The primary targets for tobacco control interventions are not individuals but the social networks that shape the attitudes of individuals (both smokers and nonsmokers) toward tobacco. For smoking control, the most relevant networks are the media, health care providers, worksites, and schools, Additional efforts to alter the environment in which the smoker smokes and the adolescent begins to smoke have been made through legislation, restriction on where smoking is allowed, restriction of access to cigarettes by adolescents, and increases in the economic costs of tobacco use. The following paragraphs review the nature of these intervention channels and provide suggestions about how each may be employed in a population-wide smoking control program.

Mass Media

The mass media play a critical role in influencing what society knows, believes and does with respect to tobacco use (Tye et al, 1987; Warner, 1986a). In 1988, U.S. cigarette manufacturers spent $3.27 billion on advertising and promotion (Centers for Disease Control, 1990a). Few popular models rival the "Marlboro man" for familiarity; this and other images from cigarette advertisements are seen daily by virtually every American Moreover, the presence of tobacco advertisements reinforces the perception the "smoking must be acceptable, otherwise the Government would ban it" (Warner, 1986).

Although the tobacco industry has used them to encourage tobacco consumption, the mass media have played and will continue to play and important role in tobacco control (Flay, 1987; US DHHS, 1989a; Warner, 1986a). Media coverage of the tobacco and health issue over the past quarter-century is credited with improving public awareness of

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smoking's hazards, shifting attitudes about smoking, and lowering the percentage of smokers in the population (US DHHS, 1989a). However, the public's understanding of tobacco's hazards is still remarkably superficial, particularly among those segments of the population at greatest risk of smoking - the poorly educated, minorities, and teenagers (Warner, 1986a).

In a comprehensive tobacco control effort, the mass media serve a number of important functions, including (1) providing information to the public about facts and issues relating to tobacco use; (2) alerting citizens and policymakers to injurious public policies that promote tobacco use; (3) motivating people to stop or not start using tobacco; (4) recruiting smokers into treatment programs; and (5) conduction smoking cessation programs.

Those who control the media do not necessarily view any of these tasks as their responsibility. to the contrary, a substantial body of evidence indicates that, because the depend on tobacco advertising revenue, the media often evade the topic of tobacco and health (Dagnoli, 1990; Warner, 1985).

Tactics

Tobacco control activities directed at the media should seek to accomplish two goals: (1) increase the public's exposure to prohealth, antitobacco messages; and (2) limit the public's exposure to protobacco messages. The following sections briefly discuss tactics for accomplishing these goals.

Counteradvertising. Perhaps the most visible use of the mass media for tobacco control has been antitobacco campaigns sponsored by the major voluntary health organizations and Government agencies (Flay, 19987; US DHHS, 1989a; Warner, 1988 and 1989). For the most part, these campaigns have relied on donated air time and advertising space.

One of the most significant periods of antismoking advertising occurred between 1967 and 1970, when the Federal Trade Commission ruled that, under the Fairness Doctrine, television and radio broadcasters were required to donate air time to antismoking messages as a balance to cigarette commercials (O'Keefe, 1971; US DHHS, 1989b; Warner 1977, 1986a, and 1989). At their peak, antismoking messages were given about 1 minute of air time (much of it in prime time) for every 3 minutes of cigarette advertisements (Whiteside, 1971). Several studies support the conclusion that the antismoking messages aired during the Fairness Doctrine era markedly discouraged smoking (O'Keefe, 1971; Warner, 1989). Cigarette consumption declined each year during the campaign (Figure 1) and rose again after removal of cigarette advertising and the antismoking advertisements from the broadcast media in 1970.

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This experience supports the idea that a public service announcement campaign can be effective in certain circumstances (Flay, 1987). After reviewing 56 evaluated antitobacco campaigns, Flay concluded that the key element in the success or failure of an antismoking campaign is its intensity. The more intensive the campaign-that is, the greater its reach, frequency, and duration-the greater the impact on behavior. The disappointing results of many health promotion campaigns, delivered through the mass media can be traced directly to inadequate exposure of campaign messages (Bettinghaus, 1986; Flay, 1987; McGuire, 1984; Wallack, 1981).

