Community-based interventions and alcohol, tobacco and other drugs: foci, outcomes and implications

Transcription

1 Drug and Alcohol Review (November 2006), 25, Community-based interventions and alcohol, tobacco and other drugs: foci, outcomes and implications NORMAN GIESBRECHT 1 & EMMA HAYDON 2 1 Social, Prevention and Health Policy Research Department, Centre for Addiction and Mental Health, and 2 Centre for Research on Inner City Health, St Michael s Hospital, Toronto, Ontario, Canada Abstract The social, health and economic burdens from alcohol, tobacco and other drugs have impacts globally, national and locally. Effective interventions are needed at each level in order to reduce the extensive harm and attendant costs. This paper examines four topics: options available to the local community, evidence of effectiveness, links between local experiences and national and regional initiatives and implications for future research and intervention. It appears that there are a substantial number of options available at the local level. However, evaluation of them is not standard practice, and the results of the higher quality evaluations indicate that many, but not all, interventions have modest or equivocal impact. There is also not a consistent relationship between local and national interventions, although some themes are apparent: in tobacco control there may be good synergy across jurisdictional levels, for alcohol there is evidence that as national control measures are eroded local communities are encouraged or required to take up these agendas, and with regard to illicit drugs there may be tension between law enforcement priorities at the national level and harm reduction orientations locally. Future initiatives need to have appropriate evaluations as a standardised part of prevention initiatives, and include the development of national databases of what is going on locally. These initiatives should promote national policies that include setting parameters and guidelines, but nevertheless do not dictate specific steps and strategies how to achieve local goals in reducing risk and harm. [Giesbrecht N, Haydon E. Community-based interventions and alcohol, tobacco and other drugs: foci, outcomes and implications. Drug Alcohol Rev 2006;25: ] Key words: alcohol, community intervention, drug, local intervention, tobacco. Introduction A substantial share of the global burden associated with social problems, disease, disability and death can be linked with consumption of alcohol, tobacco and other drugs. The WHO Global Burden of Disease project estimated that world-wide the proportion of disability-adjusted life years attributable to alcohol, tobacco, and illicit drugs was 8.9% [1]. While the substance user him- or herself is a common victim of a wide range of acute or chronic health problems, there is also collateral damage associated with consumption all three types of substances. For example, interpersonal violence or drinking/driving incidents associated with alcohol may victimise nonusers or light drinkers, consequences of second-hand smokeexposureorfirescausedbysmokersmaycause death or damage to non-smokers, and illicit drug users may be implicated in infections and neglect of significant others. Studies based on representative samples of adults have shown that in the previous 12 months a high proportion were affected negatively by the substance use of others (e.g. alcohol 70% [2]). The estimates of health damage and disease may be more detailed and reliable than those pertaining to social damage [3], particularly as the latter are often difficult to define. If the social damage is included, it is expected that human economic cost estimates would be substantially larger. Considered together, these three substances typically generate costs more than several times what is realised from revenues and taxes (for legal drugs). A recent study focusing on Canada found that the burden from tobacco, alcohol and other drugs was estimated to be $39.8 billion in 2002 ($1267 per capita). This was considered a conservative estimate based on burden on Norman Giesbrecht, Senior Scientist, Social, Prevention and Health Policy Research Department, Centre for Addiction and Mental Health, Toronto, Ontario, Canada M5S 2S1, Emma Haydon, Senior researcher, Centre for Research on Inner City Health, St Michael s Hospital, Toronto, Ontario, Canada M5B 1W8. Correspondence to Norman Giesbrecht, Social, Prevention and Health Policy Research Department, Centre for Addiction and Mental Health, Toronto, Ontario, Canada M5S 2S1. norman_giesbrecht@camh.net Received 5 April 2006; accepted for publication 26 May ISSN print/issn online/06/ ª Australasian Professional Society on Alcohol and Other Drugs DOI: /

2 634 Norman Giesbrecht & Emma Haydon services such as health care and law enforcement, and the loss of productivity in the workplace or at home resulting from premature death and disability [4]. In addition to social, health and law enforcement costs, in some jurisdictions their production and distribution use scarce valuable community resources that might be better used for meeting the basic needs of the community at large. As shown in other papers in this collection, the damage from heavy or inappropriate use of these substances has global, national, regional, and local effects. The focus of this paper is on the local level, although at several junctures we consider the interaction between local interventions and national or regional policies. As noted by others [5], it is the local level that bears a large share of the burden from drug use, including, for example, the social and physical trauma associated with drug use, the loss of local citizens and leaders through chronic disease or acute events, and inner city decay linked with a high concentration of liquor outlets. The typical arrangement of powers related to the regulation and management of alcohol, tobacco and other drugs tends to give limited control to the local jurisdiction. However, this situation is not consistent across countries, nor static, and as will be noted below, in some jurisdictions a transfer of some control for alcohol is evident from the national to municipal level. Nevertheless, there are numerous examples where a national orientation may actually create interference with the effective implementation of locally based prevention initiatives. An underlying irony is that the jurisdictions that are affected most visibly by drugs may have the least potential to implement the policies and other interventions that have the greatest potential to control drug-related damage. Four questions are examined in this paper.. What are the options open to a local community in dealing with alcohol, tobacco and other drug problems?. Which options are used most and what is the evidence of their effectiveness?. How does the experience at the local level link with regional or national levels?. What are the implications of this analysis for future research and interventions? The focus is primarily on evaluated interventions at the local level. It is clearly beyond the scope of this short paper to catalogue the countless descriptive, evaluative and anecdotal reports of communitybased interventions. The approach is to provide a summary of central themes that emerge from an overview of a number of community-based research projects focusing on alcohol, tobacco and/or other drugs. Community-based problems with alcohol, tobacco and other drugs We first consider the range and type of problems that a community may face from alcohol, tobacco or other drug use. Table 1 provides a summary, organised by type of problem along one dimension and type of drug on the other. The foci with regard to the problem dimension are on three different levels: system and institutional response, individual or drug, and damage (when the term drug is used it refers to alcohol, tobacco and/or other drugs; the term other drugs refers to street drugs and not to alcohol or tobacco). The top part of the table focuses more on system level dimensions or underlying problems, such as type of access to drugs, distribution arrangements, policies, law enforcement and other response systems. Effective interventions in these domains are likely to have farreaching and also long-term impact [6]. However, these interventions are typically not widely supported [7] and therefore difficult to implement and maintain. They typically involve system level changes that would be highly unpopular among those who profit from distribution or high-risk use (either directly or indirectly e.g. by profiting from maintaining an ineffective and costly response system). A second arena includes the drug, the user and/or his or her behaviour in connection with drug use. These are the most common foci in many interventions. A third focus is the damage from drug use. However, many interventions focus on drug use whether or not there is evidence of damage this is particularly the case with regard to use of alcohol among adolescents in cultures where abstinence has strong support among adults. Also, in cultures where use of illegal drugs is typically considered a proxy indicator for drug-related problems, even evidence of use is considered a problem. Furthermore, the major differences across the three types of drugs are with regard to access, distribution and enforcement (Table 1), while social and economic costs, problems, person and drug, indicate generically similar type of problems. Several implications for community-based interventions might be noted. First, each type of drug is associated with a wide range of health and social problems that are interrelated and not neatly grouped into the legal and illegal status of a drug. Secondly, an effective response system requires a range of skills including those with regard to systems and municipal planning, land use and service delivery, for example, and not only those associated with addictions services, health care or law enforcement. These skills are not necessarily drugspecific. Finally, there are many opportunities for cross-drug knowledge exchange and transfer, including but not limited to understanding polydrug use, effective community organisation and advocacy and

