The following describes the research questions that were identified through a systematic review of population-based interventions designed to reduce exposure to environmental tobacco smoke, decrease tobacco use initiation and increase cessation. These questions were published as part of the comprehensive evidence review conducted by the Task Force and published in a special supplement to the American Journal of Preventive Medicine (see Am J Prev Med 2001;20(2S), pp.16-66)

Public health practitioners, policy makers, employers/purchasers, and funders are encouraged to use these findings to help guide research priorities and build a broader evidence base.

RESEARCH ISSUES

Reducing Exposure to Environmental Tobacco Smoke (ETS)

Effectiveness

The effectiveness of smoking bans and restrictions in reducing exposure to ETS in the work-place is established. Research issues, which have been identified by others overlap with questions generated as a result of this review:

• What are the relative effects of smoking bans and restrictions on tobacco use behaviors?
• What is the full range of effects on tobacco use behaviors that occurs in response to smoking bans and to smoking restrictions?
• In addition to reducing exposure to ETS, what are the effects on tobacco use cessation and tobacco use prevalence?
• What are the extended effects (beyond 1 to 2 years after implementation) of smoking bans and restrictions on the tobacco use behaviors of workers? Do these effects increase over time?
• What is the full range of effects that occurs in communities in response to different types of local ordinances?
• How does the effectiveness of smoking policies vary by the specific requirements of the legislation and vigorousness of enforcement?
• How is the effect of workplace smoking policies affected by the size and composition of the workforce?
• What is the full range of health benefits that results from reducing or eliminating exposure to ETS in workers and customers currently exposed to ETS on a regular basis (e.g., in restaurants, bars, and casinos)?
• How do cultural characteristics of businesses and workers contribute to increased or decreased effectiveness of smoking bans and restrictions?

The effectiveness of community education interventions in reducing exposure to ETS in the home has not been established. Basic research questions proposed by others overlap the questions generated from this review.

• How effective are educational methods in reducing exposure to ETS in the home?
• What are the relative contributions to reducing home ETS exposures of:
  • adherence to policies that ban or restrict smoking in the home and
  • smoking cessation?
• Do policies in the home that ban or restrict smoking reduce exposure to ETS? In adults? In children? Are households with children more likely to adopt policies that ban or restrict smoking in the home?
• Are home smoking bans more effective than smoking restrictions?
• What information or message is effective in prompting and maintaining practices in the home?
• What channels are effective for dissemination of information to reduce home ETS?

Applicability

Workplace smoking bans and restrictions should be applicable in most workplace settings and populations. However, possible differences in the effectiveness of each intervention for specific subgroups of the population could not be determined. Several questions regarding applicability of these interventions in settings and populations other than those studied remain:

• Are smoking bans effective in high schools in reducing exposure to ETS and/or tobacco use?
• Are smoking bans and restrictions effective in universities in reducing exposure to ETS and/or tobacco use?
• Are smoking bans effective in child-care settings in reducing exposure to ETS?
• Do meaningful differences exist in effectiveness of smoking bans and restrictions relative to the level or scale of implementation (private, local, state, national)?

Other positive or negative effects

Smoking bans and restrictions may have important effects on such tobacco use behaviors as consumption, cessation attempts, and cessation. Assessing the full range of effects of smoking bans and restrictions is important and was addressed in the section on Effectiveness. In addition, research on the following issues would be useful:

• How effective are workplace smoking bans and restrictions in reducing relapses?
• Do smoking bans and restrictions divert tobacco consumption from cigarettes to smokeless tobacco?
• To what extent, if any, do workplace smoking bans and restrictions increase consumption and ETS exposures in the home?
• What effects do workplace smoking bans and restrictions have on productivity?

Economic evaluations

The available economic information consisted of a single evaluation. Considerable research is, therefore, warranted regarding the following questions:

• What are the costs of these interventions?
• What is the cost-effectiveness, net cost, or net benefit of smoking bans and restrictions when the cost-effectiveness analysis includes cost of illness averted?

Barriers

Research issues important to communities and local governments identified in this evaluation include the following:

• What aspects of efforts to prevent or to overturn state preemption laws are effective?
• What aspects of efforts to pass local smoking bans are effective in addressing local concerns and industry-organized opposition? What arguments for smoking bans are most persuasive to voters? To local legislative bodies?

Published reports of community and state efforts to pass smoking bans in California are informative, and continued investigation is warranted to identify and to disseminate information to counter the evolving strategies of the tobacco industry.

top of page

Increasing Tobacco Use Cessation: Community-wide Strategies

Effectiveness

The effectiveness of increasing the unit price for tobacco products and mass media campaigns (when implemented with other interventions) is established. However, research issues regarding the effectiveness of these interventions remain.

