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STRATEGIZER56

The document discusses strategies for creating healthy, tobacco-free environments. It begins with background on the tobacco epidemic in the U.S., noting that tobacco use is the leading cause of preventable death and kills over 400,000 people per year. It then outlines four strategies: 1) reducing tobacco use initiation among youth, 2) restricting minors' access to tobacco products, 3) reducing exposure to secondhand smoke, and 4) increasing tobacco cessation. It provides case studies showing how communities have implemented these strategies successfully. The importance of building partnerships is also discussed.

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STRATEGIZER 56 Creating Healthy, Tobacco-Free Environments
H Table of Contents This publication was developed by Community Anti-Drug Coalitions of America (CADCA) and supported by a grant from the Robert Wood Johnson Foundation (RWJF). Special thanks to the Smoking Cessation Leadership Center (SCLC) at the University of California, San Francisco for their time and contributions to this publication. Introduction, Background and Purpose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Tobacco Epidemic in the U.S.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Strategy I: Reducing Tobacco Use Initiation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Case Study: Youth in Missouri and Minnesota Take Action to Reduce Tobacco Use. . . . . . . . . . . . . 9 Strategy II: Restricting Minors’Access to Tobacco Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Strategy III: Reducing Exposure to Environmental Tobacco Smoke . . . . . . . . . . . . . . . . . . . . . . . . 14 Case Study: The Tobacco Free Community Partnership and the Partnership. . . . . . . . . . . . . . . . . . 15 of Community Resources Curb Secondhand Smoke Strategy IV: Increasing Tobacco Use Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Case Study: The Southern Coalfields Tobacco Prevention Coalition . . . . . . . . . . . . . . . . . . . . . . . . 19 Network (SCTPCN) Tackles Maternal Smoking Prevention Importance of Building Community Partnerships. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Helpful Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3 H he perception of tobacco use has changed with each progressing generation in the United States. We’ve shifted from a country whose doctors “prescribed” Lucky Strike brand cigarettes to patients alongside their antibiotic treatment, to a society in which system changes are now equipping healthcare providers with tools and knowledge about evidence-based tobacco cessation practices. Before the hazardous health effects of smoking were widely known and accepted, cigarette companies were able to advertise essentially regulation-free. From the late 1700s, the companynowknownasLorillardTobaccoCompany is credited with placing the very first tobacco advertisement in the United States promoting their snuff in a local New York newspaper.1 The 2009 Family Smoking Prevention and Tobacco Control Act now gives the Food and Drug Administration (FDA) the authority to regulate the manufacture, distribution and marketing of tobacco products to protect the public’s health.2 Cigarette smoking and other tobacco use were socially acceptable once upon a time – creating an era when smoking and nonsmoking sections separated patrons in trains, airplanes, office buildings and restaurants. The regard for the health of nonsmokers was not yet warranted above the common belief that smoking was not hazardous. Today, public health professionals and researchers in the United States are offering a different objective and have 1. James, Randy. “Cigarette Advertising” (2009). Time Magazine. Available at: http://www.time.com/time/magazine/article/ 0,9171,1905530,00.html. 2.  U.S. Food and Drug Administration Website. Family Smoking Prevention and Tobacco Control Act, Public Law 111-31, 123 U.S. Statutes at Large 1776 (2009). Available at: http://www.fda.gov/ TobaccoProducts/GuidanceComplianceRegulatoryInformation/ ucm246129.htm. unequivocal evidence to substantiate that there is no safe level of tobacco use, period. The purpose of Strategizer 56 is to highlight the statistically significant measures that amplify the scientific conclusions regarding the harmful effects of tobacco use, interventions that reduce access to tobacco products and evidence-based models that increase tobacco cessation.Tobacco use remains the number one cause of preventable death in the United States killing nearly 100 million worldwide in the 20th century. Contributing to more than 400,000 deaths per year, tobacco ranks higher in annual deaths toAIDS, alcohol abuse, car accidents, illegal drug abuse, murders, suicides and fires combined. More than 13 percent of those deaths represent men, women and children whose lives were lost due to secondhand smoke exposure,3,4 meaning they never even picked up a cigarette. The numbers don’t lie and the advancements in science have put public health advocates in a position to win the fight against “Big Tobacco.” Grassroots experience and evidence-based “change agents” have identified 3. McGinnis J, Foege WH. Actual Causes of Death in the United States. Journal of American Medical Association 1993; 270:2207-12. 4. CDC. Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000-2004. Morbidity and Mortality Weekly Report 2008; 57(45):1226-8. T Today, public health professionals and researchers in the United States are offering a different objective and have unequivocal evidence to substantiate that there is no safe level of tobacco use, period. Introduction Tobacco use is a major public health concern, ranking higher in annual deaths to AIDS, alcohol abuse, car accidents, illegal drugs, murders, suicides and fires combined.
H 4 proven, cost-effective strategies that prevent youth from starting, help current users quit and protect everyone from secondhand smoke exposure. Communities throughout the country have made strong, sustainable strides in tobacco control and some of those reviewed case studies will be highlighted in this publication. According to the 2010 Annual Survey of Coalitions administered to all CADCA coalitions, 59 percent of coalitions are directly addressing tobacco use in their community, 35 percent of coalitions are addressing smoking cessationand77percentofcoalitionrespondentsare collecting data on tobacco use in their community. Over 20 percent of CADCA coalitions surveyed ranked tobacco use in their top three community priorities.TheTask Force on Community Preventive Services (TFCPS), an independent, non-federal, unpaid body, appointed by the Director of the Centers for Disease Control and Prevention (CDC), developed the Guide to Community Preventive Services. The Community Guide is a compilation of all TFCPS reviews, findings, and recommendations regarding community-based health promotion and disease prevention programs, services, and policies in high-priority topic areas. The TFCPS members represent a broad range of research, practice, and policy expertise in community preventive services, public health, health promotion, and disease prevention. The TFCPS, established in 1996 by the U.S. Department of Health and Human Services (HHS), provides evidence-based recommendations about community preventive services, programs, and policies that are effective in saving lives, increasing longevity, and improving Americans’ quality of life.5 The data analysis, recommendations and conclusions outlined in this publication will be drawn from the Community Guide, the 2012 Report of the Surgeon General on Tobacco and the 2006 Robert Wood Johnson Foundation’s Series on Health Policy: Tobacco Control Policy. Tobacco Epidemic In the U.S. Tobacco Epidemic: The Science Tobacco use remains the largest cause of preventable morbidity and mortality in the United States. According to the CDC, tobacco is recognized as a cause of multiple cancers, heart disease, stroke, complications of pregnancy and chronic obstructive pulmonary disease.6 It is important to continue to encourage individuals to adopt a tobacco-free lifestyle by choosing to avoid all types of tobacco products: cigarettes, cigars, cigarillos, smokeless tobacco, pipes and hookahs. Every day, nearly 4,000 young people try their first cigarette—approximately 1,000 of them become addicted. More than 80 percent of adult cigarette 5.  The Guide to Community Preventive Services website. Available at: http://www.thecommunityguide.org/about/aboutTF.html. 6.  CDC. Vital Signs: Current Cigarette Smoking among Adults Aged >=18 Years—United States, 2005--2010. September 9, 2011, MMWR 2011; Vol 60(35); 1207-1212. Retrieved from http://www. cdc.gov/mmwr/preview/mmwrhtml/mm6035a5.htm.
H 5 smokers began smoking before their 18th birthday. Studies have shown that children of parents who smoke are twice as likely to become smokers themselves. High rates of smoking in the United States expose more than 88 million people to secondhand smoke on a regular basis.7 Tobacco Epidemic: The Face. I am Marie and I began smoking in high school with my friends. It was the thing to do and we thought it made us look older. I smoked for 40 years, although I tried several times to stop. I would quit smoking for up to nine months at a time, but something—an issue at work or a problem with the kids—would inevitably trigger a relapse. Back when I was a key puncher for a brokerage house in New York City, you could smoke in the office. Even while I smoked, I would encourage colleagues to walk and get exercise during their lunch breaks. It was during these walks that I felt something wasn’t right because my legs would stiffen up. In 1993, I was diagnosed with Buerger’s disease, a disorder linked to tobacco use that causes blood vessels in the hands and feet to become blocked and can result in infection or gangrene. It took a year for the diagnosis to be confirmed. I was taking painkillers every day because of the excruciating pain. Over time, parts of my body: feet, fingertips, and lower legs, were amputated. And, when I was 45, I had a below-the- knee amputation of my left leg. Then my fingers began to go. In 2006, I finally quit smoking for good with the help of (nicotine) patches. I wanted to be able to see my grandchildren and great- grandchildren grow.8 7.  Dube SR, McClave A, James C, Caraballo R, Kaufmann R, Pechacek T. Vital Signs: Current Cigarette Smoking Among Adults Aged >=18 Years—United States, 2009. MMWR. September 10, 2010. 59(35); 1135-1140. 8. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion. “Tips from Former Smokers” Campaign. Available at: http://www.cdc.gov/tobacco/ campaign/tips/. Tobacco Epidemic: Federal Response It is stories like Marie’s that the federal government is hoping to evoke action among tobacco prevention advocates and the courage to quit among smokers through the Tips from Former Smokers initiative. Launched in March 2012 by the CDC, the campaign features real people suffering as a result of smoking and exposure to secondhand smoke. Their compelling stories send a powerful message: Quit smoking now or better yet—don’t start. Public health professionals have taken a significant step to reduce tobacco use and exposure from the deadly chemicals produced from tobacco products to focus on keeping youth and young adults from ever starting.9 However, access to tobacco products is increasingly easier as “Big Tobacco” continues to market new products like snus, orbs, sticks, strips and other smokeless tobacco products that resemble candy or mints, making them more enticing for youth. The Tips from Former Smokers initiative is a bold step to prevent young people from starting to use tobacco and helping those who smoke quit. Recent milestones in President Obama’s administration’s agenda include the passage of the Family Smoking Prevention and Tobacco Control Act, which gives the FDA authority to regulate tobacco products to prevent use by minors. According to the Director of the CDC, Thomas R. Frieden, M.D., M.P.H., there is sound evidence that supports the use of the types of hard-hitting images and messages such as those featured in the Tips from Former Smokers initiative to encourage smokers to quit, to keep children from ever beginning to smoke, and to drastically reduce the harm caused by tobacco.10 9.  Department of Health and Human Services. (2012). CDC Ad Campaign Reveals Harsh Reality of Smoking-related Diseases: “Tips from Former Smokers” shows real lives and bodies damaged by tobacco [Press Release]. Retrieved from http://www.hhs.gov/ news/press/2012pres/03/20120315a.html. 10.  Department of Health and Human Services. (2012). CDC Ad Campaign Reveals Harsh Reality of Smoking-related Diseases:
H 6 Why DoYoung People Smoke? It is important to understand why young people begin using tobacco in order to present innovative strategies at reducing use among this population. According the 2012 Surgeon General Report on Tobacco, youth progress from early cigarette trials to intermittent use to regular use and dependence. The factors that stimulate early cigarette trials may be distinctly different from those that influence progression and persistence. The Surgeon General’s report goes on to suggest that the decision to smoke by young people is a multi-determined behavior – no one factor leads to their decision to smoke. It is influenced by overlapping combinations of biological, psychosocial, and environmental factors that function as risk or protective measures.11 Adolescence is an impressionable period of one’s life and a time that’s strongly encouraged to explore and experience new things. Community efforts must include the voice of teens to promote peer-to-peer guidance and deterrence from tobacco. Teen advocates against tobacco are the industry’s worst enemy – state supported resources provide young people with a platform to invigorate new social norms that parallel healthy lifestyle behaviors. SOLUTIONS: How can communities help keep teens and young adults tobacco-free? • Change Social Norms Create a world where seeing people smoke or use other tobacco products is the exception, not the norm (Ex. Establish tobacco-free city/ county ordinances; work with retailers to remove tobacco displays). “Tips from Former Smokers” shows real lives and bodies damaged by tobacco [Press Release]. Retrieved from http://www.hhs.gov/ news/press/2012pres/03/20120315a.html. 11.  Department of Health and Human Services (DHHS). Preventing Tobacco Use among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012. • Restrict Access Take steps that make it harder for youth to use tobacco, such as raising cigarette prices and enforcing laws that prohibit the sale of tobacco to children (Ex. Work with law enforcement officials to perform routine compliance checks at tobacco retail establishments). • Limit the Influence Further limit tobacco marketing that is likely to be seen by young people (Ex. Encourage local community event planners not to accept tobacco sponsorship at state fairs, rodeos, etc.). • Limit Media Exposure Limit youth exposure to smoking in movies and other media (Ex. Support the efforts spearheaded by the Campaign for Tobacco Free Kids to change movie ratings that feature characters using tobacco products). • Promote Comprehensive Education Educate young people and help them make healthy choices (Ex. Recruit and train youth leaders that can provide peer-to-peer encouragement to be tobacco-free). • Set the Example Encourage young people to avoid tobacco use by quitting and talking to them about why you or someone you know quit (Ex. At every op- portunity, be honest with young people about your choices and how it has affected your life). Using the Community Guide Recommendations In selecting and implementing interventions, it is recommended that communities develop and maintain a comprehensive, multifaceted strategy to reduce exposure to environmental tobacco smoke (ETS), reduce tobacco use initiation, and increase tobacco use cessation. Improvements in each category will contribute to reductions
H 7 in tobacco-related morbidity and mortality, and success in one area may contribute to improvements in the other areas as well. Although theTFCPS has provided assessments for individual interventions or intervention combinations, comprehensive community efforts will require the implementation of multiple interventions to address tobacco use and exposure to ETS in diverse settings and populations. The recommendations provided in this report can assist communities in assembling a comprehensive program consisting of interventions with demonstrated evidence of effectiveness. When selecting interventions to meet local objectives, take into consideration REDUCING TOBACCO USE INITIATION Increasing the unit price of tobacco products: include legislation at the state or national level to raise the product excise tax Recommended Mass media campaigns: mass media interventions of an extended duration, using brief, recurring messages to inform and to motivate children and adolescents to remain tobacco-free Recommended; when combined with other interventions RESTRICTING MINORS’ ACCESS TO TOBACCO PRODUCTS Increasing the unit price of tobacco products Strongly recommended Community engagement with additional interventions Recommended Community education about youth access to tobacco products when used alone Insufficient evidence; when used in isolation of other interventions Active enforcement of sales laws directed at retailers when used alone Insufficient evidence Retailer education with reinforcement and information on health consequences when used alone Insufficient evidence Retailer education without reinforcement when used alone Insufficient evidence Laws directed at minors’ purchase, possession, or use of tobacco products when used alone Insufficient evidence Sales laws directed at retailers when used alone Insufficient evidence REDUCING EXPOSURE TO ENVIRONMENTAL TOBACCO SMOKE (ETS) Smoking bans and restrictions: are policies and regulations that ban or limit the consumption of tobacco products in designated areas. Recommended; used alone or as part of a multicomponent commu- nity or workplace intervention Community education to reduce exposure in the home: provides informa- tion to parents, other occupants, and visitors to the home about the impor- tance of reducing or eliminating ETS to protect nonsmoking adults and children Insufficient Evidence; insufficient number of studies for assessing the effectiveness of the intervention DECREASING TOBACCO USE AMONG WORKERS Smoke-free policies to reduce tobacco use Recommended Incentives competitions Insufficient Evidence; when used in isolation of other interventions Incentives competitions when combined with additional interventions Recommended INCREASING TOBACCO USE CESSATION Smoking bans and restrictions Recommended Community education to reduce exposure in the home Insufficient evidence Table 1: Community Guide Recommendations Source: The Guide to Community Preventive Services
H 8 whether your coalition has the necessary resources, what other organizations or agencies in your community are already doing, and current ordinances or policies currently in place. The TFCPS recommendations are based primarily on the evidence of effectiveness of interventions as implemented, evaluated, reported, and published. A TFCPS finding of insufficient evidence does not imply evidence of ineffectiveness of the intervention, but does identify areas of uncertainty and specific continuing research needs. In these instances it should not be inferred that the targeted outcomes are not important in a comprehensive community effort. Strategy I: Reducing Tobacco Use Initiation Tobacco use remains excessively high despite nearly four decades of policies, regulations, educational efforts and increasing information on the negative health effects of tobacco use and the positive health benefits of cessation. Tobacco use initiation and the transition from experimentation to addiction are not easy to prevent because they occur primarily in adolescence, when individuals are more susceptible to influences from family, friends, peers, society and the tobacco industry that encourage tobacco use. Children and adolescents may perceive tobacco use to be normal peer and adult behaviors, and often act on this belief because tobacco products are readily available and accessible.12 The main regularity in youth smoking research observed by sociologists and psychologists is that youth are more likely to smoke if their parents, siblings and peers also smoke. Age of onset of smoking is negatively correlated with the amount smoked and the incidence of negative health effects.13 12.  Zaza, Stephanie; Briss, Peter A.; Harris, Kate W. “The Guide to Community Preventive Services: What Works to Promote Health?” Part I: Changing Risk Behaviors and Addressing Environmental Challenges. Oxford University Press. 2005. 3 - 79. 13.  Isaacs, Stephen L., Knickman, James R., Warner, Kenneth E. (2006). Robert Wood Johnson Foundation Series on Health Policy: Healthy People 2010 is an initiative introduced by HHS in 2000 that provided science-based, 10-year national objectives for improving the health of all Americans. The following objectives related to reducing tobacco use initiation were identified: • Reduce cigarette smoking from 24 percent to 12 percent among adults; • Reduce use of tobacco products from 40 percent to 21 percent among adolescents; and • Reduce initiation of tobacco use among children and adolescents by 2010.14 The Community Guide recommends interventions to reduce tobacco use initiation by preventing or delaying experimentation with tobacco or preventing the transition from experimentation to regular use by increasing the price of tobacco products, increasing frequency of mass media education campaigns and reducing access to tobacco products by minors. There are a variety of interventions to restrict and reduce the supply of tobacco products that minors can obtain from commercial sources. These interventions include components intended, in whole or in part, to reduce the demand for tobacco products by minors through efforts to educate and organize the community and to change social norms about the acceptability of tobacco use. The TRUTH campaign, the largest national youth-focused anti-tobacco education campaign, was designed to engage teens by exposing “Big Tobacco’s” marketing and manufacturing practices, and to highlight the toll of tobacco in relevant and innovative ways. Tobacco Control Policy. “The Effects of Government Regulation on Teenage Smoking,” 90, 94. 14.  U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2010. Washington, DC. 2000. Available at http://www.healthypeople.gov.
