Creating an effective smoking cessation program involves strengthening individual knowledge and skills, promoting community education, and changing organizational practices.

 The implementation of diagnosis related groups (DRGs), capping reimbursements for services more than 20 years ago, and the national mandate to prevent disease and promote health challenge RCPs to enhance their roles. As Burton et al1 suggest, “In the future, health promotion and disease prevention will be emphasized more than in the past and more RCPs will provide patient education and health promotion services.” There are three levels of prevention—primary, secondary, and tertiary—each with a different emphasis and intervention strategies. Primary prevention focuses on diseases before they occur (smoking prevention programs), secondary prevention limits the sequelae of a disease (smoking cessation programs), and tertiary prevention keeps those who are disabled from experiencing more severe effects (as in pulmonary rehabilitation programs.)2 While RCPs have carved out a unique and highly successful role in therapeutic and rehabilitative care, they are now positioned to play a significant part in primary prevention. Therefore, this article examines how RCPs can take an active role in youth smoking prevention programs and discusses Cohen and Swift’s “Spectrum of Prevention” (SPECTRUM) model as a guide for prevention efforts.

Smoking is the leading cause of preventable premature death and disability in the United States today, accounting annually for 430,000 deaths or one in every five. US smokers start at an average age of 14.5 years, and 80% of all smokers begin by age 18.3 If this trend continues, 5 million children and adolescents now under the age of 18 will die prematurely from smoking. In recent years, significant increases in smoking have been found for youth overall, underscoring the need for comprehensive youth smoking prevention programs.4

Although knowledge and awareness of the hazards of smoking have grown, smoking among youth has not declined. Why is this? The answer lies in two main areas: lack of success of many health promotion efforts for youth and the difficulty of opposing the sophisticated and expensive marketing strategies of tobacco companies; however, RCPs can make a difference by creating and supporting primary prevention smoking programs for youth, using the Spectrum model. Spectrum empowers community-based organizations and has proven effective in a wide variety of violence and injury prevention programs. RCPs can use the six steps of the model as a template that incorporates the best practices of successful youth intervention programs from many different health care arenas. In addition, RCPs can draw on the Internet for more information, materials, and examples of existing programs. If an organization lacks resources to develop a complete program, select one or more of the six Spectrum components and focus your resources to strengthen these. Prevention programs are an excellent vehicle for increasing community visibility for both RCPs and their institutions. Before making the leap, become as proficient in smoking prevention as you are in treating the patient with chronic lung disease. RCPs may wish to start with the six SPECTRUM steps and the suggestions that follow:

Strengthen Individual Knowledge and Skills
Expanding individual knowledge, skills, and resources through specifically targeted learning strategies are effective ways to prevent disease and promote health. The most successful youth HIV and smoking prevention interventions have incorporated youth culture and young people in realistic life situations. They have been used as project consultants, as peer educators, and in role-playing scenarios to encourage healthy behavior.

What Can RCPs Do?
• Develop knowledge regarding prevention programs for youth.
• Enhance skills in researching, developing, and evaluating programs.
• Become a resource person: Contact a local American Lung Association (ALA), local teen organizations, and other community groups to share expertise.

Promote Community Education
A community education perspective provides entire groups or populations with information and resources to improve their health.5 Much insight can be gained from research on successful HIV programs to understand why messages about smoking prevention have not made a significant impact on the current generation. Researchers and planners have found that, in general, youth were not responsive to messages that emphasized “adults know best” or “one size fits all” (HIV Impact, Spring 2001). They also did not respond well when program planners failed to include: the target population or peers in the design and implementation; innovative media, state-of-the-art technology, and celebrities; “social marketing” (applying techniques to promote social issues that are similar to those used for selling commercial products); and multifaceted/multisectoral approaches.

Today’s youth have been exposed to more media campaigns than any other generation in this country. By age 14, the average teen has been confronted with $20 billion of tobacco advertising.6 What can be done to combat this advertising blitz? Change organizational practices. Use the same successful strategies that induce youth to smoke. and increase pro-health messages while advocating smoking prevention.6 Contemporary health promotion incorporates paid television, radio, billboard, and print advertisements, media advocacy, and public relation techniques (press releases). TRUTH uses Master Settlement Agreement (MSA) funds to educate youth about the lies and hidden practices of the cigarette companies. It channels the natural rebellious urges of youth by using “edgy, in-your-face antismoking ads.” The TRUTH campaign stems from the multibillion-dollar MSA. It focuses attention on the organizational practices of big tobacco companies, revealing their marketing techniques, and turns the same strategies against them.

What Can RCPs Do?
• Research “best practices” and the most effective teen antismoking programs.
• Apply these practices to the program you are creating or to the existing programs you are assisting; do not reinvent the wheel.
• Help existing programs evaluate their effectiveness and make necessary revisions.

Train Providers
Providers have vast opportunities to facilitate changes in knowledge, attitudes, skills, and behavior in patients, clients, and colleagues. This is why it is crucial that they continue their own education and train other providers in smoking prevention and other related issues.

