Tobacco Use in the New Independent States

The history of tobacco in Eastern Europe throughout the major part of this century has been marked by government-controlled production and sale of tobacco products. Throughout the 1980s, cigarette production in the region grew by around 1 percent per year. However, per capita consumption was relatively stable at around 1,600 smoking pieces per person per year between 1982 and 1988. This is approximately half the per capita consumption level of the United States.

In the 1980s, approximately half the adult men in the Soviet Union smoked, compared with less than 15 percent of the women (Zaridze et al., 1986); however, there were marked differences by age, as shown in Figure 11-1. The highest prevalence was among men aged 20 to 39, over 60 percent of whom were smokers. Prevalence among men between ages 40 and 70 was around 40 percent. There appeared to be an educational gradient, with the better-educated men smoking less than the less educated (30 vs. 60 percent). The highest prevalence among women also occurred in the age group 20 to 39 years, at 20 percent. By comparison, in the United States in 1987, around 31 percent of men and 26 percent of women smoked. There was also a marked difference in prevalence for the better and less educated (16 vs. 35 percent).¹

Figure 11-1

Prevalence of smoking by gender and age: Soviet Union, 1981. SOURCE: Zaridze et al. (1986).

Tobacco Products in the New Independent States

The tobacco industry in Central and Eastern Europe has changed markedly in recent years in both structure and ownership (see also Prokhorov, in this volume).

Privatization has occurred very quickly, with purchasers being the major transnational tobacco companies. The impetus for this change in the tobacco industry started in 1990, when the rapidly developing economic crisis led to the temporary closing of 50 percent of tobacco factories in the Soviet Union. During this time, the worsening currency problem made large-scale importation of cigarettes very expensive. There was civil unrest resulting from the shortage of cigarettes. The transnational tobacco companies agreed to provide the region with a total of 38 billion cigarettes at enormously discounted rates. Since then, these tobacco companies have acquired major interests in 34 former state monopolies in Central and Eastern Europe, with 12 being owned outright. Table 11-1 shows recent investment by transnational tobacco companies in Central and Eastern Europe.

TABLE 11-1

Recent Transnational Tobacco Company Investments in Central and Eastern Europe.

The entry of the transnational tobacco industry giants into the economy and politics of the region has changed expectations for consumption over the next decade. In 1988, per capita consumption projections for the Soviet Union foresaw a negligible increase through 1998, with some projected brand switching toward filtered cigarettes (60 percent of market in 1988 to 80 percent in 1998) and a move toward milder cigarettes preferred by younger consumers and women. These projections were made with the knowledge that tobacco advertising had been banned in 1980 and that government regulation was likely to remain in force. The entrance of the transnational tobacco companies significantly changed that scenario.

In purchasing tobacco plants in Central and Eastern Europe, the transnational tobacco companies have significantly increased their manufacturing capabilities.² It is expected that the long-term goals of the companies are to expand cigarette production within the region, to expand per capita consumption levels toward those seen in the United States, and to increase the level of profitability for each cigarette sold.³

To promote higher consumption levels, the industry might be expected to follow the prescription that has been so successful in other countries: large marketing expenditures and the use of their economic might to create pressure. Indeed, the new tobacco industry in the region has moved quickly to begin stimulating demand for major brands of cigarettes produced by the transnational tobacco companies. The industry has started by completely ignoring the advertising ban. Connolly (1994) reports that of the 6,723 billboards in Moscow, 70 percent advertise tobacco products—almost exclusively key multinational brands. Indirect advertising of Marlboro and Rothman's is widespread on Moscow television. During one feature film, three commercial breaks advertised Lucky Strikes. In July of 1993, the Moscow City Council took its own action to ban tobacco advertising, and a similar ban passed in the Russian Parliament. However, the Press Ministry has refused to enforce the ban, citing the importance of the advertising revenue. Prokhorov and Alexandrov (1994) report that the Moscow Department of Public Transportation has noted an enormous expansion of protected bus stops featuring tobacco advertising. Further, the Moscow Trade Department has indicated that there will be a significant increase in ''brand-name" tobacco kiosks in Moscow, thus increasing the ease of access to Western-brand cigarettes.

Recent evidence suggests, moreover, that there has been a rapid increase in smoking prevalence among young adult women in the NIS, with prevalence already much closer to the high rates observed among men of the same age. There is also evidence suggesting a rapid recent rise in smoking among adolescents, with one study reporting 20 percent smoking rates among 12 year olds (Alexandrov et al., unpublished data, no date).