H 99 H Case Study Youth in Missouri and Minnesota Take Action to Reduce Tobacco Use n Polk County, Mo., the community calls “Smokebusters” to the table to disseminate tobacco prevention messages from teens to other teens to increase quit rates and reduce ini- tiation. Smokebusters is a teen advocacy group that educates schools and communities about the effects of secondhand smoke and works to create smoke-free environments. The training curriculum is evidence-based and, when implemented, keeps other students smoke-free.The teams are overseen by members of the Advocates for Better Communities (ABC) coalition, a drug and violence prevention group and CADCA member, that began more than 15 years ago with the Safe Drug Free Schools Act. These teens are more than sideline participants; Smokebusters actively approach community leaders to safeguard Polk County residents from secondhand smoke exposure. For example, Smokebusters urged school administra- tors to adopt smoke-free campus policies, and upon agreement, used local tobacco prevention funding to post “Respect the Smoke-free Campus” signs to remind community members and visitors. Additionally, when the Bolivar City Council decided not to mandate a smoke-free ordinance,theSmokebustersandABCworkedwith individual area restaurants to establish smoke-free workplace policies. Each participating restaurant received free advertisement and recognition to raise awareness of their support of healthy environ- ments and smoke-free workplaces. Following this attempt, a new mayor was elected – a cardiologist – who agreed to designate smoking areas away from youth at local parks and municipal building entrances. ABC and Smokebusters continued to educate Polk County health facility providers on evidence-based cessation techniques that led to the creation of smoking cessation courses offered at the Health Center. In Polk County, Minn., further north from Polk County, Mo., teen coalition members are making sure local retailers comply with the state law. The law prohibits businesses from selling tobacco products to people under 18 years old. The Polk County ATOD Task Force Coalition, also a CADCA member, gathered data from the 2008 Minnesota Youth Tobacco and Asthma Survey on “Access to Cigarettes” and found that more than three-fourths of high school smokers receive their cigarettes from other people. The survey results alsoshowedthat10percentofunderagehighschool smokers admitted to purchasing products from local stores. About one in five students reported that they know where to purchase single cigarettes, better known as “loosies.” Community members formed the youth-led, adult-guided network, The Minor League (TmL), to raise awareness about the dangers of alcohol, tobacco and other drugs in their respective schools and communities. Youth partnered with local law enforcement as part of the Tobacco Compliance Check Program that monitors tobacco retailers in order to eliminate the sale of tobacco products to minors. TmL members have established a strong relationship with their local law enforcement to keep them engaged in the comprehensive tobacco control program and maintain their support to create an environment in which tobacco use is not a social norm. As a re- sult of the TmL and law enforcement partnership, fewer youth are able to purchase tobacco and retail clerks are more likely to ask for identification. I
H 10 TFCPS Recommendations: ✓ Tobacco Pricing Controls (strongly recommended) Interventions to increase the unit price for tobacco products primarily include legislation at the municipal, state or federal level to raise the excise tax on tobacco products. In several states, excise tax increases have resulted from successful state ballot initiatives that snowball into increased calls among state-sponsored quitlines. Although other factors affect tobacco product pricing, excise tax increases have historically resulted in an equivalent or larger increase in tobacco product prices.15 Excise taxes on tobacco products increase the overall product cost and therefore make the use of tobacco products less attractive to young people with limited income and a variety of ways to spend their money. A 10 percent price increase on tobacco products results in an approximately 4 percent decrease in consumption of tobacco products and an approximately 4 percent decrease in smoking among adolescents and young adults. Consequently, these price increases also reduce tobacco use among adults; therefore protecting adolescents and children from an environment in which tobacco use is acceptable. Passage of legislation or a statewide referendum is required for an excise tax increase on tobacco products and may, therefore, present a significant barrier to implementation, although some states have passed such legislation. Political opposition has historically been well organized and funded at both the federal and state levels. In the Series on Health Policy: Tobacco Control Policy published by the Robert Wood Johnson Foundation, the authors presented a set of estimates that described the impact of advertising ban policies on the demand for cigarettes by teenagers in the United States and 15.  Zaza, Stephanie; Briss, Peter A.; Harris, Kate W. “The Guide to Community Preventive Services: What Works to Promote Health?” Part I: Changing Risk Behaviors and Addressing Environmental Challenges. Oxford University Press. 2005. 3 - 79. examined the extent to which federal excise tax increases on cigarettes reduce teenage smoking.16 These authors suggest that cigarette smoking is, in part, a habitual behavior that begins early in life and that changes in teenage smoking behavior in response to government regulatory actions could have sustainable and substantial impact in the long run.17 Therefore, communities shape and frame the social norms that youth are most receptive to in their most impressionable years. Policies help to prohibit such accessibility to dangers, such as tobacco, and prevent curiosity to experiment. ✓ Mass Media Education Campaigns (recommended, when combined with other interventions) When used for an extended duration, mass media education campaigns, combined with other interventions, that disseminate brief, recurring messages, such as the TRUTH campaign, can motivate people to remain tobacco-free. According to the TFCPS, mass media education campaigns are effective in decreasing the number of children and adolescents who use tobacco by more than 2 percentage points. The Community Guide recommends that mass media campaigns be coordinated with additional interventions, such as increases in tobacco product excise taxes, school- based education, and other community-wide educational activities. The content of mass media campaigns designed to educate and motivate children and adolescents to remain tobacco- free vary, but two primary strategies prevail: agenda setting and demand reduction education. Agenda-setting messages increase awareness of strategies used by the tobacco industry to promote tobacco use, and attempt to facilitate changes in 16.  Isaacs, Stephen L., Knickman, James R., Warner, Kenneth E. (2006). Robert Wood Johnson Foundation Series on Health Policy: Tobacco Control Policy. “The Effect of Tobacco Advertising Bans on Tobacco Consumption” 355-360. 17.  Isaacs, Stephen L., Knickman, James R., Warner, Kenneth E. (2006). Robert Wood Johnson Foundation Series on Health Policy: Tobacco Control Policy. “Does Tobacco Advertising Target Young People to Start Smoking?” 318-324.
H 11 both tobacco use behaviors and public tobacco policies. Demand reduction education messages provide information and support to young people to help them decide to remain tobacco-free. A comprehensive approach to reducing tobacco use is imperative to begin the change process and maintain positive outcomes over time. Mass media education campaigns can also include messages that contribute to reductions in tobacco use among adults, although the message content, broadcast times, and settings that reduce youth tobacco use may not be as effective in reducing adult tobacco use. The messages should be tailored for the intended audience through the use of formative research, by survey or focus group, for example. Message content should be culturally appropriate and respectful.The main barrier to implementation of mass media campaigns is the cost of purchasing advertising time. However, costs of developing and test marketing messages can be offset by cooperation between local and national tobacco control programs. What You Can Do in Your Community: Strategy I: Reduce Tobacco Use Initiation • Support legislation that increases product excise tax and limits point of purchase promotions. • Partner with high school and university administrators to educate their students about I.D. swiping (see page 13). • Educate the public and policymakers about the relationship between enforcing the law prohibiting tobacco sales to minors and preventing youth tobacco use and on the importance of enforcing state law. • Collaborate with your State Tobacco Control Program to provide technical assistance to local retailers on enforcing the tobacco sales to minors law. • Conduct compliance checks to ensure tobacco retailers are not selling tobacco to minors. Track and publicize retailer compliance. Strategy II: Restricting Minors’ Access to Tobacco Products Laws directed at retailers provide specific regulation or restriction of the sale of tobacco products to minors. These laws include licensing requirements for tobacco retailers and bans or restrictions on tobacco product vending machines and self-service displays. The laws may include additional conditions, such as requiring proof of the purchaser’s age before selling tobacco, displaying sales laws (such as warning signs at the point of purchase), banning the sale of single cigarettes, and restricting the age of the seller. These laws may designate the method of enforcement and establish the penalties and the responsible parties for each violation (for example, civil penalties directed at the retail owner or license holder). A potential benefit of these laws is that license requirements for the sale of tobacco products enable communities to identify commercial sources of tobacco. These laws also provide support for additional interventions, such as active enforcement of sales laws. Finally, self- service display bans reduce or eliminate minors’ ability to obtain cigarettes by stealing them.18 Tobacco companies have always claimed that they do not want adolescents to use their products. However, for a tobacco company to be profitable over the long term, it must compete successfully for a share of the youth market to maintain a pool of “replacement smokers.” The tobacco industry has publicly supported laws that penalize youth for possessing, using and purchasing tobacco products. But, many of these laws have been criticized because they ignore the responsibilities of the industry and retailers.19 In a 1998 study by Forster and Wolfson, 18.  Zaza, Stephanie; Briss, Peter A.; Harris, Kate W. “The Guide to Community Preventive Services: What Works to Promote Health?” Part I: Changing Risk Behaviors and Addressing Environmental Challenges. Oxford University Press. 2005. 3 - 79. 19.  Department of Health and Human Services (DHHS). Preventing Tobacco Use Among Youth and Young Adults: A Report
H 12 they found that the voluntary efforts exhibited by tobacco manufacturers and retailer organizations to educate and train retailers were aimed at pardoning them from any responsibility for smoking by youth. The idea was to focus the blame on minors who attempt to purchase tobacco and clerks who sell it to them. Further, a 2002 study of tobacco company internal documents found that the industry used its youth access programs only to gauge current tobacco control efforts: “For monitoring purposes, we fund our allies in the convenience store group to regularly report ordinance introductions and assist in campaigns to stop unreasonable measures…” Internal documents also revealed that manufacturers modified product design to enhance product appeal to novice users. The design and packaging of products was almost completely devoid of regulatory controls with the exception of the small text warning statements until the passing of the Tobacco Control Act in 2009.20 FDA regulation of tobacco product marketing presents an extraordinary opportunity for the FDA to partner with established tobacco control entities to identify and implement new ways for preventing youth tobacco use and promoting youth and adult cessation.21 Access Restrictions to Tobacco Products Access to tobacco products by minors contributes to the initiation and regular use of tobacco by children and adolescents. First, it’s important to identify where youth are accessing tobacco products. Retailers who sell tobacco products to minors (including vending machines in accessible settings) constitute one avenue of access for minors. Social sources (such as parents, family and friends) provide another route of access of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012. 20.  U.S. Department of Justice 21.  Orleans, C. Tracy, PhD, Mabry, Patricia L., PhD, Abrams, David B., PhD. “Increasing Tobacco Cessation in America: A Consumer Demand Perspective.” American Journal of Preventive Medicine (2010) 38(3S): S303-S306. for many minors. Illegal retailer sales to minors provide tobacco products for distribution to other minors, contributing to social access. Minors obtain tobacco from commercial sources through purchases from retailers (self-service displays or requests for products held behind the counter), vending machines, via mail or over the Internet, through free product samples and theft from retail sources. Overall, minors’ access reflects the availability of tobacco products within the community, the willingness of retailers to sell them and the efforts of minors to obtain them. Interventions to reduce access attempt to modify or to change one or more of these factors, according to theTFCPS.22 Smokeless Tobacco: The New Frontier Since 1970, smokeless tobacco has gone from a product used primarily by older men to one used predominantly by young men and boys. This trend has been directly proportional to the increase in smokeless tobacco promotions. The result? A new generation of smokeless tobacco products thrives in the current market. Youth using smokeless tobacco who have not begun using cigarettes for their nicotine dependence are more likely to become regular cigarette smokers.23 New users of smokeless tobacco—attracted to the product for a variety of reasons—are most likely to begin with products that are milder tasting, more flavored, and/or easier to control in the mouth, according to the U.S. Smokeless Tobacco Company (UST). After a period of time, UST indicated that there is a natural progression of product switching to brands that are more full-bodied, less flavored, have more concentrated “tobacco taste” than the entry brand.24 22.  Zaza, Stephanie; Briss, Peter A.; Harris, Kate W. “The Guide to Community Preventive Services: What Works to Promote Health?” Part I: Changing Risk Behaviors and Addressing Environmental Challenges. Oxford University Press. 2005. 3 - 79. 23.  Tomar, S, “Is use of smokeless tobacco a risk factor for cigarette smoking? The U.S. experience,” Nicotine Tobacco Research 5(4):561-569, August 2003. 24.  “The Marketing of Nicotine Addiction by One Oral Snuff Manufacturer,” Tobacco Control 4(1), Spring 1995.
H 13 Smokeless tobacco products have been heavily marketed to youth through sporting events like auto racing and rodeos that are widely attended by kids. The use of smokeless tobacco is prevalent at such events and done in plain sight where children can see and be exposed. Although the Tobacco Master Settlement Agreement (MSA) has limited UST’s ability to continue to support brand-name sponsorships of events and teams within states, UST continues to sponsor both professional motorsports, and bull riding.25 Magazines like Sports Illustrated and Rolling Stone with high youth readership have been targets for tobacco industry product marketing.26 Even after restrictions were placed on youth advertising 25.  Morrison, MA, et al., “Under the Radar: Smokeless Tobacco Advertising in Magazines With Substantial Youth Readership,” American Journal of Public Health (AJPH) 98:543-548, 2008. See also, Sports Illustrated, July 30, 2001 and Rolling Stone, July 5, 2001. 26.  Massachusetts Department of Public Health, Smokeless Tobacco Advertising Expenditures Before and After the Smokeless Tobacco Master Settlement Agreement: A Report of the Massachusetts Department of Public Health, May 2002, http://archives.lib.state.ma.us/bitstream/handle/2452/49479/ ocm50878863.pdf. by the Smokeless Tobacco Master Settlement Agreement (established the same year as the Tobacco Master Settlement Agreement), UST continued to advertise in youth-oriented magazines with a 161 percent increase in expenditures over a four-year period.27 Tobacco companies have also hired “spokesmodels” to attend venues and events highly frequented by young college-aged adults to swipe personal identification cards. “Swiping” is a technique the tobacco industry uses to retain personal information and mail free samples or coupons directly to their potential customer’s home. This marketing practice is tracked by the number of coupons redeemed and the customer continues to receive promotions tailored to the products they prefer based on previous purchases. 27.  U.S. Food and Drug Administration Website. Family Smoking Prevention and Tobacco Control Act, Public Law 111-31, 123 U.S. Statutes at Large 1776 (2009). Available at: http://www.fda.gov/ TobaccoProducts/GuidanceComplianceRegulatoryInformation/ ucm246129.htm.
