3):259-265. [PubMed: 10372799]
 * Emery, S., M. M. White, and J. P. Pierce. 2001. Does cigarette price
   influence adolescent experimentation? Journal of Health Economics
   20(2):261-270. [PubMed: 11252373]
 * Emont, S. L., W. S. Choi, T. E. Novotny, and G. A. Giovino. 1992. Clean
   indoor air legislation, taxation, and smoking behaviour in the United States:
   An ecological analysis. Tobacco Control 2:13-17.
 * Etter, J. F. 2002. Using new information technology to treat tobacco
   dependence. Respiration 69(2):111-114. [PubMed: 11961422]
 * Etter, J. F. 2006. A list of the most popular smoking cessation web sites and
   a comparison of their quality. Nicotine and Tobacco Research 8(Suppl
   1):S27-S34. [PubMed: 17491168]
 * Evins, A. E., V. K. Mays, N. A. Rigotti, T. Tisdale, C. Cather, and D. C.
   Goff. 2001. A pilot trial of bupropion added to cognitive behavioral therapy
   for smoking cessation in schizophrenia. Nicotine and Tobacco Research
   3(4):397-403. [PubMed: 11694208]
 * Fagerstrom, K., and H. J. Aubin. 2009. Management of smoking cessation in
   patients with psychiatric disorders. Current Medical Research and Opinion
   25(2):511-518. [PubMed: 19192999]
 * Falk, D. E., H. Y. Yi, and S. Hiller-Sturmhofel. 2006. An epidemiologic
   analysis of co-occurring alcohol and tobacco use and disorders: Findings from
   the National Epidemiologic Survey on Alcohol and Related Conditions. Alcohol
   Research and Health 29(3):162-171. [PMC free article: PMC6527037] [PubMed:
   17373404]
 * Farkas, A. J., E. A. Gilpin, M. M. White, and J. P. Pierce. 2000. Association
   between household and workplace smoking restrictions and adolescent smoking.
   Journal of the American Medical Association 284(6):717-722. [PubMed:
   10927780]
 * Farrelly, M. C., K. C. Davis, J. Duke, and P. Messeri. 2009. Sustaining
   “truth”: Changes in youth tobacco attitudes and smoking intentions after 3
   years of a national antismoking campaign. Health Education Research
   24(1):42-48. [PubMed: 18203679]
 * FDA (Food and Drug Administration). 2008. Varenicline (Marketed as Chantix)
   Information. http://www .fda.gov/CDER /Drug/infopage/varenicline/default .htm
   (accessed May 20, 2009).
 * Fee, E., and T. M. Brown. 2004. Hospital smoking bans and their impact.
   American Journal of Public Health 94(2):185. [PMC free article: PMC1448226]
   [PubMed: 14759925]
 * Feil, E. G., J. Noell, E. Lichtenstein, S. M. Boles, and H. G. McKay. 2003.
   Evaluation of an internet-based smoking cessation program: Lessons learned
   from a pilot study. Nicotine and Tobacco Research 5(2):189-194. [PubMed:
   12745491]
 * Fichtenberg, C. M., and S. A. Glantz. 2002. Effect of smoke-free workplaces
   on smoking behaviour: Systematic review. British Medical Journal
   325(7357):188-191. [PMC free article: PMC117445] [PubMed: 12142305]
 * Fiore, M. C. 2003. Preventing 3 million premature deaths and helping 5
   million smokers quit: A national action plan for tobacco cessation. American
   Journal of Public Health 94(2):205-210. [PMC free article: PMC1448229]
   [PubMed: 14759928]
 * Fiore, M. C., and C. R. Jaen. 2008. A clinical blueprint to accelerate the
   elimination of tobacco use. Journal of the American Medical Association
   299(17):2083-2085. [PubMed: 18460668]
 * Fiore, M. C., C. R. Jaen, T. B. Baker, et al. 2008. Clinical Practice
   Guideline—Treating Tobacco Use and Dependence: 2008 Update. Washington, DC:
   Department of Health and Human Services.
 * Fong, G. T., A. Hyland, R. Borland, D. Hammond, G. Hastings, A. McNeill, S.
   Anderson, K. M. Cummings, S. Allwright, M. Mulcahy, F. Howell, L. Clancy, M.
   E. Thompson, G. Connolly, and P. Driezen. 2006. Reductions in tobacco smoke
   pollution and increases in support for smoke-free public places following the
   implementation of comprehensive smoke-free workplace legislation in the
   Republic of Ireland: Findings from the ITC Ireland/UK Survey. Tobacco Control
   15(Suppl 3):iii51-iii58. [PMC free article: PMC2593063] [PubMed: 16754947]
 * Forchuk, C., R. Norman, A. Malla, M. L. Martin, T. McLean, S. Cheng, K. Diaz,
   E. McIntosh, A. Rickwood, S. Vos, and C. Gibney. 2002. Schizophrenia and the
   motivation for smoking. Perspectives in Psychiatric Care 38(2):41-49.
   [PubMed: 12132630]
 * Franks, P., A. F. Jerant, J. P. Leigh, D. Lee, A. Chiem, I. Lewis, and S.
   Lee. 2007. Cigarette prices, smoking, and the poor: Implications of recent
   trends. American Journal of Public Health 97(10):1873-1877. [PMC free
   article: PMC1994180] [PubMed: 17761576]
 * Fu, S. S., M. McFall, A. J. Saxon, J. C. Beckham, T. P. Carmody, D. G. Baker,
   and A. M. Joseph. 2007. Post-traumatic stress disorder and smoking: A
   systematic review. Nicotine and Tobacco Research 9(11):1071-1084. [PubMed:
   17978982]
 * Gallet, C. A., and J. A. List. 2003. Cigarette demand: A meta-analysis of
   elasticities. Health Economics 12(10):821-835. [PubMed: 14508867]
 * Gilpin, E. A., L. Lee, J. P. Pierce, H. Tang, and J. Lloyd. 2004. Support for
   protection from secondhand smoke: California 2002 [2]. Tobacco Control
   13(1):96. [PMC free article: PMC1747812] [PubMed: 14985608]
 * Gilpin, E. A., K. Messer, M. M. White, and J. P. Pierce. 2006. What
   contributed to the major decline in per capita cigarette consumption during
   California’s comprehensive tobacco control programme? Tobacco Control
   15(4):308-316. [PMC free article: PMC2563607] [PubMed: 16885580]
 * Glasgow, R. E., K. M. Cummings, and A. Hyland. 1997. Relationship of worksite
   smoking policy to changes in employee tobacco use: Findings from COMMIT, the
   Community Intervention Trial for Smoking Cessation. Tobacco Control 6(Suppl
   2):S44-S48. [PMC free article: PMC1766219] [PubMed: 9583652]
 * Glassman, A. H., L. S. Covey, F. Stetner, and S. Rivelli. 2001. Smoking
   cessation and the course of major depression: A follow-up study. Lancet
   357(9272):1929-1932. [PubMed: 11425414]
 * Godtfredsen, N. S., T. H. Lam, T. T. Hansel, M. E. Leon, N. Gray, C. Dresler,
   D. M. Burns, E. Prescott, and J. Vestbo. 2008. COPD-related morbidity and
   mortality after smoking cessation: Status of the evidence. European
   Respiratory Journal 32(4):844-853. [PubMed: 18827152]
 * Goldberg, J. O., S. Moll, and A. Washington. 1996. Exploring the challenge of
   tobacco use and schizophrenia. Psychiatric Rehabilitation Skills 1(1):51-63.
 * Gray, N. J. 2005. The case for smoker-free workplaces. Tobacco Control
   14(2):143. [PMC free article: PMC1748008] [PubMed: 15791026]
 * Gritz, E. R., C. Dresler, and L. Sarna. 2005. Smoking, the missing drug
   interaction in clinical trials: Ignoring the obvious. Cancer Epidemiology
   Biomarkers and Prevention 14(10):2287-2293. [PubMed: 16214906]
 * Gritz, E. R., M. C. Fingeret, D. J. Vidrine, A. B. Lazev, N. V. Mehta, and G.
   P. Reece. 2006. Successes and failures of the teachable moment: Smoking
   cessation in cancer patients. Cancer 106(1):17-27. [PubMed: 16311986]
 * Gritz, E. R., D. J. Vidrine, and M. Cororve Fingeret. 2007. Smoking
   cessation. A critical component of medical management in chronic disease
   populations. American Journal of Preventive Medicine 33(Suppl 6):S414-S422.
   [PubMed: 18021917]
 * Gruber, J., and J. Zinman. 2001. Youth smoking in the United States: Evidence
   and implications. In Risky Behavior Among Youths: An Economic Analysis,
   edited by J. Gruber, editor. . Chicago, IL: University of Chicago Press.
 * Gulliver, S. B., B. W. Kamholz, and A. W. Helstrom. 2006. Smoking cessation
   and alcohol abstinence: What do the data tell us? Alcohol Research and Health
