Noncommunicable diseases (NCDs) are the leading cause of illness and death in high-income countries and are emerging as a leading cause of death in low- to middle-income countries (¹). However, countries at all income levels (high, middle, and low) often lack sufficient resources and capacity to address this issue (^2-4).

There have been notable examples of collaboration between cancer prevention and tobacco control organizations in the United States and Canada (⁵). Tobacco control is the highest priority prevention component to reduce cancer mortality and a major modifiable risk factor to control the growing epidemic of NCDs (⁶). A focus on common modifiable risk factors is an opportunity to maximize available resources for NCDs and can serve as a unifying framework for collaborative organizational relationships that can increase the efficiency, effectiveness, and sustainability of public health efforts (^7-9). Although the need to collaborate is well recognized, substantial barriers to collaborations exist between public health organizations, including tobacco and cancer control programs. By focusing on the similarities between cancer prevention and tobacco control, much can be learned about future efforts for these programs and for the NCD agenda.

Despite their common focus on reducing tobacco use, substantial misunderstandings and myths have created barriers to working relationships between the tobacco control and the cancer prevention communities (¹⁰). Ameliorating these barriers requires sharing information, building trust, understanding differing organizational cultures and processes, and emphasizing the fundamental interconnections of these 2 disciplines (¹⁰). Working toward a shared vision of how resources are appropriated is also essential because competition for scarce resources is an important barrier to collaboration (¹¹) and without systematic planning, programs often prioritize treatment-oriented interventions at the expense of primary prevention (including tobacco control), early detection, and palliative care (⁶). Furthermore, differing expectations for success, as defined by a treatment-oriented versus a prevention-oriented program, are difficult to reconcile. For example, a cancer treatment with a 10% success rate is considered poor, whereas a population-wide intervention such as a tax increase that results in a 5% or 10% reduction in tobacco use is a major success (¹¹). Moreover, an effective treatment quickly yields reductions in cancer deaths, whereas an effective tobacco prevention intervention does not yield a reduction in cancer incidence and illness for decades. A shared definition of program success could provide a framework for collaboration between cancer prevention and tobacco control programs.

Our objective was to define a successful program in terms of how experts in cancer prevention and tobacco control described, categorized, and rated its components. We used concept mapping to examine the extent to which these 2 fields shared a common conceptual framework for program success.

We used concept mapping to identify and organize best practices common to both the tobacco control and cancer prevention communities. Concept mapping is a type of Delphi method, a participatory process in which findings represent the ideas of those who contribute. As a mixed-methods planning and evaluation approach, it integrates familiar qualitative group processes (brainstorming, categorizing ideas, and assigning value ratings) with multivariate statistical analyses to help a group describe its ideas on any topic of interest and represent these ideas visually through a series of maps (¹²,¹³).

Thirty-seven of the 70 original invited participants (53%) completed the brainstorming task. Of the 80 participants (the 70 original participants plus an additional 10) invited to complete the sorting and rating task, 33 (41%) completed it, a response rate comparable to published web-based survey response rates of 31% (¹³). Approximately 50% of the participants who completed the sorting and rating task were recipients of GHP funding. Their areas of expertise, experience, and geographic areas are described in Box 1.

The final map that resulted from the sorting and rating task (Figure) shows that 8 major clusters (or constructs) were considered essential in defining what constitutes a successful tobacco control or cancer prevention program. Cluster location also reflects relationship between these clusters to show how these clusters are connected to each other. Three sectors structure the 8 clusters into a 3-section map: the human and relational sector, program capacity sector, and technical and scientific sector.

Moving from the lower left side of the map through each sector, the following summarizes the 8 clusters:

In this analysis, cancer prevention and tobacco control experts identified a set of common components that characterized successful programs for both fields. Rather than focusing on the standard outcomes most frequently considered to be evidence of success, such as decreases in prevalence, incidence, illness, and death, participants focused primarily on the resources and capacity a program needs to effectively plan, implement, and sustain program activities and on the use of evidence-based information to guide program activities and achieve program goals. Since "collaboration takes a significant investment of time to build trust, to overcome differences in perspective, and to develop a workable, concrete agenda for joint action" (¹²), the time to build collaboration is during the initial planning phase of program development. This process could help reduce the cost of building separate resources and capacity for cancer prevention and tobacco control programs.

