Application of a rating system to state clean indoor air laws (USA).

OBJECTIVE: To develop and implement a system for rating state clean indoor air laws. DESIGN: The public health interest of state clean indoor air laws is to limit non-smoker exposure to environmental tobacco smoke (ETS). Current estimates of health risks and methods available for controlling ETS provided a framework for devising a ratings scale. An advisory committee applied this scale to each of seven site specific smoking restrictions and two enforcement related items. For each item, a target score of +4 was identified. The nine items were then combined to produce a summary score for each state. A state that achieved the target across all nine items would receive a summary score of 36 points and be eligible to receive an additional 6 points for exceeding the target on six of the nine items, resulting in a maximum summary score of 42 points. Individual scores were also adjusted to reflect state level preemption measures. Each state's law was evaluated annually from 1993 through 1999. SETTING: USA. MAIN OUTCOME MEASURE: A summary score measuring the extensiveness of the state's clean indoor air law. RESULTS: State laws restricting smoking in the seven individual locations of interest were relatively weak. The overall mean score across the location restrictions ranged from 0.72 in 1993 to 0.98 in 1999. Mean scores were higher for the enforcement items than for the location restrictions. Summary scores ranged from 0 to 20 in 1993 and 0 to 31 in 1994 through 1999. Average summary scores ranged from 8.71 in 1993 to 10.98 in 1999. By the end of 1999, scores increased for 22 states; however, between 1995 and 1997 there were no changes in the summary scores. Three states scored zero points across all years. From 1993 through 1999, there was a 41% increase in the number of states that had in place state level preemption measures. CONCLUSION: The number of newly enacted state clean indoor air laws has remained relatively stagnant since 1995. With a few exceptions, as of the end of 1999, progress in enacting state laws to meet specified public health targets for reducing exposure to ETS was relatively low. Thus, state laws in the USA provide, on average, only minimal protection in specified areas and, given the increase in preemption, are increasingly undermining those passed in localities.

Cancer control research and literacy.

Low literacy may be an important predictor of increased cancer risk and poor participation in cancer control programs. Results of the National Adult Literacy Survey indicate that about 90 million individuals, slightly less than half of the U.S. adult population, demonstrate low or limited literacy skills. In contrast, the average health education brochure, pamphlet, or instruction sheet requires a 10th-grade or higher level of reading ability to be understood. Guidelines exist for the development of more readable printed materials; studies have also found that nonprint approaches such as video education are viable alternatives to printed materials. Research on patient populations indicates that educational approaches targeted to low-literacy groups can be effective in reaching individuals with cancer control information. This review identifies the most important areas of needed research and makes recommendations for the development of a research agenda on cancer control and literacy.

State laws on youth access to tobacco in the United States: measuring their extensiveness with a new rating system.

OBJECTIVE: To develop and implement a rating system evaluating the extensiveness of state laws restricting youth access to tobacco. DESIGN: State laws on youth access to tobacco were analysed and assigned ratings on nine items. Six items addressed specific tobacco-control provisions, and three related to enforcement provisions. For each item, a target was specified reflecting public health objectives. Achieving the target resulted in a rating of +4 points; for three items, a rating of +5 was possible if the target was exceeded. Criteria for lower ratings were established for situations when the target was not met. SETTING: United States. RESULTS: State scores (sum of the ratings across all nine items) ranged from 0-18 in 1993, 2-21 in 1994, and 1-21 in 1995 and 1996, out of a possible total of 39. The average score across states was 7.2 in 1993, 7.9 in 1994, 8.2 in 1995, and 9.0 in 1996. The overall mean rating (per item) was 0.80 in 1993, 0.88 in 1994, 0.91 in 1995, and 1.00 in 1996, on a scale where 4.0 indicates that the target goals (per item) were met. From 1993 to 1996, scores increased for 20 states, decreased for one state, and remained unchanged for the others. The number of states for which state preemption of local tobacco regulation was a factor doubled from 10 states in 1993 to 20 states in 1996. CONCLUSIONS: Although all states have laws addressing youth access to tobacco, this analysis reveals that, as of the end of 1996, the progress towards meeting health policy targets is slow, and state legislation that preempts local tobacco regulation is becoming more common.

Perspective from the Department of Defense Breast Cancer Research Program.

The Department of Defense (DOD), Breast Cancer Research Program (BCRP) was established in 1993. Since its inception, Congress has appropriated more than 878 million dollars for the BCRP, a unique public-private partnership between the DOD, consumer advocacy, and scientific communities which has funded approximately 1,800 breast cancer research grants. Through this partnership, the BCRP designed a model program for consumer involvement in scientific peer review. This paper describes the BCRP's approach to the processes of recruitment, selection, and preparation of consumers for this expanded role. Further, factors critical to program implementation, such as effective program management, ongoing process improvement, strong program leadership, and allocation of resources, that led to the BCRP's success in developing the previously undefined role of breast cancer survivors as members of scientific peer review panels are discussed. The BCRP demonstrates the feasibility and unique contributions of consumers in scientific peer review and provides a critical foundation for future efforts to ensure consumer involvement in scientific research programs.

