2006 Biennial Evaluation Report FY 2004 – 2006 ARIZONA DEPARTMENT OF HEALTH SERVICES TOBACCO EDUCATION AND PREVENTION PROGRAM 2006 Biennial Evaluation Report Janet Napolitano, Governor State of Arizona Susan Gerard, Director Arizona Department of Health Services 150 North 18th Avenue Phoenix, Arizona 85007-3228 Division of Public Health Services Office of Tobacco Education and Prevention Program Permission to quote or reproduce materials from this publication is granted when acknowledgment is made. 2 THIS REPORT WAS PREPARED BY ARIZONA DEPARTMENT OF HEALTH SERVICES DIVISION OF PUBLIC HEALTH SERVICES Office of Tobacco Education and Prevention Program SPECIAL THANKS AND APPRECIATION ARE EXTENDED TO THE PROGRAM STAFF OF THE OFFICE OF TOBACCO EDUCATION AND PREVENTION PROGRAM and THE STAFF OF THE EVALUATION RESEARCH AND DEVELOPMENT UNIT UNIVERSITY OF ARIZONA THANKS AND APPRECIATION FOR HER CONTRIBUTIONS ARE ALSO EXTENDED TO Jeanette Shea-Ramirez, Deputy Assistant Director Division of Public Health Services 3 EXECUTIVE SUMMARY Assessing the overall effectiveness of ADHS TEPP programs is complicated by the lack of methods and resources to measure the counter-control activities of the tobacco industry. It is very likely that the industry is spending more money in promoting tobacco in the state than ADHS TEPP is spending on enhancing tobacco control. Unless and until a better understanding of the level and effectiveness of tobacco promotion efforts is achieved, it will be difficult to produce a definitive judgment on the absolute level of effectiveness of ADHS TEPP. OVERVIEW Tobacco control is a complex and difficult challenge. The Centers for Disease Control and Prevention (CDC) have urged the development of a nine-part effort directed at prevention and cessation of smoking and elimination of secondhand smoke exposure. The Arizona Department of Health Services Office of Tobacco Education and Prevention (ADHS TEPP) has used this framework to develop, maintain, and control a wide range of initiatives, programs, and activities. The ultimate goal of ADHS TEPP is to enhance the health and welfare of the people of Arizona by bringing commercial tobacco use to a minimum. These efforts require that ADHS TEPP be active in a wide range of venues, including schools, health-related organizations, community organizations, businesses, and personal, private settings. ADHS TEPP activities include educational interventions, smoking cessation services, media campaigns, and production of reports relevant to tobacco control policies and legislation. ADHS TEPP PROGRAM HIGHLIGHTS, 2004-2006 PREVENTING YOUTH INITIATION Communities vary in the nature of the tobacco problem, public reaction to it, and support for various interventions. Therefore ADHS TEPP must take into account the differences between communities, the preferences of diverse citizens, and the extent of local human resources in making decisions about which specific tobacco control efforts to support and in what communities they might be most effective. The following provides a summary of some of ADHS TEPP programming, and of the programming directions identified for ADHS TEPP to pursue in the coming years. 4 • Intensive tobacco prevention education took place in 668 schools in grades 4 through 8 across the state. This represents 47 percent of all schools in Arizona that have grades 4 through 8. • A total of 3,363 class groups were taught, reaching 87,830 students. • Of the total number of schools in Arizona that have grades 4 through 8, 533 qualify as schools serving students at higher risk of using tobacco. Nearly half of those schools (253) received intensive tobacco prevention education sponsored by ADHS TEPP. • Over 90 percent of 4th through 8th graders participating in intensive tobacco prevention classes reported that the classes gave them good reason not to smoke or use tobacco and agreed that it is important to be tobacco free. • 2,412 employees of 292 health and human service institutions. • The total number of undercover inspections of tobacco retailers conducted by the Arizona Attorney General’s Office throughout the state increased from 2177 in FY05 to 2707 in FY06. The rate of violations (i.e., sales of tobacco to minors under the Arizona statutory age of 18) decreased from 25% of all merchants inspected in FY05 to 20% of merchants inspected in FY06. REDUCING EXPOSURE TO SECONDHAND SMOKE HELPING TOBACCO USERS QUIT • A total of 12,164 Arizona residents took advantage of the cessation services offered by ADHS TEPP. • 4,519 cessation clients took advantage of the Nicotine Replacement Therapy benefit offered to clients. • • Ninety-nine percent of clients providing input on their satisfaction with cessation classes reported excellent or good experiences with the helpfulness of the information they received during the classes, and 96 percent would refer another tobacco user to the class they just completed. Over 63,748 visitors accessed the ASHline.org website. • The HealthCare Partnership held 302 certification workshops with 1,989 medical and allied health professionals, as well as 156 continuing education programs with • Arizona HealthLinks provided education on smoke-free policies to 3,831 worksites across the state. • Tobacco Free Ways in Pima County implemented two pilot secondhand smoke programs in daycare centers and four hospitals to educate families and new mothers about the dangers secondhand smoke poses to their children. IDENTIFYING AND ELIMINATING TOBACCO-RELATED DISPARATIES Of all clients in multi-session inperson or phone tobacco cessation services who were reached by phone three months after services, about 50 percent reported not having used tobacco in the past 30 days. • 3,451 clients were referred to ADHS TEPP cessation services through the Proactive Referral System by health care providers and other professionals. • The Community Partnership Program was created to involve communitybased agencies in tobacco control activities that complement and extend the reach of ADHS TEPP. • The Inter-Tribal Council of Arizona contractors engaged in a variety of events around youth prevention and reduction of secondhand smoke exposure, including 480 community outreach events. CREATING AWARENESS AND EDUCATING THROUGH SOCIAL MARKETING • 5 Social Marketing activities included television, radio and print advertisements, informational messages on school and city buses, and public service announcements and commercials. Specific campaigns included the Great American Smoke Out, Through with Chew, and the Arizona Secondhand Smoke Campaign. • Seventy percent of 1,668 randomly selected Arizona adults surveyed reported having seen advertisements on television about secondhand smoke in the previous six months. Eightyfive percent of those who had seen at least one advertisement said they were convincing, and 85 percent said the ads made them more aware of the dangers of secondhand smoke. REDUCING THE BURDEN OF CHRONIC DISEASE • • Arizona HealthLinks offered a variety of programs to promote employee health, including general health education and screenings, physical activity, nutrition and weight management, and oral health. ADHS TEPP awarded nine contracts to organizations within the state of Arizona to expand or coordinate early detection and screening programs for the four leading causes of death: cancer, heart disease, stroke and pulmonary disease. RESULTS • One out of five Arizona high school students report currently smoking cigarettes. This is slightly lower than the national average of 23 percent. 6 • An increasing percentage (59%) of Arizona school-aged youth report never having tried a cigarette. • About one out of five Arizona adults continues to smoke, but the amount they are smoking is decreasing. • Almost half of all current smokers have tried to quit in the past year, and the majority of smokers (61%) report that they are planning a quit attempt within the next six months. • Support for smoking bans in public places and workplaces has been increasing. • Most Arizonans (85%) report that smoking is completely banned in their homes. • Half of Arizona workers report that smoking is allowed in their workplace. • About one in five adults—and one in three youth—report having been exposed to smoke in a car in the week prior to being surveyed • Tobacco use is highest among males, and among those with low education. American Indians have the highest reported prevalence among ethnic groups, in both youth and adult reports. Residents who report being gay, lesbian, bisexual or transgendered also report higher tobacco use than the general population. TABLE OF CONTENTS EXECUTIVE SUMMARY 4 Overview 4 ADHS TEPP Program Highlights, 2004-2006 4 INTRODUCTION 11 Background 11 ADHS TEPP Organization 12 Tobacco Control Model 13 ADHS TEPP Contracts 14 PROGRAM ACTIVITIES AND SERVICES 19 Preventing Youth Initiation 19 Helping Tobacco Users Quit 26 Reducing Exposure to SecondHand Smoke 34 Identifying and Eliminating Tobacco-Related Disparities 36 Creating Awareness and Educating Through Social Marketing 41 Reducing the Burden of Chronic Disease 47 Evaluation and Surveillance 50 RESULTS 53 Youth Smoking Behavior 53 Adult Smoking Behavior 55 7 Exposure to & Attitudes Towards SecondHand Smoke (SHS) CONCLUSIONS AND RECOMMENDATIONS 60 64 Preventing Youth Initiation 64 Helping Tobacco Users Quit 65 Reducing Exposure to Secondhand Smoke 66 Identifying and Eliminating Tobacco-related Disparities 66 8 LIST OF FIGURES Figure 1. ADHS TEPP Organization Chart.............................................................................12 Figure 2. Arizona Tobacco Program Expenditures Per Person vs. Estimated Arizona Tobacco-Attributable Medical Expenditures Per Person ........................................................18 Figure 3. Grade Distribution of TEPP Intensive Prevention Education................................21 Figure 4. Schools Receiving TEPP Services.............................................................................23 Figure 5. Consistency of Tobacco-free Policy Enforcement in Maricopa County...................25 Figure 6. Attorney General Compliance Checks, FY 04-06 ....................................................26 Figure 7. Age of Cessation Clients and Smokers in AZ...........................................................30 Figure 8. Gender of Cessation Clients and Smokers in AZ.....................................................30 Figure 9. Ethnicity of Cessation Clients and Smokers in AZ .................................................30 Figure 10. Education of Cessation Clients and Smokers in AZ ..............................................31 Figure 11. Proactive Referrals ..................................................................................................34 Figure 12. Year-to-Year Comparisons of Visits to Ashline.org Website.................................46 Figure 13. Results of Flagstaff Air Quality Study...................................................................52 Figure 14. Percentage of Students Who Have Never Tried a Cigarette.................................54 Figure 15. Adult Cigarette Smoking, AZ vs. National ............................................................55 Figure 16. Adult Cigarette Smoking, AZ by Gender ...............................................................56 Figure 17. Smoking Rate by Self-identified Ethnic Affiliation 2005, AZ vs. National ..........57 Figure 18. Tobacco Use During Pregnancy ..............................................................................58 Figure 19. Cigarette Tax Stamps Sold Per Person, AZ and National ....................................59 Figure 20. Medical Care Provider’s Tobacco Use Counseling, Reported by ATS 2005 Respondents...............................................................................................................................60 Figure 21. Jurisdictions with Tobacco Laws or Ordinances. ..................................................61 Figure 22. Support for Complete Smoking Bans in Various Locations..................................62 LIST OF TABLES Table 1: Meeting Best Practices ...............................................................................................13 Table 2: Office of Tobacco Education and Prevention Program Contracts and Expenditures, FY05 and FY06..........................................................................................................................16 Table 3: How Clients Heard about ASHline ............................................................................28 Table 4. Healthcare Partnership Programs and Participation...............................................32 Table 5. Current Youth Cigarette Rates, by Ethnicity, YTS 2005 .........................................53 9 Table 6. When you bought cigarettes in a store during the past 30 days, what kind of store was it? YTS 2005 .......................................................................................................................54 Table 7. Have the commercials changed the way you feel about using tobacco? YTS 2005..55 Table 8. Smoking Rate & Consumption by Age, ATS 2005.....................................................56 Table 9. Smoking Rate by Education, ATS 2005 .....................................................................57 10 INTRODUCTION This report contains a description of the program activities and services of the Arizona Department of Health Services Office of Tobacco Education and Prevention Program for Fiscal Years 2005 and 2006, as well as a report of expenditures for that time period. Key outcome indicators for youth and adult tobacco-related behavior and attitudes are presented. public health problem, with an important impact on morbidity and mortality, state statute (i.e., ARS 36-772) directed the Arizona Department of Health Services (ADHS) to administer the state’s tobacco control efforts. The Office of Tobacco Education and Prevention Program (TEPP) began in 1995, funded by 23 percent of the tax revenue. In 2002 Arizona voters passed Proposition 303, which increased the state tax on cigarettes by 60 cents per pack and taxed other tobacco products. Through this proposition, tobacco tax monies are voter protected and these funds must be used to provide services related to tobacco prevention. Two percent of the new tax was dedicated to a chronic disease fund, which was administered by ADHS TEPP in FY05 and FY06. The report is complemented by detailed information found in the 2005 Youth Tobacco Survey Report, the 2005 Adult Tobacco Survey Report, the 2005 Spanish Adult Tobacco Survey Report, and the 2005 Evaluation of the Intensive Schoolbased Tobacco Prevention Education Program. These documents are available from the ADHS Office of Tobacco Education and Prevention Program. Currently, eleven full-time ADHS staff manage 16 local contracts, six statewide program contracts, five community partnership contracts, a media contract, one evaluation contract, three surveillance contracts and nine chronic disease contracts. An organization chart for TEPP and its location within the ADHS is presented on the next page. BACKGROUND In 1994, Arizona voters passed the Tobacco Tax and Health Care Act (Proposition 200) which increased the state sales tax on tobacco products to fund several programs: health care for the medically needy, medically indigent and low income children; tobacco education and prevention; and tobacco-related research. Because tobacco use is a serious 11 ADHS TEPP ORGANIZATION Figure 1. ADHS TEPP Organization Chart 12 The components are oriented towards: TOBACCO CONTROL MODEL The ADHS TEPP program is guided by the model for comprehensive tobacco control programs set out by the Centers for Disease Control and Prevention (CDC) in Best Practices for Comprehensive Tobacco Control Programs.1 The CDC have delineated nine components that should be implemented by state tobacco control programs in order to be comprehensive and ultimately effective in reaching the long-term goals of reducing tobacco-related morbidity and mortality. • Preventing the initiation of tobacco use among young people • Promoting quitting among young people and adults • Eliminating nonsmokers’ exposure to secondhand smoke • Identifying and eliminating the disparities related to tobacco use and its effects among different population groups ADHS TEPP supports these four goal areas of a comprehensive tobacco control program through contracts with partners selected to best cover the nine CDC bestpractice component areas (see Table 1). Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—August 1999. 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, August 1999. Reprinted, with corrections. 1 Funding for ADHS TEPP programming primarily comes from Arizona tobacco tax revenue. Two percent of the funding comes from the CDC Office of Smoking and Health. Table 1: Meeting Best Practices CDC Best Practice Components I. Community Programs to Reduce Tobacco Use II. Chronic Disease Programs to Reduce the Burden of TobaccoRelated Diseases III. School Programs IV. Enforcement V. Statewide Programs VI. Counter-Marketing VII. Cessation Programs VIII. Surveillance and Evaluation IX. Administration & Management ADHS TEPP Contracts Community Partnership Projects; Local Projects; Tribal Projects Arizona HealthLinks; Chronic Disease Projects; Tribal Projects Local Projects; Tribal Projects Attorney General, in conjunction with local enforcement agencies; Local Projects support through merchant education; Tribal Projects Arizona HealthLinks; Arizona Interscholastic Association; Arizona Smokers’ Helpline; Healthcare Partnership; US Script; Statewide Marketing Campaigns; Local Projects; Tribal Projects Arizona Smokers’ Helpline; Local Projects; Tribal Projects; US Script UA Evaluation, Research and Development Unit ; Arizona Criminal Justice Commission; Arizona Department of Education; Northern Arizona University ADHS TEPP and all Contractors 13 Currently the American Indian programs focus on both school and communitybased prevention education. The three Urban Centers also provide cessation services. ADHS TEPP CONTRACTS The 16 local contracts include all 15 Arizona counties: • • • • • • • • • • • • • • • Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma The five community partnership contracts include: Most of these contracts are with county health departments. These contracts include the provision of services in school and community-based prevention, in adult cessation, and in the creation of smoke-free worksites and homes. Tanner Community Development Corporation (services supporting the African American community) • Asian Pacific Community in Action (services supporting the Asian-Pacific Islander community) • Mountain Park Health Center (services supporting the low income community) • Chicanos Por La Causa (services supporting the Hispanic community) • Phoenix Fire Fighters (schoolbased prevention services supporting high-risk youth) The six statewide program contracts include: The sixteenth contract is with the InterTribal Council of Arizona, which in turn contracts with seven American Indian tribes: • • • • • • • • Colorado River Indian Tribes Kaibab-Paiute Hopi Hualapai Pascua Yaqui Salt River Pima-Maricopa White Mountain Apache • The Arizona Smokers’ Helpline, or ASHline, which offers phonebased information, referral and cessation services • Arizona HealthLinks, which provides statewide smoke-free worksite policy and healthy lifestyle education • Health Care Partnership, which offers health care provider training and education • Arizona Attorney General’s Office, who facilitates tobacco merchant compliance checks • US Script, which provides coordination of cessation And three urban American Indian centers: • Native Americans for Community Action (Flagstaff) • Native American Community Health Center (Phoenix) • Tucson Indian Center (Tucson) 14 Unit at the University of Arizona for evaluation services. The three surveillance contracts are with Northern Arizona University (Adult Tobacco Survey), the Arizona Department of Education (Youth Tobacco Survey), and the Arizona Criminal Justice Commission (Arizona Youth Survey). pharmacotherapy distribution (i.e., nicotine patch, gum, etc.) • Arizona Interscholastic Association, which provides healthy lifestyle and character education for coaches, school athletic directors, parents, and children In addition to the tobacco-focused programming, ADHS TEPP also funded nine contracts to reduce the burden of chronic diseases amongst Arizona residents. In addition to their in-house Marketing team, several marketing contractors and subcontractors work on ADHS TEPP’s counter-marketing effort. The Department contracts with the Evaluation, Research and Development 15 Table 2: Office of Tobacco Education and Prevention Program Contracts and Expenditures, FY05 and FY06 Projects Expenditures (in dollars) Fiscal Year 2005 Fiscal Year 2006 Local Projects Apache County Cochise County Coconino County Gila County Graham County Greenlee County La Paz County Maricopa County Mohave County Navajo County Pima County Pinal County Santa Cruz County Yavapai County Yuma County Total Local Projects 184,184 304,158 317,875 150,114 135,811 91,390 139,648 3,966,723 365,150 260,779 1,355,260 278,960 253,082 418,820 331,078 8,553,032 193,656 330,355 333,418 149,629 155,083 87,551 136,070 3,573,335 413,368 189,888 1,517,401 284,340 154,923 314,708 303,855 8,137,580 979,735 1,387,394 0 0 0 0 0 0 0 235,151 75,000 69,967 84,952 67,640 26,354 559,064 350,833 666,968 856,981 133,828 473,678 187,500 2,669,788 447,063 438,306 830,800 151,940 405,033 499,070 2,772,212 Tribal Projects Inter-Tribal Council of Arizona Community Partnership Projects Tanner Community Development Corporation Mountain Park Health Center Chicanos Por La Causa Asian Pacific Community in Action Wingspan Phoenix Fire Fighters Total Community Partnership Projects Statewide Projects Arizona Interscholastic Association Arizona HealthLinks Arizona Smokers’ Helpline US Script Healthcare Partnership Attorney General’s Office Total Statewide Projects 16 Projects Expenditures (in dollars) Fiscal Year 2005 Fiscal Year 2006 Other Projects Media and Social Marketing Evaluation and Surveillance Administration Total Other Projects Total ADHS TEPP Projects 6,286,959 1,294,613 1,065,578 8,647,150 20,849,705 5,937,475 1,559,399 794,121 8,290,995 21,147,245 154,619 222,511 200,643 58,068 173,782 51,506 72,300 179,303 62,739 0 200,163 1,375,634 150,275 189,404 252,726 53,134 266,600 148,833 104,453 214,994 66,024 3,500 267,014 1,716,957 22,225,339 22,864,202 Chronic Disease Projects American Cancer Society American Lung Association Arizona Interscholastic Assoc. Coconino County Maricopa County Mountain Park Health Center Native American Community Health Center T-Gen/Avondale Wingspan Media and Social Marketing Administration Total Chronic Disease Projects Office of Tobacco Education and Prevention Program Grand Total Expenditures 17 assumptions about average costs and impacts based on current findings in economic and medical science. Based on these figures, Arizona tobacco control spending remains at approximately 0.03 the amount of tobacco-attributable medical expenditures. The CDC periodically release estimates of the impact of smoking on health care expenditures for all states, through their Smoking Attributable Mortality, Morbidity, and Economic Costs—or SAMMEC—system. Health risks and expenditures are calculated by making Figure 2. Arizona Tobacco Program Expenditures Per Person vs. Estimated Arizona TobaccoAttributable Medical Expenditures Per Person Arizona Expenditures per Person $180 $157.76 $160 $140 Dollars $120 $100 $80 $60 $40 $20 $4.71 $0 Tobacco control expenditures Tobacco-related m edical expens es Note: As of October, 2006, the year 2001 is the most current year for calculating SAMMEC. 18 PROGRAM ACTIVITIES AND SERVICES PREVENTING YOUTH INITIATION • Provide program-specific training for teachers Because four out of every five people who use tobacco begin before they reach adulthood, tobacco-prevention activities focus on school-age children and adolescents, primarily those in grades 4 through 8. Evidence suggests that school health programs can be an effective means of preventing tobacco use among youth. The Centers for Disease Control and Prevention (CDC) developed guidelines to help plan, implement, and assess educational programs and school policies to prevent tobacco use.2 The seven recommendations below summarize the strategies that have been determined to be effective in preventing tobacco use among youth. To ensure the greatest impact, programs should implement all seven recommendations. • Involve parents or families in support of school-based programs to prevent tobacco use • Support cessation efforts among students and all school staff who use tobacco • Provide instruction about the short- and long-term negative physiologic and social consequences of tobacco use, social influences on tobacco use, peer norms regarding tobacco use, and refusal skills • Provide tobacco use prevention education in kindergarten through 12th grade. This instruction should be especially intensive in middle school and should be reinforced in high school • Assess the tobacco-use prevention program at regular intervals • Develop and enforce a school policy on tobacco use The Arizona Department of Health Services Office of Tobacco Education and Prevention Program (ADHS TEPP) has focused its school-based prevention efforts on supporting schools in providing intensive tobacco-use prevention programming in late-elementary and middle schools, and on providing brief educational interventions in the earlier school grades. In addition, ADHS TEPP supports local projects in providing community-based prevention education through after-school clubs, youth leadership coalitions, and community groups, and through broad outreach events such as county fairs and youth conferences. School policy enforcement currently is monitored by 11 out of 15 counties, as part of their worksite programming. INTENSIVE SCHOOL-BASED PREVENTION PROGRAMMING ADHS TEPP began sponsoring intensive tobacco prevention education in schools in 1996. Until 2004, local project contractors conducted their own evaluations using curriculum-based pre- and post-tests. To get a more comparable view of what was happening in schools across the state, ADHS TEPP moved towards a standardized evaluation effort across all schools. Centers for Disease Control and Prevention. Guidelines for School Health Programs to Prevent Tobacco Use and Addiction. Morbidity and Mortality Weekly Report, 1994;43(No. RR-2):1-18. 2 19 Instructor and student questionnaires were administered in FY05 and FY06 to those who taught and received intensive programming, defined as a minimum of four lessons from an evidence-based curriculum. The results of those questionnaires serve as feedback for ADHS TEPP about the characteristics of the tobacco prevention education classes, how many were conducted and who was reached, what was covered in the classes, the students’ interest in and satisfaction with the classes, their reports of what they learned, and their attitudes about tobacco use. Besides providing ADHS TEPP with feedback about the program, the evaluation provides county contractors and prevention educators with county-level information to assess their programming. Title I schools (federal program for Improving the Academic Achievement of the Disadvantaged) • Schools with high percentages of children who are enrolled in the federal free or reduced price lunch program (National School Lunch Program) • Schools with high proportions of minority populations, including American Indians Schools that are underperforming academically • Public schools located on American Indian Reservation land Based on that assessment, there are approximately 533 public schools in Arizona with grades 4 through 8 that serve students at higher risk of initiating and sustaining tobacco use. In the academic years 2005 and 2006, ADHS TEPP contractors provided schoolbased intensive prevention education using evidence-based curricula to 668 schools in Arizona. This represents 47 percent of all public schools in Arizona that have grades 4 through 8. In those schools, 3,363 class groups were taught, reaching 87,830 students. Of the schools served, 253 (38 percent) fell into the higher risk category. This represents nearly 50 percent of higher risk schools serving grades 4 through 8 in the state. The majority of the schools receiving intensive tobacco prevention education were district schools (90 percent) and eight percent were charter schools. Of the remaining two percent, three were tribal schools, three were private schools and seven were unidentified with respect to type. ADHS TEPP directs its contractors to provide intensive education in grades 4 through 8, targeting schools considered to serve students who are at higher risk of tobacco initiation and use. These schools are termed higher-risk schools, based on one or more of the following criteria: • • The number of students per grade receiving intensive school-based prevention education was: 30,122 4th graders, 13,699 5th graders, 17,350 6th graders, 22,176 7th graders, and 4,483 8th graders. The graph below shows the relative proportion of students receiving the programming by grade, with more 4th and 7th graders receiving programming than students in other grades. 