   29(3):208-212. [PMC free article: PMC6527036] [PubMed: 17373411]
 * Gustafson, R. 1992. Operant conditioning of activities of daily living on a
   psychogeriatric ward: A simple method. Psychological Reports 70(2):603-607.
   [PubMed: 1598377]
 * Haas, A. L., R. F. Muñoz, G. L. Humfleet, V. I. Reus, and S. M. Hall. 2004.
   Influences of mood, depression history, and treatment modality on outcomes in
   smoking cessation. Journal of Consulting and Clinical Psychology
   72(4):563-570. [PubMed: 15301640]
 * Hagman, B. T., C. D. Delnevo, M. Hrywna, and J. M. Williams. 2008. Tobacco
   use among those with serious psychological distress: Results from the
   national survey of drug use and health, 2002. Addictive Behaviors
   33(4):582-592. [PMC free article: PMC2696205] [PubMed: 18158218]
 * Haire-Joshu, D., R. E. Glasgow, and T. L. Tibbs. 1999. Smoking and diabetes.
   Diabetes Care 22(11):1887-1898. [PubMed: 10546025]
 * Hajek, P., and L. F. Stead. 2001. Aversive smoking for smoking cessation.
   Cochrane Database of Systematic Reviews 2:CD000546. [PMC free article:
   PMC7045729] [PubMed: 15266433]
 * Hajek, P., L. F. Stead, R. West, and M. Jarvis. 2005. Relapse prevention
   interventions for smoking cessation. Cochrane Database of Systematic Reviews
   1:CD003999. [PubMed: 15674921]
 * Hall, S. M., R. F. Munoz, and V. I. Reus. 1994. Cognitive-behavioral
   intervention increases abstinence rates for depressive-history smokers.
   Journal of Consulting and Clinical Psychology 62(1): 141-146. [PubMed:
   8034816]
 * Hall, S. M., K. L. Sees, R. F. Munoz, V. I. Reus, C. Duncan, G. L. Humfleet,
   and D. T. Hartz. 1996. Mood management and nicotine gum in smoking treatment:
   A therapeutic contact and placebo-controlled study. Journal of Consulting and
   Clinical Psychology 64(5):1003-1009. [PubMed: 8916629]
 * Hall, S. M., V. I. Reus, R. F. Muñoz, K. L. Sees, G. Humfleet, D. T. Hartz,
   S. Frederick, and E. Triffleman. 1998. Nortriptyline and cognitive-behavioral
   therapy in the treatment of cigarette smoking. Archives of General Psychiatry
   55(8):683-690. [PubMed: 9707377]
 * Hall, S. M., J. Y. Tsoh, J. J. Prochaska, S. Eisendrath, J. S. Rossi, C. A.
   Redding, A. B. Rosen, M. Meisner, G. L. Humfleet, and J. A. Gorecki. 2006.
   Treatment for cigarette smoking among depressed mental health outpatients: A
   randomized clinical trial. American Journal of Public Health
   96(10):1808-1814. [PMC free article: PMC1586139] [PubMed: 17008577]
 * Halperin, A. C., and N. A. Rigotti. 2003. US public universities’ compliance
   with recommended tobacco-control policies. Journal of American College Health
   51(5):181-188. [PubMed: 12822709]
 * Harris, J. E., and S. W. Chan. 1999. The continuum-of-addiction: Cigarette
   smoking in relation to price among Americans aged 15-29. Health Economics
   8(1):81-86. [PubMed: 10082146]
 * Haug, N. A., S. M. Hall, J. J. Prochaska, A. B. Rosen, J. Y. Tsoh, G.
   Humfleet, K. Delucchi, J. S. Rossi, C. A. Redding, and S. Eisendrath. 2005.
   Acceptance of nicotine dependence treatment among currently depressed
   smokers. Nicotine and Tobacco Research 7(2):217-224. [PubMed: 16036278]
 * Heffner, J. L., S. W. Barrett, and R. M. Anthenelli. 2007. Predicting alcohol
   misusers’ readiness and ability to quit smoking: A critical review. Alcohol
   and Alcoholism 42(3):186-195. [PubMed: 17526628]
 * Heironimus, J. 1992. Memorandum: Impact of Workplace Smoking Restrictions on
   Consumption and Incidence. New York: Phillip Morris USA. Bates Number
   2044762531.
 * Hertzberg, M. A., S. D. Moore, M. E. Feldman, and J. C. Beckham. 2001. A
   preliminary study of bupropion sustained-release for smoking cessation in
   patients with chronic posttraumatic stress disorder. Journal of Clinical
   Psychopharmacology 21(1):94-98. [PubMed: 11199956]
 * HHS (Department of Health and Human Services). 2007. National Healthcare
   Quality Report 2007. Rockville, MD: Agency for Healthcare Research and
   Quality.
 * Hilberink, S. R., J. E. Jacobs, B. J. A. M. Bottema, H. De Vries, and R. P.
   T. M. Grol. 2005. Smoking cessation in patients with COPD in daily general
   practice (SMOCC): Six months’ results. Preventive Medicine 41(5-6):822-827.
   [PubMed: 16203030]
 * Hill, K. G., J. D. Hawkins, R. F. Catalano, R. D. Abbott, and J. Guo. 2005.
   Family influences on the risk of daily smoking initiation. Journal of
   Adolescent Health 37(3):202-210. [PubMed: 16109339]
 * Himelhoch, S., and G. Daumit. 2003. To whom do psychiatrists offer
   smoking-cessation counseling? American Journal of Psychiatry
   160(12):2228-2230. [PubMed: 14638595]
 * Hitsman, B., D. B. Abrams, W. G. Shadel, R. Niaura, B. Borrelli, K. M.
   Emmons, R. A. Brown, R. M. Swift, P. M. Monti, D. J. Rohsenow, and S. M.
   Colby. 2002. Depressive symptoms and readiness to quit smoking among
   cigarette smokers in outpatient alcohol treatment. Psychol Addictive
   Behaviors 16(3):264-268. [PubMed: 12236463]
 * Hitsman, B., B. Borrelli, D. E. McChargue, B. Spring, and R. Niaura. 2003.
   History of depression and smoking cessation outcome: A meta-analysis. Journal
   of Consulting and Clinical Psychology 71(4): 657-663. [PubMed: 12924670]
 * Hollis, J. F., T. A. McAfee, J. L. Fellows, S. M. Zbikowski, M. Stark, and K.
   Riedlinger. 2007. The effectiveness and cost effectiveness of telephone
   counselling and the nicotine patch in a state tobacco quitline. Tobacco
   Control 16(Suppl 1):i53-i59. [PMC free article: PMC2598511] [PubMed:
   18048633]
 * Hopkins, D. P. 2001. Recommendations regarding interventions to reduce
   tobacco use and exposure to environmental tobacco smoke. American Journal of
   Preventive Medicine 20(Suppl 2):10-15. [PubMed: 11173214]
 * Houle, B., and M. Siegel. 2009. Smoker-free workplace policies: Developing a
   model of public health consequences of workplace policies barring employment
   to smokers. Tobacco Control 18(1): 64-69. [PMC free article: PMC2722043]
   [PubMed: 19168490]
 * Hovell, M., D. Wahlgren, and C. Gehrman. 2002. The behavioral ecological
   model: Integrating public health and behavioral science. In Emerging Theories
   in Health Promotion Practice and Research: Strategies for Improving Public
   Health, edited by R. DiClemente, editor. . San Francisco, CA: Jossey-Bass.
   Pp.347-385.
 * Howell, F. 2005. Smoke-free bars in Ireland: A runaway success. Tobacco
   Control 14(2):73-74. [PMC free article: PMC1748019] [PubMed: 15791009]
 * Huang, P., and M. McCusker. 2004. Impact of a smoking ban on restaurant and
   bar revenues—El Paso, Texas, 2002. Morbidity and Mortality Weekly Report
   53(7):150-152. [PubMed: 14985652]
 * Hughes, J. R., J. Keely, and S. Naud. 2004. Shape of the relapse curve and
   long-term abstinence among untreated smokers. Addiction 99(1):29-38. [PubMed:
   14678060]
 * Hughes, J. R., E. N. Peters, and S. Naud. 2008. Relapse to smoking after 1
   year of abstinence: A meta-analysis. Addictive Behaviors 33(12):1516-1520.
   [PMC free article: PMC2577779] [PubMed: 18706769]
 * Hurt, R. D., K. P. Offord, I. T. Croghan, L. Gomez-Dahl, T. E. Kottke, R. M.
   Morse, and L. J. Melton III. 1996. Mortality following inpatient addictions
   treatment: Role of tobacco use in a community-based cohort. Journal of the
   American Medical Association 275(14):1097-1103. [PubMed: 8601929]
 * Hyland, A., C. Higbee, J. E. Bauer, G. A. Giovino, and K. M. Cummings. 2004.
   Cigarette purchasing behaviors when prices are high. Journal of Public Health
   Management and Practice 10(6):497-500. [PubMed: 15643371]
 * IARC (International Agency for Research on Cancer). 2007. Smokeless Tobacco
