The third panel, moderated by Michelle Larkin, an assistant vice president at the Robert Wood Johnson Foundation, looked to the tobacco control movement for transferrable lessons on spread and scale. As background, Larkin displayed several maps showing the spread of state laws mandating that workplaces, bars, and restaurants be smoke free: From no such laws in 1998, about half of the country was covered by such laws in 2014. While this is an impressive spread of tobacco control, Larkin pointed out that comprehensive smoke-free laws have been implemented primarily in Northern states. This highlights the importance of local context. Only about 54 percent of the U.S. population is covered by state and local smoke-free laws for workplaces, restaurants, and bars, she said. Although this is a dramatic increase since the late 1990s, there is still a long way to go before the total population in the United States is not being exposed to a carcinogenic product and its byproducts.
Cheryl Healton, the director of the Global Institute of Public Health, the dean of global public health, and a professor of public health at the New York University Wagner Graduate School of Public Service, described the National truth® Campaign for the prevention of smoking by youth. Brian King, a senior scientist at the Office on Smoking and Health at the U.S. Centers for Disease Control and Prevention (CDC), provided a federal perspective on scaling tobacco control. Jeannette Noltenius, the former national director of the National Latino Tobacco Control Network, discussed the spread and scale of programs to reach minority populations. Sally Herndon, the director of North Carolina’s Tobacco Control
Network and the head of the Tobacco Prevention and Control Branch at the Division of Public Health at the North Carolina Department of Health and Human Services, discussed changing social norms as a strategy for spread and scale. (Brief background information on the case examples, including how speakers understand spread and scale in the context of their own work, was submitted by the panelists prior to the workshop and is available in Appendix C.)
The National truth® Campaign is a primary prevention campaign to help young people avoid taking up the behavior of tobacco use, Healton said. The program is based on a successful large-scale campaign in the state of Florida. The theme of the Florida campaign was manipulation by the tobacco industry, and it included hard-hitting and edgy ads. Youth were integrally involved in the development of the Florida campaign, she noted.
The campaign was developed in part at Columbia University under a contract with CDC in response to the announcement by the U.S. Food and Drug Administration (FDA) that it hoped to support national youth public education. Leaders from the youth advertising world and brand managers for key teen brands offered their expertise as did TRU (a teen brand design leader) to craft messages that could counter the big tobacco brand. Teen brands are a tool for self-expression, and a group of national youth marketing experts suggested that the approach to fighting tobacco use among adolescents was to create a brand that was more empowering and rebellious than smoking. The position of truth® as a brand was intended to help counter the pop culture smoking images that are pervasive in society. The campaign had a rational component and an emotional component, Healton explained. The rational component provided facts and information that put teens in control, exposing what Healton described as the lies of the tobacco industry. The emotional component sought to appeal to the intelligence, rebelliousness, and risk-taking behaviors of teens, directing them to rebel against the tobacco industry. The campaign did not preach at kids, Healton said, and it did not condemn smokers. It did condemn the tobacco industry, she noted, and the industry did not appreciate it. The campaign was in litigation with the industry for years, but the campaign prevailed in a unanimous decision by the Delaware Supreme Court.
The underlying philosophy of the campaign, Healton explained, was that sensation seekers are much more likely to smoke. People who are high on the sensation-seeking scale as adolescents are much more likely to be open to smoking, to ultimately become a smoker, and to stay a smoker. She added that the amount of money spent on the truth® campaign was
the second largest amount ever spent by a U.S. nonprofit organization in the media space (the first being a Partnership for a Drug-Free America campaign that aired for many years).
A multi-pronged approach was used to evaluate the impact of the campaign, including assessing receptivity and reactions to ads and national youth data for tracking smoking prevalence. There was a doubling in the rate of decline of youth smoking in the United States between 2000 and 2004, Healton said, and at least 22 percent of that was clearly attributable to the truth® campaign. This translated to an estimated 450,000 young people not starting to smoke. Despite the campaign’s success, attempts to incentivize states to bring their campaigns to a higher level failed, which Healton attributed to the politics of the campaign.
Over a very short period of time, 90 percent of all youth (from 12 to 17 years of age) in the United States were familiar with the campaign, and 75 percent could describe at least one truth® ad. Awareness of the campaign was linked to changes in key attitudes and beliefs related to smoking. For the metric “Did you talk to a friend about the campaign?” between 22 percent and 40 percent of youths said that they did, depending on the ad. This is a high level of impact, for any ad, nonprofit or for-profit, Healton said, adding that the usual response rate is around 5 percent.
