2. How Well Do Health Promotion “Best Practices” Generalize from the Ideosyncracies of the Research? Lawrence W. Green American Academy of Health Behavior Santa Fe, NM, September 24-27, 2000

3. 9/8/00LW Green CDC Pronouncements & the Paradox of Tobacco Control F “Tobacco control is one of the 10 great public health accomplishments of the 20th century.” (CDC, MMWR, 1999) F “Tobacco is the number one preventable cause of death.” (William Foege, 1989; ) F “Tobacco is the number one preventable cause of death.” (William Foege, 1989; McGinnis MJ, Foege WH. Review: Actual Causes of Death in the United States. JAMA 1993;270:2207-12 )

5. Annual Deaths from Smoking Compared with Selected Other Causes in the United States Sources: (AIDS) HIV/AIDS Surveillance Report, 1998; (Alcohol) McGinnis MJ, Foege WH. Review: Actual Causes of Death in the United States.JAMA 1993;270:2207-12; (Motor vehicle) National Highway Transportation Safety Administration, 1998; (Homicide, Suicide) NCHS, vital statistics, 1997; (Drug Induced) NCHS, vital statistics, 1996; (Smoking) SAMMEC, 1995

6. A Model of the Cigarette Epidemic Source: WHO, 1995, after Peto & Lopez

7. Debate in the American Journal of Public Health, Feb. 2000 issue, over whether the U.S. can expect to achieve the target of 12% prevalence by the year 2010.

8. 9 Aug 2000LW Green What Worked? F 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 F Similar, though later, experience in OR & AZ, and in population segments of FL

9. 9 Aug 2000LW Green 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

10. 9 Aug 2000LW Green $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

11. 9 Aug 2000LW Green 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. 9 Aug 2000LW Green 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.

13. 9 Aug 2000LW Green 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.

15. 9 Aug 2000LW Green F Tobacco control resources expanding (CDC, excise taxes, MSA; World Bank) F Increasing technical assistance requests F CDC response: Best Practices for Comprehensive Tobacco Control Programs Demand for Evidence -Based Tobacco Control Programs Growing

16. 9 Aug 2000LW Green

17. 9 Aug 2000LW Green Components of Comprehensive Tobacco Control Programs F Community Programs F Chronic Disease Programs F School Programs F Enforcement F Statewide Programs F Counter-Marketing F Cessation Programs F Surveillance and Evaluation F Administration and Management

18. 9 Aug 2000LW Green The Remaining Challenges: The Need to Bridge Between... F “best practices indicated by research and their application in practice in underserved areas F “best practices” from research and the most appropriate adaptions for special populations F The success of individual behavior changes of the affluent and the system changes needed to reach the less affluent, less educated… F University-based, investigator-driven research to practitioner- & community-centered research

19. 9 Aug 2000LW Green Best Practice Must Be More Than... F Diffusion theory and dissemination research F Cognitive & other single-factor approaches F Hard-nosed, trial-and-error, outcome-only RCT studies with their misplaced precision and theory-starved interventions F Fuzzy systems research with immediate or intermediate-only variables as outcomes, without clear linkage to health F Investigator-centered studies in unrepresentative populations

20. 9 Aug 2000LW Green Origins and Landmarks in “Best Practices” Thinking F Engineering and product quality control F Medicine and agriculture F Clinical preventive services –Canadian Task Force –US Preventive Services Task Force F Cochran systematic reviews (www.cochrane.org) F From clinical (evidence-based medicine) to community levels of intervention

21. 9 Aug 2000LW Green Alternatives to Strict RCT- Based Interpretations F Campbell Collaboration and joint Cochrane & Campbell Connections, Feb 2000 (http://campbell.gse.upenn.edu) F Consensus conference and expert panel or committee approaches of NIH, WHO, IUHPE and Royal commissions F CDC Tobacco Control and Community Preventive Services Guidelines

22. 9 Aug 2000LW Green Problems Inherent in “Best Practices” from Research F Internal validity supreme over external validity F Human organism’s homogeneity Vs social organizations’ heterogeneity F Historical, legal, and other contextual factors in health promotion F Time as a variable: communities and populations change from day to day

23. 9 Aug 2000LW Green Alternatives to “Best Practices” F “Best practice” as process rather than packaged interventions: the diagnostic-evaluative cycle F Emphasize control by practitioner, patient, client, community or population F Emphasize local evaluation and self-monitoring F More systematic study of place, setting, and culture F Research on tailoring and new technologies (e.g., EMPOWER software) F Synthesizing research other than randomized trials

24. LW Green 8/9/00 Breaking the Intervention-Based 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

25. 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

26. 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