   and Some Tobacco-Specific N-Nitrosamines. IARC Monographs on the Evaluation
   of Carcinogenic Risks to Humans. Volume 89. Lyon, France: IARC. [PMC free
   article: PMC4781254] [PubMed: 18335640]
 * IOM (Institute of Medicine). 2001. Clearing the Smoke: Assessing the Science
   Base for Tobacco Harm Reduction. Washington, DC: National Academy Press.
   [PubMed: 25057541]
 * IOM. 2005. Crossing the Quality Chasm: A New Health System for the 21st
   Century. Washington, DC: The National Academies Press. [PubMed: 25057539]
 * IOM. 2007. Ending the Tobacco Problem: A Blueprint for the Nation.
   Washington, DC: The National Academies Press.
 * Jansink, R., J. Braspenning, T. van der Weijden, L. Niessen, G. Elwyn, and R.
   Grol. 2009. Nurse-led motivational interviewing to change the lifestyle of
   patients with type 2 diabetes (MILD-project): Protocol for a cluster,
   randomized, controlled trial on implementing lifestyle recommendations. BMC
   Health Services Research 9:19. [PMC free article: PMC2646713] [PubMed:
   19183462]
 * Jha, P., F. J. Chaloupka, M. Corrao, and B. Jacob. 2006. Reducing the burden
   of smoking world-wide: Effectiveness of interventions and their coverage.
   Drug and Alcohol Review 25(6):597-609. [PubMed: 17132576]
 * Joint Commission, The. 2008. Nursing performance measurement set promises to
   deliver substantial quality improvement. PM Beat. http://www .jointcommission
   .org/NR/rdonlyres /884B9EE0-2EA8-4C00-8347-43AC13226D7 /0
   /NursingPerformanceMeasures0108.pdf (accessed March 10, 2009).
 * Jonsdottir, H., R. Jonsdottir, T. Geirsdottir, K. S. Sveinsdottir, and T.
   Sigurdardottir. 2004. Multicomponent individualized smoking cessation
   intervention for patients with lung disease. Journal of Advanced Nursing
   48(6):594-604. [PubMed: 15548250]
 * Joseph, A. M., and S. S. Fu. 2003. Smoking cessation for patients with
   cardiovascular disease: What is the best approach? American Journal of
   Cardiovascular Drugs 3(5):339-49. [PubMed: 14728068]
 * Joseph, A. M., M. L. Willenbring, D. Nelson, and S. M. Nugent. 2002. Timing
   of alcohol and smoking cessation study. Alcoholism: Clinical and Experimental
   Research 26(12):1945-1946. [PubMed: 12500130]
 * Joseph, A. M., D. B. Nelson, S. M. Nugent, and M. L. Willenbring. 2003.
   Timing of alcohol and smoking cessation (TASC): Smoking among substance use
   patients screened and enrolled in a clinical trial. Journal of Addictive
   Diseases 22(4):87-107. [PubMed: 14723480]
 * Kaiser Family Foundation. 2009. Percent of Smokers Who Attempt to Quit
   Smoking, 2007. http://www .statehealthfacts .org/comparemaptable
   .jsp?ind=83andcat=2 (accessed May 1, 2009).
 * Katzburg, J. R., M. M. Farmer, I. V. Poza, and S. E. Sherman. 2008. Listen to
   the consumer: Designing a tailored smoking-cessation program for women.
   Substance Use and Misuse 43(8-9):1240-1259. [PubMed: 18649241]
 * Khantzian, E. J. 1997. The self-medication hypothesis of substance use
   disorders: A reconsideration and recent applications. Harvard Review of
   Psychiatry 4(5):231-244. [PubMed: 9385000]
 * Klesges, R. C., C. K. Haddock, C. F. Chang, G. W. Talcott, and H. A. Lando.
   2001. The association of smoking and the cost of military training. Tobacco
   Control 10(1):43-47. [PMC free article: PMC1764000] [PubMed: 11226360]
 * Klesges, R. C., M. DeBon, M. W. Vander Weg, C. K. Haddock, H. A. Lando, G. E.
   Relyea, A. L. Peterson, and G. W. Talcott. 2006. Efficacy of a tailored
   tobacco control program on long-term use in a population of US military
   troops. Journal of Consulting and Clinical Psychology 74(2):295-306. [PubMed:
   16649874]
 * Kodl, M., S. S. Fu, and A. M. Joseph. 2006. Tobacco cessation treatment for
   alcohol-dependent smokers: When is the best time? Alcohol Research and Health
   29(3):203-207. [PMC free article: PMC6527038] [PubMed: 17373410]
 * Kornitzer, M., M. Boutsen, M. Dramaix, J. Thijs, and G. Gustavs.son. 1995.
   Combined use of nicotine patch and gum in smoking cessation: A
   placebo-controlled clinical trial. Preventive Medicine 24(1):41-47. [PubMed:
   7740014]
 * Kotov, R., L. T. Guey, E. J. Bromet, and J. E. Schwartz. 2008. Smoking in
   schizophrenia: Diagnostic specificity, symptom correlates, and illness
   severity. Schizophrenia Bulletin . http: //schizophreniabulletin
   .oxfordjournals .org/cgi/content/abstract/sbn066e (published June 17, 2008).
   [PMC free article: PMC2800136] [PubMed: 18562340]
 * Kotz, D., M. J. Huibers, R. Vos, C. P. van Schayck, and G. Wesseling. 2008.
   Principles of confrontational counselling in smokers with chronic obstructive
   pulmonary disease (COPD). Medical Hypotheses 70(2):384-386. [PubMed:
   17604568]
 * Lancaster, T., C. Silagy, and G. Fowler. 2000. Training health professionals
   in smoking cessation. Cochrane Database of Systematic Reviews 3:CD000214.
   [PubMed: 10908465]
 * Lasser, K., J. W. Boyd, S. Woolhandler, D. U. Himmelstein, D. McCormick, D.
   H. Bor. 2000. Smoking and mental illness: A population-based prevalence
   study. Journal of the American Medical Association 284(20):2606-2610.
   [PubMed: 11086367]
 * Lerman, C., D. Main, J. Audrain, N. Caporaso, N. R. Boyd, E. D. Bowman, and
   P. G. Shields. 1998. Depression and self-medication with nicotine: The
   modifying influence of the dopamine D4 receptor gene. Health Psychology
   17(1):56-62. [PubMed: 9459071]
 * Levy, D. E., and E. Meara. 2006. The effect of the 1998 Master Settlement
   Agreement on prenatal smoking. Journal of Health Economics 25(2):276-294.
   [PubMed: 16139908]
 * Levy, D. T., and K. B. Friend. 2003. The effects of clean indoor air laws:
   What do we know and what do we need to know? Health Education Research
   18(5):592-609. [PubMed: 14572019]
 * Levy, D. T., E. Romano, and E. Mumford. 2005. a. The relationship of smoking
   cessation to sociodemographic characteristics, smoking intensity, and tobacco
   control policies. Nicotine and Tobacco Research 7(3):387-396. [PubMed:
   16085506]
 * Levy, D. T., L. Nikolayev, E. Mumford, and C. Compton. 2005. b. The Healthy
   People 2010 smoking prevalence and tobacco control objectives: Results from
   the SimSmoke tobacco control policy simulation model (United States). Cancer
   Causes and Control 16(4):359-371. [PubMed: 15953978]
 * Longo, D. R., R. C. Brownson, J. C. Johnson, J. E. Hewett, R. L. Kruse, T. E.
   Novotny, and R. A. Logan. 1996. Hospital smoking bans and employee smoking
   behavior: Results of a national survey. Journal of the American Medical
   Association 275(16):1252-1257. [PubMed: 8601957]
 * Longo, D. R., J. C. Johnson, R. L. Kruse, R. C. Brownson, and J. E. Hewett.
   2001. A prospective investigation of the impact of smoking bans on tobacco
   cessation and relapse. Tobacco Control 10(3):267-272. [PMC free article:
   PMC1747578] [PubMed: 11544392]
 * Lotrean, L. M., L. M. Sánchez-Zamorano, R. Valdés-Salgado, E.
   Arillo-Santillán, B. Allen, M. Hernández-Avila, and E. Lazcano-Ponce. 2005.
   Consumption of higher numbers of cigarettes in Mexican youth: The importance
   of social permissiveness of smoking. Addictive Behaviors 30(5):1035-1041.
   [PubMed: 15893101]
 * Malouff, J., J. Slade, C. Nielsen, N. Schutte, and E. Lawson. 1993. US laws
   that protect tobacco users from employment discrimination. Tobacco Control
   2:132-138.
 * Malpass, D., and S. Higgs. 2007. Acute psychomotor, subjective and
   physiological responses to smoking in depressed outpatient smokers and
   matched controls. Psychopharmacology 190(3):363-372. [PubMed: 17136518]
