Development of a state wide tobacco treatment specialist training and certification programme for Massachusetts

OBJECTIVE: To describe the research conducted to structure and develop a statewide tobacco training and certification programme for tobacco treatment specialists (TTSs) in Massachusetts. DESIGN: Qualitative research strategies were used to obtain information on certification development and opinions regarding TTS training and certification from key informants. A role definition and validation study was then conducted to determine the core competencies for TTSs. A comprehensive training programme was developed, piloted, and finalised, and a certification programme was initiated. PARTICIPANTS: Key informants included: individuals involved in the development of their professional certification programmes; tobacco treatment providers from across Massachusetts; and national tobacco treatment experts. MAIN OUTCOME MEASURES: Participants' opinions about the need for and structure of a training and certification programme for individuals specialising in the provision of moderate to intensive tobacco treatment; delineation of core competencies for TTSs, using the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) clinical practice guideline as a foundation for the development of evidence based standards of practice for the treatment of nicotine dependence. RESULTS: The data support a comprehensive training and certification programme for TTSs in Massachusetts. Main concerns include the cost of obtaining certification, the potential to exclude uncertified healthcare professionals from delivering basic tobacco treatment, and the role of the TTS in the healthcare delivery system and the community. The training programme developed for Massachusetts was piloted, and the structure of a statewide training and certification programme for TTSs was finalised. CONCLUSIONS: The research provides support for the need and acceptance of a training and certification programme for TTSs in Massachusetts, and presents the challenges to be addressed. We demonstrated the feasibility of developing and implementing an evidence based training programme, and of initiating a statewide certification programme in Massachusetts. This work will add to a national dialogue on the development of a training and certification programme for tobacco treatment providers and encourage further research into the potential impact of statewide and national certification.     

Effectiveness of comprehensive tobacco control programmes in reducing teenage smoking in the USA

OBJECTIVE: To describe the extent to which comprehensive statewide tobacco control programmes in the USA have made progress toward reducing teenage smoking. DATA SOURCES: Literature search of Medline for reviews of effectiveness of programme and policy elements, plus journal articles and personal request for copies of publicly released reports and working papers from evaluation staff in each of the state programmes of California, Massachusetts, Arizona, Oregon, and Florida. STUDY SELECTION: All studies, reports, and commentaries that provided information on aspects of programme implementation and evaluation. DATA SYNTHESIS: Statewide comprehensive programmes show high levels of advertising recall and generally positive improvement in smoking related beliefs and attitudes among teenagers. More fully funded programmes lead to increased mass media campaign advertising and community initiatives; a greater capacity to implement school based smoking prevention programmes; and an increase in the passage of local ordinances that create smoke free indoor environments and reduce cigarette sales to youth. The combination of programme activity and increased tobacco tax reduce cigarette consumption more than expected as a result of price increases alone, and these effects seem to apply to adolescents as well as adults. Programmes are associated with a decline in adult smoking prevalence, with these effects observed to date in California, Massachusetts, and Oregon. Arizona and Florida have yet to examine change in adult prevalence associated with programme exposure. California and Massachusetts have demonstrated relative beneficial effects in teenage smoking prevalence, and Florida has reported promising indications of reduced prevalence. Arizona has yet to report follow up data, and Oregon has found no change in teenage smoking, but has only two years of follow up available. One of the most critical factors in programme success is the extent of programme funding, and consequent level of programme implementation, and the degree to which this is undermined by the tobacco industry and other competitors for funding. CONCLUSIONS: Despite the different strengths and combinations of programme messages and strategies used in these comprehensive programmes, there is evidence that they lead to change in factors that influence teenage smoking, and to reductions in teenage smoking.     