3 Table 1. Overview of problems related to alcohol, tobacco and other drugs with potential implications for community-based interventions Type of problems Alcohol Tobacco Other drugs A. Access and distribution Retailing/control system Retailing/control system Access to illegal market (high/ low availability) Price/taxation Price/taxation Price Outlet density Outlet density Spaces for consumption Days/hours of sale Minimum legal age Minimum legal age Marketing, promotion, sponsorship Server training Retailer training Marketing, promotion, Spaces for consumption sponsorship Spaces for consumption B. Enforcement Minimum age enforcement Minimum age enforcement Criminal justice system By-laws, licensing, and zoning of outlets By-laws, licensing, and zoning of outlets involvement and costs (regulating supply) Enforcement of other sales restrictions and regulations Enforcement of other sales restrictions and regulations C. Social and economic costs Lost wages and productivity Lost wages and productivity Lost wages and productivity Health care system costs Health care system costs Health care system costs Other support system costs (e.g. social services, emergency services) Other support system costs (e.g. social services, emergency services) Other support system costs (e.g. social services, emergency services) D. Person Use Use Use Underage use Underage use Underage use Heavy use Heavy use Heavy use E. Drug Poor or untested quality (non-regulated alcohol) Polydrug use Poor or untested quality Polydrug use Polydrug use High potency High alcohol content F. Behaviour Intoxication Excessive use Intoxication High risk action (e.g. binge High risk action (e.g. sharing drinking, drinking/driving) Involving others in high risk actions/consequences Community-based interventions 635 drug paraphernalia) Involving others in high-risk actions/consequences G. Damage Acute/trauma self and others Acute/trauma self and others Acute/trauma self and others Chronic self and others Chronic self and others Chronic self and others Social damage (e.g. victimisation, community disruption) Social damage (e.g. victimisation, community disruption) Social damage (e.g. victimisation, community disruption) health promotion principles, as some the same social conditions, economic principles or institutional change challenges are at play. Intervention options local opportunities and national contexts The local community may be the host of an intervention, but the secular developments at the national and international levels will have substantial influence on what is feasible and what the impacts will be [8]. In Table 2 this theme is illustrated by indicating the variation in feasibility of an intervention by drug and jurisdictional level. A few caveats might be noted. The jurisdictional home of primary control of an intervention probably varies by country and regulatory system; so, for example, in a monopoly system for alcohol retailing, which may be national (e.g. Sweden) or provincial (e.g. most Canadian provinces), pricing control is at the regional or national level. However, in a privatised system of alcohol retailing, there may be variations between municipalities within the same region. A second caveat is that international dynamics and interventions may result in changes in the division of responsibilities by jurisdiction. For example, due to the European Union interventions, there is a weakening of national alcohol policies in Sweden and Finland, and a greater emphasis on municipal responsibility for alcohol in the local situation in these jurisdictions. A third point is that combining regional with national is not ideal, but can be a useful compromise. In some

4 636 Norman Giesbrecht & Emma Haydon Table 2. Feasibility and acceptance of potential intervention options Alcohol Tobacco Other drugs Intervention foci! Local Regional or national Local Regional or national Local Regional or national Community support for legislative changes XX XX XXX XXX XX XX Programmes/supports to address social needs beyond X XX X XX X XX substance use alone (welfare, housing, criminal justice aid) Access real price and taxes X XXX X XXX N/A N/A Access density and concentration of outlets XX XX XXX XX N/A N/A Access days and hours XX XXX XX XXX N/A N/A Access type of selling venues XXX X XXX X N/A N/A Selling and serving policies XXX XXX XXX XXX N/A N/A Mass media XXX XXX XXX XXX XXX XXX Advertising X XX X XX N/A N/A Other promotion and sponsorship XX XX XX XX N/A N/A Legal purchasing age XXX XX XXX XX N/A N/A Age of onset (prevention of initiation) XX XX XX XX XX XX Consumption norms XXX X XXX X XXX X Consumption comportment norms XXX X XXX X XXX X Consumption location norms or regulations XXX XX XXX XX XXX XX Policies are high-risk behaviours XX XX XX XX XX XX Individual-level cessation or harm reduction interventions (including skills training) XXX X XXX X XXX X X ¼ intervention likely not feasible, given resources and opportunities; XX ¼ intervention possible and feasible, but certain barriers present; XXX ¼ intervention very feasible and most appropriate at the specific level and given existing evidence. countries, such as Canada and the United States, a great deal of the control of drugs is at the provincial/ state level. In other countries, which do not have provinces or states, the management of levers of control is more centralised at the national level. The result is similar, with the local jurisdiction having relatively little power with regard to some critical aspects of managing the damage from drugs. A final caveat is that dynamics are somewhat different for drugs such as alcohol and tobacco (legal in many jurisdictions) and so-called street drugs (illegal in most jurisdictions). While price, access, promotion and marketing and other dimensions that effect supply or demand are relevant across drugs, it is not the local or national governments that have the most direct and potentially efficient management options with regard to these dimensions when it comes to illegal drugs. There are several areas where local authorities typically have less influence than do regional or national domains. As indicated in Table 2, these include pricing of legal drugs, advertising, sponsorship and promotion, and minimum legal purchasing age, although commitment and related resources for enforcement tend to be a local matter. In contrast, local authorities have considerable influence on other types of access to drugs, such as concentration of outlets, number of licenses issued, hours and days of sale, selling venues, selling and serving practices and on-site advertising. Both jurisdictions have influence with regard to norms related to consumption, comportment and policies related to high-risk behaviours. Community interventions focusing on alcohol There has been an exceptionally active international tradition of community action projects focusing on alcohol, going back a number of decades. Our focus is on the more recent activity, and some illustrative community trials are summarised in Table 3a. As is the case in the tobacco control experiences at the community level, the influence of the heart health projects is also evident in with regard to evaluated community-based interventions focusing on alcohol [9]. In the case of alcohol, there has not, to date, been a community-based project of the scale of the Community Intervention Trial for Smoking Cessation (COMMIT) [10]. Nevertheless, two major projects, the Community Trials Project [11] and the Communities Mobilizing for Change [12,13], are examples of substantial initiatives to reduce damage from alcohol at the local level, each involving multiple sites and several interventions over several years. Similarly, recent initiatives in Europe, as illustrated by the Stockholm Prevents Alcohol and Drug

