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Public Health Rep. 2006 Sep-Oct; 121(5): 149–153.
PMCID: PMC1564443

Recommendations From the ASPH/legacy Scholarship, Training, And Education Program for Tobacco Use Prevention (Step Up) Strategy Planning Meeting Chicago, May 3, 2005

Christine Sheffer, PhD, Lawrence Green, DrPH, Kalpana Ramiah, MSc, MPH, CHES, and James Raczynski, PhD

In May 2005, the Association of Schools of Public Health (ASPH) invited representatives from accredited schools of public health (SPH) to attend a planning meeting to develop recommendations to inform ASPH and other partners of strategic priorities for public health research and graduate education/training programs for tobacco control. Funding was provided by the American Legacy Foundation (Legacy) through the ASPH/Legacy Scholarship, Training, and Education Program for Tobacco Use Prevention (STEP UP) project. While reduced funding to Legacy will not allow for continued funding beyond June 2006, this meeting was envisioned to reach beyond the funding period.

Thirty members representing 29 accredited schools of public health participated. Participants had an opportunity to network with other faculty focused on tobacco control, discuss issues regarding tobacco research and education/training in SPH, and develop consensus recommendations.

The meeting focused on sustaining and further developing tobacco-related research and education/training programs. Breakout groups considered either research or education/training in tobacco control as it applied to the following issues in SPH:

  • Focus areas for future funding;
  • Priorities for sustaining and further developing research or education/training programs;
  • Methods to maintain vigilance on tobacco control issues with increasing concerns about other topics (e.g., obesity); and
  • Program planning for the second National STEP-UP Academic Tobacco Workshop in January 2006.

Each breakout group generated a set of concerns and recommendations that were then presented to the larger group. The meeting culminated with the larger group collectively synthesizing the information into a unified set of recommendations to be presented to ASPH.

OVERVIEW OF RECOMMENDATIONS

The recommendations focused on nine primary areas: (1) issues carried over from the first National STEP UP Academic Tobacco Workshop in April 2004 in St. Louis; (2) research and education/training needs in regard to special populations; (3) economic issues; (4) sustaining and expanding tobacco research and education/training initiatives; (5) disseminating and translating research as a priority; (6) funding priorities; (7) continuing education priorities; (8) maintaining vigilance and focus on tobacco control research and education/training; and (9) general recommendations.

Issues from first National Academic Tobacco Workshop

Several participants reiterated concerns expressed during the first National Academic Tobacco Workshop. These concerns focused on long-term policy and funding prospects for tobacco research and education/training in a milieu of increased competition for limited health research and education/training resources. The concern that tobacco control research and teaching initiatives are competing with the new emphasis on obesity control was primary. Participants made two specific recommendations:

  • Explore strategies for integrating tobacco control research and teaching with obesity and other topics; and
  • Develop and implement strategies for influencing policy in support of tobacco research and education.

Participants indicated that implementing these strategies will help to ensure that tobacco research and teaching programs are sustained, and their priorities become integrated into the long-term policy and funding of SPH.

Research and education/training needs for special populations

Participants identified numerous research and education/training needs for special populations. In general, concerns were raised about the plight of several special populations that represent some of the most vulnerable to tobacco use and related disease as well as some of the least served through prevention and cessation programs. These populations, as a whole, consume a significant proportion of the tobacco in the U.S. and incur significant tobacco-related medical expenses. Current approaches have rarely incorporated factors necessary to address the needs of these groups. Recommendations included the need to:

