Relationships Between Theoretically Derived Short-Term Outcomes and Support for Policy Among the Public and Decision-Makers.

PURPOSE AND OBJECTIVES: Policy change is a lengthy and complex process. Thus, it is important to articulate hypothesized causal pathways between advocacy activities and policy change outcomes and to identify and monitor early indicators of progress toward policy change. INTERVENTION APPROACH: The Kansas Health Foundation supports grantee efforts to address the public health effects of obesity through evidence-based policy, systems, and environmental change interventions. To build support for policy, systems, and environmental changes in schools, workplaces, and health care and retail settings, grantees mobilize communities, educate government policy makers, and advocate with organizational decision makers. EVALUATION METHODS: To understand whether early outcomes from obesity-prevention advocacy efforts predict interim outcomes related to eventual policy change, we conducted surveys of the general public and of opinion leaders in Kansas, which were designed to measure components of Kansas Health Foundation's theory of change. We then used structural equation modeling to test the theory of change's underlying relationships by using support for obesity prevention policies as the outcome. RESULTS: Our findings supported the hypothesized model: perceptions of obesity as a serious community problem influence beliefs about causes of the problem. Beliefs about causes predict beliefs about who is responsible for the solution to the problem, which in turn predicts support for obesity prevention policies. IMPLICATIONS FOR PUBLIC HEALTH: Evaluators of advocacy for policy change interventions can use this approach to monitor proximal changes in public and opinion leader beliefs related to eventual policy change and to determine whether efforts are likely to be successful or need to be adapted or abandoned.

Public Attitudes and Support for a Sugar-Sweetened Beverage Tax in America's Heartland.

BACKGROUND: Policy and environmental strategies are part of a comprehensive approach to obesity prevention. We investigated the association between public attitudes about how the environment influences health and support for a sugar-sweetened beverage (SSB) tax in Kansas. METHOD: We collected data via a 2014 representative dual-frame (cellular and landline) telephone survey of 2,203 adult Kansans regarding healthy eating policy support and beliefs about obesity causes and solutions. RESULTS: A significant proportion of Kansas adults (40%) support an SSB tax. Support was significantly stronger among females, young people, and liberals. Causal and responsibility attributions of obesity were significantly associated with policy support. Individuals who attribute more responsibility for the solution to the obesity epidemic to environmental factors were more likely to support a tax, regardless of their political affiliation. CONCLUSIONS: Messaging that focuses on the role of the environment in creating opportunities for health may be useful in framing discussions around SSB taxes.

Using a Theory of Change to Guide Grant Monitoring and Grantmaking.

Charitable foundations play a significant role in advancing public health, funding billions of dollars in health grants each year. Evaluation is an important accountability tool for foundations and helps ensure that philanthropic investments contribute to the broader public health evidence base. While commitment to evaluation has increased among foundations over the past few decades, effective use of evaluation findings remains challenging. To facilitate use of evaluation findings among philanthropic organizations, evaluators can incorporate the foundation's theory of change-an illustration of the presumed causal pathways between a program's activities and its intended outcomes-into user-friendly products that summarize evaluation findings and recommendations. Using examples from the evaluation of the Kansas Health Foundation's Healthy Living Focus Area, we present a mapping technique that can be applied to assess and graphically depict alignment between program theory and program reality, refine the theory of change, and inform grantmaking.

Public and Opinion Leader Willingness to Fund Obesity-Focused Policies in Kansas.

Obesity increases the risk for leading causes of death, including cardiovascular disease and some cancers. Midwestern and southern states have the highest obesity rates-in Kansas, one in every three adults is obese. We compared the willingness of Kansas adults and opinion leaders to pay more in taxes to fund obesity prevention policies. In 2014, we asked a representative sample of 2,203 Kansas adults (response rate 15.7%) and 912 opinion leaders (response rate 55%) drawn from elected office and other sectors, including business and health, whether they would pay an additional $50 in annual taxes to support five policies that improve access to healthy foods and opportunities for physical activity. We used adjusted Wald tests to compare public and opinion leaders' responses, and regression analysis to assess whether differences in respondents' gender, age, location (urban/rural), race/ethnicity, and political stance affected results. Adjusting for demographic differences, Kansas adults were more willing than opinion leaders to pay $50 in taxes for each of the five policy interventions. This study demonstrates a willingness among residents of a fiscally conservative state to pay increased taxes for policies that could reduce population obesity rates. Health professionals, including nurses, can use these findings to educate policy makers in Kansas and geopolitically similar states about widespread public support for obesity prevention policies. Public health and other nurses could also apply our methods to assess support for obesity prevention policies in their jurisdictions.

