David B. Abrams Ph.D. Director Office of Behavioral and Social Sciences Research, OBSSR National Institutes of Health

1. SYSTEMS THINKING TO INCREASE DEMAND & REDUCE PREVALENCE David B. Abrams Ph.D. Director Office of Behavioral and Social Sciences Research, OBSSR National Institutes of Health AbramsD @ od.nih.gov http://obssr.od.nih.gov

2. Population Model of Tobacco Prevalence Relapse Rate Cessation Rate Initiation Rate Never Smoked Current Smoker Ex Smoker DISABILITY AND DISEASE BURDEN Source: Levy, Cummings & Hyland (2000). Am. Jnl. Public Health, 90 (8), 1311-1314

3. Population Model of Tobacco Prevalence Tobacco Industry PUSH Relapse Rate Public Health counter PUSH + -- Initiation Rate Cessation Rate Never Smoked Current Smoker Ex Smoker + -- - + + -- DISEASE BURDEN Source: Levy, D., Cummings & Hyland 2000 AJPH, 90 (8), 1311-1314

4. Population IMPACT of Stepped-Care Model Efficiency High Self-change Educational Pamphlets Plus Tailored Mass Customization PLUS PHARMACOTHERAPY Self-help guides Reach Behavioral Stepped Care Brief Counseling Group Program Individual CounselingCLINIC Effectiveness-Cost Low High

5. Dissemination to Populations IMPACT = REACH (use) x EFFICACYpublic health impact = R X E * Fidelity EFFICIENCY = IMPACT / COST Abrams et al. (1996). A Combined Stepped-Care and Matching Model. Annals of Behavioral Medicine. Glasgow et al (1999) RE AIM model.

6. Cessation to Reduce Death and Disease Source: Figure 7.1, Curbing the Epidemic: Governments and the Economics of Tobacco Control, World Bank, 1999.

7. Probability of Initiation

8. Simulated Effects of Initiation Reductions on Number (#) of Smokers (millions) and Smoking Prevalence Rates (%) 1993 2003 2023 Status quo (# smokers) % of smokers 48.1 19.0% 48.1 19.0% 48.1 19.0% 48.1 19.0% 47.8 17.6% 44.1 16.4% 40.5 15.0% 42.5 15.7% 43.6 15.7% 35.5 12.5% 25.9 9.0% 30.7 10.7% 50% Reduction (# smokers) % of smokers 100% Reduction(# smokers) % of smokers 50% Reduction + 25% delayed initiation % of smokers Source Levy, Cummings & Hyland. 2000 AJPH, 90 (8), 1311-1314

9. % of Daily Smokers Making Quit Attempts Quit attempt every 2 ½ - 3 yrs

10. How Successful are Cessation Efforts? • 47% try to quit • 41% report trying to quit, abstain for 24 h+ • 13% of quit efforts don’t last 24 h (Garvey), so • 2.5% of smokers quit permanently • Quit rate = ~5% • Biochemically verified studies suggest unaided quit rate <3%

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13. Interest in Quitting & Intention to Quit • Quitting “interest” is high (~70%), but abstract • Near-term quitting intentions are much lower • ~ 50% of those planning an attempt actually make one • Interest is often static Lights survey, 1999

14. Utilization of Quit Methods Uses/year: Rough estimates of magnitude

15. Smoking cessation in England, 2003 Smokers 28% Attempt to quit 18% use treatment 10% unaided 9% buy NRT OTC 6% use prescription only 3% use a smokers’ clinic Success rates 10% 10% 20% 5% + 0.6% + 0.6% + 0.5% 0.9% = 2.6% stop smoking Prof Robert West, robert.west@ucl.ac.uk

16. Status of Cessation Treatment and Goals for Change

17. Estimated Efficacy and Utilization of Approaches to Smoking Cessation EFFICACY REACH IMPACT (% quit at (# using method (total # 6 months) annually) quitters) None (unaided) 3 22,800,000 684,000 Internet mass customize 12 7,000,000 840,000 Rx NRT (1995) 14 2,500,000 350 ,000 OTC NRT (1996) 14 6,300,000 882 ,000 Behavioral counseling 24 3 95,000 94,800 Inpatient treatment 32 500 160 Adapted from Shiffman et al. (1998). Annual Review of Public Health.

