Selecting strategies to prevent and reduce TOBACCO

slide1. Selecting strategies to prevent and reduce TOBACCO USE in colorado Emma Goforth, M.P.H.
Kieu Vu, M.S.P.H.
Kristin McDermott, M.A.
Zoe Swaine, Ph.D. MOVING THE MARK ON TOBACCO<br>
slide2. Agenda 8:30 – 9:00 Welcome
9:00 – 9:20 Step 1: Community Assessment
9:20 – 10:20 Step 2: Quantify the Issue
10:20 – 10:30 Step 3: Concise Statement
10:30 – 10:45 Break
10:45 – 11:30 Step 4: Preparing for the Search
11:30 – 12:30 Break for Lunch
12:30 – 1:00 Step 4: Conducting the Search
1:00 – 3:00 Identifying the Literature
3:00 – 3:15 Critiquing the Articles
3:00 – 3:30 Wrap Up<br>
slide3. Welcome Welcome
Introductions
Name
Agency<br>
slide4. Acknowledgements Thank You to the following people:

Emma Goforth, M.P.H. (CDPHE)
Kieu Vu, M.S.P.H. (CDPHE)
Kristin McDermott, M.A. (CDPHE)
Zoe Swaine, Ph.D. (CDPHE)
Indira Gujral, M.S., Ph.D. (CDPHE)
Ashley Juhl, M.S.P.H. (CDPHE)

Community Epidemiology & Program Evaluation Group Jill Bednarek, M.S.W. (CDPHE)
Stephanie Walton, (CDPHE)
Jennifer Schwartz, (CDPHE)
Sharon Tracey, (CDPHE)
Terry Rousey, (CDPHE)
Tom Valand, (CDPHE)
Jess Harvat, (CDPHE)
Gabriel Kaplan, M.P.A, Ph.D. (CDPHE)
Dee Thomas, (CDPHE)
Gracie Cash, (CDPHE)<br>
slide5. Vision Why do a literature review boot camp?
Tobacco is the most damaging of health behaviors
Tobacco use, particularly cigarette smoking, responsible for 19% of U.S. deaths annually
Tobacco is a CDPHE Winnable Battle
Shared experience to select evidence-based strategies
Assets-based approach to draw on expertise from different people and programs
What is the final goal of this work?
Alignment of evidence-based strategies for disparately affected populations<br>
slide6. Day #1 Objectives How will this boot camp inform the tobacco control movement?
Select and prioritize evidence-based strategies for specific populations who are disparately affected by tobacco
Produce a preliminary list of rated strategies to help define funding priorities and program direction
What will I learn from this training?
How to rate evidence, conduct a focused search and identify and select articles for review
How to critique and summarize articles
Learn about the first 4 steps of the evidence-based public health framework<br>
slide7. Team Expectations Respect each other
Actively listen to each other
Allow sharing of all points of view
Share the floor
Focus on subject not people
“Ditto”<br>
slide8. Evidence-based Public Health Framework Emma Goforth, M.P.H.<br>
slide9. What is “Evidence-Based Public Health”? Institute of Medicine (1988) – public health is driven by “crises, hot issues, and concerns of organized interest groups”
Barriers: lack of political will, deficits in research, resources, leadership, competencies, and deficits in relevant and timely research
Goal – to improve population health through widespread adoption of evidence-based strategies<br>
slide10. Why use Evidence-Based Strategies? Higher likelihood of a successful program
Reduces costs
Impacts the population
Contribute to the body of knowledge<br>
slide11. Step 1 Step 3 Step 4 Step 5 Step 6 Step 2 Step 7 What is the Evidence-Based Public Health Framework? Slide adopted from presentation by Ross Brownson, PhD (2011)<br>
slide12. Evidence-based Public Health Framework Step 1: Community Assessment Emma Goforth, M.P.H.<br>
slide13. Step 1: Community Assessment Purpose of this step is to identify the health and resource needs, concerns, values, and assets of a community.<br>
slide15. Sources for evidence base in Tobacco Control Best Practices for Comprehensive Tobacco Control Programs (2007, CDC)
Guide to Community Preventive Services (CDC)
US Prevention Services Task Force Recommendations
US Public Health Service – Clinical Practice Guideline (2008)
Institute of Medicine: Ending the Tobacco Problem: A Blueprint for the Nation
National Institutes of Health
World Health Organization – Convention on Tobacco Control<br>
slide16. Strategic Plan, 2012-2020 Tobacco Review Committee adopted a comprehensive statewide Tobacco Prevention and Control Strategic Plan in 2007 and it was updated in 2012