Support for a ban on tobacco powerwalls and other point-of-sale displays: findings from focus groups.

This study uses focus group data to document consumer perceptions of powerwall and other point-of-sale (POS) tobacco displays, and support for a ban on tobacco displays. Four focus groups were conducted in 2012 by a trained moderator. The study comprised 34 adult residents of New York State, approximately half with children under age 18 years living at home. Measures used in the study were awareness and perceptions of powerwall and other POS displays, and level of support for a ban on tobacco displays. Analysis focused on perceptions of powerwall and other POS displays, level of support for a ban on tobacco displays and reasons participants oppose a display ban. This study documents a general lack of concern about tobacco use in the community, which does not appear to be associated with support for a ban on POS tobacco displays. Although all participants had seen tobacco powerwalls and most considered them to be a form of advertising, participants were divided as to whether they played a role in youth smoking. Additional research is warranted to determine what factors individuals weigh in assigning value to a ban on POS tobacco displays and other tobacco control policies and how educational efforts can influence those assessments.

Factors involved in the collaboration between the national comprehensive cancer control programs and tobacco control programs: a qualitative study of 6 States, United States, 2012.

INTRODUCTION: Historically, federal funding streams to address cancer and tobacco use have been provided separately to state health departments. This study aims to document the impact of a recent focus on coordinating chronic disease efforts through collaboration between the 2 programs. METHODS: Through a case-study approach using semistructured interviews, we collected information on the organizational context, infrastructure, and interaction between cancer and tobacco control programs in 6 states from March through July 2012. Data were analyzed with NVivo software, using a grounded-theory approach. RESULTS: We found between-program activities in the state health department and coordinated implementation of interventions in the community. Factors identified as facilitating integrated interventions in the community included collaboration between programs in the strategic planning process, incorporation of one another's priorities into state strategic plans, co-location, and leadership support for collaboration. Coalitions were used to deliver integrated interventions to the community. Five states perceived high staff turnover as a barrier to collaboration, and all 5 states felt that federal funding requirements were a barrier. CONCLUSIONS: Cancer and tobacco programs are beginning to implement integrated interventions to address chronic disease. Findings can inform the development of future efforts to integrate program activities across chronic disease prevention efforts.

The Haverstraw experience: the first tobacco product display ban in the United States.

In April 2012, the village of Haverstraw, New York, passed the first tobacco retail display ban in the United States. Community groups funded by the New York State Department of Health Tobacco Control Program mobilized community members to support an initiative to protect youths in their area from tobacco marketing via methods consistent with a community transformation framework. The law was soon rescinded after 7 tobacco companies and the New York Association of Convenience Stores filed a federal lawsuit against the village that challenged the law's constitutionality. We discuss lessons learned and next steps for adoption of local point-of-sale policies.

Research support for effective state and community tobacco control programme response to electronic nicotine delivery systems.

OBJECTIVE: To identify unmet research needs of state and community tobacco control practitioners pertaining to electronic nicotine delivery systems (ENDS or e-cigarettes) that would inform policy and practice efforts at the state and community levels, and to describe ENDS-related research and dissemination activities of the National Cancer Institute-funded State and Community Tobacco Control Research Initiative. METHODS: To determine specific research gaps relevant to state and community tobacco control practice, we analysed survey data collected from tobacco control programmes (TCPs) in all 50 U.S. states and the District of Columbia (N=51). Survey items covered a range of ENDS issues: direct harm to users, harm of secondhand vapour, cessation, flavours, constituents and youth access. RESULTS: There is no ENDS topic on which a majority of state TCP managers feel very informed. They feel least informed about harms of secondhand vapour while also reporting that this information is among the most important for their programme. A majority (N=31) of respondents indicated needs for research on the implications of ENDS products for existing policies. CONCLUSIONS: TCP managers report that ENDS research is highly important for practice and need research-based information to inform decision making around the inclusion of ENDS in existing tobacco control policies. For optimal relevance to state and community TCPs, research on ENDS should prioritise study of the health effects of ENDS use and secondhand exposure to ENDS vapour in the context of existing tobacco control policies.

