The reports in this supplement to the American

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1 Evidence Reviews and Recommendations on Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke A Summary of Selected Guidelines David P. Hopkins, MD, MPH, Corinne G. Husten, MD, MPH, Jonathan E. Fielding, MD, MPH, MBA, J. Niels Rosenquist, BS, Lori L. Westphal, MA, MPH Medical Subject Headings (MeSH): community health services, decision-making, evidencebased medicine, practice guidelines, preventive health services, public health practice, smoking cessation, meta-analysis, review literature, tobacco smoke pollution, tobacco use cessation (Am J Prev Med 2001;20(2S):67 87) 2001 American Journal of Preventive Medicine Introduction The reports in this supplement to the American Journal of Preventive Medicine by the Task Force on Community Preventive Services 1 (TFCPS) and Hopkins et al. 2 represent the work of the TFCPS, an independent, nonfederal group of national, regional, and local public health and prevention services experts supported by public and private partners. These reports are the second published section of what will be the forthcoming Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Methods. The first published section was on vaccine-preventable diseases. 3 5 In addition to expanding the Guide to Community Preventive Serives (the Community Guide), these reviews and evidence-based recommendations add to the growing body of guidelines that identify and document the effectiveness of interventions to reduce tobacco use and exposure to environmental tobacco smoke (ETS). The TFCPS reports complement other recent efforts that provide information and guidance to health care providers, health care systems, and communities on strategies to reduce the annual tobacco-related toll of addiction, illness, disability, and death. This article presents a summary of selected guidelines and evidence reviews available as of August 2000, and provides an From the Division of Prevention Research and Analytic Methods, Epidemiology Program Office (Hopkins, Rosenquist, Westphal), and Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion (Husten), Centers for Disease Control and Prevention, Atlanta, Georgia; Los Angeles Department of Health Services (Fielding), and University of California-Los Angeles School of Public Health (Fielding) and School of Medicine (Fielding), Los Angeles, California Address correspondence and reprint requests to: David P. Hopkins, MD, MPH, Coordinating Scientist, Epidemiology Program Office, MS K-73, Centers for Disease Control and Prevention, 4770 Buford Highway, Atlanta, GA dhh4@cdc.gov. accessible review of the current evidence of effectiveness of interventions to reduce tobacco use and exposure to ETS. The first section of this article describes the focus and general content of selected evidence reviews and guidelines, and information on the organization of the summary tables. The second section presents the summary evidence tables, organized by type or category of intervention. The third section provides a brief discussion of the comparisons across evidence reviews. Selected Evidence Reviews and Guidelines on Tobacco Use Prevention and Control The primary objective of this article is to compare the evidence reviews and recommendations from the Community Guide with reviews and recommendations recently produced by other groups. The two reports most often cited are Treating Tobacco Use and Dependence: Clinical Practice Guideline 6 (CPG) and Reducing Tobacco Use: A Report of the Surgeon General 7 (SGR). Other guidelines are also included to provide an additional assessment of the strength of the evidence for an intervention, 8 another summary effect measurement, 9 or a specific implementation recommendation from another agency or group This section identifies and briefly describes the selected guidelines and evidence reviews included in this summary report. Each of these documents employed a different methodology for finding, evaluating, and translating the evidence of effectiveness into a summary effect measurement, a recommendation for use, or both. As a result, the descriptions provided here cannot fully elaborate on the methods used or the target audience for each publication. Am J Prev Med 2001;20(2S) /01/$ see front matter 2001 American Journal of Preventive Medicine Published by Elsevier Science Inc. PII S (00)

