From the Schools of Public Health

From the Schools of Public Health ASPH/AMERICAN LEGACY FOUNDATION STEP UP PROGRAM: AN INNOVATIVE PARTNERSHIP FOR TOBACCO STUDIES IN THE SCHOOLS OF PUBLIC HEALTH Andrew E. Balas, MD, PhD Kalpana Ramiah, MSc, MPH, CHES Karen Martin, MIA In 2001, the Association of Schools of Public Health (ASPH) and the American Legacy Foundation teamed up on the Scholarship, Training, and Education Program for Tobacco Use Prevention (STEP UP). This five-year project seeks to accomplish three goals: (1) to increase the number of graduate students and faculty in public health who specialize in tobacco studies and research; (2) to better integrate tobacco-related issues into graduate public health education; and (3) to build a stronger infrastructure for tobacco-related education in schools of public health. The ASPHLegacy partnership aims to increase the visibility of tobacco control topics within the graduate public health educational setting. STEP UP’s ultimate goal is to create sustainable academic environments for training students and to support post-doctoral and faculty development in tobacco prevention and control. This project is consistent with the ASPH’s mission to support and promote research, teaching, service, and practice excellence in the member schools of public health. STEP UP ACTIVITIES AMERICAN LEGACY FOUNDATION AND HISTORY OF THE PARTNERSHIP This country wakes up to a public health tragedy each day. Tobacco-related disease kills 1,200 Americans every day and is the number one preventable cause of death in the United States, yet smoking is not treated with the same sense of urgency as other significant public health threats such as AIDS, alcohol use, and drugs. Public health practitioners—both current and future— are critical to raising the issue of tobacco to the prominence it demands and needs to save lives. However, the public health community first must educate itself more thoroughly, consistently, and widely. Yet somehow schools of public health have not made tobacco control education the priority it should be. Troubled by this situation, the American Legacy Foundation sought a way to reach the institutions that 380 䉫 educate public health professionals, who in turn have tremendous impact on public health policy and practice in this country. The foundation recognized ASPH’s preeminent position in public health and the academic community and asked the association to take a leadership role in inspiring schools of public health to make tobacco control a more prominent topic in the curriculum. The foundation felt that ASPH was well positioned to help schools understand the importance of tobacco control, and through grants, encourage schools to make the systemic changes necessary to institutionalize the topic. The American Legacy Foundation is dedicated to building a world where young people reject tobacco and anyone can quit. Located in Washington, DC, the foundation was created as a result of the 1998 Master Settlement Agreement (MSA) reached between the tobacco industry and attorneys general from 46 states and five U.S. territories. As a national, independent public health foundation, the foundation develops national programs that address the health effects of tobacco use through grants, technical training and assistance, youth activism, strategic partnerships, counter-marketing and grass roots marketing campaigns, public relations, and community outreach to populations disproportionately affected by the toll of tobacco. The STEP UP program was funded under the category of Legacy Evaluation and Research Network (LERN). ASPH has undertaken a number of activities under STEP UP that provide support to faculty and students in member schools who are either already working in tobacco research or interested in pursuing this area. Activities include creating a tobacco use prevention council within the ASPH governing structure, funding faculty and students for tobacco-related research and/ or teaching, conducting a tobacco studies survey in the schools of public health, organizing the first national academic tobacco studies workshop, and developing a tobacco journal supplement. ASPH/Legacy Review Committee A panel of faculty who are experts in tobacco research and education were recruited as members of the ASPH/Legacy Review Committee (ALRC). The deans Public Health Reports / May–June 2004 / Volume 119 From the Schools of Public Health at each member school identified these experts, of whom 10 were chosen. Dean James Merchant (Iowa) was the founding chair. Currently, Dean Andrew Balas (SLU) chairs the ALRC. Committee members are responsible for development of requests for applications (RFAs), review of grant applications, and review of the quarterly progress reports. All funding for STEP UP projects required an objective peer review process. Three grant cycles were held under this project, through which $1.8 million was funded to eligible member