5 Community-based interventions 637 Table 3. Community-based evaluations focusing on alcohol, tobacco or other drugs: an illustrative overview Project and time frame Key citations Intent of intervention Intervention foci Main impacts (a) Alcohol Saving Lives Program (United States) Preventing Alcohol Trauma: A Community Trial (United States) Communities Mobilising for Change on Alcohol (United States) Lahti Project (Finland) Community Action Project (New Zealand) 1980s Stockholm Prevents Alcohol and Drug Problems (STAD) (Sweden) [44] Comprehensive strategy to reduce alcohol impaired driving and related problems such as speeding, other moving violations, and failure to wear safety belts [11,45 47] Comprehensive community intervention to reduce alcohol access and drinking/driving 3 intervention communities and 3 matched comparison sites [12,13] Local organised approach to reduce underage drinking [48,49] Goal to prevent alcohol-related problems (2 intervention and 2 comparison communities) [50] Intent to build support for alcohol control policies (4 treatment and 2 comparison communities) [14,15,51] Community alcohol prevention programme to reduce frequency of alcohol to adolescents (100 premises in north or south central Stockholm assigned to intervention and control conditions) Mass media Program co-ordinator to raise awareness Community mobilisation component Responsible beverage service component Drinking and driving component Component to reduce retail availability of alcohol to minors (minimum age enforcement) Alcohol access component to use local zoning powers Decoys (improving enforcement) Citizen monitoring Changes in hours of sale Responsible beverage service training Education Public education Community mobilisation Brief intervention Youth outreach Responsible beverage service Alcohol-focused community organiser Media campaign Multi-component intervention Training of serving staff in responsible beverage service, policy initiatives, and enforcement of existing alcohol regulations Reduction in fatal crashes and drinking after driving by teenagers Reduction in underage sales Changes in local zoning laws to reduce outlet densities Decreases in consumption, assaults and traffic crashes Merchants: more care in sales Youth (18 20): less purchasing and consumption of alcohol, significant decrease in DUI arrests Project was not found to be effective for alcohol consumption or other outcomes Support for control policies held steady in the treatment communities, indicating project success Using actors who were judged younger than the legal drinking age of 18, the serving practices were evaluated at baseline, and in 1998 and 2001 Overall frequency of service to adolescents decline from 45% to 32% with no statistically significant difference between the intervention and control premises (continued)

6 638 Norman Giesbrecht & Emma Haydon Table 3. (Continued) Project and time frame Key citations Intent of intervention Intervention foci Main impacts (b) Tobacco North Karelia Project (Finland) Stanford Three-City Project (United States) North Coast Quit for Life Programme (Australia) Stanford Five-City Project (United States) [29,30,52,53] Decrease mortality and morbidity from cardiovascular disease through comprehensive community-based programme targeting cardiovascular risk factors (smoking, cholesterol, high blood pressure) [54] Reduction in the cardiovascular risk factors of smoking, high cholesterol and high blood pressure Community organisation and support for changes Mass media Screening, smoking cessation advice and counselling Skills training Social support for behaviour change and environmental modification Mass media Community programmes (individual risk reduction counselling) (one town received both interventions, one received the mass media component only, and a third was the comparison community) [55] Reduce the prevalence of smoking Mass media Community programme (individual level interventions and public events) [56,57] Comprehensive community and mass media intervention to reduce smoking, high cholesterol, high blood pressure, sedentary lifestyles and weight (2 cities received interventions, 2 comparison cities, and 1 city used to monitory cardiovascular mortality and morbidity data) Mass media (TV-based smoking cessation, public service announcements) Smoking cessation (work-place, health professionals and group) Age of onset (school-based prevention) After 5 years, there was a lower prevalence of smoking among women in comparison to an adjacent control community (not among men) Per capita cigarette consumption was lower among men but not among women in comparison with control community (this was present at 5 years and 10 years follow-up) Community integration was very successful The only community component was the individual level intervention of risk reduction (no attempt at community organisation) After 2 years, in comparison with the control community, there was a lower per capita cigarette consumption among both men and women in the community receiving both interventions (intermediate reduction observed in the community that received mass media only) In the community that received both interventions and the one that received mass media only, there were reductions in the prevalence of smoking (in comparison with a third control community) Follow-up analyses showed a greater rate of decline in smoking and greater quit rates for the intervention cities in comparison with the control cities Target populations were exposed to about 5 hours of educational messages per year (continued)

7 Community-based interventions 639 Table 3. (Continued) Project and time frame Key citations Intent of intervention Intervention foci Main impacts Minnesota Heart Health Programme (United States) COMMIT (Community Intervention Trial for Smoking Cessation) (United States and Canada) [58,59] Comprehensive community intervention to reduce smoking, high cholesterol, high blood pressure, and sedentary lifestyle (3 intervention and 3 comparison cities) [10,60,61] Trial to reduce the prevalence of smoking among heavy smokers 11 pairs of communities (random assignment to intervention or comparison) Community organisation (community advisory boards and citizen task forces) Mass media Health professional education Smoking prevention in schools Individual interventions (telephone support, self-help) Community organisation (community boards and task forces) Mass media Smoking cessation and self-help Smoke-free policies For men, although the prevalence of smoking feel, follow-ups did not show any intervention effect For women, a significant intervention effect was seen, with a steady decline in smoking prevalence in comparison to the control communities Over 60% of the target population participated in the screening education programme and more than 30% were recruited to face-to-face intervention programmes. Risk reduction activities increased over time Cross-sectional follow-up (after the 5 years of the program) showed falls in the prevalence of smoking in the intervention and comparison communities, but no significant differences between them For heavy smokers, the perception of smoking as a public health problem did not differ at baseline between intervention and comparison groups, but differed significantly after the 5 years of the programme. No differences in norms and values indices