H 14 In a concentrated effort to combat the potential damaging effects of increased smokeless tobacco use among young people, tobacco companies must prove the validity of any health claims to the U.S. Food and Drug Administration before using them in promotional materials under the Tobacco Control Act. Additionally, any new tobacco products (including smokeless) must go through independent testing regarding either their inherent harmfulness or their likely impact on overall tobacco use levels or public health before entering the market.28 Currently, there are six types of spit tobacco on the market: oral snuff, nasal snuff, snus, dissolvables, loose leaf chew, and plug chew. According to a study published in the November, 1998, Journal of Adolescent Health, high school students who use spit tobacco 20 to 30 days per month are nearly four times more likely to currently use marijuana than nonusers and almost three times more likely to ever use cocaine or inhalants to get high. Heavy smokeless tobacco users are almost 16 times more likely than nonusers are to currently consume alcohol, as well.29 As stated in the 2012 Surgeon General’s Report on Tobacco, tobacco marketing is a key factor in causing young people to start using tobacco. The nicotine addiction keeps them using it long after the experimental stage.30 New and easy-to-use smokeless tobacco products like those being piloted and marketed by the tobacco industry provide youth with a gradual, progressive platform to stronger forms of tobacco and higher levels of nicotine. Additionally, the staggering effects associated with dual use (smokeless and cigarettes) 28.  Everett, S, et al., “Other Substance Use Among High School Students Who Use Tobacco.” Journal of Adolescent Health, November 1998. 29.  Department of Health and Human Services (DHHS). Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012. 30.  Task Force on Community Preventive Services. Recommendations Regarding Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke. American Journal of Preventive Medicine. (2001) 20(2S). pave the way for the damaging effects of long- term use and increase the chances of long-term dependence. It becomes increasingly imperative that communities pay attention to the irrefutable scientific evidence outlined in the 2012 Surgeon General’s Report on Tobacco and work to change the indicators in their environment and deter early childhood tobacco use. What You Can Do in Your Community: Strategy II: Restrict Minors’ Access to Tobacco Products • Develop a plan of action to implement a tobacco point-of-purchase ordinance policy. • Gather data on where smokeless tobacco products and tobacco advertising are placed in retail establishments to identify priority communities; consider launching a pilot project to test the plan of action. • Educate the public and policymakers about the role limiting point-of-purchase tobacco adver- tising plays in preventing youth tobacco use. • Conduct a survey to evaluate public support for restricting point-of-purchase tobacco advertising. • Develop a local ordinance tracking system; provide report to legislators at year-end to keep them abreast of local conditions regard- ing tobacco ordinances. Strategy III: Reducing Exposure to Environmental Tobacco Smoke Preventing tobacco use in children and adoles- cents, reducing tobacco use in adults, and reducing nonsmokers’ exposure to ETS are essential public health objectives for communities. When the TFCPS developed a report to present their recom- mendations in the Community Guide, reducing ETS exposure was identified as a primary goal for communities given that tobacco use is the largest preventable cause of premature death in the United (continued on page 16)
H 15 H Case Study The Tobacco Free Community Partnership and the Partnership of Community Resources Curb Secondhand Smoke utdoor spaces are just as vulnerable to the damaging results of tobacco use as indoor spaces. Local communities are disseminating the evidence and discovering new partnerships as they work to dispel the myths associated with outdoor clean air restrictions. People are just as susceptible to the dangers of second and third-hand smoke outdoors as they are indoors. Furthermore, tobacco litter found at recreational parks, plazas and multi-unit dwellings is costly to clean up and gives an unpleasant impression to children and young adults. CADCA member, the Tobacco Free Community Partnership for Hampshire and Franklin counties in Massachusetts has been an instrumental group that educates tenants, private landlords and local housing authorities about the health consequences of secondhand smoke exposure in multi-unit dwellings such as apartments, condominiums, and other attached homes. After receiving pilot project funding, the coalition gathered baseline data on the level of knowledge and awareness of smoke-free policies among property owners and residents from five municipalities. The survey data supported a smoke-free policy. The coalition began working with the housing authority, landlord associations, boards of health, the asthma association, city planners, fire departments, realtors and the Massachusetts Rental Housing Association to establish smoke-free home policies. The result of their collaborative work resulted in the adoption of a smoke-free policy by four local housing authorities. In 2011, another CADCA member, the Partnership of Community Resources Coalition in Nevada, began a campaign to promote smoke-free playground policies. To ensure that smoking in parks wasn’t just their group’s perception, they collected cigarette butts in parks throughout the community with the StudentsTaking on Prevention team to determine if smoking was actually a problem. The group collected butts two weeks in a row totaling 200 butts; it was the proof they needed that smoking in parks was a problem in their community.Thegrouporganizeddatatopreparefor the upcoming Parks and Recreation Commission presentation. Their request was approved by the Parks and Recreation Commission to post “Young Lungs at Work” and “Watch Your Butts” signs in and around playground areas. The Parks and Recreation Commission further supported the Partnership of Community Resources Coalition to go before the County Commissioners to gain their approval, as well. The County Commissioners not only approved the request, but also showed strong interest in making all county facilities smoke-free. Additionally, the County Commissioners requested that youth attend their planning meetings to share the information regarding the policies at the start of each new school year. These steps and successes led to increasing awareness among community members about the dangers of secondhand smoke. O 15
H 16 States. Their recommendations also suggest that communities will be most successful in reducing ETS if they maintain intervention strategies that are comprehensive and multifaceted. Communities should make consistent improvements to all of the interventions highlighted; success in one area (e.g. reduce tobacco use initiation) may contribute to improvements in the other areas (e.g. reduce expo- sure to ETS and increase tobacco use cessation). The recommendations of theTFCPS outlined below are designed to assist communities with developing a comprehensive, strategic approach consisting of interventions proven to be effective. TFCPS Recommendations: ✓ Smoking bans and restrictions (strongly recommended) Smoking bans and restrictions are policies and regulations that ban or limit the consumption of tobacco products in designated areas. These include private business and employer policies, organization regulations, and government laws and ordinances. Laws and ordinances can establish minimum standards to protect workers in private- sectorworkplaces,aswellasbanorrestrictsmoking in public areas and workplaces. Smoking bans and restrictions are strongly recommended on the basis of strong scientific evidence that they reduce exposure to ETS (1) in a wide range of workplace settings and adult populations; (2) when applied at different levels of scale, from individual businesses to entire communities; and (3) whether used alone or as part of a multicomponent community or workplace intervention. In addition to evidence of effectiveness in reducing workplace exposure to ETS, several qualifying studies observed a significant reduction in daily consumption of cigarettes by workers subject to a smoking ban or restriction. Some of the qualifying studies that evaluated smoking bans observed increases in tobacco use cessation and/or reductions in tobacco use prevalence in their study populations.
H 17 ✓ Community education (insufficient evidence) Community education provides information to parents, other occupants, and visitors to the home about the importance of reducing or eliminating ETS to protect nonsmoking adults and children. Education interventions attempt to motivate household members to modify smoking habits to reduce nonsmokers’ exposure to indoor ETS (e.g. by establishing home policies restricting or banning smoking) if they cannot quit entirely. The TFCPS review identified only one qualifying study of community-wide education interventions including an ETS component, which is insufficient for assessing the effectiveness of the intervention. A recent review of efforts to reduce children’s exposure to ETS reached a similar conclusion.31 What You Can Do in Your Community: Strategy III: Reduce Exposure to Environmental Tobacco Smoke • Conduct an environmental scan to prepare a plan of action to implement outdoor (e.g. tobacco-free parks, sports facilities, beaches, etc.) and multi-unit housing policies. • Collaborate with community partners to collect local data on distribution of free to- bacco samples and gather data on tobacco advertising near faith-based organizations, school property and other child-focused facilities. • Collaborate with your State Tobacco Control Program and other partners to improve enforcement of current tobacco access restrictions. • Develop a tracking system to monitor enforcement of tobacco access restrictions in retail settings within communities through- out the state and present the data using GIS 31.  Dyann Matson Koffman, Jerry W. Lee, Joyce W. Hopp, and Seth L. Emont (1998) The Impact of Including Incentives and Competition in a Workplace Smoking Cessation Program on Quit Rates. American Journal of Health Promotion: November/ December 1998, Vol. 13, No. 2, pp. 105-111. Mapping, Photovoice, etc. • Work with businesses and other organizations to modify employer policies, regulations and local ordinances to reduce ETS exposure. • Provide businesses tobacco-free signage prohibiting the use of tobacco products at their establishments. • Motivate household members to modify smoking habits and establish tobacco-free home policies. Strategy IV: Increasing Tobacco Use Cessation The need for access and education about the use of tobacco use cessation services and products will become increasingly more necessary as communities continue to establish policies prohibiting its use. Reducing tobacco use is good for everyone—smokers and nonsmokers. Our environments have to shape better alternatives to unhealthy decisions that are easier to make the first time. Communities that create guided pathways to evidence-based tobacco cessation treatment options will witness long-term, sustainable outcomes in the number of adults and youths exposed to tobacco. In 2009, the U.S. Congress enacted the largest federal tax increase on tobacco products in the nation’s history. Some 32 states and hundreds of communities have enacted comprehensive smoke- free laws since that time and the cost of tobacco cessation decreased resulting in unprecedented, national support for smokers’ quitting efforts. The U.S. National Tobacco Cessation Collaborative (NTCC) developed a supplement to the American Journal of Preventive Medicine that aims to call attention to the value of offering a consumer- oriented perspective to population-level tobacco cessation efforts.The NTCC suggests that if public health efforts could increase consumer demand for evidence-based tobacco cessation products and services, then many more would attempt to quit, and do so successfully. The authors suggest that
H 18 more work needs to be done within communities to increase the demand for and use and reach of evidence-based treatments and potentially spur the wider adoption of policy changes that will make these treatments affordable, accessible, and easier to use.32 With the momentum created by the passage of stricter laws prohibiting use and ground-breaking national media education campaigns, the question remains: Why are cessation rates so low while tobacco use rates remain so high? Is the socio- economic gap widening? Some experts suggest that the links among public health policy changes and policy and practice changes in the treatment arena do not yield simultaneous advancements. Expansions in treatment coverage, funding for quitline promotion and staff and the fraction of tobacco excise tax and MSA funds that have been applied to tobacco prevention and treatment are all modest adjustments. Community leaders have to remain vigilant well after funding has been dispersed and laws have been enacted to achieve long-term, sustainable outcomes. This involves educating local, state and federal lawmakers con- sistently and engaging all levels and sectors of a community when establishing new policies. State-funded cessation quitlines, telephone-based tobacco cessation services, is another intervention strategy documented by a number of research studies to be efficient and effective. Quitlines are designed to help tobacco users quit through a variety of services, counseling, medications, information and self-help materials by setting a quit date, designing a quit plan and achieving permanent deliverance from nicotine addiction. Quitline services can be tailored to an individual tobacco user’s experience, tobacco use behavior and motivations. Through the leadership of state and federal governments, quitlines provide a 32.  NAQC Issue Paper: Tobacco Cessation Quitlines: A Good Investment to Save Lives, Decrease Direct Medical Costs and Increase Productivity (January 2009) . quick and easy service for tobacco users, require no travel and are readily available in rural and urban areas. Many factors including centralization and service delivery by telephone contribute to quitlines’ cost-effectiveness. Sustained funding for quitlines could contribute to the overall decline in tobacco use prevalence. In fiscal year 2006, a total of 328,795 tobacco users called U.S. quitlines to seek help. This number represents roughly 47 reporting state-funded quitlines. Additional funding for services and promotions would help increase the number of tobacco users who receive quitline services.33 Community coalitions should be aware of the services associated with their state- funded quitline to better promote and increase the level of understanding regarding those services. Promoting the quitline services and success stories through local mass media education campaigns is another strong effort local communities should engage in. TheTFCPS evaluated a wide range of interventions to increase cessation among tobacco product users. Efforts to increase cessation include strategies to 33.  Task Force on Community Preventive Services Recommendations Regarding Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke. American Journal of Preventive Medicine. (2001) 20(2S). (continued on page 20)
H 19 Case Study The Southern Coalfields Tobacco Prevention Coalition Network (SCTPCN) Tackles Maternal Smoking Prevention n a population alongside a stretch of mountainous land dotted with surface mines and underground coal mines, the McDowell County residents in Southern West Virginia represent a community in which half of the county’s residents have not completed high school, a third of the population lives below the poverty line, 35 percent of the adult population live without health insurance, and the high prevalence of tobacco use exacerbates the preventable morbidity and mortality rates in the population. The smoking during pregnancy rate was very high at 44 percent and many of the tobacco users in this rural area lacked access to evidence-based tobacco cessation and prevention services. According to the 2000 National Vital Statistics Reports, between 12 and 20 percent of all pregnant women smoke. Similarly, Barry County, a rural county in Michigan, reported a 23 percent maternal smoking rate, which is much higher than the state’s overall adult smoking rate. Both communities found it difficult to reach their high-risk population using traditional variables and both utilized some out-of-the-box strategies to render sustainable outcomes. The Southern Coalfields Tobacco Prevention Coalition Network (SCTPCN), a CADCA member, worked with the West Virginia Chapter of the March of Dimes, the McDowell County HOPE Coalition, Hands of Hope Ministries, Women Infants and Children (W.I.C.) Offices and Head Start centers to bring access to specialized tobacco treatment services and proper prenatal health education to the lowest levels of baseline interventions. The community- based workshops and home education sessions taught pregnant mothers about the importance of proper prenatal care with the main focus on the necessity of a tobacco-free pregnancy. Participating pregnant mothers and/or family members were referred to group tobacco cessation counseling services in their local community. To increase the sustainability of the project’s impact, local healthcare providers and social service workers were trained by the American Legacy Foundation in the implementation of BriefTobacco Intervention (BTI) using the 5-A’s of Smoking Cessation with pregnant smokers: Ask, Advise, Assess, Assist and Arrange follow-up. Cessation experts also advocate the use ofAAR Intervention, which is Ask, Advise and Refer. The Barry County Substance Abuse Task Force (SATF), a partner of the the SCTPCN, hosted workshops, conducted community presentations, increased their earned media presence and distributed educational materials to providers who work with pregnant women and children. SATF found that health professionals used a more skillful approach with pregnant and parenting patients about smoking behaviors and offered smoking cessation resources. More healthcare providers are voluntarily distributing cessation and educational materials to their patients. As a result, calls to the state quitline greatly increased. Among those mothers in McDowell County who had previously smoked, but reported recently quitting smoking, almost half (48 percent) indicated they quit after the tobacco education received from the SCTPCN. Of those who quit, 36 percent were pregnant mothers and 64 percent were post-partum mothers. Seventy-eight percent of the social service providers and medical providers ‘strongly agreed’ that they could list the 5-A’s and describe how they apply to individuals who are unwilling and willing to quit after the BTI training. The providers all agreed that they could describe the harmful effects of tobacco use and the risk of smoking during pregnancy and breast feeding. Ninety-six percent of the mothers reported having established a household smoke- free policy as well as a smoke-free vehicle policy (100 percent) during follow-up sessions. I 19 H
H 20 increase the number of tobacco users who attempt to quit, strategies to increase the frequency of these cessation attempts, strategies to improve the success rate of individual cessation attempts, and strategies to achieve all of these goals. TFCPS Recommendations: ✓ Increasing the unit price for tobacco products (strongly recommended) Interventions to increase the unit price of tobacco products include state and federal legislation raising the excise tax on these products. Although other factors also affect tobacco product pricing, excise tax increases historically have resulted in equivalent or larger increases in tobacco product prices. Interventions to increase the price of tobacco products are strongly recommended by the TFCPS based on strong evidence of effectiveness. These interventions have been found to: n Reduce population consumption of tobacco products; n Reduce tobacco use initiation (described in the “Strategies to Reduce Tobacco Use Initiation” page 8); and n Increase tobacco cessation. Excise tax increases demonstrated evidence of effectiveness in a variety of populations and when implemented at both the national and state levels. ✓ Community Education (insufficient evidence) These community-wide interventions provide tobacco product users with cessation information and motivation to quit through the use of broadcast and print media.TheTFCPS review of the available evidence distinguished among three types of mass media interventions (campaigns, cessation series, and cessation contests) that differ in the duration, intent, and intensity of the media messages.34 34. Task Force on Community Preventive Services. Recommendations Regarding Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke. American Journal of Preventive Medicine. (2001) 20(2S).  What You Can Do in Your Community: Strategy IV: Increase Tobacco Use Cessation • Develop a survey to determine the number of public and private healthcare systems that document tobacco use as a vital sign and deliver the 5A’s (Ask, Advise, Assist, Assess and Arrange follow-up) or AAR (Ask, Advise and Refer) interventions. • Encourage adoption of tobacco-free policies on healthcare system campuses by educating and training health care providers on how to implement provider reminder systems and how to deliver the 5A’s or AAR intervention to their patients. • Implement a provider reminder system and the 5A’s or AAR interventions in the local health units and at all clinics sponsored and/or operated by the local city/county or state Department of Health, including Women, Infants and Children (WIC) and Family Health Branch (Family Planning and Maternal Child Health) Program. • Collaborate with federally-qualified health centers (FQHC) and local dental offices to implement a provider reminder system and the 5A’s or AAR interventions. • Incorporate provider reminder systems and the 5A’s or AAR interventions into the curriculum at the higher education institutions training health care professionals, including nurses,dentists,dentalhygienists,pharmacists, respiratory therapists, optometrists, etc. • Develop a plan to educate healthcare providers about treating tobacco use and how to make fax referrals to the State Tobacco Helpline (1-800-QUIT-NOW). • Work with local health care professionals to include tobacco use prevention and cessation information on all in-take forms at clinics, hospitals and health centers.
