"Health in All Policies Approaches to Tobacco Prevention and Control" at the Leading the South to Healthier Communities: Deep South Tobacco Prevention & Control Policy Institute, Aug 3-5, 2011, New Orleans, LA.

1. Health in All Policies Approaches
to Tobacco Prevention and Control
Holly Avey, PhD, MPH
Deep South Tobacco Prevention and Control Policy Institute
New Orleans, LA
August 3, 2011

2. Health in All Policies Approaches
to Tobacco Prevention and Control
• What is Health in All Policies (HiAP)?
• HiAP and Social Determinants of Health Equity
• HiAP Trends
• HiAP Funding Opportunities
• How to Make it Work

3. WHAT IS HEALTH IN ALL POLICIES?

4. Programs vs Policies
• Historical focus on programs
– smoker quit lines, smoking cessation educational
programs
• Policies can support programs
– Workplace smoking ban supports workplace
smoking cessation programs
• Programs can drive support for policies

5. What is Health in All Policies?
(HiAP)
• A strategy that strengthens the link
between health and other policies,
creating a supportive environment
that enables people to lead healthy lives

6. Health in All Policies
• Considers the intentional or unintentional
impact of all policies on individual or
population health
– Education
– Housing
– Transportation
– Economic
– Etc.

7. Health in All Policies in Context

8. Health in All Policies
AN APPROACH WITH HIGH IMPACT
AND LEVERAGE

9. The Iceberg: A Metaphor for the Level at
Which We Interact With a System
Heart disease,
stroke, cancer
Tobacco use
Environmental
factors that support
tobacco use
Individual rights vs
population health

10. Health Impact Pyramid
Frieden, T. A Framework for Public Health Action: The Health Impact Pyramid. American Journal of Public Health,
2010, 100(4): 590-595.

11. Health in All Policies
APPROACHES TO TOBACCO
PREVENTION AND CONTROL

12. Working at All Levels of the Pyramid
Education &
counseling for
smoking
behavior
Cessation
medications
Hard-hitting
Tobacco ad campaigns
taxes, smoke-
free
workplaces,
elimination of Interventions
advertising to increase
education &
economic
status
Frieden, T. A Framework for Public Health Action: The Health Impact Pyramid. American Journal of Public Health,
2010, 100(4): 590-595.

13. HiAP Approaches to Tobacco
Prevention and Control
• Economic sector
– Taxes
• Labor/workplace sector
– Bans in workplaces
• Market sector
– Limits and bans on advertising
• Educational sector
– Bans in educational settings
• Municipal government sector
– Bans in public spaces

14. Health in All Policies
AND THE SOCIAL DETERMINANTS OF
HEALTH EQUITY

15. Social Determinants of Health
The conditions in which people
are born, grow, live, work and age,
including the health system.
These circumstances are shaped by
the distribution of money, power and resources
at global, national and local levels,
which are themselves influenced
by policy choices.
Source: World Health Organization, 2008

17. WHAT ARE THE SOCIAL DETERMINANTS
OF SMOKING?

18. Social, economic, and psychological
determinants of smoking:
– low education – depression
– low income – low religious devotion
– working class job – low religious
– young age institutional
– low self-esteem conservatism
– low optimism – divorce
– low hope
Barbou et al, 2004, Carvajal et al, 2000, Kendler et al, 1999, Simons-Morton, 2002

19. THE SOCIAL DETERMINANTS OF
SMOKING AND STRUCTURAL STRESS

20. From Policy-Driven Inequity
to Disparities

21. Structural Sources of Stress:
Social Closure
• When social and economic opportunities are
restricted for certain groups
• Includes restriction of access to:
– Employment – Transportation
– Housing – Healthcare
– Education – Legal representation

22. Structural Sources of Stress:
Relative Deprivation
• When certain groups perceive they are
deprived of resources compared to others
• Includes:
– Corporate welfare – Media and consumerism
– Wealth gap – Property taxes

