Support for Community Coalition Action
The IOM’s recommendation for support of community mobilization for tobacco control is consistent with recommendations by the Centers for Disease Control and Prevention (CDC) for comprehensive community tobacco prevention programs. The efforts of grassroots coalitions to organize citizens to influence local, state, and federal policy have been the basis for policy change to control tobacco. Policy advocacy has been an integral feature of comprehensive state tobacco control programs in all states. The tobacco industry, in recognition of the power of such an approach, has tried to equate community action and advocacy to illegal lobbying. The industry successfully achieved an amendment to the federal contracting regulations that, for the first time in U.S. history, forbade federal funds to be granted to community-based organizations that were trying to influence state and local policies. However, advocates have fought back against such efforts to quell citizen voices against tobacco use by continuing to persuade state and local legislatures to pass smoke-free laws for workplaces around the country.
A National Public-Private Partnership That Mobilized State Action
The American Stop Smoking Intervention Study (ASSIST) provides a case study of a successful national population-based program that mobilized state coalitions for tobacco control.
The program, launched by the National Cancer Institute’s (NCI) Division of Cancer Prevention and Control within the National Institutes of Health, funded 17 state health departments with the mandate of establishing state comprehensive tobacco prevention program. In each state that won ASSIST contracts, the state health department served as the lead agency for a coalition of individuals and organizations that were committed to tobacco control. Each state health department had to agree to
- establish a comprehensive tobacco control program
- build a coalition for tobacco control; and
- provide leadership for additional coalitions at the community level .
NCI formed a partnership with the American Cancer Society (ACS) in order to implement the ASSIST project. Each state was required to do the same on the assumption that management of the program would be better served by such a partnership. Each state also established an executive committee for decision making at the state level with equal representation from the state health department and ACS with two of the twelve slots filled by other community organizations.
The state coalitions’ activities focused on four policy changes:
- Eliminating exposure to environmental tobacco smoke (secondhand smoke)
- Promoting higher taxes for tobacco
- Limiting tobacco advertising and promotions
- Reducing minors’ access to tobacco
The project lasted eight years, until 1998. For the first two years, coalition members were trained to implement the ASSIST model in their states and localities. They received training in three primary intervention activities:
- How to identify and implement policy changes for tobacco control
- How to develop effective media advocacy plans
- How to implement selected program services
ASSIST focused on policy and media advocacy as the two most promising strategies for achieving lower prevalence and incidence rates at a state level within the timeframe of the intervention. Policy change and media advocacy programs require public health professionals and community volunteers to think of themselves as advocates for social change and to learn such skills as negotiations, petitioning local and state governments, framing media messages to influence social norms in favor of tobacco control and other skills related to advocacy projects. By 1994, state coalitions had completed training and had conducted local trainings and had launched tobacco control initiatives in the states.
The ASSIST evaluation called for annual reports of coalition activities so that NCI could monitor the achievements of each coalition. A state legislative database called SCLD was set up to keep track of new laws in each state. Over the eight-year period, hundreds of policy and legal changes were documented in the various states. The national evaluation of ASSIST showed a difference in prevalence for ASSIST states compared to non-ASSIST states.
The ASSIST program, as well as the CDC’s IMPACT program and the Robert Wood Johnson Foundation’s SmokeLess States program, must be considered the most successful models of tobacco control ever launched in the United States. However, the tobacco companies’ strategies were so successful that state coalition action is inhibited even today by restrictions on reimbursement by state health agencies for advocacy activities for fear that such activities constitute lobbying. Because most states use their Master Settlement Agreement monies to fund state tobacco control programs, the health departments forbid grant or contract recipients from “lobbying.” Therefore, state coalitions with advocacy goals do not receive funds while community-based organizations that are funded are restricted to program services.
There has been no repetition on the federal level of the ASSIST program. The program was shifted to the CDC at the end of 1998. The current program is hobbled by the equation of advocacy with lobbying. While the CDC recommendations for comprehensive tobacco control include citizen mobilization as the first recommendation for states, cutbacks in funding over the last decade have limited the flow of money to state health departments. Most advocacy activities are now funded only through independent agencies that have very limited resources to volunteers who are passionate about clean air environments. Even with limited resources, these agencies and individuals have achieved notable successes in the extension of clean air environments in many states. Without a resuscitation of effective state coalitions and increased federal funding, it will probably not be possible to achieve the level of policy change accomplished under ASSIST.
 NCI. (2005). ASSIST: Shaping the Future of Tobacco Prevention and Control (Monograph 16). Bethesda, MD: National Institutes of Health.
Resources:The NCI has published two monographs that document the history and evaluation of the ASSIST program. Monograph 16 records the history and process of the program. Monograph 17 evaluates the benefits to public health of the ASSIST program, the development of the strength of tobacco control (SOTC) index and provides examples of how to evaluate population interventions.