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Advocacy as a Tobacco Control Strategy

Caroline H. Sparks

Associate Professor, School of Public Health and Health Services

The George Washington University


Public advocacy for a tobacco-free society has been a national tobacco control strategy in the United States for the past 15 years. This appendix discusses the rise of advocacy as a public health intervention strategy to reduce tobacco use and assesses the evidence that may indicate whether advocacy should be a considered a best practice for tobacco control. This review is not a formal meta-evaluation, for there are too few studies that directly link advocacy to decreases in tobacco-related morbidity or mortality or tobacco use prevalence. It is, instead, an attempt to guarantee that when we review the formal evidence that links various tobacco control policies that are now considered “best practices” to changes in prevalence and consumption, we recognize that such policy changes were achieved only through advocacy by state tobacco control coalitions and the thousands of citizens that made those policy changes possible.

RISE OF COMMUNITY LEVEL INTERVENTIONS TO CONTROL TOBACCO

During the early days of tobacco use prevention, after the publication of the 1964 Surgeon General’s Report linking smoking to health problems (Public Health Service 1964), many state health departments relied on funds in state budgets for tobacco control and treatment. Interventions tended to be targeted toward smoking cessation for individuals. However, by the late 1980s, beginning with California and then expanding to all states, funding for comprehensive state tobacco control programs increased. With this funding came a shift from individual tobacco control interventions toward population-based interventions to alter the social and environmental conditions that contribute to tobacco use (Stillman et al. 1999). From the beginning, policy advocacy was an integral part of these comprehensive tobacco control programs, and as state programs matured, it became an increasingly important focus of state tobacco control efforts. Community-level interventions may seem the norm to many tobacco control veterans today but they were not the norm just 15 years ago and the effort to support them in many state and federal programs today is still a difficult task. The complexity of interactions within communities, the political realities, and the resource demands of such programs make them costly to support.

EVOLUTION OF COMPREHENSIVE STATE TOBACCO CONTROL PROGRAMS

California launched the first statewide comprehensive tobacco control program in 1988 using funds from Proposition 99, the law that devoted 20 percent of an increase in state tobacco taxes to tobacco control programs (Bal 1998; Glantz and Balbach 2000). At that time, the National Cancer Institute (NCI) was already preparing to launch the 7 year national American Stop Smok-



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Ending the Tobacco Problem: A Blueprint for the Nation O Advocacy as a Tobacco Control Strategy Caroline H. Sparks Associate Professor, School of Public Health and Health Services The George Washington University Public advocacy for a tobacco-free society has been a national tobacco control strategy in the United States for the past 15 years. This appendix discusses the rise of advocacy as a public health intervention strategy to reduce tobacco use and assesses the evidence that may indicate whether advocacy should be a considered a best practice for tobacco control. This review is not a formal meta-evaluation, for there are too few studies that directly link advocacy to decreases in tobacco-related morbidity or mortality or tobacco use prevalence. It is, instead, an attempt to guarantee that when we review the formal evidence that links various tobacco control policies that are now considered “best practices” to changes in prevalence and consumption, we recognize that such policy changes were achieved only through advocacy by state tobacco control coalitions and the thousands of citizens that made those policy changes possible. RISE OF COMMUNITY LEVEL INTERVENTIONS TO CONTROL TOBACCO During the early days of tobacco use prevention, after the publication of the 1964 Surgeon General’s Report linking smoking to health problems (Public Health Service 1964), many state health departments relied on funds in state budgets for tobacco control and treatment. Interventions tended to be targeted toward smoking cessation for individuals. However, by the late 1980s, beginning with California and then expanding to all states, funding for comprehensive state tobacco control programs increased. With this funding came a shift from individual tobacco control interventions toward population-based interventions to alter the social and environmental conditions that contribute to tobacco use (Stillman et al. 1999). From the beginning, policy advocacy was an integral part of these comprehensive tobacco control programs, and as state programs matured, it became an increasingly important focus of state tobacco control efforts. Community-level interventions may seem the norm to many tobacco control veterans today but they were not the norm just 15 years ago and the effort to support them in many state and federal programs today is still a difficult task. The complexity of interactions within communities, the political realities, and the resource demands of such programs make them costly to support. EVOLUTION OF COMPREHENSIVE STATE TOBACCO CONTROL PROGRAMS California launched the first statewide comprehensive tobacco control program in 1988 using funds from Proposition 99, the law that devoted 20 percent of an increase in state tobacco taxes to tobacco control programs (Bal 1998; Glantz and Balbach 2000). At that time, the National Cancer Institute (NCI) was already preparing to launch the 7 year national American Stop Smok-