Reliance on public service announcements most often results in campaign messages being seen infrequently (Flay, 1987; Wallack, 1981). In an evaluation of a 6-month antismoking television campaign conducted in media markets in New York and Pennsylvania, Cummings and colleagues reported that half of donated advertisements were aired between 12 midnight and 7 a.m. Airing of the same messages in purchased time significantly improved response, as measured in calls to a hotline (K.M. Cummings et al., 1989).

Several states, including Minnesota, Michigan, and California, have funded antitobacco media campaigns with revenue earmarked from cigarette excise taxes (Johnson, 1990; US DHHS, 1989a). In California, excise taxes are funding a $28.6 million, 18-month advertisement campaign against smoking (Johnson, 1990). The campaign, launched in April 1990, includes paid advertisements in newspapers and magazines, on billboards, and in prime time on television and radio.

Public relations events. Creating events that will be of interest to large segments of the population is an effective and economical way to gain media coverage for tobacco control issues (US DHHS, 1989b). The best known national public relations events for smoking cessation is the American Cancer Society's Great American Smokeout, which has been held annually since 1977 (Flay, 1987; US DHHS, 1989a). The Smokeout is a multimedia event carried out each November throughout the United States. In most communities, it constitutes and 8-day media blitz leading up to Smokeout Day, when smokers are urged to give up cigarettes for at least 24 hours. Public awareness and participation in the Smokeout has been high for years (Flay, 1987; US DHHS, 1989a). A Gallup poll of adult smokers taken after the 1989 Smokeout showed that 85 percent of smokers were aware of the event and 10.5 percent abstained from smoking on Smokeout Day.

In 1987, the American Lung Association began sponsoring Non-Dependence day, the 5th of July, as a way to bring attention to the problem of nicotine addiction and to offer assistance

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to smokers trying to stop. National events such as the Smokeout and Non-Dependence Day can be used to spin off media events such as television and radio cessation clinics (Flay, 1987), newspaper stories profiling former smokers (Cummings et al, 1987), and communitywide stop-smoking contests (Cummings et al, 1990; King et al., 1987; Pechacek at al., 1985).

Government agencies frequently designate specific times of the year to highlight specific prevention and disease control initiatives (e.g., high blood pressure control week). The State of New York designated the first week of January 1990 as "Tobacco Awareness Week" and granted $5,0000 to county health departments to create local tobacco control events. Those events varied across the state and included poster contests for schoolchildren, stop-smoking contests, smoking policy workshops for businesses, and training programs for health care providers. Local media coverage of events was heightened by the fact that local events were conduced as part of a statewide initiative.

Presentation of research findings is another way to gain access to the media (American Cancer Society, 1987; Davis, 1988a; US DHHS, 1989b). The media's desire for health stories is so strong that even familiar health information can be recycled or repackaged in such a way as to be of interest to media gatekeepers. the best example of such an event is the annual release of the U.S. Surgeon General's Reports on smoking and health. These reports usually contain little new scientific information, but their presentation by the Surgeon General in a high-profile news conference generates extensive media coverage (US DHHS, 1989a). Having a highly visible and credible spokesperson or group deliver the information will often generate media coverage, even when the message is familiar.

Tailoring information for local news media can be an effective way to extend the life of a national news story or create a new media event (American Cancer Society, 1987; US DHHS, 1989b). After a news release on the medical costs associated with treating smoking-related diseases in the United States, several state health departments issued cost information specific to their individual states, which resulted in a new wave of media coverage on the burden of smoking.

Advocacy. Media advocacy is the strategic use of the mass media to promote public policy initiatives (US DHHS, 1989b; Wallack, 1990). Media advocacy does not attempt to directly change individual smoking behavior but uses the media to promote public debate about the tobacco issue. It shifts attention from smoking as solely an individual problem to the role of public policy in shaping individual health choices. Media

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advocacy stimulates community involvement in defining public policy initiatives that influence the social environment in which consumers make choices about tobacco use.