2 The Guide to Community Preventive Services: Interventions to Reduce Tobacco Use and ETS Exposure (2001) The tobacco section of the Community Guide currently includes 14 evidence reviews on interventions to reduce tobacco use and ETS exposure, with three additional reviews in progress. Community Guide methods, which have been summarized elsewhere, 13 basically involve a systematic process of: (1) identifying and selecting interventions to review; (2) searching for published evidence (limited to studies published in the English language); (3) abstracting and evaluating the quality of each identified study; (4) summarizing the available body of evidence regarding effectiveness, other effects, applicability, economic evaluation, and barriers to implementation; (5) TFCPS translation of evidence into recommendations, based on established rules; and (6) identifying remaining questions for future research. Methods specific to the tobacco section are summarized in Hopkins et al., 2 Appendix A, in this supplement. Overall, for each selected intervention, the Community Guide report provides a range and median of effect measures from the included studies, and a practice recommendation from the TFCPS based primarily on the strength of the evidence. Treating Tobacco Use and Dependence: Clinical Practice Guideline (2000) Released in June 2000 by the Public Health Service, CPG 6 updates and expands on the review of strategies and therapies for the clinical identification and treatment of tobacco use and dependence published in the original 1996 report. 14 The CPG update provides: (1) a comprehensive review of interventions to treat patient tobacco use and dependence that are appropriate for health care providers, health care systems, and health care purchasers; (2) a standardized evaluation process for each identified study; (3) standardized inclusion criteria; (4) a pooled summary estimate using metaanalytic techniques when appropriate; (5) a standardized assessment and grade of the strength of evidence for each intervention; and (6) identification of areas for further research. A product of the Tobacco Use and Dependence Guideline Panel, the CPG update is the most recent and the most complete assessment of interventions to treat tobacco use and dependence. The evaluations provided in both editions were heavily referenced in the relevant sections of the SGR, and provided the foundation of evidence of effectiveness for several health care system strategies evaluated in the Community Guide. Reducing Tobacco Use: A Report of the Surgeon General (2000) Released in August 2000, the SGR 7 updates the status of tobacco use in the United States, and is the first Surgeon General s report to offer a composite review of the various methods used to reduce and prevent tobacco use. 15 The SGR is a comprehensive, narrative review of: (1) current tobacco use in the United States and a historical review of efforts to reduce smoking, (2) effective educational strategies to prevent tobacco use among young people, (3) individual and clinical strategies to increase tobacco use cessation, (4) regulatory efforts to reduce tobacco use and ETS exposure, (5) economic approaches (such as taxation of tobacco products), and (6) comprehensive tobacco use prevention and control programs at the community, state, and national levels. Narrative reviews of the evidence of effectiveness are provided for some interventions, usually without a summary effect measure or a formal recommendation for use. Some interventions are reviewed only in the context of comprehensive programs at the community, state, or national levels. Cochrane Collaboration (various reports) The Cochrane Collaboration is an international coalition of participating research centers conducting evidence reviews on a wide variety of clinical and public health topics. We have included ten reports from the Cochrane Collaboration on tobacco use prevention and treatment in the summary tables These reports provide assessments of the effectiveness of interventions based on a systematic process including: (1) a search for evidence (not usually restricted to the English language); (2) standardized inclusion and exclusion criteria; (3) standardized evaluation and abstraction of information; (4) a pooled summary estimate using meta-analytic techniques, when appropriate, and a narrative review when a pooled summary estimate could not be conducted; and (5) a process of updating reviews as new evidence is identified. Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force (1996) The U.S. Preventive Services Task Force (USPSTF) provides evidence-based recommendations for clinical practice on preventive interventions for a wide variety of conditions. 8 The USPSTF conducted evidence reviews using: (1) a standardized search for evidence of effectiveness of clinical preventive services, (2) standardized inclusion criteria, and (3) standardized evaluations of the evidence concluding with a narrative review and a recommendation based on the strength of the evidence of effectiveness. 68 American Journal of Preventive Medicine, Volume 20, Number 2S