schools. ASPH Tobacco Use Prevention Council The ASPH Tobacco Use Prevention Council held its first meeting at the 2001 ASPH annual meeting. This council is charged to advise the deans on tobacco use prevention and control, including curriculum and course development and research as they relate to tobacco issues among member schools of public health. Eligibility is open to all members with expertise in tobacco use prevention. The American Legacy Foundation maintains a permanent seat on the council. The council has met each year during the ASPH annual meeting. STEP UP grants Faculty and students of accredited graduate schools of public health who are members of the ASPH are eligible for STEP UP grants. Grants were awarded under the following categories: pre-doctoral scholarships; doctoral dissertation scholarships; curricular innovation grants; and small grants/pilot study grants. In the last two years, the partnership has funded 22 research and education projects at 11 ASPH-member schools. A total of 41 applications were received and 22 applications were funded, an approval rate of 53.6%. The rigorous review process included evaluation of the program plan, need for the program, support from the school, available experts to conduct the program, and program evaluation. These grants were awarded for one to three years of funding. The progress of grants is tracked by quarterly electronic progress reports. The initial reviewers (three) of each grant provide program oversight by reviewing progress reports and making decisions on 䉫 381 grant requests such as request for a change in the principal investigator, change in scope of work, nocost extension, etc. Pre-doctoral scholarship. STEP UP pre-doctoral scholarships serve as mini-training grants to institutions in which schools are supported in building a critical mass of talented graduates to supplement the existing pipeline of tobacco scholars. Three grants—to the University of California at Los Angeles School of Public Health, University of North Carolina at Chapel Hill School of Public Health, and University of Washington School of Public Health and Community Medicine—were funded under this category. Funds are used for student tuition and/or stipends, program staffing, student travel to conferences, journal clubs, other direct costs, and indirect expenses. Doctoral dissertation scholarships. Doctoral dissertation scholarships help further progress toward strengthening the pool of competent professors and researchers specializing in tobacco studies at the highest levels of academic study. Six doctoral students were funded in this category. Their dissertation topics include Internet cigarette vendors’ reported and actual sales practices to reduce sales to minors; evaluation of cigarette sales practices over the Internet: estimation of risk in adolescent girls regarding nicotine use; effect of state tobacco policies by race and class; a randomized trial to reduce tobacco use at high school sporting events; and smoking cessation in relation to the mortality rate. All the students who were funded had very strong support, guidance, and mentoring from their faculty advisors. In most cases, the faculty initiated the students’ application process. Curricular innovation grants. Curricular innovation grants support interdisciplinary approaches to tobacco research, education, service, policy, and practice. These grants seek to integrate tobacco studies into core graduate public health education and provide a mechanism for graduates to demonstrate competence in tobaccorelated areas. This category attracted the greatest number of applications and comprises the most current grantees. The funded schools are University of California at Los Public Health Reports / May–June 2004 / Volume 119 382 䉫 From the Schools of Public Health Angeles School of Public Health, University of Medicine and Dentistry of New Jersey School of Public Health, Loma Linda University School of Public Health, University of Washington School of Public Health and Community Medicine, University of Iowa College of Public Health, University of South Carolina Arnold School of Public Health, Johns Hopkins Bloomberg School of Public Health, and University of Puerto Rico Graduate School of Public Health. The projects include developing and implementing online training, certificate courses, and modules for incorporation into the core public health curriculum. Small grants/pilot study grants. Small research grants provide opportunities for junior faculty or post-doctorates to explore or build upon work with communities of interest and to advance research in tobacco studies. Tobacco studies survey ASPH conducted a tobacco studies survey among its member schools of public health. The survey aimed to collect baseline information on tobacco-related education and training, tobacco-related grants and contracts, and degrees and certificates offered in tobaccorelated studies. A dean-nominated point