Program Evaluation in Public Health California’s Efforts to Reduce Tobacco Use 1989-2005

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 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 Percent 22.8% 15.4% Definition Changed Year Source: California DHS 2005

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

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

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% Prolonged Abstinence by Study Arm Differences: P<0.001 by log-rank test Source: Zhu et al. NEJM 2002

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 Targeted Goals Outcome Measurement Options Increasing Cessation Population Consumption Prevalence Cessation (Smokers) Reducing Initiation Prevalence Youth (students) Reducing Exposure Policies Exposures Home Work Home Work

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%) Local Lead Agencies 17.4 m (16 %) Competitive Grants 35.7m (33.5%)

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

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

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

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