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International Journal of Preventive Medicine

Review Article Open Access

Health Promotion Methods for Smoking Prevention and

Cessation: AComprehensive Review of Effectiveness and the
Way Forward
Indian Institute of Public Health-Gandhinagar, India, Public Health Foundation of India, New Delhi, India, 2London School of Economics and Political Science,
London WC2A 2AE, United Kingdom, 3London School of Hygiene and Tropical Medicine, London WC1E 7HT, United Kingdom

Correspondence to:
Dr. Mahaveer Golechha, Indian Institute of Public Health-Gandhinagar, India, Public Health Foundation of India. E-mail:

How to cite this article: Golechha M. Health promotion methods for smoking prevention and cessation: A comprehensive review of
effectiveness and the way forward. Int J Prev Med 2016;7:7.

Tobacco smoking is one of the greatest causes of mortality in the world, responsible for over5
million deaths per annum. The prevalence of smoking is over1billion people, with the majority
coming from low or middle income countries. Yet, the incidence of smoking varies vastly between
many countries. Some countries have been able to decline the smoking and tobacco related
morbidity and mortality through the introduction of health promotion initiatives and effective policies
in order to combat tobacco usage. However, on the other hand, in some countries, the incidence
of smoking is increasing still further. With the growing body of evidence of detriment of tobacco to
health, many control policies have been implemented as health promotion actions. Such methods
include taxation of smoking, mass advertising campaigns in the media, peer education programs,
community mobilization, motivational interviewing, health warnings on tobacco products, marketing
restrictions, and banning smoking in public places. However, the review of the effectiveness
of various health promotion methods used for smoking prevention and cessation is lacking.
Therefore, the aim of this review is to identify and critically review the effectiveness of health
promotion methods used for smoking prevention and cessation. All available studies and reports
published were considered. Searches were conducted using PubMed, MEDLINE, Ovid, Karger,
ProQuest, Sage Journals, Science Direct, Springer, Taylor and Francis, EMBASE, CINAHL, and
Cochrane and Wiley Online Library. Various relevant search terms and keywords were used. After
considering the inclusion and exclusion criteria, we selected 23 articles for the present review.

Keywords: Health promotion, preventable deaths, smoking, tobacco

INTRODUCTION world. It has assumed the dimension of an epidemic

resulting in enormous disability, disease, and death.[1] The
Smoking is a serious public health challenge across the tobacco use attributed to more than 5 million preventable
deaths every year globally.[2] Further, at the present rate,
Access this article online
the number of such deaths is expected to double by
Quick Response Code: 2020. The tobacco use not only detrimental to personal
Website: health but also results in severe societal costs such as
reduced productivity and health care burden, poverty of
the families, and environmental damage. Ample body of
10.4103/2008-7802.173797 evidence available to infer causal relationship between
smoking and vascular diseases such as coronary heart
Copyright: 2016 Golechha M. This is an openaccess article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original author and source are credited.
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International Journal of Preventive Medicine 2016, 7:7