person (faculty and/or staff) or ASPH-identified respondent helped gather information from each school for the reporting period July 1, 2001 through June 30, 2002. All 32 schools responded to the survey. This was the first survey conducted by ASPH regarding curriculum and concomitant funding in a specialty area. This survey will be repeated in 2005 to demonstrate the effect of the STEP UP project in ASPH member schools. Survey results. Results of the study provided insight on the levels of tobacco-related education and training, tobacco-related grants and contracts, and degrees and certificates offered in tobacco-related studies at member schools of public health. • Tobacco-related education and training. Some 81% (N⫽26) of the survey respondents offered some kind of tobacco-related education and training. These included courses, modules, conferences, seminars, symposia, workshops, and research projects. Some 53% (N⫽17) of the respondents offered tobacco-related courses for credit. A total of 5,632 individual students and faculty had participated in these trainings during the survey period. • Tobacco-related grants and contracts. A total of 94% (N⫽30) of the respondents had some funding for tobacco activities (for research, training, or outreach). The total funding across the schools was more than $130 million and the average was $4.3 million per participating school. More than half (57%) of the funding came from federal grants and nearly one-third (28%) came from charitable organizations. The rest came from the state (7%), various collaborative funders (6%), and others (universities, etc.). If ASPH/Legacy STEP UP funds were removed from the equation, the total funding to schools of public health would have been reduced by $507,675. • Degrees and certificates offered in tobacco-related studies. Ninety-eight students had enrolled, graduated, or defended as a doctoral student in a tobacco-related area. A total of 176 students had enrolled, graduated, or defended as a master’s student in a tobacco-related area. Eight students had enrolled and graduated in a certificate program in a tobacco-related area. Survey limitations. Several limitations of the survey should be noted: • ASPH did not provide definitions for the educational and training units, therefore these terms were somewhat subject to interpretation; • We have no way to determine certain denominators (e.g., for the total number of students and/or faculty who could have participated in trainings; for the total students enrolled in SPH educational programs; or for those who defended as doctoral or masters students); • If the respondent did not know the number of attendees/enrollees, we counted the event and recorded 0 for the number of attendees/enrollees; • Numbers were rounded if the respondent provided an estimate (e.g., 45–50 was logged as 47); • As requested, most schools of public health reported full funding amount for grants, if the grant was multi-year. However, some respondents reported only single-year grants; • It is not clear if the numbers of students enrolled, graduated, and defending overlap in the individual reports or if the students were different individuals; and • There may be a variation in results due to the dissimilarity in the kind and level of the person serving as each school of public health’s key respondent. National tobacco studies workshop The American Legacy Foundation funded ASPH to organize the first national academic tobacco studies workshop. The workshop, entitled “STEP UP to Public Health Reports / May–June 2004 / Volume 119 From the Schools of Public Health 䉫 383 Table. List of STEP UP projects by school and category Project title School Pre-doctoral scholarships 1. STEP UP Pre-Doctoral Scholarship 2. Pre-Doctoral Tobacco Use Prevention and Control Training Programs 3. Tobacco Studies in Public Health in UW Doctoral dissertation scholarships 4. Internet Cigarette Vendors’ Reported and Actual Sales Practices to Reduce Sales to Minors 5. Promotion and Sales of Low-Priced and Tax-Free Cigarettes on the Internet a 6. Risk Perception of Potential Reduced-Exposure Products in Adolescent Girls and Their Likelihood to Use Nicotine Products 7. How Do the Effect of State Tobacco Policies Differ by Race and Class? A Multi-level Analysis 8. Randomized Trial to Reduce Tobacco Use at High School Sporting Events 9. Smoking Cessation in Relation to Mortality Rates UCLA UNC UW UNC UNC JHU Harvard UNC Harvard Curricular innovation grants 10. STEP UP Curriculum Development 11. Comprehansive Tobacco Control: Web-based Integration into the Public Health Curriculum 12. Certificate of Tobacco Prevention and Control Methods: A New Approach to Educate Health Professionals 13. Tobacco Studies and Public Health at the University of Washington 14. Integrating Tobacco into a Public Health Curriculum 15. STEP UP USC 16. Tobacco Control Educational Resources On-Line 17. Training the Trainer in Tobacco Use Prevention