Although national and statewide initiatives are critical components of a comprehensive smoking control plan, many of the most effective interventions will be individually applied in thousands of cities and towns across the United States. To achieve behavior change in a community, the target population must be involved in identifying the problem, planning and undertaking steps to correct the problem, and creating structures in the community that assure the change is maintained. An underlying assumption is that the community must be empowered to control the intervention and must accept "ownership" of it. This approach has been tested in several community health promotion initiatives, including the Stanford Five-City Project (Farquhar, 1978; Farquhar et al, 1986), the Minnesota Heart Health Program (Blackburn and Pechacek, 1984), and COMMIT-the Community Intervention Trial for Smoking Cessation (Pechacek, 1987). There are two practical ways to implement tobacco control interventions that provide community ownership. These may be described as "social action" and "locality development" (Rathman, 1979).

Social action implies grassroots organizing of disadvantaged and disaffected groups who demand change in the social structure. An excellent example of social action in the tobacco control field is in the formation of local groups (e.g., Group Against Smoking Pollution) to lobby for restrictions on public smoking. Such groups often can be strong advocates for rapid change. The strength of the social action approach is also its weakness: because they are confrontational, grassroots groups provoke conflict and may sometimes inhibit the adoption of consensus.

Locality development maximizes local participation in the intervention by including more than only the most committed groups in the change process. Essentially everyone is invited to join in identifying and solving the problem. An importune advantage of this approach is that it expedites participation by established community organizations and increases participation by community leaders.

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Table 1

Examples of tobacco control activities, by channel and group responsible for performance

_____________________________________________________________________________________

Channel Tobacco Control Activities Groups Responsible*

_____________________________________________________________________________________

Media Sponsor antitobacco information campaigns A, B, C, D

Sponsor smokeout days and/or communitywide A, B, C, G

cessation events (e.g., TV clinics, contests)

Advertise cessation services A, B, C, D

Hold press conferences to release relevant tobacco

research findings to the media A, B, C, D, E, H

Conduct and publicize surveys to document support for

tobacco control policies A, B, C, D, E, G, H

Conduct advocacy training for community leaders

Lobby politicians to earmark government funds for counter-

advertising and to regulate tobacco ads and promotions All groups

Health Disseminate materials to assist health care providers in

Care counseling patients who smoke A, B, C, D, B, H

Sector

Establish a communications network among tobacco

control advocates A, B, H

Sponsor seminars to train health care providers on ways to

counsel patients to stop smoking A, B, C, D, E

Recruit and train influential health care providers in media B, C, H

advocacy

Sponsor a program to encourage community pharmacies B, C, E, H

to become tobacco-free

Conduct surveys of patients, staff, and visitors to document

support for tobacco-free health care facilities B, C, D, E

Sponsor seminars to promote tobacco-free health care facilities B, C, D, E

Include tobacco education in medical/health professional C, E

school curricula

Gather data to support health insurance premium discounts for

nonsmokers A, C, E, I

Lobby politicians to mandate smoke-free health care facilities;

mandate insurance coverage for cessation services, and premium

discounts for nonsmokers; and mandate performance of tobacco

control services by health departments, hospitals, and other

health care facilities All Groups

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Worksite Disseminate information to support establishment of smoke-free

workplace A, B, C, H, I, J

Sponsor seminars to promote no-smoking policies in the workplace A, B, C, H, I, J

Conduct surveys of employees to document support for no-smoking A, B, E, H, I, J

policies and cessation services

Gather data to support health insurance cover of tobacco A, E, I, J

cessation services

Gather data to support health insurance premium discounts for

nonsmokers A, E, I, J

Lobby politicians to mandate smoking restrictions in worksites All groups

Lobby politicians to mandate insurance coverage for cessation

services and premium discounts for nonsmokers and to provide tax

incentives to worksites that offer cessation assistance to their

employees All groups

Support employee litigation against employers who fail to implement

meaningful smoking policies B, C, H, I

Schools Disseminate state-of-the-art curricula to schools A, B, E

Sponsor workshops to train teachers to implement tobacco

education curricula A, B, E, F

Make presentations on tobacco-free schools to school boards, PTAs B, C, H

Conduct student surveys to document the need for tobacco education A, B, F

Conduct surveys of students, faculty, and school staff to document

support for tobacco-free schools A, B, F

Mandate that all teachers receive tobacco education training A, B, E

Lobby politicians to mandate tobacco-free schools All groups

_____________________________________________________________________________________

*Key

A Government health agencies

B Health voluntaries

C Health professional associations (e.g., medical societies)