Healton shared the conceptual model for scale and spread for the new truth® campaign, which was called Finish It and was aimed at eliminating teen smoking (see Figure 5-1). While the original campaign, initiated in 2000, was entirely dependent on television and radio for delivery of its messages, the new campaign not only uses television but also seeks to use social networking activities extensively (e.g., Facebook, Twitter) to
FIGURE 5-1 2014 conceptual model for the truth® campaign.
SOURCE: Legacy. Adapted from Hornik and Yanovitzky, 2003.
grow the campaign organically. As has always been the case, she said, this is a major challenge because the campaign is competing for adolescents’ attention against a very broad range of issues and interests.
In closing, Healton lamented the challenges of combating illnesses and behaviors where there is a corporate interest (e.g., food, alcohol, tobacco, firearms). When a campaign has the capacity to reduce the use of a product and it depicts a particular industry negatively in terms of health impact of that product, it is much harder to bring partners on board.
Much of the momentum, innovation, and spread of ideas for tobacco control has started at the local level, which in turn expanded to the state level, and ultimately the federal level, King said. Current tobacco control efforts stem from more than 50 years of experience in trying to determine what works. However, evidence-based interventions are not necessarily spread to the populations that need them most. Although there has been progress over the past five decades since the first Surgeon General’s report on smoking and health in 1964 (HHS, 2014), there are still marked disparities in tobacco use and in the dissemination of innovations.
The tobacco epidemic peaked in the 1960s. King noted that it got its start in World War II, when cigarettes were included in the rations of soldiers, who later introduced smoking to their wives and other family members. Tobacco use began to decline following the release of the first Surgeon General’s report and the implementation of proven population interventions. There have been numerous reports on tobacco control, including 32 released by the Surgeon General,1 and CDC has issued standards for comprehensive programs (CDC, 2014). Marked declines have been observed over time, as the knowledge of the dangers of tobacco use and secondhand smoke has proliferated and as social norms regarding the social acceptability of tobacco have changed. Evidence also shows that the percentage of non-smokers exposed to secondhand smoke has declined, as measured using serum cotinine levels, a biomarker of nicotine (CDC, 2010; Homa et al., 2015; Pirkle et al., 2006). Still, in 2013 about 18 percent of the adult population was using cigarettes (Jamal et al., 2014), and the tobacco product landscape continues to diversify with new products, such as electronic cigarettes (e-cigarettes) (Agaku et al., 2014). All 50 states currently have tobacco control programs, but the adoption of proven population-based tobacco control strategies varies by state (CDC, 2014).
The biggest inhibitor of implementing and spreading tobacco control interventions is funding, King said. The tobacco industry outspends pre-
vention efforts by 18 to 1. State tobacco revenue from taxes and Master Settlement Agreement payments is about $25 billion per year, King said, and the federal revenue from cigarette taxes is about $15.6 billion (CDC, 2014). The tobacco industry spends about $8.8 billion per year to market and promote its products (FTC, 2013a,b). CDC recommends that annual state spending on tobacco control be $3.3 billion, but in reality states are spending only about half a billion dollars per year (CDC, 2014). The funds are not being used to implement the strategies that are known to work to effectively reduce tobacco use. If just a small portion of the income from tobacco revenue were applied to tobacco control, it would be possible to make great inroads, particularly among disparate populations, King said.
Evidence-Based Population Tobacco Control Interventions
King briefly discussed four major interventions that are part of comprehensive tobacco control programs: 100 percent smoke-free policies, tobacco price increases, cessation treatments, and counter marketing (CDC, 2014).
As Larkin mentioned, comprehensive smoke-free laws (prohibiting smoking indoors at worksites, restaurants, and bars) have spread over a relatively short time period, from zero in 2000 to 26 states and the District of Columbia in 2014.2 King said that the momentum for such laws has decreased considerably in recent years because of the issue of preemption and other factors. Much of the momentum for these policies is at the local level, he explained, but if a state law preempts localities from taking action, there is no initiative to start the discourse at the local level. He noted that there has not been a statewide law implemented since 2012.