Opportunity for collaboration: a conceptual model of success in tobacco control and cancer prevention.

INTRODUCTION: Collaborations between cancer prevention and tobacco control programs can leverage scarce resources to address noncommunicable diseases globally, but barriers to cooperation and actual collaboration are substantial. To foster collaboration between cancer prevention and tobacco control programs, the Global Health Partnership conducted research to identify similarities and differences in how the 2 programs viewed program success. METHODS: Using concept mapping, cancer prevention and tobacco control experts generated statements describing the components of a successful cancer prevention or tobacco control program and 33 participants sorted and rated the final 99 statements. Multidimensional scaling analysis with a 2-dimensional solution was used to identify an 8-cluster conceptual map of program success. We calculated Pearson correlation coefficients for all 99 statements to compare the item-level ratings of both groups and used t tests to compare the mean importance of ratings assigned to each cluster. RESULTS: Eight major clusters of success were identified: 1) advocacy and persuasion, 2) building sustainability, 3) partnerships, 4) readiness and support, 5) program management fundamentals, 6) monitoring and evaluation, 7) utilization of evidence, and 8) implementation. We found no significant difference between the maps created by the 2 groups and only 1 mean difference for the importance ratings for 1 of the clusters: cancer prevention experts rated partnerships as more important to program success than did tobacco control experts. CONCLUSION: Our findings are consistent with those of research documenting the necessary components of successful programs and the similarities between cancer prevention and tobacco control. Both programs value the same strategies to address a common risk factor: tobacco use. Identifying common ground between these 2 research and practice communities can benefit future collaborations at the local, state, tribal, national, and international levels, and inform the broader discussion on resource sharing among other organizations whose mission focuses on noncommunicable diseases.

Community Program Activities Predict Local Tobacco Policy Adoption in Florida Counties.

The Bureau of Tobacco Free Florida's community program funds county-level grantees who promote local policy change through activities that educate the public, policy-makers, and decision-makers. There is robust literature linking tobacco control policies such as smoke-free air laws and tax increases to reductions in tobacco use. There is less evidence documenting the local activities programs conduct to achieve local policy change. In the current study, we used a quantitative model to assess the relationship between community tobacco control activities and local tobacco policy adoption. Grantee activities and policy adoption for each county are recorded in a database. To evaluate the community program, we compiled inputs and used a fixed-effects negative binomial regression to examine the relationship between grantee activities and policy adoption across all 67 community-based programs in Florida from 2010 to 2017 and analyzed the data in 2018. Measures included categories of policies (organization policies and jurisdiction policies) and community-based activities associated with tobacco control programs. Organization policy (school and business policy) and jurisdiction policy (county or city ordinances, proclamations, and resolutions) were dependent on partner meetings (incident rate ratio [IRR] = 1.03, confidence interval [CI] = 1.00-1.07 and IRR = 1.04, CI = 1.01-1.07, respectively) and local decision-maker communication (IRR = 1.01, CI = 1.00-1.03 and IRR = 1.05, CI = 1.03-1.07, respectively). Jurisdiction policy was also dependent on media advocacy (IRR = 1.07, CI = 1.02-1.12) and state policy-maker education (IRR = 1.16, CI = 1.06-1.26. Community outreach was negatively associated with jurisdiction policy (IRR = 0.97, CI = 0.94-0.99), and data collection was negatively associated with organization and jurisdiction policy (IRR = 0.97, CI = 0.95-1.00 and IRR = 0.97, CI = 0.95-1.00, respectively). Results from the study demonstrate that the type and timing of community grantee activities may influence local tobacco control policy adoption.

