The Tobacco Control Network’s Policy Readiness and Stage of Change Assessment: What the Results Suggest for Moving Tobacco Control Efforts Forward at the State and Territorial Levels April Roeseler, MSPH, BSN; Madeleine Solomon, MPH; Carissa Beatty, MPH, CHES; Alison M. Sipler, MPH, CHES rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Context: The Tobacco Control Network (TCN) is comprised of the tobacco control programs in the health departments of states, territories, and the District of Columbia. During the assessment period, the TCN was managed by the Tobacco Technical Assistance Consortium at Emory University. Objective: To assess the readiness of state and territory tobacco control programs to work on evidence-based, promising policy and system change strategies aimed at preventing and reducing tobacco use and secondhand smoke exposure. Design: The Policy Readiness and Stage of Change Assessment was a Web-based survey fielded in September 2013, which was based on the Community Readiness Model. Setting: Fifty-nine comprehensive tobacco control programs. Participants: State and territory tobacco control program managers and their internal and external partners. Intervention: The TCN’s 2012 Policy Platform recommendations were used as the basis to assess state/territory readiness to adopt and implement evidence-based and promising tobacco control policy/system change strategies. Main Outcome Measures: Sixteen tobacco control strategies were rated on: (1) implementation status, (2) readiness, (3) stage of change, and (4) the appropriate level of action for work on the strategy. Results: The 3 strategies with the highest readiness scores were as follows: (1) 100% smoke-free air in workplaces (64%), (2) tobacco-free schools (61%), and (3) $1.50 or more cigarette tax with funds to tobacco control (53%). The 3 strategies with lowest readiness scores were: 1) coupon redemption (17%), 2) tobacco mitigation fee
J Public Health Management Practice, 2016, 22(1), 9–19 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
(14%), and 3) disclosure or sunshine laws (8%). Conclusion: Readiness to work on tobacco control strategies varied by region and strategy. Many states/territories are ready to work on strategies for which there is less evidence of a population-level impact for reducing tobacco use, but which contribute to denormalizing tobacco use. Working toward less impactful policies may build support, capacity, and policy success, laying an important foundation to achieve more impactful strategies. KEY WORDS: community readiness, health assessment, policy,
social norm change, stage of change, tobacco
The 50th Anniversary Surgeon General’s Report on Smoking and Health confirmed that tobacco use is the single most preventable cause of death and disease in the United States.1,2 An estimated 42.1 million Author Affiliations: California Tobacco Control Program, California Department of Public Health, Sacramento, California (Ms Roeseler); and Emory University, Emory Centers for Training and Technical Assistance, Atlanta, Georgia (Mss Solomon, Beatty, and Sipler). The authors thank Josh Berry, Student Intern, Emory University, for his assistance with programming the Web-based survey and creation of figures. The Tobacco Control Network Policy Readiness and Stage of Change Assessment was fielded by the Tobacco Technical Assistance Consortium (TTAC) at Emory University, which received funding from the Office on Smoking and Health, Centers for Disease Control and Prevention under contract number: 200-2013M-57407. The authors declare no conflicts of interest. Correspondence: April Roeseler, MSPH, BSN, California Tobacco Control Program, California Department of Public Health, PO Box 997377, MS 7206 Sacramento, CA 95899 ([email protected]). DOI: 10.1097/PHH.0000000000000247
9 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
10 ❘ Journal of Public Health Management and Practice Americans (18% of all adults) currently smoke cigarettes.3 Cigarette smoking causes 480 000 deaths each year, accounting for 1 of every 5 deaths in the United States (including 50 000 deaths from secondhand smoke).1 Adults who smoke cigarettes die an average of 14 years earlier than nonsmokers.4 For every person who dies from tobacco use, another 20 people suffer from at least 1 serious tobacco-related illness.5 Smokeless tobacco products also pose a significant health risk and are not a safe substitute for cigarettes.6 While significant progress has been made to reduce tobacco use in the United States since the release of the first Surgeon General’s Report on Smoking and Health in 1964, large disparities in smoking prevalence and tobacco-related diseases exist among groups differentiated by race/ethnicity, socioeconomic status, educational attainment, mental health, sexual orientation, occupation, and geography.7 Implementing strategies that will accelerate the rate of change among these groups at the population level is critical to reducing these disparities and achieving health equity.8 Also essential to reducing tobacco-related disparities are policies and program strategies that motivate and support successful quitting; engage communities in change; and provide the financial, human, and training resources necessary to denormalize tobacco use.9 The Tobacco Control Network (TCN), which includes tobacco control program managers and staff from all US states and territories, conducted a Policy Readiness and Stage of Change Assessment (TCN Readiness Assessment) in which TCN members rated their readiness to work on evidence-based and promising policy and system changes to prevent and reduce tobacco use. Policy and environmental and systemlevel changes are the building blocks of social norm change and are effective at decreasing tobacco use at the population level.2,10,11 The social norm change strategy influences current and potential tobacco users by creating a social and legal environment in which tobacco use is less desirable, less acceptable, and less attainable.12,13 Smoke-free air policies and mass media campaigns are examples of evidence-based strategies, which denormalize smoking and are associated with decreased intentions to smoke and increased quitting behaviors.12,14 While policy and system change strategies are powerful tools, tobacco control programs must seek to ensure that these strategies are uniformly and equitably adopted to prevent health inequities.15 The TCN Readiness Assessment was conducted to help states and territories develop their 5-year Centers for Disease Control and Prevention (CDC) Collaborative Funding Applications in 2014. While the CDC funding cycle was delayed, the results were used for
strategic planning, identification of training and technical assistance needs, and facilitation of TCN partnerships with national networks and other technical assistance and training providers.
● Background/Literature Review TCN mission and goals The TCN’s mission is to improve the public’s health by increasing the capacity of states, territories, and the District of Columbia (DC) to implement evidence-based comprehensive tobacco control programs. The network promotes information and strategy sharing, advocates for evidence-based and promising program and policy strategies, and increases collaboration among its members and national partners. The TCN is led by an Executive Committee and managed by an external contractor funded by the CDC. From September 2008 to March 2014, the Tobacco Technical Assistance Consortium (TTAC) at Emory University managed the TCN. Consistent with national directives, the network uses assessment results to drive policy development and assure high quality implementation.16,17 Policy adoption and implementation are major tobacco control interventions, which denormalize tobacco use, reduce initiation, and promote quitting.18-20 As summarized in Table 1, the TCN Policy Platform communicates a vision for policy and system changes.21 It was developed by the TCN Policy Committee in collaboration with the executive committee and regional representatives. The 2012 TCN Policy Platform highlighted raising the price of tobacco products, passing smoke-free air laws, and funding sustainable comprehensive programs as evidence-based strategies known to prevent and reduce tobacco use and secondhand smoke exposure on a population basis.13,21-24 Systematic reviews of these policy strategies indicate they are broadly effective across populations groups when uniformly implemented.22-25 For states and territories that had achieved success with these 3 evidence-based strategies, additional promising and emerging strategies were recommended that addressed non-indoor worksite smoke-free venues including multiunit housing and outdoor environments; reducing barriers to cessation services; the retail environment; and non-tax tobacco product price increase strategies.25-31 Because these additional strategies seek to increase the price of tobacco products, limit secondhand smoke exposure, reduce exposure to tobacco product marketing, and increase access to cessation treatment, they are likely to aid reductions in tobacco-related disparities.26,29,31-38 A 2012 examination of the states and territories found
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Tobacco Control Network’s Policy Readiness and Stage of Change Assessment
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TABLE 1 ● Description of 16 Tobacco Policy/System Change Strategies