3 Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths (1994) and Taking Action to Reduce Tobacco Use (1998) These publications from the Institute of Medicine 10,11 present policy positions to reduce and prevent tobacco use in the United States that are informed by scientific evidence. The reports provide a pertinent review of tobacco use in the United States, and a set of recommendations for the implementation of specific policies and/or interventions at the national, state, and local levels. Best Practices for Comprehensive Tobacco Control Programs (1999) Best Practices, 12 a guidance document from the Office on Smoking and Health at the Centers for Disease Control and Prevention, presents recommendations and funding estimates for states to establish tobacco control programs that are comprehensive, sustainable, and accountable. The report identifies nine basic components of a comprehensive tobacco control program based on a review of published intervention studies, evaluations of two state programs (California and Massachusetts), and work with six other state programs (Oregon, Maine, Florida, Minnesota, Mississippi, and Texas). In addition to a narrative evidence review for each component, Best Practices provides budget estimates for the successful implementation of each component, and generates funding estimates for a model comprehensive program in every state. Organization of the Summary Tables Evidence reviews and recommendations are summarized in tables in this article as follows: Table 1. Clinical interventions to identify and to treat tobacco use and dependence Table 2. Health care system interventions to identify and to treat tobacco use and dependence Table 3. Community interventions to reduce exposure to ETS Table 4. Community interventions to reduce tobacco use initiation by children and adolescents Table 5. Community interventions to increase tobacco use cessation All tables are located after the References section. Each intervention is displayed in a single row, with summaries of the contributing evidence reviews presented in the columns. Within each column, the evidence review is summarized from top to bottom in the following order: (1) a formal strength-of-evidence rating or recommendation, if provided; (2) narrative conclusion, if any; (3) summary effect measurements, if provided, with a brief description of the effect measure, and pertinent information (such as the period of follow-up for measurements of tobacco use cessation). With the exception of the evidence summaries provided in Table 1, the interventions identified and included follow the organization of the Community Guide. Interventions not evaluated in the Community Guide (e.g., provider counseling to reduce ETS exposure in the home; and community-wide, individual risk-factor screening and counseling) are not presented in these tables, but may have been evaluated in the other guidelines. The clinical interventions reviewed in Table 1 present evidence of effectiveness of several strategies that directly relate to the evaluations of effectiveness of health care system interventions reviewed in the Community Guide. For example, the evidence of effectiveness of provider counseling to tobacco-using patients, demonstrated in both the Guide to Clinical Preventive Services and the CPG, was referenced in the Community Guide in the evaluation of provider reminder systems. As a result, the Community Guide evaluated the evidence of effectiveness of provider reminder systems in increasing patients receipt of counseling or advice to quit from their providers. There is also some duplication of intervention summaries. For example, telephone cessation support is presented both in Tables 2 and 5 because it is an appropriate intervention for both health care systems and communities. Recommendations Three of the selected evidence reviews Guide to Clinical Preventive Services, the Community Guide, and the CPG present formal recommendations concerning the evidence of effectiveness for each intervention. In summarizing the recommendations from these reviews, the strength of evidence rating or recommendation is presented. In some cases, a brief quotation or statement is also presented. For several interventions, longer recommendation statements in the original document were abbreviated to fit the table format. In all of the guidelines, readers were cautioned not to confuse an assessment of insufficient evidence of effectiveness with evidence of ineffectiveness. In most cases, an assessment of insufficient evidence was based on an inadequate number of qualifying studies. Guide to Clinical Preventive Services A letter rating was assigned to denote the strength of the evidence of effectiveness supporting the USPSTF recommendation for or against use of the intervention. Letter ratings range from A, good evidence to support the recommendation to include to E, good evidence to support the recommendation to exclude. An evaluation of insufficient evidence is denoted by a letter rating of C. Am J Prev Med 2001;20(2S) 69

