A framework for developing an evidence-based, comprehensive tobacco control program

Why do experts disagree? The development of a taxonomy

People are increasingly exposed to conflicting health information and must navigate this information to make numerous decisions, such as which foods to consume, a process many find difficult. Although some consumers attribute these disagreements to aspects related to uncertainty and complexity of research, many use a narrower set of credibility-based explanations. Experts' views on disagreements are underinvestigated and lack explicit identification and classification of the differences in causes for disagreement. Consequently, there is a gap in existing literature to understand the range of reasons for these contradictions. Combining the findings from a literature study and expert interviews, a taxonomy of disagreements was developed. It identifies 10 types of disagreement classified under three dimensions: informant-, information- and uncertainty-related causes for disagreement. The taxonomy may assist with adoption of more effective strategies to deal with conflicting information and contributes to research and practice of science communication in the context of disagreement.

Historic tobacco legislation in Israel: a moment to celebrate

BACKGROUND

Israel was once a leader in tobacco control, but fell behind other countries, particularly during the past decade, as smoking rates stagnated. TEXT: Landmark tobacco control legislation, which banned advertising (with the exception of the print press) and limited marketing, was passed in Israel on Dec. 31^rst, 2018. The changes occurred following years of attempts which culminated in successful last-minute efforts to promote the legislation just before the early disbanding of the 20th Knesset (Israeli Parliament). Regulations concerning marketing and advertising were substantially strengthened to address all tobacco, nicotine and smoking products. Digital media was included for the first time. Electronic cigarettes, which were previously largely unregulated, now fall under existing tobacco legislation. The changes overcame intense opposition from the tobacco lobby, and occurred despite the fact that the basic elements for prevention policy postulated by the Richmond model were not in place.

CONCLUSIONS

This legislation represents an important and long-awaited change in Israeli tobacco control policy. Many deficiencies in existing tobacco control regulation were overcome, and some measures went beyond current international regulations. The cohesive partnership between legislators, public health organizations and professionals, advocacy groups, academia, and leading journalists was critical to this success. The progress was lauded by the World Health Organization with its highest award for tobacco control, which was presented to Smoke Free Israel. This case study provides important lessons for up-to-date tobacco control policy, in the age of rapid global changes in the tobacco, vaping and nicotine landscape.

Protecting Young Children From Tobacco Smoke Exposure: A Pilot Study of Project Zero Exposure

BACKGROUND

Tobacco smoke exposure (TSE) harms children, who are often "captive smokers" in their own homes. Project Zero Exposure is a parent-oriented, theory-based intervention designed to reduce child TSE. This paper reports on findings from the pilot study, which was conducted in Israel from 2013 to 2014.

METHODS

The intervention consisted of motivational interviews, child biomarker and home air quality feedback, a Web site, a video, and self-help materials. The primary outcome was child TSE as measured by hair nicotine. Secondary outcome measures were air nicotine and particulate matter, parental reports of TSE, parental smoking behavior, and TSE child protection. A single-group pre- and posttest design was used.

RESULTS

Twenty-six of the 29 recruited families completed the study. The intervention was feasible to implement and acceptable to participants. Among the 17 children with reliable hair samples at baseline and follow-up, log hair nicotine dropped significantly after the intervention (P = .04), hair nicotine levels decreased in 64.7% of children, and reductions to levels of nonexposed children were observed in 35.3% of children. The number of cigarettes smoked by parents (P = .001) and parent-reported child TSE declined (P = .01). Logistical issues arose with measurement of all objective measures, including air nicotine, which did not decline; home air particulate matter; and hair nicotine.

CONCLUSIONS

A program based on motivational interviewing and demonstrating TSE and contamination to parents in a concrete and easily understandable way is a promising approach to protect children from TSE. Further research is needed to enhance current methods of measurement and assess promising interventions.