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Ending the Tobacco Problem: A Blueprint for the Nation ing Intervention Study (ASSIST). In 1991, the ASSIST program funded community-level interventions to prevent tobacco use in 17 states. By the mid-1990s, every state in the United States had some funding for comprehensive tobacco control either from ASSIST or from the Centers for Disease Control and Prevention (CDC) Office of Smoking and Health’s (OSH) Initiatives to Mobilize for the Prevention and Control of Tobacco Use (IMPACT) program. Additional funding for tobacco control was available for some states, from 1994 to 2000, from the Robert Wood Johnson Foundation’s (RWJF) SmokeLess States (SSI) program (Gerlach and Larkin 2005; Tauras et al. 2005). In addition to educational and cessation programs, the funds from all three of these national programs— ASSIST, IMPACT and the SmokeLess States program—supported statewide coalitions of individuals and organizations that pursued action strategies toward strengthening tobacco control policies. The ASSIST program funded state health departments’ work with coalitions (NCI 1991). The IMPACT program required state health departments to establish state-level tobacco control coalitions and to build capacity for comprehensive tobacco control programs in the 33 state health departments that participated in this cooperative agreement (Federal Register 1993). SmokeLess States was the only program that funded state coalitions whose lead agencies were outside of state health departments (RWJF 1993). The state tobacco control coalitions focused from the beginning on public policy advocacy as an important strategy. Their plans reflected the shift away from interventions aimed at individuals toward interventions to change social norms and environmental conditions. By the late 1980s, NCI staff were aware that most intervention research showed that individual approaches to tobacco use prevention were not effective in reducing smoking prevalence and were ready to sponsor social and environmental approaches (NCI 1991). The planners of the ASSIST program recognized that promoting changes in public policy was consistent with a population-based solution to a population-wide epidemic of tobacco use (NCI 2005). The shift in focus enabled tobacco control advocates to pursue population-based solutions to the tobacco epidemic on a national scale for the first time in U.S. history. It was a bold initiative on the part of two federal agencies, a private foundation, state health departments, and nonprofit health organizations that deserves recognition and analysis in any effort to formulate future initiatives. The ASSIST program promoted three types of interventions: (1) program services, (2) policy, and (3) mass media. However, ASSIST guidelines stated that “efforts to achieve priority public policy objectives should take precedence over efforts to support service delivery” (NCI 2005). Mass media initiatives were intended to support those policy changes, which meant that media advocacy that engaged the news media in support of prevention policies was the focus of media initiatives rather than social marketing. The four ASSIST priority policy areas were: (1) eliminating environmental tobacco smoke, (2) higher tobacco taxes, (3) limits on tobacco advertising and promotion, and (4) reducing youth access to tobacco (NCI 2005). Evaluation of Comprehensive State Programs The evidence that the ASSIST, CDC, and SSI programs were effective must be based on whether change occurred in the priority policy areas listed above. The CDC OSH released a summary in 2005 of the literature on the evidence of the effectiveness of state tobacco control programs (Kuiper et al. 2005). Organized by major reviews and five outcome indicators (tobacco-related mortality, prevalence, consumption, cessation, and smoke-free legislation and policy), the results are presented generally by state. The evidence provided can be considered a guide for state health departments to measure the success of their comprehensive tobacco control