H 21 Importance of Building Community Partnerships Relationship building may very well be one of the single most important strategies coalitions can consistently practice and render positive tobacco prevention outcomes if maintained appropriately. It is a way to leverage resources, maximize capacity and sustain momentum around the tobacco-related indicators identified in the community. CADCA encourages coalitions to convene and combine tal- ent and resources to address local alcohol, tobacco and other drug issues by partnering with the fol- lowing sectors: law enforcement, youth, parents, businesses, media outlets, schools, youth serving organizations, faith-based organizations, civic and volunteer groups, health care professionals and state, local or tribal agencies. Partnerships with these sectors present an opportunity for recipro- cated education whereas the sectors learn about how a community coalition operates to reduce un- healthy behaviors, such as tobacco use, and the co- alition learns about these various sector operations and how to thread evidence-based tobacco preven- tion strategies into their organizational structure. A large county in Kentucky, for example, has had tremendous success in sustaining tobacco control outcomes by diversifying their coalition member- ship. Dottie Kraemer, Calloway County Alliance for Substance Abuse Prevention Project Director and CADCA member, stresses that the great les- son for any and all staff serving on a coalition is to remember who you serve and who really does the work. “The stronger the individual partners, the stronger the coalition, and thus the goals of the community do get accomplished,” Kraemer said. As community partners and agency staff get to know one another, opportunities to share resources within the coalition become apparent. Neighborhoods benefit from an influx of new contractual interactions with agencies, enhancing the tobacco use cessation services offered and provided in their communities. Many CADCA coalitions have found that investing in the building of new and trusting relationships with various sec- tors of the community can produce strong positive benefits – not just for the coalition and their target audience, but for the surrounding neighborhoods as well. These relationships change social norms. Communities with strong, active relationships become the leaders in their city and/or county for other areas in their state and the benefits become a domino effect. As a Community Transformation Grant National Network recipient, CADCA has formed partnerships with the International Association of Chiefs of Police (IACP), National Sheriffs’ Association (NSA), National District Attorneys’ Association (NDAA) and Lions Clubs International to disseminate tobacco-free living strategies to their members and employees. We recognize how the benefits of partnerships com- pound when the national focus on tobacco issues are supported and mimicked on the local level – those relationships are designed to deepen and enhance the local work coalitions are doing in meaningful ways.
H 22 Local/State: Asthma Specialty Clinics/Physicians Big Brothers, Big Sisters Program Boys and Girls Clubs of America Boy Scouts/Girl Scouts Chamber of Commerce City/County Health Departments Community Services Agencies for hearing and visually impaired Dental offices District Attorney’s Office Faith-based Organizations Family Counseling Agencies Fire Department Greek fraternity and sorority local chapters Grocery and convenience store managers Homeless Shelter/Agencies K-12 Schools The Kiwanis Club Local chapters of American Cancer Society Local chapters of American Heart Association Local chapters of American Lung Association Parks and Recreation Agencies Police Department Pre-medicine, nursing and dental college students Restaurant managers/association Sheriff’s Department State Health Department State tobacco control program University and college campuses Veterinary Pet Clinics/Associations Women, infants and children (WIC) Program YMCA/YWCA Youth Family Service agencies National: American Cancer Society American Heart Association Americans for Nonsmokers’ Rights American Lung Association Campaign for Tobacco Free Kids Centers for Disease Control and Prevention Food and Drug Administration Center for Tobacco Products Legacy for Health National Networks for Tobacco Control and Prevention Robert Wood Johnson Foundation Smoking Cessation Leadership Center at University of California, San Francisco Partners to Consider:
H 23 he findings and recommendations outlined here in Strategizer 56 offer local communities a blueprint for implementing successful tobacco prevention interventions. The recommendations are designed to provide community programs and leaders with a succinct summary on the level of effectiveness of interventions to curb the influence and change the perception of tobacco use. It’s important to note that the Community Guide reviews suggest that effectiveness within each of the noted strategic directions (cessation, initiation, reducing secondhand smoke) demands a similar comprehensive approach in the combination and coordination of interventions. This task, although challenging, is possible. Engaging the range of community members and leaders to actively contribute to the execution of the plan can alleviate burn-out and a motivational plateau among the coalition members. This publication only features a summary of the conclusions and recommendationsfromtheTFCPSoninterventions to reduce the initiation of tobacco use, to increase tobacco use cessation, and to reduce exposure to environmental tobacco smoke. The evidence provided grants local communities the opportunity to expand the listed interventions in Table 1 (page 7) through interactive and innovative avenues including social media and networking, guerilla marketing techniques influenced by youth and virtual platforms that tell the stories of tobacco prevention champions, just to name a few. The work of the TFCPS offers timely and appropriate reviews for communities to use in order to track positive changes that are complementary to the Healthy People 2020 objectives in Table 2 (page 24). This work supplements community education opportunities with “call to action” tasks that are effective, sustainable approaches to reduce the exposure to environmental tobacco smoke. Coalitions and others in the community should recognize the power of bringing all types of people and sectors to the table to tackle tobacco-related issues.Tobacco use affects everyone – nonsmokers and smokers alike. That’s why it’s important to develop a comprehensive plan with a diversified approach. Solving community problems can never be mitigated to a one-size-fits-all model. Coalitions can refer to these evidence-based strategies outlined in this publication to guide their local decisions, actions and evaluation measures, while maintaining a focus on sustainability. The information provided in this publication is, therefore, designed to contribute in different ways, to tobacco prevention and control efforts across a range of audiences, settings, environmental structures and situations. T Conclusion
H 24 TOBACCO USE Reduce tobacco use by adults from 20.6% to 12%. Reduce tobacco use by adolescents from 26% to 21%. Reduce the initiation of tobacco use among children, adolescents, and young adults from 7.7% to 5.7%. Increase smoking cessation attempts by adult smokers from 48.3% 80%. Increase recent smoking cessation success by adult smokers from 6% to 8%. Increase smoking cessation during pregnancy from 11.3% to 30%. Increase smoking cessation attempts by adolescent smokers from 58.5% to 64%. HEALTH SYSTEMS CHANGE Increase comprehensive Medicaid insurance coverage of evidence-based treatment for nicotine dependency in States and the District of Columbia from 6 states to 51 states (50 States and District of Columbia). Increase tobacco screening in health care settings from 62.4 to 68.6%. Increase tobacco cessation counseling in health care settings from 19.2% to 21.1%. SOCIAL AND ENVIRONMENTAL CHANGES Reduce the proportion of nonsmokers exposed to secondhand smoke from 52.2% to 47%. Increase the proportion of persons covered by indoor worksite policies that prohibit smoking from 75.3% to 100%. Establish laws in States, District of Columbia, Territories, and Tribes on smoke-free indoor air that prohibit smoking in public places and worksites from 30 to 51 (50 States and District of Columbia). Increase the proportion of smoke-free homes from 79.1% to 87%. Increase tobacco-free environments in schools, including all school facilities, property, vehicles, and school events to 100%. Eliminate State laws that preempt stronger local tobacco control laws. Increase the Federal and State tax on tobacco products. Reduce the proportion of adolescents and young adults grades 6 through 12 who are exposed to tobacco advertising and promotion. Reduce the illegal sales rate to minors through enforcement of laws prohibiting the sale of tobacco products to minors from 5 to 51 (50 States and District of Columbia). (Developmental) Increase the number of States and the District of Columbia, Territories, and Tribes with sustainable and comprehensive evidence-based tobacco control programs. Table 2: Healthy People 2020 Objectives: Tobacco Use H Source: Healthy People 2020
H 25 n Americans for Nonsmokers’ Rights (ANR): ANR, formed in 1976, pursues efforts to enact legislation to protect nonsmokers in the workplace and enclosed public places. http://www.no-smoke.org/ n Addiction Incorporated: A documentary that tells the true story of Dr. Victor DeNoble, one of the most important and influential whistleblowers of all time. http://www.addictionincorporated.com/ n CADCA Tobacco Initiatives Page: A library of tobacco prevention and control resources, such as toolkits, fact sheets and articles, to help coalitions implement policy interventions to reduce tobacco use in their communities. http://www.cadca.org/tobacco n Campaign for Tobacco Free Kids: Provides community coalitions with advocacy tools for public policies and fact sheets to help prevent kids from smoking, help smokers quit and protect everyone from secondhand smoke. http://www.tobaccofreekids.org n CDC Office on Smoking and Health: The lead federal agency for comprehensive tobacco prevention and control providing communities with premiere facts, evidence-based articles and practice-based strategies to reduce the harmful effects of tobacco use. http://www.cdc.gov/tobacco/index.htm n ChangeLab Solutions (formerly Public Health Law Policy): ChangeLab Solutions’ tobacco control attorneys provide advocates, health professionals, government attorneys, and elected officials with high-quality products and services on tobacco control policies. http://changelabsolutions.org/tobacco-control n FDA Center of Tobacco Products: The Center for Tobacco Products (CTP) oversees the implementation of the Family Smoking Prevention and Tobacco Control Act. Their website features a host of tobacco product topics (regulation, compliance, etc.), funding opportunities, webinars, fact sheets on youth and tobacco and resources for consumers; retailers; manufacturers; researchers; health professionals and state; local; tribal and territorial governments. http://www.fda.gov/tobaccoproducts/default.htm n Guide to Community Preventive Services: The Community Guide is a resource for evidence-based Task Force recommendations and findings about what works to improve public health. http://www.thecommunityguide.org/tobacco/ index.html n Legacy for Health: Develops game-changing public health campaigns and technical resources to reduce tobacco use among young people and adults. http://www.legacyforhealth.org/aspen/ n Legacy Tobacco Documents: The Legacy Tobacco Documents Library (LTDL) contains more than 13 million documents created by major tobacco companies related to their advertising, manufacturing, marketing, sales, and scientific research activities. http://legacy.library.ucsf.edu/ H Helpful Resources
H 2626 H n National Networks for Tobacco Control: In 2006, the Centers for Disease Control and Prevention (CDC) Office on Smoking and Health (OSH) funded six Networks to provide leadership and expertise in the development of policy related initiatives (including environmental and systems change) and utilization of proven or potentially promising practices when available or appropriate. • Asian Pacific Partners for Empowerment, Advocacy, and Leadership (APPEAL) • Break Free Alliance • National African American Tobacco Prevention Network (NAATPN) • National Latino Tobacco Control Network (NLTCN) • National Native Network (NNN) • The Network for LGBT Health Equity http://www.tobaccopreventionnetworks.org/ site/c.ksJPKXPFJpH/b.2580071/k.BD53/ Home.htm n North American Quitline Consortium: The North American Quitline Consortium (NAQC) is an international, non-profit membership organization based in Oakland, Calif. that seeks to promote evidence-based quitline services across diverse communities in North America. http://www.naquitline.org/?page=mappage n Quit Tobacco: Quit Tobacco—Make Everyone Proud is an educational campaign for the U.S. military, sponsored by the U.S. Department of Defense. http://youcanquit2.org/ n Robert Wood Johnson Foundation (RWJF): RWJF provides public health professionals and community coalitions with up-to-date resources, such as publications and policy briefs, to reduce tobacco use in their communities to transform itself for the better. http://www.rwjf.org/pr/topic.jsp?topicid=1030 n Smoking Cessation Leadership Center at the University of California, San Francisco: As a national program office of the RWJF, SCLC provides coalitions with training and research-based publications aimed to increase smoking cessation rates and the number of health professionals who help smokers quit. http://smokingcessationleadership.ucsf.edu/ index.htm 1-877-509-3786 n State Tobacco Activities Tracking and Evaluation System: The State Tobacco Activities Tracking and Evaluation (STATE) System is an interactive application that houses and displays current and historical state-level data on tobacco use prevention and control. www.cdc.gov/tobacco/statesystem n Tobacco Control Network: A database comprised of the tobacco control program managers and additional staff from each state, territory, and D.C. http://www.ttac.org/tcn/index.html n Tobacco Technical Assistance Consortium (TTAC): The Tobacco Technical Assistance Consortium (TTAC) builds and develops highly effective tobacco control programs, provides individualized technical assistance and customized trainings to help communities succeed in their tobacco control efforts. http://www.ttac.org/ n Trinkets Trash: Trinkets and Trash (TT) acts as a surveillance system that monitors, collects, and documents tobacco products and current tobacco industry marketing tactics. http://www.trinketsandtrash.org/
H 27
H 28 About CADCA Community Anti-Drug Coalitions of America (CADCA) is the nation’s leading substance abuse prevention organization representing more than 5,000 community anti-drug coalitions across the country and internationally. CADCA’s mission is to strengthen the capacity of community coalitions by providing technical assistance and training, public policy and advocacy, media strategies and marketing programs, conferences and special events. This publication is part of CADCA’s Strategizer series. Strategizers offer concise, proven solutions to issues facing coalitions. Designed to provide step-by-step guidance, Strategizers range in topics from how to start a coalition, advocacy, getting the faith community involved, youth programs, conducting evaluations to reducing underage drinking, prescription drug abuse prevention, the myths of marijuana, effective prevention strategies, and community mobilization. To order copies, visit www.cadca.org or send an e-mail to editor@cadca.org. To reproduce this publication, include the following citation: This Strategizer was developed by Community Anti-Drug Coalitions of America (CADCA). Published August 2012. 625 Slaters Lane Suite 300 Alexandria, VA 22314 1-800-54-CADCA www.cadca.org www.facebook.com/CADCA Twitter: @CADCA www.youtube.com/CADCA09

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STRATEGIZER56

  • 1.
