CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 15 • Number 3 • Fall 2002

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Overcoming the Challenges of Eliminating Disparities in Tobacco Use

CDC Guide Will Help Health Departments Eliminate Disparities in Tobacco Use and Tobacco-Related Disease

Although tobacco use prevention and control efforts are regarded as a major public health success, racial and ethnic disparities in tobacco-related health outcomes remain a concern ("Racial Disparities in Tobacco Use"). These disparities exist when 

• A community has rates of tobacco use or disease that are far greater than in the majority population. 
• A community lacks research, surveillance data, health services, and other types of capacity and infrastructure that are critical to preventing and controlling tobacco use. 

CDC funds all state health departments to support efforts to reduce tobacco use. Because eliminating disparities is an important part of this effort, CDC’s Office on Smoking and Health (OSH) is developing a resource guide to help health departments and their partners identify and eliminate disparities among population groups. 

“Although the primary focus of the resource guide is African American, Native American, Asian and Pacific Islander, and Hispanic or Latino communities, it also serves as a framework for health departments to assess all population groups,” said Robert G. Robinson, DrPH, OSH’s Associate Director for Program Development. For example, the same framework could be used for assessing disparities among gays and lesbians, rural residents, or migrant workers.

Barriers to Eliminating Disparities in Tobacco Use 
Dr. Robinson is encouraged that public health agencies are committed to reducing health disparities, but he warns that immense challenges lie ahead. These challenges are created by the following factors: 

Disparities are institutionalized. Disparities in communities and population groups are not the result of individual behavioral patterns. Rather, they result primarily from the inequitable distribution of resources and services at the institutional level— for example, programs to help people stop smoking in wealthy communities may not be available in low-income communities across town. 

Disparities cannot be solved with an incremental, piecemeal approach. Major resources required to eliminate disparities must be applied comprehensively. For example, enabling a community-based organization to provide services to help community members quit smoking is only one part of the solution because the community needs the capacity to address the broad range of problems associated with tobacco use. This strategy is contrary to the classic approach of solving problems through small-to-moderate changes. 

Disparities among population groups are not compartmentalized but involve all public sectors. Thus, we can no longer rely on the standard approach of assigning priorities to an agency that deals with only one specific aspect of the problem, such as health, education, housing, employment, or justice. Eliminating disparities requires a crosscutting approach involving all of these public agencies. 

Often, the importance of race in health disparities is understated, and factors such as poverty and low levels of education are considered better predictors of disparities. Analyses of race often understate the importance of race in health disparities because researchers use methodologies that prevent them from viewing race holistically or contextually and taking into account experiences shared by community members because of their race. Race is understated when interventions are developed solely on the basis of population risk assessments, which tend to focus on indicators other than race. For example, a program might use poverty status to identify risk and then proceed to develop an intervention focusing on poverty status. But if the proposed intervention needs to be communitywide to be effective, then race is critically important. 

Most research is based on a disease-centered model that measures illness in terms of collections of individuals and not in terms of the social systems or communities in which they live. Eliminating disparities will require a health promotion approach that emphasizes strengthening capacity and infrastructure in communities, building supportive environments, and promoting political action and policies that improve health.

To overcome these challenges, Dr. Robinson and colleagues have developed a model that has three primary components: (1) community competence; (2) capacity and infrastructure, and (3) community prevention strategies that broaden traditional public health approaches to prevention and control. 

Community Competence 
Community competence reflects the complexity of communities, groups, strata, and individuals. It is integrative because community competent interventions will mirror a population’s historical, cultural, contextual, and geographical experiences. By taking the time to understand the experiences and circumstances that have shaped a community, a program can be more effective in reaching people who are hurt by health disparities. 

For a program or publication to be community competent, it must take into account the following facets of a community: 

• History. For example, slavery is part of African Americans’ history, and European conquest is part of Native Americans’ history. 
• Culture. Shared values such as religion. 
• Context. Realities of the here and now such as racism, homophobia, environmental injustices, and lack of health insurance. 
• Geography. The unique qualities of a geographic area. 

According to Dr. Robinson, community competence is not a specific amount of history, culture, context, or geography. Rather, he said, “community competent protocols contain varying amounts of these determinants, seeking out what is important to achieve effective outcomes.” Community competence also includes other criteria: salient imagery, positive imagery, appropriate language and literacy levels, multigenerational perspectives, and diversity. 

The Pathways to Freedom program is a good example of a community competent intervention that reflects all of these criteria. Pathways to Freedom is a state-of-the-art tobacco cessation guide for the African American community that encourages African American organizations to institute smoking cessation programs and enables mainstream organizations to reach community residents and their leaders. Launched in Philadelphia a decade ago, it offers tips for helping blacks quit smoking and community activities to promote policy change. Philadelphia’s black churches, tenant groups, and Masonic organizations helped put together the Pathways to Freedom guide, which was published by the Fox Chase Cancer Center with support from the National Cancer Institute and disseminated by the American Cancer Society and CDC. 

The Pathways to Freedom guide includes images that are salient and compelling, such as photos of a baby’s healthy lung next to a mildly diseased lung and a severely diseased lung. It also features many positive images such as the photo of a smiling mother with a quote about her success in quitting smoking. The guide also gives readers a geographic connection to the material by featuring examples of tobacco industry promotions in and around Philadelphia. 

