National Academies Press: OpenBook
« Previous: 7 Evaluating and Disseminating Intervention Research
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 331
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 332
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 333
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 334
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 335
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 336
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 337
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 338
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 339
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 340
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 341
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 342
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 343
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 344
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 345
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 346
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 347
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 348
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 349
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 350
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 351
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 352
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 353
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 354
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 355
Suggested Citation:"8 Findings and Recommendations." Institute of Medicine. 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: The National Academies Press. doi: 10.17226/9838.
×
Page 356

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

8 Findings and Recommendations T his report reflects the increasing attention being paid to the be- havioral and psychosocial factors that enhance or compromise health. Many behaviors—tobacco use, excessive alcohol con- sumption and abuse of other substances, unhealthy diet, sedentary lifestyle, and nonadherence to medication regimens—are recognized as health- compromising. Evidence for the effects of social stressors, socioeconomic status, social support, and social capital on health outcomes is growing. First, this chapter explores the interactions of risk factors. Next, it pre- sents the example of tobacco interventions to illustrate an effective multi- level approach and the difficulties in evaluating the interventions. Fi- nally, it presents recommendations for research and practice regarding health and behavior. INTERACTIONS AMONG RISK FACTORS Recent decades have seen increasing attention given to the contribu- tion of psychosocial factors, particularly behavior, to promoting or com- promising health. The relationship between some behaviors and health status has been recognized since the 1974 Lalonde report. Healthy People (U.S. Department of Health, Education, and Welfare, 1979) and Health and Behavior: Frontiers of Research in the Biobehavioral Sciences (IOM, 1982) 331

332 HEALTH AND BEHAVIOR documented the importance of behavior to the burden of illness and dis- abilities in the United States. The association of tobacco use with heart disease, a variety of cancers, and poor pregnancy outcomes is perhaps the best known and most dra- matic example of the interactions addressed in this report. However, the association of physical activity with fitness and health, dietary nutrients with health or illness, and excessive alcohol consumption with driving fatalities and poor pregnancy outcomes also are recognized widely. Recently, basic and applied research from a range of disciplines has demonstrated the importance of reciprocal interactions over time among health and biological, psychological, and social factors. Biological factors include genes, neurochemical and hormonal processes, and the function- ing of physiological systems. Psychological factors include behavioral, per- sonality, temperamental, cognitive, and emotional variables. Social fac- tors include socioeconomic status, social inequalities, social networks and support, and work conditions. It is now evident that the relationships between health and many behaviors are much more complex than previ- ously thought. Evidence attests that psychosocial factors influence health directly through biological mechanisms and indirectly through an array of behaviors. Example: Social Status and Health The role of social status in health and behavior is an example of inter- actions among biological, psychological, and social factors and health. Lower mortality, morbidity, and disability rates among socioeconomically advantaged people have been observed for hundreds of years, and studies have documented these effects using various indicators of socioeconomic status (SES) and multiple disease outcomes (Kaplan and Keil, 1993). Per- haps the most striking finding is the graded and continuous nature of the association between income and mortality, with differences persisting well into the middle-class range of incomes (Chapter 4). The fact that socio- economic differences in health are not confined to segments of the popu- lation that are materially deprived in the conventional sense argues against an interpretation of socioeconomic differences as simply a function of ab- solute poverty. Moreover, because causes of death that seem not amenable to medical care show socioeconomic gradients similar to those of poten- tially treatable causes (Davey Smith et al., 1996; Mackenbach et al., 1989), differential access to health-care programs and services cannot en- tirely explain socioeconomic differences in health (Wilkinson, 1996).

FINDINGS AND RECOMMENDATIONS 333 People who are poor, have low levels of education, or are socially isolated are more likely to engage in risk-related behaviors and less likely to engage in health-promoting behaviors (Adler et al., 1994; Matthews et al., 1989). Behaviors (Chapter 3) occur in specific social contexts. Social environments influence behavior by shaping norms (e.g., the extent to which tobacco use is discouraged or encouraged); enforcing patterns of social control; providing or not providing opportunities to engage in par- ticular behaviors (e.g., safe places to exercise, availability of nutritious foods); and reducing or producing stress, for which engaging in specific behaviors might be an effective coping strategy, at least in the short term (Berkman and Kawachi, 2000). The stresses associated with environmental and behavioral factors contribute to illness (Cohen and Herbert, 1996; Cohen et al., 1991; Hermann et al., 1995; Kiecolt-Glaser et al., 1996; McEwen, 1998). “Allostatic load” refers to the wear and tear that the body experiences as a result of the repeated activation of the stress response; it also includes contributions of food, alcohol, tobacco, exercise, and sleep through their ability to influence the production of stress hormones (McEwen, 1998; McEwen and Stellar, 1993). The “stress response” triggers and modulates physiological effects that can promote disease including modulation of the immune system (Chapter 2). BEHAVIOR CHANGE Producing Behavior Change Behavior can be changed and those changes can influence health. Interventions can successfully teach health-promoting behaviors or at- tenuate risky behaviors. Interventions aimed at management of chronic pain, smoking cessation, coping with cancer, and amelioration of eating disorders have been demonstrated empirically to be effective (Compas et al., 1998). Studies show that family or structured-group support, patient education, and behavior-based interventions can increase adherence to prescribed medication regimens (Anderson, 1996). Education aimed at increasing knowledge, control, and confidence (self-efficacy) among dia- betics has produced benefits in both attitude and blood glucose manage- ment (Anderson et al., 1995). Many studies show that psychological in- terventions, especially those involving cognitive behavioral methods to enhance coping, are effective in facilitating adaptation to and coping with

334 HEALTH AND BEHAVIOR rheumatoid arthritis (Keefe and Caldwell, 1997; Lorig and Holman, 1993; NIH Technology Assessment Panel, 1996; Parker, 1995). Studies of support groups, provision of education and information, expression of emotions, and hypnosis suggest the utility of these ap- proaches in the treatment of a range of conditions, including irritable bowel syndrome (Whorwell et al., 1984, 1987), peptic ulcer disease (Klein and Spiegel, 1989), coronary heart disease (Linden et al., 1996), and can- cer (improving quality of life and psychological adjustment of cancer pa- tients, possibly affecting health status and survival; see reviews by Andersen, 1992; Compas et al., 1998; Fawzy et al., 1995; Helegeson and Cohen, 1996; Meyer and Mark, 1995). Interventions for insulin-depen- dent diabetes patients that involved family members meeting together with patients showed an effect on metabolic control (Delamater et al., 1990; Ryden et al., 1994; Satin et al., 1989), but interventions with pa- tients and family members separately did not (McNabb et al., 1994; Tho- mas-Dobersen et al., 1993). Further research is needed to replicate the results of those studies, determine their efficacy, and identify the condi- tions under which specific types of psychosocial interventions are most effective. Maintaining Behavior Change Maintaining induced behavior change over time and across a variety of settings remains a problem, however, for behaviors as diverse as smok- ing (Ockene et al., 2000), physical activity (Marcus et al., 2000), diet and weight loss (Jeffery et al., 2000), and adherence to medication regimens. Although interventions can effectively lead to weight loss or smoking cessation, for example, substantial proportions of those who are successful will regain the lost weight or resume smoking. Most studies, though dem- onstrating the ability to alter behavior, either do not test, or when tested do not demonstrate, sustained behavior change. These factors present major challenges for the research and application of behavioral interven- tions and point to the need for long-term studies. Individual behavior has biological underpinnings and consequences and is influenced by the social and psychological contexts in which it occurs. Therefore, changing behavior is generally not simply a matter of personal choice. Instead, interventions are likely to be most effective when they address the individual and the psychological and social contexts in which the behavior occurs. This suggests the utility of intervening at the