In contrast to a planned information campaign or public relations effort, a media advocacy campaign is more like a political campaign in which competing forces continually react to unexpected events, breaking news, and opportunities (US DHHS, 1989b; Wallack, 1990). When tons of imported Chilean fruit were banned after the discovery of a small amount of cyanide in two grapes, smoking control advocates alerted the media to the fact that there is more cyanide in one cigarette than was found in the grapes. The Chilean grapes incident was thus used as a vehicle to raise the issue of Government's failure to regulate the tobacco industry.

Specific kinds of knowledge are essential for effective media advocacy: knowing the media, knowing to relevant tobacco policy issues, and knowing how to frame an issue for public debate (US DHHS, 1989b). Tobacco control advocates need to understand how the different media work, that is, what types of stories are deemed newsworthy, how editors decide what stories get covered, and what deadlines and logistical issues might influence coverage. there are several excellent guides available to illustrate media advocacy skills specifically for tobacco control (American Cancer Society, 1987; US DHHS, 1989b).

Providing media advocacy training to interested persons is one way to encourage and enhance the use of news media for control of tobacco use. A communication network among advocates sharing information on local and national activities will promote media advocacy efforts. As noted earlier, local news coverage of smoking control issues is enhanced when local stories spin off from current issues in the national news media (American Cancer Society, 1987; US DHHS, 1989b). Newsletters and computer bulletin board systems provide ways to facilitate timely communications among national, state, and local advocates. The Smoking Control Advocacy Resource Center sponsors and electronic communications network (SCARCNET, 1990).

Regulations on Advertising

Because tobacco advertising is nearly ubiquitous, several medical and public health groups have argued that stronger regulatory actions are needed to curb the influence of protobacco messages delivered through the media (American Medical Association Board of Trustees, 1986; Warner, 1986a). Currently the Federal Government bans tobacco advertising in the broadcast media and regulates the content of tobacco advertisements by Federal Trade commission action (US DHHS, 1989a).

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A number of proposals to further restrict tobacco advertising and promotion are now under consideration by public health groups, state and local governments, and Congress (Colford, 1990; Myers et al., 1989). One such proposal would limit the imagery and graphics of tobacco advertisements to permit only "tombstone ads," with no models, slogans, scenes, or colors. Other proposals that would restrict tobacco advertising and promotion range from a total ban on all tobacco advertising, to limited restrictions such as disallowing certain types of promotion (e.g., tobacco company sponsorship of sporting and cultural events, brand advertising in movies, and distribution of free samples).

Most of the proposed legislation to regulate tobacco advertising is designated for action at the Federal level because of laws that preempt states and localities from regulating cigarette advertising (Myers et al, 19890; US DHHS, 1989a). However, state and local communities do have jurisdiction in regulating the location of tobacco advertising when the medium is not nation in scope. For example, several metropolitan areas (Denver, San Francisco Bay area, and Amherst, Massachusetts( have prohibited tobacco advertisements on their mass transit systems (US DHHS, 1989a). In Minnesota,, that state's Sports Commission banned tobacco advertising in the Hubert H. Humphrey Metrodome (US DHHS, 1989a). The City of Detroit banned tobacco advertisements on billboards (McMahon and Taylor, 1990). The City of New York passed an ordinance prohibiting tobacco advertisement on city-owned property. Numerous cities and two states (Minnesota and Utah) have passed laws prohibiting the distribution of free tobacco product samples (US DHHS, 1989a).