  • Address high-risk population disparities. Some high-risk populations exist in relatively small numbers and/or are difficult to access (e.g., acculturating male Asian groups, rural populations, certain lower socioeconomic status groups, etc.); however, the impact of tobacco use on these populations is disproportionately large. Other high-risk populations exist in relatively large numbers and consume a significant proportion of tobacco in the U.S. (e.g., the poor, the stigmatized, the mentally ill, etc.), but do not possess sufficient political power to attract the attention and resources needed to address their prevention and cessation needs.
  • Develop new approaches to address the needs of pregnant women. Although many pregnant women quit smoking during pregnancy, a significant number of women still smoke and many more are routinely exposed to environmental tobacco smoke (ETS). Smoking is the single most preventable cause of illness and death among mothers and infants. Eliminating tobacco use and ETS exposure for pregnant women is well documented as an extraordinary opportunity to improve the health of women and children. Eliminating or reducing ETS exposure and tobacco use during pregnancy is likely to produce a large public health benefit. ETS has since been declared a significant risk factor for breast cancer by the California Environmental Protection Agency.
  • Determine the specific social/environmental factors that affect tobacco use and cessation for various groups. Social/environmental factors play a large role in tobacco use from initiation to relapse. Because many special populations (i.e., working poor, adolescents, various cultural groups, etc.) are often found in specific settings, greater emphasis is needed on setting-specific studies (e.g., school-based or workplace-based research) to develop new strategies for addressing tobacco use at all stages as well as ETS exposure. New strategies for conceptualizing and implementing tobacco-related research and education/training programs will be required to address the needs of these special populations.

Economic issues

Several economic issues related to tobacco control and the participants' roles as researchers and educators were recognized. Numerous difficulties associated with current methods used to measure, evaluate, and interpret tobacco-attributable costs were identified. Three primary recommendations emerged:

  • Develop a standardized method for evaluating tobacco-attributable factors and effects. Different methodologies include and exclude various factors (e.g., lives lost, medical costs, lost productivity, etc.) and use different strategies for calculating these costs.
  • Resolve the potential economic dilemma resulting from successful cessation and prevention efforts and the subsequent increase in life-time medical costs per person-year saved. Because the medical costs of tobacco use are well documented and medical costs in general are growing at inflationary levels, the economic argument for tobacco control is compelling. However, fewer tobacco-related deaths will result in more people living longer lives and eventually incurring more medical costs. Negative interpretations of this cumulative effect on medical costs alone, without considering the productivity of the persons who might have died earlier, could make the economic case for tobacco control less compelling.

Many funding sources are limited to domestic or international funding issues. This limitation imposes restrictions on studying the global issues related to tobacco.

Sustaining and expanding tobacco research and education/training initiatives

Several recommendations were made for sustaining and expanding tobacco-related research and education/training programs. Participants recognized the importance of integrating tobacco programs with partners that have complementary objectives and needs as well as building on existing efforts to avoid duplication of effort and “silo” effects. Participants also recognized the variability in tobacco-related research and educational opportunities across SPH as well as the importance of providing students with a foundational understanding of tobacco use and its impact on public health. Recommendations included the need to:

  • Link tobacco research more effectively with Medicaid, Medicare, and other third-party payer issues;
  • Build on ETS data to address childhood asthma and other tobacco-related conditions;
  • Build on genetic issues related to smoking behavior;
  • Build on the mental health/substance abuse and tobacco link;
  • Develop campus/community partnerships;
  • Require tobacco-related standard and core competencies for public health training;
  • Develop a central resource for tobacco research and education, including on-line availability of syllabi and course descriptions;
  • Open appropriate SPH courses on tobacco control to undergraduates and other pre-professional training programs (e.g., nursing, law, medicine, etc.); and
  • Document job market and job opportunities for tobacco control skills.

The sustenance and expansion of tobacco research and education/training programs may depend on the extent to which these programs serve the community through sponsored research and programs and by producing professionals well trained in tobacco control. Programs may ensure sustenance as well as serve the community by integrating with programs and services that have relatively secure mandates and complementary objectives, such as Medicaid. Contributing to the community may also involve the resolution of widespread, costly, and preventable problems such as childhood asthma due to ETS exposure, and the 80% to 90% tobacco use rate among the mentally ill. A study of the genetic determinants of tobacco dependence is promising and may contribute to program expansion.1 Research and education/training programs that address and/or instruct students on these issues may be more likely to be sustained in a competitive milieu. The development of a reservoir of resources for instructors, including syllabi and core competencies, will contribute greatly to this effort. Finally, the great public health success story inherent in the struggle with the tobacco industry and reduction of tobacco consumption by some 50% per capita in the last third of the 20th century warrants development as a model for conceptualizing the obesity epidemic and other emerging public health challenges.