8 640 Norman Giesbrecht & Emma Haydon Problems (STAD Project [14,15] and the Trelleborg Project in southern Sweden (see commentary by Holder [16]) also involve multi-site interventions and extensive evaluation. However, community-based projects focusing on alcohol, with before and after measurements and comparison sites, while numerous [17], are not the most common. In countless settings there are local activities, some stimulated by researchers or involving research personal, designed to reduce drinking among youth and/or harmful or high risk drinking and related damage at the community level. For example, in 1997 at the First European Symposium on Community Action Programmes to Prevent Alcohol Problems, there were 71 abstracts accepted with representatives from 25 nations [18]. The rise of community-based projects focusing on alcohol has stimulated initiatives to also look at qualitative dimensions, such as interaction of research and programme components, process experiences and the problems and challenges encountered in these projects [19]. These themes were central to a series of symposia, six to date, beginning with the first meeting in 1989 in Scarborough, Ontario and the most recent in Mandurah, Western Australia in The reports of these symposia summarise the presentations and also the discussion and debate that were an integral part of each meeting. These symposia have offered an important and provocative counterbalance to a positivist perspective that based findings on quasi-experimental designs and quantitative outcome measures; and, in contrast, continue to highlight the importance of qualitative information, a case study perspective, and more thorough attention to process documentation. These symposia also highlighted the challenges of community-based action research [20 22]. Several challenges are particularly noteworthy in the context of this paper:. the dangers of a top-down or outsider perspective in undertaking community action to reduce the harm from alcohol;. involvement of local members in all aspects of a programme, including planning interventions, implementing them and assessing their impact;. building the intervention on a sound basis which includes a conceptual framework, understanding of intervening dimensions and insider knowledge of local traditions and cultures; and. resolving resource issues, structural changes and local commitment in order carry out the programme and sustain its impact. The orientation to alcohol issues and commitment to effective prevention at the national or regional level can facilitate or impede addressing these challenges. However, as is the case in the tobacco literature, as noted below, the gains in harm reduction with regard to alcohol problems tend to be important but modest. Even intense and well-planned initiatives that benefit from local support face formidable challenges in environments where alcohol is widely promoted and marketed, and where consumption is common and deeply integrated into everyday social events and activities [23]. The secular context and developments at the regional level and national levels often involving a deregulation of access controls and enhanced promotion of alcohol probably play an important, but contrary role, in determining the outcomes of these projects as do the specific local interventions. Community interventions and tobacco The number of local interventions focusing on tobacco probably run into hundreds, if not more. A number of these interventions are part of the movement that started a few decades ago to improve heart health conditions through a series of medium to large-scale projects, a number of them using a quasi-experimental design. However, based on the reviews summarised below, the majority of these local projects are either not evaluated formally or their evaluation does not involve appropriate design or contain sufficient information to allow one to draw conclusions about their impact on preventing smoking, reducing smoking rates or establishing local tobacco control interventions. The minimum criteria included the following: that there be baseline and outcome measures of the dependent variables, and both an intervention community or communities and comparison sites. Some projects assigned the communities randomly to the intervention versus comparison conditions, but these were the minority, whereas the others used matched sites for their comparison, or the jurisdiction as a whole. The numerous other projects not selected by reviewers might have had an impact at the local level or contributed more generally to the social climate supporting smoking cessation and prevention, including regulatory measures, but it is difficult to tell and is beyond the scope of this paper to explore this theme. Before focusing specifically on community-based interventions it is noteworthy that the school has been an important setting for much of this activity. A Cochrane review of school-based programmes for preventing smoking by Thomas [24] focused on 76 randomised controlled trials. He found that: there are well-conducted randomized controlled trials to test the effects of social influences interventions: in half of the group of best quality studies, those in the intervention group smoke less than those in the control, but many studies showed no effect of

9 Community-based interventions 641 the intervention. There is lack of high-quality evidence about the effectiveness of combinations of social influences and social competence interventions, and of multi-modal programmes that include community interventions [24]. These findings are similar to those reported reviews by Foxcroft et al. [25,26] of school-based interventions focusing on alcohol. It appears that with regard to both alcohol and tobacco, providing information about the risks to youth or adolescents is a popular but not highly effective intervention. Local communities may be tempted to devote substantial resources toward these initiatives, but as stand-alone measures they are likely to lead to disappointing outcomes. We turn now to two Cochrane reviews about community-based interventions designed to control tobacco use, one focusing on youth and the other on adults. The interventions and outcomes of a few key studies are briefly summarised in Table 3b. Sowden & Stead [27] examined community interventions for preventing smoking in young people. Their criteria for selecting studies included baseline and outcome measures and controlled trials with or without randomisation of communities. Seventeen studies were selected, and these included a great deal of variation in the type of intervention, size of the community and involvement of the community in the intervention. These reviewers noted that 15 of the 17 included a school-based component. While Sowden & Stead report that there is some evidence that community interventions reduced smoking prevalence compared to controls [28 30], this outcome is evident in only a few studies. Furthermore, of the four studies that compared community-wide interventions with controls who received a school-based intervention, only one study [31] reported a statistically significant difference in smoking prevalence (from baseline) between the intervention and control groups. Another review focused on community-based interventions for reducing smoking among adults [8]. The reviewers identified 32 studies that met the criteria of quasi-experimental design. However, 17 included only one intervention and one control community, and only four studies used random assignment of communities to either the intervention or comparison group. In 21 studies the investigators reported at least one favourable outcome in smoking behaviour, and in 11 they did not. Specifically, the reviewers noted that in 10 of the studies there was a net decline in the prevalence of smoking. They point out, however, that the two most rigorous studies showed limited evidence of an effect on prevalence referring to the US-based COMMIT project and the Australian CART study [8]. In discussing the results of their review, they highlight several concerns: the non-random assignment of communities to intervention or comparison conditions for almost all studies; the impact of secular change in smoking behaviour and national or regional controls is not fully assessed; and that, although the focus of this work is on the community, the unit of analysis of measuring outcomes as the individual. Given the equivocal or disappointing results, some caution is expressed by the reviewers. Future initiatives should not expect major impacts from these studies. The findings also signal that greater attention needs to be paid to community organising, assessment of capacity and recruitment of community members to form coalitions [8]. These themes are relevant to rather substantial activity in the United States focusing on tobacco control, which is federally funded yet managed mainly at the state level. While it is beyond the scope of this short paper to analyse these interventions, a few prominent developments are noted. The Center for Disease Control and Prevention [32] published an extensive report on best practices for comprehensive tobacco control programmes. This report indicated nine components of a comprehensive tobacco control programme: community programmes to reduce tobacco use, chronic disease programmes to reduce the burden of tobacco-related diseases, school programmes, enforcement, state-wide programmes, counter-marketing, cessation programmes, surveillance and evaluation and administration and management. This report noted that two states, namely California and Massachusetts, had local programmes that were found to be instrumental in changing local ordinances about smoking and policies that contributed to a decrease in non-smoking adults reporting exposure to second-hand smoke [32]. A recent report focused on the ASSIST project [33]. This major initiative can be considered a sequel to COMMIT, but was actually under way before the results of COMMIT were known. It was organised as a national demonstration project with purposeful sampling of states, and not random assignment. In contrast to COMMIT, the focus was more on the environmental and social contexts rather than the individual. The interventions focused on policy, mass media and programme services and there were four channels for the interventions: worksites, schools, health-care settings and community groups [34]. Seventeen states participated in this large-scale project, involving a 2-year planning phase and a 5-year implementation phase, and ending in September In subsequent years the experiences of this demonstration project served as model for building an effective infrastructure for mobilising communities and for training and technical support for media advocacy and policy. It has been noted that the core elements of ASSIST provide a process for shifting from a major focus on services for individuals to systems-level interventions for large population segments [35].