4 Guide to Community Preventive Services Recommendations for or against use of an intervention were based on the evidence of effectiveness and consideration of other effects (positive and negative). The three options are: (1) strongly recommended (for or against), (2) recommended (for or against), and (3) insufficient evidence (no recommendation). Treating Tobacco Use and Dependence: Clinical Practice Guideline A letter rating was assigned to each intervention based on the strength of the evidence supporting the recommendation. A rating of A indicates multiple welldesigned randomized clinical trials, directly relevant to the recommendation, yielding a consistent pattern of findings. A rating of B indicates some evidence from randomized clinical trials supporting the recommendation, but the scientific support was not optimal. A rating of C was reserved for important clinical situations where the panel achieved consensus on the recommendation in the absence of relevant randomized controlled trials. The panel declined to make recommendations when there was no relevant evidence or the evidence was too weak or inconsistent to support a recommendation. Narrative Reviews Some of the selected guidelines provided a narrative evaluation of the evidence of effectiveness of the intervention. For presentation in the summary tables of this article, pertinent sections of the text were quoted and identified. In most cases, the included text represents a summation or conclusion from an extended narrative evaluation of the studies providing evidence. Summary Effect Measurements Three of the evidence reviews the Community Guide, the CPG, and the reports from the Cochrane Collaboration provide summary effect measurements in evaluations of the evidence of effectiveness of the intervention. This information is provided in the tables with additional comments or information as needed. In all cases, the original document included a more detailed presentation and discussion of the summary effect measurements than is provided in these summary tables. Guide to Community Preventive Services For most interventions, the summary effect measurements were the range and median of absolute percentage differences in outcome between the intervention and comparison groups. The results are reported here as percentage point changes. For some intervention evaluations, the differences in outcome between the intervention and comparison groups were expressed as a relative percentage difference, with the results reported as the percentage change. Clinical Practice Guideline: Treating Tobacco Use and Dependence For interventions with an appropriate body of evidence, a pooled summary estimate of effect was determined using meta-analytic techniques. In these cases, the summary table presents the estimated odds ratio for the effect measurement and the 95% confidence interval. In some cases, the estimated abstinence rate (cessation outcomes) or the estimated provider intervention rate (for delivery of a measured activity such as counseling) was also reported. Cochrane Collaboration For interventions with an appropriate body of evidence, a pooled summary estimate of effect was determined using meta-analytic techniques. In these cases, the summary table presents the estimated odds ratio for the effect measurement and the 95% confidence interval. Several of the bodies of evidence reviewed on tobacco interventions, however, were not suitable for metaanalytic evaluation. In these cases, the summary tables present a quotation or conclusion from the narrative review. Discussion Comparison of the evidence summaries presented here reveals considerable general agreement on the effectiveness or ineffectiveness of the interventions reviewed, with only a few instances in which different reviews reached different conclusions. There is uniform agreement on the effectiveness of the clinical interventions, although the magnitude of the effects differed slightly. Screening patients for tobacco use, delivering brief advice or more intense or frequent counseling to quit, and the use of pharmacologic treatments (nicotine replacement or bupropion as first-line therapies) were identified as effective in increasing patient tobacco use cessation. Self-help education materials were assessed as less effective or inconsistent. The health care system interventions evaluated in these reviews primarily focused on increasing the delivery or use of effective clinical strategies. For most interventions, the assessment of effectiveness was consistent across the evidence reviews. Provider reminder systems (alone or in combination with other interventions), patient cessation support provided by telephone (when implemented with other interventions), and interventions to reduce patient out-of-pocket costs for 70 American Journal of Preventive Medicine, Volume 20, Number 2S