Disseminating and translating research priorities

Participants recognized the need for findings to be integrated into practice. While efficacy trials have produced efficacious treatments, many of these treatments, such as brief interventions in primary care, have not been disseminated quickly or well into actual practice. Some efficacious treatments, such as intensive therapy-based interventions, have yet to be translated to widespread practice. The same is true for many other evidence-based strategies. Two recommendations were made with regard to research priorities in dissemination and translational research:

  • Encourage more intensive retrospective study of those cases in controlled trials or in actual practice that have achieved the most success; and
  • Encourage rapid response to opportunities to put prospective studies into place where great innovation is occurring or where more representative experiences are occurring and describe the barriers and challenges.

Tobacco research and education/training programs will benefit from bridging the chasm between tobacco research and practice by delineating the challenges and describing the modifications necessary for practitioners to utilize research effectively.

Funding priorities

Several recommendations were made for funding priorities, many of which involve actively supporting and collaborating with institutions with complementary objectives. Such collaboration has proven successful according to several participants. Recommendations included:

  • Collaborate with state health departments in use of Master Settlement Agreement funds;
  • Support the Centers for Disease Control and Prevention in encouraging collaboration between state tobacco control programs and SPH for the training of public health professionals;
  • Support broad networking among institutions and organizations to increase funding for tobacco research;
  • Encourage National Institutes of Health (NIH) training and research grants to support graduate research assistants' work in tobacco control; and
  • Urge greater continuity of funding for chronic disease and addiction.

Continuing education priorities

Participants recognized the need for a vehicle for continued dissemination of tobacco-related education/training to public health professionals and students. Two recommendations were made in this area:

  • Promote continuing education opportunities for the public health workforce; and
  • Develop continuing and distance education through on-line and web-based courses and other mechanisms.

Establishing continuing and distance education opportunities will further advance the commitment to tobacco education; enrich the public health resources in communities; foster partnerships among public health practitioners, their organizations, and SPH; and reinforce tobacco education and research as a priority in public health.

Maintaining vigilance and focus on tobacco control research and education/training

Participants recognized the need for SPH to maintain a focus on tobacco control by increasing the awareness of issues and programs among the public and key groups. Recommendations included the need to:

  • Showcase model projects;
  • Increase awareness of tobacco control issues and the importance of tobacco research in SPH in the state and federal legislatures;
  • Increase visibility of tobacco issues, policies, and programs; and
  • Keep a watchful and studious eye on the tobacco industry's advertising and other promotional and public relation strategies.

Raising the salience of tobacco research and education/training programs reinforces the message that tobacco is a research and education priority, helps the greater and immediate communities to become aware of existing programs, and may help to foster partnerships among institutions with complementary objectives. Importantly, increased awareness of successful tobacco programs is likely to increase the likelihood that these programs are maintained.

General recommendations

Participants made general recommendations, many of which aim to develop depth and breadth in the ASPH tobacco-related agenda. Special emphasis was placed on developing collaborative partnerships as well as cultural awareness and proficiencies through research and education/training efforts. However, recommendations also addressed the need to reduce complacency and raise awareness of the relative impact of tobacco use on all populations. Recommendations included:

