Effects of a brief training program for lay health volunteers to facilitate smoking cessation among African Americans.

Abstract

This study evaluated a training program to train lay health volunteers in facilitating smoking cessation for a low-income, African American community in a Midwest city. Fourteen volunteers completed this training. The four-hour training program applied the constructs of the Social Cognitive Theory (SCT), namely self-efficacy and outcome expectations relating to the processes of behavioral change. A repeated measures design was utilized measuring participants' perceived knowledge, outcome expectations, their self-efficacy on conducting smoking cessation classes and their behavioral change in organizing and conducting smoking cessation programs. Results highlighted statistically significant changes in knowledge, outcome expectations, and self-efficacy (p [less than or equal to] 0. 05) between pre-test and post-test indicating a successful training program. However, no significance was noted for a change in behavior. Implementation and environmental issues need to be encouraged in future programs in order to effect the behavioral change and continue the success of the program.

Key words: Smoking cessation, lay health volunteers, African Americans

Introduction

Tobacco use varies among racial and ethnic groups. According to the 1998 report of the Surgeon General on Tobacco Use, the cigarette consumption among adult African Americans declined from 37.3 percent to 26.5 percent between 1978-1995 (United States Department of Health and Human Services [USDHHS], 1998). Although this decrease in adults is a favorable move, cigarette smoking is still the leading preventable cause of disease and death for all the racial groups in the United States. The African American population is presently bearing the greatest burden with lung cancer leading to the cause for cancer deaths for this subgroup (USDHHS, 1998). In a recent study on substance abuse among African Americans the data indicated that the age groups of 26-35 and 35 and over reported the highest prevalence of cigarette, smokeless tobacco, marijuana, and cocaine use. (Ma & Shive, 2000). Smoking rates are also higher for African Americans in central city locations than in non-city areas which would be attributed to the lifestyle factors of stressful conditions or just the daily hassles of urban living (King, Polendac, & Bendel, 1999). Adult smoking rates for the Midwest according to King and colleagues (1996) were estimated among the highest in the country at 25%.

African Americans have none-the-less reported a higher desire to quit smoking and a higher number of quit attempts than whites (Shorling, et al., 1997). Unfortunately, this increase in quit attempts does not correlate with success rates. According to Schorling and colleagues (1997), African Americans have experienced more of a relapse in their effort to stop smoking. There is also some evidence that medical professionals may treat African Americans differently. Physicians do not inquire about their health status, the seriousness of certain habits such as smoking, or give advice on methods to achieve cessation as frequently as with other groups (Gamble, 1997). There are also trust issues with health care providers that exist in the African American community (Gamble, 1997). Therefore, it could be helpful to utilize trusted community members in the African American community to assist in smoking cessation interventions. Many African Americans have a close relationship with their community centered around their church, neighborhoods, and extended family (Jackson & Parks, 1997).

Lay health educators have been used for years in the African American community to help address health disparities among the minority population and to promote health (Jackson & Parks, 1997). Individuals in any community trained as lay health educators could become involved with a vast range of health issues in various settings throughout their community. By diffusing a health behavior change through the community with lay advisors that are trained to facilitate a short-term smoking cessation program, possibly more African Americans could be reached.

Some of the existing programs build only on the knowledge about the addiction of smoking and the ways to enable the smoker to quit. Several theories and models have evolved to address behavioral change. There is a need for these programs to be based on empirically-tested behavioral theory that can effectively use the limited time available to conduct smoking cessation sessions. A theory-based programmatic approach could potentially address the low rate of success in smoking cessation among African Americans.

Several large studies have examined the success rate of African American smokers in the different interventions for smoking cessation such as the Harlem Health Project in New York City (Resnicow et al., 1997) and the Heart, Body, and Soul study in Maryland (Voorhees et al., 1996). In a literature review, few studies had evaluated the effectiveness of the trainers themselves involved in these types of smoking cessation programs. The research did not examine interventions designed to train trainers or lay volunteers to facilitate a quit smoking behavior change. According to Jackson and Parks (1997), the actual recruitment and training process has not been fully explored in the literature. Lay health educators have had positive effects in certain health behaviors. The support for their use can be seen with successful community interventions in smoking cessation and cardiovascular disease reduction (Lacey, Tukes, Manfredi, & Warenke, 1991). Eng and Young (1992) stated that lay health educators could be an important support system in health interventions and in collaborating with formal professional services. The question remains as to whether a formal program modified to include behavioral theories could be initiated by lay health volunteers to help address disparity on this health issue. According to Ahluwalia (1996), volunteer agencies such as the American Cancer Society and the American Lung Association have not reached the minority population to the extent that they have the white population. Poor access to these resources and the reduced access to primary care may be a drawback to successful smoking cessation in African Americans. Ahluwalia (1996) suggests that although minority populations rarely use formal smoking cessation programs, this should not deter efforts by community organizations such as churches and other networks to develop intervention strategies that would reach the African American population.