Health Care Providers

Tobacco control efforts directed at the health care sector should seek to accomplish the following goals: (1) establish routine counseling on tobacco as a minimum standard of practice for all health care settings (i.e., physicians' offices, hospitals, public health clinics); (2) make all health care facilities smoke-free; (3) increase the number of pharmacies and other health care facilities that will not sell tobacco products; (4) increase the number of health insurance companies that offer financial incentives that discourage tobacco use (e.g., lower premiums for nonsmokers, payment for cessation services); and (5) increase the number of health care providers actively involved in promoting tobacco control initiatives in other sectors of the community, such as in schools, through the media, and in worksites. Intervention activities to achieve these goals fall into three categories: education, economic incentives, and regulation.

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Antitobacco counseling efforts by health professionals appear to have great potential in encouraging patients to stop or reduce their tobacco use (Glynn et al., 1990). The strength of this approach lies in the large number of smokers who can be reached by credible sources in environments where health is a salient topic. Estimates show that if "stop smoking" messages were routinely delivered to patients by physicians, 38 million smokers could be reached and the number who stop smoking each year could be doubled. Despite the fact that most physicians believe it is their responsibility to encourage their patients to abstain from using tobacco, many fail to do so routinely with all patients (Anda et al, 1987).

A number of barriers to more active involvement in tobacco cessation counseling have been cited. Among them are insufficient time, training, and backup materials to provide effective help (Orlandi, 1987; Orleans et al, 1985). In an effort to address these barriers, several health provider groups have developed training materials and programs to assist health care providers in becoming more proficient in providing tobacco cessation assistance (Davis, 1988b). In 1989 the National Cancer Institute and the American Cancer Society initiated a national program to recruit and train physicians from around the United States who will in turn provide training in tobacco counseling to health providers on a statewide or regional basis. The establishment of a core group of health care providers who are capable of training other providers will in time result in more training opportunities and, presumable, more effective tobacco counseling by all health care providers.

Insufficient time is an important barrier that affects attendance at training programs. Too often those who voluntarily attend training programs are already predisposed and knowledgeable about counseling their patients to abstain from tobacco. To recruit other providers, some groups have advocated visiting health care offices to provide on-site training, much like the pharmacy company sales representatives who make regular visits to health care providers (Kottke et al., 1988). Such an approach has the advantage of involving the provider's office staff in training and provides the opportunity to disseminate relevant tobacco control materials (e.g., self-help guides, labels for patients' charts, list of community cessation services).

Because influential health care providers in a community are often asked to comment on the tobacco issue, providing them with training on effective use of the media is important to ensure that the prohealth message is heard (American Cancer Society, 1987; US DHHS, 1989b). the tobacco control movement has demonstrated that concerned community

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leaders, in spite of limited media experience, can be effective medial advocates. Experience has also demonstrated that such community-based advocacy can be greatly enhanced if tobacco control advocates are introduced to some basic lessons of media advocacy (US DHHS, 1989b). In the United States, Doctors Ought to Care, a concerned group of physicians and other health professionals, has created satirical media events to publicize the problem of tobacco use and promotion, a prominent example being its sponsorship of the Emphysema Slims tennis tournament as a counterpoint to the Philip Morris-sponsored Virginia Slims tournament (Doctors Ought to Care 1989).

Economic Incentives

Convincing pharmacists to stop selling a profitable product like cigarettes in not easy (Richards and Blum, 1985). However, the number of tobacco-free pharmacies is increasing and the American Pharmaceutical Association has endorsed the position that pharmacists should not sell tobacco products (US DHHS, 1989a). In Nevada, a local pharmacist made national news when he built a tobacco "bonfire" to publicize the fact that his store would no longer sell tobacco products. In Erie County, New York, the American Cancer Society urged community pharmacies to stop selling tobacco during the Great American Smokeout. In new Jersey, one advocacy group compiles and publicizes a list of tobacco-free pharmacies (New Jersey Group Against Smoking Pollution, 1988). Pharmacists have been encouraged also to be more involved in counseling their clients on ways to stop using tobacco. In 1982, the National Cancer Institute in collaboration with he American Pharmaceutical Association produced and distributed over 25,0000 copies of the "Pharmacist's Helping Smokers Quit Kit" (NCI, 1982).

