Lessons from Public Health Achievements of Lessons from Public Health Achievements of the Twentieth Century to Emerging Health the Twentieth Century to Emerging Health

Research IssuesResearch Issues

Lawrence W. Green, DrPHLawrence W. Green, DrPHDirector, Office of Science & Extramural ResearchDirector, Office of Science & Extramural Research

Centers for Disease Control & PreventionCenters for Disease Control & PreventionUNTHSC, April 4, 2003UNTHSC, April 4, 2003

0

1,000

2,000

3,000

4,000

5,000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

Nu

mb

er

of

Cig

are

tte

s

What is this public health achievement of the 20th Century?

What is the evaluation method to judge this an achievement?

0

1,000

2,000

3,000

4,000

5,000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

Nu

mb

er

of

Cig

are

tte

s

Source: USDA; 1986 Surgeon General's Report. MMWR 2001.

Great Depression

End of WW II

Nonsmokers’Rights

Movement Begins

1st SurgeonGeneral’s Report

Fairness DoctrineMessages on TVand Radio

Federal CigaretteTax Doubles

BroadcastAd Ban

Adult Per Capita Cigarette Consumption and Major Historical Events—United States, 1900-2000

MasterSettlementAgreement

NicotineMedications Available Over the Counter

1st Smoking-Cancer Concern

1st World Conferenceon Smoking and Health

Surgeon General’sReport on EnvironmentalTobacco Smoke

1st Great American Smokeout

Lesson 1: Surveillance--Making Better Use of Lesson 1: Surveillance--Making Better Use of Natural ExperimentsNatural 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.

Change in Per Capita Cigarette ConsumptionChange in Per Capita Cigarette ConsumptionCalifornia & Massachusetts versus Other 48 States, 1984-1996California & Massachusetts versus Other 48 States, 1984-1996

-25

-20

-15

-10

-5

0

5

Pe

rce

nt

Re

du

cti

on

Other 48 States California Massachusetts

1984-1988 1990-1992 1992-1996

What Worked? Making Better Use of What Worked? Making Better Use of “Natural Experiments”“Natural Experiments”

• Comprehensive program Comprehensive program andand tax increases in CA tax increases in CA

and MA resulted in: and MA resulted in:

– 2 - 3 times faster decline in adult smoking 2 - 3 times faster decline in adult smoking

prevalenceprevalence

– Slowed rate of youth smoking prevalence Slowed rate of youth smoking prevalence

compared to the rest of the nationcompared to the rest of the nation

– Accelerated passage of local ordinancesAccelerated passage of local ordinances

• Similar, though later, experience in OR & AZ, and Similar, though later, experience in OR & AZ, and

in population segments of FLin population segments of FL

Lesson 2: ComprehensivenessLesson 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

http://www.cdc.gov/tobacco

Components of Components of Comprehensive Comprehensive Tobacco Control ProgramsTobacco Control Programs

• Community Programs Community Programs

• Statewide ProgramsStatewide Programs

• Chronic Disease ProgramsChronic Disease Programs

• School ProgramsSchool Programs

• EnforcementEnforcement

• Counter-MarketingCounter-Marketing

• Cessation ProgramsCessation Programs

• Surveillance and Surveillance and EvaluationEvaluation

• Administration and Administration and ManagementManagement

Percent Reductions in Per Capita Cigarette Consumption Percent Reductions in Per Capita Cigarette Consumption Attributable to Non-Price Public Health InterventionsAttributable to Non-Price Public Health Interventions

Dollars Per Capita Annual Spending on Programs

0$2

$4

$6

$8

$10

80%

60%

40%

20%

Red

uct

ion

in

Sta

te C

on

sum

pti

on

70%

20%

55%

Lesson 3: The Ecological ImperativeLesson 3: The Ecological Imperative

• Need to address the problem at all levelsNeed to address the problem at all levels

– IndividualIndividual

– Organizational, institutionalOrganizational, institutional

– CommunityCommunity

– State, regionalState, regional

– National, internationalNational, international

• Need to make these levels of intervention Need to make these levels of intervention

mutually supportive and complementarymutually supportive and complementary

Smokefree Indoor Air Legislation as of September 30, 1998-- Government Worksites

in the United States

D.C.