    STRATEGIZER 56 Creating Healthy,Tobacco-Free Environments
  • 2.
    H Table of Contents Thispublication was developed by Community Anti-Drug Coalitions of America (CADCA) and supported by a grant from the Robert Wood Johnson Foundation (RWJF). Special thanks to the Smoking Cessation Leadership Center (SCLC) at the University of California, San Francisco for their time and contributions to this publication. Introduction, Background and Purpose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Tobacco Epidemic in the U.S.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Strategy I: Reducing Tobacco Use Initiation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Case Study: Youth in Missouri and Minnesota Take Action to Reduce Tobacco Use. . . . . . . . . . . . . 9 Strategy II: Restricting Minors’Access to Tobacco Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Strategy III: Reducing Exposure to Environmental Tobacco Smoke . . . . . . . . . . . . . . . . . . . . . . . . 14 Case Study: The Tobacco Free Community Partnership and the Partnership. . . . . . . . . . . . . . . . . . 15 of Community Resources Curb Secondhand Smoke Strategy IV: Increasing Tobacco Use Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Case Study: The Southern Coalfields Tobacco Prevention Coalition . . . . . . . . . . . . . . . . . . . . . . . . 19 Network (SCTPCN) Tackles Maternal Smoking Prevention Importance of Building Community Partnerships. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Helpful Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
  • 3.
    3 H he perception oftobacco use has changed with each progressing generation in the United States. We’ve shifted from a country whose doctors “prescribed” Lucky Strike brand cigarettes to patients alongside their antibiotic treatment, to a society in which system changes are now equipping healthcare providers with tools and knowledge about evidence-based tobacco cessation practices. Before the hazardous health effects of smoking were widely known and accepted, cigarette companies were able to advertise essentially regulation-free. From the late 1700s, the companynowknownasLorillardTobaccoCompany is credited with placing the very first tobacco advertisement in the United States promoting their snuff in a local New York newspaper.1 The 2009 Family Smoking Prevention and Tobacco Control Act now gives the Food and Drug Administration (FDA) the authority to regulate the manufacture, distribution and marketing of tobacco products to protect the public’s health.2 Cigarette smoking and other tobacco use were socially acceptable once upon a time – creating an era when smoking and nonsmoking sections separated patrons in trains, airplanes, office buildings and restaurants. The regard for the health of nonsmokers was not yet warranted above the common belief that smoking was not hazardous. Today, public health professionals and researchers in the United States are offering a different objective and have 1. James, Randy. “Cigarette Advertising” (2009). Time Magazine. Available at: http://www.time.com/time/magazine/article/ 0,9171,1905530,00.html. 2.  U.S. Food and Drug Administration Website. Family Smoking Prevention and Tobacco Control Act, Public Law 111-31, 123 U.S. Statutes at Large 1776 (2009). Available at: http://www.fda.gov/ TobaccoProducts/GuidanceComplianceRegulatoryInformation/ ucm246129.htm. unequivocal evidence to substantiate that there is no safe level of tobacco use, period. The purpose of Strategizer 56 is to highlight the statistically significant measures that amplify the scientific conclusions regarding the harmful effects of tobacco use, interventions that reduce access to tobacco products and evidence-based models that increase tobacco cessation.Tobacco use remains the number one cause of preventable death in the United States killing nearly 100 million worldwide in the 20th century. Contributing to more than 400,000 deaths per year, tobacco ranks higher in annual deaths toAIDS, alcohol abuse, car accidents, illegal drug abuse, murders, suicides and fires combined. More than 13 percent of those deaths represent men, women and children whose lives were lost due to secondhand smoke exposure,3,4 meaning they never even picked up a cigarette. The numbers don’t lie and the advancements in science have put public health advocates in a position to win the fight against “Big Tobacco.” Grassroots experience and evidence-based “change agents” have identified 3. McGinnis J, Foege WH. Actual Causes of Death in the United States. Journal of American Medical Association 1993; 270:2207-12. 4. CDC. Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000-2004. Morbidity and Mortality Weekly Report 2008; 57(45):1226-8. T Today, public health professionals and researchers in the United States are offering a different objective and have unequivocal evidence to substantiate that there is no safe level of tobacco use, period. Introduction Tobacco use is a major public health concern, ranking higher in annual deaths to AIDS, alcohol abuse, car accidents, illegal drugs, murders, suicides and fires combined.
  • 4.
    H 4 proven, cost-effective strategiesthat prevent youth from starting, help current users quit and protect everyone from secondhand smoke exposure. Communities throughout the country have made strong, sustainable strides in tobacco control and some of those reviewed case studies will be highlighted in this publication. According to the 2010 Annual Survey of Coalitions administered to all CADCA coalitions, 59 percent of coalitions are directly addressing tobacco use in their community, 35 percent of coalitions are addressing smoking cessationand77percentofcoalitionrespondentsare collecting data on tobacco use in their community. Over 20 percent of CADCA coalitions surveyed ranked tobacco use in their top three community priorities.TheTask Force on Community Preventive Services (TFCPS), an independent, non-federal, unpaid body, appointed by the Director of the Centers for Disease Control and Prevention (CDC), developed the Guide to Community Preventive Services. The Community Guide is a compilation of all TFCPS reviews, findings, and recommendations regarding community-based health promotion and disease prevention programs, services, and policies in high-priority topic areas. The TFCPS members represent a broad range of research, practice, and policy expertise in community preventive services, public health, health promotion, and disease prevention. The TFCPS, established in 1996 by the U.S. Department of Health and Human Services (HHS), provides evidence-based recommendations about community preventive services, programs, and policies that are effective in saving lives, increasing longevity, and improving Americans’ quality of life.5 The data analysis, recommendations and conclusions outlined in this publication will be drawn from the Community Guide, the 2012 Report of the Surgeon General on Tobacco and the 2006 Robert Wood Johnson Foundation’s Series on Health Policy: Tobacco Control Policy. Tobacco Epidemic In the U.S. Tobacco Epidemic: The Science Tobacco use remains the largest cause of preventable morbidity and mortality in the United States. According to the CDC, tobacco is recognized as a cause of multiple cancers, heart disease, stroke, complications of pregnancy and chronic obstructive pulmonary disease.6 It is important to continue to encourage individuals to adopt a tobacco-free lifestyle by choosing to avoid all types of tobacco products: cigarettes, cigars, cigarillos, smokeless tobacco, pipes and hookahs. Every day, nearly 4,000 young people try their first cigarette—approximately 1,000 of them become addicted. More than 80 percent of adult cigarette 5.  The Guide to Community Preventive Services website. Available at: http://www.thecommunityguide.org/about/aboutTF.html. 6.  CDC. Vital Signs: Current Cigarette Smoking among Adults Aged >=18 Years—United States, 2005--2010. September 9, 2011, MMWR 2011; Vol 60(35); 1207-1212. Retrieved from http://www. cdc.gov/mmwr/preview/mmwrhtml/mm6035a5.htm.
  • 5.
    H 5 smokers began smokingbefore their 18th birthday. Studies have shown that children of parents who smoke are twice as likely to become smokers themselves. High rates of smoking in the United States expose more than 88 million people to secondhand smoke on a regular basis.7 Tobacco Epidemic: The Face. I am Marie and I began smoking in high school with my friends. It was the thing to do and we thought it made us look older. I smoked for 40 years, although I tried several times to stop. I would quit smoking for up to nine months at a time, but something—an issue at work or a problem with the kids—would inevitably trigger a relapse. Back when I was a key puncher for a brokerage house in New York City, you could smoke in the office. Even while I smoked, I would encourage colleagues to walk and get exercise during their lunch breaks. It was during these walks that I felt something wasn’t right because my legs would stiffen up. In 1993, I was diagnosed with Buerger’s disease, a disorder linked to tobacco use that causes blood vessels in the hands and feet to become blocked and can result in infection or gangrene. It took a year for the diagnosis to be confirmed. I was taking painkillers every day because of the excruciating pain. Over time, parts of my body: feet, fingertips, and lower legs, were amputated. And, when I was 45, I had a below-the- knee amputation of my left leg. Then my fingers began to go. In 2006, I finally quit smoking for good with the help of (nicotine) patches. I wanted to be able to see my grandchildren and great- grandchildren grow.8 7.  Dube SR, McClave A, James C, Caraballo R, Kaufmann R, Pechacek T. Vital Signs: Current Cigarette Smoking Among Adults Aged >=18 Years—United States, 2009. MMWR. September 10, 2010. 59(35); 1135-1140. 8. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion. “Tips from Former Smokers” Campaign. Available at: http://www.cdc.gov/tobacco/ campaign/tips/. Tobacco Epidemic: Federal Response It is stories like Marie’s that the federal government is hoping to evoke action among tobacco prevention advocates and the courage to quit among smokers through the Tips from Former Smokers initiative. Launched in March 2012 by the CDC, the campaign features real people suffering as a result of smoking and exposure to secondhand smoke. Their compelling stories send a powerful message: Quit smoking now or better yet—don’t start. Public health professionals have taken a significant step to reduce tobacco use and exposure from the deadly chemicals produced from tobacco products to focus on keeping youth and young adults from ever starting.9 However, access to tobacco products is increasingly easier as “Big Tobacco” continues to market new products like snus, orbs, sticks, strips and other smokeless tobacco products that resemble candy or mints, making them more enticing for youth. The Tips from Former Smokers initiative is a bold step to prevent young people from starting to use tobacco and helping those who smoke quit. Recent milestones in President Obama’s administration’s agenda include the passage of the Family Smoking Prevention and Tobacco Control Act, which gives the FDA authority to regulate tobacco products to prevent use by minors. According to the Director of the CDC, Thomas R. Frieden, M.D., M.P.H., there is sound evidence that supports the use of the types of hard-hitting images and messages such as those featured in the Tips from Former Smokers initiative to encourage smokers to quit, to keep children from ever beginning to smoke, and to drastically reduce the harm caused by tobacco.10 9.  Department of Health and Human Services. (2012). CDC Ad Campaign Reveals Harsh Reality of Smoking-related Diseases: “Tips from Former Smokers” shows real lives and bodies damaged by tobacco [Press Release]. Retrieved from http://www.hhs.gov/ news/press/2012pres/03/20120315a.html. 10.  Department of Health and Human Services. (2012). CDC Ad Campaign Reveals Harsh Reality of Smoking-related Diseases:
  • 6.
    H 6 Why DoYoung PeopleSmoke? It is important to understand why young people begin using tobacco in order to present innovative strategies at reducing use among this population. According the 2012 Surgeon General Report on Tobacco, youth progress from early cigarette trials to intermittent use to regular use and dependence. The factors that stimulate early cigarette trials may be distinctly different from those that influence progression and persistence. The Surgeon General’s report goes on to suggest that the decision to smoke by young people is a multi-determined behavior – no one factor leads to their decision to smoke. It is influenced by overlapping combinations of biological, psychosocial, and environmental factors that function as risk or protective measures.11 Adolescence is an impressionable period of one’s life and a time that’s strongly encouraged to explore and experience new things. Community efforts must include the voice of teens to promote peer-to-peer guidance and deterrence from tobacco. Teen advocates against tobacco are the industry’s worst enemy – state supported resources provide young people with a platform to invigorate new social norms that parallel healthy lifestyle behaviors. SOLUTIONS: How can communities help keep teens and young adults tobacco-free? • Change Social Norms Create a world where seeing people smoke or use other tobacco products is the exception, not the norm (Ex. Establish tobacco-free city/ county ordinances; work with retailers to remove tobacco displays). “Tips from Former Smokers” shows real lives and bodies damaged by tobacco [Press Release]. Retrieved from http://www.hhs.gov/ news/press/2012pres/03/20120315a.html. 11.  Department of Health and Human Services (DHHS). Preventing Tobacco Use among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012. • Restrict Access Take steps that make it harder for youth to use tobacco, such as raising cigarette prices and enforcing laws that prohibit the sale of tobacco to children (Ex. Work with law enforcement officials to perform routine compliance checks at tobacco retail establishments). • Limit the Influence Further limit tobacco marketing that is likely to be seen by young people (Ex. Encourage local community event planners not to accept tobacco sponsorship at state fairs, rodeos, etc.). • Limit Media Exposure Limit youth exposure to smoking in movies and other media (Ex. Support the efforts spearheaded by the Campaign for Tobacco Free Kids to change movie ratings that feature characters using tobacco products). • Promote Comprehensive Education Educate young people and help them make healthy choices (Ex. Recruit and train youth leaders that can provide peer-to-peer encouragement to be tobacco-free). • Set the Example Encourage young people to avoid tobacco use by quitting and talking to them about why you or someone you know quit (Ex. At every op- portunity, be honest with young people about your choices and how it has affected your life). Using the Community Guide Recommendations In selecting and implementing interventions, it is recommended that communities develop and maintain a comprehensive, multifaceted strategy to reduce exposure to environmental tobacco smoke (ETS), reduce tobacco use initiation, and increase tobacco use cessation. Improvements in each category will contribute to reductions
  • 7.
    H 7 in tobacco-related morbidityand mortality, and success in one area may contribute to improvements in the other areas as well. Although theTFCPS has provided assessments for individual interventions or intervention combinations, comprehensive community efforts will require the implementation of multiple interventions to address tobacco use and exposure to ETS in diverse settings and populations. The recommendations provided in this report can assist communities in assembling a comprehensive program consisting of interventions with demonstrated evidence of effectiveness. When selecting interventions to meet local objectives, take into consideration REDUCING TOBACCO USE INITIATION Increasing the unit price of tobacco products: include legislation at the state or national level to raise the product excise tax Recommended Mass media campaigns: mass media interventions of an extended duration, using brief, recurring messages to inform and to motivate children and adolescents to remain tobacco-free Recommended; when combined with other interventions RESTRICTING MINORS’ ACCESS TO TOBACCO PRODUCTS Increasing the unit price of tobacco products Strongly recommended Community engagement with additional interventions Recommended Community education about youth access to tobacco products when used alone Insufficient evidence; when used in isolation of other interventions Active enforcement of sales laws directed at retailers when used alone Insufficient evidence Retailer education with reinforcement and information on health consequences when used alone Insufficient evidence Retailer education without reinforcement when used alone Insufficient evidence Laws directed at minors’ purchase, possession, or use of tobacco products when used alone Insufficient evidence Sales laws directed at retailers when used alone Insufficient evidence REDUCING EXPOSURE TO ENVIRONMENTAL TOBACCO SMOKE (ETS) Smoking bans and restrictions: are policies and regulations that ban or limit the consumption of tobacco products in designated areas. Recommended; used alone or as part of a multicomponent commu- nity or workplace intervention Community education to reduce exposure in the home: provides informa- tion to parents, other occupants, and visitors to the home about the impor- tance of reducing or eliminating ETS to protect nonsmoking adults and children Insufficient Evidence; insufficient number of studies for assessing the effectiveness of the intervention DECREASING TOBACCO USE AMONG WORKERS Smoke-free policies to reduce tobacco use Recommended Incentives competitions Insufficient Evidence; when used in isolation of other interventions Incentives competitions when combined with additional interventions Recommended INCREASING TOBACCO USE CESSATION Smoking bans and restrictions Recommended Community education to reduce exposure in the home Insufficient evidence Table 1: Community Guide Recommendations Source: The Guide to Community Preventive Services
  • 8.