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Ending the Tobacco Problem: A Blueprint for the Nation programs. Of the five indicators of success, one is a health outcome—tobacco-related mortality—and three are markers that lead to improved health outcomes—decreases in prevalence, decreases in consumption of tobacco products, and smoking cessation. The fifth indicator, smoke-free legislation and policy, is an intermediate outcome that alters the environment that supports tobacco use. This outcome should be considered the endpoint for the intervention strategy of policy advocacy. In the ASSIST evaluation, changes in policy were, in fact, considered part of an Initial Outcome Index that represented initial outcomes of advocacy efforts (Gilpin et al. 2000). While we can link smoke-free policies, such as high tobacco excise taxes, to changes in prevalence, consumption, and cessation, it is more difficult to link advocacy action directly to these intermediate outcomes or to the long-range health outcome. This may be a reason why discussions of best practices generally list a range of smoke-free policies while ignoring or obscuring advocacy as a best practice in tobacco control. If we are not alert, policies can be treated as strategies instead of endpoints, without acknowledging that policy change in most cases cannot occur without public advocacy campaigns. The best practice must be considered an active, effective tobacco coalition with a focus on policy change. As an example of the lack of attention to the importance of an advocacy strategy, the Task Force on Community Preventive Services (2001) did not list community advocacy or media advocacy in its 14 recommendations for interventions to reduce tobacco use and exposure to environmental tobacco smoke (Task Force on Community Preventive Services 2001). Yet, the advocacy work of tobacco control coalitions has been critical to the success of tobacco control policies. To what extent does a comprehensive tobacco control program make a difference in a state? To what extent does a state coalition’s policy advocacy work make a difference within a comprehensive tobacco control program? The first question seems easier to answer than the second. A number of authors have tried to assess the contribution of state comprehensive programs to policy change and/or reductions in smoking (Elder et al. 1996; Public Health Service 2000; Siegel 2002; Stillman et al. 2003; Tauras et al. 2005; Wakefield and Chaloupka 2000; Warner 2000). There is evidence that states with the most money for comprehensive programs have lower prevalence and consumption rates (Tauras et al. 2005). The CDC concluded, on the basis of analyses of the excise tax-funded state programs in California, Massachusetts, Oregon, and Maine as well as on the agency’s experience in providing assistance to four other states (Florida, Minnesota, Mississippi, and Texas), that the evidence was sufficiently compelling to encourage all states to pursue comprehensive programs. After the end of the ASSIST program in 1999, when the responsibility for tobacco prevention shifted from NCI to the CDC OSH, the OSH implemented a tobacco control program to sustain state comprehensive programs. Under that program each state can receive approximately $1 million per year for comprehensive tobacco control (CDC 2003). On the basis of the evidence, the agency issued guidance for states in 1999 in a document titled Best Practices for Comprehensive Tobacco Control Programs (CDC 1999a). The guidance lists nine areas of activity that should be included as best practices because the complexity of changing the social environment “must be addressed by multiple program elements working together in a comprehensive approach” (CDC 1999a). Suggested levels of funding per capita are included to assist states in allocating funds from various sources. The first area of best practice—community programs—includes promoting government and voluntary policies to promote clean indoor air, restrict access to tobacco products, and achieve other policy objectives. As evidence for this as a best practice, the document cites the success of

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Ending the Tobacco Problem: A Blueprint for the Nation the California, Massachusetts, and Oregon coalitions in achieving policy and program objectives (CDC 1999a;b). Statewide programs that promote media advocacy and counter-marketing campaigns are also cited among the best practices, based on the CDC’s review of core documents from the California and Massachusetts campaigns. There have been few efforts to analyze the contribution of the state tobacco control coalitions within comprehensive state programs, especially their advocacy initiatives. Most of the authors cited above acknowledge that state coalitions have played a key role in the achievement of policy changes that reduce tobacco consumption while at the same time commenting on the difficulty of measuring the extent to which coalition activities at the state or local level were responsible for either policy change or health outcomes. For example, in an article about the connection between total tobacco control spending in the states and reduced tobacco consumption, Tauras and colleagues (2005) acknowledged that no data were available that would allow them to analyze which specific programs in the states are responsible for reduced consumption (Tauras et al. 2005). Elder and colleagues’ (1996) evaluation of the California comprehensive program noted the shift from individually focused programs to community coalition and advocacy work, but they had no means of quantitatively documenting the contribution of those programs to the decline in smoking prevalence in the state. According to Nelson, one of the authors of the Kuipers and colleagues (2005) literature review from the OSH (Kuiper et al. 2005), the greatest research need is a multistate evaluation study of the impact of state programs (Personal Communication, Nelson, June 2005). If the CDC would fund a new initiative based on the ASSIST model, such a study could extend our understanding of statewide comprehensive tobacco control programs, refine evaluation measures, and help clarify the impact of such programs on changes in smoking prevalence. WEAKNESS IN PUBLIC HEALTH METHODS FOR MEASURING PRIMARY PREVENTION STRATEGIES One reason that the link between community action and reductions in tobacco use is difficult to document is that public health methodology is not as well developed for measuring complex community- and population-based social and policy change as it is for individual and small group change. This difficulty in public health methods has been noted by McKinley and Marceau (2000) in a critique of the current research paradigm in public health and their call for the development of multi-level research methods (McKinley and Marceau 2000). The ASSIST planners noted a lack of developed methods for evaluating large-scale, multisite demonstration projects (NCI 2005). The difficulty was also noted in a report of a workshop on tobacco control interventions sponsored by the Johns Hopkins Bloomberg School of Public Health (Johns Hopkins 2002). Public health experts in attendance noted that the complexity of comprehensive tobacco control programs and the contributions of specific programs cannot be evaluated using conventional experimental designs. They unanimously concurred that the current state of evaluation research has to be improved in order to evaluate higher-level public health initiatives, such as comprehensive tobacco control programs. It is easier to track the direct influence of a policy change than to track the influence of advocates in achieving that policy. For example, an economist can track declines in cigarette purchases in the years following an increase in the tobacco tax in a state, so the excise tax may then be considered a best practice. It is more difficult for a public health researcher to show that a state coalition’s activities are responsible for a change in the social climate that led to increased support for the higher tax. Most people in the tobacco control field know that a tax increase does