Arizona's tobacco control initiative illustrates the need for continuing oversight by tobacco control advocates

BACKGROUND: In 1994, Arizona voters approved Proposition 200 which increased the tobacco tax and earmarked 23% of the new revenues for tobacco education programmes. OBJECTIVE: To describe the campaign to pass Proposition 200, the legislative debate that followed the passage of the initiative, and the development and implementation of the tobacco control programme. DESIGN: This is a case study. Data were collected through semi-structured interviews with key players in the initiative campaign and in the tobacco education programme, and written records (campaign material, newspapers, memoranda, public records). RESULTS: Despite opposition from the tobacco industry, Arizonans approved an increase in the tobacco tax. At the legislature, health advocates in Arizona successfully fought the tobacco industry attempts to divert the health education funds and pass preemptive legislation. The executive branch limited the scope of the programme to adolescents and pregnant women. It also prevented the programme from attacking the tobacco industry or focusing on secondhand smoke. Health advocates did not put enough pressure at the executive branch to force it to develop a comprehensive tobacco education programme. CONCLUSIONS: It is not enough for health advocates to campaign for an increase in tobacco tax and to protect the funds at the legislature. Tobacco control advocates must closely monitor the development and implementation of tax-funded tobacco education programmes at the administrative level and be willing to press the executive to implement effective programmes.     

Adult smoking intervention programmes in Massachusetts: a comprehensive approach with promising results

This paper provides a brief overview of the history of Massachusetts' opposition to smoking. It describes the current Massachusetts Tobacco Control Program and its smoking intervention programmes; changes in public opinion, perceptions and attitudes toward smoking; and programme impact. Massachusetts has been successful in developing a comprehensive intervention that has had encouraging results in changing public attitudes about smoking and in helping smokers to quit.     

African American leadership groups: smoking with the enemy

BACKGROUND: Among all racial and ethnic groups in the USA, African Americans bear the greatest burden from tobacco related disease. The tobacco industry has been highly influential in the African American community for decades, providing funding and other resources to community leaders and emphasising publicly its support for civil rights causes and groups, while ignoring the negative health effects of its products on those it claims to support. However, the industry's private business reasons for providing such support were unknown. OBJECTIVE: To understand how and for what purposes the tobacco industry sought to establish and maintain relationships with African American leaders. METHODS: Review and analysis of over 700 previously secret internal tobacco industry documents available on the internet. RESULTS: The tobacco industry established relationships with virtually every African American leadership organisation and built longstanding social connections with the community, for three specific business reasons: to increase African American tobacco use, to use African Americans as a frontline force to defend industry policy positions, and to defuse tobacco control efforts. CONCLUSION: As the tobacco industry expands its global reach, public health advocates should anticipate similar industry efforts to exploit the vulnerabilities of marginalised groups. The apparent generosity, inclusion, and friendship proffered by the industry extract a price from groups in the health of their members. Helping groups anticipate such efforts, confront industry co-optation, and understand the hidden costs of accepting tobacco industry largesse should be part of worldwide tobacco control efforts.     

Globalisation of tobacco industry influence and new global responses

The globalisation of tobacco marketing, trade, research, and industry influence represents a major threat to public health worldwide. Drawing upon tobacco industry strategy documents prepared over several decades, this paper will demonstrate how the tobacco industry operates as a global force, regarding the world as its operating market by planning, developing, and marketing its products on a global scale. The industry has used a wide range of methods to buy influence and power, and penetrate markets across the world. It has an annual turnover of almost US$400 billion. In contrast, until recently tobacco control lacked global leadership and strategic direction and had been severely underfunded. As part of moving towards a more sustainable form of globalisation, a global enabling environment linked to local actions should focus on the following strategies: global information management; development of nationally and locally grounded action; global regulation, legal instruments, and foreign policy; and establishment of strong partnerships with purpose. As the vector of the tobacco epidemic, the tobacco industry's actions fall far outside of the boundaries of global corporate responsibility. Therefore, global and local actions should not provide the tobacco industry with the two things that it needs to ensure its long term profitability: respectability and predictability.     

