Transcript Lessons from Great PH Achievements of 20th Century

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
What is this public health achievement of the 20th Century?
What is the evaluation method to judge this an achievement?
5,000
Number of Cigarettes
4,000
3,000
2,000
1,000
0
1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
Adult Per Capita Cigarette Consumption and
Major Historical Events—United States, 1900-2000
Broadcast
Ad Ban
1st World Conference
on Smoking and Health
5,000
4,000
Number of Cigarettes
1st Great American Smokeou
Nicotine
Medications
Available Over
the Counter
Master
Settlement
Agreement
Fairness Doctrine
Messages on TV
and Radio
1st SmokingCancer Concern
Surgeon General’s
Report on
Environmental
Nonsmokers’
Tobacco Smoke
Rights
1st Surgeon
General’s Report
End of WW II
3,000
2,000
1,000
Movement
Begins
Great Depression
0
1900
1910
1920
1930
1940
1950
1960
1970
Source: USDA; 1986 Surgeon General's Report. MMWR 2001.
Federal
Cigarette
Tax Doubles
1980
1990
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.
Change in Per Capita Cigarette Consumption
California & Massachusetts versus Other 48 States, 1984-1996
Percent Reduction
5
0
-5
-10
-15
-20
-25
Other 48 States
California
1984-1988
1990-1992
Massachusetts
1992-1996
What Worked? Making Better Use of
“Natural Experiments”
• 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 FL
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
http://www.cdc.gov/tobacco
Components of Comprehensive
Tobacco Control Programs
• Community Programs
• Counter-Marketing
• Statewide Programs
• Cessation Programs
• Chronic Disease Programs
• Surveillance and
Evaluation
• School Programs
• Enforcement
• Administration and
Management
Reduction in State Consumption
Percent Reductions in Per Capita Cigarette Consumption
Attributable to Non-Price Public Health Interventions
80%
70%
60%
55%
40%
20%
0
20%
$
2
$
4
$
6
$
8
Dollars Per Capita Annual Spending on
Programs
$
10
Lesson 3: The Ecological Imperative
• Need 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 complementary
Smokefree Indoor Air Legislation as of
September 30, 1998-- Government Worksites
in the United States
D.C.
11
No smoking allowed
30
Designated smoking areas
required or allowed
2
Designated smoking areas
with separate ventilation
8
No restrictions
Lesson 4: Threshold Spending
• A critical mass of personal exposure is needed for
individuals to be influenced
• A 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
motivated
Per Capita Spending on Tobacco
Prevention and Control--FY1997
CDC
CDC/ RWJF
NCI
NCI/ RWJF
Oregon
Arizona
California
Massachusetts
$0
$2
$4
$6
$8
Dollars Per Capita
$10
$12
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
100-Percent Smokefree Ordinances, by Year of Passage
Number of
Ordinances
18
Workplace
Restaurant
Restaurant and Workplace
16
14
12
10
8
6
4
2
0
1985
1986
1987
* 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.
1988
US Dept. of Health and Human Service. Public Health
Service, National Institutes of Health. NIH Publ. No. 93-3532.
1989
1990
1991
1992*
Year
Tobacco Vending Machine Ordinances
Number of
180
Ordinances
(Cumulative)
160
Total Ban
Partial Ban
140
120
100
80
60
40
20
0
1985
1986
1987
1988
* 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.
1989
1990
1991
Year
1992*
Lesson 6: The Educational Imperative
• Public awareness of risks and benefits
• Public interest in lifestyle options
• Public understanding of behavioral steps
• Public attitudes toward the options & steps
• Public outrage at the conditions that have put
them at risk or in danger
• Personal and political actions
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” 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…
• University-based, investigator-driven research to
practitioner- & 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
Intervention or
Service to be Studied
4. Evaluate Response to the
Intervention or Service
2. Assess Response
to the Intervention or
Service
3. Increase Dose
or Increase Demand
Strengthening Population-based,
Diagnostic Planning Approaches*
1. Assess Needs & Capacities
of Population
4. Evaluate
Program
Reassess causes
2. Assess Causes,
Set Priorities &
Objectives
Redesign
3. Design &
Implement
Program
*Procedural models, such as PRECEDE, PATCH, Intervention Mapping. See
*Green & Kreuter, Health Promotion Planning, 3rd ed., Mayfield, 1999.
Uses of Evidence in Population-Based Planning Models
A. Evidence
from community
or population
4. Evaluate
Program
D2
D. Program Evidence
1. Assess Needs & Capacities
of Population B. Evidence from
Research
Reconsider X
3. Design &
Implement
Program
From previous evaluations (D1)
2. Assess Causes (X)
& Resources
C. Evidence
from R&D
and Exp’tal.
Studies
Connecting the Dots
Public Health
RESEARCH
Basic
Applied
Field
How to measure
Needs and effects
Participation
Identify researchpractice gaps
And Collaboration
SURVEILLANCE
& EVALUATION Assessment of Needs,
Planning, Monitoring
Dissemination
Translation
PRACTICE
Policy
Programs
Green & Mercer, Office of Science & Extramural Research, CDC, 2003.