Increasing the price of tobacco products is the single most effective method to reduce consumption, King said (HHS, 2014). This has been proven time and again at local, state, national, and international levels. As the price of tobacco products increases, consumption declines (see Figure 5-2). King noted that there is marked variability in cigarette excise taxes across the United States, ranging from 17 cents per pack in Missouri, to $4.35 per pack in New York.3 It is not a surprise, he said, that smoking prevalence is the lowest in the states with the highest cigarette excise taxes. The tobacco belt in the south has the highest rates of smoking and other tobacco use as well as the lowest levels of cigarette taxes and smoke-free policies or other interventions that are known to work.4
2 See http://www.cdc.gov/tobacco/data_statistics/state_data/state_system/index.htm (accessed February 19, 2015).
FIGURE 5-2 U.S. cigarette price versus consumption.
SOURCE: King presentation, December 4, 2014, derived from Orzechowski and Walker, 2009.
In 2000, very few states had tobacco quitlines that people could call for information about quitting smoking. Today, all 50 states and the District of Columbia have quitlines, and they have been expanded to reach vulnerable populations, including Spanish and Asian language speakers. King pointed out, however, that only about 6 percent of smokers access quitlines (CDC, 2014).
King also described the impact of national mass media campaigns, particularly graphic media campaigns such as the CDC Tips from Former Smokers campaign, the truth® campaign discussed by Healton, and the recent Real Cost campaign from FDA. These interventions are known to work, King concluded, adding that more than 200,000 people quit as a result of the 2012 CDC Tips campaign (McAfee et al., 2013).
There are whole regions of the country that have been left behind in terms of tobacco control policies, Noltenius said, reminding participants of the maps shown by Larkin and King. The demographics of the United States have changed over the past 20 years, and she suggested that
although there are successful tobacco control programs, they have not been scaled to reach the growing minority populations of smokers. In addition, more than 6 percent of Americans are living in deep poverty (defined as having an income 50 percent below the poverty line). Racial and ethnic minorities, women, children, and families headed by single women are particularly vulnerable to poverty and deep poverty. Higher poverty rates and a lack of education are associated with higher rates of smoking.
Although great progress has been made in reducing smoking in the overall adult population to 18 percent, Noltenius said, young adults of ages 18 to 25 have very high rates of tobacco use, and tobacco use varies across and within ethnic groups (see Figure 5-3). She added that 99 percent of adult smokers started smoking before the age of 25, and cigarette use is also present among 12- to 17-year-olds.
Noltenius stressed that ethnic and gender differences in tobacco consumption make it especially important to disaggregate data and target initiatives into specific populations and genders. For example, among the Hispanic/Latino subgroups, Puerto Ricans living in the mainland have smoking rates of 38 percent, much higher than Mexican Americans (both male and female). The second group with highest smoking rates are Cuban Americans living in Florida, New Jersey, and New York. The lowest rates are among Mexican American immigrant women and Puerto Ricans living on the island of Puerto Rico. Noltenius also reminded par-
FIGURE 5-3 Percentage of current cigarette use among 18- to 25-year-olds by race/ethnicity and gender.
SOURCE: Noltenius presentation, December 4, 2014, citing National Survey on Drug Use and Health 2008–2010 data, SAMSHA, 2015.
ticipants that Asian Americans come from 53 different countries. It is important to concentrate on place when considering racial and ethnic subgroups, she said. There is also diversity in which types of people are most likely to choose a particular product. For example, smokers who use menthol cigarettes vary by race, sex, and age, with menthol use being more common among African American smokers, new smokers, female smokers, and younger smokers.
The National Latino Tobacco Control Network
The National Latino Tobacco Control Network focuses on reducing tobacco use and promoting health equity.5 A challenge for the organization is collecting and disseminating data on subgroups in order to mobilize the diverse populations within communities. In New York City, for example, Puerto Ricans, especially Puerto Rican women, have the highest smoking rates, but Latinos in general have the lowest smoking rates. Data have to be relevant to the local community in order for that community to become engaged, she said.
Another challenge is that many national Latino and minority organizations and political leaders have received tobacco, fast food, alcohol, and soda industry funding or sponsorship and therefore are beholden to them, Noltenius said. At the local, state, and federal levels, policy initiatives have been opposed by these groups and by politicians. Public heath funders have not systematically helped these groups divest themselves of this industry funding.
Population-level interventions do not necessarily work for all subpopulations. Noltenius said that funders that provide one or several national racial/ethnic networks with $400,000 to $700,000 may think they are reaching all minorities in the nation and territories. But policies and programs need depth and breadth, and they need to be segmented to reach diverse subpopulations. There are some promising practices for engaging minority populations, but there is not enough funding to implement, evaluate, and scale them. Every time we make progress, Noltenius concluded, we have to think about who we are leaving behind and if the interventions are widening the disparities gap.
