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DHS used a report produced by the National Cancer Institute, How to Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians , and a supplement, Clinical Interventions to Prevent Tobacco Use by Children and Adolescents, as a model for developing and implementing tobacco prevention programs within CHDP.3-6 According to DHS, the department informed local agencies of the anti-tobacco requirement, developed a protocol, added three questions on tobacco to the CHDP claim form, and provided training in the use of the protocol.7 While training targeted CHDP staff, the screens were actually performed by 4,500 provider organizations, not local CHDP staff.8 The train the trainer model used by DHS assumed that the county-level staff, once trained, would indeed train the actual providers and require that the tobacco use prevention be done

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It became a symbol of leisure, sophistication, and rebellion, which further contributed to its popularity