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Ending the Tobacco Problem: A Blueprint for the Nation not occur without decision makers considering whether there is public support for such a measure. However, the link between tobacco coalition activities and the tax increase is hard to prove. As a result, even after years of citizen advocacy for tobacco control, we have a lot of anecdotal evidence but slim quantitative evidence that such coalition advocacy is essential to the process of change. A search for evidence that would meet rigorous experimental or quasi-experimental standards for cross-study comparisons cannot yet yield enough studies for a meta-evaluation of the impact of advocacy initiatives. While many members of tobacco control coalitions can point to achievements in which their coalitions participated in educating the public or in supporting strong tobacco control policies, these achievements are documented in coalition reports and case studies that do not meet conventional standards for causality. Most of these case studies have not been able, or have not attempted, to parse out or compute the contribution of coalition advocacy action to tobacco control efforts so that we can generate effect sizes for such interventions. An evaluation of the impact of California’s Propostion 99 program covering the period 1990–1994, for example, was primarily a process evaluation (Elder et al. 1996). The researchers noted their frustration at not being able to relate specific program efforts to local impact on tobacco use, even though it was clear that overall from 1988 to 1994, smoking declined by 28 percent in California. A team of researchers did attempt to measure a link between program exposure among adults and youth to the California Tobacco Control Program and reductions in smoking prevalence in counties from 1996 to 1998 (Rohrbach et al. 2002). The program design included cross-sectional surveys of random telephone samples of adults and youth at two points in time. Program exposure included community programs, community and media programs, and community and school programs. The evaluators found that 80 percent of adults reported exposure to community programs and that counties with the highest multicomponent exposure rates had the greatest reductions in adult smoking prevalence, the largest increases in home smoking bans, and the greatest reductions in workplace no-smoking policy violations. None of the changes in youth outcomes were associated with multicomponent exposure. The single national study to date that reports an attempt to document a link between statewide coalition efforts and decreasing prevalence of smoking is an evaluation of the ASSIST program (Stillman et al. 2003). For this study, the evaluators constructed an index of change in adult smoking prevalence and per capita cigarette consumption as outcome variables and compared the outcomes to tobacco control policies in the 17 ASSIST states and 33 non-ASSIST states and the District of Columbia (Gilpin et al. 2000). They computed a “strength of tobacco control index” (SOTC) for every state based on earlier concept mapping work (Trochim et al. 2003) as a means of computing tobacco control scores by state (Stillman et al. 1999). The evaluators found a small but statistically significant difference in reduction of adult smoking prevalence (−0.63 percent, p = .049), but not in per capita cigarette consumption, in ASSIST states compared to non-ASSIST states. However, per capita consumption was affected by the SOTC in the states. As the authors reported, “states with larger changes in IOI [initial outcomes index] score over time were associated with lower per capita cigarette consumption than states with smaller changes in IOI (−0.32, p < .001). For a state, per capita consumption decreased by .57 packs per person per month as the IOI values increased from the 25th to the 75th percentile over the intervention period” (Stillman et al. 2003). This decrease in consumption was largely due to the component of IOI that represented cigarette price. The authors estimated that if all 50 states had implemented ASSIST, the decrease in adult smoking would have been 1,213,000 smokers. They concluded that investing in state-level tobacco control capacity and promoting tobacco control policies are effective strate-

