Community Intervention Trial For Smoking Cessation Research Articles

National Cancer Institute's leadership role in promoting State and Community Tobacco Control research

The National Cancer Institute (NCI) has been at the vanguard of funding tobacco control research for decades with major efforts such as the Community Intervention Trial for Smoking Cessation (COMMIT)...

The Tobacco Industry's Response to the COMMIT Trial: An Analysis of Legacy Tobacco Documents

We analyzed internal tobacco industry documents that describe the industry's response to the Community Intervention Trial for Smoking Cessation (COMMIT), a multi-center community-based tobacco intervention project funded by the National Cancer Institute from 1988 to 1992. Our analysis of documents from the Legacy Tobacco Documents Library (www.legacy.library.ucsf.edu) suggests that the tobacco industry reacted to COMMIT by (1) closely monitoring trial activities, (2) confronting COMMIT in communities where it was most active, (3) distorting COMMIT findings on underage smoking data reported in the media, and (4) using COMMIT activities as practice to strengthen their attack against the subsequent ASSIST trial, falsely accusing both studies of illegal political lobbying with taxpayers' money. The tobacco industry closely monitored COMMIT activities and organized local responses to findings and activities perceived as threatening to the industry's public image or interests. Although we could not document a concerted attack by the tobacco industry that impacted the results of the COMMIT trial, data suggest that the industry used COMMIT as a learning opportunity to mount a well orchestrated and potentially damaging response to the larger American Stop Smoking Intervention Study for Cancer Prevention Trial.

State and Community Tobacco-Control Programs and Smoking-Cessation Rates among Adult Smokers: What Can we Learn from the COMMIT Intervention Cohort?

To assess the long-term effect of a randomized community-based trial of smoking cessation and to examine the effect of exposure to large state-based tobacco-control programs on smoking cessation. Longitudinal tobacco-use telephone surveys conducted in 1988, 1993, and 2001. Baseline smokers (6603) from 20 communities in 9 states completed a survey in 2001 (35% of the original sample). The Community Intervention Trial for Smoking Cessation (COMMIT) intervention was a randomized community-based smoking-cessation intervention between 1988 and 1993. In addition, cohort data were used to evaluate quasi-experimental differences in the strength of state-level tobacco control programs and policies. Multivariate logistic regression was used to compare quit rates among those who were exposed to community- or state-level tobacco-control programming and those who were not between 1988 and 2001. Quit rates were higher in the COMMIT intervention communities during the period when the trial was funded (Relative Risk [RR] = 1.19) but were no different than comparison communities 8 years later after funding stopped. Quit rates were highest in those communities in states with both strong tobacco-control policies and aggressive tobacco-control programs, such as California and Massachusetts (RR = 1.44) compared with those communities in states that had little tobacco-control activity, such as Iowa, New Mexico, and North Carolina. The findings suggest that well-funded tobacco-control programming coupled with tobacco-control policies may be associated with increases in cessation rates.

Over‐the‐counter availability of nicotine replacement therapy and smoking cessation

In 1996, the FDA approved over-the-counter (OTC) availability of nicotine gum and two brands of nicotine skin patches. Little is known about how this reclassification has influenced the effectiveness and use of nicotine replacement therapy (NRT) and whether it has been a public health benefit. Data for the present study came from a prospective cohort study of 1,639 adult smokers surveyed by telephone in 1993, as part of the National Cancer Institute's Community Intervention Trial for Smoking Cessation (COMMIT), and resurveyed in 2001. NRT-assisted quit rates, NRT use rates, and the characteristics of NRT users were calculated before and after the 1996 OTC reclassification. Also calculated was the percentage of NRT users who quit by year. Results are presented for patch and gum separately and combined. OTC NRT use rates were lower for Hispanics and higher for those with no desire to quit at baseline. The quit rate decreased for patch-assisted quit attempts after OTC reclassification (22.5% to 18.5%, p = .05), but it did not change for gum-assisted quit attempts (11.9% to 10.5%, p = .54). NRT use rates increased for both patch and gum by about 60% following reclassification. A greater percentage of gum users had quit in the post-OTC period than in the pre-OTC period (9.7% vs. 14.6%, p = .05). Long-term quit rates in patch users were similar in both periods. Insurance coverage of NRT and concurrent attendance in a stop smoking clinic decreased for both patch- and gum-assisted attempts in the post-OTC period. The results suggest that OTC reclassification may have contributed to the increased use of NRT, compared with the pre-OTC period, whereas the efficacy for quitting decreased slightly for those using nicotine patch and remained about the same for those using the gum.