 * Martinez-Donate, A. P., M. F. Hovell, D. R. Wahlgren, S. B. Meltzer, E. O.
   Meltzer, C. R. Hofstette, and G. E. Matt. 2003. Association between
   residential tobacco smoking bans, smoke exposure, and pulmonary function: A
   survey of Latino children with asthma. Pediatric Asthma, Allergy and
   Immunology 16(4):305-317.
 * Martinez-Donate, A. P., M. F. Hovell, C. R. Hofstetter, G. J. González-Pérez,
   M. A. Adams, and A. Kotay. 2007. Correlates of home smoking bans among
   Mexican-Americans. American Journal of Health Promotion 21(4):229-236.
   [PubMed: 17375488]
 * McBride, C. M., and J. S. Ostroff. 2003. Teachable moments for promoting
   smoking cessation: The context of cancer care and survivorship. Cancer
   Control 10(4):325-333. [PubMed: 12915811]
 * McChargue, D. E., S. B. Gulliver, and B. Hitsman. 2002. Would smokers with
   schizophrenia benefit from a more flexible approach to smoking treatment?
   Addiction 97(7):785-793. [PubMed: 12133113]
 * McFall, M., A. J. Saxon, C. E. Thompson, D. Yoshimoto, C. Malte, K.
   Straits-Troster, E. Kanter, X. H. Zhou, C. M. Dougherty, and B. Steele. 2005.
   Improving the rates of quitting smoking for veterans with posttraumatic
   stress disorder. American Journal of Psychiatry 162(7):1311-1319. [PubMed:
   15994714]
 * McFall, M., D. C. Atkins, D. Yoshimoto, C. E. Thompson, E. Kanter, C. A.
   Malte, and A. J. Saxon. 2006. Integrating tobacco cessation treatment into
   mental health care for patients with posttraumatic stress disorder. American
   Journal of Addiction 15(5):336-344. [PubMed: 16966189]
 * McPhillips-Tangum, C., B. Rehm, R. Carreon, C. M. Erceg, and C. Bocchino.
   2006. Addressing tobacco in managed care: Results of the 2003 survey.
   Preventing Chronic Disease 3(3):1-11. [PMC free article: PMC1636711] [PubMed:
   16776888]
 * Mohiuddin, S. M., A. N. Mooss, C. B. Hunter, T. L. Grollmes, D. A. Cloutier,
   and D. E. Hilleman. 2007. Intensive smoking cessation intervention reduces
   mortality in high-risk smokers with cardiovascular disease. Chest
   131(2):446-452. [PubMed: 17296646]
 * Mojica, W. A., M. J. Suttorp, S. E. Sherman, S. C. Morton, E. A. Roth, M. A.
   Maglione, S. L. Rhodes, and P. G. Shekelle. 2004. Smoking-cessation
   interventions by type of provider: A meta-analysis. American Journal of
   Preventive Medicine 26(5):391-401. [PubMed: 15165655]
 * Moskowitz, J. M., Z. Lin, and E. S. Hudes. 2000. The impact of workplace
   smoking ordinances in California on smoking cessation. American Journal of
   Public Health 90(5):757-761. [PMC free article: PMC1446239] [PubMed:
   10800425]
 * Muñoz, R. E., B. V. Marín, S. E. Posner, and E. J. Pérez-Stable. 1997. Mood
   management mail intervention increases abstinence rates for Spanish-speaking
   Latino smokers. American Journal of Community Psychology 25(3):325-343.
   [PubMed: 9332966]
 * NAQC (North American Quitline Consortium). 2008. Realizing Opportunities:
   Implementation Assessment of the Minimal Data Set in North America. Phoenix,
   AZ: NAQC.
 * NCI (National Cancer Institute). 2005. ASSIST: Shaping the Future of Tobacco
   Prevention and Control. NCI Tobacco Control Monograph Series, Number 16.
   Bethesda, MD: NCI. NIH Publication No. 05-5645.
 * NCI. 2008. The Role of the Media in Promoting and Reducing Tobacco Use.
   Bethesda, MD: NCI. NIH Pub. No. 07-6242.
 * NCI. 2009. Health groups hail increase in federal tobacco taxes. NCI Cancer
   Bulletin 6(3). http://www .cancer.gov /ncicancerbulletin/021009/page2
   (accessed March 5, 2009).
 * NCQA (National Committee for Quality Assurance). 2008. The State of Health
   Care Quality 2008. Washington, DC: NCQA. 132 pages.
 * NIH (National Institutes of Health). 2006. NIH State of the Science
   Conference on Tobacoo Use: Prevention, Cessation, and Control. William H.
   Natcher Conference Center, Bethesda, MD, June 12-14, 2006.
 * NRC (National Research Council). 2003. Fulfilling the Potential for Cancer
   Prevention and Early Detection, edited by S. Curry, editor; , T, Byers,
   editor; , and M. Hewitt, editor. . Washington, DC: The National Academies
   Press. [PubMed: 25057588]
 * Older Americans Report. 2005. City’s housing authority bans smoking in senior
   apartments. August 5, 2005.
 * OTRU (Ontario Tobacco Research Unit). 2006. The Smoke-Free Ontario Act:
   Extend protection to children in vehicles. OTRU Update. August 2006.
 * Otten, R., R. C. M. E. Engels, and R. J. J. M. Van Den Eijnden. 2005.
   Parental smoking and smoking behavior in asthmatic and nonasthmatic
   adolescents. Journal of Asthma 42(5):349-355. [PubMed: 16036409]
 * Parkes, G., T. Greenhalgh, M. Griffin, and R. Dent. 2008. Effect on smoking
   quit rate of telling patients their lung age: The step2quit randomised
   controlled trial. British Medical Journal 336(7644): 598-600. [PMC free
   article: PMC2267989] [PubMed: 18326503]
 * Patten, C. A., A. A. Drews, M. G. Myers, J. E. Martin, and T. D. Wolter.
   2002. Effect of depressive symptoms on smoking abstinence and treatment
   adherence among smokers with a history of alcohol dependence. Psychology of
   Addictive Behaviors 16(2):135-142. [PubMed: 12079252]
 * Pell, J. P., S. Haw, S. Cobbe, D. E. Newby, A. C. Pell, C. Fischbacher, A.
   McConnachie, S. Pringle, D. Murdoch, F. Dunn, K. Oldroyd, P. Macintyre, B.
   O’Rourke, and W. Borland. 2008. Smoke-free legislation and hospitalizations
   for acute coronary syndrome. New England Journal of Medicine 359(5):482-491.
   [PubMed: 18669427]
 * Perrin, B. 1998. Effective use and misuse of performance measurement.
   American Journal of Evaluation 19(3):367-379.
 * Perrin, B. 1999. Performance measurement: Does the reality match the
   rhetoric? A rejoinder to Bernstein and Winston. American Journal of
   Evaluation 20(1):101-111.
 * Persson, L. G., and A. Hjalmarson. 2006. Smoking cessation in patients with
   diabetes mellitus: Results from a controlled study of an intervention
   programme in primary healthcare in Sweden. Scandinavian Journal of Primary
   Health Care 24(2):75-80. [PubMed: 16690554]
 * Phisitkul, K., K. Hegazy, T. Chuahirun, C. Hudson, J. Simoni, H. Rajab, and
   D. E. Wesson. 2008. Continued smoking exacerbates but cessation ameliorates
   progression of early type 2 diabetic nephropathy. American Journal of the
   Medical Sciences 335(4): 284-291. [PubMed: 18414067]
 * Pierce, J. P. 2007. Tobacco industry marketing, population-based tobacco
   control, and smoking behavior. American Journal of Preventive Medicine
   33(Suppl 6):S327-S334. [PubMed: 18021907]
 * Pizacani, B. A., D. P. Martin, M. J. Stark, T. D. Koepsell, B. Thompson, and
   P. Diehr. 2003. Household smoking bans: Which households have them and do
   they work? Preventive Medicine 36(1):99-107. [PubMed: 12473430]
 * Pizacani, B. A., D. P. Martin, M. J. Stark, T. D. Koepsell, B. Thompson, and
   P. Diehr. 2004. A prospective study of household smoking bans and subsequent
   cessation related behaviour: The role of stage of change. Tobacco Control
   13(1):23-28. [PMC free article: PMC1747832] [PubMed: 14985591]
 * Powell, L. M., J. A. Tauras, and H. Ross. 2005. The importance of peer
   effects, cigarette prices and tobacco control policies for youth smoking
   behavior. Journal of Health Economics 24(5):950-968. [PubMed: 15990184]
 * Prochaska, J. J., P. Gill, and S. M. Hall. 2004. a. Treatment of tobacco use
   in an inpatient psychiatric setting. Psychiatric Services 55(11):1265-1270.
   [PubMed: 15534015]
 * Prochaska, J. J., J. S. Rossi, C. A. Redding, A. B. Rosen, J. Y. Tsoh, G. L.
   Humfleet, S. J. Eisendrath, M. R. Meisner, and S. M. Hall. 2004. b. Depressed