Thus, the situation in the NIS suggests that without effective tobacco control programs, there will be a major increase in tobacco use over the next few years, with the smoking-related disease epidemic worsening significantly over the next generation (see also Prokhorov, in this volume).

The Natural History of Smoking Behavior

Most societies measure the level of smoking behavior by assessing its prevalence in the community at a particular point in time and comparing this with per capita consumption (U.S. Department of Health and Human Services, 1989). Changes in the prevalence of smoking are effected either by a reduction in the proportion of nonsmokers who start to smoke, or an increase in the proportion of smokers who quit smoking, or a change in the in-out migration ratio of smokers to nonsmokers. Tobacco control focuses on the first two of these: it aims to reduce the uptake of smoking among nonsmokers and to increase successful quitting among smokers.

The uptake of smoking has been studied extensively over the past 20 years (U.S. Department of Health and Human Services, 1989, 1994a). From these studies, there is consensus that it is a time-dependent process that starts with the development of a susceptibility to smoking (U.S. Department of Health, Education and Welfare, 1964). A nonsmoker is considered susceptible once he or she has formed attitudes and beliefs about the utility of smoking. It is this susceptibility to smoking, which occurs prior to any experimentation with cigarettes, that is the focus of many tobacco control approaches. Recent evidence from California in the United States (Evans et al., 1992) supports earlier studies in Great Britain (Russell, 1978) indicating that 70 percent of those who experiment with cigarettes develop an addictive habit, as shown in Figure 11-2.

Figure 11-2

Different measures of smoking behavior for Californian females, 1992. SOURCE: Pierce et al. (1994a).

Cigarette smoking fits all the criteria for an addictive behavior (U.S. Department of Health and Human Services, 1988). Nicotine has a psychoactive effect that is generally regarded as pleasant. Most individuals who smoke have built up tolerance, and their smoking behavior is highly controlled and compulsive. They have become physically dependent on the drug so that cessation of its use is associated with unpleasant physical withdrawal symptoms. The majority of attempts to quit smoking end in relapse (Gilpin and Pierce, 1994). In the United States, from one-third to one-half of smokers try to quit in any given year; however, over 90 percent of these attempts end in failure, with over half of these quitters relapsing in the first 4 days.

Quitting is not an all-or-nothing event, but a time-dependent process. Studies of successful quitting demonstrate that there are two variables that predict the probability of success: the level of addiction of the smoker and the individual's recent experience or practice in overcoming withdrawal symptoms. Thus, successful quitting of smoking can be likened to successfully completing a long-distance run. It depends on the level of fitness of the runner (read the level of addiction) and the recent practice the runner has had in overcoming the hurdles or difficulties involved in the race. Just as in the race, the smoker with the least chance of success is the one who goes into a quit attempt with a high level of addiction and no recent practice at overcoming withdrawal. The smoker who is better prepared on both of these counts has a sixfold better chance at long-term success in quitting (Farkas et al., 1996a, 1996b).

The Role of Advertising in Increasing Tobacco Consumption

Advertising is used both to attract new consumers to tobacco products (U.S. Department of Health and Human Services, 1994a) and to convince users of alternative or competing products to switch brands (Ray, 1982). Most of the interest in tobacco advertising has focused on whether it attracts new consumers who are adolescents or minors (Albright et al., 1988; Altman et al., 1987; King et al., 1991; Mazis et al., 1992; Schooler and Basil, 1990; Schooler et al., 1991). There is little public support for the encouragement of adolescents and children to start an addictive habit, before they are old enough to appreciate its consequences. The tobacco industry strongly argues that it does not use advertising to promote smoking among minors, although it has produced little evidence to support this argument.

A recent historical analysis of cigarette advertising and the uptake of smoking in the United States examines four periods in history associated with major, different advertising campaigns.⁴ Cigarettes were advertised to males in two of these periods and to females in the other two. Strong evidence of the effectiveness of tobacco advertising is shown by the association of the timing of each campaign with a major increase in the uptake of smoking among the targeted gender-specific group (Pierce and Gilpin, 1995).