North Carolina is the leading tobacco-producing state in the nation, Herndon said. The North Carolina Tobacco Prevention and Control Branch (TPCB) works with partners to spread evidence-based practices
in tobacco prevention.6 In the early 1990s, North Carolina was 1 of 17 states to be funded by the American Stop Smoking Intervention Study (ASSIST)7 of the National Cancer Institute (NCI). Core funding of that project moved from NCI to CDC in 1999, with supplemental funds being provided by other agencies. A great deal about spread and scale has been learned in the process, Herndon said. For example, just as the planning phase of ASSIST was ending and the implementation phase was about to begin, the North Carolina General Assembly passed preemptive legislation requiring state-controlled buildings to set aside 20 percent of their space for smoking, as practicable, and prohibiting local governments from passing more restrictive regulations. This was a huge setback to the launch of the major tobacco control initiative, which was intended to eliminate exposure to secondhand smoke and change social norms about smoking in worksites and public places, Herndon said, and it was necessary to revisit the planned approach. The work then focused on making incremental progress without closing doors on future progress.
One of the approaches to spread that TPCB has taken is to collect stories from schools in North Carolina that had gone 100 percent tobacco free. School districts that had gone 100 percent tobacco free shared their success stories and started spreading tobacco control to other school districts during a series of breakfast meetings. Around the same time, Master Settlement Agreement funding was received, which helped to facilitate the 100 percent tobacco-free schools campaign. When approximately 85 percent of North Carolina schools had adopted a tobacco-free policy, a senator who was also a pediatrician introduced a bill to require all school districts to not only be tobacco free, but to adopt a 100 percent tobacco-free policy.
As a result of the school initiative, a progressive hospital administrator in one of the communities decided that hospitals also needed to be 100 percent tobacco free and started the same movement. This caught the attention of The Duke Endowment and the North Carolina Hospital Association, which provided funding to accelerate the spread of 100 percent tobacco-free hospitals. Although it took longer, mental health hospitals and substance abuse facilities in North Carolina are also now 100 percent tobacco free. Government buildings were not smoke free or tobacco free. Herndon and her team used a strategy whereby they first got the general assembly building tobacco free and then argued that what was good for the legislators ought to be good for state employees as well. Health care costs were used as leverage to get prisons to be 100 percent tobacco free. It was a major accomplishment, Herndon said, when in 2010 North Carolina became the first of the southern states—and the only tobacco-
7 Note that NCI’s ASSIST project is distinct from and unrelated to the USAID ASSIST Project discussed by Massoud in Chapter 2.
producing state—to make restaurants and bars 100 percent smoke free. Herndon noted that there is a strong complaint-based system of compliance. Consumers and employees at facilities can submit a complaint, which is sent to the local health director for rapid follow-up. She added that the Restaurant and Lodging Association was a key partner in this process. Public health coalitions and advocates wanted no exemptions, and businesses wanted a level playing field. With help from Pfizer and the CDC Foundation, TPCB evaluated the impact of the law on business, and it has found no negative economic impact in terms of lost jobs or receipts for restaurants and bars.
TPCB also found an 89 percent improvement in air quality, a 21 percent decline in weekly emergency department visits for heart attacks, and a 7 percent decline in emergency department visits for asthma in the year that the smoke-free restaurant and bar law went into effect.
There has been a fair amount of success, Herndon said, as the amount of support for smoke-free restaurants and bars in North Carolina has increased every year, and there is an 83 percent voter approval rating for the law. TPCB has had to defend the smoke-free restaurants and bars law in the general assembly every year, and it has also had to defend the part of the law that repealed part of the preemption. Future progress will depend on taking advantage of that part of the law that partially restored the local authority to ban smoking in government buildings, on government grounds, and in public places (defined as any indoor space inside which the public is invited). Because most work places have customers at some time or another, they are covered under this authority, although there are some workplaces that are considered private.
In the future, TPCB will continue to work at the local level to help build support for smoke-free government buildings, government grounds, public places, and community colleges. Herndon said that 35 of the 58 community colleges are 100 percent tobacco free. North Carolina is also poised to become the second state in the nation to require properties to be smoke free in order to quality for tax credits. Finally, TPCB plans to help community-based mental health and substance abuse organizations incorporate treatment for tobacco addiction.