• What intervention components contribute most to effectiveness of multi-component interventions? What components contribute the least?
• What are the minimum and optimal requirements for the duration and intensity of mass media campaigns?
• What are the most effective combinations of messages for mass media campaigns?
• Do tobacco users respond differently to changes in product price that result from excise tax increases than to industry-induced increases?
• How long do the effects of a single excise tax increase last?

Because the effectiveness of mass media cessation series and smoking cessation contests has not been established, basic research questions remain.

• Are these interventions effective in increasing tobacco use cessation in the population?
• Do recruited tobacco users exposed to these interventions quit at a greater rate than recruited tobacco users not exposed to these interventions?
• What are the rates of participation in these interventions?

Applicability

The effectiveness of increasing the unit price and of mass media campaigns in reducing tobacco use in the population is established. However, identifying differences in the effectiveness of each intervention for specific subgroups of the population remains important.

• Do significant differences exist regarding the effectiveness of these interventions, based on the level of scale (i.e., national, state, local) at which they are delivered?
• What are the effects of mass media campaigns among populations that differ by race and ethnicity?

Other positive or negative effects

Several potential negative effects of tobacco product price increases were reviewed in this evaluation. Although further research on the potential negative effects is warranted, evaluating the effect of potential positive effects of reductions in tobacco use should also be investigated to provide a complete picture of the effects of increases in state and Federal excise taxes.

• What are the effects of these interventions on reducing smoking-related fires? What are the effects on ETS exposure?
• What proportion of smokers substitute tobacco products, modify their smoking habits, or both in response to an increase in the price of tobacco products?
• How much of the potential health benefit of a price increase is reduced by these behaviors? How can these potential problems be reduced?
• Do mass media campaigns that focus on tobacco have additional effects on other drug use?

Economic evaluations

The available economic information on mass media campaigns was limited. Considerable research is, therefore, warranted regarding the following questions:

• What are the costs of mass media campaigns, especially campaigns that achieve an effective intensity over an extended duration?
• How do the costs per additional quitter compare with other interventions intended to reduce tobacco use?
• What is the cost-benefit, cost-utility, or cost per illness averted of these interventions?

Barriers

Implementation of these interventions requires political action and support. Research issues generated in this review include the following:

• What components of successful legislative and referendum campaigns are most effective? What components are least effective?
• What information is most important in gaining public support for these interventions? In gaining legislative support?
• What are the most effective ways to maintain adequate funding levels for mass media campaigns?

top of page

Increasing Tobacco Use Cessation: Health Care System-Level Strategies

Effectiveness

The effectiveness of recommended and strongly recommended interventions in this section (i.e., multi-component provider reminder plus provider education with or without patient education materials; provider reminder systems alone; multi-component interventions that include telephone cessation support; and reduction of patient out-of-pocket costs for cessation) is established. However, research issues regarding the effectiveness of these interventions remain:

• Which characteristics of provider-based interventions contribute to increased or decreased effectiveness?
• What are the least and most effective combinations of services in multi-component interventions?
• What is the effect of provider reminder systems on patient tobacco use cessation when implemented alone?
• What is the relative effectiveness of provider reminders that focus on determination of patient tobacco use status versus reminders that prompt for delivery of advice to quit?
• How do content and method of delivery of provider reminders relate to effectiveness?
• Can reducing patient costs for effective cessation services increase the effectiveness of provider-based interventions?
• What is the most effective level of implementation for telephone cessation support services?
• Is the use and effectiveness of telephone cessation support increased when community and clinical cessation support programs are coordinated?

Because the effectiveness of two interventions (provider education when used alone and provider feedback systems) has not been established, basic research questions remain. This is especially true for provider assessment and feedback systems for which the number of available studies was small:

• What are the effects of provider assessment and feedback interventions on provider delivery of advice to quit to tobacco-using patients? On patient tobacco use cessation?
• What is the effectiveness of HEDIS, as a form of assessment, feedback, and benchmarking, in improving patient receipt of advice to quit and patient tobacco use cessation? Does effectiveness vary by practice setting?
• What frequency, duration, and format of provider education efforts are required to obtain consistent improvements in provider performance and patient response?

Applicability

Each recommended and strongly recommended provider-based intervention should be applicable in most relevant target populations and settings. However, possible differences in the effectiveness of each intervention for specific subgroups of patient and provider populations could not be determined. Several questions regarding the applicability of these interventions in settings and populations other than those
studied remain:

• Do provider-based interventions differ in effectiveness in different patient populations?
• Are provider-based interventions effective in increasing cessation or in reducing initiation in adolescent populations?
• Do significant differences exist regarding the effectiveness of these interventions, based on the level of scale at which they are delivered?