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Tobacco Pricing Strategies/Program Funding Cigarette Excise Tax of at least $1.50 per pack of cigarettes with an equivalent tax increase on Other Tobacco Products (eg, smokeless, cigars, pipes, dissolvables) and specifically designate a portion of the revenue for a comprehensive tobacco control program to achieve greater equity and to particularly reduce tobacco use among lower socioeconomic communities. Sustainable, Comprehensive Tobacco Control Program Funding. This policy designates a portion of the tobacco excise taxes and/or tobacco industry settlement payments for a comprehensive tobacco control program. Cigarette Minimum Price Policies set a floor price for cigarettes and other products and prohibit the sale of these products for less than the minimum price. Coupon Redemption Policies restrict/eliminate tobacco industry coupon redemption, discounts, multipack discount offers, and gift with tobacco purchase. Tobacco Mitigation Fees add a “fee” to tobacco products to ameliorate the environmental impact and blight caused by tobacco-related litter. A Disclosure or Sunshine Policy requires tobacco companies to disclose payments and discounts paid to retailers within a specific geographic area such as a city, county, state, or territory. Protection from Secondhand Smoke 100% Smoke-Free Workplace Air Policies protect all workers and the public from exposure to tobacco smoke. These laws should cover all workplaces and public places, including restaurants, bars, and gaming facilities in accordance with the Fundamentals for Smoke-Free Workplaces Guide. Smoke-Free Multiunit Housing Policies protect residents and guests from involuntary exposure to secondhand smoke, which drifts between units through electrical lines, plumbing, heating and air conditioning systems, and open windows. Smoke-Free Outdoor Policies protect the public from secondhand smoke exposure, protect animal and marine life, reduce tobacco litter, and reduce fire hazards in outdoor venues such as sports arenas and fields, restaurant and bar patios, service lines, transit waiting areas, public events like county fairs and farmer’s markets, as well as parks, beaches, and recreation areas. Tobacco-Free K-12 School Policies prohibit tobacco use by students, all school staff, parents, and visitors on school property, in school vehicles, and at school sponsored functions away from school property. These policies enable and encourage children and adolescents who have not experimented with tobacco to continue to abstain from any use and promote quitting. Tobacco Accessibility and Marketing Tobacco Retail Licensing with fees earmarked for enforcement provide a broad and flexible policy strategy that may be used to address tax evasion, tobacco sales to minors, location of tobacco sales, types of business that may sell tobacco products, and the type or package size of tobacco products offered for sale (eg, flavored products, pack/volume size of products). Tobacco Retailer Density/Zoning Policies control the number, type, location, and density of tobacco retailers through tobacco retail licensing laws, a standalone law or incorporated into community General Plans. Content Neutral Advertising Restrictions limit the total amount of advertising on store windows. This type of policy affects all types of advertising, including tobacco advertisements and is considered to be the least controversial approach to restricting time, place or manner of tobacco advertising. These policies are frequently enacted for community beautification or safety reasons. Tobacco Cessation Partner With the Medicaid Program to provide and promote a comprehensive tobacco dependence treatment benefit to Medicaid beneficiaries, which covers all 7 cessation treatment drugs and individual, group and telephone counseling. Medicaid beneficiaries use tobacco at higher rates than the general population, are less able to pay for tobacco cessation treatments, and are less able to afford the cost of illness and death from tobacco use. Encourage State/Territorial Government Employee Health Plans to provide and promote a comprehensive tobacco dependence treatment health insurance benefit to government employees, which covers all 7 cessation treatment drugs and individual, group, and telephone counseling. State/territory governments are often among the largest employers and all provide health insurance to their employees. These health plans can lead by example and cover cessation treatment for tobacco users not only to create a healthier government workforce but also to serve as a model for other providers in the state/territory. Support System Change Within the Health Care and Behavioral Treatment Systems. These interventions encourage and support health care and behavioral treatment systems to systematically implement tobacco user identification systems; promote comprehensive tobacco dependence treatment as the standard of care; and support providers in delivering cessation assistance.
that 12 achieved all 3 primary policy/system change strategies and 10 achieved none (Figure 1). This finding led the TCN to develop and field an assessment that focused on a state/territory’s “readiness” to adopt and implement tobacco control strategies rather than focusing on identifying the “need” for such strategies.39 The theoretical underpinning for this assessment was based on the
Community Readiness Model (CRM) developed at Colorado State University’s Tri-Ethnic Center for Prevention Research. The CRM classifies community readiness to develop and implement prevention programming along a 9-stage continuum. Originally developed for alcohol and drug abuse prevention, it has been adapted for other social and environmental issues.40
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12 ❘ Journal of Public Health Management and Practice FIGURE 1 ● State/Territory Status on Most Recommended Tobacco Control Policies, 2012
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The CRM involves conducting key informant interviews with community stakeholders.40-46 It includes more than 30 questions, structured across 6 dimensions that assess current level of effort, knowledge of efforts, leadership, community climate, knowledge of the issue, and resources. For example, the community dimension assesses factors such as the availability of data, community awareness of the problem, and community leader support. Responses to these and other interview questions result in a score used to classify a community into 1 of 9 stages of community readiness rating from “No Awareness” to “High Level of Community Ownership.”43,44,47 A readiness assessment is important to conduct because the results inform the type of activities needed to move a strategy forward. For example, in the “No Awareness” and “Denial” stages, educational interven-
tions should focus on raising public awareness that a problem exists locally (eg, media messaging about the availability and use of cheap flavored cigars by teens). For a community in the “Pre-planning” stage, focus groups and visits with community leaders leads to a better understanding of how the issue is perceived and provides information about the support and opposition.42 The assessment objectives were to: (1) identify the stage of readiness for each Policy Platform strategy to inform interventions needed to move policy and system change efforts forward; (2) collect data that would inform development of TCN training and technical assistance efforts; and (3) reframe national discussions from grading states/territories on their successes and failure to improving their readiness to address evidence-based policy and system changes.
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Tobacco Control Network’s Policy Readiness and Stage of Change Assessment
● Methods Description of the survey instrument The TCN Policy Platform Readiness and Stage of Change Needs Assessment was designed to help tobacco prevention and control programs self-rate their readiness to work on evidence-based (n = 3) and promising (n = 13) policy and system changes in preparation for new federal funding applications and to guide future TCN technical assistance. Of these 16 policy and system changes, 15 were identified in the 2012 TCN Policy Platform and 1 strategy, tobacco-free schools, was added at the request of the CDC Office on Smoking and Health. As described in Table 1, the 16 strategies were grouped into 4 categories: (1) Price/Tobacco Control Funding, (2) Secondhand Smoke, (3) Tobacco Accessibility and Marketing, and (4) Tobacco Cessation. The survey instrument was developed by the TCN Policy Committee and pilot tested by the TCN Executive Committee in June 2013. Four areas were assessed for each of the 16 strategies: (1) Implementation Status, (2) Readiness, (3) Stage of Change, and (4) Level of Action. Implementation Status measured the extent to which the state/territory had achieved a strategy. Depending on the strategy, a 2- or 3-point scale was used that included Complete Achievement, Partial Achievement, or No Achievement. The Implementation Status question included a skip pattern. Respondents indicating that a strategy was completely achieved either at the state/territory level or by 85% of local jurisdictions, did not assess the Readiness, Stage of Change, and Level of Action measures for that strategy. The 85% of local jurisdictions threshold was selected as comparable to completely achieving the strategy at a state or territory level. The Readiness measure was modeled after the CRM community dimension. It consisted of 5 items rated on a 6-point (0-5) Likert scale of none, poor, fair, good, very good, or excellent and summed to a composite “readiness” rating for the strategy. Respondents received a rating rubric, which provided descriptions of the Likert scale responses and identified and defined each of the following 5 items: 1. Scope of the Problem. The extent that local, regional, state, or national data demonstrate the existence of a public health problem relevant to the strategy. 2. Awareness. The extent to which there is awareness that a public health problem exists relevant to the strategy. 3. Public Support. The extent to which the public would support action relevant to the strategy.
