 2007 Johns Hopkins Bloomberg School of Public Health Section B ASSIST Evaluation

 2007 Johns Hopkins Bloomberg School of Public Health 2 Measures Strength of tobacco control index  Index to measure state capacity and infrastructure Initial outcomes index  Measure of policy change Media advocacy  Assessed change in newspaper coverage of tobacco policy issue

 2007 Johns Hopkins Bloomberg School of Public Health 3 Measures Final outcomes  Smoking prevalence (number of people who smoke)  Adults 18+  Tobacco Use Supplement to the Current Population Survey (TUS-CPS), an NCI-sponsored survey that was part of the U.S. Census Bureau’s Current Population Survey in 1992, 1993, 1998, and 1999  Per capita cigarette consumption  Calculated every two months for each state  Sales data for the total number of cigarette packs moved from wholesale warehouses, divided by the state’s adult population

 2007 Johns Hopkins Bloomberg School of Public Health 4 What Is the TUS-CPS? Source:

 2007 Johns Hopkins Bloomberg School of Public Health 5 NCI State Cancer Legislative Database Image source: U.S. National Cancer Institute. (2007).

 2007 Johns Hopkins Bloomberg School of Public Health 6 Strength of Tobacco Control Index (SoTC) SoTC summarizes the multiple components of tobacco control efforts Provides information on which components of ASSIST or ASSIST-like programs might be related to lower smoking prevalence or cigarette consumption SoTC is a multi-element measurement  Assesses the effects of three variables in each state: 1.Tobacco control resources (funding) 2.Capacity and infrastructure 3.Program efforts focused on policy and environmental change

 2007 Johns Hopkins Bloomberg School of Public Health 7 SoTC Conceptual Framework

 2007 Johns Hopkins Bloomberg School of Public Health 8 Initial Outcome Index (IOI) Cigarette price  NCI Cancer Legislative Database Smoke-free work environment  TUS-CPS Clean indoor air (CIA) legislative rating  NCI Cancer Legislative Database

 2007 Johns Hopkins Bloomberg School of Public Health 9 Components of the Legislative Ratings Clean indoor air  Government work sites  Private work sites  Schools  Childcare facilities  Restaurants  Retail stores  Recreation/cultural facilities  Penalties  Enforcement Youth access  Minimum age  Packaging  Clerk intervention  Photo identification  Vending machines  Free distribution  Graduated penalties  Random inspections  Enforcement

 2007 Johns Hopkins Bloomberg School of Public Health 10 Source: adapted by CTLT from U.S. National Cancer Institute. (2006). Monograph 17. Initial Outcome Index (IOI)

 2007 Johns Hopkins Bloomberg School of Public Health 11 IOI Averaged over ASSIST/Non-ASSIST States Source: adapted by CTLT from U.S. National Cancer Institute. (2006). Monograph 17.

 2007 Johns Hopkins Bloomberg School of Public Health 12 Newspaper Tracking System Content analysis of all daily newspapers in all states (n = 1,767) Continuous tracking from October 1993 to December 2000 Selective extraction of tobacco control policy coverage  Clean indoor air  Access to minors  Economic disincentives  Advertising and promotion  Miscellaneous Image source: Daily Freeman. (May 11, 2002).

 2007 Johns Hopkins Bloomberg School of Public Health 13 Variables Collected by the Newspaper Tracking System Coverage of tobacco issues  Volume  Placement  Type of articles  Slant Image sources: The Palm Beach Post. (May 9, 2002); New York Post. (May 12, 2002).

 2007 Johns Hopkins Bloomberg School of Public Health 14 Trend in Newspaper Coverage by Policy Source: adapted by CTLT from U.S. National Cancer Institute. (2006).

 2007 Johns Hopkins Bloomberg School of Public Health 15 Overall Challenges for the ASSIST Evaluation Evaluate NCI non-randomized study and understand tobacco control as conducted within states across the United States Address the complex, independent, and non-linear forces occurring  Many state-level factors Test a process for reducing tobacco use on a population-wide level  Multiple experiments are occurring with slightly different approaches in each state

 2007 Johns Hopkins Bloomberg School of Public Health 16 Overall Challenges for the ASSIST Evaluation Lack of consistent measurement data Gaps in linking exposures to outcomes Lack methods to measure quality, fidelity, and rate of implementation Need better methods to model dynamic hierarchical and time series data

 2007 Johns Hopkins Bloomberg School of Public Health 17 Data Challenges Limited baseline data No measure of intervention dose or exposure Diffusion of intervention strategies to non-ASSIST states; variation between ASSIST states in implementation of interventions Lack of data to assess tobacco industry’s strength of counter efforts

 2007 Johns Hopkins Bloomberg School of Public Health 18 Framing the Results “The small but significant differences in the reduction of adult smoking prevalence in ASSIST, when applied on a population basis, could be expected to have a large impact on the public’s health” “If all 50 states and the District of Columbia had implemented ASSIST, there would have been approximately 1,213,000 fewer smokers nationally” Source: Stillman, F., et al. (2003).

 2007 Johns Hopkins Bloomberg School of Public Health 19 Summary ASSIST evaluation established the effectiveness of the ASSIST interventions  Lower adult smoking prevalence in ASSIST states  Lower consumption rates in states with higher levels of SoTC, especially related to capacity  Lower prevalence and consumption in states with stronger policies Results from ASSIST provided evidence that the investment in state tobacco control programs that focused on policy interventions was an effective strategy to reduce tobacco use