In recent research, we investigated the association between adolescent responsiveness to tobacco marketing and susceptibility to smoking among those who have never tried a cigarette (Pierce and Gilpin, 1995). We defined an index of receptivity that includes having a favorite cigarette advertisement and being prepared to use an item of clothing that displays a cigarette advertising logo. With this index, we demonstrated that receptivity to advertising is considerably more powerful than exposure to smokers in predicting which never-smokers will be susceptible to initiating smoking.

The Implementation of Policies to Restrict Advertising

Advertising Bans and Their Impact on Tobacco Consumption and Smoking Uptake

A number of approaches to restricting tobacco marketing have been tried. The first approach undertaken in the United States was to ban tobacco advertising from the broadcast media (U.S. Department of Health and Human Services, 1989). A number of other countries have further restricted the rights of the tobacco companies to advertise, extending the ban to all print media as well.

In the United States, the ban on tobacco advertising in the broadcast media took effect in early 1971 (Whiteside, 1971). The impact of this ban on per capita cigarette consumption is shown in Figure 11-3. From 1900 through the release of the first Surgeon General's report on smoking and health in 1964, per capita consumption of cigarettes in the United States increased almost every year, from a level of 54 cigarettes per capita in 1900 to 4,345 in 1963. Declines occurred in 1964 and again in each year from 1967 through 1970, the years of television counteradvertising. The consistent annual decline in per capita consumption started in 1973 (U.S. Department of Health and Human Services, 1989).

Figure 11-3

Adult per capita cigarette consumption and major smoking and health events: United States, 1900-1986. SOURCES: U.S. Department of Agriculture(1987); U.S. Department of Health and Human Services (1989).

For boys and girls aged 10 through 20, the first consistent decline in smoking initiation started in 1973, also approximately 2 years after the broadcast advertising ban. Before 1973, the incidence of smoking initiation among girls had sharply increased, a rise associated with the strong tobacco advertising campaign targeting women noted above. Between 1973 and 1978, the incidence rate among boys declined by approximately 25 percent and among girls by approximately 10 percent (Gilpin et al., 1994).

Can we claim that the broadcast advertising ban rather than some other contextual change was responsible for these declines in smoking uptake among minors? A plausible answer is that the broadcast advertising ban had a delayed effect on both incidence and consumption.⁵ This answer relies on the assumption that advertising works by building a susceptibility to smoking among nonsmokers and by reducing the susceptibility to quitting among smokers. An end to this stimulation of demand could thus be expected to have a delayed effect on consumption, just as demand that has already been stimulated will be reflected only in consumption over time.

The Importance of Beliefs About Health Consequences of Smoking and Environmental Tobacco Smoke

The Role of Health Professionals in Tobacco Control

The strong justification for spending public monies to undertake tobacco control comes from the enormous health consequences that result from regular use of tobacco. The central role of health professionals in conveying those consequences to the public has been well documented (U.S. Department of Health and Human Services, 1994b). Thus it is essential that health professions be the cornerstone of a tobacco control movement (although see the discussion of this issue by Prokhorov in this volume). The tobacco industry recognized the importance of physicians in the 1930s when it advertised that more doctors smoked Camels, and later advertised that dentists advised the public to smoke Viceroys.

In every country that has seen a decline in smoking prevalence, the first group that has reduced its prevalence is the medical profession. It would appear that physicians are very important role models for health behavior in society. If physicians smoke, the population is less likely to be concerned about the health hazards of smoking. In the United States, some 60 percent of physicians smoked in 1949. By 1964, some 30 percent of doctors smoked. Today, it is estimated that less than 6 percent of physicians in the United States smoke. Physicians' rate of quitting appears similar to that of other highly educated groups in society. This rapid decline in smoking prevalence among the medical profession has been brought about by the virtual elimination of smoking among medical students (U.S. Department of Health and Human Services, 1994b). Indeed, the trends in smoking among physicians, and particularly among medical students, can be used as a barometer for the level of tobacco control activity in a country.

In addition to being role models, health professionals can play an important part in convincing smokers to quit and nonsmokers not to start smoking, as shown in Table 11-2. Over two-thirds of smokers visit a physician each year in the United States. While they may seek care for a specific problem not be related to smoking, the physician has an opportunity, and many would say a duty, to counsel them about preventing future disease.⁶ The physician's role is to help reinforce the smoker's motivation to quit and to provide support on each subsequent visit. Unfortunately, physicians are much more likely to counsel a patient on smoking if the patient presents them with a problem that could be smoking related. Efforts to increase this kind of activity have not yet been able to generate widespread physician involvement in assisting patients to quit.

