# Presentation: 369682

## Program Evaluation in Public Health 

California’s Efforts to
Reduce Tobacco Use 1989-2005

**California’s Efforts to**
**Reduce Tobacco Use 1989-2005**

**David Hopkins**
**Terry Pechacek**

## California in 1988

**Population: 28,400,000**

**Adult smoking prevalence: 22.8%**

**4.8 million adult smokers**

## 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)**

**Notes:**
Plus some data from early (Stanford 5-cities, ? San Diego) and concurrent community-based intervention efforts (COMMIT)

## 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**

**Notes:**
No single intervention, but rather an environment of multiple interventions (messages+policies+etc) 

## 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**

**Notes:**
The excise tax was part of the ballot measure

The Tobacco Control Section of the California DHS runs the paid media campaign and funds the local lead agencies
Note: The count of LLA differs.  In 2003, it included 61 local health departments, 4 ethnic networks, 11 regional community linkage projects and approximately 100 community-based organizations

The California Department of Education administers funding for school-based programs
The University of California administers the Tobacco-Related Disease Research Program (TRDRP) which provides competitive grants for interventions, intervention research, and evaluations (TRDRP “funds research that leads to improved approaches to the prevention, diagnosis, and treatment of tobacco-related illnesses AND to increase the effectiveness of the California Tobacco Control Program.”)

Media described routinely as “providing air cover for school and local activities”

## Challenges in Evaluation

**A Public Health Example**

## 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**

## Evaluations of the California Program: 1990-2004 

**Outcomes, Study Designs, and Program Results**

## Smoking Prevalence among Adults in California Decreased 32.5% between 1988-2004

**22.8%**

**15.4%**

**Definition Changed**

**Source:  California DHS 2005**

**Year**

**Percent**

**Notes:**
The simple population-based surveillance provides data that can be used in simple before-after comparisons, or more complicated Time-series analyses.  This slide depicts the change in smoking prevalence among adults in California between 1988 and 2004.  This data comes from the California Tobacco Control Section and represents prevalence rates of smoking self-reported by survey participants (combined results from both the CTS and BRFSS).  Smoking prevalence among adults decreased by 32.5% over this period

Comparisons have also been done, for example, one published study compared changes in California to changes in the rest of the United States in a slightly different study period 1992/93 through 2001/02
California: -21.8% reduction in adult smoking prevalence
Rest of US: -14.0% reduction in adult smoking prevalence

## Consumption Decreased 55.6% in California  (compared to 32% in the rest of the US) 1988-2003

**141**

**45.8**

**California**

**Source:  California DHS 2003**

**Year**

**Packs / Person**

**Rest of US**

**Notes:**
The State government in California, like almost all of the other states, collects information on the number of cigarettes sold as measured by purchase of excise tax stamps (one stamp per pack).  This has provided both the program, economists, researchers with data that makes both simple and complex Time-series comparisons possible.  A number of papers have been published examining this basic data, with different papers controlling for a variety of real and potential confounders (such as “bootlegging”).  The raw data is presented here providing a simple comparison of changes in consumption in California with the rest of the United States.  Consumption, as measured here in terms of packs per person per year, has declined 55.6% in California compared to 32% in the rest of the United States.

## Comparison of Age-Adjusted Rates of Death From Heart Disease:  California 1979-1998

**California**

**Source:  Fichtenberg and Glantz;  NEJM 2000**

**Year**

**Age-Adjusted Heart Disease Mortality per 100,000**

**Predicted US rates**

**Notes:**
Note:  This was an NCI funded study conducted by investigators with a long history of evaluation of the California program.

## 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
Quit |
| --- | --- | --- |
| Comp | 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**

**Notes:**
California’s program has evolved since inception in 1990.  For example, a statewide Telephone Helpline was added in 1992

## 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**

**Notes:**
Might also add an improvement in our understanding of differential intervention effects by race/ethnicity/community.

## 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**

**Notes:**
Most Local program evaluations have not been published, so we still know very little about the impact (or lack thereof).   
Use this slide to include a note about the split of funding/evaluation between TCS and DOE and how that might play a role in why we haven’t learned as much about the impact of 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)**

**Notes:**
Might also mention (once I understand what happened) the adoption of YRBS to evaluate youth tobacco use.

Evaluation has guided some of California’s direction, for example, an increasing emphasis on measuring and changing the adoption of smoke-free policies in the 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**

**Notes:**
Use this slide to discuss application of the California model to other states (these programs were effective but MA, FLA, and Oregon were defunded despite evidence on impact).

## Discussion

## Additional Slides

## Targeted Outcomes and Measurements

**Increasing Cessation**

**Reducing Initiation**

**Reducing **
**Exposure**

_**Targeted Goals**_

_**Outcome Measurement Options**_

**Population**
**Consumption**

**Prevalence**

**Cessation**
**(Smokers)**

**Prevalence**

**Youth (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 %)**

**Notes:**
This is just one of three pies capturing funding for all tobacco control activities (the other two groups involved are the California Department of Education, which handles all school programs ($28 million) and the Tobacco-Related Research Program ($19 million).  Much of the research funding (for competative research grants) would be considered program or intervention evaluation.

## Tobacco Control is Always Outspent by the Industry

**Per 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**

**Notes:**
The clinical arm of intervention to increase tobacco use cessation among patients (an important area for improvement, but already in our environment)

## Creating an Environment to Promote Cessation

**Community**
**Events**

**Smoke-free Policies**

**Costs**

**Media Messages**

**Worksite Events**

**Advice**

**Treatments**

**Quitline**

**Smoker**

**Quit**

**Success**

**Counseling**

**Modified from: Population-based Smoking Cessation. NCI Monograph 12; 2000**

**Notes:**
This adds other interventions (channels) that together contribute to an environment that promotes cessation.  This is the goal of a multiple-channel, multiple-target comprehensive effort.