5 effective cessation treatments were all identified as effective. The reviews differed slightly in the assessment of provider education programs. Two of the reviews, the Community Guide and the SGR, identified limitations in the evidence of effectiveness of provider education when implemented alone. The reviews were consistent, however, in identifying stronger evidence of effectiveness when provider education efforts were combined with other interventions, such as a provider reminder system. The assessments of community interventions to reduce exposure to ETS, reduce tobacco use initiation, and increase tobacco use cessation were also consistent. Both the Community Guide and the SGR identified smoking bans and restrictions as effective in reducing exposure to ETS, and potentially effective in reducing tobacco use prevalence. Regarding community education efforts to reduce exposure to ETS in the home, the Community Guide found insufficient evidence to make a recommendation, whereas the SGR identified mass media messages included in the state campaigns in California and Massachusetts as effective in protecting children from exposure to ETS. The evidence reviews of interventions to reduce tobacco use initiation in children and adolescents uniformly agreed on the effectiveness of increasing the unit price of tobacco products. The reviews differed slightly in the assessment of the evidence of effectiveness of mass media campaigns in reducing tobacco use among youth. All of the guidelines, however, identified effective campaigns characterized by a solid theoretical basis, use of formative research in designing the messages, and a broadcast campaign of reasonable intensity over an extended period of time. One reason for the stronger recommendation in the Community Guide is the addition of recent evaluations of effectiveness of state campaigns in Florida 26,27 and Massachusetts, 28 which were not available for earlier reviews. Evidence reviews of interventions to increase tobacco use cessation uniformly documented the effectiveness both of increasing the unit price of tobacco products and of mass media campaigns (when implemented with other interventions). Telephone cessation support, when implemented with other interventions, was also identified as effective in increasing tobacco use cessation. Regarding telephone support, these reviews all found greater evidence of effectiveness for proactive support (contact or follow-up initiated by a clinician or counselor) than for reactive (patient initiates all contact). Conclusion This article is unique in pulling together information from various tobacco control guidelines and summarizing evidence and recommendations for complementary tobacco prevention and control activities at the individual, health care system, and community levels. The included guidelines used many of the same studies and explicitly referred to one another. Their similarity, therefore, is not surprising. Nonetheless, the similarity of the findings and recommendations in these evidence reviews and guidelines, despite the widely varied methods used to select, appraise, and summarize evidence, provides considerable reassurance about the effectiveness of the recommended interventions. The cohesiveness and coherence of these reviews and recommendations provides additional support for the policy positions and suggests that these effective and recommended interventions should be implemented and funded. The summary tables in this article provide a useful starting point for clinicians; health care providers and purchasers; state and local health departments; and local, state, and national managers, funders, and advocates of tobacco use prevention and control efforts. These brief evidence summaries cannot convey all of the important information provided in the original reviews. However, these tables provide a quick review of recent efforts, and can efficiently direct users to the original sources for additional information of interest. References 1. Task Force on Community Preventive Services. Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med 2001;20(suppl 2): Hopkins DP, Briss PA, Ricard CJ, et al. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med 2001;20(suppl 2): Task Force on Community Preventive Services. Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults. Am J Prev Med 2000;18(suppl 1): Briss PA, Rodewald LE, Hinman AR, et al. Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services. Am J Prev Med 2000;18(suppl 1): Shefer A, Briss P, Rodewald L, et al. Improving immunization coverage rates: an evidence-based review of the literature. Epidemiol Rev 1999;21: Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: Clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Available at: Accessed 13 July U.S. Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General (Stock no.: ). Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, U.S. Preventive Services Task Force. Guide to Clinical Preventive Services: report of the U.S. Preventive Services Task Force, 2nd ed. Baltimore, MD: Williams & Wilkins, The Cochrane Collaboration. The Cochrane Database of Systematic Reviews, 18 April Available at: Accessed December 20, Institute of Medicine. Growing up tobacco free: preventing nicotine addiction in children and youths. Washington, DC: National Academy Press, National Cancer Policy Board, Institute of Medicine and Commission on Life Sciences National Research Council. Taking action to reduce tobacco use. Washington, DC: National Academy Press, Centers for Disease Control and Prevention. 