Therefore, the purpose of this study was to develop, pilot test and evaluate the effects of a lay volunteers training program designed for a smoking cessation program in a predominately African American community in a Midwest city. The participant's self-reported changes in perceived knowledge, outcome expectations (anticipated benefits) and expectancies (value placed on anticipated benefits), self-efficacy to facilitate smoking cessation efforts as well as their self-reported behavior in conducting smoking cessation sessions were measured. The intent was to evaluate the process and impact of this theory based smoking cessation program. The constructs of the Social Cognitive Theory (SCT) using the concepts of outcome expectations and self-efficacy were added to the existing American Cancer Society's Fresh Start program. According to Bandura, a person engages in a behavior that leads to a given outcome based on their expectations regarding that outcome and the self-efficacy expectations in their ability to engage in the behavior (Bandura, 1986; Baranowski, Perry, & Parcel, 1997; Clark & Becker, 1998). The messages were tailored to specifically influence the African American community.

Methods

The participants for this study consisted of lay members of the community recruited through an existing outreach program by the staff at a neighborhood health center serving the health needs of a predominately African American community in a Midwest city. The African American patient population for this health clinic is 71%. The convenience sample for the study was targeted from a tract of the city with a population of approximately 50,000. An initial goal was for 50 participants to take part in the training program designed to accept referrals from a clinic based cessation referral program. Due to limited funds and physical space, a total of 26 volunteers were invited to participate in a training program to learn the skills to facilitate smoking cessation programs. The program was the American Cancer Society' s Fresh Start program that had been modified to include the Social Cognitive Theory constructs of outcome expectations, outcome expectancies, and self-efficacy. The volunteers for the training program came from various community organizations, ministers from churches, staff from the health center, the Sudanese immigrant community and the community at large. This group participated in a brief four-hour training program at the neighborhood health center. The training included four sessions developed around the original version of the Fresh Start program. The first session concentrated on the individual's reasons for smoking, their perceived benefits of quitting instead of the cons of smoking as in the original version, and the possible strategies for the individual to quit. The outcome expectations (beliefs) and expectancies (values) for facilitating smoking cessation by lay health volunteers were also discussed. The specific reasons included improvements of skills and gaining personal satisfaction. The second session dealt with managing the first few days off cigarettes and building the self-efficacy of the smoker. The participants learned how to help the smoker realize past successes in other behavioral changes and work on small steps for goal building. They also learned how to help the smoker develop coping strategies and practice relaxation techniques. The self-efficacy of the trainees was built by allowing them to practice facilitation skills in small steps. The third session dealt with the use of social support for the smoker and the methods for establishing this support in their environment. Additional discussion on building self-efficacy for overcoming barriers in facilitating smoking cessation by the potential trainers was included. The trainees were asked to rely on their fellow trainees for assistance and support as they prepared for their first cessation class. The fourth session involved discussing what smokers will go through for the next six months until their behavior is in the maintenance stage. Strategies for coping and preventing relapse were reviewed. A discussion dealt with how the trainees might overcome discouragement when smokers failed to quit. Upon completion of the training the volunteers were encouraged to organize and facilitate small group smoking cessation programs for smokers. The primary recruiting source was to be referral by physicians from the health center and by word of mouth throughout the community. At six months, a post-test was administered to evaluate the facilitators' beliefs about their knowledge of smoking cessation, attitudes about perceived outcomes of facilitating smoking programs, their self-efficacy to facilitate the programs, and their specific behaviors in organizing and facilitating smoking cessation programs.

A self-report questionnaire reviewed by a panel of three professors at a Midwest university constituted the measures that were used for this study. The questionnaire was designed to assess beliefs about the knowledge of smoking of potential facilitators, perceptions about expectations and expectancies for conducting a smoking cessation program and self-efficacy for facilitating smoking cessation by the trainees. The participants were also asked to self-report the frequency in which they engaged in the behavior of conducting smoking cessation sessions. The demographics of the trainees were collected on the pre-test survey. The post-test contained two additional questions for the trainees to assess the satisfaction with the training program.