Focuses on
Low-SES population
Young Adults
Youth 16<br>
slide17. Step 1: Community Assessment Given the data, evidence, and operating context, what must we focus on in order to have the greatest impact to eliminate tobacco related disease and death?<br>
slide18. The cessation-success gap affecting low socio-economic status (SES) smokers is decreased by 50%
Tobacco use is treated as a chronic disease in Colorado
There are major constraints to the tobacco industry with regard to time, place and manner as a result of Colorado statute and FDA regulations
Prevalence and initiation among “straight-to-work” young adults is decreased by 50%
Initiation among low SES youth is reduced by 50%
Colorado is in the top 10 among states with the highest price for tobacco products Tobacco Strategic Plan (2020)<br>
slide20. Step 1: Community Assessment Focus of the tobacco program is to target efforts to achieve Health Equity
Health Equity is achieved when every person has the opportunity to “attain his or her full health potential” AND no one is “disadvantaged from achieving this potential because of social position”<br>
slide21. Step 1: Community Assessment Why use a socio-economic status (SES) lens?
The greatest single predictor of tobacco use is low-SES status.
Poverty is directly related to tobacco use.
Low-SES communities are less likely to have members who participate in cessation programs or receive cessation advice.
Tobacco advertising is more prominent in low-SES communities.
Americans below the poverty line are 40 percent more likely to smoke than those at or above the poverty line.

Source: National Network on Tobacco Prevention and Poverty (www.tobaccopreventionnetworks.org)<br>
slide22. Step 1: Community Assessment Children growing up in Poverty:
More likely to live in a household where adults are smokers.

Smoking is modeled as a normal adult behavior and cigarettes are available for experimentation.

Source: Michael Marmot and Richard Wilkinson. Social Determinants of Health (2011).<br>
slide23. Step 1: Community Assessment Colorado examples:
Among Colorado households with an adult smoker and a child(ren) low SES households were almost three times as likely to allow smoking in the home as other smoker-and-child households (26.7% vs. 9.2%). Source: TABS, 2012.

Exposure to secondhand smoke was significantly associated with increased susceptibility to initiating smoking. The strongest predictor if susceptibility was the belief that secondhand smoke was not very harmful.

Source: Correlates and Characteristics of Susceptibility to Initiation of Cigarette Smoking, Colorado Youth, 2001-2008.<br>
slide24. Step 1: Community Assessment Why is it hard for low-SES to quit?
Smoke more cigarettes and smoke more intensively.
This combination creates a high level of nicotine dependence making it very difficult for people to quit.

Source: Michael Marmot and Richard Wilkinson. Social Determinants of Health (2011).<br>
slide25. Step 1: Community Assessment Colorado example:
Coloradans with income less than $15,000 more likely to report smoking occurring in the home than those with income over $50,000 (24.3% vs. 4.4%), and more likely to experience secondhand smoke exposure (45.2% vs. 26.1%).