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6 Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Briss PA, Zaza S, Pappaioanou M, et al. Developing an evidence-based Guide to Community Preventive Services methods. Am J Prev Med 2000;18(suppl 1): Agency for Health Care Policy and Research. Smoking cessation: clinical practice guideline, number 18. (Pub. No. [AHCPR] ).Washington, DC: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Notice to readers: publication of Surgeon General s report on smoking and health. MMWR 2000;49: Silagy C. Physician advice for smoking cessation (Cochrane Review). The Cochrane Library, Issue 3. Oxford, UK: Update Software, Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation (Cochrane Review). The Cochrane Library, Issue 3. Oxford, UK: Update Software, Lancaster T, Stead LF. Self-help interventions for smoking cessation (Cochrane Review). The Cochrane Library, Issue 3. Oxford, UK: Update Software, Silagy C, Mant D, Fowler G, Lancaster T. Nicotine replacement therapy for smoking cessation (Cochrane Review). The Cochrane Library, Issue 3. Oxford, UK: Update Software, Gourlay SG, Stead LF, Benowitz NL. Clonidine for smoking cessation (Cochrane Review). The Cochrane Library, Issue 3. Oxford, UK: Update Software, Lancaster T, Silagy C, Fowler G. Training health professionals in smoking cessation (Cochrane Review). The Cochrane Library, Issue 3. Oxford, UK: Update Software, Thomson O Brien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Audit and feedback: effects on professional practice and health care outcomes (Cochrane Review). The Cochrane Library, Issue 3. Oxford, UK: Update Software, Serra C, Cabezas C, Bonfill X, Pladevall-Vila M. Interventions for preventing tobacco smoking in public places (Cochrane Review). The Cochrane Library, Issue 3. Oxford, UK: Update Software, Sowden AJ, Arblaster L. Mass media interventions for preventing smoking in young people (Cochrane Review). The Cochrane Library, Issue 3. Oxford, UK: Update Software, Stead LF, Lancaster T. Interventions for preventing tobacco sales to minors (Cochrane Review). The Cochrane Library, Issue 3. Oxford, UK: Update Software, Centers for Disease Control and Prevention. Tobacco use among middle and high school students Florida, 1998 and MMWR 1999;48: Florida Department of Health. Florida Tobacco Youth Survey, Available at: Accessed December 20, Siegel M, Biener L. The impact of an antismoking media campaign on progressions to established smoking: results of a longitudinal youth study. Am J Public Health 2000;90: Fiore MC. The new vital sign. Assessing and documenting smoking status. JAMA 1991;266: Cohen SJ, Stookey GK, Katz BP, Drook CA, Smith DM. Encouraging primary care physicians to help smokers quit. A randomized, controlled trial. Ann Intern Med 1989;110: Ockene JK, Kristeller J, Goldberg R, et al. Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial. J Gen Intern Med 1991;6: Wells KB, Ware JE Jr, Lewis CE. Physicians attitudes in counseling patients about smoking. Med Care 1984;22: Glynn TJ. Relative effectiveness of physician-initiated smoking cessation programs. Cancer Bulletin 1988;40: Ockene JK, Aney J, Goldberg RJ, Klar JM, Williams JW. A survey of Massachusetts physicians smoking intervention practices. Am J Prev Med 1988;4: Cummings SR, Coates TJ, Richard RJ, et al. Training physicians in counseling about smoking cessation. A randomized trial of the Quit for Life program. Ann Intern Med 1989;110: Duncan C, Stein MJ, Cummings SR. Staff involvement and special follow-up time increase physicians counseling about smoking cessation: a controlled trial. Am J Public Health 1991;81: Manley M, Epps RP, Husten C, Glynn T, Shopland D. Clinical interventions in tobacco control. A National Cancer Institute training program for physicians. JAMA 1991;266: Ockene JK, Quirk ME, Goldberg RJ, et al. A residents training program for the development of smoking intervention skills. Arch Intern Med 1988; 148: Strecher VJ, O Malley MS, Villagra VG, et al. Can residents be trained to counsel patients about quitting smoking? Results from a randomized trial. J Gen Intern Med 1991;6: Dietrich AJ, O Conner GT, Keller A, Carney PA, Levy D, Whaley FS. Cancer: improving early detection and prevention. A community practice randomised trial. Br Med J 1992;304: Carney PA, Dietrich AJ, Freeman DJ, Mott LA. A standardized-patient assessment of a continuing medical education program to improve physicians cancer-control clinical skills. Acad Med 1995;70: Klein JD, Portilla M, Goldstein A, Leininger L. Training pediatric residents to prevent tobacco use. Pediatrics 1995;96: Schauffler HH, Parkinson MD. Health insurance coverage for smoking cessation services. Health Educ Q 1993;20: Eddy DM. Clinical decision making: from theory to practice. Cost-effectiveness analysis: will it be accepted? JAMA 1992;268: Kaplan RM, Orleans CT, Perkins KA, Pierce JP. Marshaling the evidence for greater regulation and control of tobacco products: a call for action. Ann Behav Med 1995;17: Rothenberg R, Koplan JP, Cutler C, Hillman AL. Changing pediatric practice in a changing medical environment: factors that influence what physicians do. Pediatr Ann 1998;27: Centers for Disease Control and Prevention. Guidelines for school health programs to prevent tobacco use and addiction. MMWR 1994;43(RR-2): Flay BR, Gruder CL, Warnecke RB, Jason LA, Peterson P. One year follow-up of the Chicago televised smoking cessation program. Am J Public Health 1989;79: Flay BR. Mass media and smoking cessation: a critical review. Am J Public Health 1987;77: American Journal of Preventive Medicine, Volume 20, Number 2S