Regulation

Two-thirds of the states now require hospitals to restrict smoking to designated areas (Pertschuk and Shopland, 1998; US DHHS, 1989a). Minnesota was the first state to pass a law that requires all hospitals to be smoke-free.

there are many compelling reasons for health care facilities, especially hospitals, to adopt strong smoking restrictions (Knapp et al., 1986). Permitting smoking in the facility may undermine physicians' advice to stop smoking. Nonsmoking patients in the facility may be adversely affected by exposure to environmental tobacco smoke. The majority of hospital firs are caused by smoking in bed. Finally, other sectors of the community look to actions in the health care sector to model their response to the tobacco issue.

One strategy that has been used effectively to help promote the establishment of stronger smoking policies is to survey patients and staff about their attitudes about restricting

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smoking (Kottke et al., 1988). Population surveys have demonstrated strong public support for tough smoking restrictions in health care facilities (US DHHS, 1989a). Getting local medical and public health organizations to endorse smoking restrictions can pressure administrators to institute stronger smoking restrictions (American Cancer Society, 1988; Knapp et al., 1986). Finally, publicly acknowledging health care facilities that have strong antismoking policies may help pressure others to adopt similar restrictions (Kottke et al, 1985). There are several comprehensive guides available that describe strategies for implementing voluntary no-smoking policies (American Hospital Association, 1988; Burtaine and Slade, 1988; Hurt et al., 1989; Knapp et al., 1986).

Licensure requirements for health care facilities could be changed to mandate that tobacco prevention and cessation services be offered. The New York State Health Department is currently considering a regulation that would require hospitals to include plans for cardiovascular disease prevention programs (including prevention of tobacco use) in their application for a "certificate of need" to build a coronary care unit. Similarly, funding for state and local health departments could be made contingent on their providing certain types of tobacco control services.

Worksites

Worksites are an important channel for tobacco control because they constitute a setting in which large numbers of smokers can be reached with programs to encourage and support cessation efforts (Fielding, 1984; US DHHS, 1985). Worksites are also an important channel for involving nonsmokers in tobacco control efforts, particularly through the promotion of no-smoking policies (American Cancer Society, 1988).

tobacco control activities for worksites should seek to accomplish the following goals: (1) increase the number of worksites that provide tobacco control programs for their employees and (2)( increase the number of worksites that adopt policies that discourage tobacco use (e.g., no smoking indoors, lower health insurance premiums for nonsmokers, hiring of nonsmokers only). Intervention activities to accomplish these goals fall into the same above-mentioned categories: education, economic incentives, and regulation.

Stimulated by both public and private initiatives, an increasing number of businesses are adopting policies that limit smoking at work. A 1987 national survey conducted by the Bureau of National Affairs found that 54 percent of the businesses responding to the survey had policies limiting smoking at work (Bureau of National Affairs, 1987). The 1986 Adult use

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of Tobacco Survey showed that 45 percent of employed adults in the survey reported having some smoking restrictions at their workplace (Centers for Disease Control, 1988).

Education

Policies limiting smoking at work have resulted in an increased demand for worksite tobacco education and cessation programs (Martin et al., 1986; Newsweek, 1988). Community organizations such as the American Lung Association, the American Heart Association, and the American Cancer Society have all developed education programs and materials to assists worksites in providing tobacco education for their employees (LaRosa and Haines, 1986). A number of commercial stop-smoking programs have created programs and marketing strategies specifically for worksites (Newsweek, 1988; US DHHS, 1989a).

In addition to offering educational programs, some businesses offer their smoking employees incentives to stop smoking (Schwartz, 1987; US DHHS, 1985). A common type of incentive is the offer to pay part or all of the cost to attend a cessation program. General Motors absorbs 75 percent of the fee for a smoking cessation program offered to its employees (Schwartz, 1987). some employers have offered a cash bonus to employees who abstain from smoking (Rosen and Lichtenstein, 1977). recently a company in Houston began charging smokers an extra $10 a month to pay for higher health care benefit costs associated with smoking (Winslow, 1990).