No smoking allowed

Designated smoking areaswith separate ventilation

Designated smoking areasrequired or allowed

No restrictions8

3011

2

Lesson 4: Threshold SpendingLesson 4: Threshold Spending

• A critical mass of personal exposure is needed for A critical mass of personal exposure is needed for

individuals to be influencedindividuals to be influenced

• A critical mass of population exposure is necessary A critical mass of population exposure is necessary

to effect detectable community responseto effect detectable community response

• A critical distribution of exposure is necessary to A critical distribution of exposure is necessary to

reach segments of the population who are less reach segments of the population who are less

motivatedmotivated

$0 $2 $4 $6 $8 $10 $12

Massachusetts

California

Arizona

Oregon

NCI/ RWJF

NCI

CDC/ RWJF

CDC

Per Capita Spending on TobaccoPrevention and Control--FY1997

Dollars Per Capita

Lesson 5: The Environmental ImperativeLesson 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

100-Percent Smokefree Ordinances, by Year of Passage

1985 1986 1987 1988 1989 1990 1991 1992*

0

2

4

6

8

10

12

14

16

18WorkplaceRestaurantRestaurant and Workplace

Number ofOrdinances

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.

Tobacco Vending Machine Ordinances

1985 1986 1987 1988 1989 1990 1991 1992*

0

20

40

60

80

100

120

140

160

180

Total BanPartial Ban

Number ofOrdinances(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.

Lesson 6: The Educational ImperativeLesson 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 Public outrage at the conditions that have put

them at risk or in dangerthem at risk or in danger

• Personal and political actionsPersonal and political actions

Lesson 7: The Evidence-Based Lesson 7: The Evidence-Based Imperative: The Need to Bridge...Imperative: The Need to Bridge...

• ““best practices” indicated by research to their best practices” indicated by research to their

application in practice in underserved areasapplication in practice in underserved areas

• ““best practices” from research to the most best practices” from research to the most

appropriate adaptations for special populationsappropriate adaptations for special populations

• The success of individual behavior changes of the The success of individual behavior changes of the

affluent to the system changes needed to reach the affluent to the system changes needed to reach the

less affluent, less educated…less affluent, less educated…

• University-based, investigator-driven research to University-based, investigator-driven research to

practitioner- & community-centered researchpractitioner- & community-centered research

Green LW. Am J Health Behav, 2001. www.ajhb.org/

Breaking the Intervention-Based Research and Planning Habit

1. Select off-the-shelf 1. Select off-the-shelf Intervention or Intervention or Service to be StudiedService to be Studied

2. Assess Response2. Assess Responseto the Intervention orto the Intervention orServiceService

3. Increase Dose3. Increase Doseor Increase Demandor Increase Demand

4. Evaluate Response to the4. Evaluate Response to theIntervention or ServiceIntervention or Service

Strengthening Population-based, Strengthening Population-based, Diagnostic Planning Approaches*Diagnostic Planning Approaches*

1. Assess Needs & Capacities 1. Assess Needs & Capacities of Populationof Population

2. Assess 2. Assess Causes, Set Causes, Set Priorities & Priorities & ObjectivesObjectives

3. Design & 3. Design & ImplementImplementProgramProgram

4. Evaluate 4. Evaluate ProgramProgram

*Procedural models, such as PRECEDE, PATCH, Intervention Mapping. See*Green & Kreuter, Health Promotion Planning, 3rd ed., Mayfield, 1999.

Reassess causesReassess causes

RedesignRedesign

Uses of Evidence in Population-Based Planning Models

1. Assess Needs & Capacities of Population

2. Assess Causes (X) & Resources

3. Design & ImplementProgram

4. Evaluate Program

Reconsider X

D. Program Evidence

Evidence fromResearch

From previous evaluations (D1)

Evidencefrom communityor population

A.

B.

C. Evidence from R&D and Exp’tal. Studies

D2

Connecting the Dots

Public Health RESEARCH

Basic

Applied

Field

SURVEILLANCE & EVALUATION

PRACTICEPolicy

Programs

ParticipationAnd Collaboration

Dissemination Translation

How to measureNeeds and effects

Identify research-practice gaps

Assessment of Needs, Planning, Monitoring

Green & Mercer, Office of Science & Extramural Research, CDC, 2003.