A process evaluation of the National Cancer Institute's Data-based Intervention Research program: a study of organizational capacity building.

This paper reports on a qualitative process evaluation of the Data-based Intervention Research (DBIR) program, that was funded by the National Cancer Institute (NCI) and operated in 21 states and the District of Columbia. The goal of DBIR was to build a foundation within state health agencies to ensure the translation of cancer control science into practice. NCI's objective reflected the readiness of cancer control research for public health application, the paucity of cancer control activity within public health settings and the recognition that state health agencies could play a critical role in the effective transfer of research results into public health practice. The qualitative process evaluation reported in this paper is based on one case study of four DBIR programs. The present study indicates that the four state health agencies executed the DBIR program with fidelity. Also, the four states offered a balanced assessment of NCI's role in enabling the state agency operation of DBIR, providing numerous citations illustrating how NCI successfully facilitated organizational capacity as compared to fewer mentions of ways NCI was less than successful. Thus, in funding the DBIR model, NCI was successful in raising state health agency capacity to implement cancer prevention and control programming. Implications for capacity building in state health departments are discussed.

The impact of the National Cancer Institute's Data-based Intervention Research program on state health agencies.

To assist state health agencies adopt a new role in cancer prevention and control, the National Cancer Institute (NCI) initiated the Data-based Intervention Research (DBIR) program. The goal of DBIR was to stimulate data-driven activities and to build capacity for ongoing programs within state health agencies to ensure the translation of cancer prevention and control science into practice across the US. Each state funded under the DBIR program was required to conduct four phases of activity: identifying and analyzing relevant data, using these data to develop a state cancer control plan, and implementing and evaluating prevention and control interventions at the local level. This paper presents the results of survey of the 22 states that participated in the DBIR program. The survey is intended as a supplement to the case study also reported in this issue of Health Education Research. Results indicated that states were able to implement the DBIR model and they show the process to be useful to their cancer prevention efforts. DBIR had a major impact on how states will use data in future planning for cancer prevention and control. States had a number of recommendations for how NCI could improve its working relationships with state health agencies.

Intervention research: a model from the National Cancer Institute's Smoking and Tobacco Control Program.

Recognizing that the scientific method is as critical to cancer control as it is to basic laboratory research, the National Cancer Institute (NCI) established a well-defined, systematic strategy for attaining its cancer control goals and objectives. This strategy, operationalized in the early 1980s as a five-phase process, emphasized cancer control as a research science rather than a demonstration science. The five phases of NCI's cancer control research strategy progress from hypothesis development, to methods development, to controlled intervention trials, to defined population studies, and finally to demonstration and implementation programs. This research base provides the foundation for nationwide prevention and health services programs. The application of this five-phase approach to NCI's efforts to reduce morbidity and mortality attributable to tobacco use is described, and some of the challenges that faced the Institute in this process are identified. These experiences provide an important framework for other disciplines faced with the challenge of translating science into practice.

Using data to plan public health programs: experience from state cancer prevention and control programs.

In 1989 the National Cancer Institute funded the second round of Data-Based Intervention Research (DBIR) cooperative agreements with state health agencies to implement a four-phase cancer prevention and control planning model that would establish ongoing cancer prevention and control programs. Activities included identifying and analyzing relevant data to develop a state cancer control plan. The authors reviewed the data analysis and planning activities of five DBIR projects to understand: how states use different types of available data to make public health planning decisions, in what ways available data were sufficient or insufficient for this planning, and perceived costs and benefits of a data-based planning approach. Many of the sources of and ways in which health statistics and behavioral data were used were consistent across states. Sources and use of data on the availability and utilization of health services and on cancer control policies were less consistent. Data were most useful in making decisions to address specific cancers, to target populations or regions, to identify general barriers, and to influence policy makers and the public. Data were less influential in identifying specific barriers within target populations and determining what proven intervention components should be implemented and how. The process of pulling this information together and involving working groups and coalitions was considered very beneficial in establishing the credibility of the state health agency in addressing the state's cancer problem. This process relied on a national infrastructure that provided financial resources, sources of data, and research results.

Building an infrastructure for data-based cancer control planning and intervention implementation.

Health agencies have traditionally played a central role in the characterization of health problems and disease. Data-based planning is considered the cornerstone of effective public health action, enabling state health agencies to use limited resources most effectively to achieve maximum reductions in disease morbidity and mortality. Over the past decade, state health agencies have made important strides in enhancing their capacity for data-based planning for cancer control and in establishing models to facilitate similar planning efforts in other states. Federal programs have served an important catalyst role in establishing states' data-based planning capacity and in facilitating the resulting increase in the application of cancer control science across the United States. This article provides an overview of the infrastructure for data-based cancer control planning and highlights the critical role of federal programs in enhancing the capacity of states to effectively plan and implement cancer control initiatives as well as some of the gaps that remain in states' capacity for data-based planning.

State laws on tobacco control--United States, 1995.