A randomised controlled trial of a community intervention to prevent adolescent tobacco use

OBJECTIVE: Experimental evaluation of comprehensive community wide programme to prevent adolescent tobacco use. DESIGN: Eight pairs of small Oregon communities (population 1700 to 13 500) were randomly assigned to receive a school based prevention programme or the school based programme plus a community programme. Effects were assessed through five annual surveys (time 1-5) of seventh and ninth grade (ages 12-15 years) students. INTERVENTION: The community programme included: (a) media advocacy, (b) youth anti-tobacco activities, (c) family communications about tobacco use, and (d) reduction of youth access to tobacco. MAIN OUTCOME MEASURE: The prevalence of self reported smoking and smokeless tobacco use in the week before assessment. RESULTS: The community programme had significant effects on the prevalence of weekly cigarette use at times 2 and 5 and the effect approached significance at time 4. An effect on the slope of prevalence across time points was evident only when time 2 data points were eliminated from the analysis. The intervention affected the prevalence of smokeless tobacco among grade 9 boys at time 2. There were also significant effects on the slope of alcohol use among ninth graders and the quadratic slope of marijuana for all students. CONCLUSION: The results suggest that comprehensive community wide interventions can improve on the preventive effect of school based tobacco prevention programmes and that effective tobacco prevention may prevent other substance use.     

Tobacco lobby political influence on US state legislatures in the 1990s

BACKGROUND: Throughout the 1990s the tobacco lobby was a potent political force in US state legislatures advancing its pro-tobacco agenda. OBJECTIVE: To describe the market and political motivations of the tobacco lobby and the strategies they use to achieve these goals in US state legislatures. DESIGN: This study is a content analysis and summary overview of recently released historical tobacco industry documents; tobacco related government documents; and recent state tobacco control policy reports. RESULTS: In the 1990s, the tobacco lobby engaged in a comprehensive and aggressive political effort in state legislatures to sell tobacco with the least hindrance using lobbying, the media, public relations, front groups, industry allies, and contributions to legislators. These efforts included campaigns to neutralise clean indoor air legislation, minimise tax increases, and preserve the industry's freedom to advertise and sell tobacco. The tobacco lobby succeeded in increasing the number of states that enacted state pre-emption of stricter local tobacco control laws and prevented the passage of many state tobacco control policies. Public health advocates were able to prevent pre-emption and other pro-tobacco policies from being enacted in several states. CONCLUSIONS: The tobacco lobby is a powerful presence in state legislatures. Because of the poor public image of the tobacco lobby, it seeks to wield this power quietly and behind the scenes. State and local health advocates, who often have high public credibility, can use this fact against the tobacco lobby by focusing public attention on the tobacco lobby's political influence and policy goals and expose links between the tobacco lobby and its legislative supporters.     

Tobacco cessation skills certification in Arizona: application of a state wide, community based model for diffusion of evidence based practice guidelines

OBJECTIVE: To describe the development and preliminary results from a community based certification model for training in tobacco cessation skills in Arizona. DESIGN: A programme evaluation using both quantitative pre-post measures and qualitative methods. SETTING: Arizona's comprehensive tobacco control programme of state funded, community based local projects and their community partners providing tobacco treatment services for geographically, socioeconomically, and ethnically diverse communities. INTERVENTION: A three tiered model of skills based training emphasising Agency for Health Care Policy and Research guidelines, and utilising a training of trainers approach to build community capacity. Certification roles addressed basic tobacco cessation skills, tobacco cessation specialist, and tobacco treatment services manager. PARTICIPANTS: Initial target audience was community based local project personnel and their community partners, with later adoption by community organisations unaffiliated with local projects, and the general public. MAIN EVALUATION MEASURES: Process measures: participant satisfaction, knowledge, skills, and self-efficacy. Outcome: participant demographics, community organisations represented, post-training, cessation related activities. RESULTS: During the model's implementation year, 1075 participants attended certification training, 947 participants received basic skills certificates and 82 received specialist certificates. Pre, post, and three month measures of self efficacy showed significant and durable increases. Analysis of participant characteristics demonstrated broad community representation. At post-training follow up, 80.9% of basic skills trainees had performed at least one brief intervention and 74.8% had made a referral to intensive services. Among cessation specialists, 48.8% were delivering intensive services and 69.5% were teaching basic skills classes. CONCLUSIONS: Initial experience with Arizona's state wide, community based model for certification of tobacco cessation skills training suggests this model may be a promising method for broad, population based diffusion of evidence based tobacco cessation guidelines.     