10 642 Norman Giesbrecht & Emma Haydon Community interventions for illicit drug use While the sections on alcohol and tobacco included Tables (3a and b) with corresponding information on specific community-based interventions, similar widereaching and comprehensive initiatives for illicit drug use do not really exist. Thus, we present a review of a number of issues relevant to community-based interventions without a corresponding summary table. The nature and extent of community-based interventions for illicit drug use are influenced by the nature of national drug policy. This section will detail the role of community interventions in relation to illicit drug use, with a focus on the Canadian situation. The tensions between overarching national policy and approach to illicit drug use and the realities within Canadian communities will be discussed. Canada s new Drug Strategy describes an integrated approach to the public health issue of illicit drug use, positioning Canada in a middle ground between zero tolerance and stricter enforcement-based policies (such as those in the United States, for the most part) and countries moving towards decriminalisation (the Netherlands, for instance). The agenda promoted in the United States regarding abstinence and zero tolerance prohibition has an important impact on the nature of both overarching national policy and smaller-scale interventions in Canada. Canada s drug policy and current activities regarding illicit drug use largely mirror those seen in Australia currently. While enforcement and supply-side reduction appear to continue to be the primary areas of concentration, harm reduction initiatives, such as safe injection facilities and the upcoming heroin prescription trial, indicate an increasing understanding of the importance of public health. One indication that Canada s approach to illicit drug use remains largely prohibitionist in nature is that the greatest part of federal funding is funnelled to supplyreduction initiatives. The budget for Canada s Drug Strategy for the period of is $245 million. Fourteen million dollars annually are provided in support of drug treatment programmes, and $9.5 million annually for the community initiative fund focused on prevention and harm reduction (for all of Canada). About half of the drug strategy budget is earmarked for enforcement costs alone ( While enforcement remains the primary focus, community interventions focused on prevention, treatment and harm reduction have been critical to encouraging the public health approach to illicit drug use. Engagement by the community and stakeholders is important for the implementation of effective programmes and policies to improve the health of marginalised populations [36]. Yates et al. [37] provide a useful typology of community-based interventions for substance use: self-help groups, parents groups, residents groups, community development groups and diversionary activity groups. Most communitybased responses to drug use are not top-down (instigated by government and larger organisations), but are rather bottom-up (inspired by people living in the community who are experiencing first-hand the issues related to drug use) [38]. In urban centres, community-based initiatives have focused largely on outreach, community drug treatment, harm reduction (primarily needle exchanges), education (either through peers or for youth) and other community support programmes. Other smaller-scale community interventions in Canada include crack pipe distribution and safe injection sites. Rather than focusing solely on changing individual behaviours, community-based interventions for illicit drug use have allowed for a population health approach to substance use. Community-focused interventions such as those involving social networks, syringe access and exchange, education and outreach reflect this perspective. Evaluations of specific community-based interventions are evident in the literature, and indicate overall that such initiatives are beneficial. We consider two approaches here, specifically HIV prevention efforts by the National Institute on Drug Abuse (NIDA) and a more recent (and radical) approach, safe infection facilities. In 1987, NIDA began to fund large-scale HIV prevention efforts targeting injecting drug users (IDUs), including education about HIV transmission, prevention through condom and bleach kit distribution. Evaluations indicated that active drug users can be engaged in meaningful education, counselling, HIV testing and referral in the community and that these changes can be associated with behavioural change. HIV prevention interventions have been successful in reducing HIV behaviours. Safe injection facilities (SIFs) have been scrutinised carefully, based largely on the criticism that many community interventions for illicit drug use have little or no evaluation data and that their implementation may lead to more harm than good. The evaluation of the safe injection site in Australia [39] indicated no increases in crime or public disorder, no detectable change in overdoses (those that did occur at the site were managed and may have been fatal if they had occurred outside the site), no increase in blood-borne virus transmission and substantial community support for the initiative. A pilot safe injection site in Vancouver (opened in 2003) also has a very specific evaluative protocol in order to help establish its effectiveness in the community. The evaluation includes both process and outcome measures [40]. Collins et al. [41] conducted a study on willingness of injection drug users to access a safe smoking room in Vancouver (where non-injection drugs could be consumed), and concluded that the

