Community interventions for reducing smoking among adults

BACKGROUND: Since smoking behaviour is determined by social context, the best way to reduce the prevalence of smoking may be to use community-wide programmes which use multiple channels to provide reinforcement, support and norms for not smoking. OBJECTIVES: To assess the effectiveness of community interventions for reducing the prevalence of smoking. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group specialised register, MEDLINE (1966-August 2001) and EMBASE (1980-August 2001) and reference lists of articles. SELECTION CRITERIA: Controlled trials of community interventions for reducing smoking prevalence in adult smokers. The primary outcome was smoking behaviour. DATA COLLECTION AND ANALYSIS: Data were extracted by one person and checked by a second. MAIN RESULTS: Thirty two studies were included, of which seventeen included only one intervention and one comparison community. Only four studies used random assignment of communities to either the intervention or comparison group. The population size of the communities ranged from a few thousand to over 100,000 people. Change in smoking prevalence was measured using cross-sectional follow-up data in 27 studies. The estimated net decline ranged from -1.0% to 3.0% for men and women combined (10 studies). For women, the decline ranged from -0.2% to + 3.5% per year (n=11), and for men the decline ranged from -0.4% to +1.6% per year (n=12). Cigarette consumption and quit rates were only reported in a small number of studies. The two most rigorous studies showed limited evidence of an effect on prevalence. In the US COMMIT study there was no differential decline in prevalence between intervention and control communities, and there was no significant difference in the quit rates of heavier smokers who were the target intervention group. In the Australian CART study there was a significantly greater quit rate for men but not women. REVIEWER'S CONCLUSIONS: The failure of the largest and best conducted studies to detect an effect on prevalence of smoking is disappointing. A community approach will remain an important part of health promotion activities, but designers of future programmes will need to take account of this limited effect in determining the scale of projects and the resources devoted to them.