1. Program Evaluation in Public Health California’s Efforts to Reduce Tobacco Use 1989-2005 David Hopkins Terry Pechacek

2. California in 1988 Population: 28,400,000 Adult smoking prevalence: 22.8% 4.8 million adult smokers

3. A Funded Mandate Voters approved ballot initiative in November, 1988  Excise tax increase of 25 cents/pack  Earmarked funding (20%) for a statewide program What to do, how to do it, and how to evaluate it?

4. The Status of Tobacco Control, 1988 Limited experience with effective population-based interventions  Clinical interventions (low success rates, relapses were common)  Price (published econometric studies)  Mass media (Fairness Doctrine Campaign 1967-1970)

5. California Had Program Options A top-down program  Interventions selected and implemented by the Tobacco Program statewide A program built on the results of smaller-scale demonstration projects  Trials would help to determine the independent impact of intervention options

6. A Comprehensive Approach was Advocated by NCI* (and others) Funding of community coalitions  Local emphasis and control Multiple channels of intervention Multiple targets of intervention A field test was needed * “Standards for Comprehensive Smoking Prevention and Control” National Cancer Institute

7. Multiple Channels, Multiple Targets Target Goals Media Campaigns Smoke-free Policies Community Activities School-based Programs Increase Cessation X(X)X Reduce Initiation X(X)XX Reduce Exposure to ETS XXX(X) Interventions

8. The California Tobacco Prevention and Control Efforts, 1990 An excise tax (price increase of 23%) Paid mass media campaign Funding for community organization and interventions (67 Local Lead Agencies) Funding for school-based programs Funding for intervention and treatment research

9. Challenges in Evaluation A Public Health Example

10. Evaluation was Built into the Mandate Some surveillance systems were in place  BRFSS; State cigarette tax receipts California added some more  California Tobacco Surveys Programs (components) were evaluated through contracts (independent evaluators) A research program was funded within the University of California

11. Local Evaluation was Included Funding for local intervention and research projects came with strings…  10% of budget to be spent on evaluation …and with support  Directory of experts for consultation or to conduct evaluations  Database of instruments and information  Annual conferences

12. Oversight was Established Appointed committee Annual review of surveillance and research results Advice and recommendations Periodic publications summarizing program progress and direction Guardians

13. Evaluations of the California Program: 1990-2004 Outcomes, Study Designs, and Program Results

14. Smoking Prevalence among Adults in California Decreased 32.5% between 1988-2004 22.8% 15.4% Definition Changed Source: California DHS 2005 Year Percent

15. Consumption Decreased 55.6% in California (compared to 32% in the rest of the US) 1988-2003 141 45.8 California Source: California DHS 2003 Year Packs / Person Rest of US

16. Comparison of Age-Adjusted Rates of Death From Heart Disease: California 1979-1998 California Source: Fichtenberg and Glantz; NEJM 2000 Year Age-Adjusted Heart Disease Mortality per 100,000 Predicted US rates

17. Some Interventions Have Been Evaluated: California’s Telephone Quitline Design: RCT Analysis:  Intention to treat Receipt of counseling  Inter arm: 72.1%  Comp arm: 32.6% Study Arm N 12m Quit Comp13096.9% Inter19739.1% Source: Zhu et al. NEJM 2002 Differences: P<0.001 by log-rank test Prolonged Abstinence by Study Arm

18. Evaluation: What Has Gone Well Provided dozens of publications influencing tobacco prevention and control efforts Documented the overall impact of a comprehensive tobacco control effort Documented the independent contributions of some components  Helpline  Smoke-free policies Contributed to Program survival

19. Evaluation: What Has Not Gone Well Local program impact is still unclear  Comparisons have been difficult  Most evaluations have not been published The effectiveness of some interventions remains unclear  School-based programs

20. Evaluation: Adjustments Adopted more uniform surveillance tools  Combined BRFSS and CTS survey results since 1993 New questions provide new directions  Smoke-free policies (work, home)

21. California’s Program Became the Model Other States adapted the comprehensive State-level approach to tobacco control  Massachusetts  Florida  Arizona  Oregon California’s experience contributed to the contents of CDC’s Best Practices Guideline in 1998

22. Discussion

23. Additional Slides

24. Targeted Outcomes and Measurements Increasing Cessation Reducing Initiation Reducing Exposure Targeted GoalsOutcome Measurement Options Population Consumption Prevalence Cessation (Smokers) Prevalence Youth (students) PoliciesExposures HomeWorkHomeWork

25. California Tobacco Control Section Funding, 2001-2002 ( $106.5 m ) Admin 1.7m (1.6%) Evaluation 6.3m (6%) Media 45.2 m (42%) Competitive Grants 35.7m (33.5%) Local Lead Agencies 17.4 m (16 %)

26. Tobacco Control is Always Outspent by the Industry Per Capita Expenditures ($) Source: California DHS 2004

27. Creating an Environment to Reduce Tobacco Use Smoker Quit Success Contemplation Relapse Modified from: Population-based Smoking Cessation. NCI Monograph 12; 2000

28. Creating an Environment to Promote Cessation AdviceTreatments Smoker Quit Success Counseling Modified from: Population-based Smoking Cessation. NCI Monograph 12; 2000

29. Creating an Environment to Promote Cessation Community Events Smoke-free Policies Costs Media Messages Worksite Events AdviceTreatments Quitline Smoker Quit Success Counseling Modified from: Population-based Smoking Cessation. NCI Monograph 12; 2000