    H 8 whether your coalitionhas the necessary resources, what other organizations or agencies in your community are already doing, and current ordinances or policies currently in place. The TFCPS recommendations are based primarily on the evidence of effectiveness of interventions as implemented, evaluated, reported, and published. A TFCPS finding of insufficient evidence does not imply evidence of ineffectiveness of the intervention, but does identify areas of uncertainty and specific continuing research needs. In these instances it should not be inferred that the targeted outcomes are not important in a comprehensive community effort. Strategy I: Reducing Tobacco Use Initiation Tobacco use remains excessively high despite nearly four decades of policies, regulations, educational efforts and increasing information on the negative health effects of tobacco use and the positive health benefits of cessation. Tobacco use initiation and the transition from experimentation to addiction are not easy to prevent because they occur primarily in adolescence, when individuals are more susceptible to influences from family, friends, peers, society and the tobacco industry that encourage tobacco use. Children and adolescents may perceive tobacco use to be normal peer and adult behaviors, and often act on this belief because tobacco products are readily available and accessible.12 The main regularity in youth smoking research observed by sociologists and psychologists is that youth are more likely to smoke if their parents, siblings and peers also smoke. Age of onset of smoking is negatively correlated with the amount smoked and the incidence of negative health effects.13 12.  Zaza, Stephanie; Briss, Peter A.; Harris, Kate W. “The Guide to Community Preventive Services: What Works to Promote Health?” Part I: Changing Risk Behaviors and Addressing Environmental Challenges. Oxford University Press. 2005. 3 - 79. 13.  Isaacs, Stephen L., Knickman, James R., Warner, Kenneth E. (2006). Robert Wood Johnson Foundation Series on Health Policy: Healthy People 2010 is an initiative introduced by HHS in 2000 that provided science-based, 10-year national objectives for improving the health of all Americans. The following objectives related to reducing tobacco use initiation were identified: • Reduce cigarette smoking from 24 percent to 12 percent among adults; • Reduce use of tobacco products from 40 percent to 21 percent among adolescents; and • Reduce initiation of tobacco use among children and adolescents by 2010.14 The Community Guide recommends interventions to reduce tobacco use initiation by preventing or delaying experimentation with tobacco or preventing the transition from experimentation to regular use by increasing the price of tobacco products, increasing frequency of mass media education campaigns and reducing access to tobacco products by minors. There are a variety of interventions to restrict and reduce the supply of tobacco products that minors can obtain from commercial sources. These interventions include components intended, in whole or in part, to reduce the demand for tobacco products by minors through efforts to educate and organize the community and to change social norms about the acceptability of tobacco use. The TRUTH campaign, the largest national youth-focused anti-tobacco education campaign, was designed to engage teens by exposing “Big Tobacco’s” marketing and manufacturing practices, and to highlight the toll of tobacco in relevant and innovative ways. Tobacco Control Policy. “The Effects of Government Regulation on Teenage Smoking,” 90, 94. 14.  U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2010. Washington, DC. 2000. Available at http://www.healthypeople.gov.
  • 9.
    H 99 H Case Study Youth inMissouri and Minnesota Take Action to Reduce Tobacco Use n Polk County, Mo., the community calls “Smokebusters” to the table to disseminate tobacco prevention messages from teens to other teens to increase quit rates and reduce ini- tiation. Smokebusters is a teen advocacy group that educates schools and communities about the effects of secondhand smoke and works to create smoke-free environments. The training curriculum is evidence-based and, when implemented, keeps other students smoke-free.The teams are overseen by members of the Advocates for Better Communities (ABC) coalition, a drug and violence prevention group and CADCA member, that began more than 15 years ago with the Safe Drug Free Schools Act. These teens are more than sideline participants; Smokebusters actively approach community leaders to safeguard Polk County residents from secondhand smoke exposure. For example, Smokebusters urged school administra- tors to adopt smoke-free campus policies, and upon agreement, used local tobacco prevention funding to post “Respect the Smoke-free Campus” signs to remind community members and visitors. Additionally, when the Bolivar City Council decided not to mandate a smoke-free ordinance,theSmokebustersandABCworkedwith individual area restaurants to establish smoke-free workplace policies. Each participating restaurant received free advertisement and recognition to raise awareness of their support of healthy environ- ments and smoke-free workplaces. Following this attempt, a new mayor was elected – a cardiologist – who agreed to designate smoking areas away from youth at local parks and municipal building entrances. ABC and Smokebusters continued to educate Polk County health facility providers on evidence-based cessation techniques that led to the creation of smoking cessation courses offered at the Health Center. In Polk County, Minn., further north from Polk County, Mo., teen coalition members are making sure local retailers comply with the state law. The law prohibits businesses from selling tobacco products to people under 18 years old. The Polk County ATOD Task Force Coalition, also a CADCA member, gathered data from the 2008 Minnesota Youth Tobacco and Asthma Survey on “Access to Cigarettes” and found that more than three-fourths of high school smokers receive their cigarettes from other people. The survey results alsoshowedthat10percentofunderagehighschool smokers admitted to purchasing products from local stores. About one in five students reported that they know where to purchase single cigarettes, better known as “loosies.” Community members formed the youth-led, adult-guided network, The Minor League (TmL), to raise awareness about the dangers of alcohol, tobacco and other drugs in their respective schools and communities. Youth partnered with local law enforcement as part of the Tobacco Compliance Check Program that monitors tobacco retailers in order to eliminate the sale of tobacco products to minors. TmL members have established a strong relationship with their local law enforcement to keep them engaged in the comprehensive tobacco control program and maintain their support to create an environment in which tobacco use is not a social norm. As a re- sult of the TmL and law enforcement partnership, fewer youth are able to purchase tobacco and retail clerks are more likely to ask for identification. I
  • 10.
    H 10 TFCPS Recommendations: ✓ TobaccoPricing Controls (strongly recommended) Interventions to increase the unit price for tobacco products primarily include legislation at the municipal, state or federal level to raise the excise tax on tobacco products. In several states, excise tax increases have resulted from successful state ballot initiatives that snowball into increased calls among state-sponsored quitlines. Although other factors affect tobacco product pricing, excise tax increases have historically resulted in an equivalent or larger increase in tobacco product prices.15 Excise taxes on tobacco products increase the overall product cost and therefore make the use of tobacco products less attractive to young people with limited income and a variety of ways to spend their money. A 10 percent price increase on tobacco products results in an approximately 4 percent decrease in consumption of tobacco products and an approximately 4 percent decrease in smoking among adolescents and young adults. Consequently, these price increases also reduce tobacco use among adults; therefore protecting adolescents and children from an environment in which tobacco use is acceptable. Passage of legislation or a statewide referendum is required for an excise tax increase on tobacco products and may, therefore, present a significant barrier to implementation, although some states have passed such legislation. Political opposition has historically been well organized and funded at both the federal and state levels. In the Series on Health Policy: Tobacco Control Policy published by the Robert Wood Johnson Foundation, the authors presented a set of estimates that described the impact of advertising ban policies on the demand for cigarettes by teenagers in the United States and 15.  Zaza, Stephanie; Briss, Peter A.; Harris, Kate W. “The Guide to Community Preventive Services: What Works to Promote Health?” Part I: Changing Risk Behaviors and Addressing Environmental Challenges. Oxford University Press. 2005. 3 - 79. examined the extent to which federal excise tax increases on cigarettes reduce teenage smoking.16 These authors suggest that cigarette smoking is, in part, a habitual behavior that begins early in life and that changes in teenage smoking behavior in response to government regulatory actions could have sustainable and substantial impact in the long run.17 Therefore, communities shape and frame the social norms that youth are most receptive to in their most impressionable years. Policies help to prohibit such accessibility to dangers, such as tobacco, and prevent curiosity to experiment. ✓ Mass Media Education Campaigns (recommended, when combined with other interventions) When used for an extended duration, mass media education campaigns, combined with other interventions, that disseminate brief, recurring messages, such as the TRUTH campaign, can motivate people to remain tobacco-free. According to the TFCPS, mass media education campaigns are effective in decreasing the number of children and adolescents who use tobacco by more than 2 percentage points. The Community Guide recommends that mass media campaigns be coordinated with additional interventions, such as increases in tobacco product excise taxes, school- based education, and other community-wide educational activities. The content of mass media campaigns designed to educate and motivate children and adolescents to remain tobacco- free vary, but two primary strategies prevail: agenda setting and demand reduction education. Agenda-setting messages increase awareness of strategies used by the tobacco industry to promote tobacco use, and attempt to facilitate changes in 16.  Isaacs, Stephen L., Knickman, James R., Warner, Kenneth E. (2006). Robert Wood Johnson Foundation Series on Health Policy: Tobacco Control Policy. “The Effect of Tobacco Advertising Bans on Tobacco Consumption” 355-360. 17.  Isaacs, Stephen L., Knickman, James R., Warner, Kenneth E. (2006). Robert Wood Johnson Foundation Series on Health Policy: Tobacco Control Policy. “Does Tobacco Advertising Target Young People to Start Smoking?” 318-324.
  • 11.
    H 11 both tobacco usebehaviors and public tobacco policies. Demand reduction education messages provide information and support to young people to help them decide to remain tobacco-free. A comprehensive approach to reducing tobacco use is imperative to begin the change process and maintain positive outcomes over time. Mass media education campaigns can also include messages that contribute to reductions in tobacco use among adults, although the message content, broadcast times, and settings that reduce youth tobacco use may not be as effective in reducing adult tobacco use. The messages should be tailored for the intended audience through the use of formative research, by survey or focus group, for example. Message content should be culturally appropriate and respectful.The main barrier to implementation of mass media campaigns is the cost of purchasing advertising time. However, costs of developing and test marketing messages can be offset by cooperation between local and national tobacco control programs. What You Can Do in Your Community: Strategy I: Reduce Tobacco Use Initiation • Support legislation that increases product excise tax and limits point of purchase promotions. • Partner with high school and university administrators to educate their students about I.D. swiping (see page 13). • Educate the public and policymakers about the relationship between enforcing the law prohibiting tobacco sales to minors and preventing youth tobacco use and on the importance of enforcing state law. • Collaborate with your State Tobacco Control Program to provide technical assistance to local retailers on enforcing the tobacco sales to minors law. • Conduct compliance checks to ensure tobacco retailers are not selling tobacco to minors. Track and publicize retailer compliance. Strategy II: Restricting Minors’ Access to Tobacco Products Laws directed at retailers provide specific regulation or restriction of the sale of tobacco products to minors. These laws include licensing requirements for tobacco retailers and bans or restrictions on tobacco product vending machines and self-service displays. The laws may include additional conditions, such as requiring proof of the purchaser’s age before selling tobacco, displaying sales laws (such as warning signs at the point of purchase), banning the sale of single cigarettes, and restricting the age of the seller. These laws may designate the method of enforcement and establish the penalties and the responsible parties for each violation (for example, civil penalties directed at the retail owner or license holder). A potential benefit of these laws is that license requirements for the sale of tobacco products enable communities to identify commercial sources of tobacco. These laws also provide support for additional interventions, such as active enforcement of sales laws. Finally, self- service display bans reduce or eliminate minors’ ability to obtain cigarettes by stealing them.18 Tobacco companies have always claimed that they do not want adolescents to use their products. However, for a tobacco company to be profitable over the long term, it must compete successfully for a share of the youth market to maintain a pool of “replacement smokers.” The tobacco industry has publicly supported laws that penalize youth for possessing, using and purchasing tobacco products. But, many of these laws have been criticized because they ignore the responsibilities of the industry and retailers.19 In a 1998 study by Forster and Wolfson, 18.  Zaza, Stephanie; Briss, Peter A.; Harris, Kate W. “The Guide to Community Preventive Services: What Works to Promote Health?” Part I: Changing Risk Behaviors and Addressing Environmental Challenges. Oxford University Press. 2005. 3 - 79. 19.  Department of Health and Human Services (DHHS). Preventing Tobacco Use Among Youth and Young Adults: A Report
  • 12.
    H 12 they found thatthe voluntary efforts exhibited by tobacco manufacturers and retailer organizations to educate and train retailers were aimed at pardoning them from any responsibility for smoking by youth. The idea was to focus the blame on minors who attempt to purchase tobacco and clerks who sell it to them. Further, a 2002 study of tobacco company internal documents found that the industry used its youth access programs only to gauge current tobacco control efforts: “For monitoring purposes, we fund our allies in the convenience store group to regularly report ordinance introductions and assist in campaigns to stop unreasonable measures…” Internal documents also revealed that manufacturers modified product design to enhance product appeal to novice users. The design and packaging of products was almost completely devoid of regulatory controls with the exception of the small text warning statements until the passing of the Tobacco Control Act in 2009.20 FDA regulation of tobacco product marketing presents an extraordinary opportunity for the FDA to partner with established tobacco control entities to identify and implement new ways for preventing youth tobacco use and promoting youth and adult cessation.21 Access Restrictions to Tobacco Products Access to tobacco products by minors contributes to the initiation and regular use of tobacco by children and adolescents. First, it’s important to identify where youth are accessing tobacco products. Retailers who sell tobacco products to minors (including vending machines in accessible settings) constitute one avenue of access for minors. Social sources (such as parents, family and friends) provide another route of access of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012. 20.  U.S. Department of Justice 21.  Orleans, C. Tracy, PhD, Mabry, Patricia L., PhD, Abrams, David B., PhD. “Increasing Tobacco Cessation in America: A Consumer Demand Perspective.” American Journal of Preventive Medicine (2010) 38(3S): S303-S306. for many minors. Illegal retailer sales to minors provide tobacco products for distribution to other minors, contributing to social access. Minors obtain tobacco from commercial sources through purchases from retailers (self-service displays or requests for products held behind the counter), vending machines, via mail or over the Internet, through free product samples and theft from retail sources. Overall, minors’ access reflects the availability of tobacco products within the community, the willingness of retailers to sell them and the efforts of minors to obtain them. Interventions to reduce access attempt to modify or to change one or more of these factors, according to theTFCPS.22 Smokeless Tobacco: The New Frontier Since 1970, smokeless tobacco has gone from a product used primarily by older men to one used predominantly by young men and boys. This trend has been directly proportional to the increase in smokeless tobacco promotions. The result? A new generation of smokeless tobacco products thrives in the current market. Youth using smokeless tobacco who have not begun using cigarettes for their nicotine dependence are more likely to become regular cigarette smokers.23 New users of smokeless tobacco—attracted to the product for a variety of reasons—are most likely to begin with products that are milder tasting, more flavored, and/or easier to control in the mouth, according to the U.S. Smokeless Tobacco Company (UST). After a period of time, UST indicated that there is a natural progression of product switching to brands that are more full-bodied, less flavored, have more concentrated “tobacco taste” than the entry brand.24 22.  Zaza, Stephanie; Briss, Peter A.; Harris, Kate W. “The Guide to Community Preventive Services: What Works to Promote Health?” Part I: Changing Risk Behaviors and Addressing Environmental Challenges. Oxford University Press. 2005. 3 - 79. 23.  Tomar, S, “Is use of smokeless tobacco a risk factor for cigarette smoking? The U.S. experience,” Nicotine Tobacco Research 5(4):561-569, August 2003. 24.  “The Marketing of Nicotine Addiction by One Oral Snuff Manufacturer,” Tobacco Control 4(1), Spring 1995.
  • 13.
    H 13 Smokeless tobacco productshave been heavily marketed to youth through sporting events like auto racing and rodeos that are widely attended by kids. The use of smokeless tobacco is prevalent at such events and done in plain sight where children can see and be exposed. Although the Tobacco Master Settlement Agreement (MSA) has limited UST’s ability to continue to support brand-name sponsorships of events and teams within states, UST continues to sponsor both professional motorsports, and bull riding.25 Magazines like Sports Illustrated and Rolling Stone with high youth readership have been targets for tobacco industry product marketing.26 Even after restrictions were placed on youth advertising 25.  Morrison, MA, et al., “Under the Radar: Smokeless Tobacco Advertising in Magazines With Substantial Youth Readership,” American Journal of Public Health (AJPH) 98:543-548, 2008. See also, Sports Illustrated, July 30, 2001 and Rolling Stone, July 5, 2001. 26.  Massachusetts Department of Public Health, Smokeless Tobacco Advertising Expenditures Before and After the Smokeless Tobacco Master Settlement Agreement: A Report of the Massachusetts Department of Public Health, May 2002, http://archives.lib.state.ma.us/bitstream/handle/2452/49479/ ocm50878863.pdf. by the Smokeless Tobacco Master Settlement Agreement (established the same year as the Tobacco Master Settlement Agreement), UST continued to advertise in youth-oriented magazines with a 161 percent increase in expenditures over a four-year period.27 Tobacco companies have also hired “spokesmodels” to attend venues and events highly frequented by young college-aged adults to swipe personal identification cards. “Swiping” is a technique the tobacco industry uses to retain personal information and mail free samples or coupons directly to their potential customer’s home. This marketing practice is tracked by the number of coupons redeemed and the customer continues to receive promotions tailored to the products they prefer based on previous purchases. 27.  U.S. Food and Drug Administration Website. Family Smoking Prevention and Tobacco Control Act, Public Law 111-31, 123 U.S. Statutes at Large 1776 (2009). Available at: http://www.fda.gov/ TobaccoProducts/GuidanceComplianceRegulatoryInformation/ ucm246129.htm.