PROBLEM/CONDITION: State laws on smoke-free indoor air, youth access to tobacco products, advertising of tobacco products, and excise taxes on tobacco products are summarized. REPORTING PERIOD COVERED: Legislation effective through June 30, 1995. DESCRIPTION OF SYSTEM: CDC and the National Cancer Institute (NCI) identified state laws addressing tobacco control by using LEXIS, which is an on-line legal research data base, and NCI's State Cancer Legislative Database (SCLD), which is a data base of legislation. CDC and NCI conducted detailed analyses of the content of the laws to identify specific provisions. RESULTS: CDC and NCI identified 1,238 state laws that address tobacco-control-related issues. Most laws either enact restrictions or strengthen current legislation that restricts tobacco use, sales to minors, or advertising; however, some laws preempt stronger measures by local ordinances. At the state level, forty-six states and Washington, DC require smoke-free indoor air to some degree or in some public places. All states prohibit the sale and distribution of tobacco products to minors, but only nine states restrict advertising of tobacco products. All states tax cigarettes (average excise tax is 31.5 cents per pack); 42 states also tax chewing tobacco and snuff. INTERPRETATION: State laws addressing tobacco control vary in relation to restrictiveness, enforcement and penalties, preemptions, and exceptions. ACTIONS TAKEN: The tables summarizing these laws are available through CDC's State Tobacco Activities Tracking and Evaluation (STATE) system and through NCI's SCLD. This information can be used by policy makers at the state and local levels to plan and implement initiatives on youth access to tobacco products and on the use, promotion, advertising, and taxation of tobacco products.

Legislative and regulatory mandates for mammography quality assurance.

The current practice of screening mammography in the United States has been the focus of numerous legislative and regulatory mandates at the state and federal levels, both in terms of increasing access to age-eligible women and elevating the quality of mammographic imaging. Several parameters have emerged as central to a comprehensive mammography quality assurance program: (1) equipment specifications, (2) equipment performance testing including radiation dose limits, (3) facility quality assurance procedures, and (4) personnel qualifications. In 1992, Congress enacted the Mammography Quality Standards Act (MQSA) (P.L. 102-539) to address the problem of differences in mandated standards across states. By October 1994, all facilities will be required to comply with interim MQSA regulations which were released in December 1993. However, depending upon the specific requirements of applicable state standards, the extent and nature of modifications of existing quality assurance procedures will differ for facilities across states as they attempt to come into compliance with uniform Federal standards. In addition, because some provisions within state standards are likely to be more stringent than Federal standards, some level of variation will persist. This paper reviews the components of mandated standards established by states and the standards established by other organizations, including the Federal Government, prior to the MQSA interim regulations. This review will provide an understanding of the highly technical and complicated requirements surrounding mammography quality assurance.

Cancer data profiles for local cancer prevention and control initiatives.

Four state health agency interventions to extend a state data-based planning model to regional areas via development of regional cancer profiles are analyzed. The content of and the process used to develop profiles in each state are characterized in terms of the objectives, target audience, cancer sites addressed, level and type of data presented, plan for profile evaluation as well as factors that influenced these characteristics and common challenges. Consistency is observed across states in profile characteristics, in the factors influencing these characteristics, and in implementation challenges.

Cancer control planning and establishment of priorities for intervention by a state health department.

A number of data sources routinely available to State health departments were analyzed as part of a State health department cancer control planning effort. This planning effort consisted of seven steps; the most challenging one was the establishment of priorities for cancer control interventions. Using data from available sources, however, a framework for prioritizing potential cancer control interventions as well as choosing a geographic area in which to implement selected interventions was developed. Factors considered in this framework for setting intervention priorities included the magnitude of the problem; the existence of scientific consensus regarding the efficacy of intervention techniques; the availability of data needed to plan, implement, and evaluate an intervention; the availability of resources within communities to implement an intervention; and the existence of public demand for the intervention. The development and use of this cancer control planning model and framework for setting cancer control intervention priorities in New York State are described in this paper. In using this planning model and framework for setting priorities, quantitative elements were found to be most necessary to define problems, but qualitative elements were most crucial for decision making.

Statutory requirements for disclosure of breast cancer treatment alternatives.

Therapeutic options for breast cancer, particularly for early-stage disease, and increased patient participation in medical decision-making have oriented state legislatures toward ensuring that women with breast cancer have adequate information about treatment alternatives. Currently, 18 states have enacted statutes regarding physician disclosure of treatment alternatives to breast cancer patients. This paper reviews these statutes in the context of the requirements imposed on the physician as health care provider and the content of medical information presented to the patient as a consequence of the laws. State statutes were identified through the National Cancer Institute's State Cancer Legislative Database, and the statutory requirements were analyzed. For statutes requiring development of a written summary of treatment alternatives, the most recent summary was obtained through the responsible state agency, and informational content was analyzed for relevance to treatment decisions in early-stage disease. As a group, these laws address informed consent for treatment, physician behavior within the patient-physician relationship, and the medical information upon which treatment decisions are based. Individual statutes vary in the scope of the issues addressed, particularly in the responsibility placed on physicians, and treatment option summaries developed in response to this legislation vary widely in content and scope. Despite broad implications of these statutes in oncology practice, little is known about their effects on breast cancer care. Additional research is needed to define the impact of these statutes on breast cancer care, as such legislation is considered by other states for this and other diseases.