23. Social, economic, and psychological
determinants of smoking:
– low education – depression
– low income – low religious devotion
– working class job – low religious
– young age institutional
– low self-esteem conservatism
– low optimism – divorce
– low hope
Barbou et al, 2004, Carvajal et al, 2000, Kendler et al, 1999, Simons-Morton, 2002

24. Social Determinants
APPROACH TO DISEASE PREVENTION

25. JEWEL Project
• HIV prevention intervention targeting illicit drug-
using women who were involved in prostitution
– HIV prevention risk reduction
– making, marketing and selling of jewelry
– income from the jewelry sale was associated with
reduction in number of sex trade partners at follow-
up
(Sherman et al, 2006)

26. Microenterprise
• Microenterprise interventions include:
– basic life-skills training, development of
commercially viable products and services, access
to markets, financial training, and financial
support or microfinance of some type (e.g., credit,
emergency loans, tax assistance)
• (Stratford et al, 2008)

27. Theories on Why Microenterprise
Programs Work
• Income: improves standard of living
• Diversification: diversifies income streams
• Compensating differential: provides non-
monetary value, such as an improved outlook on
life as a result of savings or ability to pay bills
• Social network: develops social capital and access
to resources, which further strengthens economic
activity

28. Theoretical Basis for a Social
Determinants Approach to Tobacco
Control and Prevention
• Newton & Bower (2005), Watt (2007): causal pathways
to oral health status include psychological stress, sense
of coherence, social status, and environmental factors
• Stress is impacted by social closure and relative
deprivation
• Successful interventions that address social
determinants incorporate life skills training that
improves personal empowerment (compensating
differential theory)

29. Health in All Policies
TRENDS

30. Health in All Policies Trends
• Well established in Europe, Australia
• Recent establishment of National Prevention
Council
– National Prevention Strategy
• Recent report by the Institute of Medicine
• HIA as a tool for HiAP
• HUD memo on Non-smoking policies in public
housing

31. National Prevention, Health
Promotion, and Public Health Council
• Created through health reform legislation
• Members from 17 federal agencies
• Chaired by the Surgeon General
• Coordinates and leads federal efforts on
prevention, wellness, and health promotion

32. Source: For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges; Report Release Slides
http://www.iom.edu/~/media/Files/Report%20Files/2011/For-the-Publics-Health-Revitalizing-Law-and-Policy-to-Meet-New-
Challenges/Report%20Release%20Slides.pdf

33. Source: For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges; Report Release Slides
http://www.iom.edu/~/media/Files/Report%20Files/2011/For-the-Publics-Health-Revitalizing-Law-and-Policy-to-Meet-New-
Challenges/Report%20Release%20Slides.pdf

34. Source: For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges; Report Release Slides
http://www.iom.edu/~/media/Files/Report%20Files/2011/For-the-Publics-Health-Revitalizing-Law-and-Policy-to-Meet-New-
Challenges/Report%20Release%20Slides.pdf

35. Source: http://www.apha.org/NR/rdonlyres/171AF5CD-070B-4F7C-A0CD-0CA3A3FB93DC/0/HIABenefitHlth.pdf

36. Source: http://www.hud.gov/offices/pih/publications/notices/09/pih2009-21.pdf

37. Health in All Policies
FUNDING OPPORTUNITIES

38. Health in All Policies
Funding Opportunities
• HIA Funding Opportunities (CDC, Pew)
• Communities Putting Prevention to Work
(CDC)
• Community Transformation Grants (CDC)
• Other sectors (HUD – Sustainable
Communities)

39. Health in All Policies
HOW TO MAKE IT WORK

40. Health in All Policies
Can Occur at Different Levels
• Information-sharing
• Collaboration
• Integration

41. Facilitators of Health in All Policies
• Leadership
• Internal incentives
• External pressure
• Funding
• “Win‐win framing” of the issues

42. Win-Win Opportunities
• Health in All Policies works best when it is
framed as a win-win opportunity for all
involved sectors
• Offers of resources such as workforce,
prestige, or access to additional funding
sources can foster new partnerships engaged
in promoting health

43. Working at All Levels of the Pyramid
Education &
counseling for
smoking
behavior
Cessation
medications
Hard-hitting
Tobacco ad campaigns
taxes, smoke-
free
workplaces,
elimination of Interventions
advertising to increase
education &
economic
status
Frieden, T. A Framework for Public Health Action: The Health Impact Pyramid. American Journal of Public Health,
2010, 100(4): 590-595.