The many meanings of evidence: a comparative analysis of the forms and roles of evidence within three health policy processes in Cambodia

BACKGROUND

Discussions within the health community routinely emphasise the importance of evidence in informing policy formulation and implementation. Much of the support for the evidence-based policy movement draws from concern that policy decisions are often based on inadequate engagement with high-quality evidence. In many such discussions, evidence is treated as differing only in quality, and assumed to improve decisions if it can only be used more. In contrast, political science scholars have described this as an overly simplistic view of the policy-making process, noting that research 'use' can mean a variety of things and relies on nuanced aspects of political systems. An approach more in recognition of how policy-making systems operate in practice can be to consider how institutions and ideas influence which pieces of evidence appear to be relevant for, and are used within, different policy processes.

METHODS

Drawing on in-depth interviews undertaken in 2015-2016 with key health sector stakeholders in Cambodia, we investigate the evidence perceived to be relevant to policy decisions for three contrasting health policy examples, namely tobacco control, HIV/AIDS and performance-based salary incentives. These cases allow us to examine the ways that policy-relevant evidence may differ given the framing of the issue and the broader institutional context in which evidence is considered.

RESULTS

The three health issues show few similarities in how pieces of evidence were used in various aspects of policy-making, despite all being discussed within a broad policy environment in which evidence-based policy-making is rhetorically championed. Instead, we find that evidence use can be better understood by mapping how these health policy issues differ in terms of the issue characteristics, and also in terms of the stakeholders structurally established as having a dominant influence for each issue. Both of these have important implications for evidence use. Contrasting concerns of key stakeholders meant that evidence related to differing issues could be understood in terms of how it was relevant to policy. The stakeholders involved, however, could further be seen to possess differing logics about how to go about achieving their various outcomes - logics that could further help explain the differences seen in evidence utilisation.

CONCLUSION

A comparative approach reiterates that evidence is not a uniform concept for which more is obviously better, but rather illustrates how different constructions and pieces of evidence become relevant in relation to the features of specific health policy decisions. An institutional approach that considers the structural position of stakeholders with differing core goals or objectives, as well as their logics related to evidence utilisation, can further help to understand some of the complexities of evidence use in health policy-making.

Reducing the Global Burden of Cardiovascular Disease, Part 1: The Epidemiology and Risk Factors

Current global health policy goals include a 25% reduction in premature mortality from noncommunicable diseases by 2025. In this 2-part review, we provide an overview of the current epidemiological data on cardiovascular diseases (CVD), its risk factors, and describe strategies aimed at reducing its burden. In part 1, we examine the global epidemiology of cardiac conditions that have the greatest impact on CVD mortality; the predominant risk factors; and the impact of upstream, societal health determinants (eg, environmental factors, health policy, and health systems) on CVD. Although age-standardized mortality from CVD has decreased in many regions of the world, the absolute number of deaths continues to increase, with the majority now occurring in middle- and low-income countries. It is evident that multiple factors are causally related to CVD, including traditional individual level risk factors (mainly tobacco use, lipids, and elevated blood pressure) and societal level health determinants (eg, health systems, health policies, and barriers to CVD prevention and care). Both individual and societal risk factors vary considerably between different regions of the world and economic settings. However, reliable data to estimate CVD burden are lacking in many regions of the world, which hampers the establishment of nationwide prevention and management strategies. A 25% reduction in premature CVD mortality globally is feasible but will require better implementation of evidence-based policies (particularly tobacco control) and integrated health systems strategies that improve CVD prevention and management. In addition, there is a need for better health information to monitor progress and guide health policy decisions.

Tobacco control environment: cross-sectional survey of policy implementation, social unacceptability, knowledge of tobacco health harms and relationship to quit ratio in 17 low-income, middle-income and high-income countries

OBJECTIVES

This study examines in a cross-sectional study 'the tobacco control environment' including tobacco policy implementation and its association with quit ratio.

SETTING

545 communities from 17 high-income, upper-middle, low-middle and low-income countries (HIC, UMIC, LMIC, LIC) involved in the Environmental Profile of a Community's Health (EPOCH) study from 2009 to 2014.

PARTICIPANTS

Community audits and surveys of adults (35-70 years, n=12 953).