20 Figure 3. Grade Distribution of TEPP Intensive Prevention Education Grade Distribution of TEPP Intensive Prevention Education 100 Percent 80 60 40 34 16 20 25 20 5 0 4th 5th 6th 7th 8th Grade In addition to services provided directly to youth in 4th through 8th grades, 60 curriculum trainings were held for more than 400 prevention educators, to develop capacity within schools to continue prevention education. across the state with small numbers of students. Eighty-four percent of the students in grades 4 and 5 received SAMHSA-approved curricula. The three main tobacco prevention curricula used by ADHS TEPP contractors for 6th, 7th and 8th graders were Project Alert (about 55 percent of students), Get Real About Tobacco (23 percent) and Project Towards No Tobacco (7 percent). About 95 percent of the students in grades 6, 7 and 8 received SAMHSA model programs. Prevention Curricula The curricula for intensive education interventions in schools are designed to meet the needs of students at two different developmental levels: elementary grades 4 and 5, and middle school grades 6, 7, and 8. Most curricula used by ADHS TEPP contractors are designated “model programs” by SAMHSA (United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration). Other curricula were not endorsed by SAMHSA because they were already endorsed by Get Real About Violence as a model program. On average, students in the 4th and 5th grades received approximately 8 hours of instruction time during the tobacco prevention class. The amount of teaching time varied depending on the curriculum used and how it was implemented. The span of teaching hours, as reported by the tobacco class instructors, ranged from two to 20 hours. The number of weeks the class spanned was between one and 30. On average, the class was taught once a week. In grades 6, 7, and 8, the instructors reported teaching the tobacco prevention curriculum for from three to 36 hours, with an average of nine hours. The time span covered by the classes The tobacco prevention curriculum used to teach most students (70 percent) in grades 4 and 5 was Get Real About Tobacco. Other curricula were used 21 ranged from one to 30 weeks. Again, the tobacco prevention class usually took place once a week. class. Slightly fewer 6th, 7th and 8th graders (83 percent) said they would tell their friends it was a good class. Overall, intensive school-based programming is well-received by students and teachers. Summary of Student Evaluation Forms Of those students completing a student evaluation, about 91 percent of the 4th and 5th graders thought the tobacco class they participated in was interesting, and 92 percent reported that they liked being part of the tobacco class. Among older students, about 92 percent of the 6th, 7th and 8th graders thought the tobacco class was interesting. Seventy-nine percent reported that they like being part of the tobacco class, illustrating the increasing difficulty of engaging children in prevention programming activities as they approach adolescence. BRIEF SCHOOL-BASED PREVENTION PROGRAMMING In addition to the intensive interventions tracked by the school evaluation, a select number of counties also tracked their brief interventions in schools in a standardized reporting system in FY05 and FY06 (this reporting system was rolled out to all of the counties for FY07). These brief prevention interventions were single-session boosters, presentations or events given in classes or assemblies during school hours. More than 1,400 brief intervention activities took place in 407 schools, serving over 150,000 students. Among 4th and 5th graders, 98 percent reported that the class gave them good reason not to smoke or use tobacco and 97 percent of the students agreed that it’s important to be tobacco free. Beliefs were similar for 6th, 7th, and 8th graders with 93 percent reporting that they learned things that would help them stay away from tobacco and 94 percent of the students agreeing that it is important to be tobacco free. The following map shows the locations of the schools that received intensive schoolbased interventions, and/or brief schoolbased interventions across the state. Details about one of the brief intervention programs that was evaluated in FY06 are provided below. Most 4th and 5th graders (89 percent) said they would tell their friends it was a good 22 Figure 4. Schools Receiving TEPP Services and their mascot puppet, Deliverer, educate the students on the dangers of smoking and using other tobacco products. The messages are crafted to coincide with ADHS TEPP’s prevention marketing campaigns. The program is targeted towards schools that meet the ADHS TEPP criteria of serving students who are at higher risk of tobacco use. Suns’ Gorilla Assembly The ADHS TEPP and Phoenix Suns’ Gorilla school assembly is an ongoing school prevention program first developed with ADHS TEPP in 2003. The Phoenix Suns’ Gorilla and public relations team provide tobacco prevention education events to elementary age students in 40 locations (mostly schools) across the state per year. Over 6,000 youth attended Phoenix Suns’ Gorilla assemblies in FY05 and FY06. The program capitalizes on the team and the mascot’s public appeal and star quality to communicate the importance of living a tobacco-free, healthy lifestyle. Concurrently, the City of Phoenix Firefighters are contracted to present with the Phoenix Suns’ Gorilla and public relations team. The “Fire Pals” The University of Arizona Evaluation, Research and Development Unit conducted site visits to observe the program in six schools in the Phoenix area in February and March 2006. Observations were made of the school context, the content of the program, the method of delivery, and the reaction of the students and school staff during the performance of the program. To assess the 23 program, teachers and students were asked to fill out short questionnaires after the program. Twenty-six teachers and 86 students completed the questionnaires from the six schools. Some of the results from these questionnaires found: • All the teachers expressed high praise for the program • More than half of the teachers surveyed reported that similar messages were covered in classes or other events in their school • Fifty-four percent of the teachers thought the program would definitely help students avoid taking up tobacco • The presence, participation, and support of the principal and teachers were crucial to the momentum of the assembly • The vast majority of the students enjoyed the program and reported remembering: provide prevention education to youth outside of school hours, in club, camp, youth coalition or other community settings. In FY05 and FY06, over 120 prevention events were provided and reached over 16,000 youth across Arizona. ADHS TEPP also contracts with the Arizona Interscholastic Association to provide AIA Academy and AIA Pursuing Victory with Honor clinics, programs that promote a healthy sport experience by training coaches and parents to incorporate healthy lifestyle issues (including tobacco prevention) into youth, recreational and interscholastic experiences. In FY05 and FY06, AIA held more than 74 clinics, reaching more than 3,000 coach and parent participants with healthy lifestyle and tobacco prevention information. PREVENTING YOUTH INITIATION BY RESTRICTING ACCESS TO TOBACCO School Policy Assessment – the gorilla, his antics and story As noted above, the CDC have recommended that schools develop and enforce a school policy on tobacco use. A tobacco-free school environment can provide health, social, and economic benefits for students, staff, the school, and the district. These benefits include decreased fires and discipline problems related to student smoking, improved compliance with local and state smoking ordinances, and easier upkeep and maintenance of school facilities and grounds. In Arizona, all schools, private and public, are smoke and tobacco-free by statute (A.R.S. 36-798.03). – the facts they learned about tobacco – the real life stories told by the fireman In the short term, the program sends a clear, well-communicated message to the students and the students demonstrate that they understand and remember the message. However, the longer term impact is likely to depend on how it fits in to the broader prevention education program that the students receive, i.e. how often and how many ways the message is reinforced. In 2004, ADHS TEPP contracted with the Maricopa County Tobacco Use Prevention Program (MACTUPP) to conduct tobacco policy evaluation with local high schools. MACTUPP staff utilized a previously developed school policy assessment tool to determine the existence and COMMUNITY-BASED PREVENTION PROGRAMMING In addition to school-based classes and events, community-based projects also 24 schools surveyed, 99 percent did have a written tobacco-free school policy. Of the 134 high schools completing the assessment survey, just over three quarters (78 percent) included in their policy specific enforcement procedures for tobacco related offenses. comprehensiveness of a tobacco-free policy, enforcement status of this policy at the local high school level, and existing resources for tobacco cessation and prevention. In FY05 and FY06, 157 public and charter high schools were contacted to be surveyed on their tobaccofree policy. Of those schools contacted, 134 completed the assessment tool. High schools in this sample are from across Maricopa County with the majority of schools in the two largest cities, Phoenix and Mesa. Both charter (49 percent) and district (51 percent) public schools participated equally in the assessments. The tobacco-free policy assessment asked school personnel if the policy was enforced with students, staff, and visitors (as recommended by the CDC). According to school personnel, enforcement occurs more often with students than with visitors or with school staff. Overall rates of enforcement are not high, and this is an area where MACTUPP staff offer technical assistance and training to school personnel. Although tobacco is prohibited in schools in Arizona, having a written tobacco-free policy is not mandated. However, of the Figure 5. Consistency of Tobacco-free Policy Enforcement in Maricopa County 100 Percent "Yes" 80 Is the School Policy Consistently Enforced? Maricopa County, 2004-2006 74 69 70 Staff Vis itors 60 40 20 0 Students inspections of tobacco retailers throughout the state. In doing so, AGO is able to monitor the rate at which Arizona retailers comply with state laws regulating the sale of tobacco to minors. Information obtained during these inspections is shared with ADHS TEPP and their local project contractors, and retailers found to be in violation of the law are reported to local law enforcement. The total number of compliance checks Attorney General's Youth Tobacco Program ADHS TEPP contracts with the Arizona Attorney General’s Office (AGO) to conduct the Arizona Youth Tobacco Program. The goals of this program are to reduce youth access to tobacco products and facilitate the enforcement of Arizona’s youth tobacco statutes. To accomplish these goals, AGO conducts undercover 25 increased by 25 percent from FY 05 to FY 06 (Fig. 6). retailers who sold tobacco products to minors. In the same time frame, the rate of compliance failure decreased 5 percentage points (i.e., 5 percent fewer of the vendors checked failed to comply with the Arizona minimum age of 18 years old to purchase tobacco) (Fig. 6). In FY06 a total of 276 citations, 52 percent of all 529 successful underage purchases, were issued to In addition, local projects are notified when a tobacco retailer in their county fails a compliance check, and these projects provide merchant education to encourage retailers to develop policies and procedures to prevent future violations. Figure 6. Attorney General Compliance Checks, FY 04-06 Attorney General Compliance checks, FY 04-06 3000 50% 2000 2177 40% 30% 25% 20% 1000 20% Failure rate total # of checks 2707 10% 0 0% FY 04-05 Total Inspections FY 05-06 Failure rate Operation Storefront HELPING TOBACCO USERS QUIT Through Operation Storefront, local youth count the number of tobacco advertisements inside and outside retail stores, paying attention to the size and placement of each advertisement. The youth then explain to retailers how they can change their policies about tobacco advertising. The end goal is to counteract the daily normalization and glamorization of tobacco that happens through local advertising. Peer-led activities are taking place in Graham, Gila, Mohave and Pima counties. ARIZONA SMOKERS’ HELPLINE (ASHLINE), LOCAL PROJECTS, AND COMMUNITY PARTNERS The Arizona Department of Health Services Tobacco Education and Prevention Program (ADHS TEPP) provides free-of-cost tobacco cessation services to Arizona residents through the Arizona Smoker’s Helpline (ASHline) and community-based classes. The ASHline is a telephone-based information, counseling and referral service for people who want 26 to quit using tobacco. Services are provided on an on-going basis and are available in English and Spanish. classes reported being “quit” (tobacco free) at the conclusion of the program. Of these class participants, 56 percent reported being tobacco free for at least 24 hours while enrolled in the program (an indicator of moving along the quitting continuum towards tobacco-free status). In November, 2004, the United States Department of Health and Human Services announced an initiative that launched the national tobacco quitline, 1800-QUIT-NOW. The national tobacco quitline number is a routing system that drives all calls to the particular state from which someone calls. All calls made from an Arizona telephone prefix are automatically routed to the ASHline in Arizona. Since its inception, the 1-800QUIT-NOW system has routed more than 1,600 calls to the ASHline. Three months after services were completed, about 50 percent of all clients who went through multi-session in-person or phone tobacco cessation services reported not having used tobacco in the past 30 days. Using an intent-to-treat model, in which clients who were not reached for the follow-up survey