   smokers and stage of change: Implications for treatment interventions. Drug
   and Alcohol Dependence 76(2):143-151. [PubMed: 15488338]
 * Prochaska, J. J., S. C. Fromont, P. Banys, S. J. Eisendrath, M. J. Horowitz,
   M. H. Jacobs, and S. M. Hall. 2007. Addressing nicotine dependence in
   psychodynamic psychotherapy: Perspectives from residency training. Academic
   Psychiatry 31(1):8-14. [PMC free article: PMC5108452] [PubMed: 17242046]
 * Prochaska, J. J., S. M. Hall, J. Y. Tsoh, S. Eisendrath, J. S. Rossi, C. A.
   Redding, A. B. Rosen, M. Meisner, G. L. Humfleet, and J. A. Gorecki. 2008.
   Treating tobacco dependence in clinically depressed smokers: Effect of
   smoking cessation on mental health functioning. American Journal of Public
   Health 98(3):446-448. [PMC free article: PMC2253568] [PubMed: 17600251]
 * Quinn, V. P., J. F. Hollis, K. S. Smith, N. A. Rigotti, L. I. Solberg, W. Hu,
   and V. J. Stevens. 2009. Effectiveness of the 5-As tobacco cessation
   treatments in nine HMOs. Journal of General Internal Medicine 24(2):149-154.
   [PMC free article: PMC2628990] [PubMed: 19083066]
 * Rabius, V., K. J. Pike, J. Hunter, D. Wiatrek, and A. L. McAlister. 2007.
   Effects of frequency and duration in telephone counselling for smoking
   cessation. Tobacco Control 16(Suppl 1): I71-I74. [PMC free article:
   PMC2598518] [PubMed: 18048636]
 * Ranney, L., C. Melvin, L. Lux, E. McClain, and K. N. Lohr. 2006. Systematic
   review: Smoking cessation intervention strategies for adults and adults in
   special populations. Annals of Internal Medicine 145(11):845-856. [PubMed:
   16954352]
 * Reed, M. B., C. M. Anderson, J. W. Vaughn, and D. M. Burns. 2008. The effect
   of cigarette price increases on smoking cessation in California. Prevention
   Science 9(1):47-54. [PubMed: 18256936]
 * Ribisl, K. M., A. E. Kim, and R. S. Williams. 2007. Sales and marketing of
   cigarettes on the Internet: Emerging threats to tobacco control and promising
   policy solutions. Appendix M. In Ending the Tobacco Problem: A Blueprint for
   the Nation, edited by R. J. Bonnie, editor; , K. Stratton, editor; and R.. B.
   Wallace, editor. . Institute of Medicine. Washington, DC: The National
   Academies Press.
 * Rice, V. H., and L. F. Stead. 2008. Nursing interventions for smoking
   cessation. Cochrane Database of Systematic Reviews 1:CD001188. [PubMed:
   18253987]
 * Richmond, R., and N. Zwar. 2003. Review of bupropion for smoking cessation.
   Drug and Alcohol Review 22(2):203-220. [PubMed: 12850907]
 * Rigotti, N. A., M. R. Munafo, and L. F. Stead. 2007. Interventions for
   smoking cessation in hospitalised patients. Cochrane Database of Systematic
   Reviews 3:CD001837. [PubMed: 17636688]
 * RTI International. 2004. First Annual Independent Evaluation of New York’s
   Tobacco Control Program: Final Report. Research Triangle Park, NC: RTI
   International.
 * RTI International. 2005. Second Annual Independent Evaluation of New York’s
   Tobacco Control Program: Final Report. Research Triangle Park, NC: RTI
   International.
 * Rubak, S., A. Sandbæk, T. Lauritzen, and B. Christensen. 2005. Motivational
   interviewing: A systematic review and meta-analysis. British Journal of
   General Practice 55(513):305-312. [PMC free article: PMC1463134] [PubMed:
   15826439]
 * Ryabik, B. M., S. B. Lippmann, and R. Mount. 1994. Implementation of a
   smoking ban on a locked psychiatric unit. General Hospital Psychiatry
   16(3):200-204. [PubMed: 8063087]
 * Saffer, H., and F. Chaloupka. 2000. The effect of tobacco advertising bans on
   tobacco consumption. Journal of Health Economics 19(6):1117-1137. [PubMed:
   11186847]
 * Sargent, R. P., R. M. Shepard, and S. A. Glantz. 2004. Reduced incidence of
   admissions for myocardial infarction associated with public smoking ban:
   Before and after study. British Medical Journal 328(7446):977-980. [PMC free
   article: PMC404491] [PubMed: 15066887]
 * Schroeder, S. 2008. Stranded in the periphery—the increasing marginalization
   of smokers. New England Journal of Medicine 358(21):2284-2286. [PubMed:
   18499574]
 * Schroeder, S. A. 2009. A 51-year-old woman with bipolar disorder who wants to
   quit smoking. Journal of the American Medical Association 301(5):522-531.
   [PubMed: 19126801]
 * Schroeder, S. A., and D. S. Cooper. 2005. What to do with a patient who
   smokes. Journal of the American Medical Association 294(4):482-487. [PubMed:
   16046655]
 * Scollo, M., A. Lal, A. Hyland, and S. Glantz. 2003. Review of the quality of
   studies on the economic effects of smoke-free policies on the hospitality
   industry. Tobacco Control 12(1):13-20. [PMC free article: PMC1759095]
   [PubMed: 12612356]
 * Severson, H. H. 2003. What have we learned from 20 years of research on
   smokeless tobacco cessation? American Journal of the Medical Sciences
   326(4):206-211. [PubMed: 14557736]
 * Sherman, S. E., A. B. Lanto, M. Nield, and E. M. Yano. 2003. Smoking
   cessation care received by veterans with chronic obstructive pulmonary
   disease. Journal of Rehabilitation Research and Disease 40(5 Suppl 2):1-12.
   [PubMed: 15074449]
 * Sheu, M. L., T. W. Hu, T. E. Keeler, M. Ong, and H. Y. Sung. 2004. The effect
   of a major cigarette price change on smoking behavior in California: A
   zero-inflated negative binomial model. Health Economics 13(8):781-791.
   [PubMed: 15322990]
 * Shiffman, S., S. E. Brockwell, J. L. Pillitteri, and J. G. Gitchell. 2008.
   Use of smoking-cessation treatments in the United States. American Journal of
   Preventive Medicine 34(2):102-111. [PubMed: 18201639]
 * Siahpush, M., R. Borland, and M. Scollo. 2003. Factors associated with
   smoking cessation in a national sample of Australians. Nicotine and Tobacco
   Research 5(4):597-602. [PubMed: 12959798]
 * Siegel, M. 1992. Economic impact of 100% smoke-free restaurant ordinances. In
   Smoking and Restaurants: A Guide for Policy Makers. Berkeley: University of
   California, Berkeley/University of California, San Francisco Preventative
   Medicine Residency Program; American Heart Association, California Affiliate;
   Alameda County Health Care Services Agency, Tobacco Control Program.
 * Simon, J. A., S. N. Solkowitz, T. P. Carmody, and W. S. Browner. 1997.
   Smoking cessation after surgery. A randomized trial. Archives of Internal
   Medicine 157(12):1371-1376. [PubMed: 9201012]
 * Simon, J. A., T. P. Carmody, E. S. Hudes, E. Snyder, and J. Murray. 2003.
   Intensive smoking cessation counseling versus minimal counseling among
   hospitalized smokers treated with transdermal nicotine replacement: A
   randomized trial. The American Journal of Medicine 114(7):555-562. [PubMed:
   12753879]
 * Sinclair, H. K., C. M. Bond, and L. F. Stead. 2004. Community pharmacy
   personnel interventions for smoking cessation. Cochrane Database of
   Systematic Reviews 1:CD003698. [PubMed: 14974031]
 * Sippel, J. M., K. L. Pedula, W. M. Vollmer, A. S. Buist, and M. L. Osborne.
   1999. Associations of smoking with hospital-based care and quality of life in
   patients with obstructive airway disease. Chest 115(3):691-696. [PubMed:
   10084477]
 * Siroux, V., I. Pin, M. P. Oryszczyn, N. Le Moual, and F. Kauffmann. 2000.
   Relationships of active smoking to asthma and asthma severity in the EGEA
   study. European Respiratory Journal 15(3):470-477. [PubMed: 10759439]
 * Slater, S. J., F. J. Chaloupka, M. Wakefield, L. D. Johnston, and P. M.
   O’Malley. 2007. The impact of retail cigarette marketing practices on youth
   smoking uptake. Archives of Pediatrics and Adolescent Medicine
