Effectiveness Evaluation And Methods Research On Comprehensive Intervention Program Of Environmental Tobacco Smoke Prevention

BackgroundSince the health hazard of Environmental Tobacco Smoke (ETS) has been firstly reported in 1971, the large number of epidemiological studies showed that ETS would cause adult cancers, cardiovascular diseases, respiratory diseases and respiratory symptoms et al. ETS would also stunt fetal growth and development, cause neonatal sudden death syndrome and respiratory diseases of children, as well as harm to women's reproductive health, and increase the incidence of cervical cancer and breast cancer. The disease burdens attributable to ETS are serious in China with more than 100,000 deaths per year. Unfortunately the ETS exposure is still severe and maintains at high level in China, especially among women and children. Approximately 540 million pepole are exposed to ETS in China.There is ample evidence that unhealthy lifestyles such as smoking could be changed through effective intervention, and it is the most cost-effective. Tobacco control programs are continually increased all around the world, which target subjects selected from individual to population, and the intervention measures taken from simple to complex. The development of comprehensive programs of ETS prevention undoubtedly posts a great challenge on the effectiveness evaluation. To date, few literatures have been reported in China on the comprehensive programs of ETS prevention and the effectiveness evaluation has several shortcomings as follows: (1) Evaluation methodology was not scientific. There has not a practical process evaluation index, which could rationally quantify the intervention activities, and evaluated the effectiveness of the health promotion programs according to the rules and principles to judge the causal association between intervention measures and effectiveness; (2) The evaluation indexes were selected arbitrarily and simply, which was difficult to adapt the evaluation requirement of comprehensive intervention programs; (3) There were not objective indicators, such as the reduced morbidity and mortality caused by the program intervention, to predict the long-term effect, which would bring a big difficulty on the effectiveness comparison and cost-effectiveness analysis between different programs.China tobacco control epidemiology, surveillance and intervention capacity building supported by NIH's Fogarty International Center (Fogarty program), and Towards a smoke-free China supported by Bloomberg global tobacco control fund (Bloomberg program) have been finished by the end of 2008. Fogarty program, as the first stage of comprehensive program of ETS prevention in China, was conducted at six counties of three provinces, which complied with the health promotion theory and aimed to reduce no-smokers' exposure to ETS. Bloomberg program, as the second stage of comprehensive program of ETS prevention, was expanded to 40 intervention sites of 14 provinces, 2 autonomous regions and 3 Municipalities, which based on the intervention model developed by Fogarty program. Is the comprehensive program of ETS prevention implemented in China effective? Does the effectiveness be actually caused by the intervention measures? It is necessary to synthetically evaluate their effectiveness, and conduct in depth research on effectiveness evaluation methods.Objectives1 To demonstrate whether the comprehensive program of ETS prevention is effective through effectiveness evaluation on Fogarty program. Take effectiveness evaluation on Bloomberg program to further validate the effectiveness of comprehensive program of ETS prevention in China through the association analysis on effectiveness and intervention intensity.2 To determine whether the intervention model of comprehensive program of ETS prevention in China is practical and effective combining the rules and principles to judge the causal association between intervention measures and effectiveness, and identify whether the effectiveness is really caused by the program intervention.3 To quantitatively predict the long-term effect using some comparable indicators such as Attributable Deaths and Disability Adjusted Life Years (DALY), which could be applied to the effectiveness comparison among similar programs, and provide reference for policy priority.4 To conduct in-depth research on effectiveness evaluation methods of comprehensive program of ETS prevention, and provide references for other similar intervention programs.Methods1 Evaluating the intervention effectiveness of Fogarty program using pre- and post-comparison method with parallel control design, to demonstrate whether the comprehensive intervention measures of ETS prevention program is effective.2 Developing a process evaluation index, based on five intervention strategies of comprehensive program of ETS prevention, literature review, expert consultation, and panel discussion, to evaluate the intervention activities of each Bloomberg program site.3 Weighting the process evaluation index with experts grading method, and quantifying the intervention measures after the quantification of the process evaluation results of Bloomberg program. Evaluating the intervention effectiveness of Bloomberg program, Pearson correlation analysis and mixed-effect linear model were conducted to explore the association of effectiveness and intervention intensity, and further validate the effectiveness of comprehensive intervention measures of ETS prevention program in China.4 Determining whether the intervention model of comprehensive program of ETS prevention in China is practical and effective, and identifying whether the effectiveness is really caused by the program interventions, based on the effectiveness evaluation of Fogarty program