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4. Decision Maker Support. The extent to which decision makers and community leaders demonstrate support for action (political will) relevant to the strategy. 5. Earned Media. The extent to which neutral or positive news coverage, editorials, letters to the editor, etc are covered in the media relevant to the strategy. The Stage of Change measure consolidated the CRM’s 9 stages of change to 6. The stage of change labels and definitions were modified to make them relevant to policy/system change strategies. The Stage of Change measure consisted of a 6-stage continuum rated on a scale of 0 (No formal activities) to 5 (Compliance/Enforcement). Its stages are similar to the point-of-sale tobacco control policy continuum.48 In recognition that voluntary and local policy work are often precursors to state/territorial government efforts and to simplify the rating process, respondents were instructed to select the highest stage of change achieved in at least 1 local jurisdiction within the state/territory. The 6 stages of change were as follows: 1. No Formal Activities. General information gathering and fact finding are underway, but no formal activities specific to this strategy have been completed. 2. Planning/Advocating. Partnership development, strategy development, specific data collection, and/or the provision of information and education to key opinion leaders are underway. 3. Policy/System Change Proposed. A policy or system change has been drafted or proposed; a resolution may have been enacted; educational and media activities are underway; and recruitment of partners beyond core supporters is underway. 4. Policy/System Change Adopted. A voluntary policy or system change has been adopted and may be implemented, or a legislated policy has been adopted but not yet implemented. 5. Policy Implemented. Legislated policy implementation is underway which may include the following: provision of training, communication to stakeholders notifying them of the policy and expectations, posting signage, collecting fees, and conducting compliance checks. 6. Compliance/Enforcement. A high degree of compliance has been achieved with a legislated policy(s) and progressive enforcement action is taken to address noncompliance. The Level of Action measure referred to the organizational level that the state/territory believed to be the most appropriate level to address the policy/system change within the next 3 years. The 3 levels were as follows: (1) State or Territory, (2) Local, or (3) Voluntary. Voluntary policies are those generally adopted by a nongovernmental entity and that govern the actions
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14 ❘ Journal of Public Health Management and Practice of the entity, business practices, property operations, or actions of the entity. Voluntary policies are an important tool in places where preemption prohibits local legislated policy adoption or may be a key first step on the policy continuum.30,49 Seven states piloted the assessment tool, which was subsequently revised as follows in response to feedback: (1) recognition for partial achievement of a statewide/territory strategy was added to the Implementation Status measure, (2) adoption of voluntary and locally legislated policies was incorporated into the Stage of Change measure, (3) instructions were clarified to indicate that the results would not be used to “grade” states/territories, and (4) Project Managers were encouraged to complete the survey with internal and/or external partners.
Each report provided individual findings and average scores for their Health and Human Services (HHS) region and the nation as a whole.50 Each respondent received a guide on how to interpret and use their findings for strategic planning and determining infrastructure needs. A 30-minute webinar, held the week after the reports’ release, featured state tobacco program managers who discussed how to interpret the data and how they intended to use the findings to support evidence-based policy and system change in their states. The TTAC also contacted individual states to offer personalized assistance in interpreting the data. Aggregated results were provided to CDC staff to facilitate technical assistance by Project Officers.
Needs assessment implementation
● Results
In September 2013, TTAC e-mailed tobacco control program managers from all 50 states, 8 US territories, and Washington, DC, inviting them to complete the Webbased assessment. The e-mail explained the benefits of participating and was signed by the network’s Chair and Policy Committee Chair. Survey respondents were encouraged to convene a group of staff and key partners to review the needs assessment, discuss their answers, and enter consensus responses. TTAC provided 2 resources to facilitate responses: a copy of the needs assessment and a scoring rubric. Respondents were advised that the needs assessment would take 60 to 90 minutes to complete. To boost participation rates, (1) TCN leaders emailed and telephoned state/territory tobacco program managers within their region, which stimulated a friendly competition between leaders, who strove to attain 100% participation from their region; (2) TTAC sent 3 reminder e-mails and extended the response deadline by 3 weeks; and (3) TTAC sent personalized reminder e-mails during the final 2 weeks and placed phone calls to individuals who had not yet completed the assessment. To compensate survey respondents for their time, print copies of tobacco control resources and educational DVDs were offered as incentives. Each participating state/territory received a 10-page report summarizing the following information for each of the 16 strategies: (1) Implementation Status; (2) Readiness score, (3) Stage of Change score, and (4) Level of Action designation. In addition, the report provided an Overall Score for each strategy. The Overall Score reflected the ratings given to Implementation Status, Readiness, and Stage of Change. The Overall Score provided a simple approach to making comparisons across strategies and geography.
Of the 59 jurisdictions invited to complete the assessment, 46 of the states and DC (90%), 3 of the 8 US territories (37.5%), submitted responses. Sixteen tobacco control program managers (32.7%) completed their assessments unassisted; 19 (38.8%) convened internal staff to complete the assessment; and 14 (28.6%) collaborated their assessment with internal staff and external partners. Table 2 presents the results provided to a state for 6 of the 16 policy/system change strategies assessed and illustrates the data provided to states/territories. This state’s results indicate that the state has (1) achieved good progress, but not complete passage, of a statewide comprehensive smoke-free air law; (2) an excise tax well below the national average; and (3) achieved at least 25% of the 2007 CDC-recommended funding level for a comprehensive tobacco control program. The readiness scores in descending order indicate readiness for tobacco-free schools, tobacco retail licensing, and partnering with Medicaid programs for cessation services. Table 3 provides a comparison of the average Overall Scores for the US and HHS regions for the 3 primary tobacco control policy/system change strategies identified in the 2012 TCN Policy Platform. The Overall Score is a summary score reflecting current Status of Implementation, Readiness, and Stage of Change. The Overall Score reflects the mean score among the states and territories responding to the item for each HHS region and the nation as a whole. Overall scores were categorized into 5 tiers: Very Low (0%-20%), Low (21%40%), Medium (41%-60%), Medium High (61%-80%), and High (81%-100%). The Northeast/Caribbean region appears twice in the lowest tiers while the Mountain/Plains region is the only region to score in the High tier twice.
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35 56
Good
Good Good Tobacco retail licensing Partner with medicaid program
Figure 2 depicts the average policy readiness score across all respondents for each of the 16 policy/system change strategies. The 3 strategies with the highest readiness scores were (1) 100% smoke-free air in workplaces (64%), (2) tobacco-free schools (61%), and (3) ≥$1.50 cigarette tax with funds dedicated to tobacco control (53%). The 3 strategies with the lowest readiness scores were (1) coupon redemption (17%), (2) tobacco mitigation fee (14%), and (3) disclosure or sunshine laws (8%).
● Discussion
Abbreviation: HHS, Health and Human Services.
16 32
60
Excellent
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1. 100% Smoke-free workplaces. Eight regions had “Medium to Medium High” scores and 2 regions had “High” scores. While no region rated “Very Low” or “Low,” the lowest scores were reported by the Southeast, South Central, and Southwest/Pacific regions. 2. Cigarette excise tax greater than $1.50 with funds dedicated to tobacco control. Overall Scores were the lowest for this strategy with four regions having “Low” scores and 6 regions having “Medium” scores. The lowest scores were reported by the Northeast/Caribbean, Midatlantic, Southeast, and South Central regions. 3. Sustainable comprehensive tobacco control funding (achieving 10% of the 2007 CDC recommended levels). The greatest variation in Overall Scores was found with this strategy; scores ranged from “Very Low” to “High.” This strategy also had the greatest number (3) of regions scoring “High.” The Northeast/Caribbean region reported the lowest score.
21 52 20 31 Local government State/Territory government
72
Achieved
None
≥$1.50 Tobacco excise tax with funds dedicated to tobacco control Sustainable comprehensive tobacco control funding Tobacco-free schools
66 51 State/Territory government
Policy/System change proposed No formal activities Compliance/ Enforcement
73 100 100 Not applicable Not applicable
43 34 31 State/Territory government 46
Good 100% Smoke-free air in workplaces
56
Status Policy/System Change Strategy
56 49 State/Territory government
Stage of Change
Policy/System change proposed Planning/Advocating
68
Overall US/Territory Score Percent Overall HHS Region Score Percent Overall State Score Percent Level Most Appropriate to Address Policy/ System Change Readiness Percent
TABLE 2 ● Data From an Anonymous State Illustrating Findings on 6 Policy/System Change Strategies
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Tobacco Control Network’s Policy Readiness and Stage of Change Assessment
The high response rate (90% of states including DC) is a strong indication of the TCN members’ commitment to the network and its mission. While relationships among the states in the network are very strong, the 37.5% response rate among territories suggests that more effort is needed to engage these jurisdictions. Geographical distances, cultural differences, and technological limitations require additional effort for communications and technical assistance. Participants commented that the process of completing the assessment provided insights into the range of possible strategies that could reduce tobacco use. However, it is important to note that the assessment findings are limited in 2 ways. First, 12 states/territories did not complete the assessment and, as such, the regional and national reported scores do not reflect a census. Nonresponse bias may have contributed to variability within regions or skewed results positively or negatively. Also, while 28.6% of tobacco control program managers convened internal and external stakeholders to complete the assessment, 71.5% completed the
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16 ❘ Journal of Public Health Management and Practice TABLE 3 ● Mean Overall Scores, by HHS Region for Three Primary Tobacco Control Policy/System Change Strategies
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq ≥$1.50 Excise Tax,† % (N)
100% Smoke-Free Workplaces,* % (N)
Region States/Territories Overall U.S./Territories Region 1: New England CT, ME, MA, NH, RI, VT Region 2: Northeast / Caribbean NJ, NY, Puerto Rico, Virgin Islands Region 3: Midatlantic DE, DC, MD, PA, VA, WV Region 4: Southeast AL, FL, GA, KY, MS, NC, SC, TN Region 5: North Central IL, IN, MI, MN, OH, WI Region 6: South Central AR, LA, NM, OK, TX Region 7: Midwest IA, KS, MO, NE Region 8: Mountain / Plains CO, MT, ND, SD, UT, WY Region 9: Southwest / Pacific AZ, CA, HI, NV, American Samoa, Commonwealth of the Northern Mariana Islands, Federated State of Micronesia, Guam, Marshall Islands, Republic of Palau Region 10: Northwest AK, ID, OR, WA Range within policy topic
68 (48) 64 (6) 100 (2)
43 (48) 49 (6) 33 (2)
69 (5) 55 (7) 80 (5) 56 (4) 73 (4) 82 (6) 57 (6)
39 (5) 32 (7) 48 (5) 34 (4) 47 (4) 53 (6) 41 (6)
67 (4) 55-100 (48)
Tobacco Control Funding,‡ % (N) 73 (48) 69 (6) 17 (2) 73 (5) 67 (7) 63 (5) 100 (4) 52 (4) 100 (6) 75 (6)
44 (4) 32-53 (48)
86 (4) 17-100 (48)
Abbreviation: HHS, Health and Human Services. *100% Smoke-free Workplace Air Policies protecting all workers and the public from exposure to tobacco smoke. †Cigarette Excise Tax of at least $1.50 per pack of cigarettes with an equivalent tax increase on Other Tobacco Products (e.g., smokeless, cigars, pipes, dissolvables). ‡This policy designates a portion of the tobacco excise taxes and/or tobacco industry settlement payments for a comprehensive tobacco control program.
assessment by themselves or with an internal group. Not including external stakeholders in the ratings may have skewed ratings upwards as a result of social desirability bias. As indicated in Figure 1, only 12 states/territories achieved all 3 primary tobacco policy/system strategies, and 10 states had yet to achieve 1 strategy. The TCN advised the states/territories regarding application of the findings toward achievement of policy/
systems change. Each jurisdiction was encouraged to examine their status on the strategies, along with their readiness for change. Depending on their capacity (funding and infrastructure), the TCN recommended that participants focus on a strategy that had the highest readiness and work to address each of the stages of change (collect evidence, raise community/decisionmakers awareness and support, raise earned media coverage and support). In addition, the TCN
FIGURE 2 ● Average US Policy Readiness Scores
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq 100% Smoke-free Air in Workplaces
64%
Tobacco-free Schools
61%
≥$1.50 Cigarette Tax w/ Funds to Tobacco Control
53%
Smoke-free Outdoor Areas
52%
Smoke-free Multi-unit Housing
48%
Partner with Medicaid Program
44%
Sustainable Comp. Tobacco Control Funding
44%
Government Health Insurance Cessation Benefits
41%
Health Care and Behavioral Health Cessation
40%
Tobacco Retail Licensing
25%
Content Neutral Advertising Restrictions
21%
Tobacco Retailer Density/Zoning
21%
Minimum Price
18%
Coupon Redemption
17%
Tobacco Mitigation Fee
14%
Disclosure or Sunshine
8% 0%
10%
20%
30% 40% Percent Readiness
50%
60%
70%
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Tobacco Control Network’s Policy Readiness and Stage of Change Assessment
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encouraged jurisdictions to select a “stretch” goal, one that goes beyond their current capacity, as a long-term goal.51 The variability among respondents’ policy readiness scores makes it clear that a “one size fits all” approach, such as expecting all jurisdictions to focus individually or as a region on the 3 primary tobacco policy/system change strategies, is not the best approach to advancing tobacco control efforts and building capacity. In some cases, jurisdictions had very low readiness and stage of change scores for the 3 primary policy/system change strategies. In these cases, there may be more readiness to work on a less impactful strategy, one that would create a victory and demonstrate capacity to change social norms, even on a small scale. For example, the state in Table 2, while working to achieve a comprehensive smoke-free air law, may build capacity by continuing their successful tobacco-free school activities at the local level. Other jurisdictions with low scores on the 3 primary policy/system change strategies may need to first focus on local voluntary smoke-free multiunit housing policies or smoke-free parks to build capacity and success. Previous experience suggests that incremental steps build momentum toward more impactful policies, especially in rural areas that may be resistant to tobacco control policies, and that success helps to normalize an issue for policy makers.30,52 As such, less impactful policy approaches may be an important strategy to build support for more impactful strategies. While technical assistance providers should focus their efforts toward adoption of policy strategies where readiness is highest, these assessment results indicate that education and tools are needed to promote diffusion and evaluation of innovative policy strategies (eg, coupon redemption, mitigation fees, and sunshine laws), which may work synergistically with evidencebased strategies.53
sults to select policy priorities and tailor their intervention approaches. Those implementing strategies that fall within the promising practices realm must vigorously evaluate them to further practice-based evidence and assess their impact on reducing tobacco use and tobacco-related disparities.54,55 National and state technical assistance and training providers should consider supporting local/state/territory policy action on strategies where the readiness scores are highest. In jurisdictions where the 3 primary tobacco policy/system change strategies have not advanced despite serious efforts, training and technical assistance providers should consider coordinating with state/territory tobacco control programs to shift priorities to more achievable policy outcomes. Building capacity to adopt tobacco control polices through successful adoption of policies categorized as promising practices may advance jurisdictions down the social norm change path more quickly, building momentum for successful adoption of tobacco tax and comprehensive clean indoor air workplace policies. Other chronic disease programs could benefit from consensus-building activities to establish priorities and from developing complementary assessment tools to help state and local programs strategically select policy/system strategies. Even in public health program areas like tobacco control where the evidence-based strategies are well-defined, the strategies that have the greatest potential for achieving public health goals are those that are attainable; a high-impact strategy will have no impact if it is not achievable, given a community’s readiness. For chronic disease prevention topics where the evidence for program and policy strategies is still growing, the activities of building a consensus around recommendations and drafting a policy platform provides additional guidance.
