Questions and Answers

ASSIST

1. What is ASSIST? What is its purpose?

ASSIST--the American Stop Smoking Intervention Study for cancer prevention--is the nation's largest-ever project to reduce smoking and tobacco use in the United States. It is a collaborative effort between the National Cancer Institute and the American Cancer Society, along with state and local health departments and other voluntary organizations, to develop and implement comprehensive tobacco control programs in 17 states.

2. What will ASSIST accomplish?

The ultimate goal of ASSIST is to reduce the burden of smoking-related diseases in the U.S. population, especially lung cancer, heart disease, and chronic obstructive lung disease.

The program's major objective is to reduce smoking prevalence in all ASSIST sites combined to less than 15% of adults by the year 2000 (the current estimated U.S. prevalence is 28%). This objective will be accomplished by both encouraging smokers to quit and discouraging young people from starting to use tobacco.

3. How many people will stop smoking as a result of ASSIST? How many lives will be saved?

NCI estimates that ASSIST will help 4.5 million people stop smoking--individuals who otherwise would continue to smoke. The project will also prevent another 2 million youths from beginning to smoke.

Based on this reduction in smoking prevalence in ASSIST states, NCI estimates that the project will prevent about 1.2 million people from dying prematurely of smoking-related problems, in particular lung cancer, heart disease, and chronic obstructive lung disease.

4. Why is ASSIST necessary? Aren't smoking rates going down fast enough already?

Smoking prevalence rates among American adults are at their lowest level in 30 years and declining by about 0.5% per year. However, ASSIST will accelerate the current downward trend, especially among populations that have higher-than-average smoking rates or have displayed slower rates of decline. These groups include women, the less educated, and several minority populations.

It would be irresponsible public health policy not to apply developed technologies as aggressively as possible, given what is now known about smoking and how to help people stop smoking.

5. How is ASSIST different from other government antismoking programs?

ASSIST is unique in at least three ways:

1. ASSIST will have a broader reach for tobacco control than any other health promotion effort ever conducted. About 91 million Americans, including nearly 18 million adult smokers, will be reached by ASSIST.
2. ASSIST combines the resources of NCI, ACS and state health departments in the development of community-based coalitions throughout entire states.
3. ASSIST is built on proven, state-of-the-art tobacco control interventions developed from more than a decade of intensive research by the government and private sector. From this research has come the strategy that ASSIST emphasizes: using public information and advocacy approaches to change the community environment and reinforce tobacco-free community norms.

6. What is the research base for ASSIST:

Through an aggressive tobacco control research program over the past 10 years, NCI has tested the effectiveness and feasibility of a wide range of promising approaches to community health promotion and individual behavior change. This research has resulted in the development of proven technologies that are ready to be applied through ASSIST. These technologies include intervention delivered through the mass media, physicians and dentists, self-help activities, schools, and community-based approaches. Special populations served by these interventions include Black Americans, Hispanic Americans, adolescents, women, and smokeless tobacco users.

NCI's latest tobacco control effort--the Community Intervention Trial for Smoking Cessation, or COMMIT--is applying these technologies in controlled community-based studies in 11 cities and towns in the United States and Canada. COMMIT's strategy, which ASSIST will extend throughout entire states, recognizes that there are powerful social forces affecting people's use of tobacco in a community and that the community itself must be mobilized to make smoking socially unacceptable. Community mobilization means that networks of public and private organizations and special interest groups will pool and coordinate their resources--personnel, time, money, goods, and services--to support a broad range of tobacco control activities. These activities may be one-on-one, group, or community-wide.

7. How does ASSIST relate to COMMIT?

COMMIT is NCI's ongoing community intervention trial that is testing models for comprehensive tobacco control in 11 matched pairs of communities.

The evaluation of COMMIT is ongoing. Although the final evaluation will not be complete until mid-1993, some evaluation is now available and will be used to shape the intervention plans for ASSIST.

ASSIST's 2-year planning phase allows emerging information for COMMIT to be fully integrated into ASSIST activities. The intervention phase of ASSIST will not begin until the COMMIT intervention is complete.

8. But don't we still have a lot to learn about what works and doesn't work in tobacco control?

At least one-third of all cancer deaths are directly related to tobacco use. Overall, more than 434,000 tobacco-related deaths occur in the United States each year. Therefore, it would not be wise merely to continue research to "fine-tune" smoking cessation interventions. Research needs to continue, but the interventions that behavioral research has shown to be effective should be applied intensively and systematically to reduce the health threat posed by tobacco use.