TABLE 11-2

Other Progress Toward Successful Cessation of Smoking.

School-Based Smoking Prevention Programs

Since the 1964 Surgeon General's report started the official public health campaign against smoking, prevention of the uptake of smoking has been recognized as crucial to major long-term reductions in prevalence among the population (U.S. Department of Health and Human Services, 1964). To this end, the 1964 Surgeon General's report advocated the conduct of programs directed at educating high school and college students about the health hazards of smoking. Early programs assumed that young people who started to smoke had somehow either not been exposed to or not paid attention to information on the health effects of smoking. Efforts were concentrated on presenting the information as vividly as possible; educational aids included films, posters, and pamphlets, which focused on arousing fear of the long-term effects of smoking. However, by the late 1970s there was general agreement that these smoking prevention programs had little impact on the probability that an adolescent would become a smoker (Goodstadt, 1978; Thompson, 1978). An alternative approach was based on the observation that those adolescents who did start smoking were those who were not performing as well at school. Programs implementing this approach aimed to change student attitudes toward school, family, or community. However, long-term evaluations failed to demonstrate any impact on reducing adolescent smoking.

Both of the above approaches have given way to a focus on the social environment as a major determinant of behavior. Programs with this focus emphasize developing community norms, as well as individual skills, to identify and resist social influences to smoke. While there has been considerable variation on this theme, usual components of these programs have included training in identifying and interpreting tobacco marketing messages; practice in saying ''no" to peer pressures to smoke: and training that fosters general assertiveness, decision-making, and communication skills. In addition, these programs have sought to present the negative short-term consequences of smoking and the socially salient advantages of being a nonsmoker.⁷

These school-based approaches have been extensively researched through a series of randomized controlled trials, which appear to have been successful in the short term. However, these lower initiation rates had completely disappeared by the time the intervention groups had reached adulthood. The conclusion from these studies is that school-based programs can be very effective in the short term, but we should not expect to be able to inoculate students against ubiquitous social influences toward smoking by providing a few classes at an important point in their development. In order for these school interventions to have long-term impact on the uptake of smoking, they need to be supported by other tobacco control efforts that reduce the environmental influences promoting smoking.

Use of Cigarette Pricing for Tobacco Control

The price of a commodity is known to affect its consumption in the marketplace. Price has not been used as a tool of competition among the cigarette manufacturers, but there have been price or tax changes on a number of occasions, offering the opportunity to assess the impact of price in tobacco control efforts.

During the years before the United States entered World War I, pictures of the war tended to show soldiers relaxing after a difficult time at the front, frequently smoking cigarettes. Cigarettes became viewed as an aide to help soldiers endure the strain, "to soothe the nerves and to deaden the loneliness," in the words of a reporter of the time. In addition, General Pershing became an ardent advocate for the provision of free cigarettes to the troops. The tobacco industry was fond of quoting him: "I'll tell you what we need to win the war: we need cigarettes just as much as bullets." As a result, the Red Cross became one of many associations raising money to dispatch free cigarettes to allied soldiers. Across the United States, soldiers received free chewing gum, toothpaste, and cigarettes.

There was a marked increase in the incidence of initiation of smoking among males aged 16 through 20 in 1917 and 1918 (Pierce and Gilpin, 1995). This increased uptake rate among nonsmokers disappeared when the free cigarettes were discontinued with demobilization. The war years were also associated with a major increase in per capita consumption of cigarettes. However, unlike initiation rates, the level of consumption did not decrease to previous levels after the end of the war. The most likely interpretation is that the young men who started to smoke because of the availability of free cigarettes during the war were unable or unwilling to quit when they returned to civilian life.

This war phenomenon was repeated during World War II. Free cigarettes were again available to the troops. There was a marked increase in the incidence of initiation among young men (Kennett, 1987). With demobilization, the incidence level declined to what it had been previously; again, however, there was no similar return to prewar levels in per capita consumption.