Source: Colorado Behavioral Risk Factor Surveillance System (2011-2012)<br>
slide26. Step 1: Community Assessment By focusing efforts on target populations, we will:
Target resources to reduce health disparities and achieve health equity
Make a population-based impact on tobacco usage in Colorado, AND
Increase the likelihood of success and maximize the benefit to the state.<br>
slide27. Teams/Populations<br>
slide28. Evidence-based Public Health FrameworkStep 2: Quantifying the issue Kieu Vu, M.S.P.H.<br>
slide29. Step 2: Quantifying the Issue Purpose of this step is to measure and characterize tobacco behaviors in defined populations. Use the tobacco data to further explain behaviors by focusing on prevalence, cessation, and secondhand smoke exposure.<br>
slide30. Step 2: Quantifying the Issue Small Group Activity
Relocate to your group table
Introduce yourself to your team
Select a spokesperson (not a team lead)
Select a scribe to take Notes (not a team lead)
Team Leads: Share Data Sheets<br>
slide31. Adult Current Smoking Prevalence, Colorado vs. US, 1998-2012 (percent)<br>
slide32. Tobacco Disparities: Prevalence of Smoking Data Source: The Tobacco and Behaviors Survey, 2012
*The Healthy Kids Colorado Survey on Tobacco and Health, 2008<br>
slide33. Step 2: Quantifying the Issue Orientation to the Data
All of the data are Population-Level & generalizable to the select population
Data Sources are TABS or HKCS-TH
Data are organized into 3 behavior categories (prevalence, cessation, SHS)
Data gaps are noted at the bottom<br>
slide34. Step 2: Quantifying the Issue Small Group Activity (Write Answers on Large Paper): [~20 minutes]
Looking at the Prevalence Data, what data stand out for your group? Why?
Looking at Cessation Data, is your group successful at quitting? Why or why not?
Did you notice any areas where low SES did not explain data differences?<br>
slide35. Step 2: Quantifying the Issue Large Group Summary
How did this data inform your thinking?
What are some common themes?<br>
slide36. Evidence-based Public Health Framework Step 3: Concise Statement Emma Goforth, M.P.H.<br>
slide37. Step 3: Concise Statement Purpose of this step is to develop a concise public health statement about the issue under consideration in a measurable manner.<br>
slide38. Step 3: Concise Statement Tobacco remains the leading cause of preventable death and disease for Coloradans. Even though Colorado has made significant progress in reducing the burden of tobacco for our citizens, some groups continue to suffer disproportionately from tobacco addiction and related health effects. Our data shows that those most likely to use tobacco have significantly lower incomes and less education, and are more likely to be young, a racial or ethnic minority, or identify as LGBT. In general these groups of people smoke more, suffer more, spend more, and die more from tobacco use.
Through Amendment 35, Colorado has resources to address tobacco use. We also have established and proven evidence-based strategies to reduce tobacco use. However, in order to move the mark among our most disparately-affected residents, tobacco control interventions and strategies must be focused or adapted to better address the social determinants of health contributing to tobacco disparities.<br>
slide39. Break Stretching session<br>
slide40. Evidence-based Public Health Framework Step 4: Lit Review Kristin McDermott, M.A.<br>
slide41. Objectives Understand “Evidence” in the PH context
Learn to use the PICO method to define and organize your search
Brainstorm key words for the literature review (using the PICO methodology)
Learn how to use key words to search databases for each level of evidence
Increase knowledge of sources for grey literature<br>
slide42. What is “Evidence?” Systematic reviews (meta-analysis)
Literature from one or more journal articles
Public health surveillance data
Program evaluations
Qualitative data
Community members
Other stakeholders
Media/marketing data
Word of mouth
Personal experience Objective Subjective Slide modified from presentation by Ross Brownson, PhD (2011)<br>
slide43. Types of Public Health Research Studies Slide modified from presentation by Ross Brownson, PhD (2011)<br>
slide45. Sources for evidence base in Tobacco Control Best Practices for Comprehensive Tobacco Control Programs (2007, CDC)
Guide to Community Preventive Services (CDC)
US Prevention Services Task Force Recommendations
US Public Health Service – Clinical Practice Guideline (2008)
Institute of Medicine: Ending the Tobacco Problem: A Blueprint for the Nation
National Institutes of Health
World Health Organization – Convention on Tobacco Control<br>
slide46. CDC's Best Practices for Comprehensive Tobacco Control Programs—2014 An evidence-based guide to help states plan and establish effective tobacco control programs to prevent and reduce tobacco use.
CDC recommends that states establish and sustain tobacco control programs that contain the following overarching components:
State and Community Interventions
Health Communication Interventions
Cessation Interventions
Surveillance and Evaluation
Administration and Management<br>
slide47. Evidence Base for Interventions<br>
slide49. DEFINING YOur search Kristin McDermott, M.A.<br>
slide50. PICO The acronym PICO can be used to describe a question that you are looking for answers to:

“P”= population
“I” = intervention
“C” = comparison intervention
“O” = outcome<br>
slide51. PICO ExampleYouth: Retail<br>
slide52. PICO ExampleYouth: Schools<br>
slide53. Step 4: Searching The Literature Small Group Activity
Select a scribe to write down PICO’S (someone with good handwriting)
Team Leads: Start conversation to complete the PICO’S for each target population:sector combination
Write at least one PICO per population:sector
Exclude the Comparisons<br>
slide54. Searching the databases Zoe Swaine, Ph.D.<br>
slide55. What is “Evidence?” Systematic reviews (Meta-analysis)
Literature from one or more journal articles
Public health surveillance data
Program evaluations
Qualitative data
Community members
Other stakeholders
Media/marketing data
Word of mouth
Personal experience Objective Subjective Slide modified from presentation by Ross Brownson, PhD (2011)<br>
slide56. Digital Library<br>
slide58. Systematic Reviews PubMed
http://www.ncbi.nlm.nih.gov/pubmed?holding=codphlib
searches for systematic reviews in biomedical literature
free database
Annual Review of Public Health
http://www.annualreviews.org/journal/publhealth
reviews in the field of public health
free full text from CDPHE computer<br>
slide59. Systematic Reviews Continued The Cochrane Library
http://www.thecochranelibrary.com/view/0/index.html
systematic reviews of primary research in human health care and health policy
free full text from CDPHE computer
The Campbell Library
http://www.campbellcollaboration.org/library.php
prepare, maintain and disseminate systematic reviews in education, crime and justice, and social welfare
free full text
The Community Guide
http://www.thecommunityguide.org/index.html
resource for evidence-based task force recommendations and findings about what works to improve public health.
free full text<br>
slide60. What is “Evidence?” Systematic reviews (Meta-analysis)
Literature from one or more journal articles
Public health surveillance data
Program evaluations
Qualitative data
Community members
Other stakeholders
Media/marketing data
Word of mouth
Personal experience Objective Subjective Slide modified from presentation by Ross Brownson, PhD (2011)<br>
slide61. PubMed Search citations for biomedical literature from MEDLINE, life science journals, and online books
Clinical Queries will locate clinical studies, systematic reviews, and medical genetics citations
MeSH Database will help pinpoint concepts

http://www.ncbi.nlm.nih.gov/pubmed?holding=codphlib<br>
slide62. PubMed Feature: My NCBI Save searches and records
Automatic email alerts
Filter search results by subject
Free
http://www.ncbi.nlm.nih.gov/sites/myncbi/<br>
slide63. PubMed Search Demonstrate a search using PubMed<br>
slide64. What is “Evidence?” Systematic reviews (Meta-analysis)
Literature from one or more journal articles
Public health surveillance data
Program evaluations
Qualitative data
Community members
Other stakeholders
Media/marketing data
Word of mouth
Personal experience Objective Subjective Slide modified from presentation by Ross Brownson, PhD (2011)<br>
slide65. Types of Grey Literature Conference papers/posters/abstracts
Official documents and white papers
Reports and proceedings
Theses and dissertations
Official documents
Informal communications
Research in progress reports
Registered clinical trials<br>
slide66. Grey Literature NOT controlled by commercial publishers
Often includes information vital to research – especially public health
NOT indexed in major databases, including PubMed
More current than published material<br>
slide67. Grey Literature Sources Specialized search engines
New York Academy of Medicine Grey Literature Report
Science.gov
Scirus
Google Scholar
Promising Practices
Institutional repositories, scientists websites<br>
slide68. Small Group Exercise Conducting the Search
Each Group Breaks into Pairs on one PICO
Systematic reviews (i.e Cochrane, PubMed, Annual Review of Public Health, etc.)
Peer-review journal articles (PubMed and Annual Review of Public Health)
Grey literature (i.e. Science.gov, Scirus, etc.)
One or more individuals work through each PICO
Copy and paste citations in a word document (printer available)
NOTE: PubMed – Login to My NCBI to save searches and articles; LoansomeDoc log-in to order articles<br>
slide69. How to critique an article Kieu Vu, M.S.P.H.<br>
slide70. Abstracting InformationCritique an Article Critique: “an act of criticizing”
Merriam Webster

Key Elements:
Balanced
Includes strengths and weaknesses
Constructive
Providing suggestions for how the study might be improved<br>
slide71. What Will I Be Critiquing? Systematic reviews (Meta-analysis)
Literature from one or more journal articles
Public health surveillance data
Program evaluations
Qualitative data
Community members
Other stakeholders
Media/marketing data
Word of mouth
Personal experience Objective Subjective Slide modified from presentation by Ross Brownson, PhD (2011)<br>
slide72. How to Critique an Article (Handout) 1. Source
* Is the report from a peer reviewed publication?
* Is the research current?
* More than one author?