are assumed to still be using tobacco, about 10 percent of all clients are estimated to still be quit at three months postprogram. This 10 percent is a very conservative estimate of the quit rate for ADHS TEPP cessation clients. Individuals who contact the ASHline also are offered the option of a referral to community-based classes. These are intensive cessation classes offered once a week in a face-to-face group setting, run by certified cessation facilitators in each of the counties. Worksite Cessation Worksite cessation programs increase employee quit rates and have the potential to decrease exposure to secondhand smoke, improve worksite wellness norms, and improve the health of employees. Arizona HealthLinks, the worksite outreach program (described in more detail under Reducing Exposure to Secondhand Smoke below) offers cessation classes in worksites throughout the state, and offers information about and referrals to community-based classes and ASHline in other counties. Cessation classes were held in worksites across Arizona. For example, in Maricopa County in FY05 and FY06, 121 cessation classes were held at 62 individual worksites. In addition to counseling services, ASHline maintains a website (www.ASHline.org) to provide information about cessation services available in the state and additional quit resources for those who prefer to attempt to quit on their own. The website also contains a section for professionals (both in health care settings and worksites) assisting their patients or employees in quitting. In FY05 and FY06, the ASHline.org website registered a total of 63,748 unique visitors (about 2700 visitors a month), for a total of 226,917 sessions. Cessation Service Clients In FY05 and FY06 a total of 12,164 Arizona residents took advantage of the cessation services offered by ADHS TEPP. Of these, 4,156 received services through the ASHline and 8,008 through the Local Projects. During this period, 44 percent of the clients who completed cessation Provision of Medication to Assist Clients in Quitting ADHS TEPP offers a medication benefit to clients older than 18 years old who are enrolled in their intensive cessation 27 services (ASHline phone counseling, and multi-session community classes). The medication benefit, administered by US Script, provides cessation clients with a 50 percent discount on the price of overthe-counter nicotine replacement therapy (nicotine patches, gum, or lozenges) at any participating pharmacy in their area. The 50 percent voucher can also be used to buy Buproprion, a prescription medication that has been approved for smoking cessation. Each client is entitled to a six-week supply of the medication. The vouchers are dispensed every two weeks at the class session or mailed after the phone counseling session. week intensive Quit Tobacco curriculum providing nicotine replacement therapy for the duration of the program. Through June 2006, 138 employees participated in the program with 56 percent of clients reporting being “quit” at the last class and 58 percent reported being tobacco free for at least 24 hours during the program. How Clients Heard about the Program ADHS TEPP has focused efforts on recruiting clients to cessation services through healthcare providers and worksites. The numbers of clients who reported hearing about the program through these and other sources are described below. Referrals from family and friends continue to be a large source of recruitment for community-based classes. Although there was not a widespread cessation media campaign in these years, the ongoing social marketing campaign also is a source of information about the program that drives clients to take up services. During FY05 and FY06, 4,519 cessation clients took advantage of this benefit and a total of 6,543 vouchers were redeemed. Of these, 97 percent were for nicotine replacement therapy and 3 percent were for Buproprion. Beginning March 1, 2004, Maricopa County government employees and covered dependents on a Maricopa County health plan were offered access to a unique tobacco cessation program: a 12Table 3: How Clients Heard about Cessation Services How Client Heard about Program Number of All Clients Percent of All Clients Number of Communitybased Clients Percent of Communitybased Clients Number of ASHLine Clients Percent of ASHLine Clients 3253 27% 1656 21% 1597 Health Care Provider 2560 21% 2191 27% 369 Family and Friends Media 2035 17% 1474 18% 561 Worksite 1269 10% 1244 16% 25 2178 18% 1318 16% 860 Program Referral Other 2075 17% 1312 16% 763 Note: Sums to great than 100 percent because clients could chose more than one referral source. 28 38% 9% 13% 1% 21% 18% About 87 percent of respondents stated that the class met their needs and about 13 percent reported that the class “somewhat” met their needs. Only about 1 percent reported that the class did not meet their needs. Virtually all clients (96 percent) who completed the satisfaction questionnaire would refer another tobacco user to the class they just completed. Users’ Satisfaction with Tobacco Cessation Classes At the last session of the class, clients who attend community-based classes are asked to complete an evaluation questionnaire that assesses their satisfaction with the class. Users rate their level of satisfaction with the following areas: logistics (e.g., class length, number of sessions etc.), facilitator, confidence in acquired skills and general experiences with the class. A total of 2,302 clients provided input on their satisfaction with the cessation classes through during FY05 and FY06. Who are Service Users? Comparisons to Arizona Adult Tobacco Survey (ATS) 2005 smoker characteristics The ATS data provide ADHS TEPP with a profile of the current smoker population in the state. A comparison with the characteristics of the cessation clients allows ADHS TEPP to better understand which smokers in the state are accessing ADHS TEPP cessation services. Overall, clients who finished the quit classes were highly satisfied with all aspects of the classes. Ninety-nine percent of all clients reported excellent or good experiences with the helpfulness of the information they received during the classes. 29 Figure 7. Age of Cessation Clients and Smokers in AZ Age: Cessation Clients FY 04-06 and ATS 2005 Current Smokers 100 Ces s ation Clients FY 04-06 ATS 2005 percent 80 60 40 24 18 20 23 21 15 29 20 18 10 5 9 9 0 18-24 25-34 35-44 45-54 55-64 65+ Age–Cessation clients tend to be older than the smokers in the state. Figure 7 shows in more detail the differences in ages for cessation clients as compared to ATS. The most notable difference in the rates is in the 18 to 24 year old category, with only 5 percent of the cessation clients falling under this category, although this age group accounts for 18 percent of the smokers in the state. Smokers in the 25 to 34 year old age group also are underrepresented as cessation clients. Figure 8. Gender of Cessation Clients and Smokers in AZ Gender: Cessation Clients FY 04-06 and ATS 2005 Current Smokers 100 Ces s ation Clients FY 04-06 ATS 2005 percent 80 60 57 60 Gender–ADHS TEPP cessation services serve a higher percentage of females than males, although males account for a larger percentage of the smoking population. 43 40 40 20 0 Male Fem ale Figure 9. Ethnicity of Cessation Clients and Smokers in AZ Ethnicity: Cessation Clients FY 04-06 and ATS 2005 Current Smokers 100 percent 80 74 76 Ces s ation Clients FY 04-06 ATS 2005 60 40 18 20 4 14 2 1 5 0 W hite African American Hispanic American Indian 30 Ethnicity–The ethnic background of cessation clients does not differ substantially from the ATS current smoker population. However, American Indians are underrepresented among cessation clients (5 percent of the smoking population but only 1 percent of cessation clients). Figure 10. Education of Cessation Clients and Smokers in AZ Education–Cessation clients tend to have slightly more years of education than the ATS 2005 current smoker population. This is indicated in Figure 10 by the higher percentage of cessation clients who have a high school diploma and are college graduates. Education: Cessation Clients FY 04-06 and ATS 2005 Current Smokers 100 Ces s ation Clients FY 04-06 ATS 2005 percent 80 60 40 20 18 25 31 28 34 36 16 11 0 Les s than high s chool graduate High s chool graduate 1-3 year college College graduate Basic Skills Certification – Brief/Intermediate Interventions HEALTHCARE PROVIDER SERVICES HealthCare Partnership The HealthCare Partnership (HCP) provides an evidence-based statewide Continuing Education, Certification and Training model. HCP supports the ADHS TEPP mission by researching, developing, implementing, coordinating, and managing the statewide Arizona Certification Program & the Tobacco Dependence Treatment Continuing Education Program for Medical and Allied Health Professionals to encourage the advancement and diffusion of brief/intermediate and intensive tobacco cessation interventions. • Knowledge and skills-based workshops • Special cultural, language and target population adaptations Treatment Specialist Certification Intensive Interventions • Online learning center and library • Knowledge and skills-based workshops Tobacco Dependence Treatment for Healthcare Professionals HCP works in conjunction with ADHS TEPP Local Projects to deliver these services to healthcare providers throughout the state. • Continuing education programs for clinicians, as well as other health and human service workers • Knowledge-based programs • Spanish language intensive cessation program curricula • Instructor certification for all programs HCP, working with representatives of Arizona’s diverse populations, has developed 14 programs addressing the needs of those who are dependent on and/or use tobacco and are members of the State’s multi-cultural communities. HCP also provides systems-level programs for healthcare, workplace and schools. The major components and content of the continuing education and certification programs are as follows: During FY05 and FY06, HCP efforts resulted in 302 certification workshops with 1,989 participants, as well as 156 31 programs using and teaching the effectiveness of the tobacco-cessation interventions at the point-of-care and bringing awareness of ADHS TEPP tobacco control resources to health and human service providers. continuing education programs with 2,412 employees of 292 documented health and human service institutions. During this two-year period, a total of 4,401 health and human service providers participated in HCP educational Table 4. Healthcare Partnership Programs and Participation Arizona Certification Program Basic Tobacco Intervention Skills Native American Basic Tobacco Intervention Skills Medical & Allied Health Professionals Basic Tobacco Intervention Skills Maternal & Child Health Basic Tobacco Intervention Skills Spanish Language Basic Tobacco Intervention Skills Instructor of Basic Tobacco Intervention Skills Instructor of Native American Basic Tobacco Intervention Skills Instructor of Medical & Allied Health Professionals Basic Tobacco Skills Instructor of Maternal & Child Health Basic Tobacco Intervention Skills Instructor of Spanish Language Basic Tobacco Intervention Skills Tobacco Treatment Specialist Spanish Language Tobacco Treatment Specialist Instructor of Tobacco Treatment Specialist Déjate de Ese Vicio Total Certification Workshop & Participant Total (FY04-05 & FY05-06) Continuing Education Program Participation Tobacco Dependence Treatment Continuing Education Program for Medical and Allied Health Professionals Continuing Education Presentation & Participant Total (FY04-05 & FY05-06) HCP Participant Total (FY05 & FY06) Workshops Participants FY05 FY06 N N FY06 N N 67 8 42 53 2 59 434 49 357 289 14 465 1 1 4 2 4 4 3 3 0 14 6 5 22 22 30 19 25 30 0 105 0 0 0 0 0 13 na 2 1 145 0 16 1 1 1 157 0 35 na 10 4 974 0 32 15 5 16 1,015 Workshop Total Participant Total 302 Presentations FY05 FY06 N N 84 72 Presentation Total 156 Presentation/ Workshop Total 458 32 FY05 1,989 Participants FY05 N 1,328 FY06 N 1,084 Participant Total 2,412 Participant Total 4,401 cessation services. Through the PRS, the referral agent (e.g. physician) obtains the client’s consent and contact information on a form that is then faxed to the ASHline. The ASHline in turn proactively calls the client to offer all available services (information, counseling or referral to Local Projects). Additionally, HCP is responsible for the On-Line Learning Center (www.aztreattobacco.org), which delivers the initial course content for the ADHS TEPP Tobacco Treatment Specialist course along with an e-library of current scientific information on tobacco use and dependence. The On-Line Learning Center, with the support of the American Legacy Foundation and ADHS TEPP, has been translated and culturally adapted to address the needs of Arizona’s Spanishspeaking population. In FY05 and FY06, the on-line learning center registered about 126,000 unique visitors (about 5,200 visitors a month), for a total of about 209,000 sessions. In the period of FY05 and FY06, 3,451 clients were referred to ADHS TEPP cessation services through the PRS. There were 532 identified referral agents and 145 referring health care systems or agencies that utilized the service during this period. The following map reflects the PRS activity during FY05 and FY06. Each circle represents a referral agent/system and the size of the circle reflects the number of individuals referred to ADHS TEPP cessation services. Proactive Referral System/QuitFax ADHS TEPP has established a Proactive Referral System (PRS) through which health care providers or individuals at other settings (i.e. worksites; WIC offices) can proactively refer patients/clients to 33 Figure 11. Proactive Referrals Coconino Mohave Apache Navajo Yavapai Gila La Paz Agent Referrals Maricopa System Referrals Greenlee Graham Pinal Yuma Pima 1 - 10 1 - 10 11 - 25 11 - 25 26 - 50 26 - 50 51 - 79 51 - 96 97 - 150 Cochise 151 - 184 Santa Cruz Starting FY07, the Proactive Referral System will be known as QuitFax Referral System. concludes that 1) secondhand smoke causes premature death and disease in children and in adults who do not smoke, and 2) the scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke. REDUCING EXPOSURE TO SECONDHAND SMOKE The Arizona Department of Health Services Tobacco Education and Prevention Program (ADHS TEPP) and its contractors support the development of smoke-free environments by providing community-based education on the dangers of tobacco use and secondhand smoke through presentations, health fairs, and outreach events; by providing education, resources and technical assistance to worksites; through targeted efforts of local projects and community partnership projects (see Identifying and The 2006 United States Surgeon General’s report on the health consequences of secondhand smoke3 U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. 