Characteristics of low‐level smokers

Average daily cigarette consumption has decreased, and some evidence suggests that the rate of "some day" smoking has increased; however, relatively little is known about low-level smokers. The present analysis describes and compares low-level versus heavier smokers, using cross-sectional and longitudinal data. Data from the Community Intervention Trial for Smoking Cessation (COMMIT) were used in this analysis. Population-based cross-sectional tobacco use telephone surveys were performed in 22 North American communities in 1988 and 1993, and the prevalence and characteristics of low-level smoking and reasons for quitting are reported from the 1993 prevalence survey. In addition, a cohort of 6,603 smokers was identified in 1988 and interviewed again in 1993 and 2001 to assess patterns of low-level smoking over time and its association with smoking cessation. In 1988, 7.6% were low-level smokers; in 1993, 10.7% were low-level smokers. Compared with heavier smokers, low-level smokers were more likely to be female, older, not married, Black or Hispanic; to have a 4-year college degree; to have no other adult smokers in the household; and to wait longer in the day to have their first cigarette. Low-level smokers also were less likely to report trying to quit because of the expense of smoking or physician advice to quit. They were more likely to try to quit because of trying to set a good example; concern for second-hand smoke; and factors such as bad breath, smell, or the taste of smoking. Those who smoked full-priced premium brands and who worked in a completely smoke-free worksite were more likely to be low-level smokers. Compared with heavier smokers, low-level smokers had similar rates of making a future quit attempt, lower use rates of nicotine replacement therapy, and higher cessation rates. Low-level smokers may be a growing segment of the smoker population and have different characteristics, health risks, and intervention needs compared with their heavier smoking counterparts.

Higher cigarette prices influence cigarette purchase patterns

Objective: To examine cigarette purchasing patterns of current smokers and to determine the effects of cigarette price on use of cheaper sources, discount/generic cigarettes, and coupons. Background: Higher cigarette prices...

Predictors of cessation in a cohort of current and former smokers followed over 13 years

The present study attempted to identify predictors of smoking cessation in a cohort of cigarette smokers followed over 13 years. Data are reported on 6,603 persons who resided in one of 20 U.S. communities involved in the National Cancer Institute's Community Intervention Trial for Smoking Cessation (COMMIT) study, were current smokers in the COMMIT trial in 1988, and completed detailed tobacco use telephone surveys in 1988, 1993, and 2001. A person was classified as a former smoker if at the time of follow-up he or she reported not smoking for at least 6 months prior to the interview. Reasons and methods for quitting also were assessed in 1993 and 2001. Among smokers in 1988, 24% had stopped smoking by 1993 and 42% were not smoking by 2001. The most frequently cited reasons for quitting were health and cost reasons, while assisted methods to quit were more common in more recent years. Measures of nicotine dependence were much more strongly associated with cessation than measures of motivation. Other predictors included male gender, older age, higher income, and less frequent alcohol consumption, although the gender effect no longer existed when cessation from cigarettes as well as other tobacco products was considered as the outcome. The present study shows that nicotine dependence is a major factor predicting long-term cessation in smokers. This finding has implications for tobacco control policy and treatment approaches.

Mentholated cigarettes and smoking cessation: findings from COMMIT

Objective: To examine the association between the use of menthol cigarettes and smoking cessation, amount smoked, and time to first cigarette in the morning. Background: The majority of African American...

The Paucity of Effects in Community Trials: Is Secular Trend the Culprit?

Background. The most recent major U.S. trials that evaluated community-level programs to influence risk factors and health behaviors identified secular trends in the risk factors and health behaviors among the factors that might have limited community-level effects. The research reported in this paper uses data from one of the trials to examine the secular trend explanation directly.Methods. Data from the 22-community Community Intervention Trial for Smoking Cessation (COMMIT) were analyzed to test a hypothesis based on secular trend reasoning: program effects for smoking prevalence were larger for treatment communities matched to control communities with small declines in smoking than in treatment communities matched to control communities with larger declines in smoking.Results. Consistent with the secular trend explanation, program effects were larger when control communities had relatively small declines in smoking prevalence.Conclusions. The findings suggest that secular trends masked community-level program effects in COMMIT.

Measuring attitudes towards smoking in the Community Intervention Trial for Smoking Cessation (COMMIT).

We present the development of indices using baseline data from the Evaluation Survey for the Community Intervention Trial for Smoking Cessation (COMMIT). The indices are designed to measure two primary attitude constructs that relate to smoking behavior: beliefs about smoking as a public health problem (SPHP); and norms and values concerning smoking (NVS). Two general approaches to index construction, the rational method and the factor analytic method, were used. Item analysis suggested good internal consistency for both indices (alpha > 0.75). Seven subconstructs emerged from the factor analysis accounting for 55.0% of the total variance. The SPHP and NVS items uniquely identify with four factors and three factors, respectively, confirming the validity of the two indices. Confirmatory factor analyses of a different data set provided further validation. Validity was also assessed by an examination of the relationships between index scores and smoking status. Smokers reported significantly higher scores than non-smokers on the two measures indicating, as anticipated, that smokers have more favorable attitudes towards smoking than non-smokers. These findings suggest that the two a priori constructs of SPHP and NVS are empirically distinguishable components of attitudes towards smoking, and that the indices developed here are reliable and valid measures of those constructs.

