Health in All Policies Approaches to Tobacco Prevention and Control

Holly Avey, PhD, MPH

Deep South Tobacco Prevention and Control Policy Institute

New Orleans, LA

August 3, 2011

Health in All Policies Approaches to Tobacco Prevention and Control

• What is Health in All Policies (HiAP)?

• HiAP and Social Determinants of Health Equity

• HiAP Trends

• HiAP Funding Opportunities

• How to Make it Work

WHAT IS HEALTH IN ALL POLICIES?

Programs vs Policies

• Historical focus on programs

– smoker quit lines, smoking cessation educational programs

• Policies can support programs

– Workplace smoking ban supports workplace smoking cessation programs

• Programs can drive support for policies

What is Health in All Policies? (HiAP)

• A strategy that strengthens the link between health and other policies, creating a supportive environment that enables people to lead healthy lives

Health in All Policies

• Considers the intentional or unintentional impact of all policies on individual or population health

– Education

– Housing

– Transportation

– Economic

– Etc.

Health in All Policies in Context

AN APPROACH WITH HIGH IMPACT AND LEVERAGE

Health in All Policies

The Iceberg: A Metaphor for the Level at Which We Interact With a System

Heart disease, stroke, cancer

Tobacco use

Environmental factors that support tobacco use

Individual rights vs population health

Health Impact Pyramid

Frieden, T. A Framework for Public Health Action: The Health Impact Pyramid. American Journal of Public Health,

2010, 100(4): 590-595.

APPROACHES TO TOBACCO PREVENTION AND CONTROL

Health in All Policies

Working at All Levels of the Pyramid

Frieden, T. A Framework for Public Health Action: The Health Impact Pyramid. American Journal of Public Health,

2010, 100(4): 590-595.

Education & counseling for smoking behavior

Cessation medications

Hard-hitting ad campaigns Tobacco

taxes, smoke-free workplaces, elimination of advertising

Interventions to increase education & economic status

HiAP Approaches to Tobacco Prevention and Control

• Economic sector – Taxes

• Labor/workplace sector – Bans in workplaces

• Market sector – Limits and bans on advertising

• Educational sector – Bans in educational settings

• Municipal government sector – Bans in public spaces

AND THE SOCIAL DETERMINANTS OF HEALTH EQUITY

Health in All Policies

Social Determinants of Health

The conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices.

Source: World Health Organization, 2008

WHAT ARE THE SOCIAL DETERMINANTS OF SMOKING?

Social, economic, and psychological determinants of smoking:

– low education

– low income

– working class job

– young age

– low self-esteem

– low optimism

– low hope

– depression

– low religious devotion

– low religious institutional conservatism

– divorce

Barbou et al, 2004, Carvajal et al, 2000, Kendler et al, 1999, Simons-Morton, 2002

THE SOCIAL DETERMINANTS OF SMOKING AND STRUCTURAL STRESS

From Policy-Driven Inequity to Disparities

Structural Sources of Stress: Social Closure

• When social and economic opportunities are restricted for certain groups

• Includes restriction of access to:

– Employment

– Housing

– Education

– Transportation

– Healthcare

– Legal representation

Structural Sources of Stress: Relative Deprivation

• When certain groups perceive they are deprived of resources compared to others

• Includes:

– Corporate welfare

– Wealth gap

– Media and consumerism

– Property taxes

Social, economic, and psychological determinants of smoking:

– low education

– low income

– working class job

– young age

– low self-esteem

– low optimism

– low hope

– depression

– low religious devotion

– low religious institutional conservatism

– divorce

Barbou et al, 2004, Carvajal et al, 2000, Kendler et al, 1999, Simons-Morton, 2002

APPROACH TO DISEASE PREVENTION

Social Determinants

JEWEL Project

• HIV prevention intervention targeting illicit drug-using women who were involved in prostitution

– HIV prevention risk reduction

– making, marketing and selling of jewelry

– income from the jewelry sale was associated with reduction in number of sex trade partners at follow-up

(Sherman et al, 2006)

Microenterprise

• Microenterprise interventions include:

– basic life-skills training, development of commercially viable products and services, access to markets, financial training, and financial support or microfinance of some type (e.g., credit, emergency loans, tax assistance)

• (Stratford et al, 2008)

Theories on Why Microenterprise Programs Work

• Income: improves standard of living

• Diversification: diversifies income streams

• Compensating differential: provides non-monetary value, such as an improved outlook on life as a result of savings or ability to pay bills

• Social network: develops social capital and access to resources, which further strengthens economic activity

Theoretical Basis for a Social Determinants Approach to Tobacco

Control and Prevention • Newton & Bower (2005), Watt (2007): causal pathways

to oral health status include psychological stress, sense of coherence, social status, and environmental factors

• Stress is impacted by social closure and relative deprivation

• Successful interventions that address social determinants incorporate life skills training that improves personal empowerment (compensating differential theory)

TRENDS

Health in All Policies

Health in All Policies Trends

• Well established in Europe, Australia

• Recent establishment of National Prevention Council – National Prevention Strategy

• Recent report by the Institute of Medicine

• HIA as a tool for HiAP

• HUD memo on Non-smoking policies in public housing

National Prevention, Health Promotion, and Public Health Council

• Created through health reform legislation

• Members from 17 federal agencies

• Chaired by the Surgeon General

• Coordinates and leads federal efforts on prevention, wellness, and health promotion

Source: For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges; Report Release Slides http://www.iom.edu/~/media/Files/Report%20Files/2011/For-the-Publics-Health-Revitalizing-Law-and-Policy-to-Meet-New-