How Low-Income Smokers in New York Access Cheaper Cigarettes.

PURPOSE: To understand the tobacco acquisition practices of low-income smokers in New York State in light of high cigarette prices due to high cigarette taxes. DESIGN: Eight focus groups with low-income smokers were conducted in spring 2015 and 2016 (n = 74). SETTING: New York City (NYC) and Buffalo, New York. PARTICIPANTS: Low-income adults aged 18 to 65 who smoke cigarettes regularly. METHOD: Qualitative analysis of focus group transcripts that explored differences and similarities by region. We used the interview guide-which covered the process of acquiring cigarettes and the impact of cigarette prices-as a framework for analysis to generate themes and subthemes (deductive coding). We also generated themes and subthemes that emerged during focus group discussions (inductive coding). RESULTS: Some smokers in Western New York have switched to untaxed cigarettes from Native American reservations, whereas low-income smokers in NYC described convenient sources of bootlegged cigarettes (packs or loosies) in their local neighborhood stores, through acquaintances, or on the street. Familiarity with the retailer was key to accessing bootlegged cigarettes from retailers. CONCLUSIONS: Smokers in this study could access cheaper cigarettes, which discouraged quit attempts and allowed them to continue smoking. The availability of lower priced cigarettes may attenuate public health efforts aimed at reducing smoking prevalence through price and tax increases.

Community guide recommendations and state level tobacco control programmes: 1999-2004.

OBJECTIVE: To identify the level of effort state tobacco control programmes and partners have expended on interventions recommended by the community guide and how those efforts have changed over time between 1999 and 2004. DESIGN: Longitudinal study. SETTING: United States. PARTICIPANTS: State tobacco control partners, including the state health department, voluntary agencies and tobacco control coalitions. MAIN OUTCOME MEASURE: We used the Strength of Tobacco Control survey responses in 1999, 2002 and 2004 to calculate the mean proportion of state tobacco control partners working on recommended interventions and subsequently analysed changes in effort over time. RESULTS: The proportion of state tobacco control partners working to promote clean indoor air legislation remained at more than 70% in all three years. The proportion working to increase taxes on tobacco rose significantly between 1999 and 2002 (from 54% to 70%), and those working to reduce patient costs for tobacco cessation treatments never exceeded 31% in any year. Use of mass media targeting youths decreased significantly in all years (from 40% to 32% to 26%), and the proportion of state tobacco control partners participating in a quitline has increased steadily and significantly in all years (from 24% to 36% to 41%). The level of effort in each area varied widely between states and over time. CONCLUSIONS: State tobacco control partners are implementing evidence based interventions, but more focus is needed on the tobacco cessation and mass media campaign components of comprehensive tobacco control programmes.

Impact of home smoking rules on smoking patterns among adolescents and young adults.

INTRODUCTION: Smoking restrictions in public places have been shown to reduce cigarette consumption and may reduce smoking prevalence. Evidence is emerging that smoke-free policies in nonpublic places may have a similar effect. The purpose of this study was to determine whether an association exists between household smoking rules and smoking patterns among adolescents (aged 15 to 18 years) and young adults (aged 19 to 24 years) living in parental homes (i.e., the homes of their parents, grandparents, or foster parents). METHODS: Cross-sectional data from the 1998-1999 Tobacco Use Supplement to the Current Population Survey were analyzed for the association between household smoking rules and smoking behaviors among adolescents and young adults. We used a probability sample of noninstitutionalized adolescents (aged 15 to 18 years) and young adults (aged 19 to 24 years) living in the United States and assessed smoking status, attempts to quit, and smoking intensity. RESULTS: After controlling for smoking status of others in the household, the odds of ever having smoked, being a current smoker, and smoking more than five cigarettes per day were significantly smaller in households with strict no-smoking policies than in households where smoking was permitted anywhere. These results were relevant for adolescents and young adults. CONCLUSION: Household smoking rules are a type of antitobacco socialization that help deter adolescents from smoking. The influence of household smoking rules seems to extend beyond adolescence into the young adult years among people who continue to live at home with their parents, grandparents, or foster parents.

