In the South Pacific, on the tiny island of Guam, one person dies every day from tobacco-related causes. That’s both statistically significant and emotionally compelling in a place so small that practically everyone knows everyone else. And it's the reason why the U.S. Territory’s State Epidemiological Outcomes Workgroup (SEOW)—formed with funding from the Substance Abuse and Mental Health Services Administration (SAMHSA)—prioritized tobacco for its substance abuse prevention efforts, which focused on improved data collection, public education, and increased tobacco regulations.
"Data isn’t just for defining problems," said Dr. Annette David, a representative from Guam’s SEOW. "It also helps to build a compelling case for what works and what doesn’t; it is a valuable monitoring and evaluation tool. But you have to use it, work with it, and tell stories with it, not just gather it."
Filling Data Gaps, Prioritizing Tobacco
Almost all states, territories, and jurisdictions have received funding from SAMSHA to create an SEOW, which are networks of people and organizations that bring substance abuse and mental health data, analytical thinking, and epidemiological capacity to the forefront of prevention planning and decision-making.
"When we formed our SEOW and brought all the data pieces together for the first time, we saw that we had lots of good information, but it was in pieces and spread across many different agencies and organizations," said David. "No one was really looking at it or interpreting it in a comprehensive way."
David went on: "The SEOW put the data together to help us understand more about substance use and mental health on the island, but even then we still couldn’t see the big picture," she said. "For example, we had a lot of information on some types of substance use in certain populations groups, but not in others. We had to fill in the gaps first to really understand where our prevention challenges lay."
According to David, rather than creating a new tool for collecting the data needed to fill in the gaps, the SEOW instead worked on adding questions to and expanding use of existing survey tools, including the federally developed, widely-used, and well-tested Behavioral Risk Factor Surveillance Survey (BRFSS) and the Youth Risk Behavior Survey (YRBS). For example, questions regarding illicit drug use among adults were added to Guam’s BRFSS, and Guam’s Department of Youth Affairs, which works with at-risk youth, agreed to administer the YRBS to adolescents not in the educational system—a high-risk population that had not previously been surveyed.
"The additional data helped us paint a clearer picture. As a result, we were able to identify tobacco as one of our biggest challenges and a critical prevention priority," said David.
The data also helped shape the group’s prevention message. "Using the data, we made our message simple and clear: 'Tobacco kills at least one person in Guam every day.' That really got peoples' attention. We also pointed out that the top three causes of death on the island are tobacco-related, and we were able to drill down into other useful details and present those to policymakers and the public."
Those additional details include the fact that smoking prevalence in Guam is higher than in most U.S. states and territories. According to an SEOW fact sheet, one-quarter of adults and one-fifth of youth in Guam are smokers. Further, adult men in Guam smoke more than adult women, but women in Guam smoke more than men in the U.S. They also found that smoking rates are highest among residents with the lowest incomes and education levels, and disproportionately high among the island’s indigenous populations.
Using Data to Call for Policy Changes
Guam's SEOW also used data to identify appropriate policy interventions. "We could look back over data collected since the 1990s and see that smoking rates went down in the years immediately following a tobacco policy change," said David. "For example, following a devastating typhoon in 2003, the tobacco tax went up to $1.00 per pack to help raise revenue for rebuilding the island, and smoking rates went down as a side effect. We saw that again when we were able to get a second-hand smoke law passed in 2006 and smoking rates went down in 2007."
Armed with this information, in 2010, agencies involved with the SEOW and other organizations interested in improved public health advocated for another $1.00 per pack tax increase on cigarettes as a way to reduce consumption. "That tax increase was so well-received," said David, "that it eventually passed as a $2 per pack increase and, in 2011, smoking rates went down again."
David said that the arguments made by the SEOW and its partners included educating policymakers and the public about what they could expect from the legislation in terms of data outcomes—how many lives would be saved, how many young people wouldn’t become smokers, etc. They also linked the tax increase to a cancer trust fund, promising to put some of the tax revenue into the fund. As a result, families that had been negatively impacted by the costs of cancer treatment testified before lawmakers and told their stories about the negative impact of smoking on their lives.
According to David, over the last 10 years, Guam has enacted six new laws controlling tobacco and alcohol use. Smoking rates have decreased 10 percent among youth and three percent among adults. Similar decreases also been seen in alcohol consumption, which is also another focus for prevention efforts on the island.
"The 2010 tobacco tax wasn’t an easy thing to pass," said David. "There were certainly detractors, powerful people on the opposite side who did not want us to succeed. But, our emotional and economic appeals, supported by compelling data, won the day."