To start the discussion, Larkin observed that a theme that ran through all of the presentations was the need to work at multiple levels—federal, state, and local—and with a range of partners. She suggested that tobacco control is somewhat unique in how successful it has been in translating evidence into action and creating policy campaigns that move the issue forward at the local, state, and to some degree, federal levels. Policy change is critical, she said. Another issue Larkin highlighted from the pre-
sentations was preemption of local action, which is specifically designed to stifle a growing movement. In thinking about spread, she said, it is important to think about who the opposition is and what tactics they might use to thwart pro-population health innovations that they perceive as counter to their interests. Healton added that the federal preemption of state action is also an issue and that significant amounts of corporate dollars are spent to secure federal policies that are favorable to industry.
Panelists discussed further the need to engage nontraditional partners, such as schools and the hotel industry, in spreading tobacco control. Based on her work with schools, Herndon said that it appears that the majority of smokers start at age 12 to 14 and that few people start smoking after the age of 24. Many children think that “Everyone smokes.” Having 100 percent tobacco-free schools changes the social norm at the school level and could affect children who are starting to smoke. When Governor Hunt convened a youth summit of two students from every high school in North Carolina, the students said that when they see their teachers smoking, they are being taught to smoke, Herndon said. The students asked for tobacco-free schools, and the governor gave the authority at the state level for action at the local level.
Healton said that the Legacy Foundation felt that if one major hotel chain could be convinced to become smoke free, others would follow, thus spreading the practice. It is very costly to businesses to have smoking on their property, she said, and the cleaning costs are significant when someone has smoked in a non-smoking part of the hotel.
The Legacy Foundation also partnered with willing governmental entities at all levels. One area where they have had a large impact and also a large pushback, she said, is the depiction of smoking in movies. No one had raised this issue with the state attorneys general before, she said, but state attorneys general have now called on moviemakers to take action on this issue multiple times.
Panelists also discussed engaging local governments and the community, especially young people, in spreading tobacco control. King said that having locally relevant information and data is essential. We do have the data, he said, and the challenge is finding the appropriate policy and decision makers and providing them with information that is relevant to them. One of the biggest arguments he has heard against tobacco control interventions, for example, is “They are not like me.” Bringing New York data to Georgia is not going to be effective, he said. Whether the decision makers on smoking policy are restaurant and bar owners or public housing authorities and landlords, it is essential to have information that supports the cause and that it is relevant to them.
Noltenius emphasized the value of engaging youth in spreading the values and practices of tobacco control and observed that many community advocates started as youth advocates. Fostering youth advocacy creates sustainable leadership not just for issues such as tobacco or public health, but for democratic engagement. Noltenius described the Minnesota afterschool program, Jovenes de Salud, as an example. Latino students advocated before the St. Paul legislature to eliminate all candy cigarettes. They also mobilized to get the organizers of Cinco de Mayo, the largest Mexican American/Latino fair in Minnesota, to go smoke free and not accept tobacco industry funding. Noltenius said that many of the legislators are parents and that they responded to having a child stand before them and ask if they wanted their children to be smokers. Youth empowerment puts a human face on these issues, she said.
Larkin commented that civic engagement is an important element in community health, no matter which issues one would like to spread—tobacco, obesity, housing, environmental issues, or something else.
Participants discussed further the concept of virtual braided funding that was mentioned by Sanghavi and Herndon (see Chapter 3). It is important to think about how health and other programs at the national level might cooperate, Herndon said. The U.S. Department of Housing and Urban Development recommends, but does not require, that multifamily public housing go smoke free (HUD, 2014). Smoke-free public housing is moving in a positive direction in North Carolina, she said, because the public health interests overlap with business interests. As mentioned above, the public health interests are working to require properties to be smoke free in order to qualify for tax credits. Larkin added that it is very expensive to clean housing units and to deal with lawsuits and complaints. It is a good business decision to not allow smoking. As she noted, previous roundtable workshops have discussed the investments that the business community is making in healthy communities, healthy housing, and healthy businesses (IOM, 2015a,c).
Stopping the Spread of Ineffective Programs
Paula Lantz of The George Washington University pointed out that sometimes programs spread with great speed and skill, despite evidence that they are not effective. Tobacco control is a great example of the spread and scale of evidence-based policies and programs, she said, but it is important to acknowledge that many ineffective tobacco policies and programs have also been scaled and spread. For example, the Drug Abuse Resistance Education (DARE) program spread very quickly, with 75 percent of schools in the United States having a DARE program at one point. Many schools still have programs, she noted, even in the face of evidence that it is ineffective and may actually have counterproductive effects.