D Hospitals and other health care facilities

E Universities, including medical schools

F Elementary/secondary schools

G Community organizations (e.g., youth groups, services clubs)

H Activist groups (e.g., Group Against Smoking Pollution, Doctors Ought to Care)

I Insurance industry

J Business organizations (e.g., Chamber of Commerce)

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Coalition building is a form of locality development. Coalitions encourage local organizations and groups to adopt tobacco control as their won project. Networking among coalition members fosters sharing of resources and reduces conflict. It lends instant credibility to the program because it involves recognized community leaders and tends to isolate opponents.

Involving organizations encourages them to divert their resources to tobacco control, in itself a change in norms. Because community organizations network with each other, this change diffuses throughout the community and affects the membership of every organization. Seen from a systems perspective, change in organizations leads to change in the entire community.

the role of the tobacco control interventionist in a locality development approach is to catalyze and coordinate action by the wide cross-section of organizations and individuals recruited to the effort. Under a broad, communitywide strategy, small task-oriented groups within the coalition pursue specific, manageable goals. Maintaining communication among organizations and promptly resolving disputes is an important function of leadership, and a democratic structure of coalition governance is critical to building a true sense of ownership by all the members.

there are four major steps in the coalition-building process: community analysis, planning, implementation, and maintenance. each is critical to the development of a lasting tobacco control intervention that will permanently change community structures and norms.

Community Analysis

Community analysis provides an accurate, in-depth understanding of the community's needs, resources, social structures, and values. At the same time, it provides an opportunity to begin involving the community in the problem-solving process.

The first task is to fine the community geographically. A community may be as small as a neighborhood or as large as a major metropolitan area. The important factors in defining a community are interdependence among important social groups and a sense of shared values and norms that lead to individual identification with the community. Because of the importance of major media in determining such identify and in changing norms, consideration should be given to defining the scope of the communities widely as the area of dominant influence of the local broadcast and daily print media. In any case, such a definition should be undertaken in consultation with the leadership of important community sectors, including health, education, business, labor, and government.

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Once the community is defined, the next step is to identify the community resources and structures that are potentially available to focus on the tobacco control effort. A large body of quantitative and interpretive data is collected from both secondary sources (e.g., census data, economic reports, histories) and primary sources (leaders and members of the various community sectors). Information should be gathered on the demographic makeup of the population, smoking patterns, and the levels of illness and disability in the community. I should assess the economic structure and well-being of the community, identify business leaders, and tabulate major employers. Political activity and the level of citizen participation should be appraised.

The analysts should carefully assess the level of health promotion and treatment programs available. Wheat resources and skills already exists, and what is the level of service being provided? How ready are providers to join in a tobacco controleffort?

the important public and private educational systems should be identified, and the content of the health curriculum appraised. In addition, an effort should be made to identify important social, fraternal, and community improvements organizations and to characterize their memberships. Important religious denominations and major and minor media outlets also must be identified and analyzed. A calendar of major community events should be compiled.

the community leadership structure, because it is likely to affect the intervention, is a important as a list of community resources. What organizations and groups are currently involved in tobacco control? Who are the groups and individuals likely to help or hinder the project? who are the important leaders who could make a significant contribution? What are competing community priorities, and who are their advocates? How do people want to participate?

this information should be gathered in interviews with community leaders, beginning with those most likely to be interested in the intervention, such as the leadership of major volunteer health organizations and those in charge of health promotion at the local health department and hospitals. From these interviews, influential community leaders will be identified. These leaders in turn should be interviewed to identify additional community leaders and important organizations. This process should be pursued as long as profitable.