FINDINGS AND RECOMMENDATIONS 335 multiple levels that influence behavior individual (physiological, psycho- logical), family, social networks, organizations, community, and society (state or national population). For example, a person might lose weight as the result of an intervention, but in the months and years after that inter- vention, the effects of family and friends, eating and offering favorite fatty foods, advertisements for high-calorie treats, exposure to situations in which more nutritious food is not readily available, stress at work com- bined with little time to seek out nutritious foods, and confusing labeling or messages emphasizing low-fat but not sugar and caloric content are likely to result in weight gain. Interventions that involve family and com- munity members and others with whom an individual has social relation- ships; community, organizational, and workplace changes; and public policy interventions have all been demonstrated to affect behavior. How- ever, additional research is needed on the functioning and effectiveness of interventions at the levels of family, community, organizations, and public policy, as well as on combinations of them to determine which might be most effective and under what circumstances. Interventions that focus solely on individual attributes, such as self-control or willpower, to change behavior leave many relevant factors to chance and thus are unlikely to be successful over the long term unless other factors (e.g., family and so- cial relationships, work policies, social norms, and individual stress reac- tivity) happen to be aligned in a way that is conducive to the desired change. AN INTERVENTION CASE STUDY: TOBACCO Tobacco use is the leading cause of preventable death in the United States (McGinnis and Foege, 1993), and tobacco control provides a good illustration of the translation of research to application. This example was selected because there is substantial evidence that tobacco use causes ill health (Chapter 3), public health interventions and clinical effectiveness have been evaluated, and cost-effectiveness studies are available. Clinical Interventions In 1994, the Agency for Health Care Policy and Research (AHCPR) launched a comprehensive effort to translate research findings on the most effective smoking-cessation strategies into clinical guidelines for health care providers, administrators, and smoking-cessation specialists. AHCPR

336 HEALTH AND BEHAVIOR convened a panel of researchers to summarize the findings of 300 studies into a series of guidelines for clinical practice (USDHHS, 1996; AHCPR, 1996). Primary, secondary, and tertiary prevention strategies were pro- posed on the basis of meta-analyses of relevant studies: • A combination of psychosocial counseling and nicotine replace- ment therapy appeared to be the most effective strategy. • A dose/response relationship demonstrated that longer counseling sessions (more than 10 minutes) were more effective than were shorter ones (less than 3 minutes) and that more sessions (more than 8) produced better results than did fewer (under 4), but that even fewer or shorter sessions still had a more substantial influence on smoking behavior than did no sessions at all. • All health-care providers could provide effective counseling that resulted in measurable smoking cessation, but cessation specialists were more effective than were generalists, and multiple providers were more effective than were single providers. Since that review, new treatments have become available, including nicotine inhalers and nasal spray and bupropion hydrochloride (Hughes et al., 1999). Moreover, the nicotine patch and gum have been made avail- able over the counter. A review of studies of these treatments led to the recommendation that physicians intervene by discussing smoking and po- tential treatment with every patient who smokes (Hughes et al., 1999). Assessing patients for a combination of behavioral and pharmacothera- peutic approaches also was advised. The trend in smoking-cessation research has been away from brief interventions studied sequentially to multicomponent interventions that integrate several approaches (Schwartz, 1992). Those programs target smoking at the social, physiological, and psychological levels. They have been found to be more effective in promoting sustained smoking cessation than are single-component approaches (Shiffman, 1993). Recent evidence also suggests that smoking-cessation efforts are more successful when they are tailored to the target population. Specifically, an intervention tailored to specific needs, barriers, and smoking patterns of African Americans resulted in a higher cessation rate at 1 year than did a standard interven- tion (Orleans et al., 1998). Opportunities to increase the influence of smoking-cessation strate- gies are becoming available through managed-care programs in which more aggressive efforts can be undertaken to reach target populations. For

FINDINGS AND RECOMMENDATIONS 337 example, interactive telephone contact combined with tailored self-help materials (computer-generated recommendations based on questionnaire response patterns; Velicer et al., 1999) and smoking-cessation programs tailored to be responsive to the weight control concerns of women (Suchanek et al., 1999) were provided to substantial portions of the eli- gible populations and yielded impressive results. Although long-term ab- stinence rates were low (for instance, around 5–10%), participation of 50–85% produced success rates well beyond what would be expected from a typical reactive program. It should be noted that when success rates were matched to readiness stage (Prochaska, 1997), abstinence signifi- cantly improved for those in the preparation stage (to 20–30%) (Velicer et al., 1999), although this stage accounted for only 20% of the sample. Cost-Effectiveness A study by Cromwell et al. (1997) evaluated the cost-effectiveness of 15 smoking-cessation interventions endorsed by AHCPR (1996). The entry in Table 7-4 for smoking cessation comes from that study and shows the result for the guidelines as a whole and for each intervention. The authors presented results in terms of cost per quitter, per life-year saved, and per QALY. They also presented sensitivity analyses that included the time that smokers spent in the programs as a cost. (The committee en- dorses the inclusion of time, a scarce resource, in costs. Recognizing that analysts do not have much experience with this variable, sensitivity analy- ses might be the way to start.) The results of the study by Cromwell et al. (1997) show that smoking- cessation programs are a cost-effective way to improve health. More in- tensive interventions, which involve more counseling or use of nicotine replacement, are more cost-effective (their higher costs are more than offset by greater effectiveness). The total first-year cost of implementing the guidelines was estimated at $6.7 billion (1997 dollars). The return for that investment would be smoking cessation by 1.7 million people at a cost (in 1997 dollars) of about $4,000 per person. In terms of health out- come, the cost would be $2,800 per life-year, or just over $2,000 per QALY. Evaluating Clinical Interventions Chambless and Hollon (1998) have proposed a four-component model for the evaluation of health behavior change strategies: efficacy, effectiveness, generalizability, and cost-effectiveness. In a recent review of