Numerous studies indicate that the demand for cigarettes generally decreases with increasing price; an example is shown in Figure 11-4. Economists use the price elasticity of demand for cigarettes to estimate the impact of an increased excise tax on consumption.⁸ These models suggest that a price elasticity of between -0.2 and -1.3 has existed in the United States and member countries of the Organization for Economic Cooperation and Development over the past 20 years (U.S. Department of Health and Human Services, 1989). Thus, a 10 percent increase in price could be expected to produce a reduction in consumption of between 2 and 13 percent. Variation in the level of response to a price increase may be associated with the amount of public agenda setting that accompanies the price increase. For example, in California in 1988, a 25-cent increase in the excise tax led to a 9-cent increase in price, which was associated with a 13 percent decrease in consumption. This tax increase was the subject of a major advertising campaign and an initiative voted on in a general election. In contrast, in 1991 a 4-cent increase in tax was subsumed into a major price increase by the cigarette industry. There was no public discussion of the tax or price increase and no identifiable effect on consumption.

Figure 11-4

Cigarette consumption and real price: United Kingdom, 1971-1992. SOURCE: Townsend (1988).

From the mid-1980s through 1993 in the United States, the tobacco industry introduced generic "no-name" cigarettes at a lower price while it systematically increased the price of its premium brand products. Thus, the smokers who converted to generic cigarettes could be assumed to be price sensitive. Heavier smokers, older women, and those with lower disposable incomes were much more likely to switch to generic brands. Importantly, many young people preferred to smoke the more expensive premium brands, even though the price differential was as high as 30 percent. This suggests that the price of cigarettes in the United States does not represent a recognizable drain on disposable income for many new smokers during the early years of the uptake process. Presumably, the daily consumption level is low during these years, and the smokers are less addicted and better able to adjust their consumption level to their budget. Teenagers are price sensitive, though, as was demonstrated with the reduction in adolescent smoking following the very large tax increases in the late 1980s (Ferrence et al., 1991).

Efforts to Control Access By Minors

The first major efforts to control access to cigarettes by minors occurred in the United States in the late 1890s with the formation of the anti-cigarette league.⁹ By 1910, the league had been successful in introducing legislation banning the sale of cigarettes to minors in many states.

Today, all states have laws prohibiting the sale of cigarettes to persons under the age of 18 (U.S. Department of Health and Human Services, 1994a). Many surveys have demonstrated that these laws have overwhelming public support among adults (both smokers and nonsmokers). However, one survey indicated that 80 percent of adults thought it was either very easy or somewhat easy for teenagers to buy cigarettes near where they live. In 1993, 40 percent of Californian 12 to 13 year olds reported that it would be easy for them to get cigarettes if they wanted to (Pierce et al., 1994a). By age 16, 85 percent of adolescents said it was easy to get cigarettes.

Of those who have bought cigarettes, 35 percent have bought from a vending machine, 55 percent from a supermarket, and 94 percent from a small convenience store such as a 7-Eleven. Worse still, Californian small store owners break open packs and sell single cigarettes to adolescents. This action breaks four different laws (Klonoff et al., 1994; Pierce et al., 1994a). However, it is being done with impunity, since chances of being prosecuted are almost nonexistent. While all states have legislation banning cigarette sales to minors, small business owners have significant financial incentives to ignore the law, and police do not see enforcement of this law as a priority issue. Thus, we have no experience with providing major barriers to access to cigarettes by minors.

Use of Mass Media for Counteradvertising

The major tobacco control success stories involving the mass media have been in encouraging people to stop smoking. The first use of the mass media to counter the tobacco industry's marketing messages occurred between 1967 and 1970, when a young attorney successfully argued that the Fairness Doctrine applied to cigarette advertising (U.S. Department of Health and Human Services, 1989). Over this period, television stations were required to show anti-smoking commercials as public service announcements if they allowed paid cigarette advertisements. Although there was a plan for a 1 to 3 ratio, the effective ratio of anti-smoking messages to cigarette ads was 1 to 12. Nevertheless, this period was the first during which there was a sustained decline in per capita consumption (see Figure 11-5). The requirement for anti-smoking messages is widely believed to have provided the disincentive for the tobacco industry to conduct a vigorous fight against the broadcast media advertising ban. Following on this success, large-scale paid media campaigns have been undertaken in Australia and in California, with published evaluations demonstrating a major impact on smoking prevalence (Pierce et al., 1990, 1994a).

Figure 11-5

Adult per capita cigarette consumption: United States, 1950-1979. SOURCE: U.S. Department of Agriculture (1985, 1989).