Both cancer prevention and tobacco control experts perceived all 8 clusters as important to success, rating all clusters between 4.0 and 4.2. The only significant difference in ratings focused on partnerships. The lack of difference was surprising because cancer prevention programs traditionally focus on program implementation such as screening and treatment, whereas tobacco control programs have historically focused on policy change (¹²). It does, however, suggest opportunities for each field to learn from the other. For example, cancer control programs seeking to integrate best practices for cancer screening, treatment, and palliative care into systematic practice could adapt some of the strategies tobacco control has successfully used toward smoke-free air policies and adoption of cessation practices in health care settings. Likewise, tobacco control programs that could be rejected for political and policy reasons may be more acceptable to national governments if housed within a comprehensive cancer prevention program (⁷).

Similarly, both sets of experts acknowledged the importance of surveillance and monitoring, including the importance of measuring both process and outcome indicators. The focus on leadership within both the sustainability and advocacy and persuasion clusters presents an opportunity to develop and collect common process indicators. The higher perceived importance that cancer experts assigned to partnerships may indicate how essential collaborations are to effectively integrate the diverse approaches and organizations required to successfully implement all 4 components of cancer control — from prevention to early detection through treatment and palliative care — and further to integrate multiple and widely varied cancer types within a comprehensive cancer model. Cancer experts can use their expertise and experience in partnership building to facilitate collaborations with tobacco control programs.

Our results represent the views and opinions of a small sample of experts in tobacco control and cancer prevention. However, concept mapping is a technique that has been used to develop frameworks that can be adapted to similar contexts and thus does provide a basis for generalization. In this case, we are comparing tobacco and cancer organizations. The results can be generalized to other groups or organizations that are working on prevention and control issues, especially those related to NCDs (http://www.socialresearchmethods.net/kb/external.php3) and thus could prove useful as the dialogue concerning NCDs continues to develop.

Most low- and middle-income countries lack the basic knowledge and capacity to plan and implement separate cancer prevention and tobacco control programs (⁶) and thus also lack the resources, capacity, and political will to implement comprehensive programs to address modifiable NCD risk factors (¹⁶). Organizations should plan integrated interventions and pool limited resources before separate programs are institutionalized. Collaborative relationships also engage stakeholders with access to global and national leadership. Building collaborations during the planning phase is consistent with World Health Organization (WHO) recommendations for national cancer prevention program planning in countries of all income levels. Those recommendations include building the capacity to implement and sustain core functions of a comprehensive cancer control program that includes tobacco control as a key component of prevention (⁶). Collaboration building is also consistent with WHO recommendations for preventing NCDs through an integrated approach to addressing modifiable risk factors (¹⁷).

Tackling modifiable risk factors through prevention is essential to successfully ameliorating the coming epidemic of NCDs in low- and middle-income nations (¹⁷). However, collaborative relationships between allied organizations are essential to effective use of limited resources; without comprehensive planning, treatment may be prioritized at the expense of prevention (⁶). Our findings demonstrate that cancer prevention and tobacco control programs have the opportunity to integrate their approaches to cancer and more broadly to NCD prevention as low- and middle-income countries develop comprehensive plans to address the modifiable risk factor they share: tobacco use.

Content source: National Center for Chronic Disease Prevention and Health Promotion

Suggested citation for this article: Stillman FA, Schmitt CL, Rosas SR. Opportunity for collaboration: a conceptual model of success in tobacco control and cancer prevention. Prev Chronic Dis 2012;9:110067. DOI: http://dx.doi.org/10.5888/pcd9.110067.

Funding for this manuscript was provided by the Pfizer Foundation through its Global Health Partnership Program.