In Puerto Rico, the National Latino Tobacco Control Network was able to mobilize all of the teachers in Puerto Rico to reject an ineffective, tobacco-industry-funded curriculum, Right Decision, Right Now, on tobacco-free choices, Noltenius said. The Tobacco Control Network also wrote a letter to alert the Substance Abuse and Mental Health Services Administration that the tobacco-industry program was ineffective because it was listed on the agency’s website; the curriculum was later eliminated from the site. King said that the tobacco industry is a “prime example” of spreading interventions that do not work, but it has the money, resources, and political clout to move them. King cited the tobacco-industry-initiated We Card program as another example. It was an effort to prevent the retail sale of tobacco to people under age 18 by asking for identification.8
Lantz clarified that it is not just industry-funded initiatives that are of concern. State health departments have implemented programs without evidence because there was a lot of interest in a program or a sense that it was right. King concurred, saying that interventions later found to be ineffective are sometimes implemented during the process of building that evidence base. At other times, the evidence is there, but people ignore it.
Lessons from Tobacco Control
George Isham of HealthPartners reiterated the point by King that the tobacco industry outspends prevention efforts by 18 to 1 and agreed with the characterization of the industry as an opponent. However, he questioned the wisdom of a strategy that characterizes the opposition as an enemy, rather than co-opting the resistance. He reminded participants of previous Institute of Medicine roundtable workshops on social movements for health and the role of communities (IOM, 2014b,c). Some movements need to have a clear opponent to mobilize against.
Isham noted also that there are regional disparities in how tobacco control policies are implemented. The roundtable’s definition of population health is “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” If we are not having reach, he said, improving health outcomes becomes less an issue of science and more an issue of engaging individuals where they are culturally. He suggested that industries probably have a stronger skill set in this area—engaging individuals—than many public health advocates. This is something to consider in terms of overall strategy, he said.
Terry Allan of the Cuyahoga County Board of Health commented on the appeal of certain products to selected subpopulations, such as results in minority populations having higher rates of smoking flavored small
cigars. King said that tobacco products are taxed based on weight, and if a product weighs a certain amount, it is classified as a cigar. In 2009 the Family Smoking Prevention and Tobacco Control Act effectively banned characterizing flavors in cigarettes. The tobacco industry circumvented this by adding weight to the flavored product so that it is the same size, shape, and filter as a cigarette, but it is heavier, so that it is not classified a cigarette (King et al., 2014). King agreed with Allan that the use rates of these flavored products are highest among minority populations, specifically non-Hispanic blacks (Corey et al., 2014). This is a prime example of how the tobacco industry can identify and adapt to loopholes in laws, he said.
Healton said that there is a critically important role for advocates in speaking truth to power. She suggested that without the sustained truth® national media campaign, there would likely not have been a public education strategy from CDC or FDA. They saw the evidence that the campaign worked. The other side of speaking truth to power is giving the tobacco industry a wakeup call.
Sanne Magnan of the Institute for Clinical Systems Improvement asked presenters what specific lessons from the spread and scale of tobacco control might apply more broadly to population health, especially when dealing with multi-billion-dollar international corporations. At the community level, Herndon said, a key element was the brave commitment of resource dollars at a time when tobacco control was really needed. The early community-level programs helped to advance the evidence. Another lesson from the community level is the impact of price in driving consumer behavior. The tobacco control movement had the Advocacy Institute, Noltenius said, which brought together multi-sectoral cohorts of leaders to foster partnerships. Scale up requires these types of cohorts that represent national leadership. This is not only a scalable leadership process, but also an investment in partnerships for the future, she said. Larkin suggested that one of the lessons from tobacco control, childhood obesity, and housing is the importance of having stories of success to hold up and of being able to demonstrate a return on investment for partners, whether it is a financial return or achieving the intended population health goal. It is also important to co-create initiatives so that partners have a sense of accountability and ownership. Isham said that there is a need for metrics that can provide information at the community level and thus offer the sorts of insights that can trigger community engagement.
Martha Gold from City College of New York asked about the use of social impact bonds. Larkin responded that this has not been done specifically for tobacco control, but that there is some work being done around asthma that is focused on environmental contaminants that exacerbate asthma and that are tied to health care usage.