disease, subclinical atherosclerosis and stroke, respiratory used for smoking cessation and prevention. We excluded
diseases such as pneumonia and chronic obstructive studies which involved multiple health promotion
pulmonary disease, and cancer at ten sites.[3] Despite methods for smoking cessation and prevention.
the serious health risks, a considerable number of people
across the world continue to smoke. It is well recognized
Data extraction
Data were collected according to a standard protocol by
that overall mortality rates for cigarette smokers are
the author and reviewed by an independent reviewer.
6080% higher than for nonsmokers.[4] The degree of
The disagreement was resolved by discussion between
devastation brought to bear upon the individual and
them. In cases could not reach a consensus, a third
society outstrips the returns generated by tobacco
reviewer was consulted. The extracted information from
production and consumption in terms of revenue and
the literature included the name of the first author, the
employment. As awareness of the dangers posed by
year of publication, the study region, type of study(local
tobacco spread, countries across the globe resolved to
study or survey), type of health promotion method used,
forge a campaign strategy and frame a battle plan to
total sample size, age and sex groups, urban/rural areas,
overcome the tobacco threat.
and the effectiveness of the health promotion method.
Health promotion is pivotal in the drive to reduce the After considering inclusion and exclusion criteria, we
growing burden of chronic disease worldwide due to selected 23 articles.
tobacco and particularly smoking. Comprehensive and
active awareness of the population through the health Peer education
promotion strategies are the primary tools for smoking Peer education involves sharing of information in
prevention and cessation. Public education is an integral small groups or one to one by a peer matched either
part of the efforts to both prevent the initiation of demographically or through risky behavior to the target
smoking use and encourage smoking cessation. Increased population.[5] The theoretical basis of peer education
method can primarily be derived from behavioral
health promotion efforts about the detrimental health
theories relating to health, theory of participatory
effects from smoking use may result in higher levels of
education, Information, Motivation, Behavioral skills,
knowledge about the harms of smoking and this in turn
and Resources model and developmental theory.
could increase quit intentions and subsequent quitting
among users. By increasing their knowledge about smoking Effectiveness
cessation methods, health professionals can support and A Stop Smoking in Schools Trial(ASSIST) program
encourage the large majority of smokers who want to quit. assessed the effectiveness of a peerled intervention
Several health promotion methods are being used that aimed to prevent smoking uptake in secondary
for smoking prevention and cessation. Evaluation of schools. The study has shown that the ASSIST training
some of the health promotion intervention studies has program was effective in the achievement of a sustained
shown a positive impact on the reduction in smoking reduction in uptake of regular smoking in adolescents
prevalence. However, studies showing the effectiveness for 2years after its delivery. Furthermore, it was well
of various methods are lacking. Therefore, the present received by both students and school staff.[6] Further,
review was carried out to comprehensively evaluate the the multilevel modeling showed a 22% reduction(odds
effectiveness of important health promotion methods ratio: 0.78[95% confidence interval(CI): 0.640.96]) in
used for smoking prevention and cessation. the odds of being a regular smoker in an intervention
school compared with a control school, with the 95%
METHODS of CIs not including a null effect.[6] Pooled results
from 10 randomized controlled trials(RCTs) that
used experimental smoking as the main outcome also
To obtain all related studies, we searched in PubMed,
found that peer education interventions could be
MEDLINE, Ovid, Karger, ProQuest, Sage Journals, Science
marginally effective in preventing smoking uptake.[7]
Direct, Springer, Taylor and Francis, EMBASE, CINAHL,
Resnicow etal., reported that the programs based on
and Cochrane and Wiley Online Library. The search terms
peer training model produced a net change of 6% in
were smoking cessation, smoking prevention, health
the smoking habit relative to the 3% change brought
promotion methods for smoking cessation, health
about by other models(harm minimization, and life
promotion methods for smoking prevention, Cochrane
skills training) among the South African high school
and smoking cessation/prevention.
students.[8] Prince compared a sixsession peerled
Inclusion and exclusion criteria smoking intervention program for high school youth
We included all available populationbased studies to the same program led by the adults. Selfefficacy
including local, subnational studies and national studies, was measured postand followup.[9] The significant
which were related to single health promotion method reduction in a number of cigarettes smoked was found
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International Journal of Preventive Medicine 2016, 7:7