It's complicated: Examining smokers' relationships with their cigarette brands.

Despite increased restrictions and taxes, decreased social acceptability, and widespread awareness of the harms of tobacco use, many in the U.S. continue to smoke cigarettes. Thus, understanding smokers' attitudes and motivations remains an important goal. This study adopts the consumer psychology concept of brand relationship to provide a new lens through which to examine smokers' attitudes about their cigarette use. Twelve focus groups (N = 143) were conducted with adult cigarette smokers from September to November, 2013. Using a semistructured moderator guide and "top of mind" worksheets, the discussion examined participants' attitudes toward (a) their own cigarette brand and (b) tobacco companies in general. Data were coded and analyzed following principles of thematic analysis. Adult smokers reported positive attitudes toward their cigarette brand, as their brand was strongly associated with the positive experience of smoking (e.g., satisfying craving and relief from withdrawal). In contrast, thinking about tobacco companies in general evoked negative reactions, revealing overwhelmingly negative attitudes toward the industry. Findings reveal a complicated relationship between smokers and their cigarette brand: simultaneously embracing their cigarettes and rejecting the industry that makes them. Taken together, these data suggest smokers maintain largely positive brand relationships, diverting negative feelings about smoking toward the tobacco industry. Finally, they highlight the synergy between branding and the subjective smoking experience, whereby positive brand attitudes are reinforced through withdrawal relief. Ultimately, this information could inform a more complete understanding of how smokers interpret and respond to tobacco communications, including marketing from their brand. (PsycINFO Database Record

Measuring infrastructure: A key step in program evaluation and planning.

State tobacco prevention and control programs (TCPs) require a fully functioning infrastructure to respond effectively to the Surgeon General's call for accelerating the national reduction in tobacco use. The literature describes common elements of infrastructure; however, a lack of valid and reliable measures has made it difficult for program planners to monitor relevant infrastructure indicators and address observed deficiencies, or for evaluators to determine the association among infrastructure, program efforts, and program outcomes. The Component Model of Infrastructure (CMI) is a comprehensive, evidence-based framework that facilitates TCP program planning efforts to develop and maintain their infrastructure. Measures of CMI components were needed to evaluate the model's utility and predictive capability for assessing infrastructure. This paper describes the development of CMI measures and results of a pilot test with nine state TCP managers. Pilot test findings indicate that the tool has good face validity and is clear and easy to follow. The CMI tool yields data that can enhance public health efforts in a funding-constrained environment and provides insight into program sustainability. Ultimately, the CMI measurement tool could facilitate better evaluation and program planning across public health programs.

Public and policy maker support for point-of-sale tobacco policies in New York.

PURPOSE: To compare public and policy maker support for three point-of-sale tobacco policies. DESIGN: Two cross-sectional surveys--one of the public from the New York Adult Tobacco Survey and one of policy makers from the Local Opinion Leader Survey; both collected and analyzed in 2011. SETTING: Tobacco control programs focus on educating the public and policy makers about tobacco control policy solutions. SUBJECTS: Six hundred seventy-six county-level legislators in New York's 62 counties and New York City's five boroughs (response rate: 59%); 7439 New York residents aged 18 or older. Landline response rates: 20.2% to 22%. Cell phone response rates: 9.2% to 11.1%. MEASURES: Gender, age, smoking status, presence of a child aged 18 years or younger in the household, county of residence, and policy maker and public support for three potential policy solutions to point-of-sale tobacco marketing. ANALYSIS: t-tests to compare the demographic makeup for the two samples. Adjusted Wald tests to test for differences in policy support between samples. RESULTS: The public was significantly more supportive of point-of-sale policy solutions than were policy makers: cap on retailers (48.0% vs. 19.2%, respectively); ban on sales at pharmacies (49.1% vs. 38.8%); and ban on retailers near schools (53.3% vs. 42.5%). LIMITATIONS: cross-sectional data, sociodemographic differences, and variations in item wording. CONCLUSIONS: Tobacco control programs need to include information about implementation, enforcement, and potential effects on multiple constituencies (including businesses) in their efforts to educate policy makers about point-of-sale policy solutions.