   161(5):440-445. [PubMed: 17485618]
 * Smith, B., M. A. Ryan, D. L. Wingard, T. L. Patterson, D. J. Slymen, and C.
   A. Macera. 2008. Cigarette smoking and military deployment: A prospective
   evaluation. American Journal of Preventive Medicine 35(6):539-46. [PubMed:
   18842388]
 * Smith, C. M., C. A. Pristach, and M. Cartagena. 1999. Obligatory cessation of
   smoking by psychiatric inpatients. Psychiatric Services 50(1):91-94. [PubMed:
   9890586]
 * Smith, M. Y., J. Cromwell, J. DePue, B. Spring, W. Redd, and M. Unrod. 2007.
   Determining the cost-effectiveness of a computer-based smoking cessation
   intervention in primary care. Managed Care 16(7):48-55. [PubMed: 17907712]
 * Smith, R. B., P. R. Gwilt, and C. E. Wright. 1983. Single-dose and
   multiple-dose pharmacokinetics of oral alprazolam in healthy smoking and
   nonsmoking men. Clinical Pharmacy 2(2):139-143. [PubMed: 6883942]
 * Smokefree Apartment House Registry. 2007. Smokefree Living in Apartments and
   Condominiums: A Newsletter for Residents, Owners, and Managers 1(5).
   http://www .smokefreeapartments .org/newsletter.html (accessed March 4,
   2009).
 * Soria, R., A. Legido, C. Escolano, A. L. Yeste, and J. Montoya. 2006. A
   randomised controlled trial of motivational interviewing for smoking
   cessation. British Journal of General Practice 56(531):768-774. [PMC free
   article: PMC1920717] [PubMed: 17007707]
 * Spencer, N., C. Blackburn, S. Bonas, C. Coe, and A. Dolan. 2005. Parent
   reported home smoking bans and toddler (18-30 month) smoke exposure: A
   cross-sectional survey. Archives of Disease in Childhood 90(7):670-674. [PMC
   free article: PMC1720498] [PubMed: 15970606]
 * Stage, K. B., A. H. Glassman, and L. S. Covey. 1996. Depression after smoking
   cessation: Case reports. Journal of Clinical Psychiatry 57(10):467-469.
   [PubMed: 8909333]
 * Stapleton, J. A., L. Watson, L. I. Spirling, R. Smith, A. Milbrandt, M.
   Ratcliffe, and G. Sutherland. 2008. Varenicline in the routine treatment of
   tobacco dependence: A pre-post comparison with nicotine replacement therapy
   and an evaluation in those with mental illness. Addiction 103(1):146-154.
   [PubMed: 18028247]
 * Stead, L. F., R. Perera, and T. Lancaster. 2006. Telephone counselling for
   smoking cessation. Cochrane Database of Systematic Reviews 3:CD002850.
   [PubMed: 16855992]
 * Stead, L. F., R. Perera, C. Bullen, and T. Lancaster. 2007. Nicotine
   Replacement Therapy for Smoking Cessation. Cochrane Database of Systematic
   Reviews 4:CD000146. [PubMed: 23152200]
 * Steinberg, M. B., J. Foulds, D. L. Richardson, M. V. Burke, and P. Shah.
   2006. Pharmacotherapy and smoking cessation at a tobacco dependence clinic.
   Preventive Medicine 42(2):114-119. [PubMed: 16375954]
 * Stoller, G. 2008. More hotels go completely smoke-free. USA Today, November
   18, 2008.
 * Strasser, K., K. Moeller-Saxone, G. Meadows, B. Hocking, J. Stanton, and P.
   Kee. 2002. Smoking cessation in schizophrenia. General practice guidelines.
   Australian Family Physician 31(1):21-24. [PubMed: 11840883]
 * Strecher, V. J., and W. F. Velicer. 2003. Tailoring smoking cessation
   programs to the specific needs and interests of the patient. British Medical
   Journal 327(7418):E57-E58.
 * Strecher, V. J., J. McClure, G. Alexander, B. Chakraborty, V. Nair, J.
   Konkel, S. Greene, M. Couper, C. Carlier, C. Wiese, R. Little, C. Pomerleau,
   and O. Pomerleau. 2008. The role of engagement in a tailored web-based
   smoking cessation program: Randomized controlled trial. Journal of Medical
   Internet Research 10(5):e35. http://www .pubmedcentral .nih.gov/articlerender
   .fcgi?artid=2630833. [PMC free article: PMC2630833] [PubMed: 18984557]
 * Stuber, J., S. Galea, and B. G. Link. 2008. Smoking and the emergence of a
   stigmatized social status. Social Science and Medicine 67(3): 420-430. [PMC
   free article: PMC4006698] [PubMed: 18486291]
 * Sundblad, B. M., K. Larsson, and L. Nathell. 2008. High rate of smoking
   abstinence in COPD patients: Smoking cessation by hospitalization. Nicotine
   and Tobacco Research 10(5):883-890. [PubMed: 18569763]
 * Sussman, S. 2002. Smoking cessation among persons in recovery. Substance Use
   and Misuse 37(8-10):1275-1298. [PubMed: 12180567]
 * Tashkin, D., R. Kanner, W. Bailey, S. Buist, P. Anderson, M. Nides, D.
   Gonzales, G. Dozier, M. K Patel, and B. Jamerson. 2001. Smoking cessation in
   patients with chronic obstructive pulmonary disease: A double-blind,
   placebo-controlled, randomised trial. Lancet 357(9268):1571-1575. [PubMed:
   11377644]
 * Tauras, J. A. 2004. Public policy and smoking cessation among young adults in
   the United States. Health Policy 68(3):321-332. [PubMed: 15113643]
 * Thomas, S., D. Fayter, K. Misso, D. Ogilvie, M. Petticrew, A. Sowden, M.
   Whitehead, and G. Worthy. 2008. Population tobacco control interventions and
   their effects on social inequalities in smoking: Systematic review. Tobacco
   Control 17(4):230-237. [PMC free article: PMC2565568] [PubMed: 18426867]
 * Thomson, G., and N. Wilson. 2009. Public attitudes to laws for smokefree
   private vehicles: A brief review. Tobacco Control 18(4):256-261. [PubMed:
   19052041]
 * Thomson, C. C., M. Siegel, J. Winickoff, L. Biener, and N. A. Rigotti. 2005.
   Household smoking bans and adolescents’ perceived prevalence of smoking and
   social acceptability of smoking. Preventive Medicine 41(2):349-356. [PubMed:
   15917032]
 * Thomson, N. C., R. Chaudhuri, and E. Livingston. 2004. Asthma and cigarette
   smoking. European Respiratory Journal 24(5):822-833. [PubMed: 15516679]
 * Thorndike, A. N., R. S. Stafford, and N. A. Rigotti. 2001. US physicians’
   treatment of smoking in outpatients with psychiatric diagnoses. Nicotine and
   Tobacco Research 3(1):85-91. [PubMed: 11260815]
 * Thorndike, A. N., S. Regan, and N. A. Rigotti. 2007. The treatment of smoking
   by US physicians during ambulatory visits: 1994-2003. American Journal of
   Public Health 97(10):1878-1883. [PMC free article: PMC1994176] [PubMed:
   17761570]
 * Thorsteinsson, H. S., J. C. Gillin, C. A. Patten, S. Golshan, L. D. Sutton,
   S. Drummond, C. P. Clark, J. Kelsoe, and M. Rapaport. 2001. The effects of
   transdermal nicotine therapy for smoking cessation on depressive symptoms in
   patients with major depression. Neuropsychopharmacology 24(4):350-358.
   [PubMed: 11182530]
 * Tonstad, S., C. Farsang, G. Klaene, K. Lewis, A. Manolis, A. P. Perruchoud,
   C. Silagy, P. I. Van Spiegel, C. Astbury, A. Hider, and R. Sweet. 2003.
   Bupropion SR for smoking cessation in smokers with cardiovascular disease: A
   multicentre, randomised study. European Heart Journal 24(10):946-955.
   [PubMed: 12714026]
 * Toschi, L., and F. Cappuzzo. 2007. Understanding the new genetics of
   responsiveness to epidermal growth factor receptor tyrosine kinase
   inhibitors. Oncologist 12(2):211-220. [PubMed: 17296817]
 * Tyc, V. L., and L. Throckmorton-Belzer. 2006. Smoking rates and the state of
   smoking interventions for children and adolescents with chronic illness.
   Pediatrics 118(2):e471-e87. [PubMed: 16882787]
 * Unrod, M., M. Smith, B. Spring, J. DePue, W. Redd, and G. Winkel. 2007.
   Randomized controlled trial of a computer-based, tailored intervention to
   increase smoking cessation counseling by primary care physicians. Journal of
   General Internal Medicine 22(4):478-484. [PMC free article: PMC1829425]
   [PubMed: 17372796]
 * US Surgeon General. 2001. Women and Smoking: A Report of the Surgeon General.
   Washington, DC: HHS. [PubMed: 20669521]