in both peerand adultled groups when compared to and Teamwork involved the media advocacy and the
the control group. Furthermore, there was a continuous retailer were rewarded with positive newspaper coverage
reduction in smoking both treatment groups at the for compiling the underage laws for selling tobacco
1month followup measure. products, whereas those who did not were named and
shamed.[15] The impact of the project was significant
Although the peer education has proven efficacy one
must consider relevant factors before its implementation. on smoking prevention. Niederdeppe etal., assessed the
These include selection, training, supervision, type of impact of media advocacy activities on news coverage,
intervention, and the relationship between peer educators policy changes, and reductions in youth smoking
and peer educated. It is important to have the right implemented by the Florida Tobacco Control Program.
environment and motivated peer educators for successful They demonstrated a significant decrease in volume of
implementation. programrelated news coverage after the onset of media
advocacy initiatives, but the ratio of coverage about
Theatre in health promotion students working against tobacco relative to other topics
For health promotion, the theater is an effective platform increased. Because of news coverage, there was a passage
to create awareness and disseminate messages related to of tobacco product placement ordinances in Florida
good health. The theater provides an interesting strategy as counties, but these ordinances did not significantly
the audience is whole heartedly involved and encouraging reduce the prevalence of smoking among the youth.[16]
the actor. The actor, who is integral to the dramatic
narrative, explores the chosen topic as a relationship Media advocacy can be looked at as a tool in the broader
between facts and fiction.[10] The theater method premised policy implementation. It can help provide a platform
upon the drama theories and social cognitive theory, which to raise policy related issues. Further studies to see its
recognizes the human behavior as an interaction between effectiveness needs to be done. The use of media as an
the individual aspects, behavior, and the context.[11] advocacy tool must be conceived and developed only
in the context of other approaches such as community
Effectiveness organizing, coalition building, and policy advocacy.
Thrush etal., in their study divided 24 primary schools
into 3 groups, a theater in education intervention Community mobilization
group, a school smoking policy intervention group and a Community mobilization is aimed at inducing a
control group. The results showed that there was a weak change of normal social norms from the utility of
positive effect on the boys but none of the girls in the various intricate interventions to help raise awareness of
intervention group.[12] The theater production 2 Smart 2 community participants. It is brought about by teamwork,
Smoke and accompanying activities showed a significant educational entertainment and the participation of other
impact on psychosocial risk factors for smoking among members, and groups and associations to help inspire
students in grades 13 and grades 46. The percentage revolutionize a change. Community mobilization is based
of students who told that they would never smoke a on 3 key concepts: Social capital, empowerment, and
cigarette increased by 10% following play intervention.[13] social change.[17]
While theater could possibly be a vehicle for longterm Effectiveness
change, it still remains to be seen if the positive results A systematic review by SeckerWalker etal., of community
can be elicited for those concentrating on promotion of interventions to reduce the prevalence of smoking shows
nonsmoking habit. It is important that the content is the effectiveness of communitybased health promotion
assessed on a professional level, and the intervention be initiatives. Afavorable outcome was suggested as a
made as scientific as possible. significant change in smoking behavior, being either
lower prevalence, reduced cigarette consumption per
Media advocacy capita or an increase in smoking cessation rate. Of the
Media advocacy is to frame an issue well and advocate
studies, 23(62%) suggested at least one favorable
that issue using the media as a platform. Information
outcome with relation to smoking change, whilst 14
is disseminated through the media with a view to alter
studies(38%), showed no marked difference. Where the
public mind or change their views.[14] Media advocacy
community was the unit of assignment and analysis, 5
needs to be based on the solid principles of planning.
of the 8 studies(62.5%) reported a positive change in
Media advocacy planning used GOTME approach:
smoking behavior. In the remaining studies, where the
Goal, objective, target, message, and evaluation.[14]
individual was the unit of analysis, hence with a reduced
Effectiveness significance level, 18 out of 29 studies(62%) showed
Media advocacy was used in many health promotion at least one favorable outcome with relation to smoking
interventions and it is particularly concerned with behavioral outcome. This systematic review concluded
significant environmental and policy change. The that community health promotion methods were more
Project Tobacco Reduction Using Effective Strategies effective than other methods of smoking prevention.[18]
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International Journal of Preventive Medicine 2016, 7:7

