Although smoking has declined steadily since the 1964 publication of the Surgeon General's first report on the dangers of cigarettes, rates remain high in some groups. About 25 percent of Americans smoke cigarettes, but the percentage exceeds 30 percent among African Americans.
Several major campaigns have failed to lower smoking rates in this group. But researchers from Washington University in St. Louis and the St. Louis University School of Public Health have come up with new neighborhood-based programs that are planned and implemented by residents. After two years, targeted neighborhoods had a significantly lower percentage of African-American smokers than neighborhoods that did not take part in a program.
Reporting in the November 1998 American Journal of Public Health, the researchers say the two-year project, which was funded by the National Institutes of Health, helped cut smoking rates from 34 percent to 27 percent in three predominantly low-income, African-American neighborhoods. Smoking rates remained essentially level, declining only from 34 percent to 33 percent in demographically similar neighborhoods in Kansas City that did not receive the intervention.
"In addition, we found that smoking rates declined even more in people who said they'd heard of Grace Hill Neighborhood Services, the community agency we worked with," says Edwin B. Fisher, Ph.D., professor of psychology, medicine and pediatrics at Washington University in St. Louis and director of the Division of Health Behavior Research at the School of Medicine. "That seems to indicate that the agency's clientele - the people the program was most designed to help - did indeed benefit."
Ross C. Brownson, Ph.D., professor and chair of the Department of Community Health at St. Louis University School of Public Health, evaluated the smoking cessation program. He was director of the Division of Chronic Disease Prevention and Health Promotion for the Missouri Department of Health when the study began. "Smoking rates in African American communities are at alarming levels, so it is important to try to replicate any program that has been successful. And this one was very successful," Brownson says.
Fisher says African Americans are at increased risk from tobacco partly because of how cigarettes are marketed in the United States and partly because of lingering racism and inequality in society. Many advertising campaigns equate cigarette smoking with independence and prosperity, and those can be attractive notions to people who are more likely to be economically or socially disadvantaged, he points out.
In the early 1990s, Fisher and colleagues, public health researchers from the State of Missouri and the staff of Grace Hill Neighborhood Services designed a program that would give smokers input into how their smoking cessation program was put together. The audience was low-income, African Americans in north St. Louis neighborhoods, and the program was modeled after similar programs the researchers had organized for various businesses.
"When we put together worksite programs, we decided that instead of bringing in a dog and pony show, we needed to help people develop their own promotional campaigns and activities to encourage and support each other as they tried to quit smoking. Those programs worked better when the workers themselves were involved in designing them," Fisher explains. The smoking cessation program, Neighbors for a Smoke Free North Side, formed Wellness Councils in neighborhoods. It also created a City-Wide Council, made up mostly of African Americans, which connected project leaders with key individuals and resources in the community and advised the Wellness Councils. A Nuts 'n Bolts Committee composed of university researchers, staff from Grace Hill Neighborhood Services and staff representing the Wellness Councils carried out the main planning.
"We know that the traditional medical model of service delivery is not always effective in low-income, minority communities," says project director Wendy F. Auslander, Ph.D., associate professor of social work at Washington University's George Warren Brown School of Social Work. "A peer-delivered program seems to hold more promise, not only for smoking but for many disease-prevention programs."
The Neighbors for a Smoke Free North Side program lasted 24 months and included regular meetings and ads and stories in African-American newspapers and on radio stations popular in the neighborhoods. A major event, called a Gospelfest, brought together youth choirs from several neighborhood churches. Each choir chose one song it particularly liked and performed a second piece dealing with smoking. The concert drew 800 people to a church in one of the target neighborhoods.
Defining success
To evaluate the success of the meetings, concerts and other activities, the investigators conducted random telephone surveys before the program began and after it had concluded. In addition to the general decline in smoking and the decline in those who had heard of Grace Hill Neighborhood Services, they also found a steep decline in smoking among women under age 35. The percentage of smokers in this group fell from 34 to 24 percent.
"That's a particularly gratifying number," Fisher says. "A lot of the programs at Grace Hill focus on women or parents who are on Medicaid, and the drop in smokers in that group shows that we were especially reaching that target population. And we are very concerned about smoking in women of child-bearing age, so the fact that their smoking rates declined is especially gratifying." Brownson says the smoking cessation program could be widely applicable. "Many cities have agencies like Grace Hill, and I believe our program could be taken to those communities if the proper tailoring is done up front," he says.
Fisher says an important part of replicating the success is keeping the program small and designing interventions for individual neighborhoods. "Over the years, public health professionals have designed a fair number of community-based health programs addressing dietary fat or smoking or exercise, and they have had mixed results," he says. "To establish a program that really involves neighbors, that really has grass roots involvement and participation, you probably need to organize in smaller units like neighborhoods."
Note: For more information, refer to: Fisher, EB. et. al. "Neighbors for a Smoke Free North Side: Evaluation of a Community Organization Approach to Promoting Smoking Cessation Among African Americans," American Journal of Public Health, vol. 88 (11), pp. 1658-1663, November 1998.
Journal
American Journal of Public Health