Tobacco control advocates must demand high-quality media campaigns: the California experience

OBJECTIVE: To document efforts on the part of public officials in California to soften the media campaign's attack on the tobacco industry and to analyse strategies to counter those efforts on the part of tobacco control advocates. METHODS: Data were gathered from interviews with programme participants, direct observation, written materials, and media stories. In addition, internal documents were released by the state's Department of Health Services in response to requests made under the California Public Records Act by Americans for Nonsmokers' Rights. Finally, a draft of the paper was circulated to 11 key players for their comments. RESULTS: In 1988 california voters enacted Proposition 99, an initiative that raised the tobacco tax by $0.25 and allocated 20% of the revenues to anti-tobacco education. A media campaign, which was part of the education programme, directly attacked the tobacco industry, exposing the media campaign to politically based efforts to shut it down or soften it. Through use of outsider strategies such as advertising, press conferences, and public meetings, programme advocates were able to counter the efforts to soften the campaign. CONCLUSION: Anti-tobacco media campaigns that expose industry manipulation are a key component of an effective tobacco control programme. The effectiveness of these campaigns, however, makes them a target for elimination by the tobacco industry. The experience from California demonstrates the need for continuing, aggressive intervention by nongovernmental organisations in order to maintain the quality of anti-tobacco media campaigns.     

The tobacco settlement: an analysis of newspaper coverage of a national policy debate, 1997-98

OBJECTIVE: To examine the framing of tobacco policy issues in the news media during the national tobacco settlement debate of 1997-98. The major aims were (1) to describe the extent of newspaper coverage of each of the specific components of the proposed tobacco settlement; (2) to identify the tobacco control frames, and the dominant frame, appearing in each newspaper article; and (3) to examine trends in tobacco control frames over time. DESIGN: A content analysis was performed on 117 articles related to national tobacco legislation appearing in the Washington Post from 1 January 1997 through 18 June 1998. MAIN OUTCOME MEASURES: (1) Major policy themes of the settlement referred to or implied in each article; (2) major frames used to discuss the problem of tobacco in each article. RESULTS: The generation of new revenue was the dominant theme of the articles, appearing as a major focus in 44% (52) of the articles. Other than the issues of Food and Drug Administration regulation of tobacco and restrictions on cigarette advertising, the public health policy aspects of the tobacco settlement received little attention. The problem of tobacco was portrayed as one of youth smoking in 55% (64) of the articles, but as one of a deadly product in none of the articles. CONCLUSIONS: Future discussions of comprehensive tobacco policy should be driven by a more specific discussion of the precise programme and policy mechanisms by which tobacco use can be most effectively prevented and controlled. The public health community must find ways to frame the tobacco issue more broadly than simply as one of youth smoking.     

State variation in retail promotions and advertising for Marlboro cigarettes

BACKGROUND: There is some evidence that tobacco companies marketing efforts undermine the effects of comprehensive tobacco control programmes. OBJECTIVE: To determine whether point-of-purchase advertising and promotions are more pervasive in states where comprehensive tobacco control programmes are underway. DESIGN: Cross sectional survey using 1996 data, with merged records of the existence of local tobacco advertising restrictions. PARTICIPANTS AND SETTING: 581 tobacco retail stores located in close proximity to high schools in mainland USA. MAIN OUTCOME MEASURES: Existence of gift-with-purchase, number of interior advertisements, and exterior store advertisements for Marlboro cigarettes. RESULTS: After controlling for store type and existence of advertising restrictions, offer of a gift-with-purchase for Marlboro cigarettes was significantly more likely in states with comprehensive tobacco control programmes than those without programmes (odds ratio 2.59, 95% confidence interval 1.57 to 4.26). Although not significant, results show an increase in the number of interior and exterior store advertisements for stores located in states with a comprehensive tobacco control programme than those in other states. CONCLUSION: Results suggest some point-of-purchase tobacco promotions and advertising are more pervasive in states with comprehensive tobacco control programmes. These efforts are likely to act against the objectives of programmes and need to be accounted for in programme evaluations.     