11 Community-based interventions 643 level of interest could translate into public health benefit. While there is some evidence of the effectiveness of specific community interventions for drug use, there is overall a paucity of evaluative evidence indicating what works and why it does work [38], similar to the research on community interventions for alcohol and tobacco. The low priority given to evaluation is due probably to a number of factors, including reliance on individuals, tensions between service provision and research, lack of evaluation research knowledge, misplaced energies, timeframes, size of the projects, suspicion about their utility and hostility/discrimination. Not only is there a lack of strong evaluative evidence for community interventions, but there is also a lack of dissemination outside of the research community for the evidence that does exist [38]. Vancouver s approach to illicit drug use: the four pillars The four pillars approach to substance use was first implemented in Switzerland and Germany in the 1990s, and cities such as Geneva, Zurich, Frankfurt, and now Sydney (Australia) have seen dramatic reductions in open drug scenes and improvements in health outcomes for illicit drug users. Former Vancouver Mayor Philip Owen released the Four Pillars Drug Strategy in 2000 ( Framework for Action: A Four Pillar Approach to Vancouver s Drug Problems ). It is an integrated policy and plan for reducing drug-related harm in Vancouver. The four pillars are (regarding Vancouver, Harm reduction: reducing the spread of communicable disease, preventing overdose deaths, and increasing contact with health and social care services.. Prevention: helping people understand the risks of substance use, encouraging people to make healthy choices, providing opportunities to reduce likelihood of substance use.. Treatment: offering access to services that help people deal with substance use, including outpatient and peer-based counselling, methadone, daytime and residential treatment, housing support and medical care.. Enforcement: targeting organised crime, drug dealing, drug houses and problem businesses involved in the drug trade and improving coordination with health services. The four pillars approach is a community drug strategy that has been implemented in other areas of the country, and some cities in the United States and internationally. It is focused on understanding the particular social context of drug use in the community and implementing a balanced approach that is not solely reliant on enforcement in order to address the public health issue of illicit drug use on a community level. Reworking Canada s drug strategy In a critical review of Canada s drug policy, Kerr & O Britain [42] recommended changes to policy and law to reduce the harms of illicit drug use, including developing a comprehensive and integrated strategy, exploring alternative legal frameworks, piloting innovative approaches and investing in broad social policies directed at the determinants of illicit drug use. This critique of the approach to illicit drug use in Canada has been taken into consideration in some ways in the development of new policy and implementation of new initiatives. In 2003, Canada s Drug Strategy was renewed. The 5-year plan relies on a balanced approach based on the four pillars of prevention, enforcement, treatment and harm reduction ( strateg/drugs-drogues/index_e.html). While the rhetoric behind the strategy is on the four pillars, a closer look and recent changes in Canada (for example, the increases in criminal sanctions for methamphetamine instituted in August 2005) indicate that enforcement and supply reduction remain the main focus, with community initiatives focused on harm reduction, prevention and treatment left on the back burner. One of the important components of the national drug policy is the implementation of a Community Initiatives Fund. The funding areas within the Drug Strategy Community Initiatives Fund are health promotion/ prevention and harm reduction. Eligible applicants are not-for-profit health organisations, educational institutions, business associations, charitable groups and offreserve Aboriginal groups, among others. The four pillars approach is community-specific, and takes into account the needs and resources in a particular community in order to address their specific issues related to substance use. It remains to be seen whether all components of the integrated strategy will be implementable on a national scale in Canada. Community interventions: Tensions and difficulties within the national context Because community interventions focusing on other drugs have come about largely from a bottom-up process, emphasising the needs of a particular community, they may not necessarily fit within the overarching approach to drug use on a national level and may not be reflective of general population consensus. Community-based programmes have the ability to be tailored specifically to the needs of those who will be accessing. Government policy does not always reflect

12 644 Norman Giesbrecht & Emma Haydon what may work best in a particular neighbourhood or city. However, with regard to alcohol, there are examples that a decline in a control and management agenda at the national level contributes to greater emphasis on municipal responsibility. As noted above, in Finland and Sweden concurrent with a weakening of the national policy due to European Union interventions there has been increased control of licensing and control of alcohol outlets at the municipal level. Rigorous scientific inquiry of community measures requires several years in order to truly examine the impact and benefits/costs. However, even without evidence of direct health benefit, community interventions may serve an important role in bringing hidden individuals using drugs into contact with services. The lack of dissemination of the (few) existing evaluations of community interventions for substance use means that the impact of positive community activities on overarching national policy may be difficult. Without evaluation and establishment of best practices (and gold standards), the government is reluctant to policy change. Community-backed interventions are also often difficult to sustain, especially when there is lack of funding. Lack of funding may be the direct result of inconsistencies between a particular community initiative and the national drug policy. Increasing the funding sustainability and level of support on a government level is an important step to increasing the number and positive effects of community interventions for drug use. National government and funding bodies should learn from those providing interventions in the community that making community change and improvement often involves the specific knowledge of the community leaders, not the national ones. Quite often it is the community that knows best for itself, and government should be willing to incorporate flexible communitybased policy in order to improve outcomes. Communities often seek ways to make the situation better for residents living there, and probably understand better the resources and abilities of their members to achieve this. However, this dynamic may vary greatly between licit and illicit drugs. With regard to alcohol, for example, a community may seek to control or manage access, such as imposing a ceiling on on-premise or offpremise outlets, but find little support at the national or provincial levels for interventions. The alcohol producers who are most effective at the national or international level can put pressure on national governments more efficiently to deregulate controls or allow increased promotion than in doing this municipality by municipality. Thus, communities with awareness of high rates of damage from alcohol may seek populationlevel interventions which find limited support, or a cold reception at the next level of government. In contrast, with illicit drugs, national governments may introduce policies that are oriented to reduce crime or reduce the aggregate numbers of morbidity or mortality, but do so in ways that do not consider the realities of community life. The community may be willing to experiment with a harm reduction approach, whereas national policies may be more oriented to victimisation or criminalisation. Implications for research, policy and action While community-based interventions need to be put into perspective, and exaggerated claims of their potential in reducing harm be avoided, there is a role for more focused funding of these initiatives. This funding should require that proposed communitybased interventions be sensitive to local dynamics and issues. It should also include explicit funding for evaluation. Funding for prevention should be linked consistently and routinely with funding for monitoring and evaluation, and the common practice of having separate and often unco-ordinated funding streams for prevention and evaluation of prevention should be phased out [43]. There should be increased priority and funding for interventions that include plans for building infr-structure so that long-term impact is feasible. A striking finding from the Cochrane reviews, focusing on tobacco for example, is that a large number of projects had flaws in design, missing information and insufficient resources to achieve their desired prevention aims. This generalisation is also relevant to a number of the experiences of community-based projects focusing on alcohol. Therefore, a second and related recommendation is to implement national databases of community-based interventions. This initiative might also provide evaluation support and training for front-line workers. Two examples from the United States, while not as rigid as Cochrane, are relevant to this recommendation. The Center for Substance Abuse Prevention (CSAP), as part of the US Department of Health and Human Services, has developed standards for evidence-based community prevention programmes along with a mechanism to register prevention programmes. These efforts to establish and to rate and register effective programmes reflect a national effort to provide guidance to future community action initiatives. A current initiative by CSAP is give funds to states to identify high incidence of alcohol, tobacco and other drug problems, and to work with communities in their state to initiate and evaluate evidence-based strategies to address local problems. The reviews noted above provide post hoc assessment of the strengths and weaknesses of projects. What we are proposing is a mechanism for transferring this international experience early on in the project planning, rather than long after unfortunate steps have been taken and resources depleted.