 * US Surgeon General. 2004. The Health Consequences of Smoking: A Report of the
   Surgeon General. Washington, DC: HHS. [PubMed: 20669512]
 * VA/DoD (Department of Veterans Affairs/Department of Defense). 2004. VA/DoD
   Clinical Practice Guideline for the Management of Tobacco Use. Washington,
   DC: VA/DoD.
 * Van Schayck, O. C. P., H. Pinnock, A. Ostrem, J. Litt, R. Tomlins, S.
   Williams, J. Buffels, D. Giannopoulos, S. Henrichsen, J. Kaper, O. Korzh, A.
   M. Rodriguez, S. Kawaldip, N. Zwar, and H. Yaman. 2008. IPCRG Consensus
   statement: Tackling the smoking epidemic—Practical guidance for primary care.
   Primary Care Respiratory Journal 17(3):185-193. [PMC free article:
   PMC6619895] [PubMed: 18769845]
 * Van Spall, H. G. C., A. Chong, and J. V. Tu. 2007. Inpatient
   smoking-cessation counseling and all-cause mortality in patients with acute
   myocardial infarction. American Heart Journal 154(2):213-220. [PubMed:
   17643569]
 * Volpp, K. G., A. Gurmankin Levy, D. A. Asch, J. A. Berlin, J. J. Murphy, A.
   Gomez, H. Sox, J. Zhu, and C. Lerman. 2006. A randomized controlled trial of
   financial incentives for smoking cessation. Cancer Epidemiology Biomarker and
   Prevention 15(1): 12-18. [PubMed: 16434580]
 * Volpp, K. G., M. V. Pauly, G. Loewenstein, and D. Bangsberg. 2009. Market
   watch. P4P4P: An agenda for research on pay-for-performance for patients.
   Health Affairs 28(1):206-214. [PMC free article: PMC3507539] [PubMed:
   19124872]
 * Wagena, E. J., R. M. van der Meer, R. J. W. G. Ostelo, J. E. Jacobs, and C.
   P. van Schayck. 2004. The efficacy of smoking cessation strategies in people
   with chronic obstructive pulmonary disease: Results from a systematic review.
   Respiratory Medicine 98(9):805-815. [PubMed: 15338790]
 * Wakefield, M., D. Banham, J. Martin, R. Ruffin, K. McCaul, and N. Badcock.
   2000. a. Restrictions on smoking at home and urinary cotinine levels among
   children with asthma. American Journal of Preventive Medicine 19(3):188-192.
   [PubMed: 11020596]
 * Wakefield, M. A., F. J. Chaloupka, N. J. Kaufman, C. T. Orleans, D. C.
   Barker, and E. E. Ruel. 2000. b. Effect of restrictions on smoking at home,
   at school, and in public places on teenage smoking: Cross sectional study.
   British Medical Journal 321(7257):333-337. [PMC free article: PMC27448]
   [PubMed: 10926588]
 * Wakefield, M. A., S. Durkin, M. J. Spittal, M. Siahpush, M. Scollo, J. A.
   Simpson, S. Chapman, V. White, and D. Hill. 2008. Impact of tobacco control
   policies and mass media campaigns on monthly adult smoking prevalence.
   American Journal of Public Health 98(8): 1443-1450. [PMC free article:
   PMC2446442] [PubMed: 18556601]
 * Walker, M. S., D. J. Vidrine, E. R. Gritz, R. J. Larsen, Y. Yan, R. Govindan,
   and E. B. Fisher. 2006. Smoking relapse during the first year after treatment
   for early-stage non-small-cell lung cancer. Cancer Epidemiology Biomarkers
   and Prevention 15(12):2370-2377. [PubMed: 17132767]
 * Wallace, A. E., N. A. Sairafi, and W. B. Weeks. 2006. Tobacco cessation
   counseling across the ages. Journal of the American Geriatric Society
   54(9):1425-1428. [PubMed: 16970653]
 * Warner, D. M. 1994. We do not hire smokers: May employers discriminate
   against smokers? Employee Responsibilities and Rights Journal 7(2):129-140.
 * Warner, K. 2007. Tobacco policy research: Insights and contributions to
   public health policy. In Tobacco Control Policy, edited by K. Warner, editor.
   . San Francisco, CA: Jossey-Bass. Pp.3-86.
 * Wechsler, H., J. E. Lee, and N. A. Rigotti. 2001. Cigarette use by college
   students in smoke-free housing: Results of a national study. American Journal
   of Preventive Medicine 20(3):202-207. [PubMed: 11275447]
 * White, A. R., H. Rampes, and J. L. Campbell. 2006. Acupuncture and related
   interventions for smoking cessation. Cochrane Database of Systematic Reviews
   1:CD000009. [PubMed: 16437420]
 * WHO (World Health Organization). 2008. WHO Report on the Global Tobacco
   Epidemic. Geneva, Switzerland: WHO.
 * Williams, J. M., and D. Ziedonis. 2004. Addressing tobacco among individuals
   with a mental illness or an addiction. Addictive Behaviors 29(6):1067-1083.
   [PubMed: 15236808]
 * Williams, J. M., and D. M. Ziedonis. 2006. Snuffing out tobacco dependence.
   Behavioral Healthcare 26(5):27-31. [PubMed: 16736916]
 * Wilt, T. J., D. Niewoehner, R. L. Kane, R. MacDonald, and A. M. Joseph. 2007.
   Spirometry as a motivational tool to improve smoking cessation rates: A
   systematic review of the literature. Nicotine and Tobacco Research
   9(1):21-32. [PubMed: 17365733]
 * Workgroup on Substance Use Disorders. 2006. Practice Guideline for the
   Treatment of Patients with Substance Use Disorders, 2nd Edition. Washington,
   DC: American Psychiatric Publishing.
 * Yun, S., F. Chanetsa, A. Kelsey, and B. P. Zhu. 2006. Active and passive
   smoking among asthmatic Missourians: Implications for health education.
   Preventive Medicine 42(4):286-290. [PubMed: 16488000]
 * Zeller, M., D. Hatsukami, C. Backinger, N. Benowitz, L. Biener, D. Burns, P.
   Clark, G. Connolly, M. V. Djordjevic, T. Eissenberg, G. A. Giovino, C.
   Healton, S. S. Hecht, J. E. Henningfield, C. Husten, K. Kobus, S. Leischow,
   D. T. Levy, S. Marcus, M. L. Myers, M. Parascandola, P. Ponkshe, P. G.
   Shields, P. Slovic, D. Sweanor, and K. E. Warner. 2009. The strategic
   dialogue on tobacco harm reduction: A vision and blueprint for action in the
   United States. Tobacco Control 18(4):324-332. [PMC free article: PMC4915216]
   [PubMed: 19240228]
 * Zevin, S., and N. L. Benowitz. 1999. Drug interactions with tobacco smoking:
   An update. Clinical Pharmacokinetics 36(6):425-438. [PubMed: 10427467]
 * Zhu, S. H., and C. M. Anderson. 2004. Tobacco quitlines: Where they’ve been
   and where they’re going. In VA in the Vanguard: Building on Success in
   Smoking Cessation, edited by S. I. Isaacs, J. A. Simon and S. A. Schroeder.
   San Francisco, CA: VA.
 * Ziedonis, D. M. 2004. Integrated treatment of co-occurring mental illness and
   addiction: Clinical invervention, program, and system perspectives. CNS
   Spectrums 9(12). [PubMed: 15618940]
 * Ziedonis, D. M., and T. P. George. 1997. Schizophrenia and nicotine use:
   Report of a pilot smoking cessation program and review of neurobiological and
   clinical issues. Schizophrenia Bulletin 23(2): 247-254. [PubMed: 9165635]
 * Ziedonis, D. M., J. Guydish, J. Williams, M. Steinberg, and J. Foulds. 2006.
   Barriers and solutions to addressing tobacco dependence in addiction
   treatment programs. Alcohol Research and Health 29(3):228-235. [PMC free
   article: PMC6527042] [PubMed: 17373414]
 * Ziedonis, D. M., J. Parks, M. Hanos Zimmermann, and P. McCabe. 2007. Program
   and system level interventions to address tobacco amongst individuals with
   schizophrenia. Journal of Dual Diagnosis 3(3-4):151-175.
 * Ziedonis, D. M., B. Hitsman, J. C. Beckham, M. Zvolensky, L. E. Adler, J.
   Audrain-McGovern, N. Breslau, R. A. Brown, T. P. George, J. Williams, P. S.
   Calhoun, and W. T. Riley. 2008. Tobacco use and cessation in psychiatric
   disorders: National Institute of Mental Health report. Nicotine and Tobacco
   Research 10(12):1691-1715. [PubMed: 19023823]
 * Zvolensky, M. J., L. E. Gibson, A. A. Vujanovic, K. Gregor, A. Bernstein, C.
   Kahler, C. W. Legues, R. A. Brown, and M. T. Feldner. 2008. Impact of
   posttraumatic stress disorder on early smoking lapse and relapse during a
   self-guided quit attempt among community-recruited daily smokers. Nicotine
   and Tobacco Research 10(8):1415-1427. [PubMed: 18686190]