3 34 In FY05 and FY06, AZHL provided education on smoke-free policies to 3,831 worksites across the state, provided smoke-free signage to 774 worksites, and supported 565 worksites in making policy changes, 186 of which became smoke-free. Of the worksites making policy changes, 351 (62 percent) were targeted worksites, and of the worksites becoming smoke-free, 141 (76 percent) were targeted worksites. Eliminating Tobacco-Related Disparities below); and with a marketing campaign specific to secondhand smoke (see Creating Awareness and Educating through Social Marketing, in the following section). COMMUNITY-BASED OUTREACH Local county programs engage in many activities that are designed to raise public awareness about the dangers of tobacco use and of secondhand smoke, and to promote their services. These activities typically involved participating in or organizing community events such as health fairs and festivals, and providing educational presentations about tobacco control to various community groups. In FY05 and FY06, more than 360 events were conducted statewide, reaching more than 50,000 people. PIMA COUNTY SECONDHAND SMOKE PILOT PROGRAMS The Tobacco Free Way’s (TFW) Program in the Pima County Health Department partners with childcare providers throughout Pima County in a program to allow daycare providers to inform and educate families about the danger of secondhand smoke. Messages are delivered to families via brochures, newsletters, handouts and posters. Staff at childcare centers also implement the Environmental Protection Agency (EPA) curriculum, Protecting Children from Exposure to Secondhand Smoke. Childcare centers that participate in the program are eligible to receive materials and supplies worth $200 when they provide a minimum of three secondhand smoke messages to families over the course of a year. WORKSITE SECONDHAND SMOKE POLICY ASSISTANCE The Arizona HealthLinks (AZHL) program works collaboratively with local projects and tribes to help worksites create smoke-free environments by providing an array of technical assistance and training services. AZHL educates employers and employees on creating, revising, and implementing comprehensive smoke-free policies including providing signage of the policy and helping to design a compliance program. AZHL target worksites with underserved populations or employees that may be exposed to high incidence of secondhand smoke. Worksites were targeted in two ways: 1) worksites fell into industry sectors that have high rates of low income, low education, high minority employee populations, or limited health care offered by employers, or 2) worksites were located in traditionally underserved areas. During FY05, TFW’s staff identified and recruited local day care centers and trained center staff in the use of the EPA secondhand smoke curriculum. By the end of FY 06, 102 childcare centers in Pima County had implemented the secondhand smoke curricula in their centers, and provided informational materials on the danger of secondhand smoke to the families of the children they serve. TFW also implements a secondhand smoke program in hospitals, called the Maternity Discharge and Neo-natal Intensive Care Units (NICU) Program. 35 TFW staff educate maternity and NICU nurses at four hospitals on the dangers of secondhand smoke. As part of the discharge procedure at these hospitals, new mothers and families are given secondhand smoke information and materials, such as “Designated NonSmoking Area” bibs, and a 12-month “new mom” planner with secondhand smoke information on each page. As a result of TFW’s program, the four hospitals involved provided secondhand smoke information to over 10,000 new mothers during FY05 and FY06. existing strategic plans related to identifying and/or addressing health disparities. The team then began to review ADHS TEPP contracts to see how communities with high-tobacco related disparities were being served. The team also made field site visits to each county and tribe in the state to share data and build collaborative relationships. Interventions for programs were reviewed and adopted to ensure sensitivity toward each priority community (e.g. faith-based outreach for African Americans; teaching about the traditional use of tobacco with American Indians, etc.). ADHS TEPP created definitions and guidelines for working with disparate communities, strategic goals/objectives, and crafted recommendations for ADHS TEPP contractors to address health relateddisparities in their communities. IDENTIFYING AND ELIMINATING TOBACCO-RELATED DISPARITIES ADHS TEPP COMMUNITY PARTNERSHIP PROGRAM At the conclusion of these assessments, ADHS TEPP decided to implement direct contracts with grassroots organizations working with disparate populations and to dedicate staff to provide technical assistance and contract oversight. Thus, the Community Partnership Program (CPP) was created during FY05-06 to involve community-based agencies in tobacco control activities that complement and extend the reach of ADHS TEPP. The goals of the CPP are to: 1) address unmet community needs; 2) leverage or build upon existing agency strengths, resources and community networks; 3) increase capacity of community agencies to implement new health-related programs; 4) implement innovative programs that can be replicated by others. The Centers for Disease Control and Prevention (CDC) have stressed the need for comprehensive tobacco control programs to work closely with communities that have marked tobaccorelated health disparities. Before 2004, the Arizona Department of Health Services Tobacco Education and Prevention Program (ADHS TEPP) had funded tobacco cessation programs targeting disparate populations through media sub-contractors and through the Local Projects. Through this endeavor, appropriate media messages were produced and the ground was laid for identifying collaborative links, potential services and infrastructure needs. A series of assessments were also done to better understand the needs of disparate populations in the state and how to better provide them with tobacco cessation services. Through the CPP, ADHS TEPP seeks to address tobacco-related disparities in the state of Arizona by funding grassroots capacity building within disparate communities. The populations on which the program currently focuses are those who have low socio-economic status, and In 2004 ADHS TEPP established a Disparate Populations Team which conducted research on literature and 36 those who are Hispanic, African American, Asian-Pacific Islander, or Lesbian, Gay, Bisexual or Transgendered. Through these collaborations and events, TCDC distributed numerous informational materials focusing both on prevention and on cessation with information from the Arizona Smokers’ Helpline. TCDC also delivered intensive cessation classes and brief cessation interventions. TCDC offered a number of secondhand smoke educational presentations at community events and assisted churches and worksites to create smoke-free spaces. CPP’s activities include, but are not limited to, culturally specific awareness and educational programs, anti-tobacco support networks, capacity building/ infrastructure, smoke-free events, and creating marketing materials to help increase awareness and education on tobacco-related disparities. Technical assistance is provided on an on-going basis related to capacity building, program implementation, budget, best approaches, marketing, resources, outreach activities, and maximizing collaborations with other stakeholders. Asian Pacific Community in Action (APCA) Population Focus & Geographical Area Covered: Asians in Chandler and Greater Phoenix Metro areas APCA is a non-profit agency serving the community of Asian Pacific Islanders (API) in Maricopa County and contracts with ADHS TEPP to provide tobacco prevention and cessation services to the local API community. ADHS TEPP began contracting with APCA in September 2005 and initiated tobacco training for project staff. In addition, APCA participated in numerous health outreach events providing prevention and cessation information and conducting brief interventions with adult smokers. Strategies are underway to implement secondhand smoke, smoke-free spaces and cessation activities in the APCA community. The following section describes the projects that were funded during FY0506. Starting in FY 06-07, these projects will be participating in the standardized data collection systems that the Evaluation, Research and Development Unit utilizes to evaluate and report ADHS TEPP funded tobacco-related activities. Tanner Community Development Corporation (TCDC) Population Focus & Geographical Area Covered: African Americans in Maricopa County, Tucson, and Flagstaff areas, faith-based and community level ADHS TEPP contracts with TCDC, a nonprofit organization linked to the Tanner Chapel AME, to coordinate, implement and execute the Ashes to Ashes Campaign. This campaign aims at educating African Americans about tobacco-related diseases and their impact on their community, as well as to encourage tobacco users to quit. During FY 05-06 TCDC involved various churches and other African American community agencies in this campaign as well as in other outreach and/or health fairs targeting African Americans. Mountain Park Health Center (MPHC) Population Focus & Geographical Area Covered: Low SES residents seeking medical assistance who are primarily Hispanic, African American or Asian in the Phoenix area Mountain Park Health Center is a nonprofit community health center and contracts with ADHS TEPP to provide prevention and cessation services targeting Hispanic, low-income children and families. During FY 2005-2206 MPHC attended and presented at 37 numerous community outreach events in an effort to inform youth about the dangers of tobacco use and to provide information to smokers on resources for quitting. Community collaborations were developed by engaging multiple community and governmental organizations on the topics of prevention, cessation, secondhand smoke and healthy lifestyles. Community Assessments During FY05-06 ADHS TEPP continued to conduct assessments of other disparate populations in the state in order to identify their needs and develop adequate interventions for these groups. Three community assessment projects that took place in this period were: the Tobacco Use and Interventions among Arizona Lesbian, Gay, Bisexual and Transgender People Study; the ADHS-AHCCCS Collaborative Study; and the Arizona Spanish Adult Tobacco Survey. MPHC is active in referring smokers to the Arizona Smoker’s Helpline, providing cessation classes at their four clinics, and increasing the number of smoke-free places by implementing a smoke-free home and cars pledge drive within the community they serve. Tobacco Use and Interventions Among Arizona Lesbian, Gay, Bisexual and Transgender People The smoking prevalence among lesbian, gay and bisexual (LGB) adults has been reported to be higher than that of heterosexual men and women. To investigate tobacco-related health disparities relevant to LGB and transgendered (LGBT) Arizona residents, ADHS TEPP funded a study to assess health-related disparities among LGBT people in Phoenix, Tucson, and Yavapai County. This study was conducted by Wingspan, a non-profit, charitable organization that serves Tucson and Southern Arizona with the mission to promote the freedom, equality, safety and well-being of LGBT people. Chicanos Por La Causa (CPLC) Population Focus & Geographical Area Covered: Hispanics, Low SES residents enrolled in Migrant Program & Early Head Start Programs CPLC is a community development corporation committed to building stronger, healthier communities. CPLC contracts with ADHS TEPP to provide youth prevention and cessation services. A main component of CPLC’s Tobacco Prevention Program is the recruitment and training of Peer Health Leaders to become agents for change within their schools and communities. Many Peer Health Leaders were trained in FY 20052006 and participated in community outreach events and tobacco trainings. Data were collected via a community survey of 657 LGBT Arizonans, 12 focus groups, 24 key informant interviews, and strategic planning meetings in each community. Results from this assessment found that the smoking prevalence rate among this population is 50 percent higher than among non-LGBT Arizonans. The results of this study also provide insight into strategies to distribute information around tobacco prevention and cessation among LGBT people and around means of increasing tobaccorelated health and/or health care for LGBT people. CLPC addressed program objectives through activities in and around the five schools districts in which they work, specifically targeting low-income children and families. CPLC conducted multiple educational presentations and trainings to staff and members of the target community on the topic of secondhand smoke including education to families with asthmatic children and adult smokers. 