13 Community-based interventions 645 In this paper we have noted the importance of national and provincial/state policies for local action projects. However, there are many opportunities, possibly more than is often realised, for local communities to take initiatives to develop and promote local policies. These locally based initiatives not only have the potential to reduce harm at the local level, but also they can illustrate where national level interventions and policies are misguided, and provide positive examples to other communities facing similar challenges. Finally, national policies need to give more power to the communities and be more flexible in allowing communities to address their needs. This may require setting national parameters and guidelines without dictating specific steps and strategies of how to achieve these goals. It may also require that national level initiatives include a willingness to compromise on policy options, particularly when there is evidence that specific communities can benefit from different perspectives. Acknowledgements We wish to thank Lise Anglin for contributing to the literature search, and Peter Anderson, Harold Holder, Robin Room and Bob Vollinger for providing information and advice. The highly relevant suggestions from an anonymous reviewer were incorporated in revising this manuscript. The views and opinions are those of the authors and do not necessarily reflect those of the persons acknowledged or the organisations with which they are affiliated. References [1] Rehm J, Room R, Monteiro M, et al. Alcohol as a risk factor for the global burden of disease. Eur Addict Res 2003; 9: [2] Allen B, Anglin L, Giesbrecht N. Effects of others drinking as perceived by community members. Can J Public Health 1998;89: [3] Rehm J, Room R, Graham K, Monteiro M, Gmel G, Sempos CT. The relationship between average volume of alcohol consumption and patterns of drinking to burden of disease an overview. Addiction 2003;98: [4] Rehm J, Baliunas D, Brochu S, et al. The costs of substance abuse in Canada 2002 highlights. Ottawa: Canadian Centre on Substance Abuse, [5] Room R, Babor T, Rehm, J. Alcohol and public health. Lancet 2005;365: [6] Babor T, Caetano R, Casswell S, et al. Alcohol, no ordinary commodity: research and public policy. Oxford: Oxford University Press, [7] Anglin L, Kavanagh L, Giesbrecht N. Alcohol-related policy measures in Ontario: who supports what and to what degree? Can J Public Health 2001;92:24 8. [8] Secker-Walker RH, Gnich W, Platt S, Lancaster T. Community interventions for reducing smoking among adults. The Cochrane Tobacco Addiction Group. Cochrane Database of Systematic Reviews, [9] Holder HD, Howard J, eds. Methodological issues in community prevention trials for alcohol problems. Westport, CT: Praeger, [10] The COMMIT Research Group. Community intervention trial for smoking cessation (COMMIT): I Cohort results from a four-year community intervention. Am J Public Health 1995;85: [11] Holder HD, Gruenewald PJ, Ponicki WR, et al. Effects of community based interventions on high risk drinking and alcohol related injuries. JAMA 2000;284: [12] Wagenaar AC, Murray DM, Gehan JP, et al. Communities mobilizing for change on alcohol: outcomes from a randomized community trial. J Stud Alcohol 2000;61: [13] Wagenaar AC, Murray DM, Toomey TL. Communities mobilizing for change on alcohol: effects of a randomized trial on arrests and traffic crashes. Addiction 2000;95: [14] Andreasson S, Lindewald B, Rehnmen C. Over-serving patrons in licensed premises in Stockholm. Addiction 2000;95: [15] Wallen E, Andreasson S. Can I have a beer, please? A study of alcohol service to young adults on licensed premises in Stockholm. Prev Sci 2004;5: [16] Holder HD. The power of local prevention and the Trelleborg Project in southern Sweden. Addiction 2006; 101:763. [17] Holder HD. Community action in an international perspective. Berkeley, CA: Prevention Research Center, [18] Larsson S, Hanson BS. Alcohol prevention in Europe an introduction. In: Larsson S, Hanson BS, eds. Community based alcohol prevention in Europe research and evaluation. Proceedings of the First European Symosium on Community Action Programmes to Prevent Alcohol. Lund: Studentlitteratur. 1999: [19] Allamani A. Preface. Community action to prevent alcohol problems. Copenhagen: WHO Regional Office for Europe, 1995:vii ix. [20] Giesbrecht N, Conley P, Denniston RW, et al. Research, action, and the community: experiences in the prevention of alcohol and other drug problems. OSAP Prevention Monograph no. 4. Rockville, MD: Office of Substance Abuse Prevention, [21] Casswell S, Holder H, Holmila M, et al., eds. Kettil Bruun Society Thematic Meeting Fourth Symposium on Community Action Research and the Prevention of Alcohol and Other Drug Problems. Auckland: Alcohol and Public Health Research Unit, University of Auckland, [22] Holmila M. Developing a science-based understanding of local prevention. Editorial. Nord Stud Alcohol Drugs 2003;20(English suppl.):3 4. [23] Giesbrecht N. Alcohol, tobacco and local control: a comparison of several community-based prevention trials. Nord Stud Alcohol Drugs 2003;20(English suppl.): [24] Thomas R. School-based programmes for preventing smoking [Review]. The Cochrane Tobacco Addiction Group. Cochrane Database of Systematic Reviews, [25] Foxcroft DR, Lister-Sharp D, Lowe G. Alcohol misuse prevention for young people: a systematic review reveals methodological concerns and lack of reliable evidence of effectiveness. Addiction 1997;92: [26] Foxcroft DR, Ireland D, Lister-Sharp DJ, Lowe G, Breen R. Long-term primary prevention for alcohol misuse in young people: a systematic review. Addiction 2003;98(suppl. 4): [27] Sowden A, Stead L. Community interventions for preventing smoking in young people. The Cochrane Tobacco Addiction Group. Cochrane Database of Systematic Reviews, 2005.