Go to:


FOOTNOTES

1

National Association of Attorneys General. http://www .naag.org/settle.htm
(accessed February 2, 2009).

2

Current list of signatories can be viewed at: http://www .who.int/fctc
/signatories_parties/en/index.html (accessed May 19, 2009).

3

Children’s Health Insurance Program Reauthorization Act of 2009, §701. Public
Law No.111-3 (February 4, 2009).

4

The NHIS is conducted annually, but detailed tobacco questions are asked only as
part of the cancer supplement; the supplement was last administered in 2005. It
is available online at http://www .cdc.gov/nchs/nhis.htm (accessed on March 10,
2009).


 * COMPREHENSIVE TOBACCO-CONTROL PROGRAMS
 * COMMUNICATION INTERVENTIONS
 * TOBACCO-USE RESTRICTIONS
 * TOBACCO RETAIL ENVIRONMENT
 * TOBACCO-CESSATION INTERVENTIONS
 * DELIVERY OF INTERVENTIONS
 * TOBACCO CESSATION IN SPECIAL POPULATIONS
 * RELAPSE-PREVENTION INTERVENTIONS
 * SURVEILLANCE AND EVALUATION
 * REFERENCES
 * Footnotes

Copyright 2009 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK215335
Contents
< PrevNext >


 * Share on Facebook
 * Share on Twitter




VIEWS

 * PubReader
 * Print View
 * Cite this Page
 * PDF version of this title (1.7M)


IN THIS PAGE

 * COMPREHENSIVE TOBACCO-CONTROL PROGRAMS
 * COMMUNICATION INTERVENTIONS
 * TOBACCO-USE RESTRICTIONS
 * TOBACCO RETAIL ENVIRONMENT
 * TOBACCO-CESSATION INTERVENTIONS
 * DELIVERY OF INTERVENTIONS
 * TOBACCO CESSATION IN SPECIAL POPULATIONS
 * RELAPSE-PREVENTION INTERVENTIONS
 * SURVEILLANCE AND EVALUATION
 * REFERENCES


RELATED INFORMATION

 * PMC
   PubMed Central citations
 * PubMed
   Links to PubMed


RECENT ACTIVITY

ClearTurn OffTurn On
 * TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES - Combating Tobacco Use in
   Mi...
   TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES - Combating Tobacco Use in
   Military and Veteran Populations
   
   

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...



Follow NCBI
Twitter Facebook LinkedIn GitHub NCBI Insights Blog

Connect with NLM

 * Twitter
 * Facebook
 * Youtube

National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894

Web Policies
FOIA
HHS Vulnerability Disclosure

Help
Accessibility
Careers

 * NLM
 * NIH
 * HHS
 * USA.gov

PreferencesTurn off
External link. Please review our privacy policy.

Cite this Page Close
Institute of Medicine (US) Committee on Smoking Cessation in Military and
Veteran Populations; Bondurant S, Wedge R, editors. Combating Tobacco Use in
Military and Veteran Populations. Washington (DC): National Academies Press
(US); 2009. 4, TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK215335/
Making content easier to read in Bookshelf Close

We are experimenting with display styles that make it easier to read books and
documents in Bookshelf. Our first effort uses ebook readers, which have several
"ease of reading" features already built in.

The content is best viewed in the iBooks reader. You may notice problems with
the display of some features of books or documents in other eReaders.

Cancel Download
Share
 * Share on Facebook
 * Share on Twitter

URL