Program Evaluation in Public Health California’s Efforts to Reduce Tobacco Use 1989-2005 David Hopkins Terry Pechacek.
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Program Evaluation in Public Health
California’s Efforts toReduce Tobacco Use 1989-2005
David Hopkins
Terry Pechacek
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?
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)
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
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
Multiple Channels, Multiple Targets
Target
Goals
Media
Campaigns
Smoke-free
Policies
Community
Activities
School-based
Programs
Increase
Cessation X (X) X (X)
Reduce Initiation X (X) X X
Reduce
Exposure to ETS
X X X (X)
Interventions
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
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
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
Oversight was Established
Appointed committee Annual review of surveillance and research
results Advice and recommendations Periodic publications summarizing program
progress and direction
Guardians
Smoking Prevalence among Adults in California Decreased 32.5% between 1988-2004
0
5
10
15
20
25
30
88 89 90 91 92 93 94 95 96 97 98 99 0 1 2 3 4
22.8%
15.4%Definition Changed
Source: California DHS 2005 Year
Percent
Consumption Decreased 55.6% in California (compared to 32% in the rest of the US) 1988-2003
0
50
100
150
200
85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 0 1 2 3
141
45.8
California
Source: California DHS 2003 Year
Packs / Person
Rest of US
Comparison of Age-Adjusted Rates of Death From Heart Disease: California 1979-1998
100
110
120
130
140
150
160
170
180
190
79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98
California
Source: Fichtenberg and Glantz; NEJM 2000 Year
Age-Adjusted Heart Disease Mortality per 100,000
Predicted US rates
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
QuitComp 1309 6.9%
Inter 1973 9.1%
Source: Zhu et al. NEJM 2002
Differences: P<0.001 by log-rank test
Prolonged Abstinence by Study Arm
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
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
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)
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
Targeted Outcomes and Measurements
Increasing
Cessation
Reducing Initiation
Reducing
Exposure
Targeted Goals Outcome Measurement Options
Population
ConsumptionPrevalence
Cessation
(Smokers)
PrevalenceYouth
(students)
Policies Exposures
Home Work Home Work
California Tobacco Control Section Funding, 2001-2002 ( $106.5 m )
Admin 1.7m (1.6%)
Evaluation 6.3m (6%)
Media 45.2 m (42%)
Competitive Grants
35.7m (33.5%)
Local Lead Agencies
17.4 m (16 %)
Tobacco Control is Always Outspent by the Industry
0
10
20
30
40
50
60
90 91 92 93 94 95 96 97 98 99 0 1 2
Year
California Tobacco IndustryPer Capita Expenditures ($)
Source: California DHS 2004
Creating an Environment to Reduce Tobacco Use
Smoker Quit Success
Contemplation
Relapse
Modified from: Population-based Smoking Cessation. NCI Monograph 12; 2000
Creating an Environment to Promote Cessation
Advice Treatments
Smoker Quit Success
Counseling
Modified from: Population-based Smoking Cessation. NCI Monograph 12; 2000
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