● Conclusion
REFERENCES
These data provide a snapshot of individual states/territories, regions, and the nation in relation to the 16 policy/system change strategies assessed. In 2012, 47 states/territories had not achieved all 3 primary policy/system change strategies. The data indicate that many states/territories are ready to work on strategies for which there is less evidence of a population-level impact on the prevalence of tobacco use, but which may contribute to an environment where tobacco-free behaviors are the perceived norm. Individual state/territory results provide a diagnostic assessment of readiness to move tobacco control efforts forward as well as a benchmark for measuring progress. States and territories should use these re-
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Tobacco Control Network’s Policy Readiness and Stage of Change Assessment
36. Toomey TL, Chen V, Forster JL, Van Coevering P, Lenk KM. Do cigarette prices vary by brand, neighborhood, and store characteristics? Public health Rep. 2009;124(4): 535-540. 37. Schroeder SA, Morris CD. Confronting a neglected epidemic: tobacco cessation for persons with mental illnesses and substance abuse problems. Annu Rev Public Health. 2010;31(1):297-314. 38. Richard P, West K, Ku L. The return on investment of a medicaid tobacco cessation program in Massachusetts. PLoS ONE. 2012;7(1):e29665. 39. Backer TE. Assessing and enhancing readiness for change: implications for technology transfer. NIDA Res Monogr Series. 1995;155:21-41. 40. Jumper-Thurman P, Plested BA, Edwards RW, Foley R, Burnside M. Community readiness: the journey to community healing. J Psychoactive Drugs. 2003;35(1):27-31. 41. Edwards RW, Jumper-Thurman P, Plested BA, Oetting ER, Swanson L. Community readiness: research to practice. J Community Psychol. 2000;28(3):291-307. 42. Oetting ER, Donnermeyer JF, Plested BA, Edwards RW, Kelly K, Beauvals F. Assessing community readiness for prevention. Int J Addict. 1995;30(6):659-683. 43. Plested BA, Edwards RW, Jumper-Thurman P. Disparities in community readiness for HIV/AIDS prevention. Subst Abuse Use Misuse. 2007;42:729-739. 44. Plested BA, Smitham DM, Jumper-Thurman P, Oetting ER, Edwards RW. Readiness for drug use prevention in rural minority communities. Subs Use Misuse. 1999;34(4-5):521-544. 45. Slater MD. Integrating application of media effects, persuasion, and behavior change theories to communication campaigns: a stages-of-change framework. Health Commun. 1999;11(4):335-354. 46. Ogilvie KA, Moore RS, Ogilvie DC, Johnson KW, Collins DA, Shamblen SR. Changing community readiness to pre-
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Context: The Tobacco Control Network (TCN) is comprised of the tobacco control programs in the health departments of states, territories, and the District of Columbia. During the assessment period, the TCN was managed by the Tobacco Technical Assistance Consortium at Emory University. Objective: To assess the readiness of state and territory tobacco control programs to work on evidence-based, promising policy and system change strategies aimed at preventing and reducing tobacco use and secondhand smoke exposure. Design: The Policy Readiness and Stage of Change Assessment was a Web-based survey fielded in September 2013, which was based on the Community Readiness Model. Setting: Fifty-nine comprehensive tobacco control programs. Participants: State and territory tobacco control program managers and their internal and external partners. Intervention: The TCN’s 2012 Policy Platform recommendations were used as the basis to assess state/territory readiness to adopt and implement evidence-based and promising tobacco control policy/system change strategies. Main Outcome Measures: Sixteen tobacco control strategies were rated on: (1) implementation status, (2) readiness, (3) stage of change, and (4) the appropriate level of action for work on the strategy. Results: The 3 strategies with the highest readiness scores were as follows: (1) 100% smoke-free air in workplaces (64%), (2) tobacco-free schools (61%), and (3) $1.50 or more cigarette tax with funds to tobacco control (53%). The 3 strategies with lowest readiness scores were: 1) coupon redemption (17%), 2) tobacco mitigation fee
J Public Health Management Practice, 2016, 22(1), 9–19 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
(14%), and 3) disclosure or sunshine laws (8%). Conclusion: Readiness to work on tobacco control strategies varied by region and strategy. Many states/territories are ready to work on strategies for which there is less evidence of a population-level impact for reducing tobacco use, but which contribute to denormalizing tobacco use. Working toward less impactful policies may build support, capacity, and policy success, laying an important foundation to achieve more impactful strategies. KEY WORDS: community readiness, health assessment, policy,
social norm change, stage of change, tobacco
The 50th Anniversary Surgeon General’s Report on Smoking and Health confirmed that tobacco use is the single most preventable cause of death and disease in the United States.1,2 An estimated 42.1 million Author Affiliations: California Tobacco Control Program, California Department of Public Health, Sacramento, California (Ms Roeseler); and Emory University, Emory Centers for Training and Technical Assistance, Atlanta, Georgia (Mss Solomon, Beatty, and Sipler). The authors thank Josh Berry, Student Intern, Emory University, for his assistance with programming the Web-based survey and creation of figures. The Tobacco Control Network Policy Readiness and Stage of Change Assessment was fielded by the Tobacco Technical Assistance Consortium (TTAC) at Emory University, which received funding from the Office on Smoking and Health, Centers for Disease Control and Prevention under contract number: 200-2013M-57407. The authors declare no conflicts of interest. Correspondence: April Roeseler, MSPH, BSN, California Tobacco Control Program, California Department of Public Health, PO Box 997377, MS 7206 Sacramento, CA 95899 ([email protected]). DOI: 10.1097/PHH.0000000000000247
9 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
10 ❘ Journal of Public Health Management and Practice Americans (18% of all adults) currently smoke cigarettes.3 Cigarette smoking causes 480 000 deaths each year, accounting for 1 of every 5 deaths in the United States (including 50 000 deaths from secondhand smoke).1 Adults who smoke cigarettes die an average of 14 years earlier than nonsmokers.4 For every person who dies from tobacco use, another 20 people suffer from at least 1 serious tobacco-related illness.5 Smokeless tobacco products also pose a significant health risk and are not a safe substitute for cigarettes.6 While significant progress has been made to reduce tobacco use in the United States since the release of the first Surgeon General’s Report on Smoking and Health in 1964, large disparities in smoking prevalence and tobacco-related diseases exist among groups differentiated by race/ethnicity, socioeconomic status, educational attainment, mental health, sexual orientation, occupation, and geography.7 Implementing strategies that will accelerate the rate of change among these groups at the population level is critical to reducing these disparities and achieving health equity.8 Also essential to reducing tobacco-related disparities are policies and program strategies that motivate and support successful quitting; engage communities in change; and provide the financial, human, and training resources necessary to denormalize tobacco use.9 The Tobacco Control Network (TCN), which includes tobacco control program managers and staff from all US states and territories, conducted a Policy Readiness and Stage of Change Assessment (TCN Readiness Assessment) in which TCN members rated their readiness to work on evidence-based and promising policy and system changes to prevent and reduce tobacco use. Policy and environmental and systemlevel changes are the building blocks of social norm change and are effective at decreasing tobacco use at the population level.2,10,11 The social norm change strategy influences current and potential tobacco users by creating a social and legal environment in which tobacco use is less desirable, less acceptable, and less attainable.12,13 Smoke-free air policies and mass media campaigns are examples of evidence-based strategies, which denormalize smoking and are associated with decreased intentions to smoke and increased quitting behaviors.12,14 While policy and system change strategies are powerful tools, tobacco control programs must seek to ensure that these strategies are uniformly and equitably adopted to prevent health inequities.15 The TCN Readiness Assessment was conducted to help states and territories develop their 5-year Centers for Disease Control and Prevention (CDC) Collaborative Funding Applications in 2014. While the CDC funding cycle was delayed, the results were used for
strategic planning, identification of training and technical assistance needs, and facilitation of TCN partnerships with national networks and other technical assistance and training providers.