14 646 Norman Giesbrecht & Emma Haydon [28] Perry CL, Kelder SH, Klepp K. Community-wide cardiovascular disease prevention in young people: long-term outcomes in the Class of 1989 study. Eur J Public Health 1994;4: [29] Vartainen E, Korhonen HJ, Koskela K, Puska P. Twenty year smoking trends in a community-based cardiovascular diseases prevention programme results from the North Karelia Project. Eur J Public Health 1998;8: [30] Vartiainen E, Paavola M, McAlister A, Puska P. Fifteenyear follow-up of smoking prevention effects in the North Karelia Youth Project. Am J Public Health 1998;88:81 5. [31] Biglan A, Ary DV, Smolkowski K, Duncan T, Black C. A randomised controlled trial of a community intervention to prevent adolescent tobacco use. Tob Control 2000;9: [32] Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs August Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, [33] McAdams Motsinger B, Vollinger RE Jr, Niemeyer D. The promise of ASSIST. In: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute. ASSIST-Shaping the Future of Tobacco Prevention and Control. Monograph no. 16: NCI Tobacco Control Monograph Series. Washington: National Cancer Institute, 2005: [34] Vollinger RE Jr, Moon RW, Greenwald P. The historical context. In: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute. ASSIST-Shaping the Future of Tobacco Prevention and Control. Monograph no. 16: NCI Tobacco Control Monograph Series. Washington: National Cancer Institute, 2005:1 17. [35] Moon RW, Havlicek D, Garcia JM, Vollinger RE Jr, McAdams Motsinger B. The conceptual framework, In: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute. ASSIST Shaping the Future of Tobacco Prevention and Control. Monograph no. 16: NCI Tobacco Control Monograph Series. Washington: National Cancer Institute, 2005: [36] Frankish CJ, Hwang SW, Quantz D. Homelessness and health in Canada: research lessons and priorities. Can J Public Health 2005;96(suppl. 2):S23 9. [37] Yates R, Morris S, Pratt R. Effective responses to alcohol and drug concerns in the community: evidence, dilemmas and solutions. Report prepared for the Greater Glasgow Health Board, Health Promotion Department. Glasgow: Greater Glasgow Health Board, [38] Eley S. Community-backed drug initiatives in the UK: a review and commentary on evaluations. Health Social Care Commun 2002;10: [39] MSIC Evaluation Committee. Final report on the evaluation of the Sydney Medically Supervised Injecting Centre. Sydney: Authors, [40] Wood E, Kerr T, Lloyd-Smith E, et al. Methodology for evaluating Insite: Canada s first medically supervised safer injection facility for injection drug users. Harm Reduct J 2004;1: [41] Collins CL, Kerr T, Kuyper LM, et al. Potential uptake and correlates of willingness to use a supervised smoking facility for non-injection drug use. J Urban Health 2005;82: [42] Kerr T, O Britain W. Drug policy in Canada the way forward. Can HIV/AIDS Policy Law Rev 2002;7: [43] Haydon E, Roerecke M, Giesbrecht N, Rehm J, Kobus- Matthews M. Chronic disease in Ontario and Canada: determinants, risk factors and prevention priorities. Report prepared for the Ontario Chronic Disease Prevention Alliance and the Ontario Public Health Association, [44] Hingson R, McGovern T, Howland J, Heeren T, Winter M, Zakocs R. Reducing alcohol-impaired driving in Massachusetts: The Saving Lives Program. Am J Public Health 1996;86: [45] Holder HD, Saltz FR, Grube JW, et al. Summing up: lessons from a comprehensive community prevention trial. Addiction 1997;92:S [46] Reynolds RI, Holder HD, Gruenewald PJ. Community prevention and alcohol retail access. Addiction 1997;92: S [47] Holder HD, Reynolds RI. Application of local policy to prevent alcohol problems: experiences from a community trial. Addiction 1997:92:S [48] Holmila M. Community action on alcohol: experiences of the Lahti Project in Finland. Health Prom Int 1995; 10: [49] Holmila M. Community prevention of alcohol problems. Houndmills and London: Macmillan Press Ltd, [50] Casswell S, Gilmore L. An evaluated community action project on alcohol. J Stud Alcohol 1998;50: [51] Wallen E, Gripenberg J, Andreasson S. Overserving at licensed premises in Stockholm: effects of a community action program. J Stud Alcohol 2005;66: [52] Puska P, Nissinen A, Salonen JT, Touilehto J. The community-based strategy to prevent coronary heart disease: conclusions from the ten years of the North Karelia Project. Ann Rev Public Health 1985;6: [53] Vartainen E, Puska P, Koskela K, Nissinen A. Ten-year results of a community-based anti-smoking program (as part of the North Karelia Project in Finland). Health Educ Res 1986;1: [54] Maccody N, Farquhar JW, Wood PD, Alexander J. Reducing the risk of cardiovascular disease: effects of a community-based campaign on knowledge and behaviour. J Commun Health 1977;3: [55] Egger G, Fitzgerald W, Frape G, et al. Results of large scale media antismoking campaign in Australia: North Coast Quit for Life programme. BMJ 1983;287: [56] Fortmann SP, Taylor CB, Flora JA, Jatulis D. Changes in adult cigarette smoking prevalence after 5 years of community health education: the Stanford Five-City Project. Am J Epidemiol 1993;137: [57] Winkleby MA, Fortmann SP, Rockhill B. Cigarette smoking trends in adolescents and young adults: the Stanford Five-City Project. Prev Med 1993;22: [58] Lando HA, Pechacek TF, Pirie PL, et al. Changes in adult cigarette smoking in Minnesota Heart Health Program. Am J Public Health 1995;85: [59] Perry CL, Kelder SH, Murray DM, Klepp K-I. Community-wide smoking prevention: long-term outcomes of the Minnesota Heart Health Program and the class of 1989 study. Am J Public Health 1992;82: [60] Pomrehn P, Schiandra R, Shipley R, Lynn W, Lando H. Enhancing resources for smoking cessation through community intervention COMMIT as a prototype. Int Q Commun Health Educ 1990;11: [61] Taylor SM, Ross NA, Goldsmith CH, Zanna MP, Lock M. Measuring attitudes towards smoking in the community intervention trial for smoking cession (COMMIT). Health Educ Res Theory Pract 1998;13: