2. Lessons from Public Health Achievements of the Twentieth Century to Emerging Health Research Issues Lawrence W. Green, DrPH Director, Office of Science & Extramural Research Centers for Disease Control & Prevention UNTHSC, April 4, 2003

3. What is this public health achievement of the 20th Century? What is the evaluation method to judge this an achievement?

4. Source: USDA; 1986 Surgeon General's Report. MMWR 2001. Great Depression End of WW II Nonsmokers’ Rights Movement Begins 1st Surgeon General’s Report Fairness Doctrine Messages on TV and Radio Federal Cigarette Tax Doubles Broadcast Ad Ban Adult Per Capita Cigarette Consumption and Major Historical Events—United States, 1900-2000 Master Settlement Agreement Nicotine Medications Available Over the Counter 1st Smoking- Cancer Concern 1st World Conference on Smoking and Health Surgeon General’s Report on Environmental Tobacco Smoke 1st Great American Smokeout

5. Lesson 1: Surveillance--Making Better Use of Natural Experiments Key to establishing baselines & trend lines that can be projected to warn against neglect Key to putting an issue on the public policy agenda Key to showing change in relation to other trends, policy and program interventions Key to comparing progress in relation to objectives and programs, over time and between jurisdictions.

6. Change in Per Capita Cigarette Consumption California & Massachusetts versus Other 48 States, 1984-1996 -25 -20 -15 -10 -5 0 5 Percent Reduction Other 48 StatesCaliforniaMassachusetts 1984-19881990-19921992-1996

7. What Worked? Making Better Use of “Natural Experiments” Comprehensive program and tax increases in CA and MA resulted in:Comprehensive program and tax increases in CA and MA resulted in: –2 - 3 times faster decline in adult smoking prevalence –Slowed rate of youth smoking prevalence compared to the rest of the nation –Accelerated passage of local ordinances Similar, though later, experience in OR & AZ, and in population segments of FLSimilar, though later, experience in OR & AZ, and in population segments of FL

8. Lesson 2: Comprehensiveness In trying to isolate the essential components of tobacco control programs that made them effective, none could be shown to stand alone Any combination of methods was more effective than the individual methods The more components, the more effective The more components, the better coverage

9. http://www.cdc.gov/tobacco

10. Components of Comprehensive Tobacco Control Programs Community ProgramsCommunity Programs Statewide ProgramsStatewide Programs Chronic Disease ProgramsChronic Disease Programs School ProgramsSchool Programs EnforcementEnforcement Counter-MarketingCounter-Marketing Cessation ProgramsCessation Programs Surveillance and EvaluationSurveillance and Evaluation Administration and ManagementAdministration and Management

11. Percent Reductions in Per Capita Cigarette Consumption Attributable to Non-Price Public Health Interventions Dollars Per Capita Annual Spending on Programs 0 $2$2 $4$4 $6$6 $8$8 $ 10 80% 60% 40% 20% Reduction in State Consumption 70% 20% 55%

12. Lesson 3: The Ecological Imperative Need to address the problem at all levelsNeed to address the problem at all levels –Individual –Organizational, institutional –Community –State, regional –National, international Need to make these levels of intervention mutually supportive and complementaryNeed to make these levels of intervention mutually supportive and complementary

13. Smokefree Indoor Air Legislation as of September 30, 1998-- Government Worksites in the United States D.C. No smoking allowed Designated smoking areas with separate ventilation Designated smoking areas required or allowed No restrictions 8 30 11 2

14. Lesson 4: Threshold Spending A critical mass of personal exposure is needed for individuals to be influencedA critical mass of personal exposure is needed for individuals to be influenced A critical mass of population exposure is necessary to effect detectable community responseA critical mass of population exposure is necessary to effect detectable community response A critical distribution of exposure is necessary to reach segments of the population who are less motivatedA critical distribution of exposure is necessary to reach segments of the population who are less motivated

15. $0$2$4$6$8$10$12 Massachusetts California Arizona Oregon NCI/ RWJF NCI CDC/ RWJF CDC Per Capita Spending on Tobacco Prevention and Control--FY1997 Dollars Per Capita

16. Lesson 5: The Environmental Imperative Environments provide opportunities Environments provide cues Environments enable choices Social environments reinforce positive behavior and punish negative behavior Legal penalties and financial incentives can be built into environments

17. 100-Percent Smokefree Ordinances, by Year of Passage 19851986198719881989199019911992* 0 2 4 6 8 10 12 14 16 18 Workplace Restaurant Restaurant and Workplace Number of Ordinances Year * Through September 1992. Source : National Institutes of Health, National Cancer Institute (1993). Smoking and Tobacco Control - Monograph 3. Major Local Tobacco Control Ordinates in the U.S. US Dept. of Health and Human Service. Public Health Service, National Institutes of Health. NIH Publ. No. 93-3532.

18. Tobacco Vending Machine Ordinances 19851986198719881989199019911992* 0 20 40 60 80 100 120 140 160 180 Total Ban Partial Ban Number of Ordinances (Cumulative) Year * Through September 1992. Source : National Institutes of Health, National Cancer Institute (1993). Smoking and Tobacco Control - Monograph 3. Major Local Tobacco Control Ordinates in the U.S. US Dept. of Health and Human Service. Public Health Service, National Institutes of Health. NIH Publ. No. 93-3532.

19. Lesson 6: The Educational Imperative Public awareness of risks and benefitsPublic awareness of risks and benefits Public interest in lifestyle optionsPublic interest in lifestyle options Public understanding of behavioral stepsPublic understanding of behavioral steps Public attitudes toward the options & stepsPublic attitudes toward the options & steps Public outrage at the conditions that have put them at risk or in dangerPublic outrage at the conditions that have put them at risk or in danger Personal and political actionsPersonal and political actions

20. Lesson 7: The Evidence-Based Imperative: The Need to Bridge... “best practices” indicated by research to their application in practice in underserved areas“best practices” indicated by research to their application in practice in underserved areas “best practices” from research to the most appropriate adaptations for special populations“best practices” from research to the most appropriate adaptations for special populations The success of individual behavior changes of the affluent to the system changes needed to reach the less affluent, less educated…The success of individual behavior changes of the affluent to the system changes needed to reach the less affluent, less educated… University-based, investigator-driven research to practitioner- & community-centered researchUniversity-based, investigator-driven research to practitioner- & community-centered research Green LW. Am J Health Behav, 2001. www.ajhb.org/

21. Breaking the Intervention-Based Research and Planning Habit 1. Select off-the-shelf Intervention or Service to be Studied 2. Assess Response to the Intervention or Service 3. Increase Dose or Increase Demand 4. Evaluate Response to the Intervention or Service

22. Strengthening Population-based, Diagnostic Planning Approaches* 1. Assess Needs & Capacities of Population 2. Assess Causes, Set Priorities & Objectives 3. Design & ImplementProgram 4. Evaluate Program *Procedural models, such as PRECEDE, PATCH, Intervention Mapping. See *Green & Kreuter, Health Promotion Planning, 3rd ed., Mayfield, 1999. Reassess causes Redesign

23. Uses of Evidence in Population-Based Planning Models 1. Assess Needs & Capacities of Population 2. Assess Causes (X) & Resources 3. Design & Implement Program 4. Evaluate Program Reconsider X D. Program Evidence Evidence from Research From previous evaluations (D 1 ) Evidence from community or population A. B. C. Evidence from R&D and Exp’tal. Studies D2D2

24. Connecting the Dots Public Health RESEARCH Basic Applied Field SURVEILLANCE & EVALUATION PRACTICE Policy Programs Participation And Collaboration Dissemination Translation How to measure Needs and effects Identify research- practice gaps Assessment of Needs, Planning, Monitoring Green & Mercer, Office of Science & Extramural Research, CDC, 2003.