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Optimal Mix to Nix Smoking

Optimal Mix to Nix Smoking

Since 1965, the prevalence of cigarette smoking in America has been cut in half, from over 40 percent to about 20 percent.  Behind that cultural shift lies an enormous effort by government and NGOs to attack smoking as a public health problem, with taxes, warning labels, TV ads, even 24/7 call-in “quitlines.”

Numerous studies have established that interventions like these work well.  So what’s next?  “One challenge is to find out the optimal combination of these interventions,” says health behavior expert David Holtgrave. “I think that’s a new frontier. The goal is to mix interventions at different levels to get the greatest effect as quickly as possible.”

Studying an intervention singly in an experimental, controlled setting can generate solid data on its efficacy. But interventions applied to communities or other large populations can’t be studied in such a controlled and conclusive way.“You’re dealing with a complex system in which many factors are changing at once,” notes epidemiologist Ben Apelberg.

In the near-future of intervention research, says Holtgrave, there will be an emphasis on techniques to get useful information even from complex programs that are applied to big populations.  “For example, if we roll out a set of policies in 15 communities across the U.S.,” he says, “we could look at what was the pre- and post-intervention impact in each of the communities, to see if there’s a similar pattern over time.”

Another big challenge is to tailor interventions in the international domain, where lessons learned from U.S. intervention studies don’t necessarily apply. “We need to understand how to adapt interventions to different political, economic and social environments,” notes tobacco expert Frances Stillman. “These environments differ from state to state within the U.S. So it’s an even bigger challenge when you’re comparing different countries.”

Cost-effectiveness analyses, which compare intervention costs to the health care and other costs they save, represent a closely related area. Holtgrave recently led a study of a high profile, expensively produced, smoking prevention ad campaign, the Truth campaign.  “Even with a relatively pessimistic estimate of the impact, we found that it could be considered a cost-effective use of resources,” he says.

Knowing that an intervention not only improves public health, but will pay for itself is more important than ever in these days of shrinking budgets. “Many states are losing their funding,” says Stillman. “Coalitions that have been built and have functioned successfully in many states are being disbanded.”

And that’s not because the battle has been won. Nationwide, drops in smoking prevalence have tailed off since 2005, while some inner city and rural communities still have sky-high rates. “Here in Baltimore, about half of 18- to 24-year-olds still smoke,” Stillman says.

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