David B. Abrams Ph.D.

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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 _at_
od.nih.gov http//obssr.od.nih.gov
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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
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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
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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
High
Low
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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.
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Cessation to Reduce Death and Disease
Source Figure 7.1, Curbing the Epidemic
Governments and the Economics of Tobacco Control,
World Bank, 1999.
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Probability of Initiation
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of Daily Smokers Making Quit Attempts
Quit attempt every 2 ½ - 3 yrs
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How Successful are Cessation Efforts?

• 47 try to quit
• 41 report trying to quit, abstain for 24 h
• 13 of quit efforts dont last 24 h (Garvey), so
• 2.5 of smokers quit permanently
• Quit rate 5
• Biochemically verified studies suggest unaided
  quit rate lt3

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smoking heroin alcohol
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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
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Utilization of Quit Methods
Uses/year Rough estimates of magnitude
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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_at_ucl.ac.uk
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Status of Cessation Treatment and Goals for Change
Efficacy/Supply/ Access Efficacy/Supply/ Access
Low High
Demand Low Present
Demand High Goal
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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.

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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 Generals 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 Generals Report on Environmental Tobacco
Smoke
1000
Federal Cigarette Tax Doubles
Great Depression
0
1900
1910
1920
1930
1940
1950
1970
1960
1998
1990
1980
Year
Sources United States Department of Agriculture
Surgeon Generals Reports.
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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 gt18 years old.
Beginning in 1982, fine-cut chewing tobacco was
reclassified as snuff.
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Greater Than the Sum

• The ISIS ProjectStrategic Systems Thinking in
  Tobacco Control

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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

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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.

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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?

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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

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Concept Mapping ExampleLocal Strength of
Tobacco Control
One specific component of a strong tobacco
control program is
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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

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Causal Map of Factors in Tobacco Prevalence and
Consumption
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Causal Map of Factors in Tobacco Prevalence and
Consumption
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Shard of Causal Map
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Formal Systems Model Public Opinion
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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
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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.

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The Goal An Integrated Systems Thinking
Environment
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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

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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

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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.

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• 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