Challenges/Report%20Release%20Slides.pdf

Source: For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges; Report Release Slides http://www.iom.edu/~/media/Files/Report%20Files/2011/For-the-Publics-Health-Revitalizing-Law-and-Policy-to-Meet-New-

Challenges/Report%20Release%20Slides.pdf

Source: For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges; Report Release Slides http://www.iom.edu/~/media/Files/Report%20Files/2011/For-the-Publics-Health-Revitalizing-Law-and-Policy-to-Meet-New-

Challenges/Report%20Release%20Slides.pdf

Source: http://www.apha.org/NR/rdonlyres/171AF5CD-070B-4F7C-A0CD-0CA3A3FB93DC/0/HIABenefitHlth.pdf

Source: http://www.hud.gov/offices/pih/publications/notices/09/pih2009-21.pdf

FUNDING OPPORTUNITIES

Health in All Policies

Health in All Policies Funding Opportunities

• HIA Funding Opportunities (CDC, Pew)

• Communities Putting Prevention to Work (CDC)

• Community Transformation Grants (CDC)

• Other sectors (HUD – Sustainable Communities)

HOW TO MAKE IT WORK

Health in All Policies

Health in All Policies Can Occur at Different Levels

• Information-sharing

• Collaboration

• Integration

Facilitators of Health in All Policies

• Leadership

• Internal incentives

• External pressure

• Funding

• “Win‐win framing” of the issues

Win-Win Opportunities

• Health in All Policies works best when it is framed as a win-win opportunity for all involved sectors

• Offers of resources such as workforce, prestige, or access to additional funding sources can foster new partnerships engaged in promoting health

Working at All Levels of the Pyramid

Frieden, T. A Framework for Public Health Action: The Health Impact Pyramid. American Journal of Public Health,

2010, 100(4): 590-595.

Education & counseling for smoking behavior

Cessation medications

Hard-hitting ad campaigns Tobacco

taxes, smoke-free workplaces, elimination of advertising

Interventions to increase education & economic status

References American Public Health Association. http://www.apha.org/NR/rdonlyres/171AF5CD-

070B-4F7C-A0CD-0CA3A3FB93DC/0/HIABenefitHlth.pdf Avey, H. Racial and Socioeconomic Health Disparities: Policy-Driven Inequities and

Chronic Stress. Oral presentation. Academy Health Annual Research Meeting, Chicago, IL, June, 2009.

Barbeau, EM, Krieger, N, and Soobader, M-J. Working Class Matters: Socioeconomic Disadvantage, Race/Ethnicity, Gender, and Smoking in NHIS 2000. American Journal of Public Health, 2004, 94(2): 269-278.

Carvajal, SC, Wiatrek, DE, Evans, RI, Knee, CR, and Nash, SG. Psychosocial Determinants of the Onset and Escalation of Smoking: Cross-sectional and Prospective Findings in Multiethnic Middle School Samples. Journal of Adolescent Health, 2000;27:255–265.

Frieden, T. A Framework for Public Health Action: The Health Impact Pyramid. American Journal of Public Health, 2010, 100(4): 590-595.

Institue of Medicine of the National Academies. For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges; Report Release Slides. http://www.iom.edu/~/media/Files/Report%20Files/2011/For-the-Publics-Health-Revitalizing-Law-and-Policy-to-Meet-New-Challenges/Report%20Release%20Slides.pdf

Iton A. Transforming public health practice to achieve health equity. Paper presented at: HealthEquity Summitt, 2009; Cambpell, CA.

Kendler, KS, Neale, MC, Sullivan, P, Corey, LA, Gardner, CO and Prescott, CA. A population-based twin study in women of smoking initiation and nicotine dependence. Psychological Medicine, 1999, 29: 299-308.

References National Prevention Council.

http://www.healthcare.gov/center/councils/nphpphc/about/index.html#mem

National Prevention Strategy http://www.healthcare.gov/center/councils/nphpphc/about/index.html#mem

Newton JT, Bower EJ. The social determinants of health: new approaches to conceptualizing and researching complex causal networks. Community Dent Oral Epidemiol 2005; 33: 25–34.

Sherman, SG, German, D, Cheng, Y, Marks, M & Bailey-Kloche, M. The evaluation of the JEWEL project: An innovative economic enhancement and HIV prevention intervention study targeting drug using women involved in prostitution AIDS Care, 2006; 18(1): 1-11.

Simons-Morton, BG. Prospective Analysis of Peer and Parent Influences on Smoking Initiation Among Early Adolescents. Prevention Science, 2002, 3(4): 275-283.

Stratford, D, Mizuno, Y, Williams, K, Courtenay-Quirk, C, and O’Leary, A. Addressing Poverty as Risk for Disease: Recommendations from CDC’s Consultation on Microenterprise as HIV Prevention. Public Health Reports, 2008 , 123:9-20.

Turrell, G, Battistutta, D, and McGuffog, I. Social determinants of smoking among parents with infants. Australian and New Zealand Journal of Public Health, 2002, 26(1):30-37.

US Department of Housing and Urban Development Source: http://www.hud.gov/offices/pih/publications/notices/09/pih2009-21.pdf

Watt RG. From victim blaming to upstream action: tackling the social determinants of oral health inequalities. Community Dent Oral Epidemiol 2007; 35: 1–11.

Holly Avey, PhD, MPH Associate Project Director

Georgia Health Policy Center Georgia State University

havey@gsu.edu

404-413-0291

www.gsu.edu/ghpc