and Bloomberg program, combining the rules and principles to judge the causal association between intervention measures and effectiveness.5 Predicting the possible reduction of attributed deaths in the future caused by program interventions with Attributable Fraction method of summary measures of population. Further predicting the possible DALY saves with disease burden method developed by WHO based on the estimation of attributed deaths, uncertainty and sensitivity analysis were considered.Results1 The results of effectiveness evaluation on Fogarty program showed:1.1 As a result of Fogarty program interventions, the prevalence of secondhand smoke decreased by 4.90%, and the prevalence of current smoking among male decreased by 12.25% in intervention county of Jiangxi province. While the prevalence of secondhand smoke decreased by 1.43% in intervention county of Henan province.1.2 Because of the program interventions, the prevalence of knowing the health hazards of ETS has been much improved which include: knowing ETS is more likely to have heart disease, knowing wife of a smoker is more likely to have lung cancer, knowing child having smoking parents is more likely to have asthma or respiratory disease, and knowing ETS has serious health hazards. The prevalence of awareness of avoiding the exposure of ETS has also been obviously improved, which include: recognizing no smoking in public places, recognizing no smoking in front of other people, and recognizing do not offer cigarettes during social interactions.1.3 The prevalence of approving to completely ban smoking at each public/work place has been increased in intervention county of Jiangxi province, and decreased in intervention county of Henan province, though it is also effective comparing with non intervention county. The prevalence of approving to completely ban smoking at restaurants and karaoke ok offices were lower than that at other places. The prevalence of approving to protect the health of no-smokers by prohibiting smoking at public places, and ban all cigarette advertising have been increased in intervention county of Jiangxi province, and no changes in intervention county of Henan province, but maintained at high level. The proportion of doctor and teacher should not smoke at any time have no changes, but maintained at high level in all intervention counties. The proportion of approving to tobacco control policies has been improved in the intervention communities, and it was higher in intervention hospitals than that in no-intervention hospitals.1.4 The behaviors related to smoking and avoiding ETS have been improved, the proportion of persuading to smoke outdoor increased, and the proportion of offering cigarette among no-smokers decreased in intervention counties. The proportion of smoking at public places has been decreased significantly, but it was also very serious to smoke at home, and the proportion of exposure to ETS at home was still very high. The proportion of smoking at home when guest visited was very high, which was close to 100%. The proportion of smoking at home without any restrictions has been declined in intervention county of Jiangxi province, but increased in Henan province.2 The results of effectiveness evaluation on Bloomberg program showed:2.1 The positive association between total intervention intensity of county/city level and initial, intermediate, final outcome all showed statistical significance (P = 0.0327, 0.0245 and 0.0431) under adjusting the effect of the lower level outcome index, baseline value of outcome index, the gender, age, education level, marriage status of survey population, and the impact of province cluster. The greater the total intensity, the better the initial, intermediate, and final outcome would be.2.2 The results of association analysis showed that the effect was not obvious after divided the total intervention intensity into several intervention intensity according to the five strategies. The effectiveness was reflected in the results of comprehensive intervention.2.3 Whether it was the final, intermediate, or the initial outcome, the worse the baseline value of effectiveness index, the better the intervention effectiveness.2.4 The intervention effectiveness in intervention community and hospital as demonstration were not as good as that of intervention county/city, but the trend was consistent. The total intervention intensity in intervention community as demonstration showed statistically significant association with initial outcome (P =0.0132). The total intervention intensity in intervention hospital as demonstration showed statistically significant association with initial and intermediate outcome (P =0.0327 and 0.0104).3 It was estimated that 1,656 (1,332-1,920) premature deaths, and 25,438 (20,386-29,545) DALYs with 3% discount rate would be saved in intervention county of Jiangxi Province. The number was 184 (108-242) and 2923 (1,663-3,859) respectively in Henan.Conclusions1 The intervention model developed by comprehensive program of ETS prevention in China is practical and effective. The intervention effectiveness should be further epidemiologically surveilled.2 The situation of exposure to ETS is still serious in China, especially at home. The proportion of offering cigarette to guest remains very high, and it is still very difficult to change the customs and traditions related to smoking. Both the government and non-governmental organizations should take immediate actions to strengthen their efforts to curb the tobacco epidemic in China.3 The effectiveness evaluation methods of comprehensive program of ETS prevention developed in this study can be used in other similar programs for reference. The indexes of process evaluation and effectiveness evaluation need to be further improved.