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Ending the Tobacco Problem: A Blueprint for the Nation gies. The authors discuss the limitations of the study, especially their inability to develop an overall measure for the strength of the tobacco industry’s opposition in the states. They acknowledged that the complex political and socioeconomic variability among states that probably affected implementation of the ASSIST program was beyond the control of the ASSIST intervention (NCI 2006). The Tobacco Control Branch of the NCI published a monograph in 2005 that documents the history of the ASSIST program (NCI 2005). The authors discuss lessons learned and describe in detail the extent to which policy advocacy was a core feature of the innovative ASSIST program. The NCI’s ASSIST evaluation, not yet available but to be published in late 2006, may add to public understanding of the impact of ASSIST on tobacco policy outcomes. If we consider documented changes in tobacco control policy to be the initial endpoint of coalition advocacy initiatives, then we do have evidence of the effectiveness of citizen advocacy. Even without data that directly link citizen advocacy to reductions in tobacco use, the evidence of the effectiveness of advocacy as a strategy, for now, rests in the large number of documented changes in law and policy that have occurred in the states. For example, members of statewide coalitions were often the primary movers in countering the marketing techniques of the tobacco industry and in developing counter campaigns that reframed the positive spin on smoking of the tobacco companies. Much of this report focuses on the impact of tobacco policy changes on smoking rates. It is important to remember that strong tobacco control policies are an outcome of hundreds of local and state citizen campaigns. While we must hone our ability to measure the contribution of advocacy initiatives, we must be careful not to obscure the importance of continued advocacy work as a public health strategy. In discussing the SmokeLess States program, Gerlach and Larkin (2005) link citizen campaigns to policy change, although they do not document it quantitatively (Gerlach and Larkin 2005). These authors discuss the success of the SmokeLess States program in terms of the policy changes that states adopted over the 10 years of the program. Even without quantitative studies of the efficacy of advocacy, most people in the tobacco control community make a reasonable assumption, based on their experiences, that without citizen advocacy it is doubtful that the changes in tobacco taxes, smoke-free workplace laws, restrictions on smoking in public accommodations, and restrictions on sales to youth would have occurred. This assumption is reasonable because decision makers do not decide to strengthen tobacco control policies unless an active citizenry, working through state and national tobacco control coalitions to create tobacco-free environments, demands such policies. In 2002, by the end of the decade of coalition advocacy, the Surgeon General’s report, Reducing Tobacco Use in 2000, called the emergence of statewide coalitions the most important advance in comprehensive programs and concluded that comprehensive state programs, such as those in California and Massachusetts, provide evidence that such programs reduce smoking (Public Health Service 2000). TOBACCO INDUSTRY ATTACKS ON PUBLIC POLICY ADVOCACY Certainly, even without proof that coalition advocacy could change tobacco use, the potential power of an advocacy strategy by state coalitions was immediately recognized by the tobacco industry. The industry attacked the ASSIST program from its inception (NCI 2005; Trochim et al. 2003; White and Bero 2004) in order to reduce the threat of citizen action. In an industry document from 1995, a Phillip Morris consultant, objecting to the activities in the Community Environment Channel of ASSIST, wrote that “the most effective way of reaching low-educated

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Ending the Tobacco Problem: A Blueprint for the Nation populations will be through policy and media advocacy” (National Institute of Health Publication 2005). An analysis of tobacco industry internal documents indicates that the tobacco industry deliberately pursued a campaign to derail ASSIST by equating citizen advocacy efforts with illegal lobbying. The tobacco industry successfully pressured the federal legislature to add prohibitions on such efforts at the state and local levels (NCI 2005; White and Bero 2004). For the first time in U.S. history, it became illegal for anyone receiving federal funds to lobby state and local governments (Federal Acquisition Regulation 2005). A Tobacco Institute document of December 15, 1994, stated: “This Fall we were able to attach an amendment to the Federal Acquisition Streamlining Act legislation … which—for the first time—would prohibit federal funds from being used to lobby a local legislative body” (National Institute of Health Publication 2005). The tobacco industry used the Freedom of Information Act to divert state health department resources and threatened lawsuits against state health departments and individual state employees as a scare tactic (NCI 2005). The industry continued its opposition to advocacy by ensuring that the national tobacco settlement included language that prohibited the national foundation that was created from engaging in any political activities or lobbying (National Association of Attorneys General 1998). The industry’s attack equates advocacy with lobbying and cites Internal Revenue Service regulations that forbid public agencies from using public money for lobbying (White and Bero 2004). The Impact of Obscuring the Distinction Between Policy Advocacy and Lobbying Federal agencies and many state health departments, for political reasons or for caution, reacted to tobacco industry attacks by severely limiting advocacy activities that were, and still are, perfectly legal. Within the public health field, advocacy is a much broader concept and set of activities than lobbying (Gerlach and Larkin 2005; Wallack et al. 1993). The definitional issue is important if advocacy strategies are to survive as important interventions. The simplest dictionary definition of advocacy is to act to persuade others to support a cause (Merriam Webster 1995). In his book on media advocacy as a public health strategy, Wallack and colleagues (1993) use a definition of advocacy as organized social action to improve social conditions (Wallack et al. 1993). They draw this definition from a 1988 Institute of Medicine report that defines the mission of public health as “fulfilling society’s interest in assuring conditions in which people can be healthy” and assumes that improving social conditions is the route to success (IOM 1988). Wallack and colleagues (1993) refer further to advocacy as a term that represents a set of skills used to create a shift in public opinion and mobilizes resources and forces to support an issue, policy, or constituency (Wallack et al. 1993). Others define advocacy specifically in terms of social change related to tobacco. Most state coalitions adopted names incorporating the words “tobacco free.” The school-based Kids Act to Control Tobacco program uses the definition of advocacy as “to act to support a tobacco free environment” (NEA HIN 2000). Gerlach and Larkin (2005), in their article on the SmokeLess States program, refer to advocacy as the process of educating policy makers and members of the community about issues and measures that can be taken to address them (Gerlach and Larkin 2005). They emphasize the importance of advocacy to change tobacco control policies and discuss how the RWJF considered such work the key to success as the SmokeLess States program matured. Gerlach and Larkin (2005) point out that as early as the first year of the SmokeLess States program, RWJF’s support of the Coalition for Tobacco-Free Colorado was challenged as lobby-