38 ADHS-AHCCCS Collaborative Study state. This population constitutes an important target for tobacco control efforts because they face language and cultural barriers to accessing services and health care. AHDS TEPP identified the need to better understand the tobaccorelated behaviors and attitudes of Spanish-speaking residents, and so conducted the first statewide Adult Tobacco Survey (ATS) in Spanish in FY06. Research shows the smoking prevalence among Medicaid recipients is 50 percent higher than the national average. During FY 2005-2006, ADHS TEPP, in partnership with the Arizona Health Care Cost Containment System (AHCCCS), conducted a research study among AHCCCS clients, AHCCCS-affiliated health care providers and health plans. This project assessed how tobacco cessation services are delivered to the AHCCCS population and whether improvements can be made to better serve this high-risk population. Individual faceto-face interviews were conducted with 37 health care providers, 31 clinic staff members and 96 AHCCCS clients at 10 Federally Qualified Health Centers (FQHCs) in Apache, Coconino, Maricopa, Pima, Pinal and Santa Cruz counties. Interviews were also conducted at one non-profit primary care facility in Mohave County. FQHCs were selected as field sites because their patient population is comprised largely of AHCCCS clients. ADHS TEPP contracted with the Northern Arizona University Social Research Laboratory (NAU SRL) to conduct the Spanish ATS. High-density Hispanic residential blocks with large percentages of Spanish-speaking households were identified and included in the sample for this survey. NAU SRL staff used a computer-assisted telephone interviewing (CATI) system to conduct the survey and collect data. In addition to the Spanish ATS, the Shortened Spanish Adult Tobacco Survey (SS-ATS) was fielded concurrently with the Adult Tobacco Survey (ATS) 2005 for the general population of Arizona. No special sampling procedure was used to select for Spanish-speaking residents. Those respondents who preferred to answer the ATS in Spanish were provided with these items, which were a subset of the full ATS. Details about the design and sampling procedure of the ATS 2005 can be found in ADHS TEPP Adult Tobacco Survey Report 2005. For methodological purposes and to better understand the tobacco-use behaviors and attitudes of the Spanish-speaking Hispanic community in Arizona, both surveys were combined to provide an aggregated sample of 1,059 self-identified Hispanic residents. Interview topics included awareness of existing ADHS TEPP cessation services, barriers to service utilization, and suggestions for service improvement. Staff from the UA Evaluation, Research and Development Unit (ERDU) will present a report with the findings and recommendations from this project to ADHS TEPP and AHCCCS in December 2006. This collaborative project has the longterm goal of creating a systematic collaboration between AHCCCS and ADHS TEPP in order to effectively address and diminish tobacco use among the high-risk AHCCCS population. Results of this assessment show that fewer than 13 percent of the Spanishspeaking Hispanic residents of Arizona surveyed are current smokers, and about one out of five individuals report being Arizona Spanish Adult Tobacco Survey In Arizona, the population of selfidentified Hispanic individuals is the most rapidly growing subpopulation within the 39 former smokers. Moreover, the smoking prevalence differed dramatically for the two sexes. Males were almost four times more likely to report being current smokers than females (20 percent vs. 5 percent). In terms of cigarette consumption, Spanish-speaking Hispanic current smokers reported substantially lower consumption than the general population of Arizona (8 packs per month vs. 18 packs per month, median values). Traditional Tobacco; school-based intensive curricula; culturally sensitive adult cessation classes; youth leadership programs; community outreach events; and technical assistance to tribal governments and organizations. During FY05 and FY06, ITCA contractors engaged in a variety of events around youth prevention and reduction of secondhand smoke exposure. More than 480 community outreach events took place during this time. Two annual youth conferences were held by ITCA subcontractors: the Hualapai Youth Conference and the American Indian Tobacco Youth Conference which was attended by more than 200 American Indian youth from Reservations. An important accomplishment around secondhand smoke took place with the Hopi Tribe Tobacco Prevention Program providing advice to the tribe on the Smoke-Free Tribal Resolution. This resolution, passed in September 2005, bans smoking in tribal facilities and requires smokers to smoke 15 feet away from the facilities. Also, in an effort to create culturally appropriate cessation services, the Tucson Indian Center continues to develop the Arizona American Indian Cessation Curricula, which will use the addiction model approach and will include stories around traditional use of tobacco. ERDU has been working in close collaboration with the CDC to develop a standardized version of the Adult Tobacco Survey in Spanish. ADHS TEPP and ERDU will continue to provide input into the development of this instrument, which the CDC will make available to all states interested in identifying tobaccorelated disparities among the Spanishspeaking population in the United States. SERVICES TO SUPPORT AMERICAN INDIAN COMMUNITIES ADHS TEPP supports tobacco control efforts within American Indian communities by collaborating with the Indian Health Service and by contracting with the Inter-Tribal Council of Arizona (ITCA) Community Tobacco Education and Prevention Program. ITCA in turn contracts with the following tribes: Colorado River Indian Tribes; KaibabPaiute; Hopi; Hualapai; Pascua Yaqui; Salt River Pima-Maricopa; and White Mountain Apache. ITCA also contracts with three urban programs: Native Americans for Community Action (Flagstaff); Native Health (Formerly Native American Community Health Center Inc.) (Phoenix); and Tucson Indian Center (Tucson). These programs provide tobacco control services to American Indian communities while addressing important issues such as traditional use of tobacco within ceremonies. Services provided include: presentations on In addition, the collaboration with Indian Health Services ensures that ADHS TEPP tobacco control services are easily available to American Indians in the state of Arizona. This was accomplished by connecting healthcare settings serving this population, such as Phoenix Indian Medical Center, to ADHS TEPP statewide programs like Arizona HealthLinks, the HealthCare Partnership and the Arizona Smokers’ Helpline. 40 Specific campaigns are generated to address communities with health disparities, including but not limited to African American, Asian Pacific Islander, Hispanic and Native American communities. CREATING AWARENESS AND EDUCATING THROUGH SOCIAL MARKETING Social marketing is the planning and implementation of programs designed to bring about social change using concepts from commercial marketing. Unlike product marketing, social marketing seeks to influence social behaviors not to benefit the marketer, but rather to benefit the target audience and the general society. To address the prevention and cessation of tobacco use and the health issues that occur from that use, the Arizona Department of Health Services Office of Tobacco Education and Prevention Program (ADHS TEPP) provides a comprehensive, innovative, and diverse social marketing campaign. This campaign includes education and awareness through: • A multi-venue media campaign • Message integration in school prevention programs • Local project cessation programs • A call to action to the ASHline.org website and ASHline quitline for tobacco control counseling assistance • Campaign involvement with local community projects Native American Market ADHS TEPP has contracts with various advertising and public relations agencies. ADHS TEPP uses several tactics including an integrated mix of traditional marketing (print, TV, radio, movie theaters, websites, kiosks, and billboards) and public relations efforts that relate back to ADHS TEPP’s goal of elevating awareness about the dangers of tobacco use, and moving Arizonans to quit using tobacco. ADHS TEPP’s statewide marketing campaign (counter-marketing campaign) supports the program goals to decrease tobacco use through prevention and cessation efforts and to reduce exposure to secondhand smoke by increasing awareness and knowledge levels among many target markets. 41 awareness of the dangers of tobacco. Also, cessation messages with a call to action to the ASHline were placed on City of Phoenix buses. ADHS TEPP has used various marketing initiatives over time to create a continuous statewide presence. The campaigns included in the rotation are those related to smokeless tobacco, secondhand smoke, cessation, prevention, as well as a focus to specifically identify the disparity groups within those campaigns. Additionally, marketing campaigns were developed by other states and sanctioned by the Centers for Disease Control and Prevention (CDC). ADHS TEPP has customized the messages for the Arizona market. Using these previously developed advertisements results in significant production cost savings for the state. ADHS TEPP has used the various advertising tactics listed below, which also will be employed to execute cessation, prevention, chew tobacco and multi-cultural marketing campaigns that will launch in 2007. PSAs Public Service Announcements (PSA’s) were formulated with anti-tobacco messages for smokeless tobacco, prevention and cessation services using players from professional sports teams in Arizona. Teams involved with this messaging include the following teams and players: Arizona Diamondbacks • • Arizona Cardinals • • • • • • • • • • • • • Scott Player Phoenix Coyotes • ADVERTISING TACTICS • • • • Shawn Green Miguel Batista Shane Doan Phoenix Suns Television ads Radio ads Print ads Television and radio public service announcements Web banner ads Movie screen ads Billboard ads Mall kiosks School bus ads City bus ads Cell phone ads Text messages Concert spots Glendale Arena Airport billboards Professional sports arenas and personnel • Eddie House Marketing Campaigns Great American Smoke Out (GASO) The “Great American Smoke Out” is a nationwide campaign held every year in November and sponsored by the American Cancer Society. The main premise of the campaign is to help smokers quit cigarettes for at least one day, in hopes they will quit forever. In 2005, ADHS TEPP initiated an integrated marketing campaign for the state’s participation in GASO within various communities. Local project managers in each county were given GASO press kits for public press releases and advertising coverage in their area. Specific budgets were allocated for each county as well as a supply of “Quit Kits” to be distributed to smokers trying to quit at various community GASO functions. School Buses and City Buses Educational information messages were displayed on school buses to prevent initiation of tobacco by youth and promote 42 Through with Chew prevention programs. R&R Partners in Phoenix, Arizona, is the media contractor for this campaign and arranged a schedule consisting of print, radio, television, online, movie theaters, and mall kiosks advertisements. The campaign also contained paid media directed toward specific African American, Asian American, Hispanic, and GLBT populations, with advertisements produced in English, Spanish, and Chinese languages. Some smokers appear to be turning to smokeless tobacco as a perceived safe and commercially viable alternative to smoking cigarettes. In the United States, smokeless tobacco predominately is used in the form of chewing tobacco. ADHS TEPP, along with Delta Dental of Arizona Foundation, conducted a six-week campaign to build awareness about the dangers of smokeless tobacco, and to help smokeless tobacco users quit dipping and chewing for good. The first four weeks focused on a prevention media message for youth, ages 6 to 17 years. The remaining two weeks focused on a cessation media campaign for young adults, ages 18-24 years. The target audience for the campaign are those who: Commercials featuring popular sports figures Shawn Green of the Arizona Diamondbacks and Shane Doan of the Phoenix Coyotes were run on cable TV and at Phoenix Suns, Coyotes and Roadrunners games. Statewide radio spots and movie theatre screen advertisements also were used. Visits to the ASHline.org website increased during the campaign, with an average of approximately 2,700 total visits during the six weeks of the media campaign. This represented an 8 percent increase from the average visits to the website since the beginning of 2006. • Are 18 to 34 years old (particularly families, and women of childbearing age) • Have obtained less than a college degree (e.g. those with a GED, high school diploma or some college education) • Are members of various communities including: Whites, Hispanics, African American, Native American, LGBT and Asian. The campaigns make use of existing inventory developed by other states that are sanctioned by the Centers for Disease Control and Prevention (CDC). The advertisements encourage readers, viewers and listeners to keep secondhand smoke out of the lives of children and to imagine a world without secondhand smoke. They also are directed to go to ASHline.org website and the Arizona Smokers’ Helpline (ASHline) for more information or help with quitting smoking. SECONDHAND SMOKE (SHS) CAMPAIGN ADHS TEPP launched its Secondhand Smoke Campaign in March, 2006 to help educate Arizonans on the impact and dangers of secondhand smoke. The campaign is part of a comprehensive approach toward tobacco education and includes links to secondhand smoke education on all ADHS TEPP websites, a media campaign, community outreach events, and message integration in school The specific TV advertisements included: The Bubbles Advertisement People in a variety of typical smoking scenarios are blowing bubbles instead of smoking. Tagline: Imagine a world without secondhand smoke. 