338 HEALTH AND BEHAVIOR smoking-cessation interventions using the Chambless and Hollon model, Compas et al. (1998) identified the most efficacious and effective smok- ing-cessation programs as multicomponent (typically, cognitive/behav- ioral therapy combined with nicotine patch or gum or such other pharma- cologic agents as buproprion [Hurt et al., 1997], nicotine inhalers, social support, and environmental restructuring) and group-based, consisting of 8–12 sessions (Hall et al., 1994; Hill et al., 1993; Stevens and Hollis, 1989), achieving 1-year abstinence rates of 32–34%. Maintenance ses- sions that included relapse prevention skill training were particularly ef- fective, raising 1-year abstinence rates to 41%. Other studies (e.g., Cinciripini et al., 1995, 1994) have achieved similar 1-year abstinence rates (44%) with the addition of scheduled smoking-reduction strategies. These rates compare favorably with those of earlier studies (e.g., Hunt et al., 1971) in which 20–25% abstinence after 1 year was the norm. Community-Based Interventions Chapters 5 and 6 review a number of community, workplace, and school-based interventions targeting the reduction of tobacco use. In the workplace, several programs were successful in reducing smoking among employees through implementation of restrictive tobacco control poli- cies. School-based programs tried to provide educational messages about the health risks of tobacco use and to develop social skills that would allow youths to resist the pressures to smoke. These programs met with varied success, and changes were difficult to sustain. The study of Altman et al. (1999) illustrates a broad-based commu- nity participation approach to reducing tobacco availability and use among adolescents and youths. In that study, four rural communities in Monterey, California, were randomly assigned to treatment or comparison groups. Middle school and high school students in the communities com- pleted questionnaires that evaluated their knowledge, attitudes, and be- haviors concerning tobacco use. In the intervention communities, a series of actions were implemented over a 3-year period: widespread community education, training of merchants who sold tobacco, and voluntary policy change. Within the treatment communities, the proportion of stores that sold tobacco to minors dropped from 75% at the baseline assessment to zero at the final evaluation period. There also were reductions in tobacco sales in the comparison communities, but they were much less dramatic (from 64% down to 39%). Although tobacco availability was reduced in

FINDINGS AND RECOMMENDATIONS 339 the intervention communities, young people still reported that they were able to obtain tobacco from other sources. The strongest effect of the intervention was for younger students (seventh graders). The interven- tion had only small effects for ninth and eleventh graders. A recent school-based smoking prevention program (Peterson et al., 2000) calls into question the effectiveness of the social-influences ap- proach to smoking prevention. The Hutchinson Smoking Prevention Project (HSPP), conducted 1984–1999, randomly assigned 40 school dis- tricts to experimental or control groups. Students were followed from grade 3 until 2 years after high school. An enhanced social-influence approach to the intervention was used, containing the 15 “essential elements” for school-based tobacco prevention developed by an NCI Advisory Panel (explained in Flay, 1985; Glynn, 1989). Included in the interventions were the following activities. Every year, from grade 3 to grade 10, the students received multiple lessons from trained teachers regarding the strategies for identifying and resisting the influences to smoke, motivating the students not to smoke, and promoting self-confidence in the ability to refuse to smoke. This was supplemented by a biannual newsletter and the availability of materials to help stop smoking. No significant differences between the control and experimental groups were evident at grade 12 or 2 years after high school, suggesting that the intervention had little, if any, impact. The highly controlled, and well-designed nature of the study, including the high follow-up rates, high compliance with the interven- tion, the maintenance of the randomization by the school districts, well- matched control and treatment groups, and appropriate statistical analy- sis, strongly suggest that the failure to achieve change was a result of a failed intervention and not poor methodology. This conclusion implies that future interventions need to take a different approach, critically re- thinking the interactions of biological, behavioral, and psychosocial risk factors at social and cultural contexts. Government Level Anti-Tobacco Interventions The government has adopted multiple strategies to reduce smoking, particularly among children and adolescents. Those interventions are di- rected toward individual-level behavioral changes using education (e.g., anti-tobacco campaigns), deterrence (e.g., bans on retail sales to minors), and disincentives (e.g., tobacco taxes). They also are directed toward manufacturers (various litigation strategies), information sources (e.g.,

340 HEALTH AND BEHAVIOR advertising restrictions), and physical environments (e.g., bans on smok- ing in the workplace and other public areas). There has been no system- atic evaluation of all of the interventions, but researchers have sought to analyze several of the government’s anti-tobacco strategies. Media Campaigns It has been half a century since the publication of the first evidence that smoking causes lung cancer (Doll and Hill, 1950). Since 1950, knowl- edge of the health effects of tobacco use has continued to grow systemati- cally. The increasing number of magazine articles on the risks of cancer parallels the increasing knowledge that tobacco use is harmful (Albright et al., 1988) and suggests a positive association between mass-media cov- erage and public attitudes concerning smoking (Pierce and Gilpin, 1995; Figure 8.1). Although the increase in public knowledge parallels the inci- dence of smoking cessation in adults (35–50 years old), even in 1990, the cessation rate in the general population was only around 4%. The data on younger adults (20–34 years old) follow a similar but weaker pattern, with 100 12 90 Smoking causes lung cancer 80 10 70 Articles in Major Magazines Smoking is hazardous % of Population 60 80 to nonsmokers’ health 50 60 40 Magazine Articles 40 30 20 20 10 0 0 1950 1955 1960 1965 1970 1975 1980 1985 1990 Year FIGURE 8-1 Dissemination of Health Consequences of Smoking and Population Level of Knowledge, U.S. 1950-1990. SOURCE: Reducing the Health Consequences of Smok- ing. A Report of the Surgeon General, 1989.

FINDINGS AND RECOMMENDATIONS 341 a cessation-rate of about 5% in 1990 (Evans et al., 1995; Gilpin and Pierce, 1997). The use of the mass-media for anti-smoking campaigns was developed to counter the influence of tobacco industry advertisements promoting smoking. The impact of the media on smoking behavior was most dra- matic during the time of the Fairness Doctrine mass-media campaign. In 1967, television networks were required to give equal time to anti-to- bacco messages (Pierce and Gilpin, 1995), and per capita cigarette con- sumption decreased for the first time. In 1972, the tobacco industry vol- untarily accepted restrictions on broadcast advertising. Clearly, the use of mass-media can be effective for antitobacco communication. A major issue of research, policy, and legal debate has been the extent to which tobacco industry communication strategies (cigarette advertis- ing and promotion) encourage teenagers to start smoking (Albright et al., 1988; Gilpin et al., 1997). The tobacco industry’s annual budget for ad- vertising and promotional expenditures is upwards of $5 billion. However, a shift is apparent from advertising toward promotional expenditures. In 1995, the tobacco industry reduced its advertising budget and put money into increased incentives to merchants, coupons, and specialty items with visible cigarette brand names or symbols (Emery et al., 1999). Changes in smoking initiation among adolescents can be shown to track with promo- tional strategies (Pierce et al., 1998a). Joe Camel was introduced in 1985, when smoking initiation by adolescents was at an all-time low (10%), and initiation rates began to rise. With the addition of promotional items like Camel Cash and the Marlboro Miles campaign, and decreases in price, adolescent initiation reached a high of 14% (Evans et al., 1995). Initia- tion of daily use among minors follows a similar trend. Pierce et al. (1998a) showed that having a favorite brand and being willing to use a promo- tional item substantially increased the odds that people would move along the smoking-uptake continuum from nonsusceptible never-smoker in 1993 to susceptible or higher in 1996. Effective antitobacco campaigns have been conducted in Sydney and Melbourne, Australia, and in California (Pierce, 1999). A statewide me- dia-led tobacco control program initiated in Sydney and extended to Melbourne led to a drop in smoking prevalence in both places. The ex- pected delay in effect was observed: Melbourne showed changes after Sydney at the point when the campaign started. The effect was much stronger in males than in females. In California, per capita consumption trends were tracked before, during, and after an antismoking campaign,

342 HEALTH AND BEHAVIOR and smoking behavior was compared with that in the rest of the United States. California showed decreases in per capita consumption and lower consumption overall than the rest of the country. The United States, how- ever, showed a decrease of similar magnitude to that observed in Califor- nia; no interaction was apparent (Pierce et al., 1998b,c) (Figure 8.2). It is unclear what influence the program had. Similar relationships were ob- served in measures of smoking prevalence. 40 Pre-Program Early Later Program Program 35 30 Percent (%) 25 California 20 Fitted Line US-California Fitted Line 15 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 Year FIGURE 8-2 Smoking Prevalence Among Adults Aged 18 and Older, California vs. U.S. SOURCE: NHIS 1978-80, 1983, 1985, 1987-88, 1990-91, 1993-94; CTS 1990, 1992, 1993, 1996; BRFS.CATS 1991-1995; CPS 1992-93, 1995-96.