● Background/Literature Review TCN mission and goals The TCN’s mission is to improve the public’s health by increasing the capacity of states, territories, and the District of Columbia (DC) to implement evidence-based comprehensive tobacco control programs. The network promotes information and strategy sharing, advocates for evidence-based and promising program and policy strategies, and increases collaboration among its members and national partners. The TCN is led by an Executive Committee and managed by an external contractor funded by the CDC. From September 2008 to March 2014, the Tobacco Technical Assistance Consortium (TTAC) at Emory University managed the TCN. Consistent with national directives, the network uses assessment results to drive policy development and assure high quality implementation.16,17 Policy adoption and implementation are major tobacco control interventions, which denormalize tobacco use, reduce initiation, and promote quitting.18-20 As summarized in Table 1, the TCN Policy Platform communicates a vision for policy and system changes.21 It was developed by the TCN Policy Committee in collaboration with the executive committee and regional representatives. The 2012 TCN Policy Platform highlighted raising the price of tobacco products, passing smoke-free air laws, and funding sustainable comprehensive programs as evidence-based strategies known to prevent and reduce tobacco use and secondhand smoke exposure on a population basis.13,21-24 Systematic reviews of these policy strategies indicate they are broadly effective across populations groups when uniformly implemented.22-25 For states and territories that had achieved success with these 3 evidence-based strategies, additional promising and emerging strategies were recommended that addressed non-indoor worksite smoke-free venues including multiunit housing and outdoor environments; reducing barriers to cessation services; the retail environment; and non-tax tobacco product price increase strategies.25-31 Because these additional strategies seek to increase the price of tobacco products, limit secondhand smoke exposure, reduce exposure to tobacco product marketing, and increase access to cessation treatment, they are likely to aid reductions in tobacco-related disparities.26,29,31-38 A 2012 examination of the states and territories found
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Tobacco Control Network’s Policy Readiness and Stage of Change Assessment
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TABLE 1 ● Description of 16 Tobacco Policy/System Change Strategies
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Tobacco Pricing Strategies/Program Funding Cigarette Excise Tax of at least $1.50 per pack of cigarettes with an equivalent tax increase on Other Tobacco Products (eg, smokeless, cigars, pipes, dissolvables) and specifically designate a portion of the revenue for a comprehensive tobacco control program to achieve greater equity and to particularly reduce tobacco use among lower socioeconomic communities. Sustainable, Comprehensive Tobacco Control Program Funding. This policy designates a portion of the tobacco excise taxes and/or tobacco industry settlement payments for a comprehensive tobacco control program. Cigarette Minimum Price Policies set a floor price for cigarettes and other products and prohibit the sale of these products for less than the minimum price. Coupon Redemption Policies restrict/eliminate tobacco industry coupon redemption, discounts, multipack discount offers, and gift with tobacco purchase. Tobacco Mitigation Fees add a “fee” to tobacco products to ameliorate the environmental impact and blight caused by tobacco-related litter. A Disclosure or Sunshine Policy requires tobacco companies to disclose payments and discounts paid to retailers within a specific geographic area such as a city, county, state, or territory. Protection from Secondhand Smoke 100% Smoke-Free Workplace Air Policies protect all workers and the public from exposure to tobacco smoke. These laws should cover all workplaces and public places, including restaurants, bars, and gaming facilities in accordance with the Fundamentals for Smoke-Free Workplaces Guide. Smoke-Free Multiunit Housing Policies protect residents and guests from involuntary exposure to secondhand smoke, which drifts between units through electrical lines, plumbing, heating and air conditioning systems, and open windows. Smoke-Free Outdoor Policies protect the public from secondhand smoke exposure, protect animal and marine life, reduce tobacco litter, and reduce fire hazards in outdoor venues such as sports arenas and fields, restaurant and bar patios, service lines, transit waiting areas, public events like county fairs and farmer’s markets, as well as parks, beaches, and recreation areas. Tobacco-Free K-12 School Policies prohibit tobacco use by students, all school staff, parents, and visitors on school property, in school vehicles, and at school sponsored functions away from school property. These policies enable and encourage children and adolescents who have not experimented with tobacco to continue to abstain from any use and promote quitting. Tobacco Accessibility and Marketing Tobacco Retail Licensing with fees earmarked for enforcement provide a broad and flexible policy strategy that may be used to address tax evasion, tobacco sales to minors, location of tobacco sales, types of business that may sell tobacco products, and the type or package size of tobacco products offered for sale (eg, flavored products, pack/volume size of products). Tobacco Retailer Density/Zoning Policies control the number, type, location, and density of tobacco retailers through tobacco retail licensing laws, a standalone law or incorporated into community General Plans. Content Neutral Advertising Restrictions limit the total amount of advertising on store windows. This type of policy affects all types of advertising, including tobacco advertisements and is considered to be the least controversial approach to restricting time, place or manner of tobacco advertising. These policies are frequently enacted for community beautification or safety reasons. Tobacco Cessation Partner With the Medicaid Program to provide and promote a comprehensive tobacco dependence treatment benefit to Medicaid beneficiaries, which covers all 7 cessation treatment drugs and individual, group and telephone counseling. Medicaid beneficiaries use tobacco at higher rates than the general population, are less able to pay for tobacco cessation treatments, and are less able to afford the cost of illness and death from tobacco use. Encourage State/Territorial Government Employee Health Plans to provide and promote a comprehensive tobacco dependence treatment health insurance benefit to government employees, which covers all 7 cessation treatment drugs and individual, group, and telephone counseling. State/territory governments are often among the largest employers and all provide health insurance to their employees. These health plans can lead by example and cover cessation treatment for tobacco users not only to create a healthier government workforce but also to serve as a model for other providers in the state/territory. Support System Change Within the Health Care and Behavioral Treatment Systems. These interventions encourage and support health care and behavioral treatment systems to systematically implement tobacco user identification systems; promote comprehensive tobacco dependence treatment as the standard of care; and support providers in delivering cessation assistance.
that 12 achieved all 3 primary policy/system change strategies and 10 achieved none (Figure 1). This finding led the TCN to develop and field an assessment that focused on a state/territory’s “readiness” to adopt and implement tobacco control strategies rather than focusing on identifying the “need” for such strategies.39 The theoretical underpinning for this assessment was based on the
Community Readiness Model (CRM) developed at Colorado State University’s Tri-Ethnic Center for Prevention Research. The CRM classifies community readiness to develop and implement prevention programming along a 9-stage continuum. Originally developed for alcohol and drug abuse prevention, it has been adapted for other social and environmental issues.40
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12 ❘ Journal of Public Health Management and Practice FIGURE 1 ● State/Territory Status on Most Recommended Tobacco Control Policies, 2012
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The CRM involves conducting key informant interviews with community stakeholders.40-46 It includes more than 30 questions, structured across 6 dimensions that assess current level of effort, knowledge of efforts, leadership, community climate, knowledge of the issue, and resources. For example, the community dimension assesses factors such as the availability of data, community awareness of the problem, and community leader support. Responses to these and other interview questions result in a score used to classify a community into 1 of 9 stages of community readiness rating from “No Awareness” to “High Level of Community Ownership.”43,44,47 A readiness assessment is important to conduct because the results inform the type of activities needed to move a strategy forward. For example, in the “No Awareness” and “Denial” stages, educational interven-
tions should focus on raising public awareness that a problem exists locally (eg, media messaging about the availability and use of cheap flavored cigars by teens). For a community in the “Pre-planning” stage, focus groups and visits with community leaders leads to a better understanding of how the issue is perceived and provides information about the support and opposition.42 The assessment objectives were to: (1) identify the stage of readiness for each Policy Platform strategy to inform interventions needed to move policy and system change efforts forward; (2) collect data that would inform development of TCN training and technical assistance efforts; and (3) reframe national discussions from grading states/territories on their successes and failure to improving their readiness to address evidence-based policy and system changes.
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Tobacco Control Network’s Policy Readiness and Stage of Change Assessment
● Methods Description of the survey instrument The TCN Policy Platform Readiness and Stage of Change Needs Assessment was designed to help tobacco prevention and control programs self-rate their readiness to work on evidence-based (n = 3) and promising (n = 13) policy and system changes in preparation for new federal funding applications and to guide future TCN technical assistance. Of these 16 policy and system changes, 15 were identified in the 2012 TCN Policy Platform and 1 strategy, tobacco-free schools, was added at the request of the CDC Office on Smoking and Health. As described in Table 1, the 16 strategies were grouped into 4 categories: (1) Price/Tobacco Control Funding, (2) Secondhand Smoke, (3) Tobacco Accessibility and Marketing, and (4) Tobacco Cessation. The survey instrument was developed by the TCN Policy Committee and pilot tested by the TCN Executive Committee in June 2013. Four areas were assessed for each of the 16 strategies: (1) Implementation Status, (2) Readiness, (3) Stage of Change, and (4) Level of Action. Implementation Status measured the extent to which the state/territory had achieved a strategy. Depending on the strategy, a 2- or 3-point scale was used that included Complete Achievement, Partial Achievement, or No Achievement. The Implementation Status question included a skip pattern. Respondents indicating that a strategy was completely achieved either at the state/territory level or by 85% of local jurisdictions, did not assess the Readiness, Stage of Change, and Level of Action measures for that strategy. The 85% of local jurisdictions threshold was selected as comparable to completely achieving the strategy at a state or territory level. The Readiness measure was modeled after the CRM community dimension. It consisted of 5 items rated on a 6-point (0-5) Likert scale of none, poor, fair, good, very good, or excellent and summed to a composite “readiness” rating for the strategy. Respondents received a rating rubric, which provided descriptions of the Likert scale responses and identified and defined each of the following 5 items: 1. Scope of the Problem. The extent that local, regional, state, or national data demonstrate the existence of a public health problem relevant to the strategy. 2. Awareness. The extent to which there is awareness that a public health problem exists relevant to the strategy. 3. Public Support. The extent to which the public would support action relevant to the strategy.