A strong policy against smoking is the cornerstone of a successful workplace tobacco control effort (Emont and Cummings, in press; Fielding, 1986). The most common barrier to adopting a restrictive smoking policy is a perceived absence of employee demand (Bureau of National Affairs, 1987; Emont and Cummings, 1989). In a 1987 survey, two-thirds of companies without policies cited insufficient employee demand as the reason for not adopting a policy (Bureau of Nation Affairs, 1987). In addition, many employers fear a negative reaction from smoking employees, including possible legal action and grievances (Bureau of National Affairs, 1987). However, surveys of smokers and nonsmokers consistently show support for smoking restrictions at work (US DHHS, 1986 and 1989a).

conduction workshops to educate employers about the rationale and tactics for implementing smoking restrictions is one approach to encouraging worksites to implement no-smoking policies. Publicizing surveys that demonstrate support for worksite smoking restrictions can be an effective way to make employers aware of employee demand for such policies. In the same vein, actively marketing tobacco control services to worksites, rather than just reacting to requests for such assistance, can substantially increase the number of worksites

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voluntarily implementing tobacco control polices and programs for their employees.

Economic Incentives

A growing body of evidence shows that health care costs are greater for smokers than for nonsmokers (Kristein, 1983; Winslow, 1990). This information is particularly relevant to employers, because a large share of health insurance is purchased by employers as a benefit for employees. The issues related to insurance as an economic incentive are covered later in this chapter.

The courts have established that it is the employer's common law duty to provide a safe workplace. In several cases employers have been held legally and financially responsible for smoking-related illnesses and disability caused by exposure to environmental tobacco smoke at work (Myers and Arnold, 1987). As evidence about the health hazards posed by environmental tobacco smoke continues to mount, the concern about liability for allowing unrestricted smoking a work will probably stimulate more employers to institute restrictive smoking policies (US DHHS, 1986).

Regulation

Government efforts to regulate smoking restrictions for private and public worksites have increased markedly in the past decade (Pertschuk and Shopland, 1989; US DHHS, 1986 and 1989a). As of 1990, 14 states and nearly 300 cities and counties had mandated the adoption of workplace smoking policies (Pertschuk and Shopland, 1989). there has been little evaluation of the adequacy of implementation or level compliance with smoking laws. The available evidence does not support the tobacco industry claim that smoking laws in workplaces are expensive and unenforceable (US DHHS, 1989a).

Schools

Most smokers begin using tobacco before the age of 18; only a small percentage take up smoking after age 21 (US DHHS, 1989a). Most health professionals agree that the reduction of tobacco-caused disease can best be achieved through preventing children from initiating tobacco use (American Academy of Pediatrics, 1987; American Medical Association, 1987; Blum, 1986; Colorado Department of health, 1986; Coye, 1988; Maine Department of Human Services, 1983; Minnesota Department of health, 1984; Pennsylvania Plan for Tobacco or Health, 1986; Warner et al, 1986). Schools are important for tobacco control efforts also because they are significant community institutions.

School activities to control tobacco use should seek to accomplish the following two goals; (1) increase the number of schools that implement state-of-the-art tobacco prevention curricula and (2) increase the number schools that are tobacco-free. Intervention activities to accomplish these goals

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fall into two broad categories: information dissemination, which includes activities to encourage voluntary actions by schools, and regulation, which mandates that schools take specific actions. Examples of each of these intervention strategies are given below