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Ending the Tobacco Problem: A Blueprint for the Nation ing by the tobacco industry (Gerlach and Larkin 2005). As a response, RWJF was careful to make a distinction between lobbying, which the SmokeLess States program would not fund, and advocacy. The foundation defined lobbying as direct communication to a legislator on specific legislation or grassroots communication to the general public urging them to take action on specific legislation. While RWJF would not fund coalitions to conduct lobbying, coalitions were free to use their own funds for such activity. Indeed, the foundation encouraged and finally insisted that coalitions find such funds. Both RWJF and the NCI ASSIST program held training workshops for state coalitions on policy advocacy. As the ASSIST report from NCI makes clear (NCI 2005, p. 352), policy advocacy and lobbying are not the same thing. The fierce opposition of the tobacco industry to advocacy is a good indication of how important such initiatives should be in any blueprint for future tobacco control. Already, the industry attacks have weakened federal and state willingness to fund advocacy programs or, at least, have led them to obfuscate the language of advocacy while continuing to promote policy changes. The potential for future gains through this strategy is endangered if state health departments and coalitions become hesitant to openly acknowledge how critical citizen advocacy is for successful policy change. The restrictions on state and local lobbying added to the 1994 Federal Acquisitions Streamlining Act are still part of federal acquisition regulations (Federal Acquisition Regulation 2005). Unless these restrictions are rolled back, the hesitancy to engage in activities that could be confused with lobbying on the part of federal agencies and state health departments will remain. The original funding that promoted coalition advocacy work ended in the late 1990s. It is important that new funding initiatives not equate advocacy with lobbying and not obscure the purposes of comprehensive programs and state coalitions. NCI’s ASSIST program ended in 1999. The IMPACT program ended in 1998, and the CDC OSH assumed responsibility for continued funding of state health departments through the National Tobacco Control Program. While the focus is still on comprehensive tobacco programs, advocacy per se is not mentioned (Public Health Service 2000). From the ASSIST emphasis on policy advocacy as primary, the best practices recommendations have expanded to nine areas, with the potential for diluting funds for advocacy action. RWJF’s SmokeLess States program funding for advocacy initiatives ended in 2004, after an investment of $99 million over 10 years. While the foundation continues to fund tobacco use initiatives, the focus on advocacy as a strategy has diminished (Gerlach and Larkin 2005). Without further funding for state coalition advocacy initiatives and the development of evaluation methods that can measure the contribution of statewide coalitions, the potential for continued policy change may be further weakened. THE FUTURE OF ADVOCACY EFFORTS Although federal dollars for advocacy may be somewhat obscured by language about comprehensive state programs and although funding has decreased, promotion of tobacco control advocacy is alive and well among state and local workers in the field of tobacco control. For example, at the National Conference on Tobacco or Health held in Chicago, May 4–6, 2005, the focus on advocacy and social change was everywhere, from the keynote speakers to workshop presenters to people’s discussions about action in their states (National Conference of Tobacco or Health 2005). Speakers at the conference made it clear that advocacy, even as a means to maintain funding for comprehensive state tobacco control programs, is essential for success. The advocacy focus included media and community advocacy. State health department policies toward advocacy have an influence on the extent to which these types of programs survive. Faced with