PRIMARY AND SECONDARY OUTCOME MEASURES

Summary scores of tobacco policy implementation (cost and availability of cigarettes, tobacco advertising, antismoking signage), social unacceptability and knowledge were associated with quit ratios (former vs ever smokers) using multilevel logistic regression models.

RESULTS

Average tobacco control policy score was greater in communities from HIC. Overall 56.1% (306/545) of communities had >2 outlets selling cigarettes and in 28.6% (154/539) there was access to cheap cigarettes (<5cents/cigarette) (3.2% (3/93) in HIC, 0% UMIC, 52.6% (90/171) LMIC and 40.4% (61/151) in LIC). Effective bans (no tobacco advertisements) were in 63.0% (341/541) of communities (81.7% HIC, 52.8% UMIC, 65.1% LMIC and 57.6% LIC). In 70.4% (379/538) of communities, >80% of participants disapproved youth smoking (95.7% HIC, 57.6% UMIC, 76.3% LMIC and 58.9% LIC). The average knowledge score was >80% in 48.4% of communities (94.6% HIC, 53.6% UMIC, 31.8% LMIC and 35.1% LIC). Summary scores of policy implementation, social unacceptability and knowledge were positively and significantly associated with quit ratio and the associations varied by gender, for example, communities in the highest quintile of the combined scores had 5.0 times the quit ratio in men (Odds ratio (OR) 5·0, 95% CI 3.4 to 7.4) and 4.1 times the quit ratio in women (OR 4.1, 95% CI 2.4 to 7.1).

CONCLUSIONS

This study suggests that more focus is needed on ensuring the tobacco control policy is actually implemented, particularly in LMICs. The gender-related differences in associations of policy, social unacceptability and knowledge suggest that different strategies to promoting quitting may need to be implemented in men compared to women.

Addressing Tobacco Use Among Consumers and Staff at Behavioral Health Treatment Facilities Through Comprehensive Workplace Programming

Tobacco use is the leading cause of death and disability in the United States; cigarette smoking is the most common form of tobacco use. Smoking has become increasingly concentrated among individuals with behavioral health needs (e.g., persistent mental illness) and has led to increased morbidity and mortality in this group relative to the general population. Comprehensive tobacco-free workplace programs are effective in reducing tobacco use and cigarette smoke exposure among behavioral health consumers and the individuals who serve them. Taking Texas Tobacco-Free (TTTF) represents an academic-community partnership formed to address tobacco use among consumers and employees at behavioral health clinics across Texas via the dissemination of an evidence-based, multicomponent tobacco-free workplace program. Program components of TTTF include tobacco-free campus policy implementation and enforcement, staff education about tobacco use hazards, provider training to regularly screen for and address tobacco dependence via intervention, and community outreach. These components, the nature of the academic-community partnership, the process of behavioral health facility involvement and engagement, and the benefits and challenges of implementation from the perspectives of the project team and participating clinic leaders are described. This information can guide similar academic and community partnerships and inform the implementation of other statewide tobacco-free workplace programming.

Complying with the framework convention for tobacco control: an application of the Abridged SimSmoke model to Israel

BACKGROUND

The World Health Organization Framework Convention for Tobacco Control (FCTC) established the MPOWER policy package to provide practical country-level guidance on implementing effective policies to reduce smoking rates. The Abridged SimSmoke tobacco control policy simulation model is applied to Israel to estimate the effects on reducing smoking-attributable mortality resulting from full implementation of MPOWER policies.

METHODS

Smoking prevalence from the 2014 Israel National Health Interview Survey 3 and population data from the Israel Central Bureau of Statistics were used to calculate the number of current smokers. The status of current Israeli policy was determined using information from MPOWER 2015 and from local sources. Based on existing knowledge that between 50 % and 65 % of smokers will die prematurely from smoking, the model is used to determine mortality reductions among current smokers from full implementation of MPOWER policies.