Information Dissemination

Since the mid-1960's, tobacco education has been a common element of school health programs. However, the nature of tobacco education efforts and their designated targets have changed over time (US DHHS, 1989a). There has been a shift away from information-oriented programs to psychosocial curricula designed not only to address youth's motivations to smoke but also to impart skills for resisting influences to smoke (Flay, 1985; US DHHS, 1989a). There has also been a shift in the target group from high school and college students to middle school and elementary schoolchildren (US DHHS, 1989a). Although evaluations of school-based tobacco prevention programs indicate that no single program can be relied on to deter adolescents' tobacco use across the board, evidence does point to certain key features of school-based programs that have been consistently associated with positive preventive effects. These include multiple sessions over may grades; information about the social consequences and short-term physiological effects of tobacco use; information about social influences on tobacco use, especially peer, parent, and media influences; and training in refusal skills (Glynn, 1989).

the extent to which state-of-the-art curricula for prevention of tobacco use have been adopted and are used by schools has not been systematically documented, although anecdotal evidence suggests that few school systems provide truly substantial curricula (Best et al., 1988; Cleary et al, 1988; US DHHS, 1989a). Barriers to widespread adoption of tobacco prevention programs within schools include demands on teacher time, cost of materials for specific programs and teacher training, and competing education and health priorities (Best et al., 1988; Cleary et al, 1988). Packaging program materials so that they are easy for teachers to use will facilitate their adoption. Recruiting and training influential representatives from school systems to serve as local smoking control resources will help ensure that teachers stay current with program materials and will develop advocates for tobacco prevention within school systems (Glynn, 1989).

School-based no-smoking policies are important because the school environment should be free of tobacco smoke, and teachers and school staff are influential role models for children. Evidence suggests that the rules about smoking at school influence the efficacy of tobacco prevention programs. Tobacco education programs implemented in schools that

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prohibit smoking appear to be more effective than identical programs in schools with less restrictive policies (Best et al., 1988).

Conducting workshops to educate school administrators and board members about the rationale and tactics for implementing no-smoking policies is one approach to encourage schools to implement such policies. Conducting and publicizing surveys that demonstrate support for tobacco-free schools can be used to pressure school boards to consider implementing stronger tobacco use policies (National School Boards Association, 1987).

Regulation

School education about the health consequences of tobacco use is mandated by law in 20 state (US DHHS, 1989a). Several states also require teacher training about the effects of tobacco use. In Connecticut, to be certified to teach in public school, a person must pass an exam on the effects of nicotine and tobacco use (US DHHS, 1989a).

Little is known about the level of compliance with state regulations. As noted previously, the nature and scope of tobacco education efforts appear to vary widely across school districts. Regulatory actions that fail to stipulate the nature and scope of tobacco curricula will likely be ineffective. Moreover, standards should be established to guide implementation and evacuation of curricula. Standards should address the curricula that should be used, teacher training, and minimum number of hours devoted to tobacco education at each grade level.

By 1990, 15 states had prohibited smoking by secondary school students, and another 17 states had laws that restrict students' smoking to designated areas (US DHHS, 1989a). Most secondary schools have written policies that prohibit or restrict smoking by students (National School Boards Association, 1987; US DHHS, 1989a). Smoking by school faculty and staff members is generally permitted, but only in areas away from students. Three states, New Jersey, Wisconsin, and Utah, have passed laws that prohibit smoking by anyone on school property. Although most schools have policies regulating smoking, fewer than 5 percent are totally smoke-free (National School Boards Association, 1987). An important barrier to adoption of a tobacco-free policy is concern about opposition from the teacher's union. Union contracts often negotiate smoking areas for teachers, even though the vast majority of teachers do not smoke. Thus, legislation that mandates schools to be tobacco-free is probably necessary. In general, public support is greater for laws restricting smoking in schools than for other locations such as private worksites and restaurants (US DHHS, 1989a). If additional evidence can be produced to demonstrate.

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a link between school smoking policies and smoking initiation, it is probable that measures to prohibit tobacco use on school grounds will become more common.

Table 1 summarizes the tobacco control activities discussed in this section and identifies groups and organizations that may assume responsibility for each. These interventions may have a greater synergistic effect when combined, compared to the sum of individual effects. The key to a community-based approach lies in assuring that the intervention is broad-based and permeates the social networks.

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