The point of the analytic exercise is to determine how the community makes decisions and to begin involving the community in the task of solving the tobacco problem. At the end of the process, the analysts should be able to determine the

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community's readiness for change. Are the various elements of the community able to work together to identify and solve common problems? Can they achieve consensus on goals and priorities? Who are the key players who must be part of that consensus? Is there a history of collaboration to build on or must trust-building and conflict resolution be an early component of the tobacco control intervention? To what extent is tobacco control a community priority?

Planning

At this point the process of planning the intervention begins. A small group of influential individuals willing to commit the time and energy needed to plan and begin implementing the project should be selected. An important consideration in choosing members for this initial group is that major stakeholders be included, that is, those with a preexisting commitment to tobacco control. In many communities this will include representatives of the major voluntary health agencies and other health promotion organizations. Other important community sectors, such as education and business, should be represented if possible.

This planning group will determine the structure and initial membership of the coalition and will begin recruiting members. It will set overall goals for the program and will determine staffing structure, office location, and similar needs. If resources are available to pay a staff, the program director should be hired at this point, and the planning group should have a significant role in writing the job description and screening candidates. Staff support is vital to the success of the intervention. If funds are not available to pay for a staff, individuals employed by health agencies may be reassigned from current activities. In either case, clear role definitions are important.

Implementation

The program director should be someone familiar with the target community (preferable a member of it ) and should be acquainted with local resources, values, and decision-making processes. The most important skill is the ability to "network," preferable on a communitywide level.

the coalition should be as broad as possible and divided into task forces according to members' interests. Obvious choices for task forces would be media, public policy, health care, worksites, youth and education, and cessation services, though there may be others. A scheme for coalition governance should be devised early. Some type of board or executive group is needed to make important management decisions, but care should be taken to ensure that interventions are planned and implemented by the task forces. An important board function may be allocating resources among the task forces, so it is important that the board be responsive to the coalition's membership, possible through election to fixed terms.

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Training and education of board and task force members are important and continuing aspects of the community mobilization process. Most members will not be experts in tobacco control and may approach the problem with strategies that are ineffective or incomplete. They will benefit from further education on the smoking problem, nationally and as it exists in their community, and they should be exposed to strategies established as effective in previous interventions. Many will bring important skills to the program that can be enhanced by training in other areas, but some will benefit from learning new skills. For example, physicians trained in media advocacy can be a powerful addition to the project's efforts.

A strategic tobacco control plan presents the coalition's overall goals and a series of specific objectives toward meeting those goals. It is important both in guiding rational, sequential implementation of the intervention and as a tool for mobilizing the community to recognize tobacco use as an important public health problem. The plan should be a product of the task forces, which will set priorities, identify resources, and plan activities. In developing the plan, the community begins to assume ownership of the project.

Above all, the tobacco control plan should represent a comprehensive, communitywide approach employing multiple, integrated interventions. Coordination among task forces and intervention activities is vital and is the primary responsibility of the program staff. Rather than providing interventions themselves, the staff will identify others in the community to undertake the intervention activities and to coordinate those efforts. A number of state and local tobacco control plans have been produced and are available for guidance (Colorado Department of Health 1986; Coye, 1988; Minnesota Department of Health, 1984).

Maintenance

Maintenance of the intervention is necessary to its success. Smoking will not disappear from a community in months or in a few years, and changes in community norms will probable occur over the course of a generation. Any outside financial support for a community intervention will be restricted in amount and duration. More fundamentally, ownership of the intervention will not be complete until the community redirects its resources to smoking control. This action will, in itself, constitute a significant normative change.

Planning for transfer to the community should be an integral part of the intervention. Activities should be structured to elicit the greatest possible participation from community organizations and structures. The strategic use of seed money grants and contracts can build a constituency for tobacco control within organizations and ensure a continuing interest in addressing the problem.

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In addition to broadening the group of stakeholders who believe in the importance of tobacco control and have actively worked at it, this approach gives individuals and organizations the experience of successfully implementing programs they might otherwise not have attempted. Selecting low-cost activities, or at least demonstrably cost-effective activities, will increase the sense of self-sufficiency.

Only by letting the members of the community implement the tobacco control program can it continue after outside funding is exhausted. Staff members must not become service providers. Rather, they are facilitators, coordinators, and trainers. It is recognized that the community will make mistakes, but it will learn from these mistakes and, given time, will institutionalize an effective tobacco control program.

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