RESULTS

We estimate that between 547 and 711 thousand smokers of the current 1.1 million Israeli smokers will prematurely die due smoking. Within 40 years, complete implementation of MPOWER policies is projected to reduce smoking prevalence among current smokers by 34% and avert between 187 and 243 thousand deaths. Taxes, smoke-free air laws, marketing restrictions and media campaigns each reduce smoking by about 5 % within 5 years. Improved cessation treatment and health warnings each have smaller effects in the next five years, but their effects grow rapidly over time.

CONCLUSIONS

Israel Abridged SimSmoke shows that complete implementation of the MPOWER strategies has the potential to substantially reduce smoking prevalence, and avert premature deaths due to smoking. Additional benefits are also expected from reduced morbidity, reduced initiation among nonsmokers, and reduction in exposure of nonsmokers to tobacco smoke.

Feasibility of Measuring Tobacco Smoke Air Pollution in Homes: Report from a Pilot Study

Tobacco smoke air pollution (TSAP) measurement may persuade parents to adopt smoke-free homes and thereby reduce harm to children from tobacco smoke in the home. In a pilot study involving 29 smoking families, a Sidepak was used to continuously monitor home PM(2.5) during an 8-h period, Sidepak and/or Dylos monitors provided real-time feedback, and passive nicotine monitors were used to measure home air nicotine for one week. Feedback was provided to participants in the context of motivational interviews. Home PM(2.5) levels recorded by continuous monitoring were not well-accepted by participants because of the noise level. Also, graphs from continuous monitoring showed unexplained peaks, often associated with sources unrelated to indoor smoking, such as cooking, construction, or outdoor sources. This hampered delivery of a persuasive message about the relationship between home smoking and TSAP. By contrast, immediate real-time PM(2.5) feedback (with Sidepak or Dylos monitor) was feasible and provided unambiguous information; the Dylos had the additional advantages of being more economical and quieter. Air nicotine sampling was complicated by the time-lag for feedback and questions regarding shelf-life. Improvement in the science of TSAP measurement in the home environment is needed to encourage and help maintain smoke-free homes and protect vulnerable children. Recent advances in the use of mobile devices for real-time feedback are promising and warrant further development, as do accurate methods for real-time air nicotine air monitoring.

Parental receptivity to child biomarker testing for tobacco smoke exposure: A qualitative study

OBJECTIVE

Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their children's exposure. Biomarkers demonstrate exposure and may motivate behavior change, but their acceptability is not well understood.

METHODS

Sixty-five in-depth interviews were conducted with parents of young children, in smoking families in central Israel. Data were analyzed using thematic analysis.

RESULTS

Consent to testing was associated with desire for information, for reassurance or to motivate change, and with concerns for long-term health, taking responsibility for one's child, and trust in research. Opposition to testing was associated with preference to avoid knowledge, reluctance to cause short-term discomfort, perceived powerlessness, and mistrust of research. Most parents expressed willingness to allow measurement by urine (83%), hair (88%), or saliva (93%), but not blood samples (43%); and believed that test results could motivate behavior change.

CONCLUSIONS

Parents were receptive to non-invasive child biomarker testing. Biomarker information could help persuade parents who smoke that their children need protection.

PRACTICE IMPLICATIONS

Biomarker testing of children in smoking families is an acceptable and promising tool for education, counseling, and motivation of parents to protect their children from TSE. Additionally, biomarker testing allows objective assessment of population-level child TSE.

Global prevention and control of NCDs: Limitations of the standard approach

The five-target '25 × 25' strategy for tackling the emerging global epidemic of non-communicable diseases (NCDs) focuses on four diseases (CVD, diabetes, cancer, and chronic respiratory disease), four risk factors (tobacco, diet and physical activity, dietary salt, and alcohol), and one cardiovascular preventive drug treatment. The goal is to decrease mortality from NCDs by 25 per cent by the year 2025. The 'standard approach' to the '25 × 25' strategy has the benefit of simplicity, but also has major weaknesses. These include lack of recognition of: (i) the fundamental drivers of the NCD epidemic; (ii) the 'missing NCDs', which are major causes of morbidity; (iii) the 'missing causes' and the 'causes of the causes'; and (iv) the role of health care and the need for integration of interventions.