Other positive or negative effects

With the exception of the use of provider reminder systems to prompt action on other preventive services, studies in this review did not report on other positive and negative effects of these interventions. Research on the following questions would be useful:

• Do provider-based interventions for tobacco use cessation interfere with office flow or efficiency? If so, how can this effect be minimized?
• Do provider-based interventions increase or decrease the delivery of other preventive services?

Economic evaluation

Available economic information was limited in this section. Considerable research is warranted regarding the following questions:

• What are the costs for provider-based interventions?
• What are the costs for patient-based interventions?
• How do the costs per additional quitter compare with other interventions intended to reduce tobacco use?
• What is the cost-benefit, cost-utility, or the cost per illness averted of these interventions?
• What is the cost-effectiveness for provider interventions that target tobacco alone compared with provider interventions that target multiple preventive services?

Barriers

Research questions regarding the potential barriers identified for the interventions evaluated in this section include the following:

• How can provider-based interventions that place minimal administrative burden on providers or systems be implemented?
• What information is needed to overcome potential barriers to the implementation of provider assessment and feedback interventions?
• What information is needed to overcome potential barriers to reducing patient out-of-pocket costs for effective cessation therapies?
• What is the effect on use of combining effective pharmacologic therapies and behavioral programs as a criterion for reimbursement? What is the effect on use and effectiveness if these cessation options are provided independently?

top of page

Strategies to Reduce Tobacco Use Initiation

Effectiveness

The effectiveness of increasing the unit price for tobacco products and mass media campaigns in reducing tobacco use by adolescents is established. Important questions remain regarding the composition and content of effective campaigns and the effective-ness in different settings and populations. Some issues raised by others overlap with questions generated as a result of this review:

• What interventions are most effective in combination with mass media campaigns? What interventions are least effective?
• What are the relative effects of these interventions on adolescent initiation, consumption, access to tobacco products, and cessation?
• What is the required intensity (frequency of spots and the broadcast exposure) of media messages for an effective campaign?
• What are the independent contributions of particular intervention features (e.g., components, content, intensity, and duration) to overall intervention effectiveness?
• What are the most effective ways to maintain reductions in youth tobacco use into young adulthood?
• Does tobacco use in adults respond to mass media campaigns that are youth-focused?

Applicability

The effectiveness of these interventions should be applicable in most settings and populations. However, there could be differences in the effectiveness of these interventions for specific subgroups of the population. The following questions remain about the applicability of these interventions in various settings and populations:

• Are there differences in the responses of adolescents to tobacco product price increases by age, race, and ethnicity?
• Are the effects of mass media campaigns on adolescents by gender, race, and ethnicity similar to or different from those observed in Florida?

Other positive or negative effects

The studies in these reviews did not provide information on other positive or negative effects. Some issues generated by the review of mass media campaigns are the following:

• Do mass media campaigns that target children and adolescents result in increases in tobacco initiation among young adults by delaying the age of initiation?
• What are the most effective ways to maintain reductions in youth tobacco use into young adulthood?

Economic evaluations

Available economic information was limited to a single study of mass media campaigns. Therefore, considerable research is warranted regarding the following questions:

• Are the costs and cost-effectiveness, net cost, or net benefit of mass media campaigns similar to or substantially different from those that have been previously reported?
• How do the costs per tobacco user averted compare with other tobacco prevention strategies?
• How do specific characteristics of mass media campaigns contribute to economic efficiency?
• What combinations of components in multi-component interventions are most cost-effective?

Barriers

The strategies evaluated in this section require political action and support. Research questions generated in this review include the following:

• What characteristics are effective in successful legislative and referendum campaigns?
• How can adequate funding levels be maintained for mass media campaigns?

Methods of intervention research

Evaluations of mass media campaigns should provide information on the costs, scale, duration, and content of the campaign. Researchers should identify concurrent tobacco control efforts, especially excise taxes or changes in the price of tobacco products, and should attempt to control for these changes in their analyses.

top of page

Additional Interventions Under Evaluation

The TFCPS is currently reviewing the evidence of effectiveness of three additional interventions that may affect the use of tobacco products among adolescents.

• Youth access restrictions include laws that regulate and enforce bans on the sale of tobacco products to, or their purchase or consumption by, children and adolescents.
• School-based education includes all efforts in school settings to educate and motivate young people to remain tobacco free.
• Tobacco-industry restrictions focus on laws that regulate the content, labeling, promotion, and advertising of tobacco products.