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Ending the Tobacco Problem: A Blueprint for the Nation declining funds for a media campaign, one young man, who did not want to be identified as a state worker, referred to recent youth action in his home state as “guerilla advocacy,” meaning that when the state health department refused to support advocacy, the youth took advocacy out into the streets by staging events that spoke directly to community members (Personal communication, Anonymous, May 2005). He mentioned that when banned from handing out educational materials in a local mall, each member of the group wore a T-shirt with one letter so that when the members lined up the shirts spelled out “T-O-B-A-C-C-O F-R-E-E!” Such actions are cheap but effective ways of involving youth in creating anti-tobacco messages. Training youth to become advocates was one theme at the conference. While evaluation studies of advocacy training programs are often still more qualitative than quantitative, several speakers presented results of youth training in advocacy skills at the tobacco conference. The National Education Association Health Information Network’s Kids Act to Control Tobacco (Kids ACT!) program’s outcome evaluation, conducted over 4 years by Sparks and Simmens (2005) is the first large, group-randomized trial of a school-based youth advocacy program in the United States. Based on a four-step advocacy model, the analysis of this 3-year program showed that the program produced small to moderate differences between intervention and control groups at three points in time. It should be noted that the primary outcome of this advocacy program was advocacy action rather than smoking behavior (Sparks et al. 2005). The Smokebusters advocacy training program in Missouri involves youth in 8th through 10th grades in a 3-year advocacy program. The program monitors youth participation and has data that can be used in an outcome evaluation if funds were available (Lara 2005). The Campaign for Tobacco Free Kids sponsors an action program and awards for youth advocates (Campaign for Tobacco-Free Kids 2006) and the American Legacy Foundation’s truth­® campaign involves youth in a media advocacy program (American Legacy Foundation 2004). These advocacy efforts indicate that adults in tobacco control believe that training the next generation of advocates is important, not just as a smoking reduction strategy, but as a strategy for future social and policy change. Many state activities for policy change are clearly based on increasing public support for tobacco-free environments. Even though funding for advocacy has decreased since the three national programs mentioned earlier ended, coalition action in the states has centered on grassroots advocacy for smoke-free environments in workplaces, restaurants, and bars. Americans for Nonsmokers’ Rights (ANR) and other national organizations have worked with grassroots citizen coalitions to support smoke-free laws and policies. These efforts have been funded by national voluntary organizations such as the American Cancer Society, the American Heart Association, and the American Lung Association as well as by RWJF (Personal Communication, Frick, ANR, March 13, 2006). These coalition activities have had a tremendous success in decreasing environmental tobacco smoke. By April 2006, 461 municipalities in 33 states and the District of Columbia had passed smoke-free laws in workplaces, restaurants, or bars. One hundred and thirty-five of these had laws covering all three types of sites, while the others had laws covering one or more of these sites (ANR 2006). By January 2006, 11 states had passed smoke-free workplace legislation (Cherner 2006). An initiative to promote fire-safe cigarette laws has also emerged and self-extinguishing cigarettes are now required in five states—New York, California, Vermont, Illinois, and New Hampshire (Coalition for Fire Safe Cigarettes 2006). In January 2006, the California Environmental Protection Agency announced that environmental tobacco smoke is a Toxic Air Contaminant subject to state assessment for health effects (CEPA 2006).