FINDINGS AND RECOMMENDATIONS 343 Tobacco Taxes Cigarette excise taxes are an attractive public policy tool for two rea- sons. First, they generate substantial revenue, whether for a local munici- pality, a state, or the federal government. Second, there is substantial evi- dence that, by raising the price of a pack of cigarettes, an excise tax increase will reduce cigarette consumption—some smokers will stop and some will cut down (Chaloupka and Grossman, 1996; Hu et al., 1995; Keeler et al., 1993; Lewit et al., 1981; Manning et al., 1991). These be- havioral changes eventually might be reflected in improved population health status (Warner, 1986). But the long-term effectiveness of this in- tervention has yet to be demonstrated. Elasticity is the term economists use to measure responsiveness to price changes. It is a unitless measure calculated as the percentage change in overall demand that results from a 1% change in the price of an item. For example, an elasticity estimate of minus 0.40 means that consumption will decrease by 4% in response to a 10% price increase. If fewer people smoke, health benefits are likely. The health benefits, which can be ex- pressed in terms of improved life expectancy and quality of life, are sum- marized in QALYs. Simulation studies estimate that for a $0.50 tax and an elasticity of minus 0.40, about 25,000 QALYs would result each year. Higher taxes would produce even greater health benefits. The simulations also suggest that the tax has a greater influence each year it is in effect, until a plateau at about 70 years in the future. The reason for the delayed benefit is that youth might be more price sensitive than are older habitual smokers. Thus, the tax could have a greater effect in later years by pre- venting youths from entering the smoking pool and by inducing current smokers to quit. The analysis suggests that a tobacco excise tax could be among the few policy options that will enhance population health status while raising revenues (Kaplan et al., 2001). Evaluation Studies The most encompassing studies have evaluated broad, multidimen- sional anti-tobacco campaigns initiated in several states. The initiatives differ from one state to another, but they all involve taxation of cigarettes and the use of those revenues for a multipronged approach to reducing smoking. In California, for example, the state mandated funding for health education campaigns, and local health agencies were required to provide technical support and monitor adherence to antismoking laws, commu-

344 HEALTH AND BEHAVIOR nity-based interventions, and enhancement of school-based prevention programs (Bal et al., 1990). Evaluation studies in Massachusetts (Abt, 1997), California (Pierce et al., 1998b), and Oregon (Centers for Disease Control and Prevention, 1999) all reported per capita reductions in ciga- rette consumption. Despite the promising results shown in the studies, they do have em- pirical and methodologic limitations. The California study reported a sharp decline in smoking directly after the intervention, but the effect dissipated over time and, ultimately, failed to significantly affect tobacco use (Pierce et al., 1998b). There are several possible explanations. One is that the political and social environment had as much effect as the inter- ventions themselves. Changes in the law, which often are associated with political debate and media coverage, have a “declarative effect” that influ- ences behavior indirectly by changing attitudes. Legal norms reinforce, stimulate, accelerate, or symbolize changes in public attitudes about so- cially desirable behaviors (Bonnie, 1986). Other possible explanations are temporary reductions in state funding for anti-tobacco programs, political interference with anti-tobacco messages, and industry advertising and pricing policies. The studies also face challenges in methodology. Most important, pub- lic or private funding for evaluation research, including population sur- veys of smoking behavior, becomes available only after the intervention has occurred. After-the-fact research funding thwarts a comparison of spe- cific behaviors before and after intervention. Even if this important prob- lem could be overcome, however, it would be hard to identify precisely which intervention is having the desired effect. The Massachusetts, Cali- fornia, and Oregon studies, by definition, examined multiple interven- tions but had no ability to separate the effects of each. There are, of course, numerous studies of discrete tobacco regulation strategies. Two major interventions that have been studied are programs to prevent youth access to cigarettes and bans on smoking in the work- place and other public places. In the absence of enforcement, banning cigarette sales to minors does not significantly reduce teenage tobacco use. Compliance with the law by retailers is low; youth access studies have demonstrated that most retailers do sell to children. The Tobacco Institute’s own “It’s the Law” campaign, perhaps predictably, has not been effective (DiFranza and Brown, 1992). Education efforts aimed at retailers have shown an effect, but a small one (Wildey et al., 1995). The most successful legal strategy to reduce youth access imposes civil penalties

FINDINGS AND RECOMMENDATIONS 345 against store owners (not just clerks), incorporates progressively higher fines culminating in suspension or revocation of the tobacco retailer’s li- cense, and forces regular enforcement by using minors in unannounced purchase attempts to monitor compliance. This strategy, implemented by legislation in Woodbridge, Illinois, is successful over time (Jason et al., 1999). Locking devices on cigarette vending machines do not appear to be as effective as outright bans on these machines (Forster et al., 1992). Legal restrictions on smoking in the workplace and in other public places have demonstrated high conformance with the rule and some re- duction in cigarette use. A study of compliance with an indoor clean air act in Brookline, Massachusetts, showed that the law was popular and the incidence of restricted smoking was high (Rigotti et al., 1992). A sum- mary of 19 studies that evaluated the effects of smoke-free workplaces on smoking habits showed that both smoking rates (cigarettes smoked during a 24 hour period) and smoking prevalence (proportion of workers who smoke) decreased as a result of the indoor smoking bans. The authors estimate an annual reduction of 9.7 billion cigarettes (2%) in the United States as a result of smoke-free workplaces (Chapman et al., 1999). What is notably absent from the evaluative research are rigorous stud- ies of the effects of tobacco litigation and other forms of litigation. Al- though tort strategies are much used and publicized—by private parties, classes, and state and federal government—there is considerable debate about the effects. Public health advocates strongly favor the approach, whereas some law and economic scholars are skeptical about the tort sys- tem as a useful and cost-effective means of intervention (Rose-Ackerman, 1991; Vicusi, 1992). The experience with government strategies to reduce cigarette-smok- ing shows that both the interventions and the behavior are highly com- plex. Many interventions have not been carefully evaluated, and methodologic difficulties have thwarted some of the studies that have been undertaken. A comprehensive, multipronged approach to smoking reduc- tion appears to work best, but long-term problems still exist. What Works? Many approaches have been used to decrease the prevalence of to- bacco use. Despite the multitude of interventions, it is still not possible to conclude what works and what does not. Some general conclusions can be drawn.