18. Annual adult per capita cigarette consumption and major smoking and health events - United States, 1900-2000 1st. World Conference on Smoking and Health 1st Surgeon General’s Report Broadcast Ad Ban 1st Great American Smoke-out 5000 End of WW 2 Nicotine Medications Available Over the Counter 4000 Fairness Doctrine Messages on TV and Radio Master Settlement Agreement 3000 Number 1st Smoking Cancer Concern 2000 Surgeon General’s Report on Environmental Tobacco Smoke 1000 Federal Cigarette Tax Doubles Great Depression 0 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 1998 Year Sources: United States Department of Agriculture; Surgeon General’s Reports.

19. Trends in Per Capita Consumption of Various Tobacco Products – United States, 1880-2000 Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. Census Note: Among persons >18 years old. Beginning in 1982, fine-cut chewing tobacco was reclassified as snuff.

20. Greater Than the Sum • The ISIS Project:Strategic Systems Thinking in Tobacco Control

21. Why ISIS? • Build on belief that quantum improvements in tobacco-related health outcomes require a systems approach • Build on systems work in private sector, defense, other areas • Seek new ways to link research and practice • Address fundamental organizational issues in tobacco control and public health

22. Tobacco Control at a Crossroads • A diverse federation of stakeholders: research, practice, advocacy, funding, government, etc. • Fits classic epidemiological model: • Agent: Tobacco products • Host: Smokers and affected parties • Vector: For-profit tobacco industry • Environment: Context in which ahv operates • These factors behave as a system.

23. What If? • We could model which interventions will work, and which will succumb to countervailing forces? • Our research agenda was informed by best practices in the field? • We had global visibility and collaboration among stakeholders? • We could build a consistent, evolving evidence base?

24. Managing Systems: How We Organize • Re-examining the traditional management paradigm • People as process: harnessing the power of a participatory, collaborative, transorganizational environment • From discrete to continuous evaluation • Participatory mixed methods approaches: concept mapping, other methodologies

25. Concept Mapping Example:Local Strength of Tobacco Control “One specific component of a strong tobacco control program is…”

26. Systems Methods: How We Anticipate Change • From simple cause-and-effect models to the complexity of the real world • Simulation of real behavior, including feedback, evolution, and unintended consequences • Broad continuum spanning qualitative and quantitative approaches • Future directions: chaos and complexity theory, simultaneous equations, others

27. Causal Map of Factors in Tobacco Prevalence and Consumption

28. Causal Map of Factors in Tobacco Prevalence and Consumption

29. “Shard” of Causal Map

30. Fraction of pro-tobacco Fraction of undecided becoming becoming undecided per year Pro-control per year Public Supporters of Public Undecided Undecided to Public Supporters Dissenting to Tobacco Control Supporting of Tobacco Undecided Public support to Undecided to Undecided Dissenting Fraction of undecided Fraction of anti-tobacco becoming pro-tobacco per becoming undecided per year year Formal Systems Model: Public Opinion

31. Aging Chain Simulation: Effect of Public Opinion on Quit Rate Base ReferenceMode Adj quit effect 10 7.5 5 Adult Quit Rates 2.5 0 0 5 10 Public Opinion

32. Synthesis: Pulling It All Together • Trends in both tobacco control strategy and methodology have evolved in a systems direction. • Systems thinking has evidenced itself in recent and current tobacco control efforts. • Considerable methodological synergies exist between the four ISIS approaches. • Trends point toward an integrated systems thinking environment.

33. The Goal: An Integrated Systems Thinking Environment

34. Develop and Apply Systems Methods and Processes • Encourage systems thinking theory and research development • Foster mixed-methods systems thinking • Conduct participatory systems needs assessments • Encourage an ecological perspective on implementation • Foster systems evaluation

35. Build and Maintain Network Relationships • Create multijurisdictional/multilevel networks of networks for systems thinking and action • Study the networks of networks to determine their effects • Encourage transdisciplinarity

36. Summary • Tobacco control has become a complex, adaptive environment. • Systems approaches represent a major hope for substantial future change in health outcomes. • This trend mirrors fundamental changes in how we solve problems within a society as a whole. • We seek integrated systems thinking within tobacco control, not just an implementation of system techniques.

37. Population model of tobacco interventions over time • Interventions must be comprehensive - at individual and group or “systems” levels to make an impact on disease • Population Impact requires broad reach x effective intervention / per unit cost = efficiency • A Stepped-care model distributes a range of evidence-based interventions efficiently from least to most intensive • A substantial, sustained commitment of resources is needed to make an impact on reducing population prevalence, associated disease burden and costs. • To benefit society as a whole will take time (decades) but will be the best long term investment