9. When will ASSIST work get under way? When will the program end?

ASSIST has two phases:

Sites immediately will begin a 2-year planning period, which will end September 1993. During this time states will develop specific tobacco control plans based on their own needs and resources. They also will build and strengthen their community-based coalitions.

ASSIST's 5-year intervention phase will begin October 1993 and continue through 1998.

10. How will we know if ASSIST is successful?

A key indicator of success for ASSIST will be a major reduction in smoking prevalence (based on 1985 rates) in ASSIST states. To measure changes in state-to-state smoking prevalence, NCI will fund add-on questions to the Current Population Survey (CPS) conducted by the Bureau of the Census. Three surveys will be conducted: before the ASSIST implementation phase, at the project's midpoint, and after implementation ends.

NCI also will analyze smoking-related data from a number of other surveys, including the National Health Interview Survey, the Centers for Disease Control's Behavioral Risk Factor Survey, and state-specific cigarette consumption data published by the Internal Revenue Service.

The evaluation of ASSIST is designed not to test or compare any single tobacco control intervention or combination of interventions, but rather to determine if multiple, community-based, statewide efforts can accelerate the reduction of smoking prevalence. Because ASSIST is a demonstration project and not a research project, the proportion of evaluation dollars to intervention dollars is quite low--less than 10%.

11. What happens after ASSIST is over?

Each ASSIST state will be building coalitions of organizations to work together in this effort. These coalitions are fully expected to be successful in their work for tobacco-free communities and to continue to function cohesively after ASSIST ends. The capacity for tobacco control that ASSIST will help build in the states will be sustained through the grassroots volunteer movement--the essence of ASSIST.

12. How were ASSIST states chosen?

The 17 states were chosen after a fully competitive process that involved the following steps:

• NCI released a Request for Proposals (RFP) for ASSIST projects and gave each state 9 months to apply. This extended application period allowed states enough time to initiate tobacco control coalitions and to develop thoughtful proposals based on their unique populations, resources, and tobacco control needs.
• Thirty-seven states submitted proposals. An outside panel of experts reviewed and scored the proposals based on their technical merit.
• A second panel of government officials reviewed both the proposals and the outside panel's evaluation, then developed questions for the states to answer to clarify and strengthen their proposals.
• The government panel reviewed the states' answers to the questions ("best and final" proposals) and gave new scores to the proposals, as appropriate. From this review the panel recommended states that were "technically acceptable" to carry out ASSIST projects.

13. Why is NCI conducting ASSIST? Why isn't some other government agency with less of a research focus and with closer ties to the states doing the project?

NCI is a research agency but also has a congressional mandated responsibility for application of information gained through research. After more than a decade of research in the area of community-based tobacco control, NCI is in a leadership position to apply science-based interventions on widespread basis.

14. Why was ACS chosen as the government's partner in ASSIST?

ACS will play a major role in planning and implementing ASSIST through its staff dedicated to the project, its large network of volunteers, and a substantial commitment of financial and in-kind resources.

Many other voluntary organizations--including the American Lung Association and American Heart Association--are participating as members of state and/or local coalitions in ASSIST.

15. How much will ASSIST cost, and who will receive money?

As with any project of the Federal government, NCI funding of ASSIST depends on availability of funds. It is estimated that NCI will spend about $135 million for ASSIST, a total that includes the contracts to states ($115 million over 7 years), as well as support for national coordination and evaluation of ASSIST ($20 million).

ACS will contribute staff, training, travel, and materials equal to at least 15% of total contract funds in each ASSIST state throughout the project. This contribution includes at least one full-time staff person in each state devoted exclusively to ASSIST. Total ACS support for ASSIST over the course of the project is estimated at $25 to $30 million.

State health departments, because of their disease-control focus and existing public health structure, will receive the ASSIST funds and act as fiscal agents for the project. During the intervention phase each state health department will receive about $1 million per year, the specific amount depending on the number of smokers in the state. Total funds going to ASSIST states during the 2 years of planning will be about $7 million annually; during the 5 years of intervention, about $20 million annually.

ACS, because of its historical commitment OT tobacco control and its strong local presence, will be an effective partner in activating and maintaining a high level of community involvement; however, ACS will receive no federal funds for its ASSIST participation, in keeping with longstanding ACS policy.

16. How can ASSIST's large budget be justified in these difficult economic times for Federal and state governments?

The budget for ASSIST pales in comparison to the $3.6 billion the tobacco industry spends each year on advertising and promotion.