  • Develop networks to promote a global approach to tobacco control while at the same time acknowledging culture-specific and acculturation issues. The traditional focus on the U.S. population is no longer realistic or ethical.
  • Implement strategies to increase U.S. awareness of global tobacco issues (i.e., increased tobacco industry marketing outside the U.S.; tobacco control attitudes, strategies, and progress in other countries; ETS exposure for U.S. travelers; and immigration to the U.S. by people who use tobacco.)
  • Build on the ethical concerns of the U.S. companies marketing tobacco abroad.
  • Support diversification of the public health workforce and participatory research to represent knowledge of diverse communities.
  • Establish diverse field opportunities in tobacco control.
  • Support the development of innovative curricular approaches to reach global and diverse audiences.
  • Support education of the public and policy-makers as to the relative importance of various health problems and the leading role that tobacco continues to play in death and disease.
  • Give salience to the debates over university investments in tobacco. SPH are ethically invested in the debates over their universities' relationship with tobacco and the tobacco industry. SPH should actively denounce university acceptance of tobacco industry resources and actively support campus tobacco control policies.
  • Urge proportionate teaching time to problems according to their societal burden. Tobacco use is the single largest cause of preventable death and disease in the world and should be given appropriate attention in public health education.
  • Encourage greater attention to the issues of co-morbidities associated with tobacco and their implications for policy, education, and research.
  • Encourage follow-up to the federal Interagency Committee's deliberations on the global tobacco control problem.

Implementing these recommendations will require a shift in the relative focus of SPH research and education/training programs and the adoption of new strategies for engaging students, professionals, instructors, partners, and researchers. A global focus not only provides a more realistic and ecologic view of the role of tobacco, but also provides the opportunity for understanding this issue and all its complexities in depth. With this understanding, however, is the responsibility to participate fully in the ethical challenges posed by tobacco industry marketing and funding in our university communities and elsewhere.

SUMMARY

During this meeting, the participants developed a strategic set of recommendations for ASPH to continue to advance the study of tobacco control in public health through research and education/training programs. The meeting focused on sustaining and further developing tobacco-related research and education/training programs. All four issues were addressed in depth through valuable discussion and exchange and reflected in the nine areas of focus.

Recommendations for advocacy for future funding for SPH in tobacco control included developing collaborative relationships with ASPH partners, organizations, and institutions with complementary objectives (state departments of health, third party payors, etc). Priorities for sustaining and further developing research and education/training programs within SPH included developing a focus on particular research areas (e.g., special populations, economic issues, dissemination and translational issues), building on existing knowledge, and attempting to avoid the effects of “siloing” with collaborative relationships and methods for addressing the sustenance of programs beyond initial funding periods. Methods to maintain vigilance on tobacco control with increasing concerns about other risk factors included fostering an increasing awareness of tobacco-related issues, projects, and programs as well as developing collaborative relationships with organizations and institutions with complementary health-risk related objectives.

Other recommendations focused on enhancing SPH leadership in the tobacco control field by developing standards and methodologies and translating research to practice. They included (1) developing standards for consistent tobacco control-related education to public health students, public health professionals, and other students and professionals; (2) developing a standardized method for evaluating tobacco-attributable factors and effects; and (3) conducting effectiveness trials of treatments known to be efficacious. Effectively addressing these perennial issues will enable SPH to enhance its leadership position and contribute greatly to research and education/training in tobacco control.

All of these issues were factors in program planning for the second National STEP UP Academic Tobacco Workshop. For instance, reviews of particular research areas might be offered or facilitated as well as methods for developing collaborative partnerships and subsequent efforts. Steps toward the development of tobacco control education core competencies might be developed as well. The second National STEP UP Academic Tobacco Workshop—STEP UP to Sustain Tobacco Control and Prevention through Education and Research—was held on January 30–31, 2006. The topics of discussion ranged from use of secondary data to behavioral economics. More information about the workshop can be found at http://www.asph.org/document.cfm?page=882.

Attention to the recommendations that resulted from the planning meeting will provide a strategic platform from which ASPH and the public health community can continue to address the single greatest cause of preventable disease and death in the world.

Acknowledgments

The authors would like to thank the participants at the Strategy Planning meeting for their valuable suggestions and recommendations. The recommendations listed in this article were generated from discussions during the meeting. The information contained in this publication does not necessarily reflect the views of ASPH, the American Legacy Foundation, Legacy staff, or the Legacy board of directors.

REFERENCES

1. Batra V, Patkar AA, Berrettini WH, Weinstein SP, Leone FT. The genetic determinants of smoking. Chest. 2003;123:1730–9. [PubMed]

Articles from Public Health Reports are provided here courtesy of Association of Schools of Public Health