64

V. Infrastructure, Administration, 

and Management 

Justification 

A comprehensive tobacco control program requires 

considerable funding to implement; therefore, a 

fully functioning infrastructure must be in place in 

order to achieve the capacity to implement effective interventions.1–6 Sufficient capacity is essential 

for program sustainability, efficacy, and efficiency, 

and enables programs to plan their strategic 

efforts, provide strong leadership, and foster collaboration among the state and local tobacco control 

communities. An adequate number of skilled 

staff is also necessary to provide or facilitate program oversight, technical assistance, and training. 

Staff resources dedicated to administration 

and management of infrastructure development 

and maintenance activities include:1

 Engaging in strategic planning to guide program 

efforts and resources to accomplish their goals

 Recruiting and developing qualified and diverse 

technical, program, and administrative staff

 Awarding and monitoring program contracts 

and grants, coordinating implementation 

across program areas, and assessing 

grantee program performance 

 Developing and maintaining a realtime fiscal management system

 Increasing capacity at the local 

level by providing ongoing training 

and technical assistance 

 Coordinating across chronic disease programs 

and with local coalitions and partners

 Educating the public and decision 

makers on the health effects of 

tobacco and effective, evidence-based 

program and policy interventions 

In part due to rising fiscal challenges, an 

increasing number of state health departments 

have taken steps to combine efforts and 

increase efficiency by realigning diseasespecific programs into a coordinated chronic 

disease infrastructure. These steps often 

include developing and implementing crosscutting policies, conducting integrated chronic 

disease surveillance and evaluation, targeting 

interventions toward areas of the state with the 

greatest burden, and developing coordinated 

messaging to reach people with comorbidities. 

Addressing tobacco control strategies in 

the broader context of chronic diseases can 

be beneficial from the standpoint of enhanced 

coordination and efficiencies related to basic 

administrative functions, as well as the potential to 

synergistically increase the reach and efficacy 

of interventions. 

However, the realignment of disease-specific 

programs may also result in the dismantling of 

dedicated staff and resources for state tobacco 

control programs. Potential strategies to reduce 

any adverse impact of infrastructural changes 

on state tobacco control programs include: 

 Establishing or maintaining a full-time 

tobacco control program manager 

 Retaining core staff positions necessary and 

unique to tobacco control interventions

 Developing and sustaining collaborations 

with external partners 

 Expanding staff and partner capacity through 

trainings for state and community staff

 Exploring alternative funding opportunities 

to support staffing for a broad chronic 

disease infrastructure that includes a highly 

functioning tobacco control program
65

Section A: Infrastructure, Administration, and Management

Figure 2. Component Model of Infrastructure (CMI) 

Functioning Infrastructure

Program infrastructure is the foundation that supports program capacity, implementation, and 

sustainability.2–7 The Component Model of Infrastructure (CMI) defines infrastructure in a practical, 

actionable, and evaluable manner so that grant 

planners, evaluators, and program implementers can link infrastructure to capacity, measure 

success, and increase the likelihood for sustainable 

health achievements (See Figure 2). According to 

CMI, functioning program infrastructure includes 

five core components: networked partnerships, 

multilevel leadership, engaged data, managed 

resources, and responsive plans/planning.2-5
66

Section A: Infrastructure, Administration, and Management

Networked Partnerships: Strategic collaboration 

is crucial at the national, state, and local levels. These 

partnerships can be made between multiple types of 

organizations and content areas to promote progress 

toward health goals. Although many partners are 

working towards a common mission, they may fill 

different roles. In this way, networked partnerships 

can work to ensure the accomplishment of all 

activities necessary to achieve public health goals.

Multi-level Leadership: Leaders and champions can 

be identified and nurtured at all levels. This includes 

leadership above the tobacco control program 

in the health department or other organizational 

unit where the program is located; leadership 

within the program beyond the program manager; 

leadership among partners and other chronic 

disease areas; and leadership in local programs. 

Leadership at all levels is necessary to develop 

relationships and to ensure functioning program 

infrastructure and progress toward health goals. 

Engaged Data: Data can be used in a manner 

that engages staff, partners, decision makers, and 

local programs to act. Data should not merely be 

collected and displayed but also used to promote 

public health goals. Therefore, training, technical 

assistance, and follow-through are necessary 

to ensure the proper utilization of data.

Managed Resources: A functional infrastructure 

requires resources beyond financing, including 

an adequate number of staff and partners 

who are qualified and have diverse technical, 

program, and administrative skills. Staff, 

partners, and local programs must also have 

the necessary training and skills to effectively 

implement the tobacco control program.

Responsive Plans/ Planning: Responsive 

strategic plans are dynamic and evolve in response 

to contextual influences, such as changes in 

scientific evidence, priorities, funding levels, 

and external support. In addition, the planning 

process is collaborative and includes viewpoints 

from multiple stakeholders.8 This process 

fosters shared ownership and responsibility 

for the goals and objectives between the state 

program, partners, and local programs.