The survey questionnaire consisted of 29 items on a 5-point Likert scale. The perceived knowledge on the questionnaire consisted of 7 items ranging from not all (0) to enough to teach (4). The construct of their beliefs about their knowledge of smoking cessation were operationally defined by what the trainee self-reported as he or she knew about such factors as reasons people smoked, smoking cessation strategies, the benefits of quitting and ways to build a smoker's self confidence. The outcome expectations consisted of 6 items with the range of never (0) to always (4). The construct for these beliefs was operationally measured by asking about perceptions of such outcomes as supplementing their income, pleasing their supervisor, enhancing their skills and deriving personal satisfaction. For the outcome expectancies the range for the 6 items were from not at all important (0) to extremely important (4). This construct of the value the trainee placed on the perceived outcome was operationally defined by items such as significantly benefiting others, helping people quit smoking, enhancing their skills, and deriving personal satisfaction. The range for the 6 items on self-efficacy was from not at all sure (0) to completely sure (4). The construct for their self-efficacy was operationally measured by factors such as believing they could organize a smoking cessation program, conduct the smoking cessation program, tailor the program to the African American individual and to record a smoker's progress. The behavioral items consisted of three questions from never (0) to always (4). The construct for the trainees' behavioral change was operationally measured by such factors as making efforts to organize a cessation program, conducting a cessation session, and recording a smoker's quitting process. The reliability alpha coefficient was found to be 0.89 that is high and acceptable (Polit & Hungler, 1999). The training satisfaction consisted of two questions on a range from needs a lot of improvement (0) to excellent (4). No comparison or control group was used to compare the program's impact or to compare with the original ACS Fresh Start program.

Results

Sixteen participants completed the pre-test and post-test questionnaires with fourteen of those participants returning the follow-up survey at six months. The age range of the sixteen participants was between 25-54 years with a mean of 34.6 years and a standard deviation of 8.07 years.

The majority of the participants were females (62.5%). The level of education of trainees was 43.8% reporting completion of high school and 50% reporting a college degree or more. Only one participant reported an educational level of less than high school. Most of the participants were African Americans (81.3%) with one white and two classified as other that included all other racial groups.

For data analysis, univariate repeated measures analyses of variance (ANOVA) were conducted using SPSS for Windows, Version 8.0 under the general linear model (GLM) procedure. The descriptive statistics were obtained to compare the means between pre-test, post-test, and the follow-up surveys for perceived knowledge, outcome expectations for facilitating smoking cessation interventions (outcome expectations multiplied by outcome expectancies), self-efficacy in conducting smoking cessation programs, and the change in training related behaviors.

Table 1 lists the means and standard deviations of the study variables on perceived knowledge, outcome expectations, self-efficacy and self-reported behaviors between the pre-test, post-test, and follow up. For all the study variables, the mean from pre-test to post-test had increased with a two-fold difference for perceived knowledge and self-efficacy. At follow-up, the means had decreased for all the study variables compared to the post-test means. The mean for outcome expectations had actually dropped below the pre-test mean. Table 2 shows the ANOVA results for all dependent variables. A statistical significance was found for all study variables (p [less than or equal to] 0.05) across measurement periods. As suggested by Kennedy and Bush (1985), a dependent t-test was utilized for post-hoc comparisons with a stringent significance level set at 0.017 (0.05/3) to reduce the Type II error. These post-hoc tests revealed no statistical significance for outcome expectations between pre-test and follow-up (p=0.149). Significant comparisons among outcome expectancies between pre-test and post-test as well as post-test and follow-up means was observed (p [less than or equal to] 0.017). No statistical significance was found among any of the three pairs in the self reported behavioral variable (p [greater than or equal to] 0.017). However, statistical significance was found among all pairs for perceived knowledge and self-efficacy (p [less than or equal to] 0.017). The results from satisfaction ratings for the training program demonstrate high ratings by the participants for organization of the four-hour sessions (mean 3.50, standard deviation 0.73) and overall satisfaction (mean 3.63, standard deviation 0.50).

Conclusions

The goal of this study was to develop and pilot test a "Train the Trainer's" program for smoking cessation in a predominately African American community. The aim was to evaluate the training program for changes in the trainees' beliefs about their knowledge of smoking cessation, outcome expectations and expectancies, their self-efficacy in facilitating smoking cessation sessions, and the behavioral change among the participants. The results of the study found statistical significance for differences between pre-test and post-test for the defined variables based on the behavioral theories that were integrated into the modified Fresh Start program. Yet, no actual significance was noted for the behavioral variable when calculating the post-hoc tests.