Community mobilization methods are essential in the The important guiding principles of MI are expressing
field of health promotion. Empowering communities to empathy, supporting selfefficacy, developing discrepancy
bring about change in their own social domains is not only and rolling with resistance. It primarily derived from
more sustainable but however, is also extremely effective. social psychology, cognitive dissonance, selfefficacy, and
empathic processes. Various forms of MI are Motivational
Social marketing Enhancement Therapy, Brief MI(BMI), and telephone
Kotler and Zaltman coined the term social marketing
using it in an article evaluating the application of
commercial marketing principles.[19] The social marketing Effectiveness
is the systematic application of principles and techniques MI has been used successfully for smoking cessation.
of marketing to create, communicate, and deliver value Glasgow etal., demonstrated the effectiveness of a
in order to influence a target audience to achieve BMIbased intervention given by clinical staff versus
specific behavioral goals, for social good.[20] It is best advice to quit smoking among 1154 women attending
described as a behavioral approach that helps to create a plannedparenthood clinics. There were a higher 7day
longterm sustainable impact upon the choices of people. abstinence rates in the MI intervention group at
Social marketing draws on and incorporates the use of 6weeks(10.2% vs. 6.9%). The MI intervention group
behavioral theory. showed a significant reduction in a number of cigarettes
smoked at both 6weeks and 6months.[26] The relatively
Effectiveness brief training of staffs for MI and low rate of completion
Despite many challenges, the evidence for the
for followup telephone calls were a limitation of this
effectiveness of social marketing interventions does
study. Valanis etal., found a significant impact of MI
exist and is growing. The project 16 incorporates social
intervention for women attending prenatal clinics on
marketing method for reducing both illegal sales of
selfreported quitting rates both during pregnancy and
tobacco and youth tobacco use showed a significant effect
612months after delivery.[27] In another study, 536
on lowering the smoking prevalence.[21] In a review by
smokers from 21 clinical practices were randomized
Gordon etal., 18 out of 21 studies examined shortterm
to receive either MI or brief advice to quit smoking
impact(up to 1year) of social marketing intervention
from their general practitioner showed a significant
on smoking prevention. Thirteen studies demonstrated
effect on smoking cessation.[28] Metaanalysis of MI
the significant positive effects.[22] The Sunderland
versus brief advice or usual care yielded a modest but
project was based on social marketing strategy for
significant increase in quitting. Subgroup analyzes
increasing the uptake of smoking cessation services and
demonstrated that the MI intervention was more
quit rate among pregnant women in Sunderland. The
effective when administered by primarycare physicians
intervention primarily includes the design and pretesting
and by counselors, and when it was conducted in longer
of new marketing/information material and consumer
sessions(more than 20min per session).[29] Recently
friendly cessation support. There was a significant
conducted systematic review of RCTs in which MI used
impact of project and there was a 10fold increase in the
for smoking cessation showed that MI versus brief advice
smoking quitting or setting a date for quitting smoking
or usual care yielded a modest but significant increase in
among pregnant women as compared to neighboring
quitting(risk ratio: 1.26; 95% CI: 1.161.36; 28 studies;
primarycare trusts which did not apply similar social
marketing approach.[23]
MI appears to have broad application to behavioral
A metaanalysis of the efficacy of SMS text message
medicine. Although the initial outcome studies have
interventions for smoking cessation showed that smoking
produced mixed results, MI appears to have potential
quit rates for the text messaging intervention group were
efficacy. Further research studies required to address the
35% higher compared to the control group quits rates.
numerous questions regarding how MI works in different
Results also suggest that SMS text messaging may be a
conditions and individuals and which health professionals
promising way to improve smoking cessation outcomes.[24]
are best able to deliver MI with fidelity.
The social marketing interventions should always be
adapted according to local needs and contexts. There
Mass media campaigns
Mass media campaigns are widely used to expose the
is a need for integrating specific vertical and horizontal
population to messages through television, radio, and
interventions with social marketing to make it more
newspapers. Such campaigns can produce positive
sustainable and effective.
or negative changes in healthrelated behavior in
Motivational interviewing populations and is a useful method for raising an issue
Motivational interviewing(MI) defined as a and encouraging debate.[31] The mass media campaign
clientcentered, directive approach to stimulate the approach based on the theories of the social influences or
positive behavior change and resolve ambivalence.[25] social learning theory.
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International Journal of Preventive Medicine 2016, 7:7