Multiple states have successfully realized the core 

components of the CMI. For example, Oregon has 

three levels of Networked Partnerships, including local community partners, chronic disease 

areas, and other agencies such as substance abuse 

and mental health treatment facilities. In 2011, 

networked partnerships were instrumental in successfully producing Oregon’s first-ever report on 

how managed care organizations serving Medicaid clients identify tobacco users and provide 

tobacco cessation services, and determine whether 

those services met evidence-based standards. 

Similarly, Utah utilized Multi-level Leadership 

to address cessation via a project addressing the 

health burden of tobacco use among those suffering 

from substance abuse or mental health issues. 

The program developed a leadership team for the 

project that included leaders from the substance 

abuse and mental health programs, as well as local 

health departments, non-profits, clinical directors, 

and clients. They worked with every leader to 

ensure that each felt ownership of the project. 

For Engaged Data, New York developed 

a surveillance and evaluation system using 

program logic models that included evaluation 

data from locally funded programs. Data have 

been used to evaluate the state’s comprehensive 

smokefree law using multiple indicators, including 

hospitality venue sales, indoor air quality, 

biomarkers of secondhand smoke exposure 

in employees, and long term measures such 

as hospital admissions for heart attacks. 

For Managed Resources, Massachusetts 

adheres to a model in which core capabilities 

are kept in house and the rest are outsourced. 

This model includes cross-training and preparing 

staff to move into leadership roles, as well as 

maintaining a robust training program that 

ensures staff and partners’ capabilities grow and 

keep pace with technological advancement. 

Finally, for Responsive Plans/Planning,

Colorado created a flexible, budget- and 

evidence-based, strategic plan that enabled 

their staff to respond to changes, including 

funding reductions. Key components of the plan 

comprised evaluation as well as infrastructure 

development and maintenance, which 

included training and technical assistance.

However, CMI goes beyond the core 

components in its depiction of functioning 

program infrastructure. The five core components 

of the CMI model are enveloped in contextual 

influences as well as supporting components, 
67

Section A: Infrastructure, Administration, and Management

Ideal Staffing Plan for a 

Comprehensive Tobacco 

Control Program

 Program director.

 Policy coordinator. 

 Communications specialist.

 Cessation coordinator.

 Surveillance and evaluation staff.

 Fiscal management systems staff.

 Administrative staff.

including Strategic Understanding and 

Operations.2–7 This type of framework enables 

a tobacco control program to quickly align 

with strategic plans and partners, irrespective 

of what opportunities or challenges emerge.

The Strategic Understanding component 

encompasses the ideas, guidelines, and thinking 

that initiate, nurture, and sustain infrastructure. 

Core concepts include perception of the problem 

as a public health issue—both among the public 

and decision makers—as well as planning 

for program sustainability at the beginning 

rather than at the end of a funding cycle. A 

sustainability plan can be one of the critical plans 

included under the Responsive Plans/Planning 

component, along with the strategic plan.

The Operations component comprises the 

day-to-day work structures, communications, 

and procedures associated with implementing 

a comprehensive tobacco control program. 

Operations can include roles and responsibilities 

of staff, partners, and local programs, as well as 

a formal and effective communications system. 

This communication system needs to include 

methods for communicating data, evaluation results, 

program operations, funding guidelines, and goals 

and objectives, not only among staff, but also 

within the health department, across connected 

programs and chronic disease areas, and with 

partners, local programs, and decision makers.

Capacity

Capacity is the ability to implement evidencebased interventions.2–4 Once infrastructure is 

built and properly supported, it facilitates the 

capacity to take advantage of opportunities, 

create opportunities, and to defend against 

threats to the achievement of the program goals. 

Building and maintaining the infrastructure to 

support capacity to provide guidance, technical 

assistance, and coordination among programs and 

partners are critical, foundational activities for 

comprehensive tobacco control programs.1–4,9,10

State experience has shown the importance 

of having all of the program’s components 

coordinated and working together. Program 

management and coordination present a 

challenge in that a comprehensive program 

involves multiple state agencies (e.g. public 

health, education, and law enforcement) and 

levels of local government, other public health 

programs, and numerous health-related voluntary 

organizations, coalitions, and community groups. 

Administration and management staff 

provide the stable foundation on which any 

program is built and maintained. Accordingly, 

an adequate number of skilled staff is required 

to fully implement and sustain a comprehensive 

tobacco control program. The exact percentage 

of full time equivalent positions required 

will depend on the state population, current 

tobacco control progress, and program needs. 

However, all programs should consider having 

staff to cover the necessary components of a 

comprehensive tobacco control program.

Continued Support

Once a strong, functioning program 

infrastructure is in place, the cumulative 

effect of funding on program effectiveness 

becomes evident. Research shows that the 

longer states invest in comprehensive tobacco 

control programs, the greater and quicker the 

impact.11–13 Because a significant amount of time 

and resources may be required to establish a 

functional infrastructure capable of implementing 

effective tobacco control interventions, it is 

critical to maintain that infrastructure. 

