Process Evaluation in the Community Intervention Trial for Smoking Cessation (COMMIT)

The reach and complexity of the multi-site Community Intervention Trial for Smoking Cessation (COMMIT) project call for an extensive, comprehensive evaluation plan. This article reports on the objectives, methods, and data sets of the part of the plan designed for process evaluation. We describe the systems developed for: monitoring progress in the sites, the quality of local intervention activities and data collection, and compliance with the trial-wide protocol; disseminating information for formative purposes; and generating and using process data for outcome evaluation. The process evaluation approach includes both quantitative and qualitative methods. We provide examples from community mobilization and intervention in different communities.

Media Advocacy and Public Education in the Community Intervention Trial to Reduce Heavy Smoking (COMMIT)

The Community Intervention Trial (COMMIT) is designed to reduce the rate of heavy smoking in eleven pairs of North American communities over an eight-year period. The intervention, consisting of a minimum of fifty-one activities, is being implemented through local community boards and task forces. This article describes the goals and activities for the public education task force with a specific focus on “media advocacy,” an innovative use of mass media that follows more closely political activist models than traditional public service models. Two brief case studies are presented to illustrate some applications of media advocacy. The reasons for relatively infrequent use of media advocacy are discussed.

Enhancing Resources for Smoking Cessation through Community Intervention: COMMIT as a Prototype

Of the 17 million smokers in North America who attempt to quit smoking each year, fewer than one in ten succeed [1, 2]. How can communities improve smokers' chances of quitting? The National Cancer Institute addresses this question through COMMIT, the Community Intervention Trial for Smoking Cessation. COMMIT is the largest smoking intervention trial in the world, involving over 2 million people in twenty-two North American communities. The study protocol requires that the implementation of mandated interventions in each community be managed by a Community Board and at least four task forces (Health Care, Worksites and Organizations, Cessation Resources, and Public Education, including Media and Youth). Three required and three optional interventions in the COMMIT protocol relate to the availability of cessation resources and services. The Cessation Resources Task Force, composed of community volunteers, supervises implementation of these interventions at each site. The activities of each task force are integrated with the others in a community action plan. How COMMIT activities enhance the utilization of cessation resources and services and how these services fit into a community intervention is the subject of this article. Descriptions of the study design and evaluation plan, and of the community mobilization process are presented elsewhere [3, 4].

Evaluation Plan for the Community Intervention Trial for Smoking Cessation (COMMIT)

The National Cancer Institute is sponsoring the Community Intervention Trial for Smoking Cessation (COMMIT), a multi-center research project designed to test the value of a community-based effort to promote smoking cessation. The trial involves eleven matched pairs of communities with random assignment of one community per pair to the intervention or to the comparison condition. This article reviews the rationale and methodology of the COMMIT evaluation plan which is organized into four components: 1) outcome assessment, monitoring changes in community smoking patterns; 2) impact assessment, measuring the effect of the COMMIT intervention on mediating factors thought to be important in facilitating changes in community smoking behavior (e.g., social norms supporting nonsmoking); 3) process assessment, monitoring the quality and timeliness of intervention delivery; and 4) economic assessment, estimating the cost effectiveness of the intervention.

Introduction to the Community Intervention Trial for Smoking Cessation (COMMIT)

The Community Intervention Trial for smoking cessation (COMMIT) is sponsored by the National Cancer Institute and involves eleven pairs of communities in North America. COMMIT emphasizes a partnership between the eleven research institutions and their respective intervention communities in developing the structures needed to implement the intervention protocol. We summarize the epidemiological data and describe the prior community interventions that set the stage for COMMIT, and discuss how COMMIT may inform state-wide tobacco reduction demonstration programs. An overview of the articles that describe the COMMIT intervention and evaluation plan is presented.

