Most children are highly impressionable and easily influenced, particularly by people they admire. Role models in sports and entertainment who publicly use or commercially promote tobacco products potentially influence children to do the same. Motorsports events are saturated with tobacco sponsorship. We describe the counter-promotion of tobacco at the famed Indianapolis 500 and suggest other venues to continue this "Tobacco Free America" theme.

Smoking and other tobacco exposure have been recognized for several decades as the most significant preventable factors in premature morbidity and mortality. Most physicians believe they should address the issue of tobacco intake with their patients but are rarely provided with adequate training or support to do so effectively. Recent research identifies several ways in which physicians can have substantial impact on patient smoking rates, by use of very brief patient-centered counseling and by prescribing nicotine replacement therapies. This paper describes a model curriculum for medical students, residents, medical faculty and community physicians that can be integrated into current training and teaching practices. The goal is to create a "preventive" intervention perspective to smoking that is effective, practical, efficacious and cost-effective.

Approximately 20% of the adult population in the United States have low-literacy skills. The subpopulations with the highest incidence of low literacy are nearly identical to those with the highest prevalence of tobacco use. Low-literacy smokers are more likely to underestimate the risks related to tobacco use, have less social pressure and support to quit smoking, may experience more life stress and consequently rely more heavily on nicotine use for stress reduction and require more assistance in developing a sense of self-efficacy. This indicates a need to modify smoking cessation methods of counselling, content and selection of educational materials for the marginally literate. Currently available low-literacy materials are listed, and suggestions for adjusting or developing materials are made.

The Indiana Prenatal Substance Use Prevention Program (PSUPP) was established in 1988 to help pregnant women quit cigarette smoking as well as alcohol and drugs. PSUPP directors implement the Screen, Intervene and Follow-up (SIF) model to assess substance use and provide services to help clients stop smoking. During fiscal year 1995, almost 25,000 individuals were impacted directly or indirectly by the PSUPP. Of these, 1,334 pregnant women were screened for substance use by PSUPP. Of the 987 women identified with a known substance use risk factor, 42.4% (418) were high-risk smokers (more than five cigarettes per day) and 9.9% (98) were medium-risk smokers (smoking between one and four cigarettes per day). PSUPP directors counseled their high/medium risk smokers an average of four times during their pregnancy. The PSUPP appears to be effective in getting high-risk smokers to change their smoking behavior during their pregnancy. Approximately one-half (49.9%) of the 516 high- or medium-risk smokers decreased or quit smoking while participating in the PSUPP. When surveyed, about 80% of the PSUPP participants stated that the knowledge they gained through PSUPP relative to tobacco use was "very helpful." Only two-thirds of the PSUPP clients responded that they "strongly agreed" with the statement that tobacco use causes babies to have a lower birth weight. While pregnancy may provide the "teachable moment" for women who smoke, more attention needs to be placed on making women more aware of the risks involved with smoking during pregnancy.

A multi-disciplinary workgroup of health care professionals and consumers has developed evidence-based best practices guidelines, an algorithm and clinical pathways for smoking cessation intervention for hospitalized patients. These practice recommendations can be adapted for implementation in managed care settings.

During the past 25 years, the consumption of chewing tobacco and moist snuff has been increasing in frequency, especially among the youth. Smokeless tobacco (ST) use among Indiana youngsters is higher than its use among youngsters nationally. More than 10% of current Indiana high school junior and senior female students report some ST usage. ST ingestion causes addiction and serious health consequences, including various forms of cancer and significant dental diseases. It is not a safe alternative to cigarette smoking. Nicotine levels in ST are very high, and ST intake is rapidly addicting. Tobacco companies have been accused of "graduating" youthful customers from flavored lower-nicotine "starter" products to forms that contain a more highly concentrated nicotine content. Clinicians should routinely ask children, teens and adults about ST use. Early intervention in youth who are experimenting with ST or using "starter" products may prevent addiction and disease. Physicians should be alert to the intraoral physical signs of ST use. To strengthen their tobacco intervention skills, physicians should require continuing education training regarding ST.