Geographical variation in attitudes towards smoking: findings from the COMMIT communities

This paper examines the links between attitudes towards cigarette smoking and the social environments of communities involved in the U.S. National Cancer Institute's Community Intervention Trial for Smoking Cessation (COMMIT). Our objective is to identify sources of social–geographic variation in smoking attitudes and norms which can hinder or enhance public health efforts to reduce tobacco use. The analysis had two stages: (1) place (measured as region and community) was identified as an important main effect accounting for individual variation in smoking attitudes independent of smoking status and personal characteristics; (2) case studies of COMMIT sites in North Carolina, Iowa, Washington, New Jersey and New Mexico were conducted to reveal features of the local milieux which could account for variations in smoking attitudes. Some of the place characteristics that we suggest are linked to local attitudes include economic reliance on the tobacco industry, libertarian political orientations, socio-economic conditions, legislative context and ethnic composition. Given the effects of regional and community attributes on individual attitudes towards smoking, we conclude that public health efforts to control smoking should continue to be targeted beyond individual smokers to the broader social environment.

A Voluntary Smokers' Registry: Characteristics of joiners and non-joiners in the Community Intervention Trial for Smoking Cessation (COMMIT).

This paper examines differences between joiners and nonjoiners of a voluntary smokers' registry. A baseline prevalence survey was used to identify characteristics of smokers who joined or did not join a smokers' registry. Communities varied significantly in registry enrollment rates. Heavy-smoking joiners expressed more desire to quit, were more likely to live with nonsmokers, and were older than nonjoiners. Light-to-moderate joiners smoked more, were more addicted to cigarettes, and expressed more desire to quit than nonjoiners. Few baseline characteristics differentiated joiners from nonjoiners. Nonjoiners were significantly more likely to achieve cessation than joiners.

The advantages of community-randomized trials for evaluating lifestyle modification

Observational studies may provide suggestive evidence for the results of behavior change and lifestyle modification, but they do not replace randomized trials for comparing interventions. To obtain a valid comparison of competing intervention strategies, randomized trials of adequate size are the recommended approach. Randomization avoids bias, achieves balance (on average) of both known and unknown predictive factors between intervention and comparison groups, and provides the basis of statistical tests. The value of randomization is as relevant when investigating community interventions as it is for studies that are directed at individuals. Randomization by group is less efficient statistically than randomization by individual, but there are reasons why randomization by group (such as community) may be chosen, including feasibility of delivery of the intervention, political and administrative considerations, avoiding contamination between individuals allocated to competing interventions, and the very nature of the intervention. One example is the Community Intervention Trial for Smoking Cessation (COMMIT), which involved 11 matched pairs of communities and randomized within these pairs to active community-level intervention versus comparison. For analysis of results, community-level permutation tests (and corresponding test-based confidence intervals) can be designed based on the randomization distribution. The advantages of this approach are that it is robust, and the unit of randomization is the unit of analysis, yet it can incorporate individual-level covariates. Such covariates can play a role in imputation for missing values, adjustment for imbalances, and separate analyses in demographic subsets (with appropriate tests for interaction). A communityrandomized trial can investigate a multichannel community-based approach to lifestyle modification, thus providing generalizability coupled with a rigorous evaluation of the intervention.

Gender, social pressure, and smoking cessations: The Community Intervention Trial for Smoking Cessation (COMMIT) at baseline

This study was undertaken to examine gender differences in the perception of social constraints against smoking and to explore the role of other sociodemographic and smoking factors that influence the perception of social pressure. Baseline data from the 20 U.S. sites in the National Cancer Institute's Community Intervention Trial for Smoking Cessation (COMMIT) were analyzed. We found that women were less likely than men to be heavy smokers and to report that smoking had affected their health, but more likely to report behavior indicating physiological addition (timing of first cigarette). At all smoking levels, women were about twice as likely as men to report feeling pressure to quit, after adjusting for education, income, ethnic group, age, and other factors. The source of pressure, however, was different: more women report pressure from their children, whereas more men report pressure from friends and coworkers. Women were equally likely as men to make quit attempts, after adjusting for other factors, but were less likely to remain abstinent for at least 10 days. Women, regardless of education, ethnicity, and age, reported a greater tendency to ask permission before smoking in non-restricted public places. College-educated men were less likely than men without college education to smoke without asking in non-restricted places, but education did not influence whether women asked permission. For both sexes, smoking level and nicotine dependence were significant predictors of lighting up without asking in public places, after adjustment for other variables. We discuss these findings and their implications for the gender gap in smoking cessation and women's conflicting pressures to stop/continue smoking. Tobacco control efforts are discussed within the context of gender differences in social norms, roles, socialization, and communication cultures.