For beliefs about their knowledge of smoking cessation, the mean at the post-test doubled from a score of 12.07 units at pre-test to 25.07 units, signifying a successful training program from a score cessation that is based on empirically-tested behavioral theories. This not only exhibits statistical but, practical significance with the two-fold increase in the mean for the self-reported perceived knowledge following the training program. However, the results for the six-month follow up expressed a loss with the mean dropping to 19.78 units. A similar finding was seen in the results for the perceptions of outcome expectations and outcome expectancies with the mean score for pre-test at 36.78 units increasing to 56.64 units at post-test; again demonstrating a favorable training program for the participants. The range of this scale was from 0-96 compiled by multiplying outcome expectations by outcome expectancies. Their score on the pre-test was below mid range, perhaps indicating that the volunteers were not quite sure they could influence behavior of smokers. At post-test, the mean increased by nearly 18 units, signifying that the volunteers may believe that they could influence the outcomes delineated in the training program. When looking at the follow up results for attitudes, the mean score actually dropped below the pre-test mean to 28.50 units. There were few referrals from the health center and as the time passed, the volunteers may have felt less sure about the outcomes since they had no opportunities to present programs. The degree to which the volunteers had confidence that the action of organizing and conducting smoking cessation classes would lead to positive changes in a smoker determined the strength of their expectations.

How confident these trainees were performing this behavior of facilitating smoking cessation classes determined the strength of their reported self-efficacy (Devins, 1992). The self-efficacy mean score in facilitating smoking cessation sessions for the participants nearly doubled from a pre-test score of 11.76 units to a post-test mean of 21.36 units. Another two-fold increase in the mean scores that exhibits statistical and practical significance. The mean score of the follow up survey at 17.93 unites had slid back toward the pre-test mean.

No statistical significance was found for the comparison of means in any behavioral variables among the three measurement periods. This finding is not surprising due to the fact that no training was put into practice during the time period of the study. To increase self-efficacy, small steps to success will build an individual's self-efficacy and lead to a positive behavioral change (Baranowski et al., 1997). Unfortunately, due to circumstances beyond the control of the participants, they could not build upon their knowledge and experience from the training session to exhibit any statistical or practical significance for the behavioral change. The timeline for the modified Fresh Start smoking cessation classes for smokers was solely dependent on the health center for the referrals. As is often the case when learning new skills, there is a decay of learning if there is not an opportunity to apply newly acquired skills (Green and Lewis, 1986). After six months of no implementation, the participants perceived a decrease in their knowledge, changes in outcome expectations and expectancies, and a decrease in self-efficacy in organizing and conducting the smoking cessations classes.

No experimental studies were found in the literature that evaluated the impact of training on perceptions of facilitators or lay health educators involved in a smoking cessation program. It is more difficult to examine the effect of a training program for volunteers compared with the effect of a cessation program that has a primary outcome, the quit rate of smokers. Dependent variables studied in training programs can be affected by multiple confounding variables. Figa-Talamangia (1974) believed a very large number of individuals would have to be randomly assigned to a training and non-training group in order to identify the relevant outcomes. A control group for evaluating this training program was not feasible but must be attempted by future researchers.

The interpretations of the findings for this study are limited by the small sample size. Therefore, generalizing to the population would not be warranted. It is often challenging to find more volunteers who are willing to work with low-income, minority communities. A larger study might corroborate the findings of this pilot project. In the research design, there was no control or comparison group and as such, the participants were not randomly assigned or compared to groups who received either a different version of the training or no training at all, which threatens the internal validity of the current study. Due to situational constraints a randomized control group research design could not be utilized, but the external validity of the current study was improved because the "Train and Trainers" program was implemented in a typical setting.

Attrition was an apparent limitation in this study. Nineteen attended the beginning of the training program, sixteen completed the pre-test and post-test, and fourteen completed the follow-up questionnaire. It is not known why these particular questionnaires were not completed and returned.

Recommendations for further research

Additional research about the efficacy of training facilitators for smoking cessation should attempt to enhance internal validity. A comparison group trained with the Fresh Start program may help draw conclusions about the impact of introducing behavioral constructs into training.

A comparison study could be done on the success rate of smokers enrolled in the modified Fresh Start program with smokers who participated in the standard Fresh Start program or who relied solely on physicians' interventions. Past studies have been contradictory concerning the assumption that most smokers of any race prefer to quit on their own (Dijkastra, DeVries, Roijackers, & Van Breukelen, 1998) to the statement that more than two-thirds of a large population of African Americans polled would attend a formal program (USDHHS, 1998).