  • 14.
    H 14 In a concentratedeffort to combat the potential damaging effects of increased smokeless tobacco use among young people, tobacco companies must prove the validity of any health claims to the U.S. Food and Drug Administration before using them in promotional materials under the Tobacco Control Act. Additionally, any new tobacco products (including smokeless) must go through independent testing regarding either their inherent harmfulness or their likely impact on overall tobacco use levels or public health before entering the market.28 Currently, there are six types of spit tobacco on the market: oral snuff, nasal snuff, snus, dissolvables, loose leaf chew, and plug chew. According to a study published in the November, 1998, Journal of Adolescent Health, high school students who use spit tobacco 20 to 30 days per month are nearly four times more likely to currently use marijuana than nonusers and almost three times more likely to ever use cocaine or inhalants to get high. Heavy smokeless tobacco users are almost 16 times more likely than nonusers are to currently consume alcohol, as well.29 As stated in the 2012 Surgeon General’s Report on Tobacco, tobacco marketing is a key factor in causing young people to start using tobacco. The nicotine addiction keeps them using it long after the experimental stage.30 New and easy-to-use smokeless tobacco products like those being piloted and marketed by the tobacco industry provide youth with a gradual, progressive platform to stronger forms of tobacco and higher levels of nicotine. Additionally, the staggering effects associated with dual use (smokeless and cigarettes) 28.  Everett, S, et al., “Other Substance Use Among High School Students Who Use Tobacco.” Journal of Adolescent Health, November 1998. 29.  Department of Health and Human Services (DHHS). Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012. 30.  Task Force on Community Preventive Services. Recommendations Regarding Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke. American Journal of Preventive Medicine. (2001) 20(2S). pave the way for the damaging effects of long- term use and increase the chances of long-term dependence. It becomes increasingly imperative that communities pay attention to the irrefutable scientific evidence outlined in the 2012 Surgeon General’s Report on Tobacco and work to change the indicators in their environment and deter early childhood tobacco use. What You Can Do in Your Community: Strategy II: Restrict Minors’ Access to Tobacco Products • Develop a plan of action to implement a tobacco point-of-purchase ordinance policy. • Gather data on where smokeless tobacco products and tobacco advertising are placed in retail establishments to identify priority communities; consider launching a pilot project to test the plan of action. • Educate the public and policymakers about the role limiting point-of-purchase tobacco adver- tising plays in preventing youth tobacco use. • Conduct a survey to evaluate public support for restricting point-of-purchase tobacco advertising. • Develop a local ordinance tracking system; provide report to legislators at year-end to keep them abreast of local conditions regard- ing tobacco ordinances. Strategy III: Reducing Exposure to Environmental Tobacco Smoke Preventing tobacco use in children and adoles- cents, reducing tobacco use in adults, and reducing nonsmokers’ exposure to ETS are essential public health objectives for communities. When the TFCPS developed a report to present their recom- mendations in the Community Guide, reducing ETS exposure was identified as a primary goal for communities given that tobacco use is the largest preventable cause of premature death in the United (continued on page 16)
  • 15.
    H 15 H Case Study The TobaccoFree Community Partnership and the Partnership of Community Resources Curb Secondhand Smoke utdoor spaces are just as vulnerable to the damaging results of tobacco use as indoor spaces. Local communities are disseminating the evidence and discovering new partnerships as they work to dispel the myths associated with outdoor clean air restrictions. People are just as susceptible to the dangers of second and third-hand smoke outdoors as they are indoors. Furthermore, tobacco litter found at recreational parks, plazas and multi-unit dwellings is costly to clean up and gives an unpleasant impression to children and young adults. CADCA member, the Tobacco Free Community Partnership for Hampshire and Franklin counties in Massachusetts has been an instrumental group that educates tenants, private landlords and local housing authorities about the health consequences of secondhand smoke exposure in multi-unit dwellings such as apartments, condominiums, and other attached homes. After receiving pilot project funding, the coalition gathered baseline data on the level of knowledge and awareness of smoke-free policies among property owners and residents from five municipalities. The survey data supported a smoke-free policy. The coalition began working with the housing authority, landlord associations, boards of health, the asthma association, city planners, fire departments, realtors and the Massachusetts Rental Housing Association to establish smoke-free home policies. The result of their collaborative work resulted in the adoption of a smoke-free policy by four local housing authorities. In 2011, another CADCA member, the Partnership of Community Resources Coalition in Nevada, began a campaign to promote smoke-free playground policies. To ensure that smoking in parks wasn’t just their group’s perception, they collected cigarette butts in parks throughout the community with the StudentsTaking on Prevention team to determine if smoking was actually a problem. The group collected butts two weeks in a row totaling 200 butts; it was the proof they needed that smoking in parks was a problem in their community.Thegrouporganizeddatatopreparefor the upcoming Parks and Recreation Commission presentation. Their request was approved by the Parks and Recreation Commission to post “Young Lungs at Work” and “Watch Your Butts” signs in and around playground areas. The Parks and Recreation Commission further supported the Partnership of Community Resources Coalition to go before the County Commissioners to gain their approval, as well. The County Commissioners not only approved the request, but also showed strong interest in making all county facilities smoke-free. Additionally, the County Commissioners requested that youth attend their planning meetings to share the information regarding the policies at the start of each new school year. These steps and successes led to increasing awareness among community members about the dangers of secondhand smoke. O 15
  • 16.
    H 16 States. Their recommendationsalso suggest that communities will be most successful in reducing ETS if they maintain intervention strategies that are comprehensive and multifaceted. Communities should make consistent improvements to all of the interventions highlighted; success in one area (e.g. reduce tobacco use initiation) may contribute to improvements in the other areas (e.g. reduce expo- sure to ETS and increase tobacco use cessation). The recommendations of theTFCPS outlined below are designed to assist communities with developing a comprehensive, strategic approach consisting of interventions proven to be effective. TFCPS Recommendations: ✓ Smoking bans and restrictions (strongly recommended) Smoking bans and restrictions are policies and regulations that ban or limit the consumption of tobacco products in designated areas. These include private business and employer policies, organization regulations, and government laws and ordinances. Laws and ordinances can establish minimum standards to protect workers in private- sectorworkplaces,aswellasbanorrestrictsmoking in public areas and workplaces. Smoking bans and restrictions are strongly recommended on the basis of strong scientific evidence that they reduce exposure to ETS (1) in a wide range of workplace settings and adult populations; (2) when applied at different levels of scale, from individual businesses to entire communities; and (3) whether used alone or as part of a multicomponent community or workplace intervention. In addition to evidence of effectiveness in reducing workplace exposure to ETS, several qualifying studies observed a significant reduction in daily consumption of cigarettes by workers subject to a smoking ban or restriction. Some of the qualifying studies that evaluated smoking bans observed increases in tobacco use cessation and/or reductions in tobacco use prevalence in their study populations.
  • 17.
    H 17 ✓ Community education(insufficient evidence) Community education provides information to parents, other occupants, and visitors to the home about the importance of reducing or eliminating ETS to protect nonsmoking adults and children. Education interventions attempt to motivate household members to modify smoking habits to reduce nonsmokers’ exposure to indoor ETS (e.g. by establishing home policies restricting or banning smoking) if they cannot quit entirely. The TFCPS review identified only one qualifying study of community-wide education interventions including an ETS component, which is insufficient for assessing the effectiveness of the intervention. A recent review of efforts to reduce children’s exposure to ETS reached a similar conclusion.31 What You Can Do in Your Community: Strategy III: Reduce Exposure to Environmental Tobacco Smoke • Conduct an environmental scan to prepare a plan of action to implement outdoor (e.g. tobacco-free parks, sports facilities, beaches, etc.) and multi-unit housing policies. • Collaborate with community partners to collect local data on distribution of free to- bacco samples and gather data on tobacco advertising near faith-based organizations, school property and other child-focused facilities. • Collaborate with your State Tobacco Control Program and other partners to improve enforcement of current tobacco access restrictions. • Develop a tracking system to monitor enforcement of tobacco access restrictions in retail settings within communities through- out the state and present the data using GIS 31.  Dyann Matson Koffman, Jerry W. Lee, Joyce W. Hopp, and Seth L. Emont (1998) The Impact of Including Incentives and Competition in a Workplace Smoking Cessation Program on Quit Rates. American Journal of Health Promotion: November/ December 1998, Vol. 13, No. 2, pp. 105-111. Mapping, Photovoice, etc. • Work with businesses and other organizations to modify employer policies, regulations and local ordinances to reduce ETS exposure. • Provide businesses tobacco-free signage prohibiting the use of tobacco products at their establishments. • Motivate household members to modify smoking habits and establish tobacco-free home policies. Strategy IV: Increasing Tobacco Use Cessation The need for access and education about the use of tobacco use cessation services and products will become increasingly more necessary as communities continue to establish policies prohibiting its use. Reducing tobacco use is good for everyone—smokers and nonsmokers. Our environments have to shape better alternatives to unhealthy decisions that are easier to make the first time. Communities that create guided pathways to evidence-based tobacco cessation treatment options will witness long-term, sustainable outcomes in the number of adults and youths exposed to tobacco. In 2009, the U.S. Congress enacted the largest federal tax increase on tobacco products in the nation’s history. Some 32 states and hundreds of communities have enacted comprehensive smoke- free laws since that time and the cost of tobacco cessation decreased resulting in unprecedented, national support for smokers’ quitting efforts. The U.S. National Tobacco Cessation Collaborative (NTCC) developed a supplement to the American Journal of Preventive Medicine that aims to call attention to the value of offering a consumer- oriented perspective to population-level tobacco cessation efforts.The NTCC suggests that if public health efforts could increase consumer demand for evidence-based tobacco cessation products and services, then many more would attempt to quit, and do so successfully. The authors suggest that
  • 18.
    H 18 more work needsto be done within communities to increase the demand for and use and reach of evidence-based treatments and potentially spur the wider adoption of policy changes that will make these treatments affordable, accessible, and easier to use.32 With the momentum created by the passage of stricter laws prohibiting use and ground-breaking national media education campaigns, the question remains: Why are cessation rates so low while tobacco use rates remain so high? Is the socio- economic gap widening? Some experts suggest that the links among public health policy changes and policy and practice changes in the treatment arena do not yield simultaneous advancements. Expansions in treatment coverage, funding for quitline promotion and staff and the fraction of tobacco excise tax and MSA funds that have been applied to tobacco prevention and treatment are all modest adjustments. Community leaders have to remain vigilant well after funding has been dispersed and laws have been enacted to achieve long-term, sustainable outcomes. This involves educating local, state and federal lawmakers con- sistently and engaging all levels and sectors of a community when establishing new policies. State-funded cessation quitlines, telephone-based tobacco cessation services, is another intervention strategy documented by a number of research studies to be efficient and effective. Quitlines are designed to help tobacco users quit through a variety of services, counseling, medications, information and self-help materials by setting a quit date, designing a quit plan and achieving permanent deliverance from nicotine addiction. Quitline services can be tailored to an individual tobacco user’s experience, tobacco use behavior and motivations. Through the leadership of state and federal governments, quitlines provide a 32.  NAQC Issue Paper: Tobacco Cessation Quitlines: A Good Investment to Save Lives, Decrease Direct Medical Costs and Increase Productivity (January 2009) . quick and easy service for tobacco users, require no travel and are readily available in rural and urban areas. Many factors including centralization and service delivery by telephone contribute to quitlines’ cost-effectiveness. Sustained funding for quitlines could contribute to the overall decline in tobacco use prevalence. In fiscal year 2006, a total of 328,795 tobacco users called U.S. quitlines to seek help. This number represents roughly 47 reporting state-funded quitlines. Additional funding for services and promotions would help increase the number of tobacco users who receive quitline services.33 Community coalitions should be aware of the services associated with their state- funded quitline to better promote and increase the level of understanding regarding those services. Promoting the quitline services and success stories through local mass media education campaigns is another strong effort local communities should engage in. TheTFCPS evaluated a wide range of interventions to increase cessation among tobacco product users. Efforts to increase cessation include strategies to 33.  Task Force on Community Preventive Services Recommendations Regarding Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke. American Journal of Preventive Medicine. (2001) 20(2S). (continued on page 20)
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    H 19 Case Study The SouthernCoalfields Tobacco Prevention Coalition Network (SCTPCN) Tackles Maternal Smoking Prevention n a population alongside a stretch of mountainous land dotted with surface mines and underground coal mines, the McDowell County residents in Southern West Virginia represent a community in which half of the county’s residents have not completed high school, a third of the population lives below the poverty line, 35 percent of the adult population live without health insurance, and the high prevalence of tobacco use exacerbates the preventable morbidity and mortality rates in the population. The smoking during pregnancy rate was very high at 44 percent and many of the tobacco users in this rural area lacked access to evidence-based tobacco cessation and prevention services. According to the 2000 National Vital Statistics Reports, between 12 and 20 percent of all pregnant women smoke. Similarly, Barry County, a rural county in Michigan, reported a 23 percent maternal smoking rate, which is much higher than the state’s overall adult smoking rate. Both communities found it difficult to reach their high-risk population using traditional variables and both utilized some out-of-the-box strategies to render sustainable outcomes. The Southern Coalfields Tobacco Prevention Coalition Network (SCTPCN), a CADCA member, worked with the West Virginia Chapter of the March of Dimes, the McDowell County HOPE Coalition, Hands of Hope Ministries, Women Infants and Children (W.I.C.) Offices and Head Start centers to bring access to specialized tobacco treatment services and proper prenatal health education to the lowest levels of baseline interventions. The community- based workshops and home education sessions taught pregnant mothers about the importance of proper prenatal care with the main focus on the necessity of a tobacco-free pregnancy. Participating pregnant mothers and/or family members were referred to group tobacco cessation counseling services in their local community. To increase the sustainability of the project’s impact, local healthcare providers and social service workers were trained by the American Legacy Foundation in the implementation of BriefTobacco Intervention (BTI) using the 5-A’s of Smoking Cessation with pregnant smokers: Ask, Advise, Assess, Assist and Arrange follow-up. Cessation experts also advocate the use ofAAR Intervention, which is Ask, Advise and Refer. The Barry County Substance Abuse Task Force (SATF), a partner of the the SCTPCN, hosted workshops, conducted community presentations, increased their earned media presence and distributed educational materials to providers who work with pregnant women and children. SATF found that health professionals used a more skillful approach with pregnant and parenting patients about smoking behaviors and offered smoking cessation resources. More healthcare providers are voluntarily distributing cessation and educational materials to their patients. As a result, calls to the state quitline greatly increased. Among those mothers in McDowell County who had previously smoked, but reported recently quitting smoking, almost half (48 percent) indicated they quit after the tobacco education received from the SCTPCN. Of those who quit, 36 percent were pregnant mothers and 64 percent were post-partum mothers. Seventy-eight percent of the social service providers and medical providers ‘strongly agreed’ that they could list the 5-A’s and describe how they apply to individuals who are unwilling and willing to quit after the BTI training. The providers all agreed that they could describe the harmful effects of tobacco use and the risk of smoking during pregnancy and breast feeding. Ninety-six percent of the mothers reported having established a household smoke- free policy as well as a smoke-free vehicle policy (100 percent) during follow-up sessions. I 19 H
  • 20.