Tobacco policy in Israel: 1948-2014 and beyond

BACKGROUND

Tobacco is the only consumer product known to kill half of its users, and is a significant cause of death and disability to exposed nonsmokers. This presents a unique conundrum for modern democracies, which emphasize personal liberty, yet are obligated to protect citizens. In Israel, the death toll in 2014 from smoking is expected to reach 8000 deaths; nearly a fifth of the population smokes, and over two-thirds of the population are exposed to tobacco smoke.

AIM

This paper provides an overview of tobacco policy in Israel since the inception of the State, presents the development of the National Tobacco Control Plan, and recommends future actions.

METHODS

Sources for this article included the Knesset (Israeli Parliament) and Ministry of Health websites, Health Minister Reports to the Knesset on Smoking, and the scientific literature.

RESULTS

Israel has an impressive record on tobacco control policy, beginning with taxation in 1952, landmark smoke-free air and marketing legislation in the early 1980's, tax increases and expansions of smoke-free air and marketing legislation in the ensuing years, and the addition of subsidized smoking cessation technologies in 2010. Until 2011, actions were taken by various organizations without formal coordination; since the passage of the National Tobacco Control Plan in 2011, the Ministry of Health has held responsibility for coordinating tobacco control, with an action plan. The plan has been partially implemented. Smoke-free air laws were expanded, but enforcement is poor. Passage of critical marketing and advertising restrictions is stalled. Requested funds for tobacco control did not materialize.

RECOMMENDATIONS

In order to prevent hundreds of thousands of preventable premature deaths in the coming decades, Israel should considerably strengthen tobacco control policies to include: guaranteed funding for tobacco control; strong curbs on advertising, promotion and sponsorship of tobacco and smoking products; public education; law enforcement; protection of children from exposure to tobacco; regulation of electronic cigarettes and other alternative harm-reducing products; tobacco control research; and systematic monitoring of, and periodic updates to, the National Tobacco Control Plan. Israel should also begin discussions of Endgame scenarios, and consider abolition of tobacco, as it continues its progress towards making smoking history.

Towards a comprehensive global approach to prevention and control of NCDs

BACKGROUND

The "25×25" strategy to tackle the global challenge of non-communicable diseases takes a traditional approach, concentrating on a few diseases and their immediate risk factors.

DISCUSSION

We propose elements of a comprehensive strategy to address NCDs that takes account of the evolving social, economic, environmental and health care contexts, while developing mechanisms to respond effectively to local patterns of disease. Principles that underpin the comprehensive strategy include: (a) a balance between measures that address health at the individual and population level; (b) the need to identify evidence-based feasible and effective approaches tailored to low and middle income countries rather than exporting questionable strategies developed in high income countries; (c) developing primary health care as a universal framework to support prevention and treatment; (d) ensuring the ability to respond in real time to the complex adaptive behaviours of the global food, tobacco, alcohol and transport industries; (e) integrating evidence-based, cost-effective, and affordable approaches within the post-2015 sustainable development agenda; (f) determination of a set of priorities based on the NCD burden within each country, taking account of what it can afford, including the level of available development assistance; and (g) change from a universal "one-size fits all" approach of relatively simple prevention oriented approaches to more comprehensive multi-sectoral and development-oriented approaches which address both health systems and the determinants of NCD risk factors.

SUMMARY

The 25×25 is approach is absolutely necessary but insufficient to tackle the the NCD disease burden of mortality and morbidity. A more comprehensive approach is recommended.

Do health policy advisors know what the public wants? An empirical comparison of how health policy advisors assess public preferences regarding smoke-free air, and what the public actually prefers

BACKGROUND

Health policy-making, a complex, multi-factorial process, requires balancing conflicting values. A salient issue is public support for policies; however, one reason for limited impact of public opinion may be misperceptions of policy makers regarding public opinion. For example, empirical research is scarce on perceptions of policy makers regarding public opinion on smoke-free public spaces.