Tobacco control activities of primary-care physicians in the Community Intervention Trial for Smoking Cessation. COMMIT Research Group.

OBJECTIVE: To compare tobacco control practices of physicians and their staff in Intervention communities with those in Comparison communities of the Community Intervention Trial for Smoking Cessation (COMMIT). DESIGN: COMMIT...

The efficiency of the matched-pairs design of The Community Intervention Trial for Smoking Cessation (COMMIT)

The Community Intervention Trial for Smoking Cessation (COMMIT) was a randomized trial to evaluate the effects of a community-wide smoking cessation intervention on smoking behavior. The statistical design involved 22 pair-matched communities and the randomization of one community in each of the 11 pairs to the intervention, with the other community in the pair acting as a comparison. Communities were matched on the basis of their geographical proximity and similarity of demographic composition. In this paper, we use the data on the rates of quitting smoking among cohorts of heavy and light/moderate smokers in each community to estimate the gains in efficiency achieved by the matched-pairs design compared to an unmatched randomized trial. We find evidence of some gain in efficiency, although the data are not extensive enough to give estimates of efficiency gain that have good precision.

Use of the nicotine skin patch by smokers in 20 communities in the United States, 1992-1993.

OBJECTIVE: To measure the characteristics of smokers associated with the use of the nicotine skin patch in the general population and to evaluate whether use of the patch is associated...

Promoting Worksite Smoking Control Policies and Actions: The Community Intervention Trial for Smoking Cessation (COMMIT) Experience

Background.As an important aspect of the COMMIT trial, worksite smoking-control consultations and supports were provided to employers in 11 diverse, moderate-sized communities. After a 4-year intervention period (1989–1992), impacts on worksite policies, support resources for smokers, and employee perceptions were assessed in these communities and in 11 matched Comparison communities.Methods.Data from two surveys are reported here. In each of the 22 COMMIT communities, a sample of worksites within each of four size strata were surveyed to determine worksite policies, activities, and resources regarding smoking. Data from employees were obtained from independent community-wide surveys of community residents.Results.Overall, 44% of the worksites surveyed reported having smokefree policies, with no differences between Intervention and Comparison communities. Thirty-seven percent of Intervention community worksites reported offering smoking cessation resources or assistance for employees during the period of the study, compared to 31% of Comparison community worksites (P= 0.04). Employees in Intervention communities, relative to those in Comparison communities, reported greater awareness of stop-smoking resources, but equivalent increases in worksite smoking bans.Conclusion.Although the level of worksite smoking-cessation activities was higher in Intervention than in Comparison communities, there remains a substantial need to increase the level of such activities and to integrate such activities with restrictive smoking policies.

Durability of tobacco control activities in 11 north American communities: life after the Community Intervention Trial for Smoking Cessation (COMMIT).

Durability of tobacco control activities in the 11 intervention sites of the Community Intervention Trial for Heavy Smokers (COMMIT) was examined. Although continuation of COMMIT activities was not a major goal, all communities made plans to continue some tobacco control activity. Information was gathered at focus groups of former COMMIT volunteers and staff who were assembled in each community and asked to describe tobacco control activities in their communities during the past 12-16 months-the period after the termination of COMMIT funding. It was found that a tobacco coalition, board or other structure was still operating in nine of the 11 communities and 10 had some level of paid staff dedicated to smoking control. There was also substantial activity in three of the four channels that COMMIT used as an intervention framework: worksites, public education and cessation resources. Many communities were currently engaged in considerable smoking control activity aimed at youth, an area that was intentionally de-emphasized by COMMIT. Implications for the durability of health promotion programs by communities are discussed.

Interplay between Design and Analysis for Behavioral Intervention Trials with Community as the Unit of Randomization

This paper outlines an approach for the design and analysis of randomized controlled trials investigating community-based interventions for behavioral change aimed at health promotion. The approach is illustrated using the Community Intervention Trial for Smoking Cessation (COMMIT), conducted from 1988 to 1993, involving 11 pairs of communities in North America, matched on geographic location, size, and sociodemographic factors. The situation discussed is when assignment to intervention is done at the community level; for COMMIT, the very nature of the intervention required this. The number of communities as a key determinant of the statistical power of the trial. The use of matched pairs of communities can achieve a gain in statistical efficiency. Randomization is used to obtain an unbiased assessment of the intervention effect; randomization also provides the basis for statistical analysis. Permutation tests (and corresponding test-based confidence intervals), using community as the unit of analysis, follow directly from the randomization distribution. Within this framework, individual-level covariates can be used for imputation of missing values and for adjusting analyses of intervention effect.