346 HEALTH AND BEHAVIOR At the individual level, findings suggest that counseling and pharma- cological therapies are effective (AHCPR, 1996; Tobacco Use and De- pendence Clinical Practice Guideline Panel, 2000). The U.S. Public Health Service issued a Clinical Practice Guideline (Tobacco Use and Dependence Clinical Practice Guideline Panel, 2000) based upon the rec- ommendations of an expert panel. They reviewed nearly 6,000 peer-re- viewed articles and recommended that all tobacco users should be offered treatment since effective treatments exist: institutionalizing consistent identification, documentation, and treatment of all tobacco users; brief treatment is effective; greater intensity of counseling is more effective; three types of counseling and five pharmacotherapies were found to be effective. This approach was evaluated for tobacco cessation, but in modi- fied form might also be effective for prevention. Many community-based interventions have shown variable success. Many of them have been directed toward youth in the belief that they would have the greatest impact for the future. One exemplary study of school-based smoking prevention, the Hutchinson Smoking Prevention Project (HSPP) (Peterson et al., 2000) sponsored by the National Cancer Institute, is described above. This 15-year study, in 40 school districts of Washington state that were randomly assigned to intervention or control groups, involved 8,388 third graders who were followed to 2 years after high school with 94% follow-up. The authors concluded “there is no evi- dence from this trial that a school-based social-influences approach is ef- fective in the long-term deterrence of smoking among youth.” Similarly, an assessment of policy interventions in a school setting was found to have limited impact. Based on the observation that organiza- tional smoking policy may be a potentially effective way to influence smoking behavior in worksites (Borland et al., 1990), Bowen et al. (1995) surveyed 239 schools as to their smoking policies. They identified three types of policies: a ban on smoking on school grounds; smoking allowed on school grounds; and smoking allowed in designated areas in the build- ing. Their conclusion was: “current smoking policies may have limited ability to reduce student smoking.” A scholarly review of government level approaches to tobacco use prevention and cessation by the Advocacy Institute (2000) found that although single approaches via clean air laws, price increases, counter- advertising, enforcement of existing laws restricting youth access and oth- ers may be effective with some people. However, a combination of these approaches has the greatest possibility of success.

FINDINGS AND RECOMMENDATIONS 347 In summary, there is limited evidence that any single step is effective in reducing tobacco use. Although a number of studies have been pub- lished, many if not most suffer from design flaws that fail adequately to consider co-factors existing in the community. The conclusion of the com- mittee is that a multi-pronged approach including (but not limited to) education, physician intervention, price increases, restricted access to to- bacco, clean air laws, and counter-advertising must be used. In current tobacco users, counseling and pharmacotherapies have the greatest po- tential. APPLICATION OF RESEARCH RESULTS Much research is needed to complete the picture of how individual genetic endowments and physiological processes interact with individual personalities, development, other psychological characteristics and pro- cesses, and social status and relationships to affect health status. Simply put, how does the environment “get under the skin” (Taylor et al., 1997), and what can be done to optimize health (Ryff and Singer, 1998)? Such research will require the collaboration and cooperation of multiple disci- plines. New research methods are likely to be required as multiple influ- ences are considered simultaneously and as causes and effects are consid- ered dynamically and systemically, rather than linearly. To develop programs that are effective in modifying health behaviors, expanded efforts in all five phases (NHLBI, 1983) of intervention research are needed. These five phases include hypothesis generation, develop- ment of intervention methods, controlled intervention trials, studies in defined populations, and demonstration research (Chapter 7). Systematic clinical trials are needed to evaluate the value of behavioral and psycho- social interventions; in particular, more studies are needed that document the effects of these interventions on health, quality of life, and longevity. Studies suggest that interventions at multiple levels are more effective than interventions at single levels, but well-designed evaluations are nec- essary. Innovative methods and naturalistic experiments also will be nec- essary to evaluate community, organizational, and public policy interven- tions, and particularly multilevel interventions. Those methods will be critically important if knowledge from behavioral and psychosocial re- search is to be translated into applications in more natural settings.

348 HEALTH AND BEHAVIOR FINDINGS AND RECOMMENDATIONS Finding 1: Health and disease are determined by dynamic interactions among biological, psychological, behavioral, and social factors. These in- teractions occur over time and throughout development. Cooperation and interaction of multiple disciplines are necessary for understanding and influencing health and behavior. Recommendation 1: Funding agencies should direct resources toward interdisciplinary efforts for research and intervention studies that inte- grate biological, psychological, behavioral, and social variables. The investigations that will be most productive will reflect an understanding of the complexity and interconnections of disciplines. Collaborations across disciplines need to be encouraged and expanded. Finding 2: A fundamental finding of the report is the importance of the interaction of psychosocial and biological processes in health and disease. Psychosocial factors influence health directly through biological mecha- nisms and indirectly through an array of behaviors. Social and psychologi- cal factors include socioeconomic status, social inequalities, social net- works and support, work conditions, depression, anger, and hostility. Recommendation 2: Research efforts to elucidate the mechanisms by which social and psychological factors influence health should be en- couraged. Intervention studies are needed to evaluate the effectiveness of modifying these factors to improve health and prevent disease. Such intervention studies should span the breadth of all phases of clinical trials, from feasibility studies to randomized double-blind studies. Com- munity-based participatory research should also be conducted. Research should include all levels of intervention, from individual to family, com- munity, and society. Finding 3: Behavior can be changed: behavioral interventions can suc- cessfully teach new behaviors and attenuate risky behaviors. Maintaining behavior change over time, however, is a greater challenge. Short-term changes in behavior are encouraging, but improved health outcomes will often require prolonged interventions and lengthy follow-up protocols. Recommendation 3: Funding for health-related behavioral and psycho- social interventions should support realistically long-duration efforts. Finding 4: Individual behavior, family interactions, community and work- place relationships and resources, and public policy all contribute to health

FINDINGS AND RECOMMENDATIONS 349 and influence behavior change. Existing research suggests that interven- tions at multiple levels (individual, family, community, society) are most likely to sustain behavioral change. Recommendation 4: Concurrent interventions at multiple levels (indi- vidual, family, community, and society) should be encouraged to pro- mote healthy behaviors. Assessments of coordinated efforts across lev- els are needed. Such efforts should address the psychosocial factors associated with health status (e.g., access to healthy foods or safe places to exercise) as well as individual behavior. Finding 5: Initiating and maintaining a behavior change is difficult. Evi- dence indicates that it is easier to generalize a newly learned behavior than to change existing behavior. The old adage “an ounce of prevention is worth a pound of cure” is valid in the context of behavior and health as well. Recommendation 5: Resources should be allocated to the promotion of health-enhancing behavior and primary prevention of disease. This should be a priority for public health and health care systems. Finding 6: The goals of public health and health care are to increase life expectancy and improve health-related quality of life. Many behavioral intervention trials document the capacity of interventions to modify risk factors, but relatively few measured mortality and morbidity. However, ramifications of interventions are not always apparent until they are fully evaluated, and unexpected consequences can result. Recommendation 6: Intervention research must include appropriate measures (including biological measures) to determine whether the strategy has the desired health effects. Finding 7: Changing unhealthy behavior is not simply a matter of “will- power.” Individual behavior has biological underpinnings and conse- quences and is influenced by the social and psychological contexts in which it occurs. While biological interventions and exhortations to indi- viduals to change their behaviors are easier to administer, changes in so- cial factors, policies, and norms are necessary for improvement and main- tenance of population health. Much can be learned as states change cigarette taxes, create controls on public advertising for various products, and increase or decrease opportunities for exercise during the school day or as communities implement or eliminate walking and bicycle paths.