Not all mass media campaigns have been effective. The media are, after all, merely channels through which people receive information and entertainment. It has been estimated that there are up to 1,500 persuasive messages each day aimed at any given individual in the United States. Advertisers have closely studied behavior and know where to put a message to maximize our chances of being exposed to it. We are not passive as an audience, however. We actively seek some messages, avoid others, and let the majority flow by us, paying attention to one here and there that catches our attention and interest.

The amount of money that needs to be spent to ensure that a target audience is exposed to and pays attention to a given message depends on how the message is packaged. To minimize the money needed for mass media campaigns, tobacco control programs have sought to produce television advertisements that viewers will remember forever after seeing them once. However, what is recalled is a version of the original message. One cannot predict how the media message will be processed to fit the individual's experience or how it will relate to other salient messages the person has received. Powerful messages focusing on the health consequences of smoking appear to have been very important in promoting a community atmosphere that encourages smokers to quit. In addition, many smokers think about quitting when they see such advertisements and will take an immediate action, such as picking up the telephone and asking for help in quitting. This window of willingness to change can be quite brief, and the emotional impact that demands an action response to the message is generally gone in a few days. Linking such messages with telephone counseling help lines is an effective way of extending the life of a message (Pierce et al., 1992; Zhu et al., 1996). If assistance in quitting is quickly available to these responding smokers, it becomes possible to double the rate of successful quitting.

Another mass media approach that has been used is to challenge the credibility of the tobacco industry. This approach, which has been used extensively in California, argues that the industry needs to present itself in a very positive light to sustain its influence on legislators and others in thwarting tobacco control efforts. Negative advertising on the image of the industry is seen as one means of reinforcing community norms against smoking. These norms appear to play an important role in influencing smokers' willingness to attempt to quit and in influencing nonsmokers' willingness to experiment with smoking (Pierce et al., 1993, 1994a).

The third area in which the mass media have been extensively used is in advertising to prevent the uptake of smoking. Typically, tobacco control programs have emphasized images that are salient to confirmed nonsmokers. Unfortunately, there are very few success stories in this area. The tobacco industry typically outspends these campaigns by orders of magnitude as high as 25 to 30 times. Furthermore, the industry, in conjunction with advertisers, has carefully honed its messages and their presentation so that it is virtually impossible for tobacco control programs to win the image war with adolescents. Recall that adolescents did not respond well to messages about long-term health effects of smoking (U.S. Department of Health and Human Services 1989, 1994a). They appear to qualify their willingness to experiment with the notion that they will quit before they suffer health problems. The inability of tobacco control programs to influence significantly the proportion of adolescents who start smoking is the major failing of the field to the present time. In recent years, adolescent smoking appears to have been increasing in the United States (Gilpin and Pierce, 1996).

Thus tobacco control efforts urgently need to develop a new approach for adolescents. The advertising message that is most successful is the one that ties the product to the values of the target group. The "cool," "fun," and ''relaxing" image has been staked out extremely well by the industry. However, this industry message may be vulnerable in the area of "lack of control." Many adolescent smokers report considerable difficulty in trying to quit, and for this age group in particular, such a loss of control could serve as an effective disincentive to start smoking.

The Role of Restrictions on Smoking Behavior

One of the major goals of tobacco control is to protect nonsmokers from the harmful effects of environmental tobacco smoke. As discussed earlier, the majority of the population in the United States believes that environmental tobacco smoke is harmful to nonsmokers. When the U.S. Environmental Protection Agency (1992) released its report concluding that environmental tobacco smoke is a carcinogen in the same category as asbestos, a significant additional impetus was added to the drive for clean indoor air legislation. We have a great deal of experience in developing public health legislation to protect the innocent, and rapid changes in this regard are being observed across the United States. In California, for example, in 1993, two-thirds of workers reported having a completely smoke-free workplace, and over 90 percent reported having a smoke-free work area. Since 1994, California has had statewide legislation that mandates smoke-free workplaces for all workers in the state.

There is considerable evidence that smoke-free workplaces lead to a reduction in the smoking level of heavy smokers (Borland et al., 1992). The evidence suggests that California's worksite policies assist heavy smokers in reducing their level of addiction, which in turn makes it easier for them to quit successfully in the future (Farkas et al., 1996a, 1996b; Gottlieb et al., 1990; Petersen et al., 1988; Pierce et al., 1994a; Stillman et al., 1990; Woodruff et al., 1993).

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