Smoking causes more premature deaths each year than AIDS, cocaine, heroin, alcohol, fire, car crashes, homicide, and suicide. Smoking-related illnesses cost the United States at least $65 billion annually in terms of health care costs and lost earnings.

Through ASSIST, these costs--to taxpayers, employers, and the government--will be reduced, and early deaths will be avoided.

17. Is the funding for ASSIST drawing resources away from other important cancer research projects?

NCI remains committed to a comprehensive program of cancer research including basic biology, early detection, diagnosis, treatment, rehabilitation, and prevention. During full ASSIST implementation, only about 1 percent of NCI's annual budget will be committed to ASSIST. Furthermore, most of these funds will come not from "new" NCI funds, but from "reprogrammed" cancer control funds that will become available as other smoking intervention studies like COMMIT are completed.

Moreover, the control of smoking-related cancers is NCI's most compelling public health problem if the criteria of preventability, survival, and prevalence in the population are used as the basis for judging "importance" of expenditures. Unlike some other cancers, including breast cancer, we have the opportunity through primary prevention to dramatically reduce the burden of smoking-related cancers on the population.

18. How will states be held accountable for the funds they receive?

As with any government contract, state health departments receiving ASSIST awards are required to perform specific activities with careful oversight by NCI program staff. The sites will be required to report regularly on their progress, will file financial disclosure statements, and will have regular site visits from NCI representatives.

19. How much of ASSIST funds will actually go toward community programs (intervention vs. administration)?

ASSIST is designed to harness and direct the resources of state and local tobacco control coalitions involved in the project. Resources donated by these coalition members will include manpower, office space, supplies, and access to existing relationships in the communities. By awarding ASSIST funds to state health department, which have low overheads and restrictions on how they may use funds, NCI has reduced administrative expenses and substantially increased funds available for community interventions.

20. What exactly will ASSIST states do to reduce smoking?

ASSIST will work to increase anti-tobacco messages and activities throughout communities:

• There will be education efforts at worksites, in schools, through hospitals, clinics, and doctor's offices, and through various groups.
• ASSIST project staff will work with local media to keep tobacco and health stories in the public eye.
• Volunteers will provide information to community leaders and policy makers on how communities can be made tobacco-free.

It is known that all of these initiatives will both speed the rate at which people stop smoking and decrease the numbers of young people who take up the habit.

21. Are government dollars going to be used for lobbying?

In accordance with Federal law and regulations, ASSIST will not support lobbying for specific legislation. ASSIST will focus on public education about the roles that public and private policies can play in making the community environment supportive of nonsmoking norms.

A tremendous amount of tobacco-related policy has been established during the past 5 years at the state and local level. It is expected that many of these "grassroots" movements will continue at the same time that ASSIST is being conducted. These developments have proven very effective in reducing smoking, particularly among children below the legal age of purchase, and community leaders and public officials have a right to know about them.

Furthermore, ASSIST represents a much larger framework for pro-health advocacy. It includes educating community leaders, policy makers, health professionals, and the general public. It involves working with businesses, schools, the media, and voluntary organizations to promote tobacco control and to restrict exposure, both voluntary and involuntary, to tobacco smoke and tobacco products.

Of course, all of those involved in ASSIST will comply fully with any and all applicable Federal, state, or local regulations that restrict lobbying.

22. What will the government and ACS do to support nonsmoking activities in states not receiving ASSIST contracts?

NCI, ACS, and other public health organizations will be actively involved in spreading the progress of ASSIST nationwide. For example:

• Key public education and resource materials developed for ASSIST will be shared with all states through a number of networks including ACS divisions and units and the tobacco control network of the Association of State and Territorial Health Officials (sponsored jointly by the National Institutes of Health and the Centers for Disease Control).
• All ACS divisions and units will continue to be active in tobacco education and policy efforts, particularly efforts targeted to underserved populations.
• NCI's Cancer Information Service (1-800-4-CANCER) and ACS's Cancer Response System (1-800-ACS-2345) will continue to serve as sources of state-of-the-art information about tobacco control and referrals to community resources in all states.
• In addition to the states receiving ASSIST contracts, NCI is supporting about 150 tobacco control projects in other states. Other NIH institutes and federal agencies also are funding numerous tobacco-related grants and contracts to institutions in these states.

Office of Cancer Communications
October 1991

ASSIST Training Manual * November, 1991