Principles of Community Organization and Partnership for Smoking Cessation in the Community Intervention Trial for Smoking Cessation (COMMIT)

The Community Intervention Trial for Smoking Cessation (COMMIT) has adopted a community approach to smoking cessation. State-of-the-art interventions that have proven efficacious for smoking cessation are delivered to smokers through community-based organizations. An innovative adaptation of community organization methods accommodated the need for a standardized protocol with the flexibility required for diverse and unique communities. The unique characteristics of the eleven intervention communities are examined with a focus on differences in size, location, availability and importance of the intervention channels, and other factors that were important for community mobilization. Initial results of the mobilization process are summarized. Although there were some differences in the structures formed and the time required to complete the initial project activities, all eleven intervention sites were mobilized around the COMMIT goals and activities.

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.

Evaluation of a workplace brief intervention for excessive alcohol consumption: the workscreen project

BACKGROUND

The workplace provides a useful setting for early identification and intervention with individuals who have unhealthy lifestyles. The objective was to evaluate the effects of a workplace-based lifestyle intervention (Workscreen) to reduce excessive drinking.

METHOD

There were eight Australia Post networks randomly allocated to experimental and control conditions, comprising 67 worksites and 1206 employees. The experimental condition involved a broad spectrum lifestyle campaign, incorporating support from management, employee awareness of health, and brief interventions for high-risk behaviors, including excessive alcohol use. Focus groups identified relevant cultural factors. Changes in workplace culture and employee behavior were assessed 10 months after baseline. Males and females were analyzed separately.

RESULTS

Over half of APOST employees participated at each screening point. In the experimental condition 61% of employees overall and 58% of those identified as excessive drinkers in Phase 1 responded to the lifestyle campaign by attending health assessments. Analyses focusing on the organization as a whole did not reveal significant reductions in excessive alcohol consumption among men or women. However, a significant reduction in number of drinks was observed in the experimental condition among women for whom completion of baseline and follow-up could be confirmed (P < 0.001).

CONCLUSIONS

The present study indicates that a workplace-based lifestyle campaign can assist self-selected employees in reducing their alcohol consumption. There was a moderately high level of participation among those identified as drinking excessively, which supports our approach of embedding a low-intensity alcohol program within the context of a broader health promotion campaign.

The effects of a health promotion-health protection intervention on behavior change: the WellWorks Study

OBJECTIVES

This study assessed the effects of a 2-year integrated health promotion-health protection work-site intervention on changes in dietary habits and cigarette smoking.

METHODS

A randomized, controlled intervention study used the work site as the unit of intervention and analysis; it included 24 predominantly manufacturing work sites in Massachusetts (250-2500 workers per site). Behaviors were assessed in self-administered surveys (n = 2386; completion rates = 61% at baseline, 62% at final). Three key intervention elements targeted health behavior change: (1) joint worker-management participation in program planning and implementation, (2) consultation with management on work-site environmental changes, and (3) health education programs.

RESULTS

Significant differences between intervention and control work sites included reductions in the percentage of calories consumed as fat (2.3% vs 1.5% kcal) and increases in servings of fruit and vegetables (10% vs 4% increase). The intervention had a significant effect on fiber consumption among skilled and unskilled laborers. No significant effects were observed for smoking cessation.

CONCLUSIONS

Although the size of the effects of this intervention are modest, on a populationwide basis effects of this size could have a large impact on cancer-related and coronary heart disease end points.

A Voluntary Smokers' Registry: Characteristics of joiners and non-joiners in the Community Intervention Trial for Smoking Cessation (COMMIT)

OBJECTIVES

This paper examines differences between joiners and nonjoiners of a voluntary smokers' registry.

METHODS

A baseline prevalence survey was used to identify characteristics of smokers who joined or did not join a smokers' registry.

RESULTS

Communities varied significantly in registry enrollment rates. Heavy-smoking joiners expressed more desire to quit, were more likely to live with nonsmokers, and were older than nonjoiners. Light-to-moderate joiners smoked more, were more addicted to cigarettes, and expressed more desire to quit than nonjoiners.

CONCLUSIONS

Few baseline characteristics differentiated joiners from nonjoiners. Nonjoiners were significantly more likely to achieve cessation than joiners.