Another strong aspect of the guide is its use of multigenerational images. For instance, “Introducing the Freeman Family” is a color illustration of three generations of a family. The surname Freeman reminds people of their shared history of freedom from slavery. Next to each family member’s name is a note about their smoking status—“used to smoke,” “trying to quit,” “never smoked,” or “smoker.” The Pathways guide is currently being revised to be more diverse by including text and imagery responsive to non-Christian faiths and to members of the community who are gay, lesbian, bisexual, or transgender.

“So you see, community competency forces us to look more broadly and more complexly at the population,” said Dr. Robinson. “If we’re going to develop programs and materials that are community competent, we’re going to have to take all of these aspects into account. It is really a matter of degree and intensity as to how community competent criteria will be applied to groups, strata, and individuals.” 

Capacity and Infrastructure 
The second component of the model addresses the importance of developing capacity and infrastructure in populations and communities. This component relies on a perspective that views the community holistically and views strata within the population as part of the community. Such an approach acknowledges the complexity of a community because it views population groups in the context of the communities in which they live. According to Dr. Robinson, the challenge for public health is to be able to respond to this complexity. He notes that public health interventions often pose a choice of “either/or” when in fact a “both/and” approach is needed. People living in poverty require specific interventions, but the communities in which they reside also require the capacity and infrastructure to serve them appropriately. 

Communities and populations experiencing disparities in tobacco use require the capacity and infrastructure with which to counter tobacco industry strategies and to engage in tobacco prevention and control initiatives at all levels (e.g., planning, coordination, program development, implementation, evaluation).

According to Dr. Robinson, a community or population group has high levels of capacity and infrastructure if it possesses the following: 

• Research that not only addresses its particular needs but also includes researchers who represent the community or the interests of the population.
• Community competent programs that reflect the community or population.
• Tobacco control leaders representative of the community or population. 
• Organizations able to represent the community’s or population’s tobacco control interests and provide related services. 
• Networks representing the community or population that facilitate communication, planning, policy analysis, coordination, and agenda setting. 

The tobacco industry has well-defined strategies for specific communities and populations that are based on longstanding relationships with community organizations and leaders, Dr. Robinson said. “Developing capacity and infrastructure will enable communities to defend themselves against these strategies,” he noted. 

One means of developing capacity and infrastructure, according to Dr. Robinson, is by funding minigrants to stimulate the development of tobacco prevention and control programs at the community level. In addition, community programs can be further empowered by funding networks of researchers, leaders, experts, and organizations to provide technical assistance, develop strategic plans, establish priorities, and make recommendations related to the tobacco prevention and control needs of specific population groups or communities. “For example,” said Dr. Robinson, “the American Legacy Foundation, a national, independent public health foundation established by the 1998 tobacco settlement, used networks to develop strategic plans for tobacco control among racial and ethnic communities, populations defined by sexual orientation, and population groups defined by low socioeconomic status. As with community competence, capacity and infrastructure are needed by all population groups, and differences are a matter of degree and intensity.” 

Community Prevention Strategies That Broaden Public Health Approaches to Prevention and Control 
The third axis of the model developed by Dr. Robinson and colleagues relates to public health applications and incorporates the concepts embodied in the other two axes. The underlying assumption of the model is that the more homogenous the population, or relatedly, the more relevant the constructs of history, culture, context, and geography that shape the community and distinguish it from a group or strata, the more likely the community will require interventions that support capacity and infrastructure development. Population groups that are less determined by history, culture, context, and geography and are thus less easily described as whole communities may still require capacity and infrastructure support, but not at the same level of intensity. “Community prevention strategies combined with public health approaches to prevention and control provide a continuum along which all populations groups and interventions appropriate to their needs can be placed,” Dr. Robinson explained. 

According to Dr. Robinson, community prevention involves broadening traditional public health approaches to prevention and control to include an explicit focus on community development. “Traditionally, the success of prevention and control efforts is determined by one dimension: time. If the intervention is early and successful, then some event has been prevented,” he stated. “Control strategies occur downstream and are intended to lessen the consequences of an event or to provide a cure. Community prevention relies on two dimensions: time and geography. Geography provides a way for strategic planners to envision communities and not just populations or individuals at risk.” Including geography reinforces the principles of community competence and capacity and infrastructure development. It enables planners and policy makers to envision the community as the defining unit and not just aggregations of individuals. 

Dr. Robinson stresses that community prevention distinguishes between working “with” communities and working “in” communities. “Establishing a program on a street corner that reaches out to the homeless or other strata has merit but should not to be confused with community development or a holistic approach to community competence,” he said. For example, Africans Americans of low socioeconomic status require specific interventions, but given the likelihood that they live in black communities, it is also important that these communities are enabled to better serve their needs. Dr. Robinson also pointed out that this analogy is applicable to other strata or population groups at high risk. 

The resource guide that CDC is developing to help communities use the model to eliminate disparities in tobacco use will be available later this year. For further information, please visit CDC’s Office on Smoking and Health Web site at http://www.cdc.gov/tobacco/ or call 770/488-5705 and press 3 for a publications specialist.

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