350 HEALTH AND BEHAVIOR Such social and policy decisions are rich opportunities for learning about behavior change and health. Recommendation 7: Program planners and policy makers need to con- sider modifying social and societal conditions to enable healthy behav- ior and social relationships. Interventions must be evaluated to enable continuous improvement of programs and policies. Research in these domains should be rigorous and scientific, but method should not domi- nate substance. Longitudinal research designs, natural experiments, quasi- experimental methods, community-based participatory research, and de- velopment of new research methods are necessary to advance knowledge in these areas. REFERENCES Abt (1997). Independent Evaluation of the Massachusetts Tobacco Control Program. Cambridge, MA: Abt Associates. Adler, N., Boyce, T., Chesney, M., Cohen, S., Folkman, S., Kahn, R., and Syme, L. (1994). Socioeconomic status and health: The challenge of the gradient. American Psychologist, 49, 15–24. Advocacy Institute (2000) Making The Case: State Tobacco Control Policy Briefing Papers, 1707 L St., NW, Suite 400, Washington, DC 20036. AHCPR (Agency for Health Care Policy and Research) (1996). Smoking Cessation Clinical Practice Guideline. Journal of the American Medical Association, 275 (16), 1270–1280 Albright, C.L., Altman, D.F., Slater, M.D., and Maccoby, N. (1988). Cigarette advertisements in magazines: Evidence for a differential focus on women’s and youth magazines. Health Education Quarterly, 15, 225–233. Altman, D.G., Wheelis, A.Y., McFarlane, M., Lee, H., and Fortmann, S.P. (1999). The relationship between tobacco access and use among adolescents: A four community study. Social Science and Medicine, 48, 759–775. Andersen, B.L. (1992). Psychosocial interventions for cancer patients to enhance quality of life. Journal of Consulting and Clinical Psychology, 60, 552–568. Anderson, B.J. (1996). Involving family members in diabetes treatment. In B.J. Anderson and R.R. Rubin (Eds.) Practical Psychology for Diabetes Clinicians (pp. 43–50). Alexandria, VA: American Diabetes Association. Anderson, R.M., Funnell, M.M., Butler, P.M., Arnold, M.S., Fitzgerald, J.T., and Feste, C.C. (1995). Patient empowerment. Results of a randomized controlled trial. Diabetes Care, 18, 943–949. Bal, D.G., Kizer, K.W., Felten, P.G., Mozar, H.N., and Niemeyer, D. (1990). Reducing tobacco consumption in California. Development of a statewide anti-tobacco use campaign. Journal of the American Medical Association, 264, 1570–1574. Berkman, L. and Kawachi, I. (Eds.) (2000). Social Epidemiology. New York: Oxford University Press.

FINDINGS AND RECOMMENDATIONS 351 Bonnie, R. (1986). The efficacy of law as a paternalistic instrument. In G. Melton (Ed.) Nebraska Symposium on Human Motivation, 1985: The Law as a Behavioral Instrument (pp. 131–211). Lincoln, NE: University of Nebraska Press. Borland, R., Chapman, S., Owen N., and Hall D. (1990). Effects of worksite smoking bans on cigarette consumption, American Journal of Public Health, 80, 178–180. Bowan, D.J., Kinne, S., and Orlandi, M. (1995). School policy in COMMIT: A promising strategy to reduce smoking by youth. Journal of School Health, 65, 140–144. Centers for Disease Control and Prevention. (1999). Decline in cigarette consumption following implementation of a comprehensive tobacco prevention and education program—Oregon, 1996–1998. Morbidity and Mortality Weekly Report, 48, 140–143. Chaloupka, F.J. and Grossman, M. (1996). Price, tobacco control policies, and youth smoking. Working Paper No. 5740. Cambridge, MA: National Bureau of Economic Research. Chambless, D.L. and Hollon, S.D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66, 7–18. Chapman, S., Borland, R., Scollo, M., Brownson, R.C., Dominello, A., and Woodward, S. (1999). The impact of smoke-free workplaces on declining cigarette consumption in Australia and the United States. American Journal of Public Health, 89, 1018–1023. Cinciripini, P.M., Lapitsky, L., Seay, S., Wallfisch, A., Kitchens, K., and Van Vunakis, H. (1995). The effects of smoking schedules on cessation outcome: Can we improve on common methods of gradual and abrupt nicotine withdrawal? Journal of Consulting and Clinical Psychology, 63, 388–399. Cinciripini, P.M., Lapitsky, L.G., Wallfisch, A., Mace, R., Nezami, E., and Van Vunakis, H. (1994). An evaluation of a multicomponent treatment program involving scheduled smoking and relapse prevention procedures: Initial findings. Addictive Behaviors, 19, 13–22. Cohen, S. and Herbert, T.B. (1996). Health psychology: Psychological factors and physical disease from the perspective of human psychoneuroimmunology. Annual Review of Psychology, 47, 113–142. Cohen, S., Tyrrell, D.A., and Smith, A.P. (1991). Psychological stress and susceptibility to the common cold. New England Journal of Medicine, 325, 606–612. Compas, B.E., Haaga, D.F., Keefe, F.J., Leitenberg, H., and Williams, D.A. (1998). Sampling of empirically supported psychological treatments from health psychology: Smoking, chronic pain, cancer, and bulimia nervosa. Journal of Consulting and Clinical Psychology, 66, 89–112. Cromwell, J., Bartosch, W.J., Fiore, M.C., Hasselblad, V., and Baker, T. (1997). Cost- effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. Journal of the American Medical Association, 278, 1759–1766. Davey Smith, G., Neaton, J.D., Wentworth, D., Stamler, R., and Stamler, J. (1996). Socioeconomic differentials in mortality risk among men screened for the Multiple Risk Factor Intervention Trial. II. Black men. American Journal of Public Health, 86, 497–504. Delamater, A.M., Bubb, J., Davis, S.G., Smith, J.A., Schmidt, L., White, N.H., and Santiago, J.V. (1990). Randomized prospective study of self-management training with newly diagnosed diabetic children. Diabetes Care, 13, 492–498.