2. Research Problem
* Is the problem identified clearly?
* Is it significant--does the researcher provide a good argument for significance?<br>
slide73. 3. Literature Review
* Is it convincing that the author reviewed a sufficient amount of literature? (More than one source?)
* Is it balanced, presenting literature that supports and that differs from the researcher's position?
* Is the review written critically (giving strengths and weaknesses of previous work)?
* Are references current, or a combination of current and classic? How to Critique an Article<br>
slide74. 4. Theoretical Framework
* Is a theoretical framework specified?
* Does the framework "fit" the problem? Include all relevant variables?
* Are results interpreted in reference to the theoretical framework?
--Note: qualitative research, descriptive studies, and physiologic studies typically will not have a theoretical framework. How to Critique an Article<br>
slide75. 5. Variables
* Are the variables in the study appropriate to the problem?
* Are the means to measure the variables appropriate?

6. Hypotheses
* Are hypotheses stated? If not, does the researcher provide sufficient information to determine what the hypotheses were?
* If stated, are the hypotheses clear? Specific? Testable?
--Note: qualitative research and many types of descriptive studies do not involve hypotheses. In a qualitative study the researcher may suggest hypotheses as a result of the research. How to Critique an Article<br>
slide76. 7. Design (overall)
* Is the design specified correctly?
* What design was used?
* Is the design appropriate to answer the research question?
* Did the researcher attempt to control for threats to internal and external validity? How to Critique an Article<br>
slide77. 8. Sample
* Is the sample size adequate?
* Is the sample likely to be similar to members of the appropriate population overall?
* Are the criteria for including and/or excluding people or items from the sample clear and appropriate? How to Critique an Article<br>
slide78. 9. Data Collection
* Are the instruments or other means for data collection described sufficiently?
* Are reliability and validity of instruments addressed? Are these adequate?
* Are data collection methods described clearly?
* Are the data collection methods appropriate?
* Could the researcher have affected the results of the study in some way related to the collection of data? How to Critique an Article<br>
slide79. 10. Data Analysis
* Is the process used to analyze data clear?
* Were the processes for data analysis appropriate to answer the research question?
* Do the results provide an answer to the research question?
* If tables are provided, are these clear and understandable?
For qualitative studies, some additional items for critique include:
* Does the researcher provide sufficient examples of the data (for example, passages or quotations from interviews) to support the identified results?
* Does the researcher describe processes that were used to avoid biasing or influencing the data obtained and the analysis procedures used? (Ex. Peer review, logs, memos, "member check“) How to Critique an Article<br>
slide80. 11. Discussion and Interpretation of Findings
* Does the discussion "fit" with the data? Is it logical based on the data and results presented?
* Does the researcher discuss the findings in regard to previous research?
* Does the researcher discuss the findings in regard to the theoretical framework?
* Does the researcher identify limitations of the study? How do these affect the quality of the study?
* Does the researcher discuss implications for practice? Are these appropriate? How to Critique an Article<br>
slide81. 12. Ethical Considerations
* Does the researcher indicate that approval was obtained from appropriate review boards?
* Were the rights of human subjects protected (confidentiality)? 
13. Application to Public Health
* How similar are the conditions of the study (setting, sample, interventions, etc.) to our setting?
* How feasible would it be to make a change in practice based on this research? How to Critique an Article<br>
slide82. How to organize my articles Emma Goforth, MPH<br>
slide83. Organizing Documents for Review TIPS FOR KEEPING YOURSELF SANE….AND ORGANIZED!
Organize by publication type (review articles, government/agency guidelines, original research)
Enter information into a Literature Library that will be sent to you by your team lead
Bring Articles and your notes to Day 2 Review<br>
slide84. Literature Library Literature Library
Use the Excel Sheet and enter all of the pertinent information
More information than an abstract
Critical for sustaining work over time<br>
slide85. Homework Team Leader: Retrieve all full text materials
Team Leader: Send Articles and Lit Library template to Each Reader
Reader Responsibilities:
Read article, summarize, and enter into Literature Library
Complete Literature Library before Monday April 14, 2014
Bring All Articles with you to the Meeting on the 14th

THANK YOU<br>