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4. Decision Maker Support. The extent to which decision makers and community leaders demonstrate support for action (political will) relevant to the strategy. 5. Earned Media. The extent to which neutral or positive news coverage, editorials, letters to the editor, etc are covered in the media relevant to the strategy. The Stage of Change measure consolidated the CRM’s 9 stages of change to 6. The stage of change labels and definitions were modified to make them relevant to policy/system change strategies. The Stage of Change measure consisted of a 6-stage continuum rated on a scale of 0 (No formal activities) to 5 (Compliance/Enforcement). Its stages are similar to the point-of-sale tobacco control policy continuum.48 In recognition that voluntary and local policy work are often precursors to state/territorial government efforts and to simplify the rating process, respondents were instructed to select the highest stage of change achieved in at least 1 local jurisdiction within the state/territory. The 6 stages of change were as follows: 1. No Formal Activities. General information gathering and fact finding are underway, but no formal activities specific to this strategy have been completed. 2. Planning/Advocating. Partnership development, strategy development, specific data collection, and/or the provision of information and education to key opinion leaders are underway. 3. Policy/System Change Proposed. A policy or system change has been drafted or proposed; a resolution may have been enacted; educational and media activities are underway; and recruitment of partners beyond core supporters is underway. 4. Policy/System Change Adopted. A voluntary policy or system change has been adopted and may be implemented, or a legislated policy has been adopted but not yet implemented. 5. Policy Implemented. Legislated policy implementation is underway which may include the following: provision of training, communication to stakeholders notifying them of the policy and expectations, posting signage, collecting fees, and conducting compliance checks. 6. Compliance/Enforcement. A high degree of compliance has been achieved with a legislated policy(s) and progressive enforcement action is taken to address noncompliance. The Level of Action measure referred to the organizational level that the state/territory believed to be the most appropriate level to address the policy/system change within the next 3 years. The 3 levels were as follows: (1) State or Territory, (2) Local, or (3) Voluntary. Voluntary policies are those generally adopted by a nongovernmental entity and that govern the actions
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14 ❘ Journal of Public Health Management and Practice of the entity, business practices, property operations, or actions of the entity. Voluntary policies are an important tool in places where preemption prohibits local legislated policy adoption or may be a key first step on the policy continuum.30,49 Seven states piloted the assessment tool, which was subsequently revised as follows in response to feedback: (1) recognition for partial achievement of a statewide/territory strategy was added to the Implementation Status measure, (2) adoption of voluntary and locally legislated policies was incorporated into the Stage of Change measure, (3) instructions were clarified to indicate that the results would not be used to “grade” states/territories, and (4) Project Managers were encouraged to complete the survey with internal and/or external partners.
Each report provided individual findings and average scores for their Health and Human Services (HHS) region and the nation as a whole.50 Each respondent received a guide on how to interpret and use their findings for strategic planning and determining infrastructure needs. A 30-minute webinar, held the week after the reports’ release, featured state tobacco program managers who discussed how to interpret the data and how they intended to use the findings to support evidence-based policy and system change in their states. The TTAC also contacted individual states to offer personalized assistance in interpreting the data. Aggregated results were provided to CDC staff to facilitate technical assistance by Project Officers.
Needs assessment implementation
● Results
In September 2013, TTAC e-mailed tobacco control program managers from all 50 states, 8 US territories, and Washington, DC, inviting them to complete the Webbased assessment. The e-mail explained the benefits of participating and was signed by the network’s Chair and Policy Committee Chair. Survey respondents were encouraged to convene a group of staff and key partners to review the needs assessment, discuss their answers, and enter consensus responses. TTAC provided 2 resources to facilitate responses: a copy of the needs assessment and a scoring rubric. Respondents were advised that the needs assessment would take 60 to 90 minutes to complete. To boost participation rates, (1) TCN leaders emailed and telephoned state/territory tobacco program managers within their region, which stimulated a friendly competition between leaders, who strove to attain 100% participation from their region; (2) TTAC sent 3 reminder e-mails and extended the response deadline by 3 weeks; and (3) TTAC sent personalized reminder e-mails during the final 2 weeks and placed phone calls to individuals who had not yet completed the assessment. To compensate survey respondents for their time, print copies of tobacco control resources and educational DVDs were offered as incentives. Each participating state/territory received a 10-page report summarizing the following information for each of the 16 strategies: (1) Implementation Status; (2) Readiness score, (3) Stage of Change score, and (4) Level of Action designation. In addition, the report provided an Overall Score for each strategy. The Overall Score reflected the ratings given to Implementation Status, Readiness, and Stage of Change. The Overall Score provided a simple approach to making comparisons across strategies and geography.
Of the 59 jurisdictions invited to complete the assessment, 46 of the states and DC (90%), 3 of the 8 US territories (37.5%), submitted responses. Sixteen tobacco control program managers (32.7%) completed their assessments unassisted; 19 (38.8%) convened internal staff to complete the assessment; and 14 (28.6%) collaborated their assessment with internal staff and external partners. Table 2 presents the results provided to a state for 6 of the 16 policy/system change strategies assessed and illustrates the data provided to states/territories. This state’s results indicate that the state has (1) achieved good progress, but not complete passage, of a statewide comprehensive smoke-free air law; (2) an excise tax well below the national average; and (3) achieved at least 25% of the 2007 CDC-recommended funding level for a comprehensive tobacco control program. The readiness scores in descending order indicate readiness for tobacco-free schools, tobacco retail licensing, and partnering with Medicaid programs for cessation services. Table 3 provides a comparison of the average Overall Scores for the US and HHS regions for the 3 primary tobacco control policy/system change strategies identified in the 2012 TCN Policy Platform. The Overall Score is a summary score reflecting current Status of Implementation, Readiness, and Stage of Change. The Overall Score reflects the mean score among the states and territories responding to the item for each HHS region and the nation as a whole. Overall scores were categorized into 5 tiers: Very Low (0%-20%), Low (21%40%), Medium (41%-60%), Medium High (61%-80%), and High (81%-100%). The Northeast/Caribbean region appears twice in the lowest tiers while the Mountain/Plains region is the only region to score in the High tier twice.
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35 56
Good
Good Good Tobacco retail licensing Partner with medicaid program
Figure 2 depicts the average policy readiness score across all respondents for each of the 16 policy/system change strategies. The 3 strategies with the highest readiness scores were (1) 100% smoke-free air in workplaces (64%), (2) tobacco-free schools (61%), and (3) ≥$1.50 cigarette tax with funds dedicated to tobacco control (53%). The 3 strategies with the lowest readiness scores were (1) coupon redemption (17%), (2) tobacco mitigation fee (14%), and (3) disclosure or sunshine laws (8%).
● Discussion
Abbreviation: HHS, Health and Human Services.
16 32
60
Excellent
❘ 15
1. 100% Smoke-free workplaces. Eight regions had “Medium to Medium High” scores and 2 regions had “High” scores. While no region rated “Very Low” or “Low,” the lowest scores were reported by the Southeast, South Central, and Southwest/Pacific regions. 2. Cigarette excise tax greater than $1.50 with funds dedicated to tobacco control. Overall Scores were the lowest for this strategy with four regions having “Low” scores and 6 regions having “Medium” scores. The lowest scores were reported by the Northeast/Caribbean, Midatlantic, Southeast, and South Central regions. 3. Sustainable comprehensive tobacco control funding (achieving 10% of the 2007 CDC recommended levels). The greatest variation in Overall Scores was found with this strategy; scores ranged from “Very Low” to “High.” This strategy also had the greatest number (3) of regions scoring “High.” The Northeast/Caribbean region reported the lowest score.