The incidence of smoking still contributes to large health disparities among African Americans and White Americans making sound research necessary for effective approaches to smoking cessation for African Americans.

Implications for Practitioners

Statistical and practical significance in perceived knowledge, attitudes, and self-efficacy of these volunteers indicates that the training program successfully changed the constructs of the Social Cognitive Theory (SCT). The absence of statistical significant difference in training for the behaviors does not necessarily point to a theory-based failure in the training program rather the lack of active practice of newly learned training material may have led to the absence of significant behavioral change.

Smokers for the cessation program were to have recruited through referral from physicians who treated patients at the neighborhood health center and through community networking by the lay health educators. However, there were very few referrals from physicians. Other sources of referrals from clinical social workers, nurses, nurse practitioners, and day care workers need to be explored by future planners. Inadequate organization on part of all entities to properly implement the programs impeded the process. A goal for practitioners should be to outline a definitive plan that has an established timeline for referrals. In this regard a health educator would be invaluable in coordinating all aspects for a community smoking cessation endeavor.

Environmental influence deals with the personal and behavioral interactions of individuals (Baranowski et al., 1997). Important aspects of the environment for this minority community that could lead to a positive behavioral change would be to incorporate churches in establishing the smoking cessation sessions. As stated in the literature review, cultural and spiritual aspects are very important to the African American community. In this training program the outline did not stress this component. The trainees themselves, who were ex-smokers interjected into the discussion portion to a great degree the value of spiritual guidance based on their own experience of the quitting process. Other such training programs should incorporate this crucial spiritual component into the discussion of social support and building self-efficacy.

To build on trainees' organization skills, health educators should assist them in implementing initial cessation programs. Self-efficacy in training could be enhanced by setting up the smoking cessation classes with two trainees for their initial facilitation. The construct of self-control from SCT (Bandura, 1986) can be used. This can be in the form of setting realistic goals for outcomes with volunteers conducting smoking cessation sessions.

Although only a small sample size was available for this pilot study on a "Train the Trainers" program, this type of program could be a cost-effective smoking cessation intervention for the minority community. Further, use of informal networks has been well established in research literature for addressing other disease management and risk reduction behaviors (Fisher et al., 1998). Therefore, smoking cessation interventions through volunteers need to be high priority for African American communities ro reduce health risks.

Table 1
Comparison of the means and standard deviations of perceived
knowledge, SCT constructs and self-reported behavioral changes,
before, after and at six-month follow-up among lay health volunteers

Variable            Valid   Possible   Pre-test
                      n     Range      Mean (std.dev.)

Mean (std.dev.)

Perceived
  knowledge         14      0-28       12.07 (5.64)
Outcome
  Expectations      14      0-96       36.79 (16.21)
  (expectations *
  expectancies)

Self-efficacy       14      0-28       11.78 (6.84)

Self-reported
  Behaviors         14      0-12       3.14 (4.75)

Variable            Post-test         Follow-up
                    Mean (std.dev.)

Mean (std.dev.)

Perceived
  knowledge         25.07 (4.10)      19.79 (5.03)
Outcome
  Expectations      56.64 (20.00)     28.50 (20.50)
  (expectations *
  expectancies)

Self-efficacy       21.36 (4.97)      17.93 (5.80)

Self-reported
  Behaviors          5.75 (5.12)       4.14 (3.94)

Table 2
summary of univariate repeated measures analysis of variance between
pre-test, post-test, and follow-up for the variable about smoking
cessation among lay health volunteers

(n=14)

Variable               Sum of     df   Mean         F      p-value
                       Squares         Square

Perceived
  Knowledge            1196.762    2     598.38   34.13    0.0001
Error                    455.91   26      17.54

Outcome
  Expectations         4213.905    2   2106.952   12.726   0.0001
Error                  4304.726   26    165.568

Self-efficacy           658.476    2    329.238   20.308   0.0001
Error                   421.524   26     16.212

Self-reported
  Behaviors              41.714    2     20.857    4.038   0.03
Error                   134.286   26      5.165

Note: Dependent t-test were utilzed as post-hoc tests to analyze
and compare the significant mean differences for the three times.

Level of significance was set at 0.017 (0.05/3).

References

Ahluwalis, J.S. (1996). Smoking cessation in African Americans. American Journal of Health Behavior, 20, 312-318.

Bandura, A. (1986). Social foundations of thought and action. Englewood Cliffs, NJ: Prentice Hall, Inc.