352 HEALTH AND BEHAVIOR DiFranza, J.R. and Brown, L.J. (1992). The Tobacco Institute’s “It’s the Law” campaign: Has it halted illegal sales of tobacco to children? American Journal of Public Health, 82, 1271–1273. Doll, R. and Hill, A.B. (1950). Smoking and carcinoma of the lung. Preliminary report. British Medical Journal, 2, 739–748. Emery, S., Gilpin, E.A., White, M.M., and Pierce, J.P. (1999). How adolescents get their cigarettes: Implications for policies on access and price. Journal of the National Cancer Institute, 91, 184–186. Evans, N., Farkas, A., Gilpin, E., Berry, C., and Pierce, J.P. (1995). Influence of tobacco marketing and exposure to smokers on adolescent susceptibility to smoking. Journal of the National Cancer Institute, 87, 1538–1545. Fawzy, F.I., Fawzy, N.W., Arndt, L.A., and Pasnau, R.O. (1995). Critical review of psychosocial interventions in cancer care. Archives of General Psychiatry, 52, 100–13. Flay, B.R. (1985). Psychosocial approaches to smoking prevention: A review of findings, Health Psychology, 4, 449–488. Forster, J.L., Hourigan, M.E., and Kelder, S. (1992). Locking devices on cigarette vending machines: Evaluation of a city ordinance. American Journal of Public Health, 82, 1217– 1219. Gilpin, E.A. and Pierce, J.P. (1997). Trends in adolescent smoking initiation in the United States: Is tobacco marketing an influence? Tobacco Control, 6, 122–127. Gilpin, E.A., Pierce, J.P., and Rosbrook, B. (1997). Are adolescents receptive to current sales promotion practices of the tobacco industry? Preventive Medicine, 26, 14–21. Glynn, T.J. (1989). essential elements of school-based smoking prevention programs, Journal of School Health, 59, 181–188, Hall, S.M., Munoz, R.F., and Reus, V.I. (1994). Cognitive-behavioral intervention increases abstinence rates for depressive-history smokers. Journal of Consulting and Clinical Psychology, 62, 141–146. Helegeson, V.S. and Cohen, S. (1996). Social support and adjustment to cancer: Reconciling descriptive, correlational, and intervention research. Health Psychology, 15, 75–83. Hermann, G., Beck, F.M., and Sheridan, J.F. (1995). Stress-induced glucocorticoid response modulates mononuclear cell trafficking during an experimental influenza viral infection. Journal of Neuroimmunology, 56, 179–186. Hill, R.D., Rigdon, M., and Johnson, S. (1993). Behavioral smoking cessation treatment for older chronic smokers. Behavior Therapy, 24, 321–329. Hu, T.W., Sung, H.Y., and Keeler, T.E. (1995). Reducing cigarette consumption in California: Tobacco taxes vs. an anti-smoking media campaign. American Journal of Public Health, 85, 1218–1222. Hughes, J.R., Goldstein, M.G., Hurt, R.D., and Shiffman, S. (1999). Recent advances in the pharmacotherapy of smoking. Journal of the American Medical Association, 281, 72–76. Hunt, W.A., Barnett, L.W., and Branch, L.G. (1971). Relapse rates in addiction programs. Journal of Clinical Psychology, 27, 455–456. Hurt, R.D., Sachs, D.P.L., Glover, E.D., Offord, K.P., Johnston, J.A., Dale, L.C., Khayrallah, M.A., Schroeder, D.R., Glover, P.N., Sullivan, C. R., Crogan, I.T., and Sullivan P.M. (1997). A comparison of sustained-released buproprion and placebo for smoking cessation. New England Journal of Medicine, 337, 1195–1202.

FINDINGS AND RECOMMENDATIONS 353 IOM (Institute of Medicine) (1982) Health and Behavior: Frontiers of Research in the Biobehavioral Sciences. D.A. Hamburg, G.R. Elliott, and D.L. Parron (Eds.). Washington: National Academy Press. Jason, L.A., Berk, M., Schnopp-Wyatt, D.L., and Talbot B. (1999). Effects of enforcement of youth access laws on smoking prevalence. American Journal of Community Psychology, 21, 143–160. Jeffery, R.W., Drewnowski, A., Epstein, L.H., Stunkard, A.J., Wilson, T., and Hill, R. (2000). Long-term maintenance of weight loss: Current status. Health Psychology, 19, 5–16. Kaplan, G.A. and Keil, J.E. (1993). Socioeconomic factors and cardiovascular disease: A review of the literature. Circulation, 88, 1973–1998. Kaplan, R.M., Ake, C.F., Emery, S.L., and Navarro A.M. (2001). Simulated effect of tobacco tax variation on population health in California. American Journal of Public Health, 91, 239–244 Keefe, F.J. and Caldwell, D.S. (1997). Cognitive behavioral control of arthritis pain. Medical Clinics of North America, 81, 277–290. Keeler, T.E., Hu, T.W., Barnett, P.G., and Manning, W.G. (1993). Taxation, regulation, and addiction: A demand function for cigarettes based on time-series estimates. Journal of Health Economics, 12, 1–18. Kiecolt-Glaser, J.K., Glaser, R., Gravenstein, S., Malarkey, W.B., and Sheridan, J.F. (1996). Chronic stress alters the immune response to influenza virus vaccine in older adults. Proceedings of the National Academy of Sciences, 93, 3043–3047. Klein, K.B. and Spiegel, D. (1989). Modulation of gastric acid secretion by hypnosis. Gastroenterology, 96, 1383–1387. Lalonde, M.A. (1974). New Perspectives on the Health of Canadians. A Working Document. Ottawa: Information Canada. Lewit, E.M., Coate, D., and Grossman, M. (1981). The Effects of Government Regulations on Teenage Smoking. Journal of Law and Economics, 24, 545–569. Linden, W., Stossel, C., and Maurice, J. (1996). Psychosocial interventions for patients with coronary artery disease: a meta-analysis. Archives of Internal Medicine, 156, 745– 752. Lorig, K. and Holman, H. (1993). Arthritis self-management studies; A twelve year review. Health Education Quarterly, 20, 17–28. Mackenbach, J.P., Stronks, K., and Kunst, A.E. (1989). The contribution of medical care to inequalities in health: Differences between socio-economic groups in decline of mortality from conditions amenable to medical intervention. Social Science and Medicine, 29, 369–376. Manning, W.G., Keeler, E.B., Newhouse, J.P., Sloss, E.M., and Wasserman, J. (1991). The Costs of Poor Health Habits. Cambridge, MA: Harvard University Press. Marcus, B.H., Blair, S.N., Dubbert, P.M., Dunn, A.L., Forsyth, L.H., McKenzie, T.L., and Stone, E.J. (2000). Physical activity behavior change: Issues in adoption and maintenance. Health Psychology, 19, 32–41. Matthews, K., Kelsey, S., Meilahn, E., Kuller, L.H., and Wing, R.R. (1989). Educational attainment and behavioral and biologic risk factors for coronary heart disease in middle-aged women. American Journal of Epidemiology, 129, 1132–1144. McEwen, B. (1998). Protective and damaging effects of stress mediators. New England Journal of Medicine, 338, 171–179.