What Can RCPs Do?
• Take the lead in prevention efforts. Get involved with local school systems.
• Train the teachers or become a regular part of the school curriculum. Antismoking messages should be presented on a regular basis to be effective. Make your presentation an annual event.
• Offer youth antismoking prevention program to area community health centers.

Foster Coalitions and Networks
The Spectrum model encourages collaborative efforts among groups of complementary participants. Coalition and network building ensures community support and participation, increases trust among disparate groups, takes advantage of individual organizations’ skills, and makes efficient use of scarce resources, thereby enhancing the likelihood of a successful program.

What Can RCPs Do?
• Take the initiative. Be the catalyst to form coalitions with the different smoking prevention factions within your community.
• Utilize new contacts that have been made with voluntary organizations, schools, and other health institutions and use this as an opportunity to bring them together to increase their effectiveness.

Change Organizational Practices
“Examining the practices of key organizations… has potential for affecting the health and safety of the greater community…. By changing its own internal regulations and norms, an organization can affect the health and safety of its members.”5 Effective antismoking programs demand organizational assessment and change.

We all have the right to live, work, and socialize in a safe environment. Exposure to environmental tobacco smoke (ETS)—a Class A carcinogen—places everyone at risk for many of the same diseases that afflict smokers. Every year, ETS causes thousands of deaths from lung cancer and heart disease in adults and hundreds of thousands of respiratory related illnesses in children.7

Thousands of ordinances have been passed to ban smoking in schools, restaurants, stores, and workplaces. Take action; complain when a smoker violates a non-smoking designation or when there are no accommodations for a smoke-free environment. There is evidence that smoking restrictions encourage smokers to quit. So do not think of yourself as a nuisance when you protest, but as a catalyst who advocates for both the smoker and the nonsmoker.7

What Can RCPs Do?
• Be prepared to assess your own organization to understand how prevention efforts can be incorporated into the existing services.
• Propose extended RCP roles to include seeking external funding for youth smoking prevention programs.
• Establish smoking cessation programs within your department.

Influence Policy and Legislation
“Changes in local, state, and national laws, as well as the adoption of formal policies by boards and commissions, fall under the umbrella of policy and legislation.” Policy changes typically bring large-scale changes in health. Antismoking policy changes are no exception.5

A federal policy called the Fairness Doctrine was developed once researchers linked adverse health conditions to smoking. This legislation mandated that television broadcasters air one antismoking message in the form of a Public Service Announcement for every three cigarette commercials. In 1966, the federal government required health-warning labels to appear on cigarette packages. Correlated with these regulations was a 10% decline in cigarette consumption between 1967 and 1970. Other policies affecting smoking include “no smoking” restrictions at work and in public settings.

What Can RCPs Do?
• Research the antismoking laws in your area and give voice to those that are not being enforced.
• Encourage community organizations to establish strong antismoking policies.

Understanding that most departments have very limited funding, here are a few possible resources to help RCPs get started on youth smoking prevention efforts. There is a strong possibility that money has been allotted for smoking prevention in your state as part of the MSA, so take advantage of it!

Funding Sources:
Centers for Disease Control and Prevention—Funding Resources

Tobacco Settlement Money

Summary of the Attorney’s General Master Tobacco Settlement Agreement  

Additional E-Resources:
In the Mix

Kick Butt

A Guide to Youth Prevention Policies and of Programs

Educational Materials

No Smoke Software Program

Developing Effective Coalitions: An Eight Step Guide


Donna Oliver-Freeman, RRT, is adjunct professor, Northern Virginia Community College, Amandale; Autumn Saxton-Ross, is a graduate assistant, Howard University, Washington, DC; Roberta B. Hollander, PhD, MPH, is interim chairperson, Department of Health, Human Performance, and Leisure Studies, Howard University, Washington, DC; and Larry Cohen, MSW, is executive director, Prevention Institute, Oakland, Calif.

1. Burton G, Hodkin JE, Ward JJ. Respiratory Care: A Guide to Clinical Practice. Philadelphia: Lippincott Williams & Wilkins; 1997.
2. Anspaugh DJ, Digman MB, Anspaugh SL. Developing Health Promotion Programs. Boston: McGraw Hill; 2000.
3. Centers for Disease Control and Prevention. Tobacco surveillance—United States 1998-1999. MMWR Morb Mortal Wkly Rep. 2000;49:S1-S93.
4. Centers for Disease Control and Prevention. Tobacco use among high school students—United States, 1997. MMWR Morb Mortal Wkly Rep. 1998:47(12):229-233.
5. Cohen L, Swift S. The spectrum of prevention: developing a comprehensive approach to injury prevention. Injury Prevention. 1999;5:203-207.
6. Oklahoma State Health Department. Counter Marketing. Available at: Accessed July 15, 2001.
7. Insel PM, Walton RT. Core Concepts in Health. Burr Ridge, Ill: McGraw Hill; 2002.