Tobacco industry successfully prevented tobacco control legislation in Argentina

Objective: To evaluate how transnational tobacco companies, working through their local affiliates, influenced tobacco control policymaking in Argentina between 1966 and 2005. Methods: Analysis of internal tobacco industry documents, local newspapers and magazines, internet resources, bills from the Argentinean National Congress Library, and interviews with key individuals in Argentina. Results: Transnational tobacco companies (Philip Morris International, British American Tobacco, Lorillard, and RJ Reynolds International) have been actively influencing public health policymaking in Argentina since the early 1970s. As in other countries, in 1977 the tobacco industry created a weak voluntary self regulating code to avoid strong legislated restrictions on advertising. In addition to direct lobbying by the tobacco companies, these efforts involved use of third party allies, public relations campaigns, and scientific and medical consultants. During the 1980s and 1990s efforts to pass comprehensive tobacco control legislation intensified, but the organised tobacco industry prevented its enactment. There has been no national activity to decrease exposure to secondhand smoke. Conclusions: The tobacco industry, working through its local subsidiaries, has subverted meaningful tobacco control legislation in Argentina using the same strategies as in the USA and other countries. As a result, tobacco control in Argentina remains governed by a national law that is weak and restricted in its scope.     

An analysis of the successful 1992 Massachusetts tobacco tax initiative

In November 1992, voters in Massachusetts (United States) passed a statewide tax initiative adding an extra 25 cents to the price of a pack of cigarettes. The Massachusetts Coalition for a Healthy Future, led by volunteers from the Massachusetts Division of the American Cancer Society, achieved this victory, despite a public anti-tax mood and $7.3 million spent by the tobacco industry. The tax has since generated millions of dollars for tobacco education and control programmes, leading to acceleration of the decline of tobacco consumption in the state. An analysis of the passage of this initiative should help other states considering this approach to tobacco control.


     

Development and destruction of the first state funded anti-smoking campaign in the USA

Background: Minnesota was the first state in the USA to implement a large state funded tobacco control programme (in 1985). Despite evidence of effectiveness, it was dismantled in 1993.

Objective: To describe and analyse how and why these events transpired and identify lessons for tobacco control advocates facing similar challenges in the 21st century.

Design: Case study based on previously secret tobacco industry documents, news reports, research reports, official documents, and interviews with health advocates and state government officials.

Results: Unable to defeat funding for this campaign in 1985, the tobacco industry organised groups which eliminated it later. Despite the programme's documented effectiveness, it was dismantled based on claims of fiscal crisis. These claims were not true; the real debate was what to do with the state's surplus. Health advocates failed to challenge the claim of fiscal crisis or mobilise public support for the programme.

Conclusions: Simply quoting evidence that a tobacco control programme is effective does not ensure its continuing survival. Claims of fiscal crisis are an effective cover for tobacco industry efforts to dismantle successful programmes, particularly if health advocates accept these claims and fail to mobilise political pressure to defend the programme.

     

The passage and initial implementation of Oregon's Measure 44

OBJECTIVE: To prepare a history of the passage and early implementation of Ballot Measure 44, "An Act to Support the Oregon Health Plan", and tobacco control policymaking in Oregon. Measure 44 raised cigarette taxes in Oregon by US$0.30 per pack, and dedicated 10% of the revenues to tobacco control. METHODS: Data were gathered from interviews with members of the Committee to Support the Oregon Health Plan, Measure 44's campaign committee, as well as with state and local officials, and tobacco control advocates. Additional information was obtained from public documents, internal memoranda, and news reports. RESULTS: Although the tobacco industry outspent Measure 44's supporters 7 to 1, the initiative passed with 56% of the vote. Even before the election, tobacco control advocates were working to develop an implementation plan for the tobacco control programme. They mounted a successful lobbying campaign to see that the legislature did not divert tobacco control funds to other uses. They also stopped industry efforts to limit the scope of the programme. The one shortcoming of the tobacco control forces was not getting involved in planning the initiative early enough to influence the amount of money that was devoted to tobacco control. Although public health groups provided 37% of the money it cost to pass Measure 44, only 10% of revenues were devoted to tobacco control. CONCLUSIONS: Proactive planning and aggressive implementation can secure passage of tobacco control initiatives and see that the associated implementing legislation follows good public health practice.     