354 HEALTH AND BEHAVIOR McEwen, B.S. and Stellar, E. (1993), Stress and the individual: Mechanisms leading to disease. Archives of Internal Medicine, 153, 2093–2101. McGinnis, J.M. and Foege, W.H. (1993). Actual causes of death in the United States. Journal of the American Medical Association, 270, 2207–2212. McNabb, W.L., Quinn, M.T., Murphy, D.M., Thorp, F.K., and Cook, S. (1994). Increasing children’s responsibility for diabetes self-care: The In Control study. Diabetes Educator, 20, 121–124. Meyer, T.J. and Mark, M. (1995). Effects of psychosocial interventions with adult cancer patients: A meta-analysis of randomized experiments. Health Psychology, 14, 101– 108. NHLBI (National Heart, Lung, and Blood Institute). (1983). Guidelines for Demonstration And Education Research Grants. Washington, DC: National Institutes of Health. NIH Technology Assessment Panel. (1996). Integration of behavioral and relaxation approaches into the treatment of chronic pain in insomnia. Journal of the American Medical Association, 276, 313–318. Ockene, J.K., Emmons, K., Mermelstein, R., Perkins, K.A., Bonollo, D., Hollis, J.F., and Vorhees, C. (2000). Relapse and maintenance issues for smoking cessation. Health Psychology, 19, 17–31. Orleans, C.T., Boyd, N.R., Bingler, R., Sutton, C., Fairclough, D., Heller, D., McClatchey, M., Ward, J.A., Graves, C., Fleisher, L., and Baum, S. (1998). A self-help intervention for African American smokers: Tailoring cancer information service counseling for a special population. Preventive Medicine, 27 (5 Pt 2), S61–S70. Parker, J.C. (1995). Effects of stress management on clinical outcomes in rheumatoid arthritis. Arthritis and Rheumatism, 38, 1807–1818. Peterson, A.V. Jr., Kealey, K.A., Mann, S.L., Marek, P.M., and Sarason, I.G. (2000). Hutchinson smoking prevention project: long-term randomized tiral in school-based tobacco use prevention—results on smoking. Journal of the National Cancer Institute, 92, 1979–1991. Pierce, J.P. (1999). The Effectiveness of Various Communication Strategies in Promoting Behavior Change. Presented at the Workshop on Health, Communications and Behavior of the IOM Committee on Health and Behavior: Research, Practice and Policy, Irvine, CA. Pierce, J.P. and Gilpin, E.A. (1995). A historical analysis of tobacco marketing and the uptake of smoking by youth in the United States: 1890–1977. Health Psychology, 14, 500–508. Pierce, J.P., Choi, W.S., Gilpin, E.A., Farkas, A.J., and Berry, C.C. (1998a). Tobacco industry promotion of cigarettes and adolescent smoking. Journal of the American Medical Association, 279, 511–515. Pierce, J.P., Gilpin, E.A., and Farkas, A.J. (1998c). Can strategies used by statewide tobacco control programs help smokers make progress in quitting? Cancer Epidemiology, Biomarkers and Prevention, 7, 459–464. Pierce, J.P., Gilpin, E.A., Emery, S.L., White, M.M., Rosbrook, B., and Berry, C.C. (1998b). Has the California tobacco control program reduced smoking? Journal of the American Medical Association, 280, 893–899.

FINDINGS AND RECOMMENDATIONS 355 Prochaska, J.O. (1997). Revolution in health promotion: Smoking cessation as a case study. In G.A. Marlatt and G.R. Vandenbos (Eds.) Addictive Behaviors: Readings on Etiology, Prevention and Treatment (pp. 361–375). Washington, DC: American Psychological Association Press. Rigotti, N.A., Bourne, D., Rosen, A., Locke, J.A., and Schelling, T.C. (1992). Workplace compliance with a no-smoking law: A randomized community intervention trial. American Journal of Public Health, 82, 229–235. Rose-Ackerman, S. (1991). Tort law in the regulatory state. In P.H. Schuck (Ed.) Tort Law and the Public Interest (pp. 105–126). New York: Norton. Ryden, O., Nevander, L., Johnsson, P., Hansson, K., Kronvall, P., Sjoblad, S., and Westbom, L. (1994). Family therapy in poorly controlled juvenile IDDM: Effects on diabetic control, self-evaluation and behavioral symptoms. Acta Paediatrica, 83, 285–291. Ryff, C.D. and Singer, B. (1998). The contours of positive human health. Psychological Inquiry 9, 1–28. Satin, W., La Greca, A.M., Zigo, M.A., and Skyler, J.S. (1989). Diabetes in adolescence: Effects of multifamily group intervention parent simulation of diabetes. Journal of Pediatric Psychology, 14, 259–275. Schwartz, J.L. (1992). Methods of smoking cessation. Medical Clinics of North America, 76, 451–476. Shiffman, S. (1993). Smoking cessation treatment: Any progress? Journal of Consulting and Clinical Psychology, 61, 718–722. Stevens, V.J., and Hollis, J.F. (1989). Preventing smoking relapse, using individually tailored skills training techniques. Journal of Consulting and Clinical Psychology, 57, 420–424. Suchanek Hudmon, K., Gritz, E.R., Clayton, S., and Nisenbaum, R. (1999). Eating orientation, postcessation weight gain, and continued abstinence among female smokers receiving an unsolicited smoking cessation intervention. Health Psychology. 18, 29–36. Taylor, S.E., Repetti, R.L., Seeman, T. (1997). Health psychology: What is an unhealthy environment and how does it get under the skin? Annual Review of Psychology, 48, 411–447. Thomas-Dobersen, D.A., Butler-Simon, N., and Fleshner, M. (1993). Evaluation of a weight management intervention program in adolescents with insulin-dependent diabetes mellitus. Journal of the American Dietetic Association, 93, 535–540. Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. (2000). A Clinical Practice Guideline For Treating Tobacco Use and Dependence: A US Public Health Service report, Journal of the American Medical Association, 28, 3244–3254. United States Department of Health, Education, and Welfare. (1979). Healthy People. DHEW Publication Number (PHS) 79-55071. Washington, DC: U.S. Government Printing Office. USDHHS (U.S. Department of Health and Human Services) (1996). Clinical Practice Guideline, No 18. Smoking Cessation . Rockville, MD: Agency for Health Care Policy and Research. Centers for Disease Control and Prevention. AHCPR Publication No. 96-0692.

356 HEALTH AND BEHAVIOR Velicer, W.F., Prochaska, J.O., Fava, J.L., Laforge, R.G., and Rossi, J.S. (1999). Interactive versus noninteractive interventions and dose–response relationships for stage- matched smoking cessation programs in a managed care setting. Health Psychology, 18, 21–28. Vicusi, W.K. (1992). Fatal Tradeoffs. New York: Oxford University Press. Warner, K.E. (1986). Smoking and health implications of a change in the federal cigarette excise tax. Journal of the American Medical Association, 255, 1028–1032. Whorwell, P.J., Prior, A., and Colgan, S.M. (1987). Hypnotherapy in severe irritable bowel syndrome: Further experience. Gut, 28, 423–425. Whorwell, P.J., Prior, A., and Farragher, E.B. (1984). Controlled trial of hypnotherapy in the treatment of severe refractory irritable bowel syndrome. Lancet, 2 (8414), 1232– 1234. Wildey, M.B., Woodruff, S.I., Agro, A., Keay, KD, Kenney, E.M., and Conway, T.L. (1995). Sustained effects of educating retailers to reduce cigarette sales to minors. Public Health Rep., 110, 625–629. Wilkinson, R.G. (1996). Unhealthy Societies: The Afflictions of Inequality. London: Routledge.

Next: APPENDIX A Workshop on Health, Communications, and Behavior »
Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences Get This Book
×
Buy Paperback | $54.95 Buy Ebook | $43.99
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

Health and Behavior reviews our improved understanding of the complex interplay among biological, psychological, and social influences and explores findings suggested by recent research—including interventions at multiple levels that we can employ to improve human health.

The book covers three main areas:

  • What do biological, behavioral, and social sciences contribute to our understanding of health—including cardiovascular, immune system and brain functioning, behaviors that influence health, the role of social networks and socioeconomic status, and more.
  • What can we learn from applied research on interventions to improve the health of individuals, families, communities, organizations, and larger populations?
  • How can we expeditiously translate research findings into application?
  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  6. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  7. ×

    View our suggested citation for this chapter.

    « Back Next »
  8. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!