Worksite characteristics and changes in worksite tobacco-control initiatives. Results from the COMMIT study

Few studies have prospectively examined the characteristics associated with worksite adoption of tobacco-control initiatives. Data were collected as part of the Community Intervention Trial (COMMIT) for Smoking Cessation, which conducted interventions in 11 communities. This smoking cessation intervention was based on community organization principles and delivered through multiple community channels, including worksites, health care providers, the media, and cessation resources. This article reports results from telephone interviews of intervention community worksites having 50 or more employees, conducted at baseline and the end of the intervention period. Among worksites that responded to both baseline and final surveys, 83% had not adopted a smoke-free policy at baseline, and 61% did not offer any cessation aid or quitting resources at baseline. By the final survey, 34% of those with no smoking ban at baseline had become smoke-free, and 36% of those offering no cessation assistance at baseline were offering cessation resources at the follow-up. The prevalence of policy adoption was higher among worksites employing more female employees and offering other health-promotion activities; manufacturing businesses were significantly less likely than businesses other than service and wholesale/retail businesses to adopt policies. Adoption of cessation programs was significantly more likely among worksites employing 100 to 249 workers, compared with those employing 50 to 99 workers; those predominantly employing men; those offering other types of health-promotion activities; and those with a higher rate of turnover. These results provide important information about the characteristics of worksites likely to engage in tobacco-control efforts. Health educators and others may choose to target those worksites most ready for adoption of tobacco control policies and programs, as indicated by these findings.

Worker participation in an integrated health promotion/health protection program: results from the WellWorks project

According to prior reports, blue-collar workers are less likely to participate in worksite health promotion programs than are white-collar workers. This study examined worker participation in the WellWorks worksite cancer prevention intervention, which integrated health promotion and health protection. Analyses were conducted to assess relationships among participation in health promotion and health protection programs, and workers' perceptions of management changes to reduce potential occupational exposures. Results indicate that blue-collar workers were less likely to report participating in health promotion activities than white-collar workers. A significant association was observed between participation in nutrition- and exposure-related activities, suggesting that participation in programs to reduce exposures to occupational hazards might contribute to blue-collar workers' participation in health promotion activities. Furthermore, when workers were aware of changes their employer had made to reduce exposures to occupational hazards, they were more likely to participate in both smoking control and nutrition activities, even when controlling for job category. These findings have clear implications for future worksite cancer prevention efforts.

School policy in COMMIT: a promising strategy to reduce smoking by youth

Organizational smoking policy has been identified as a potentially effective way to influence health behavior, particularly in worksites. Examining the elements of existing school smoking policies for both students and employees can provide insight into the potential effectiveness of these policies in changing young people's smoking behavior. This paper examines selected components of existing school smoking policies in a national sample of schools at all levels of education as part of the Community Intervention Trial for Smoking Cessation. Schools were questioned about their school smoking policies, related resources, and compliance. The data show much variation in the elements of school tobacco use policy to change smoking behavior. Existing policies in schools differ among grade levels, thus providing different messages about the appropriateness of smoking. Policies differ for students and adults, providing another opportunity for confusion about the messages that policy can deliver. In general, resources available to support existing policies are lacking. Many schools offer classes on knowledge of negative health effects of smoking but do not teach the psychosocial skills necessary to resist tobacco use. In its present forms, school policy has great potential for an effective tool for health promotion, but considerable reform is needed to overcome current barriers.

Community Intervention Trial for Smoking Cessation (COMMIT): I. cohort results from a four-year community intervention

OBJECTIVES

The primary hypothesis of COMMIT (Community Intervention Trial for Smoking Cessation) was that a community-level, multi-channel, 4-year intervention would increase quit rates among cigarette smokers, with heavy smokers (> or = 25 cigarettes per day) of priority.

METHODS

One community within each of 11 matched community pairs (10 in the United States, 1 in Canada) was randomly assigned to intervention. Endpoint cohorts totaling 10,019 heavy smokers and 10,328 light-to-moderate smokers were followed by telephone.