    H 20 increase the numberof tobacco users who attempt to quit, strategies to increase the frequency of these cessation attempts, strategies to improve the success rate of individual cessation attempts, and strategies to achieve all of these goals. TFCPS Recommendations: ✓ Increasing the unit price for tobacco products (strongly recommended) Interventions to increase the unit price of tobacco products include state and federal legislation raising the excise tax on these products. Although other factors also affect tobacco product pricing, excise tax increases historically have resulted in equivalent or larger increases in tobacco product prices. Interventions to increase the price of tobacco products are strongly recommended by the TFCPS based on strong evidence of effectiveness. These interventions have been found to: n Reduce population consumption of tobacco products; n Reduce tobacco use initiation (described in the “Strategies to Reduce Tobacco Use Initiation” page 8); and n Increase tobacco cessation. Excise tax increases demonstrated evidence of effectiveness in a variety of populations and when implemented at both the national and state levels. ✓ Community Education (insufficient evidence) These community-wide interventions provide tobacco product users with cessation information and motivation to quit through the use of broadcast and print media.TheTFCPS review of the available evidence distinguished among three types of mass media interventions (campaigns, cessation series, and cessation contests) that differ in the duration, intent, and intensity of the media messages.34 34. Task Force on Community Preventive Services. Recommendations Regarding Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke. American Journal of Preventive Medicine. (2001) 20(2S).  What You Can Do in Your Community: Strategy IV: Increase Tobacco Use Cessation • Develop a survey to determine the number of public and private healthcare systems that document tobacco use as a vital sign and deliver the 5A’s (Ask, Advise, Assist, Assess and Arrange follow-up) or AAR (Ask, Advise and Refer) interventions. • Encourage adoption of tobacco-free policies on healthcare system campuses by educating and training health care providers on how to implement provider reminder systems and how to deliver the 5A’s or AAR intervention to their patients. • Implement a provider reminder system and the 5A’s or AAR interventions in the local health units and at all clinics sponsored and/or operated by the local city/county or state Department of Health, including Women, Infants and Children (WIC) and Family Health Branch (Family Planning and Maternal Child Health) Program. • Collaborate with federally-qualified health centers (FQHC) and local dental offices to implement a provider reminder system and the 5A’s or AAR interventions. • Incorporate provider reminder systems and the 5A’s or AAR interventions into the curriculum at the higher education institutions training health care professionals, including nurses,dentists,dentalhygienists,pharmacists, respiratory therapists, optometrists, etc. • Develop a plan to educate healthcare providers about treating tobacco use and how to make fax referrals to the State Tobacco Helpline (1-800-QUIT-NOW). • Work with local health care professionals to include tobacco use prevention and cessation information on all in-take forms at clinics, hospitals and health centers.
  • 21.
    H 21 Importance of Building CommunityPartnerships Relationship building may very well be one of the single most important strategies coalitions can consistently practice and render positive tobacco prevention outcomes if maintained appropriately. It is a way to leverage resources, maximize capacity and sustain momentum around the tobacco-related indicators identified in the community. CADCA encourages coalitions to convene and combine tal- ent and resources to address local alcohol, tobacco and other drug issues by partnering with the fol- lowing sectors: law enforcement, youth, parents, businesses, media outlets, schools, youth serving organizations, faith-based organizations, civic and volunteer groups, health care professionals and state, local or tribal agencies. Partnerships with these sectors present an opportunity for recipro- cated education whereas the sectors learn about how a community coalition operates to reduce un- healthy behaviors, such as tobacco use, and the co- alition learns about these various sector operations and how to thread evidence-based tobacco preven- tion strategies into their organizational structure. A large county in Kentucky, for example, has had tremendous success in sustaining tobacco control outcomes by diversifying their coalition member- ship. Dottie Kraemer, Calloway County Alliance for Substance Abuse Prevention Project Director and CADCA member, stresses that the great les- son for any and all staff serving on a coalition is to remember who you serve and who really does the work. “The stronger the individual partners, the stronger the coalition, and thus the goals of the community do get accomplished,” Kraemer said. As community partners and agency staff get to know one another, opportunities to share resources within the coalition become apparent. Neighborhoods benefit from an influx of new contractual interactions with agencies, enhancing the tobacco use cessation services offered and provided in their communities. Many CADCA coalitions have found that investing in the building of new and trusting relationships with various sec- tors of the community can produce strong positive benefits – not just for the coalition and their target audience, but for the surrounding neighborhoods as well. These relationships change social norms. Communities with strong, active relationships become the leaders in their city and/or county for other areas in their state and the benefits become a domino effect. As a Community Transformation Grant National Network recipient, CADCA has formed partnerships with the International Association of Chiefs of Police (IACP), National Sheriffs’ Association (NSA), National District Attorneys’ Association (NDAA) and Lions Clubs International to disseminate tobacco-free living strategies to their members and employees. We recognize how the benefits of partnerships com- pound when the national focus on tobacco issues are supported and mimicked on the local level – those relationships are designed to deepen and enhance the local work coalitions are doing in meaningful ways.
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    H 22 Local/State: Asthma Specialty Clinics/Physicians BigBrothers, Big Sisters Program Boys and Girls Clubs of America Boy Scouts/Girl Scouts Chamber of Commerce City/County Health Departments Community Services Agencies for hearing and visually impaired Dental offices District Attorney’s Office Faith-based Organizations Family Counseling Agencies Fire Department Greek fraternity and sorority local chapters Grocery and convenience store managers Homeless Shelter/Agencies K-12 Schools The Kiwanis Club Local chapters of American Cancer Society Local chapters of American Heart Association Local chapters of American Lung Association Parks and Recreation Agencies Police Department Pre-medicine, nursing and dental college students Restaurant managers/association Sheriff’s Department State Health Department State tobacco control program University and college campuses Veterinary Pet Clinics/Associations Women, infants and children (WIC) Program YMCA/YWCA Youth Family Service agencies National: American Cancer Society American Heart Association Americans for Nonsmokers’ Rights American Lung Association Campaign for Tobacco Free Kids Centers for Disease Control and Prevention Food and Drug Administration Center for Tobacco Products Legacy for Health National Networks for Tobacco Control and Prevention Robert Wood Johnson Foundation Smoking Cessation Leadership Center at University of California, San Francisco Partners to Consider:
  • 23.
    H 23 he findings andrecommendations outlined here in Strategizer 56 offer local communities a blueprint for implementing successful tobacco prevention interventions. The recommendations are designed to provide community programs and leaders with a succinct summary on the level of effectiveness of interventions to curb the influence and change the perception of tobacco use. It’s important to note that the Community Guide reviews suggest that effectiveness within each of the noted strategic directions (cessation, initiation, reducing secondhand smoke) demands a similar comprehensive approach in the combination and coordination of interventions. This task, although challenging, is possible. Engaging the range of community members and leaders to actively contribute to the execution of the plan can alleviate burn-out and a motivational plateau among the coalition members. This publication only features a summary of the conclusions and recommendationsfromtheTFCPSoninterventions to reduce the initiation of tobacco use, to increase tobacco use cessation, and to reduce exposure to environmental tobacco smoke. The evidence provided grants local communities the opportunity to expand the listed interventions in Table 1 (page 7) through interactive and innovative avenues including social media and networking, guerilla marketing techniques influenced by youth and virtual platforms that tell the stories of tobacco prevention champions, just to name a few. The work of the TFCPS offers timely and appropriate reviews for communities to use in order to track positive changes that are complementary to the Healthy People 2020 objectives in Table 2 (page 24). This work supplements community education opportunities with “call to action” tasks that are effective, sustainable approaches to reduce the exposure to environmental tobacco smoke. Coalitions and others in the community should recognize the power of bringing all types of people and sectors to the table to tackle tobacco-related issues.Tobacco use affects everyone – nonsmokers and smokers alike. That’s why it’s important to develop a comprehensive plan with a diversified approach. Solving community problems can never be mitigated to a one-size-fits-all model. Coalitions can refer to these evidence-based strategies outlined in this publication to guide their local decisions, actions and evaluation measures, while maintaining a focus on sustainability. The information provided in this publication is, therefore, designed to contribute in different ways, to tobacco prevention and control efforts across a range of audiences, settings, environmental structures and situations. T Conclusion
  • 24.
    H 24 TOBACCO USE Reduce tobaccouse by adults from 20.6% to 12%. Reduce tobacco use by adolescents from 26% to 21%. Reduce the initiation of tobacco use among children, adolescents, and young adults from 7.7% to 5.7%. Increase smoking cessation attempts by adult smokers from 48.3% 80%. Increase recent smoking cessation success by adult smokers from 6% to 8%. Increase smoking cessation during pregnancy from 11.3% to 30%. Increase smoking cessation attempts by adolescent smokers from 58.5% to 64%. HEALTH SYSTEMS CHANGE Increase comprehensive Medicaid insurance coverage of evidence-based treatment for nicotine dependency in States and the District of Columbia from 6 states to 51 states (50 States and District of Columbia). Increase tobacco screening in health care settings from 62.4 to 68.6%. Increase tobacco cessation counseling in health care settings from 19.2% to 21.1%. SOCIAL AND ENVIRONMENTAL CHANGES Reduce the proportion of nonsmokers exposed to secondhand smoke from 52.2% to 47%. Increase the proportion of persons covered by indoor worksite policies that prohibit smoking from 75.3% to 100%. Establish laws in States, District of Columbia, Territories, and Tribes on smoke-free indoor air that prohibit smoking in public places and worksites from 30 to 51 (50 States and District of Columbia). Increase the proportion of smoke-free homes from 79.1% to 87%. Increase tobacco-free environments in schools, including all school facilities, property, vehicles, and school events to 100%. Eliminate State laws that preempt stronger local tobacco control laws. Increase the Federal and State tax on tobacco products. Reduce the proportion of adolescents and young adults grades 6 through 12 who are exposed to tobacco advertising and promotion. Reduce the illegal sales rate to minors through enforcement of laws prohibiting the sale of tobacco products to minors from 5 to 51 (50 States and District of Columbia). (Developmental) Increase the number of States and the District of Columbia, Territories, and Tribes with sustainable and comprehensive evidence-based tobacco control programs. Table 2: Healthy People 2020 Objectives: Tobacco Use H Source: Healthy People 2020
  • 25.
    H 25 n Americans forNonsmokers’ Rights (ANR): ANR, formed in 1976, pursues efforts to enact legislation to protect nonsmokers in the workplace and enclosed public places. http://www.no-smoke.org/ n Addiction Incorporated: A documentary that tells the true story of Dr. Victor DeNoble, one of the most important and influential whistleblowers of all time. http://www.addictionincorporated.com/ n CADCA Tobacco Initiatives Page: A library of tobacco prevention and control resources, such as toolkits, fact sheets and articles, to help coalitions implement policy interventions to reduce tobacco use in their communities. http://www.cadca.org/tobacco n Campaign for Tobacco Free Kids: Provides community coalitions with advocacy tools for public policies and fact sheets to help prevent kids from smoking, help smokers quit and protect everyone from secondhand smoke. http://www.tobaccofreekids.org n CDC Office on Smoking and Health: The lead federal agency for comprehensive tobacco prevention and control providing communities with premiere facts, evidence-based articles and practice-based strategies to reduce the harmful effects of tobacco use. http://www.cdc.gov/tobacco/index.htm n ChangeLab Solutions (formerly Public Health Law Policy): ChangeLab Solutions’ tobacco control attorneys provide advocates, health professionals, government attorneys, and elected officials with high-quality products and services on tobacco control policies. http://changelabsolutions.org/tobacco-control n FDA Center of Tobacco Products: The Center for Tobacco Products (CTP) oversees the implementation of the Family Smoking Prevention and Tobacco Control Act. Their website features a host of tobacco product topics (regulation, compliance, etc.), funding opportunities, webinars, fact sheets on youth and tobacco and resources for consumers; retailers; manufacturers; researchers; health professionals and state; local; tribal and territorial governments. http://www.fda.gov/tobaccoproducts/default.htm n Guide to Community Preventive Services: The Community Guide is a resource for evidence-based Task Force recommendations and findings about what works to improve public health. http://www.thecommunityguide.org/tobacco/ index.html n Legacy for Health: Develops game-changing public health campaigns and technical resources to reduce tobacco use among young people and adults. http://www.legacyforhealth.org/aspen/ n Legacy Tobacco Documents: The Legacy Tobacco Documents Library (LTDL) contains more than 13 million documents created by major tobacco companies related to their advertising, manufacturing, marketing, sales, and scientific research activities. http://legacy.library.ucsf.edu/ H Helpful Resources
  • 26.
    H 2626 H n National Networksfor Tobacco Control: In 2006, the Centers for Disease Control and Prevention (CDC) Office on Smoking and Health (OSH) funded six Networks to provide leadership and expertise in the development of policy related initiatives (including environmental and systems change) and utilization of proven or potentially promising practices when available or appropriate. • Asian Pacific Partners for Empowerment, Advocacy, and Leadership (APPEAL) • Break Free Alliance • National African American Tobacco Prevention Network (NAATPN) • National Latino Tobacco Control Network (NLTCN) • National Native Network (NNN) • The Network for LGBT Health Equity http://www.tobaccopreventionnetworks.org/ site/c.ksJPKXPFJpH/b.2580071/k.BD53/ Home.htm n North American Quitline Consortium: The North American Quitline Consortium (NAQC) is an international, non-profit membership organization based in Oakland, Calif. that seeks to promote evidence-based quitline services across diverse communities in North America. http://www.naquitline.org/?page=mappage n Quit Tobacco: Quit Tobacco—Make Everyone Proud is an educational campaign for the U.S. military, sponsored by the U.S. Department of Defense. http://youcanquit2.org/ n Robert Wood Johnson Foundation (RWJF): RWJF provides public health professionals and community coalitions with up-to-date resources, such as publications and policy briefs, to reduce tobacco use in their communities to transform itself for the better. http://www.rwjf.org/pr/topic.jsp?topicid=1030 n Smoking Cessation Leadership Center at the University of California, San Francisco: As a national program office of the RWJF, SCLC provides coalitions with training and research-based publications aimed to increase smoking cessation rates and the number of health professionals who help smokers quit. http://smokingcessationleadership.ucsf.edu/ index.htm 1-877-509-3786 n State Tobacco Activities Tracking and Evaluation System: The State Tobacco Activities Tracking and Evaluation (STATE) System is an interactive application that houses and displays current and historical state-level data on tobacco use prevention and control. www.cdc.gov/tobacco/statesystem n Tobacco Control Network: A database comprised of the tobacco control program managers and additional staff from each state, territory, and D.C. http://www.ttac.org/tcn/index.html n Tobacco Technical Assistance Consortium (TTAC): The Tobacco Technical Assistance Consortium (TTAC) builds and develops highly effective tobacco control programs, provides individualized technical assistance and customized trainings to help communities succeed in their tobacco control efforts. http://www.ttac.org/ n Trinkets Trash: Trinkets and Trash (TT) acts as a surveillance system that monitors, collects, and documents tobacco products and current tobacco industry marketing tactics. http://www.trinketsandtrash.org/
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  • 28.
    H 28 About CADCA Community Anti-DrugCoalitions of America (CADCA) is the nation’s leading substance abuse prevention organization representing more than 5,000 community anti-drug coalitions across the country and internationally. CADCA’s mission is to strengthen the capacity of community coalitions by providing technical assistance and training, public policy and advocacy, media strategies and marketing programs, conferences and special events. This publication is part of CADCA’s Strategizer series. Strategizers offer concise, proven solutions to issues facing coalitions. Designed to provide step-by-step guidance, Strategizers range in topics from how to start a coalition, advocacy, getting the faith community involved, youth programs, conducting evaluations to reducing underage drinking, prescription drug abuse prevention, the myths of marijuana, effective prevention strategies, and community mobilization. To order copies, visit www.cadca.org or send an e-mail to [email protected]. To reproduce this publication, include the following citation: This Strategizer was developed by Community Anti-Drug Coalitions of America (CADCA). Published August 2012. 625 Slaters Lane Suite 300 Alexandria, VA 22314 1-800-54-CADCA www.cadca.org www.facebook.com/CADCA Twitter: @CADCA www.youtube.com/CADCA09