21 52 20 31 Local government State/Territory government
72
Achieved
None
≥$1.50 Tobacco excise tax with funds dedicated to tobacco control Sustainable comprehensive tobacco control funding Tobacco-free schools
66 51 State/Territory government
Policy/System change proposed No formal activities Compliance/ Enforcement
73 100 100 Not applicable Not applicable
43 34 31 State/Territory government 46
Good 100% Smoke-free air in workplaces
56
Status Policy/System Change Strategy
56 49 State/Territory government
Stage of Change
Policy/System change proposed Planning/Advocating
68
Overall US/Territory Score Percent Overall HHS Region Score Percent Overall State Score Percent Level Most Appropriate to Address Policy/ System Change Readiness Percent
TABLE 2 ● Data From an Anonymous State Illustrating Findings on 6 Policy/System Change Strategies
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Tobacco Control Network’s Policy Readiness and Stage of Change Assessment
The high response rate (90% of states including DC) is a strong indication of the TCN members’ commitment to the network and its mission. While relationships among the states in the network are very strong, the 37.5% response rate among territories suggests that more effort is needed to engage these jurisdictions. Geographical distances, cultural differences, and technological limitations require additional effort for communications and technical assistance. Participants commented that the process of completing the assessment provided insights into the range of possible strategies that could reduce tobacco use. However, it is important to note that the assessment findings are limited in 2 ways. First, 12 states/territories did not complete the assessment and, as such, the regional and national reported scores do not reflect a census. Nonresponse bias may have contributed to variability within regions or skewed results positively or negatively. Also, while 28.6% of tobacco control program managers convened internal and external stakeholders to complete the assessment, 71.5% completed the
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16 ❘ Journal of Public Health Management and Practice TABLE 3 ● Mean Overall Scores, by HHS Region for Three Primary Tobacco Control Policy/System Change Strategies
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq ≥$1.50 Excise Tax,† % (N)
100% Smoke-Free Workplaces,* % (N)
Region States/Territories Overall U.S./Territories Region 1: New England CT, ME, MA, NH, RI, VT Region 2: Northeast / Caribbean NJ, NY, Puerto Rico, Virgin Islands Region 3: Midatlantic DE, DC, MD, PA, VA, WV Region 4: Southeast AL, FL, GA, KY, MS, NC, SC, TN Region 5: North Central IL, IN, MI, MN, OH, WI Region 6: South Central AR, LA, NM, OK, TX Region 7: Midwest IA, KS, MO, NE Region 8: Mountain / Plains CO, MT, ND, SD, UT, WY Region 9: Southwest / Pacific AZ, CA, HI, NV, American Samoa, Commonwealth of the Northern Mariana Islands, Federated State of Micronesia, Guam, Marshall Islands, Republic of Palau Region 10: Northwest AK, ID, OR, WA Range within policy topic
68 (48) 64 (6) 100 (2)
43 (48) 49 (6) 33 (2)
69 (5) 55 (7) 80 (5) 56 (4) 73 (4) 82 (6) 57 (6)
39 (5) 32 (7) 48 (5) 34 (4) 47 (4) 53 (6) 41 (6)
67 (4) 55-100 (48)
Tobacco Control Funding,‡ % (N) 73 (48) 69 (6) 17 (2) 73 (5) 67 (7) 63 (5) 100 (4) 52 (4) 100 (6) 75 (6)
44 (4) 32-53 (48)
86 (4) 17-100 (48)
Abbreviation: HHS, Health and Human Services. *100% Smoke-free Workplace Air Policies protecting all workers and the public from exposure to tobacco smoke. †Cigarette Excise Tax of at least $1.50 per pack of cigarettes with an equivalent tax increase on Other Tobacco Products (e.g., smokeless, cigars, pipes, dissolvables). ‡This policy designates a portion of the tobacco excise taxes and/or tobacco industry settlement payments for a comprehensive tobacco control program.
assessment by themselves or with an internal group. Not including external stakeholders in the ratings may have skewed ratings upwards as a result of social desirability bias. As indicated in Figure 1, only 12 states/territories achieved all 3 primary tobacco policy/system strategies, and 10 states had yet to achieve 1 strategy. The TCN advised the states/territories regarding application of the findings toward achievement of policy/
systems change. Each jurisdiction was encouraged to examine their status on the strategies, along with their readiness for change. Depending on their capacity (funding and infrastructure), the TCN recommended that participants focus on a strategy that had the highest readiness and work to address each of the stages of change (collect evidence, raise community/decisionmakers awareness and support, raise earned media coverage and support). In addition, the TCN
FIGURE 2 ● Average US Policy Readiness Scores
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq 100% Smoke-free Air in Workplaces
64%
Tobacco-free Schools
61%
≥$1.50 Cigarette Tax w/ Funds to Tobacco Control
53%
Smoke-free Outdoor Areas
52%
Smoke-free Multi-unit Housing
48%
Partner with Medicaid Program
44%
Sustainable Comp. Tobacco Control Funding
44%
Government Health Insurance Cessation Benefits
41%
Health Care and Behavioral Health Cessation
40%
Tobacco Retail Licensing
25%
Content Neutral Advertising Restrictions
21%
Tobacco Retailer Density/Zoning
21%
Minimum Price
18%
Coupon Redemption
17%
Tobacco Mitigation Fee
14%
Disclosure or Sunshine
8% 0%
10%
20%
30% 40% Percent Readiness
50%
60%
70%
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Tobacco Control Network’s Policy Readiness and Stage of Change Assessment
❘ 17
encouraged jurisdictions to select a “stretch” goal, one that goes beyond their current capacity, as a long-term goal.51 The variability among respondents’ policy readiness scores makes it clear that a “one size fits all” approach, such as expecting all jurisdictions to focus individually or as a region on the 3 primary tobacco policy/system change strategies, is not the best approach to advancing tobacco control efforts and building capacity. In some cases, jurisdictions had very low readiness and stage of change scores for the 3 primary policy/system change strategies. In these cases, there may be more readiness to work on a less impactful strategy, one that would create a victory and demonstrate capacity to change social norms, even on a small scale. For example, the state in Table 2, while working to achieve a comprehensive smoke-free air law, may build capacity by continuing their successful tobacco-free school activities at the local level. Other jurisdictions with low scores on the 3 primary policy/system change strategies may need to first focus on local voluntary smoke-free multiunit housing policies or smoke-free parks to build capacity and success. Previous experience suggests that incremental steps build momentum toward more impactful policies, especially in rural areas that may be resistant to tobacco control policies, and that success helps to normalize an issue for policy makers.30,52 As such, less impactful policy approaches may be an important strategy to build support for more impactful strategies. While technical assistance providers should focus their efforts toward adoption of policy strategies where readiness is highest, these assessment results indicate that education and tools are needed to promote diffusion and evaluation of innovative policy strategies (eg, coupon redemption, mitigation fees, and sunshine laws), which may work synergistically with evidencebased strategies.53
sults to select policy priorities and tailor their intervention approaches. Those implementing strategies that fall within the promising practices realm must vigorously evaluate them to further practice-based evidence and assess their impact on reducing tobacco use and tobacco-related disparities.54,55 National and state technical assistance and training providers should consider supporting local/state/territory policy action on strategies where the readiness scores are highest. In jurisdictions where the 3 primary tobacco policy/system change strategies have not advanced despite serious efforts, training and technical assistance providers should consider coordinating with state/territory tobacco control programs to shift priorities to more achievable policy outcomes. Building capacity to adopt tobacco control polices through successful adoption of policies categorized as promising practices may advance jurisdictions down the social norm change path more quickly, building momentum for successful adoption of tobacco tax and comprehensive clean indoor air workplace policies. Other chronic disease programs could benefit from consensus-building activities to establish priorities and from developing complementary assessment tools to help state and local programs strategically select policy/system strategies. Even in public health program areas like tobacco control where the evidence-based strategies are well-defined, the strategies that have the greatest potential for achieving public health goals are those that are attainable; a high-impact strategy will have no impact if it is not achievable, given a community’s readiness. For chronic disease prevention topics where the evidence for program and policy strategies is still growing, the activities of building a consensus around recommendations and drafting a policy platform provides additional guidance.
● Conclusion
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These data provide a snapshot of individual states/territories, regions, and the nation in relation to the 16 policy/system change strategies assessed. In 2012, 47 states/territories had not achieved all 3 primary policy/system change strategies. The data indicate that many states/territories are ready to work on strategies for which there is less evidence of a population-level impact on the prevalence of tobacco use, but which may contribute to an environment where tobacco-free behaviors are the perceived norm. Individual state/territory results provide a diagnostic assessment of readiness to move tobacco control efforts forward as well as a benchmark for measuring progress. States and territories should use these re-
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