Building capacity for tobacco control research and policy

The Fogarty International Center (FIC) initiative, "International Tobacco and Health Research Capacity Building Program" represents an important step in US government funding for global tobacco control. Low- and middle-income countries of the world face a rising threat to public health from the rapidly escalating epidemic of tobacco use. Many are now parties to the Framework Convention on Tobacco Control (FCTC) and capacity development to meet FCTC provisions. One initial grant provided through the FIC was to the Institute for Global Tobacco Control (IGTC) at the Johns Hopkins Bloomberg School of Public Health (JHSPH) to support capacity building and research programmes in China, Brazil, and Mexico. The initiative's capacity building effort focused on: (1) building the evidence base for tobacco control, (2) expanding the infrastructure of each country to deliver tobacco control, and (3) developing the next generation of leaders as well as encouraging networking throughout the country and with neighbouring countries. This paper describes the approach taken and the research foci, as well some of the main outcomes and some identified challenges posed by the effort. Individual research papers are in progress to provide more in-depth reporting of study results.     

Public health foundations and the tobacco industry: lessons from Minnesota

Objective: To investigate whether private foundations can be created in a way that will insulate them from attacks by the tobacco industry, using the Minnesota Partnership for Action Against Tobacco (MPAAT) as a case study.

Design: Information was collected from internal tobacco industry documents, court documents, newspapers, and interviews with health advocates and elected officials.

Results: The creation of MPAAT as an independent foundation did not insulate it from attacks by tobacco industry allies. During 2001–2002, MPAAT was repeatedly attacked by Attorney General Mike Hatch and major media, using standard tobacco industry rhetoric. This strategy of attack and demands for information were reminiscent of previous attacks on Minnesota's Plan for Nonsmoking and Health and the American Stop Smoking Intervention Study (ASSIST). MPAAT was ultimately forced to restructure its programme to abandon effective community norm change interventions around smoke-free policies and replace them with less effective individual cessation interventions. Neither MPAAT nor other health advocates mounted an effective public response to these attacks, instead relying on the insider strategy of responding in court.

Conclusion: It is not possible to avoid attacks by the tobacco industry or its political allies. Like programmes administered by government agencies, tobacco control foundations must be prepared for these attacks, including a proactive plan to educate the public about the principles of community based tobacco control. Public health advocates also need to be willing to take prompt action to defend these programmes and hold public officials who attack tobacco control programmes accountable for their actions.

     

Social movements and human rights rhetoric in tobacco control

After achieving breathtaking successes in securing state and local restrictions on smoking in public places and restricting youth access to tobacco products, the tobacco movement faces difficult decisions on its future strategic directions. The thesis of this article is that the tobacco control movement is at a point of needing to secure its recent successes and avoiding any public retrenchment. To do so requires rethinking the movement's strategic direction. We use the familiar trans-theoretical model of change to describe where the movement is currently and the threats it faces. The new tobacco control strategy should encompass a focus on voluntary non-smoking strategies, use human rights rhetoric to its advantage, and strengthen the public health voice to be more effective in political battles. In developing a new strategy, tobacco control advocates need to build a social movement based on a more forceful public health voice, along with the strategic use of human rights rhetoric, to focus on the power of voluntary non-smoking efforts. Using human rights rhetoric can help frame the movement in ways that have traditionally appealed to the American public. Perhaps more importantly, doing so can help infuse the tobacco control movement with a broader sense of purpose and mission.     

Consensus for tobacco policy among former state legislators using the policy Delphi method

OBJECTIVE: To test a novel approach for building consensus about tobacco control policies among legislators. DESIGN: A pilot study was conducted using a two-round, face-to-face policy Delphi method. PARTICIPANTS: Randomly selected sample of 30 former Kentucky legislators (60% participation rate). MAIN OUTCOME MEASURE: Consensus on tobacco control and tobacco farming policies. RESULTS: Former state legislators were more supportive of tobacco control policies than expected, and highly supportive of lessening the state's dependence on tobacco. Former state legislators were in agreement with 43% of the second-round items for which there was no agreement at the first round, demonstrating a striking increase in consensus. With new information from their colleagues, former lawmakers became more supportive of workplace smoking restrictions, limitations on tobacco promotional items, and modest excise tax increases. CONCLUSIONS: The policy Delphi method has the potential for building consensus for tobacco control and tobacco farming policies among state legislators. Tobacco control advocates in other states might consider using the policy Delphi method with policymakers in public and private sectors.