Project LLU UW Iowa USC JHU UPR Small grants/pilot study grants 18. Poverty, Childcare Responsibility and Women’s Smoking 19. Access to Bidis Among Adolescents in New Jersey 20. Integrating Smoking Cessation in a Homeless Shelter: A Demonstration Project 21. Does Guided Imagery Help Adults Quit Smoking? A Randomized Pilot Study Harvard UMDNJ Columbia Harvard UCLA UMDNJ a Completed project UCLA = University of California at Los Angeles School of Public Health UNC = University of North Carolina at Chapel Hill School of Public Health UW = University of Washington School of Public Health and Community Medicine JHU = The Johns Hopkins Bloomberg School of Public Health UMDNJ = University of Medicine and Dentistry of New Jersey School of Public Health LLU = Loma Linda University School of Public Health Iowa = University of Iowa College of Public Health USC = University of South Carolina Arnold School of Public Health UPR = University of Puerto Rico Graduate School of Public Health Tobacco Control: Advancing the Role of Public Health and Public Health Professionals,” aims to promote the development of education in tobacco control and to enhance participation in tobacco studies, tobacco research, and competency-based training among graduate public health students and professionals. The three-day workshop includes a poster session by STEP UP grantees and other tobacco scholars in schools of public health and from other health professional schools. The workshop agenda is focused on tobacco studies in schools of public health, particularly the successes and challenges. In addition to the poster session, the workshop includes panels on defining the challenge for academic-practice infrastructure and application, competencies, reaching the next generation of public health professionals, supporting fac- Public Health Reports / May–June 2004 / Volume 119 384 䉫 From the Schools of Public Health ulty and administrators, enriching tobacco education efforts through partnerships, funding opportunities, and STEP UP grants. Faculty members or graduate students engaged in tobacco-related research and/or teaching or those interested in learning more about this field stand to benefit from this workshop. Speakers include academics, government, private funders, practitioners, and students. Tobacco journal supplement Planning for a tobacco journal supplement is underway as part of the STEP UP project. The pending journal supplement aims to showcase tobacco studies that are taking place in the schools of public health. This will include grants funded under the STEP UP project. The journal is anticipated to be published in 2005. This journal will also serve as a touchstone for the schools of public health to support tobacco studies in the schools of public health. • • • LESSONS LEARNED The STEP UP project demonstrates a successful partnership that has increased the number of faculty and/ or students interested in tobacco research and has increased the tobacco-related curricular offering at graduate level. This project was the first undertaken by ASPH to support one particular specialty in public health. The project was implemented with few problems due to wholehearted support from the American Legacy Foundation and expert guidance from review committee members. As a pilot project, STEP UP has highlighted some key lessons: • Need for infrastructure to initiate the project. Some smaller schools with less capacity were less likely to undertake a STEP UP project. There was a gap in STEP UP participation between larger schools—which demonstrate a greater number of full-time equivalent (FTE) faculty and were more likely to apply for and receive STEP UP funding—and smaller schools, which applied less often and were funded less often. • Clause 12. Grants awarded under this program required that the dean or CEO of the school of public health confirm that the school of public health does not currently accept nor will accept any grant or anything else of value from any tobacco manufacturer, distributor, or other tobacco-related company during the grant period. This restriction is a policy of the American Legacy Foundation and applies to all of the foundation’s grantees and sub-grantees. This clause imposed • • a major obstruction for some schools to apply for the STEP UP funding. The schools unwilling to agree to this clause saw it as a hindrance to academic freedom, even if they disagreed with the ethics of taking tobacco money. Restriction on global health studies. The American Legacy Foundation cannot support activities conducted outside of the United States. This restriction prevented students who were interested in international health from participating in STEP UP. Saturation point. Though all ASPH schools were informed about this unique opportunity of funding through many different channels, it appeared that the same dozen schools (over 30% of the ASPH eligible membership) repeatedly competed for the available