Baranowski, T., Perry, C.L., & Parcel, G.S. (1997). How individuals, environments, and health behavior interact. In K. Glanz, F.M. Lewis, & B.K. Rimer (Eds.), Health behavior and health education (pp. 153-178). San Francisco, CA: Jossey-Bass, Inc.

Clark, N.M. & Becker, M.N. (1998). Theoretical models and strategies for improving adherence and disease management. In Shumaker, S.A., Schorn, E.B., Ockene, J.K., & McBee, W.L. (Eds.), The handbook of health behavior change, (pp. 5-27). New York, New York: Springer Publishing Co.

Devins, G. (1992). Social cognitive analysis of recovery from a lapse after smoking cessation: comment on Haaga and Stewart, 1992. Journal of consulting and Clinical Psychology, 60, 29-31.

Dijkstra, A., De Vries, H., Roikackers, J., & van Breukelen, G. (1998). Tailored interventions to communicate stage-matched information to smokers in different motivational stages. Journal of Consulting and Clinical Psychology, 66, 549-557.

Eng. E., & Young, R. (1992). Lay health advisors as community change agents. Family Community Health, 15, 24-40.

Figa-Talamanca, I. (1974). Problems in the evaluation of training health personnel. Baltimore, MD: John Hopkins University, School of Hygiene and Public Health.

Fisher, E.B., Auslander, W.F., Munro, J.F., Arfken, C.L., Browson, R.C., & Owens, N.W. (1998). Neighbors for a smoke free north side: Evaluation of a community organization approach to promote smoking cessation among African Americans. American Journal of Public Health, 88, 1658-1663.

Gamble, V.N., (1997). Under the shadow of Tuskegee: African Americans and health care. American Journal of Public Health, 87, 1773-1777.

Green, L.W., & Lewis, F.M. (1986). Measurement of evaluation in health education and health promotion. Mountain View, CA: Mayfield.

Jackson, E.J. & Parks, C.P. (1997). Recruitment and training from selected lay health advisor programs among African Americans: A 20-Year perspective. Health Education & Behavior, 24, 418-431.

Kennedy, J.J., & Bush, A.J. (1985). An introduction to the design and analysis of experiments in nehavioral research., MD: University Press of America.

King, G., Polednak, A.P., & Bendel, R. (1999). Regional Variation in smoking among African Americans. Preventive Medicine, 29, 126-132.

Lacey, L., Tukes, S., Manfredi, C., & Warencke, R.B., (1991). Use of lay health educators for smoking cessation in a hard-to-reach urban community. Journal of Community Health, 16, 269.282.

Ma, G.X. & Shive, S. (2000). A comparative analysis of perceived risks and substance abuse among ethnic groups. Addictive Behaviors, 25, 361-371.

Polit, D.F., & Hungler, B.P. (1999). Nursing research. Principles and Methods. Philadelphia: Lippincott.

Resnicow, K., Vaughn, R., Futterman, R. Weston, R.E., Royce, J., Parms, C., Hearn, M.D., Smith, M., Freeman, H.P., & Orlandi, M.A. (1997). A self-help smoking cessation program for inner-city African Americans: Results from the Harlem Health Connection Project. Health Education & Behavior, 24, 201-217.

Schorling, J.B., Roach, J., Siegel, M., Baturka, N., Hunt, R.N., Guterbock, T.M., & Stewart, H.L. (1997). A trail of church-based smoking cessation interventions for rural African Americans. Preventive Medicine, 26, 92-101.

United States Department of Health and Human Services. (1998). Tobacco use among United States racial/ethnic groups-African American and Alaskan Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report of the Surgeon General. Atlanta, GA: United States Department of Health and Human Services, Centers for Disease Prevention and Health Promotion, Office on Smoking and Health.

Voorhees, C.C., Stillman, F.A., Swank, R.T., Heagerty, P.J., Levine, D.M., & Becker, D.M. (1996). Heart, body, and soul: Impact on church-based smoking cessation interventions on readiness to quit. Preventive Medicine, 25, 277-285.

JADE"s website: www.unomaha.edu/~healthed/JADE.html

THERESE A. SULLIVAN, R.D.H., M.S. *

MANOJ SHARMA, MBBS, Ph.D.

RICHARD STACY, MPH, Ed.D.

Nebraska at Omaha

Therese A. Sullivan, Corresponding author and correspondence address:

Therese A. Sullivan

P. O. Box 815

O'Neill, ME 68763

402-336-3824 (phone)

[e-mail] (e-mail)