RESULTS

The mean heavy smoker quit rate (i.e., the fraction of cohort members who had achieved and maintained cessation at the end of the trial) was 0.180 for intervention communities versus 0.187 for comparison communities, a nonsignificant difference (one-sided P = .68 by permutation test; 90% test-based confidence interval (CI) for the difference = -0.031, 0.019). For light-to-moderate smokers, corresponding quit rates were 0.306 and 0.275; this difference was significant (P = .004; 90% CI = 0.014, 0.047). Smokers in intervention communities had greater perceived exposure to smoking control activities, which correlated with outcome only for light-to-moderate smokers.

CONCLUSIONS

The impact of this community-based intervention on light-to-moderate smokers, although modest, has public health importance. This intervention did not increase quit rates of heavy smokers; reaching them may require new clinical programs and policy changes.

Take heart: results from the initial phase of a work-site wellness program

OBJECTIVES

The purpose of this study was to evaluate the short-term effects of a low-intensity work-site heart disease risk reduction program using a matched pair design with work site as the unit of analysis.

METHODS

Twenty-six heterogeneous work sites with between 125 and 750 employees were matched on key organization characteristics and then randomly assigned to early or delayed intervention conditions. Early intervention consisted of an 18-month multifaceted program that featured an employee steering committee and a menu approach to conducting key intervention activities tailored to each site.

RESULTS

Cross-sectional and cohort analyses produced consistent results. At the conclusion of the intervention, early and delayed intervention conditions did not differ on changes in smoking rates, dietary intake, or cholesterol levels. There was considerable variability in outcomes among work sites within each condition.

CONCLUSIONS

Despite documented implementation of key intervention activities and organization-level changes in terms of perceived support for health promotion, this intervention did not produce short-term improvements beyond secular trends observed in control work sites. Research is needed to understand determinants of variability between work sites.

Compliance with worksite nonsmoking policies: baseline results from the COMMIT study of worksites

PURPOSE

Little is known about compliance with worksite nonsmoking policies. This study provides an examination of the relationship of policy compliance to characteristics of the organization and the manner in which the policy was implemented.

DESIGN

Data came from two separate surveys of 1) representatives of worksites that reported having a nonsmoking policy and 2) employed residents from the same communities whose worksites had nonsmoking policies.

SETTING

This study was conducted as part of the Community Intervention Trial for Smoking Cessation (COMMIT), being conducted in 11 diverse intervention communities.

SUBJECTS

Data are presented from surveys of 710 worksites (response rate = 90%) and 3,143 employed residents (response rate = 80%) of the same communities.

MEASURES

Compliance with nonsmoking policies was measured by self-report in both surveys and is compared with worksite and respondent characteristics, type of policy, and methods of policy implementation.

RESULTS

Compliance with nonsmoking policies was high; 55% of worksites with a policy restricting smoking reported that employees always adhered to the policy. Compliance was highest in worksites with more restrictive policies and where labor-management relations were reported to be good. Compliance also was high where the policy was effectively communicated to workers, as through worksite distribution channels, the absence of cigarette vending machines, and the availability of cessation assistance.

CONCLUSIONS

These findings indicate that compliance with worksite nonsmoking policies is generally high, especially in the presence of more stringent policies.

Aspects of statistical design for the Community Intervention Trial for Smoking Cessation (COMMIT)

We present statistical considerations for the design of the Community Intervention Trial for Smoking Cessation (COMMIT). One outcome measurement, the quit rate in randomly selected cohorts of smokers, is compared with another outcome measurement, the decrease in smoking prevalence, in terms of statistical efficiency and interpretability. The COMMIT study uses both types of outcome measurements. The merits of pair-matching the communities are considered, and sample size calculations take into account heterogeneity among pair-matched communities. In addition to significance tests based on the permutational (randomization) distribution, we also describe approaches for covariate adjustment. The COMMIT design includes 11 pair-matched communities, which should provide good power to detect a 10% or greater difference in quit rates between the intervention and control communities in cohorts of heavy smokers and in cohorts of light or moderate smokers. The power is only moderate to detect intervention effects on the decreases in overall smoking prevalence or in the prevalence of heavy smoking.