Healthy People 2000 Consortium Meeting
November 7, 1997


Summary of Breakout Group Discussion Concerning
Priority Area 3: Tobacco


Special Populations

 The group discussed different options regarding the elimination of health disparities. The group expressed the importance of maintaining data on subpopulations. There was some difference in opinion about the best approach to take to set targets if the goal is to eliminate health disparities. In particular, questions were raised about what to do when there are large disparities. Should targets be based on the "best" group or the "worst" group? If they are set based on the "worst" group, does that mean that the "best" group has nothing to strive for? If targets are set based on the "best" group or we setting the "worst" group up for failure?

One suggestion was to set the same goal for each group but different years by which they could meet the goal. Another suggestion was to seek the same percentage drop across all groups rather than set the same absolute target for each group. Another was to set a larger percentage drop for populations with a greater burden of the problem, even if the absolute target was not the same across all groups.

The participants emphasized the importance of strategies that are targeted to special populations regardless of how the objectives are set. Participants also raised concerns about how to address individuals who are biracial or multiracial, and discussed the importance of culture in approaches to eliminating disparities.

Healthy People 2010 Framework

The group felt that the overarching goals for Healthy People 2010 were good. Participants felt that the goals were broad enough and set an appropriate standard. In the area of enabling goals, the group questioned the difference between the goal of "assuring access to quality health care" and "strengthening community prevention." Additional discussion revealed that there was the sense that there was overlap across several of the enabling goals, particularly when they were viewed in relation to the focus areas.

In general, the participants indicated that the linking of focus areas into specific enabling goals was too rigid, and also was somewhat arbitrary. They felt that a more holistic approach needed to be taken, and felt that the "fan" incorrectly conveyed that only certain focus areas were linked to certain enabling goals. The group mentioned that a topic like tobacco actually could fit into all four of the enabling goals.

Participants reported that having the special populations over on the right side of the "fan" seemed to relegate these groups to a lesser importance. The group suggested another arc on the top of the "fan" to address special populations in a more inclusive way.

Participants also had questions regarding how focus area 1 differed from focus area #2. Additional concerns were raised regarding focus area 2; specifically, there was concern that only five chronic diseases were singled out in the framework. Participants were also concerned that the issue of obesity was not explicitly addressed and felt that it could get lost within the areas on physical activity and nutrition.

In response to the question of whether anything was missing from the framework, the following issues were raised: Duplicate Objectives

 In general the group had few concerns about the proposal to limit duplicate objectives. The group did indicate that there might be disagreements about where the "home" of a particular objective should be. The group also discussed the possibility of there being a limit on the number of objectives. The general consensus was that the number of objectives should not be limited. The group felt that communities generally have chosen a subset of objective son which to focus and that people only use the objectives they need anyway. Thus, setting a limit on the number of objectives was not seen as being necessary.

Measurable and Developmental Objectives

 There was limited discussion on measurable and developmental objectives. The group appeared to feel comfortable with the existence of developmental objectives and saw them as a way to develop data sets. The question was raised as to whether development objectives should have a target given that they generally won't have a baseline. The group also discussed the need to look at qualitative data in addition to quantitative data.

Discussion of Healthy People 2010 Objectives

 To organize this discussion, the group reviewed the existing Healthy People 2000 objectives for tobacco. Limited time was spent on health status objectives (3.1-3.3, 3.17, 3.18) because the concern was that these would probably have a primary "home" in another focus area. However, the group felt that objective 3.4, which currently is in the health status section, should be moved to the risk reduction section. The group also suggested adding a subobjective within 3.4 to cover young adults (perhaps 18-24 year olds).

The group suggested that objective 3.5 be dropped because the issue of youth smoking could be handled more directly (e.g., in objective 3.20). The group indicated that measures of youth smoking need to differentiate between initiation and more regular use of tobacco. One way to do so would be to measure both daily use and past-month use. Another suggested approach was to set the target for youth smoking at half that for adult smoking. Participants also suggested subobjectives on youth smoking for both racial and gender groups.

The group felt that objective 3.6 was too weak in that it only measured quit attempts for a day. The group felt it was more important to measure sustained quitting behavior, perhaps through a developmental objective on this topic. The group also suggested that a higher target be set for objective 3.7 to raise quitting among pregnant women to higher than 60%.

The group reported that a lower target should be set for objective 3.8 regarding children's exposure to environmental tobacco smoke in the home. The group stressed the importance of clinician interventions to educate patients about environmental tobacco smoke exposure. In addition, the group suggested subobjectives for racial and SES groups. There was also discussion about the possibility of raising the age of youth covered by this objective.

The group suggested potential subobjectives for objective 3.9 to include rural use of smokeless tobacco and use by athletes. There was also discussion of a potential need to change the data sources for this objective and of the possibility of measuring smokeless tobacco use in adults over the age of 24 as well. The group also suggested including objectives on cigar use in Healthy People 2010.

Discussion regarding objective 3.10 focused on whether it was appropriate to indicate that provision of any tobacco-related education in the schools is sufficient to meet the objective. Instead, the group suggested that some standards for curriculum might be considered. However, it was acknowledged that implementation of standardized curriculum could be difficult. The group also discussed the possibility of objectives on college policies related to smoking.

Objectives 3.11 and 3.12 were discussed together. There was discussion of making the language in the two objectives on clean indoor air more similar, but others felt that the language in 3.11 needed to be different because it addressed voluntary policies in the private sector. It was suggested that 3.11 should strive for the promotion of smoke-free environments, rather than focusing on requiring smoke-free restrictions by private work sites. The importance of local clean indoor air ordinances was also discussed, including policies promulgated by local boards of health. A developmental objective on local policies is one possibility.

Participants felt that the current target for 3.13 is too high. The group also acknowledged data concerns in assessing enforcement of minors' access laws, particularly concerns regarding the validity and comparability of data on State enforcement.

The group felt that objective 3.14 was vague and should be deleted. The group discussed the possibility of developing an objective on State tobacco control programs in its place. The group also suggested eliminating objective 3.15 and considering alternate, more measurable means of assessing exposure to tobacco advertising. Suggestions included policies restricting advertising on transportation and billboards, and kids' possession of promotional items. Participants reported that the target for objective 3.16 should be raised and that efforts should be made to address tobacco control issues for students in medical and dental schools.

Participants indicated that objective 3.19 was not particularly important and could be dropped. As youth tobacco use was addressed extensively during the discussion of objective 3.5, it was not addressed when the group reached objective 3.20. The participants had no comments on objectives 3.21 and 3.22. For objective 3.23, the participants felt that the target should be higher. For objective 3.24, the participants suggested also measuring public coverage of nicotine addiction treatment including coverage by Medicaid, Medicare, CHAMPUS, IHS, and other Government-sponsored programs.

The group suggested that objective 3.25 be expanded to address preemption in all areas, not just clean indoor air. For objective 3.26, the group suggested that the objective be changed to only include complete bans on vending machines, rather than bans on machines only in areas where children are present.

The session ended with a discussion of additional topics that may be considered for Healthy People 2010 objectives. These included: Participants

Julie Fishman, Facilitator/Recorder Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention
Ned Baker, National Association of Local Boards of Health
Anthony DeLucia, American Lung Association
Jim Guillory, American Osteopathic College of Occupational and Preventive Medicine
Sarah Knab, Partnership for Prevention
Sarah McMullen, American Academy of Family Physicians