44. References
American Public Health Association. http://www.apha.org/NR/rdonlyres/171AF5CD-
070B-4F7C-A0CD-0CA3A3FB93DC/0/HIABenefitHlth.pdf
Avey, H. Racial and Socioeconomic Health Disparities: Policy-Driven Inequities and
Chronic Stress. Oral presentation. Academy Health Annual Research Meeting,
Chicago, IL, June, 2009.
Barbeau, EM, Krieger, N, and Soobader, M-J. Working Class Matters: Socioeconomic
Disadvantage, Race/Ethnicity, Gender, and Smoking in NHIS 2000. American Journal
of Public Health, 2004, 94(2): 269-278.
Carvajal, SC, Wiatrek, DE, Evans, RI, Knee, CR, and Nash, SG. Psychosocial
Determinants of the Onset and Escalation of Smoking: Cross-sectional and
Prospective Findings in Multiethnic Middle School Samples. Journal of Adolescent
Health, 2000;27:255–265.
Frieden, T. A Framework for Public Health Action: The Health Impact Pyramid.
American Journal of Public Health, 2010, 100(4): 590-595.
Institue of Medicine of the National Academies. For the Public’s Health: Revitalizing
Law and Policy to Meet New Challenges; Report Release Slides.
http://www.iom.edu/~/media/Files/Report%20Files/2011/For-the-Publics-Health-
Revitalizing-Law-and-Policy-to-Meet-New-
Challenges/Report%20Release%20Slides.pdf
Iton A. Transforming public health practice to achieve health equity. Paper presented
at: HealthEquity Summitt, 2009; Cambpell, CA.
Kendler, KS, Neale, MC, Sullivan, P, Corey, LA, Gardner, CO and Prescott, CA. A
population-based twin study in women of smoking initiation and nicotine
dependence. Psychological Medicine, 1999, 29: 299-308.

45. References
National Prevention Council.
http://www.healthcare.gov/center/councils/nphpphc/about/index.html#mem
National Prevention Strategy
http://www.healthcare.gov/center/councils/nphpphc/about/index.html#mem
Newton JT, Bower EJ. The social determinants of health: new approaches to conceptualizing and
researching complex causal networks. Community Dent Oral Epidemiol 2005; 33: 25–34.
Sherman, SG, German, D, Cheng, Y, Marks, M & Bailey-Kloche, M. The evaluation of the JEWEL
project: An innovative economic enhancement and HIV prevention intervention study
targeting drug using women involved in prostitution AIDS Care, 2006; 18(1): 1-11.
Simons-Morton, BG. Prospective Analysis of Peer and Parent Influences on Smoking Initiation
Among Early Adolescents. Prevention Science, 2002, 3(4): 275-283.
Stratford, D, Mizuno, Y, Williams, K, Courtenay-Quirk, C, and O’Leary, A. Addressing Poverty as
Risk for Disease: Recommendations from CDC’s Consultation on Microenterprise as HIV
Prevention. Public Health Reports, 2008 , 123:9-20.
Turrell, G, Battistutta, D, and McGuffog, I. Social determinants of smoking among parents with
infants. Australian and New Zealand Journal of Public Health, 2002, 26(1):30-37.
US Department of Housing and Urban Development Source:
http://www.hud.gov/offices/pih/publications/notices/09/pih2009-21.pdf
Watt RG. From victim blaming to upstream action: tackling the social determinants of oral health
inequalities. Community Dent Oral Epidemiol 2007; 35: 1–11.

46. Holly Avey, PhD, MPH
Associate Project Director
Georgia Health Policy Center
Georgia State University
havey@gsu.edu
404-413-0291
www.gsu.edu/ghpc