METHODS

Public desire for smoke-free air was compared with health policy advisor (HPA) perception of these desires. Two representative studies were conducted: one with the public (N = 505), and the other with a representative sample of members of Israel's health-targeting initiative, Healthy Israel 2020 (N = 34), in December 2010. Corresponding questions regarding desire for smoke-free areas were asked. Possible smoke-free areas included: 100% smoke-free bars and pubs; entrances to health facilities; railway platforms; cars with children; college campuses; outdoor areas (e.g., pools and beaches); and common areas of multi-dweller apartment buildings. A 1-7 Likert scale was used for each measure, and responses were averaged into a single primary outcome, DESIRE. Our primary endpoint was the comparison between public preferences and HPA assessment of those preferences. In a secondary analysis, we compared personal preferences of the public with personal preferences of the HPAs for smoke-free air.

RESULTS

HPAs underestimated public desire for smoke-free air (Public: Mean: 5.06, 95% CI:[4.94, 5.17]; HPA: Mean: 4.06, 95% CI:[3.61, 4.52]: p < .0001). Differences at the p = .05 level were found between HPA assessment and public preference for the following areas: 100% smoke-free bars and pubs; entrances to healthcare facilities; train platforms; cars carrying children; and common areas of multi-dweller apartment buildings. In our secondary comparison, HPAs more strongly preferred smoke-free areas than did the public (p < .0001).

CONCLUSIONS

Health policy advisors underestimate public desire for smoke-free air. Better grasp of public opinion by policy makers may lead to stronger legislation. Monitoring policy-maker assessment of public opinion may shed light on incongruities between policy making and public opinion. Further, awareness of policy-maker misperceptions may encourage policy-makers to demand more accurate information before making policy.

The Program Assessment Guide: an approach for structuring contextual knowledge and experience to improve the design, delivery, and effectiveness of nutrition interventions

As evidence from small-scale trials has accumulated concerning the efficacy of low-cost interventions to address undernutrition, the design, implementation, and strengthening of large-scale programs to deliver these interventions has become a high priority. This scaling up process involves a large number of technical, logistical, administrative, political, and social considerations and little research exists on how to address these in a systematic way. This paper introduces the Program Assessment Guide (PAG), a set of analysis and decision tools that seeks to fill this gap, and reports on its application in Kyrgyzstan and Bolivia. The PAG places a special focus on eliciting and systematizing contextual knowledge and experience through a structured, participatory workshop and is grounded in theory, principles, and experience from program planning, management, change management, and intervention planning. When applied in Kyrgyzstan and Bolivia, the PAG was successful in helping workshop participants identify key implementation bottlenecks, questionable assumptions in the program theory, and feasible ways to address some of the shortcomings. These experiences also identified the need for a number of modifications to the PAG related to the workshop design itself, the preparations prior to the workshop, and follow-up after the workshop. The PAG represents one approach for strengthening decisions related to the design and large-scale implementation of interventions. The development and full-scale testing of alternative methods such as these for strengthening program analysis and decision making is an important and intellectually challenging subject for further research.

'Balancing acts': the politics and processes of smokefree area policymaking in a small state

OBJECTIVE

To examine the influences on contemporary smokefree area policy development in New Zealand.

METHOD

Semi-structured interviews were conducted with 62 New Zealand politicians and senior officials. They were asked about their views of possible interventions to reduce smoking around children, and how to achieve progress on smokefree homes, cars and public places. Transcribed data were analysed for themes, some of which were determined by the questions asked, and some emerged from the dynamic nature of the interviews.

RESULTS

Policymaking for smokefree areas was seen by participants as a complex, highly politicised activity, concerned with balancing a number of factors including evidence, personal experience, concern for smokers, and the desire for public support for policy. The majority of participants were cautious about making substantive policy moves on smokefree places because of their perception of the issue as highly controversial, their wish to avoid public resistance and their desire for community engagement. Preference was shown for a policy approach based on persuasion rather than legislation, as a means to make progress on smokefree cars and outdoor spaces.

CONCLUSIONS

The results indicate the need for good communication of the acceptability and benefits of legislative smokefree changes to both the political and public arena.