7 Table 1. Clinical interventions to identify and to treat tobacco use and dependence: recommendations and summary effect measurements from selected tobacco control guidelines and evidence reviews Am J Prev Med 2001;20(2S) 73

8 74 American Journal of Preventive Medicine, Volume 20, Number 2S

9 Am J Prev Med 2001;20(2S) 75

10 Table 2. Health care system interventions to identify and to treat tobacco use and dependence: recommendations and summary effect measurements from selected evidence reviews 76 American Journal of Preventive Medicine, Volume 20, Number 2S

11 Am J Prev Med 2001;20(2S) 77

12 78 American Journal of Preventive Medicine, Volume 20, Number 2S

13 Am J Prev Med 2001;20(2S) 79

14 Table 3. Community interventions to reduce exposure to environmental tobacco smoke: recommendations and summary effect measurements from selected tobacco control guidelines and systematic reviews 80 American Journal of Preventive Medicine, Volume 20, Number 2S

15 Table 4. Community interventions to reduce tobacco use initiation by children and adolescents: recommendations and summary effect measurements from selected tobacco control guidelines and systematic reviews Am J Prev Med 2001;20(2S) 81

16 82 American Journal of Preventive Medicine, Volume 20, Number 2S

17 Am J Prev Med 2001;20(2S) 83

18 Table 5. Community interventions to increase tobacco use cessation: recommendations and summary effect measurements from selected tobacco control guidelines and systematic reviews 84 American Journal of Preventive Medicine, Volume 0, Number 2S

19 Am J Prev Med 0;0(2S) 85

20 86 American Journal of Preventive Medicine, Volume 20, Number 2S

21 Am J Prev Med 2001;20(2S) 87

22 Reprinted by permission of Elsevier Science from: Evidence Reviews and Recommendations on Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke: A Summary of Selected Guidelines, David P. Hopkins, MD, MPH, Corrinne G. Husten, MD, MPH, Johnathan E. Fielding, MD, MPH, MBA, J. Niels Rosenquist, BS, Lori L. Westphal, MA, MPH, American Journal of Preventive Medicine, Vol 20 No 2S, pp 67-87, Copyright 2001 by American Journal of Preventive Medicine.