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Ending the Tobacco Problem: A Blueprint for the Nation RECOMMENDATIONS FOR FUTURE TOBACCO CONTROL The adoption of the types of smoke-free policies mentioned above by cities and towns across America provides the most important evidence for the impact of citizen policy advocacy as a public health strategy in the first 6 years of the twenty-first century. Even as funding for coalitions has become less secure, these policy successes continue to roll forward with a momentum that was unanticipated in the late 1990s. The success of smoke-free policy change in the past 6 years illustrates the importance of continued federal and state support for community-level strategies for tobacco control and broad demonstration programs. As mentioned earlier, the CDC OSH currently offers only approximately $1 million per state to continue comprehensive tobacco control efforts (CDC 1999b). Although the CDC recommends funding levels for each state based on smoking prevalence, state governments are not funding such efforts at the levels recommended for best practices by the CDC (Tauras et al. 2005). The Master Settlement Agreement money has been siphoned off by state governments to programs other than tobacco control. The NCI currently funds only small research projects and has no plans for funding broad community, multilevel programs such as ASSIST. Even though smoking rates are dropping, tobacco use remains the greatest preventable cause of death, continuing to kill more than 400,000 Americans every year (CDC 2004). If we expect to reduce significantly the burden of tobacco use on the health of people, we need the vision of the early planners and activists that brought ASSIST, IMPACT, and SmokeLess States into existence. The evidence reviewed above indicates that the comprehensive approach of the 1990s, including policy advocacy, has resulted in many policy changes for tobacco control that, in turn, have had an effect on the prevalence of tobacco use. There are two main reasons to continue a comprehensive approach that focuses on policy advocacy. The first, specific to tobacco control, is that if we count all the state and local policies for tobacco control adopted in the last 15 years, the public advocacy approach has had the most effect in altering the environment that supports tobacco use. State health departments have broadened the scope of tobacco control activities and can document changes in social norms that support tobacco-free environments and public support for tobacco control and can list changes in public policy that limit tobacco use. A cadre of public health advocates was trained intensively through the ASSIST, IMPACT, and SmokeLess States coalition initiatives. Not only should this cadre be maintained, but funding and resources should be available so that they may provide training for the younger tobacco control workers in the 50 states so that the momentum of public advocacy is not lost. The second and even more crucial reason is that continuing to implement and evaluate comprehensive social and environmental interventions is critical to the continued development of effective public health promotion. Our understanding of how to implement such interventions as well as how to develop methods for evaluating the effectiveness of such interventions cannot advance if the Federal government, state governments, and national nonprofit foundations will not take the lead in advancing public health through such initiatives. Involvement in broad initiatives is critical to the training of future public health professionals who need practice in population-based solutions to public health problems. Such initiatives, with their national focus, are so costly that they require federal coordination and support. As an example of the kind of advances the field needs, the recent OSH release of Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs (Starr et al. 2005) illustrates how to enhance program evaluation of complex initiatives. The OSH tobacco control program requires states that receive tobacco control money to develop action plans based on logic models in which community mobilization and policy and regulatory action are interventions that lead to defined short- , intermediate-, and

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Ending the Tobacco Problem: A Blueprint for the Nation long-term outcomes for tobacco control. Detailed outcome indicators then make it possible to quantitatively measure success. This approach is an example of how to train future tobacco control advocates to implement and evaluate community-level interventions. RECOMMENDATIONS FOR FUTURE ACTION As the ASSIST project was closing down in the late 1990s, a number of committees and task groups made recommendations for future comprehensive tobacco control programs that would continue innovative strategies and continue advocacy activities (NCI 2005). Many of those recommendations have yet to be acted upon. The 2005 Tobacco or Health Conference adopted recommendations for the future. At the World Tobacco Conference in July 2006, participants also adopted resolutions for future tobacco control. Even as citizen action continues, in this decade a lack of political will at the state and federal levels has resulted in lost time, missed opportunities, and gaps in training and continued development of advocacy research and expertise. The following recommendations, based on this review, incorporate some of the recommendations from various sources that should be part of a blueprint to advance tobacco control and public health intervention methods: Federal funds disbursed to states and local communities for tobacco control activities should not be restricted from use for lobbying/advocacy efforts at the state or local level (ASSIST 1997). The government should immediately repeal language that implies that state and local citizen advocacy is illegal for recipients of federal health funding. A federal policy promoting citizen participation in the policy arena should be publicized and the distinction between legitimate citizen advocacy and professional lobbying should be made clear. A distinction can be made between corporate lobbying and citizen action. The Federal government should continue to fund initiatives, such as ASSIST, in which multilevel, community-wide programs can be tested and evaluated. ASSIST should be considered only the beginning of a population approach to the national health threat of tobacco use. Similar recommendations were made by the ASSIST Coordinating Committee (ASSIST 1995). State health departments should continue to position tobacco prevention as a priority in the media and through policy advocacy initiatives (ASSIST 1995). State health departments and tobacco control advocates should publicize the difference between advocacy for social change and lobbying. Comprehensive tobacco programs should encourage residents to demand their rights in a democracy to advocate for health policies that benefit the general public rather than the tobacco industry. Federal and state agencies should increase funding to strengthen the ability of public health researchers to develop better methods to evaluate population strategies (Johns Hopkins 2002). Far higher levels of public funding must be made available by federal and state governments to tobacco control coalitions to continue advocacy activities in their broadest sense. Training grants to schools of public health should be made available to train graduate students in social and environmental approaches to public health problems. The NCI and CDC should catalog advocacy training materials used in the ASSIST and IMPACT programs and make them widely available to professionals in the public health field so that training of advocates can continue.

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