CMI depicts the critical nature of continued 

support and the cyclical nature of maintaining 

functioning program infrastructure and its impact 

on outcomes and sustainability. Sustainability 

has been defined as the “existence of structures 

and processes that allow a program to leverage 

resources to effectively implement and maintain 

evidence-based policies and activities.”10 These 

structures and processes are embodied in the 

core and enveloping components of CMI.
68

Section A: Infrastructure, Administration, and Management

Achieving Equity to Reduce 

Tobacco-Related Disparities

In order to adequately identify and effectively eliminate tobacco-related disparities, 

state tobacco control programs must implement a number of tobacco prevention and 

control strategies, including establishing infrastructure and building capacity.14 These 

strategies help guide the development of policies and practices that reflect the principles of 

inclusion, cultural competency, and equity.

To support achieving equity and reaching 

the goal of identifying and eliminating tobaccorelated disparities, it is crucial that state tobacco 

control programs work to achieve the infrastructure 

and capacity necessary to: conduct surveillance to 

identify populations disproportionately affected by 

tobacco use and disseminate the data; partner with 

population groups disproportionately affected by 

tobacco and the community organizations that serve 

them; ensure that disparity issues are an integral part 

of state and community tobacco control strategic 

plans, fund organizations that can effectively 

reach, involve, and mobilize these populations; 

and provide culturally competent technical 

assistance and training to grantees and partners. 

This guidance highlights the minimum 

infrastructure and capacity needed by state 

tobacco control programs to pursue a strategic 

plan with initiatives that will most effectively 

achieve equity in tobacco prevention and 

control through the identification and 

elimination of tobacco-related disparities.

Budget

Best practices dictate that 5% of total annual 

tobacco control program funds be allocated for 

administration and management of infrastructure development and maintenance activities. This 

budget is for the administration and management 

of infrastructure, not for all infrastructure activities. This might include costs pertaining to office 

expenses, postage and shipping, printing and 

duplication, occupancy expenses, equipment and 

maintenance, training and travel, planning, coordination activities, as well as staff time directly 

related to core planning and program oversight 

functions. 

Because of the importance of maintaining 

functioning infrastructure and the capacity to 

provide guidance, technical assistance, and 

coordination among programs and other key 

partners, the suggested target for administration 

and management of infrastructure activities should 

generally be 5% of a state’s total CDC-recommended 

program budget, even if actual program funding 

is below the CDC-recommended level.
69

Section A: Infrastructure, Administration, and Management

References

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Best Practices for Comprehensive Tobacco Control 

Programs—October 2007. Atlanta: U.S. Department 

of Health and Human Services, Centers for 

Disease Control and Prevention, National Center 

for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2007.

2. Lavinghouze SR, Snyder K, Rieker P, Ottsoson 

J. Consideration of an applied model of public 

health program infrastructure. Journal of Public 

Health Management and Practice 2013;19(6):E28–

E37. DOI: 10.1097/PHH.0b013e31828554c8. 

3. Lavinghouze SR. The difficulties and complexities of 

evaluating “inputs”: the forgotten box of the logic 

model. Panel presentation #406 at the TwentyFifth Annual American Evaluation Association 

Conference; November 2011; Anaheim, CA. 

4. Lavinghouze SR. The components of infrastructure: 

A model in progress. Panel presentation #576 at the 

Twenty-Fifth Annual American Evaluation Association 

Conference; November 2011; Anaheim, CA.

5. Lavinghouze, SR, Rieker P, Snyder K. The Component 

Model of Infrastructure (CMI): an infrastructure model 

for evaluating tobacco control programs. Evaluation 

ancillary meeting at the National Conference on 

Tobacco or Health; August 2012; Kansas City, MO.

6. Lavinghouze SR, Snyder K. Developing your 

evaluation plans: a critical component of public 

health program infrastructure. American Journal 

of Health Education 2013;44(4):237–43. 

7. Centers for Disease Control and Prevention. 

Developing an Effective Evaluation Report. Atlanta: 

Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, Division 

of Nutrition, Physical Activity and Obesity, 2013.

8. Institute of Medicine. Living Well with Chronic 

Illness: A Call for Public Health Action. Washington: 

The National Academies Press, 2012. 

9. Chapman R. Organization development in 

public health: A foundation for growth. 2010.

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Herbers SH, Mueller NB, Bunger AC. Public 

health program capacity for sustainability: 

A new framework. Implementation Science 

2013;8(15). DOI: 10.1186/1748-5908-8-15.

11. Farrelly MC, Pechacek TF, Chaloupka FJ. The 

impact of tobacco control program expenditures 

on aggregate cigarette sales: 1981–2000. Journal 

of Health Economics 2003;22(5):843–59.

12. Farrelly MC, Pechacek TF, Thomas KY, 

Nelson D. The impact of tobacco control 

programs on adult smoking. American 

Journal of Public Health 2008;98(2):304–9. 

13. Farrelly MC, Loomis BR, Han B, Gfroerer J, Kuiper N, 

Couzens GL, Dube SR, Caraballo RS. A comprehensive 

examination of the influence of state tobacco 

control programs and policies on youth smoking. 

American Journal of Public Health 2013;103(3):549–55.

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RG, Banks D, et al. Eliminating tobacco-related 

health disparities: directions for future research. 

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