Effectiveness encourage the smoking cessation. Cahill etal., conducted

It has been suggested that the mass media is particularly an interventional review of 51 studies covering 53
appropriate for delivering antismoking messages to young interventions. They found 37 studies of workplace
people because they are more exposed to the media. interventions aimed at individual workers, covering
In the interventional review of studies for assessing group therapy, individual counseling, selfhelp materials,
smoking behavior by Brinn etal., investigated the effect nicotine replacement therapy, and social support. Group
of a mass media prevention effort directed at young programs, individual counseling, and nicotine replacement
people<25years using a parallel groupRCT or controlled therapy increased cessation rates in comparison to no
clinical trial design.[31] Three studies were associated with treatment or minimal intervention controls. Selfhelp
a reduction in smoking outcomes. One study found a materials were less effective. They also found 16 studies
statistically significant decrease in smoking uptake by testing interventions applied to the workplace as a whole
girls(with net increase of 8.6% in Intervention County and found the settings based approach is more effective
vs. 12.4% in the control) and a nonsignificant trend in than other interventions.[36] But overall, there was a lack
boys at 3year followup(6.810.5%). In an another study, of evidence that comprehensive programs reduced the
impact compared between school based programs with prevalence of smoking. Incentive schemes increased the
mass media and school based intervention alone, showed attempts to stop smoking though there was less evidence
a significant effect of combined intervention as compared that they increased the rate of actual quitting. They
to school alone. The results reported in all seven studies failed to detect an effect of comprehensive programs in
tended to be based on outcome data relating to a reducing the prevalence of smoking.
subsample of participants rather than on the basis of
allocation to groups. Evaluation of effectiveness on the The better understanding of health promoting setting
basis of data provided by those participants available at among various actors, politicians, and well as workers
followup is likely to be biased.[32] is essential for the efficient implementation of setting
based health promotion methods. There is a need
Bala etal., assessed the effectiveness of mass media to understand the implementation process and the
interventions in reducing smoking among the adults importance of carrying out systematic evaluations for
through systematic review has shown that the sustainable, healthy settings.
comprehensive tobacco control programs which include
the mass media campaigns can be effective in changing CONCLUSIONS
smoking behavior in adults. The intensity and duration
of campaigns may influence effectiveness.[33] Health promotional interventions for prevention
Mass media campaigns should be included as a key and cessation of smoking are thought to involve a
component of approaches to improve population health threetiered approach. Reaching the mass public by social
behavior. Careful planning and testing with target marketing and mass media interventions, reaching the
audiences is crucial. Emphasis should be placed on the individual by MI, peer education, whilst approaching the
involvement of small groups of representative samples at community via community mobilization and changing
whom the campaign is directed. Such groups can also be the environment by media advocacy and setting based
involved in message development. intervention seems to be an extremely effective method
of inducing smoking prevention and cessation. These
Setting based approach methods incorporate the principles of inducing change
The emergence of the settings approach has been at an individual level, a change in social norms in the
attributed to the Ottawa Charters assertion that, health
community and sociopolitical efforts to promote the
is created and lived by people within the settings of their
health of the population. It would be more effective
everyday life; where they learn, work, play, and love.[34]
to implement the interventions focusing on social
Settings for health are defined as the place for social
attitudinal and environmental changes before trying to
context in which the people engage in daily activities
focus on individual behavioral change, which is difficult
in which environmental organizational and personal
to bring about. Foundation for multiple interventions
factors interact to affect health and wellbeing.[35] A
can only be developed with innovative approaches to
settings approach is built upon the principles of health
work with the population at different levels. In the past
promotion, in a holistic manner, and as a process of
years, we have learned how to engage the population
enabling people to increase control over, and to improve
and various stakeholders for developing effective and
their health.
sustainable partnership for health promotion. Population
Effectiveness capacity to address change and readiness are the key
The workplace has potential as a setting through factors influences effective health promotion efforts for
which the large groups of people can be reached to smoking prevention and cessation.
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International Journal of Preventive Medicine 2016, 7:7

ACKNOWLEDGEMENTS 16. NiederdeppeJ, FarrellyMC, WenterD. Media advocacy, tobacco control

policy change and teen smoking in Florida. Tob Control 2007;16:4752.
17. BlochP, ToftU, ReinbachHC, ClausenLT, MikkelsenBE, PoulsenK, etal.
This work was supported by a Welcome Trust Capacity Revitalizing the setting approachSupersettings for sustainable impact in
Strengthening Strategic Award to the Public Health Foundation community health promotion. Int J Behav Nutr Phys Act 2014;11:118.
of India and a consortium of UK universities. 18. SeckerWalkerRH, GnichW, PlattS, LancasterT. Community interventions
for reducing smoking among adults. Cochrane Database Syst Rev
Note: MG is an alumnus of AIIMS, NewDelhi; London School 2002;3:CD001745.
of Economics; and London School of Hygiene and Tropical 19. KotlerP, ZaltmanG. Social marketing: An approach to planned social change.
Medicine. JMark 1971;35:312.
20. SmithWA. Social marketing: An overview of approach and effects. Inj Prev
Received: 13 Nov 14 Accepted: 30 Jun 15 2006;12Suppl1:i3843.
Published: 11 Jan 16 21. BiglanA, AryDV, SmolkowskiK, DuncanT, BlackC. Arandomised controlled
trial of a community intervention to prevent adolescent tobacco use. Tob
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Rep 1995;110:6259. Conflict of Interest: None declared.