funding. It seems, therefore, that ASPH members have reached a saturation point regarding their likelihood to compete. Tobacco is no longer considered a “public health problem.” Due to the events of September 11, 2001, and pressing public health alerts about obesity, SARS, and other contemporary problems, the public health community has shifted away from a focus on tobacco. It seems that the academic public health community has lost interest in tobacco after the successful battle that resulted in the MSA. Amount of funding. Annual funding for each of the grant categories (including indirect costs) are: pre-doctoral scholarship grants, $30,000; doctoral dissertation scholarships, $30,000; curricular innovation grants, $50,000; and small grants/pilot study grants, $20,000. This level of funding was considered minimal for the amount of work that goes into developing an application, actual project work, reporting, and other aspects of project implementation. A maximum of 8% indirect costs was allowed for all categories other than doctoral dissertation. This allocation for indirect costs is also not very appealing to school administrators. Re-categorization. During the course of the project, the committee and project members realized that pre-doctoral scholarship grants and curricular innovation grants could possibly interface in one grant category. As these grants focused on building the tobacco workforce by scholarships and increased course work, it was more rational to combine these two grants. The committee therefore decided to merge these two categories in Public Health Reports / May–June 2004 / Volume 119 From the Schools of Public Health the last grant round and fund for a maximum of $80,000 per year for each approved grant. Two applications were received for this category. However, none were approved for funding. • Lessons from the institutional grants. The curricular innovation grants faced some barriers during the course of the project. Principal investigators expressed problems getting faculty support from their schools to incorporate course modules in the core public health curriculum. This was not necessarily due to lack of interest for tobacco, but due to a tight curriculum and the tedious process involved in incorporating or creating new courses in the schools in graduate public health education. • Sustainability of the project. No additional funding is currently expected for the STEP UP project. The schools and the faculty (principal investigators) are left with the challenge of sustaining courses and modules that had been developed with STEP UP funds. Without grant funds there is less incentive for a school or a faculty to sustain incorporation of tobacco-related education in his/her school. In conclusion, after nearly three years, the partnership between ASPH and the American Legacy Foundation continues to be a success in one very important respect: STEP UP has brought to life innovative tobacco projects in the nation’s best schools of public health. Due to the challenges described above, there 䉫 385 has not been maximum utilization of the funds provided by the American Legacy Foundation. Some schools’ lack of infrastructure to support research projects, the controversy regarding the restriction on acceptance of tobacco-related funds, the restriction on global health studies, a reduced focus on tobacco as a public health issue in light of other public health problems, the relatively small size of the grants, and problems incorporating a course/module in the curriculum are some of the challenges faced by potential applicants as well as existing grantees. STEP UP has successfully stimulated schools of public health to support more faculty and students in the field of tobacco prevention and control and those interested in pursuing careers in tobacco studies. ASPH and the American Legacy Foundation hope to continue this partnership into the future in order to further accentuate tobacco as an important research, teaching, and practice issue. Such collaboration on behalf of tobacco use prevention and control will have clear benefits for the health of the public. Andrew Balas is with the School of Public Health, Saint Louis University, St. Louis, MO. Kalpana Ramiah is with the Association of Schools of Public Health, Washington, DC. Karen Martin is with the American Legacy Foundation, Washington, DC. Address correspondence to: Kalpana Ramiah, MSc, MPH, CHES, Association of Schools of Public Health, 1101 15th St. NW, Ste. 910, Washington, DC 20005; tel. 202-293-1099; fax 202-2961252; e-mail <kramiah@asph.org>. Articles for “From the Schools of Public Health” focus on practice-related collaborations between the schools and non-academic partners. Abstracts (approximately 250 words) should be submitted to Michael Maetz, School of Public Health, University of Alabama at Birmingham, RPHB 220, 1530 3rd Avenue S., Birmingham, AL 35294. Public Health Reports / May–June 2004 / Volume 119