43 Community Outreach Baby in Playpen Advertisement Expectant Mother’s Night Out was a community outreach activity used to coincide with the Secondhand Smoke marketing campaign. The objective of the activity was to build awareness about the importance of being a mother who does not smoke and to educate the public about the dangers of secondhand smoke for babies and developing children. The events were conducted in Mohave County: Kingman, AZ; and Pinal County: Casa Grande, AZ. A baby in a playpen is surrounded by secondhand smoke while the announcer describes all the ways this smoke can hurt the baby. Quit Smoking Around the Kids Advertisement Pictures of enlarged bacteria, viruses, etc. are shown while announcer states “there are lots of things that can make your child sick. Some of them you can’t do much about.” An enlarged burning end of a cigarette is shown and announcer states “And there’s one you can.” Tagline: Even if you can’t quit smoking, quit smoking around the kids. These events were designed to create a fun, educational event in which to urge expectant mothers to remain smoke-free through their pregnancy and continuing through their child’s developing years. The night included give-aways, raffles, and a maternity clothing modeling show. The Jasmine Advertisement A little girl stands in a gymnasium surrounded by playing children as she describes how secondhand smoke affects her asthma. Tagline: Make the choice your children can’t. Keep secondhand smoke out of their lives. The Baby Bib Campaign was an additional avenue to continue community education and establish partnerships with local restaurants to help communicate the Secondhand Smoke campaign message. Approximately 9,000 “I’m a designated non-smoking area” bibs were distributed in 114 restaurants in Apache, Cochise, Coconino, Gila, Graham, La Paz, Maricopa, Mohave, Navajo, Pima, Pinal, Santa Cruz, Yavapai, and Yuma. Local media coverage was used to promote the 44 campaign (e.g., Arizona Republic and Casa Grande Dispatch). smoke advertisement said that the ads were convincing, and 83 percent said the ads made them more aware of the health dangers of secondhand smoke. Campaign Evaluation After launching the Secondhand Smoke media campaign ADHS TEPP contracted to determine awareness of the campaign, responses to campaign elements and messages, and impact of media exposure on behavior change or beliefs about the dangers of secondhand smoke. The University of Arizona Evaluation, Research, and Development Unit collaborated with Northern Arizona University Social Research Laboratory and Partners in Brainstorms Research team to conduct two evaluation components using different methodologies, one by telephone surveys and one by community questionnaires. Partners in Brainstorms, Inc. (PIB) conducted face-to-face and Internet-based interviews throughout Arizona from July 21, 2006 through October 6, 2006 to measure parents’ perceptions of and experiences with secondhand smoke. The primary focus of this research was to better evaluate the effectiveness of the Secondhand Smoke Campaign among young adults, primarily women ages 18 to 34 years old, with children living in the household. A total of 853 interviews were conducted in English or Spanish, depending on the participant’s preference. Three-quarters of participants (74 percent) had children under the age of 6 years old living at home. Telephone surveys were conducted with 1,668 randomly-selected adult residents in four Arizona counties: Maricopa, Mohave, Pima, and Pinal to measure their perceptions of and experiences with secondhand smoke. The survey was conducted in both English and Spanish. • • • Sixty-six percent of these young adults/parents reported having seen an anti-smoking or anti-tobacco advertisement on television in the last 30 days, 31 percent recalled seeing an antismoking message on a billboard, 27 percent had heard an anti-tobacco message on the radio, 23 percent had seen this type of message on a poster or pamphlet, and 12 percent recalled seeing a newspaper advertisement. Seventy percent of respondents reported seeing advertisements on television about secondhand smoke in the last six months. Fifty percent had seen advertisements in the newspaper and 46 percent in magazines. The research included testing four television commercials by showing them to the participants in this study: “Bubbles,” “Inhaler,” “Baby in Playpen,” and “Quit Smoking Around Kids.” When asked to give their opinions about the commercials in general as compared with other advertisements they have seen about not smoking, the overall responses were as follows: Thirty-five percent of respondents recalled seeing the television advertisement entitled “Quit Smoking Around your Kids.” Smaller percentages had seen “Baby in the Playpen” advertisement (15 percent), the “Jasmine” advertisement (14 percent), and the “Bubbles” advertisement (12 percent). • Eighty-five percent of those who had seen at least one secondhand 45 Sixty-two percent agree that these advertisements are more likely than others they have seen to convince people to protect children Website visits from exposure to secondhand smoke. • Sixty percent agree that these advertisements are more likely to motivate people to support policies against secondhand smoke. • Fifty-nine percent agree these advertisements are more interesting. • Fifty-three percent agree these advertisements are more likely to convince smokers to eliminate secondhand smoke from their homes and workplaces. Because the call to action for the advertisements included a reference to ASHline.org for more information, the number of visits to the ASHline.org website was tracked. Data do not indicate that any particular media venue increased or decreased visits to the website more than any other. However, in general, total visits to the ASHline.org website have increased during the campaign when compared to the same period in 2005 (see Figure 12). Figure 12. Year-to-Year Comparisons of Visits to Ashline.org Website All Visits to Ashline.org - March 1 - October 14 for 2005 and 2006 4500 2005 4000 2006 3500 2500 2000 1500 1000 500 We e k 46 9/ 30 9/ 16 9/ 2 8/ 19 8/ 5 7/ 22 7/ 8 6/ 24 6/ 10 5/ 27 5/ 13 4/ 29 4/ 15 4/ 1 3/ 18 0 3/ 4 Website visits 3000 worksites, and attended 370 health fairs across the state. More than 1,690 (65 percent) of these programs were offered in worksites that had been targeted as having employees at higher risk for chronic disease. REDUCING THE BURDEN OF CHRONIC DISEASE WORKSITE CHRONIC DISEASE PREVENTION Arizona HealthLinks (AZHL) uses a comprehensive approach of providing education, resources, and technical assistance worksites to reduce the incidence of chronic diseases, especially those related to tobacco use. AZHL offers a variety of programs to promote employee health, including general health education and screenings, physical activity, nutrition and weight management, and oral health. CHRONIC DISEASE PARTNERSHIPS Proposition 303, passed in 2002, requires that 2 percent of the tobacco tax monies collected annually be put towards the prevention and early detection of the four leading disease-related causes of death; cancer, heart disease, stroke and pulmonary disease. Treatment for these diseases is much more effective, and less costly, if screened for and detected early. As a result, the Arizona Department of Health Services Tobacco Education and Prevention Program (ADHS TEPP) awarded nine contracts to organizations within the state of Arizona to expand or coordinate early detection and screening programs for the four leading causes of death. These programs also address health disparities that exist among the populations the organizations serve. Particular emphasis was placed on collaborative efforts between governmental, non-governmental, and community agencies that address systemlevel disease management and prevention. These projects will be completed in FY07, and outcomes for these projects are being monitored by the ADHS Office of Chronic Disease Management and Prevention Fund. List of Educational Programs Offered • • • • • • • • • • • • • • • • • • • • • • • • • 5-A-Day Fruit/Vegetable Active For Life Asthma Bone Builders Controlling Your Risk Factors Diabetes Health Fair/Screening Heart Disease & Stroke Cessation Instructor Training Lung Health Education Lung Health Screening Meeting Well Newsletter Oral Health Education Other Health Topics Other Fitness Topics Other Nutrition Topics Other Tobacco Topics People Together for Health Policy Training Portion Distortion Secondhand Smoke Effects Walking Works Well AZ Women Together for Health American Cancer Society: Colorectal Cancer Early Detection & Screening (CRC ED&S) A collaboration between the American Cancer Society and the Arizona Cancer Center. Objective: to further understand the reasons why colorectal cancer (CRC) screening is not completed in Arizona, to During FY05 and FY06, AZHL provided 2,582 educational programs to 1,180 47 develop a state screening plan, and to identify effective methods for increasing screening compliance. to be welcoming to LGBT people and provide culturally competent care Goals: • • • • Mountain Park Health Center: Keep the Beat: Heart Healthy South-Central Phoenix To conduct a statewide survey of physicians performing colonoscopy to define current CRC screening practices, assess capability for expanding these services, and to enlist support to educate primary referring physicians on screening guidelines and options To conduct a statewide survey of primary care physicians to define their current attitudes to CRC screening and CRC screening recommendations they give their patients To conduct a survey of managed care organizations to define the CRC screening that these organizations recommend and reimburse To develop culturally competent educational materials for the lay communities on CRC screening and introduce these materials at the CRC Capacity Building Conference A partnership between Mountain Park Health Center and the Black Nurses Association of Greater Phoenix. Objective: to prevent and/or manage cardiovascular disease among African Americans and others at high risk for cardiovascular disease in the South Central Phoenix area. Goals: • • • Wingspan: Early Detection and Screening – Community Based Objective: to focus on early detection and screening programs for cancer, heart disease, stroke and pulmonary diseases for the LGBT community. Native American Community Health Center (NACHC): Chronic Illness Prevention Project Goals: • • To ensure that the target group is aware of the risk factors for cardiovascular disease and the opportunity for and the benefits of early detection and screening services To ensure easy access to cardiovascular screening and early detection services To improve the prevention and treatment of cardiovascular disease among Mountain Park Health Center clients through the development of a cardiovascular disease management program, based on the Chronic Care Model Objective: to reduce the impact of chronic illness among American Indians and other impacted minority persons through promotion of healthy nutrition and physical activity lifestyle choices in three settings; the workplace, the community, and within schools. To increase LGBT people’s awareness of cancer, cardiovascular disease, stroke and pulmonary diseases and the importance of screening To increase health care providers’ knowledge about LGBT cancer, cardiovascular disease, stroke and pulmonary disease, and about how 48 Coconino County Department of Health Services: Williams Community Health Project Goals: • • • To provide leadership for an ongoing physical activities program and activities to promote healthy nutrition to NACHC employees To provide educational activities and demonstrations promoting physical activity and healthy nutrition to American Indian and other minority residents of Maricopa County To provide educational activities and demonstrations promoting physical activity and healthy nutrition to American Indian youth and other minority youth residents of Maricopa County in after school activity venues Objective: to promote healthy lifestyles in the Williams community by assessing perceptions and implementing community education activities. Goals: • • Translational Genomics Research Institute (TGen): Healthy Avondale 2010 • A collaboration between TGen, Sun Health, and the American Heart Association. • Objective: to improve the health of the Avondale community by implementing community health plans involving Hispanic residents of Avondale, students and parents in the Fit Start and Fit Source programs, and community leaders to encourage their constituents to commit to individual health activity plans. Arizona Interscholastic Association (AIA): Chronic Heart Disease Prevention A collaboration between AIA Academy, Tolleson Elementary School District, Tolleson High School, City of Phoenix, and Arizona State University. Goals: • • • • To assess how the Williams community perceives its own needs and desires for improved physical activity and nutrition education, and develop collaborative relationships with community organizations to build community support for activities To increase the proportion of community members who perceive regular physical activity as an important factor in their own health and well-being To increase the proportion of youth who engage in regular physical activity To increase the proportion of community members who perceive eating five fruits and vegetables a day as an important factor in their own health and well-being To determine baseline chronic disease data To implement healthy activity plan toolkits through community groups To change nutrition and exercise behaviors, and health-related knowledge, attitudes, skills and practices in schools To provide heart-related screening and education activities to Avondale residents Objective: to reduce the risk factors related to coronary heart disease through a school-based intervention integrating physical activity and healthy eating with an at-risk youth population. Goals: • 49 To increase the amount of physical activity participants accumulate on a daily basis • • • • To enhance participant attitudes towards physical activity and healthy eating To enhance participant selfperceptions related to physical activity To enhance participant knowledge concerning the elements of a healthy diet To enhance participant food choice • EVALUATION AND SURVEILLANCE American Lung Association of Arizona: Breath Free Objective: to identify individuals at risk for COPD and reduce the severity and prevalence of the disease, within Maricopa, Pima, Pinal, Yavapai, and Yuma counties. Evaluation activities for the Arizona Department of Health Services Tobacco Education and Prevention Program (ADHS TEPP) are provided by the Evaluation, Research and Development Unit (ERDU) in the Department of Psychology at the University of Arizona. The primary focus of ERDU has been to provide technical assistance on evaluation methods both to ADHS TEPP and to local and statewide contractors, and to collect and assemble information from all levels (i.e., national, state and local) appropriate for the planning, design and operation of effective tobacco programs in Arizona. Goals: • • culturally appropriate health information To achieve healthy lifestyle changes through a system-based approach using a public awareness supermarket campaign for heart disease risk reduction and a social marketing campaign for cancer risk reduction To increase the incidence of screening and early detection of COPD among the target population To increase the number of individuals in the targeted area who understand the importance of screening and early detection, avoidance of high-risk behaviors such as smoking, and the advantages of disease management In the past two years ERDU has concentrated on building an infrastructure to support standardized data systems for the three core services areas (i.e., prevention, cessation, and social marketing). These systems have been developed to collect data in accordance with the document Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs from the Centers for Disease Control and Prevention (CDC).4 Maricopa County Department of Public Health: People Together for Health (PTFH) and Comer Bien, Estar Bien (CBEB) Objective: to educate, motivate, and empower at risk individuals and families to make healthy choices related to diet, heart health, cancer prevention, physical activity, weight, smoking cessation, and stress. Goals: • Starr G, Rogers T, Schooley M, Porter S, Wiesen E, Jamison N. Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs. Atlanta, GA: Centers for Disease Control and Prevention; 2005. 4 To reduce the risk of heart disease and cancer by facilitating behavior change through the provision of 50 Several data systems currently are in operation: • Program Events. A reporting system to gather data on service delivery events across all areas in the ADHS TEPP program scope • Prevention. A system to record all prevention classes provided to students in Arizona public schools, and to monitor students’ satisfaction and perceptions at the end of the classes • Cessation. A system to record all clients served by cessation classes or by the Arizona Smokers’ Helpline, and to monitor client satisfaction and tobacco use after services have been delivered • Surveillance. Fieldings of the Arizona Adult Tobacco Survey (ATS) and of the Arizona Youth Tobacco Survey (YTS). These two surveys, along with the Behavioral Risk Factor Survey (BRFS — implemented by ADHS), Arizona Youth Risk Behavior Survey (YRBS – implemented by the Arizona Department of Education) and the Arizona Youth Survey (AYS – implemented by the Arizona Criminal Justice Commission), represent the state’s primary adult and youth tobacco behavior surveillance • For the future, the Evaluation goals are: • To use Web tools for data collection and for data distribution so that critical data are available in a timely fashion to the appropriate segments of the ADHS TEPP community. A revised set of tools has been developed, and is being implemented across the ADHS TEPP program areas, one by one • To extend the standardization of data collection to all areas of the ADHS TEPP program • To conduct analyses that integrate process, outcome and surveillance results into timely information that can be used easily in program planning, policy development, and legislative oversight FLAGSTAFF AIR QUALITY STUDY The effect of a smoking ban that went into effect on May 1, 2005, in Flagstaff, Arizona, was measured by counting small particulate matter suspended in the air with special air monitoring equipment. The United States Environmental Protection Agency (EPA) identifies small particles as one of six criteria of air quality: carbon monoxide, ground level ozone, lead, nitrogen dioxide, sulfur dioxide, and small particles – also called particulate matter. Small particles have been implicated in a number of studies as a danger in disease. Particles smaller than 2.5 microns – called PM2.5’s – go deep into lungs, are difficult for the body to dispose of, and elicit chemical and immune functions that damage delicate lung tissue. These particles are of such concern that the EPA has established a standard of no more than 15 of PM2.5’s per cubic meter per day annually, and no more than any single day exposure of 65 particles per cubic meter during one year. Social marketing. A system to monitor public traffic to the Arizona Smokers’ Helpline telephones and Web site, as a basis to measure the effectiveness of media campaigns In addition to these ongoing systems, ERDU staff work with ADHS and its contractors on an ad hoc basis to evaluate particular program pilots or other specific program elements. 51 observed in the establishments after the ban. No decrease in patronage was measured in sampled establishments, and no decrease in monthly revenue across all Flagstaff entertainment establishments was observed before or after the ban went into effect. Air samples were collected from 17 standalone bars on two weekends just before the ban and four weekends after the ban. Suspended particulate matter dropped by an average 87 percent after the ban to levels below the EPA maximum limit exposure in a single day. Other than on the night of Northern Arizona University (NAU) graduation, no lit cigarettes were Figure 13. Results of Flagstaff Air Quality Study 52 RESULTS This section contains additional data relevant to the results of the Arizona tobacco control program. The data have been assembled to correspond with the outcome indicators for evaluating comprehensive tobacco control programs developed by the Centers for Disease Control and Prevention (CDC). All reported data in this section (unless referenced otherwise) stem from two surveillance systems for tobacco-related behaviors and attitudes, the ATS and the YTS. They were last fielded in 2005. Although this report covers only FY 05 and FY06, several outcome measures are most useful when looked at over a longer time period. The ATS and YTS were previously fielded in 2002 and 2003, respectively, so on selected items data are drawn from those earlier databases. other special schools are not included in the surveys. This limitation is important because of existing evidence demonstrating that adolescents who are not in school (and those with high numbers of absences) have higher rates of tobacco use than do adolescents who are in school. This is known to be true for high school drop-outs in particular. TOBACCO USE CDC Outcome Indicator 1.14.1. Prevalence of tobacco use among young people Among Arizona high school students, one out of five (20 percent) reported having smoked cigarettes within the last 30 days on at least one day. This represents a slightly lower rate than the national average of 23 percent for high school youth in 2005 (measured by the CDC’s Youth Risk Behavior Survey). Results for all identified CDC outcome indicators are not presented here. Rather, a selection of outcome measures with the highest relevance to Arizona tobacco control activities was chosen. The behavioral and attitude-related results are reported separately for youth and adults. Among all youth who responded to the Arizona YTS 2005 (MS and HS), about 13 percent of female and 15 percent of male students reported having smoked cigarettes at least one day out of the previous 30 days. American Indian youth are the most likely to report current (past 30 day) cigarette smoking. For every outcome measure reported the respective CDC indicator number and label are presented to ensure consistency of reported results with CDC recommended and approved standard outcome measures for comprehensive tobacco control measures. Table 5. Current Youth Cigarette Rates, by Ethnicity, YTS 2005 Self-identified Ethnicity Hispanic White African American American Indian Asian American YOUTH SMOKING BEHAVIOR It is important to remember that the data in these school-based surveys are representative of the public school student population. Private schools, parochial schools, juvenile detention centers and 53 Current cigarette smoking, 2005 13% 14% 12% 30% 13% cigarettes. This is slightly higher than the national average for 2005 which was estimated to be 46 percent. A further breakdown and comparison with 2003 revealed an increase in Arizona students who have never tried cigarettes in both middle and high school (Figure 14). SUSCEPTIBILITY TO INITIATING SMOKING CDC Outcome Indicator 1.13.2. Proportion of young people who report never having tried a cigarette In 2005, 48 percent of Arizona high school students reported never having tried Figure 14. Percentage of Students Who Have Never Tried a Cigarette Rate of students who have never tried cigarettes Source: YTS 03 & 05 2003 2005 100 Percent 80 67 72 60 44 48 40 20 0 Middle School High School Table 6 below illustrates where underage youth (younger than 18 years old) reported having bought their cigarettes. Gas stations were mentioned most often followed by other, unidentified commercial sources. ACCESS TO TOBACCO PRODUCTS CDC Outcome Indicator 1.11.2. Proportion of young people reporting that they have been sold tobacco products by a retailer When asked where they usually bought their own cigarettes, 21 percent of youth under 18 years old (the age of legal purchase) reported having bought their cigarettes in a store such as a gas station, a convenience store, grocery store, or drugstore. Table 6. When you bought cigarettes in a store during the past 30 days, what kind of store was it? YTS 2005 Kind of store a gas station a convenience store a grocery store a drugstore a tobacco or smoke shop other This rate closely mirrors the compliance check failure rate reported by the Attorney General’s office for Youth Tobacco Enforcement which sends minors into stores to attempt to buy tobacco products. (see the Attorney General’s findings on page 25). 34% 15% 5% 5% 14% 26% The majority of underage students report a variety of sources other than stores for getting their tobacco products, including 54 bumming them from friends, giving someone money to buy for them, or taking them. In 2005, 50 percent of all youth who reported having smoked during the last 12 month also reported having tried to quit smoking cigarettes. Youth smokers were asked if they knew a place where they could get help to quit smoking, and only 49 percent answered “yes.” MEDIA AWARENESS CDC Outcome Indicator 1.6.2. Level of receptivity to anti-tobacco media messages About 70 percent of school-based youth reported that they had seen or heard commercials on TV, the Internet, or on the radio about the dangers of cigarette smoking in the months before the survey. Youth were also asked if those commercials changed the way they feel about using tobacco. ADULT SMOKING BEHAVIOR TOBACCO USE CDC Outcome Indicator 3.14.1. Smoking prevalence About one out of five adult Arizonans currently smokes cigarettes, and the overall adult cigarette smoking rate was roughly stable from 2002 to 2005. In both years, Arizona was slightly below the national average (Fig. 15). Table 7. Have the commercials changed the way you feel about using tobacco? YTS 2005 Definitely yes Probably yes Probably not Definitely not 32% 24% 22% 22% Smoking prevalence appears to be roughly stable for males in both years, whereas female smoking prevalence decreased by 4 percentage points from 2002 to 2005 (Fig. 16). CESSATION CDC Outcome Indicator 3.11.2. Proportion of young smokers who have made a quit attempt Figure 15. Adult Cigarette Smoking, AZ vs. National Adult cigare tte smoking: AZ v s. National Source: ATS 02 & 05, CDC BRFSS A rizona 30 National 23 20 20 Percent 21 19 10 0 2002 2005 55 Figure 16. Adult Cigarette Smoking, AZ by Gender Adult cigare tte smoking by ge nde r Source: ATS 02 & 05 2002 30 22 21 Percent 2005 20 20 16 10 0 Male Female Those between 18 and 24 years of age reported the highest rate of current cigarette smoking of all age groups (Table 9). Generally, cigarette smoking prevalence rate estimates are lower as age increases. However, consumption (packs per month per smoker) was lowest for the youngest age group and gradually increased with older age. This finding reflects the fact that older smokers are more likely to be “established” smokers who consume about one pack a month. Smoking rates broken down by selfidentified ethnic categories reveal that cigarette smoking was most prevalent among those who self-identified as American Indian. This also was true at the national level. However, in Arizona, self-identified American Indian and African American respondents reported much lower smoking rates than the national average, and self-identified Hispanic respondents reported slightly lower rates. (Fig. 17). Table 8. Smoking Rate & Consumption by Age, ATS 2005 Age group 18-24 years old 25-34 years old 35-44 years old 45-54 years old 55-64 years old 65+ years old Current cigarette smoking rate 29% 21% 23% 20% 18% 11% Packs per month per smoker [Median] 15 15 23 30 29 17 56 Figure 17. Smoking Rate by Self-identified Ethnic Affiliation 2005, AZ vs. National Adult cigare tte smoking by e thnicity Source: ATS 05, CDC NHIS 05 A rizona 40 National 32 Percent 30 21 22 22 20 13 16 23 14 10 0 Self -identif ied White Self -identif ied Hispanic Self -identif ied A f rican A m. Smoking rates continue to be lower amongst those with more education. The highest rates were found for people who reported not having completed high school; the lowest rate was found for individuals who reported a college degree (Table 9). CDC Outcome Indicator 3.14.2. Prevalence of tobacco use during pregnancy For Arizona as a whole, smoking during pregnancy remained fairly stable from 2000 until 2005, leveling off around five percent (Fig. 18). However, considerable variation within Arizona was observed. Although there appears to be a moderate downward trend from 2000 to 2005, Mohave County consistently displayed the highest pregnancy smoking rates of all Arizona counties. Yuma County is among the counties with the lowest rates. Table 9. Smoking Rate by Education, ATS 2005 Educational attainment Less than high school High school graduate 1-3 yrs. college College graduate Self -identif ied A m. Indian Current cigarette smoking rate 25% 22% 21% 9% 57 Figure 18. Tobacco Use During Pregnancy Se lf-re porte d tobacco use during pre nancy: Arizona ov e rall, M ohav e C. & Yuma C., 1999-2005 Source: ADHS Vital Statistics Arizona overall Mohave County Yuma County 25 Per 100 Live Births 21 19 20 17 16 15 15 6 6 6 5 1 1 1 1 15 10 5 7 2 7 2 0 2000 2001 2002 2003 2004 2005 percent faster in Arizona than the United States generally. After tax increases consumption drops and then recovers, but on a lower level. This demonstrates the well-established research finding that raising cigarette taxes is a highly effective measure to bring down consumption. CDC Outcome Indicator 3.14.4. Per capita consumption of tobacco products Cigarette consumption measured by tax stamp sales has been falling in the United States and in Arizona since the early 1980’s as seen in Figure 14. Arizona’s pack-per-person sales average almost 8 percent less than the rest of entire United States, and sales have been decreasing 10 58 Figure 19. Cigarette Tax Stamps Sold Per Person, AZ and National Cigare tte Tax Stamps Pe r Pe rson for Arizona and Unite d State s, 1983 - 2005 Source: Arizona Department of Revenue Luxury Tax Division Avg bimonthly pack purchases per person 16 AZ 1994 pre-tax purchasing 14 AZ 2002 pre-tax purchasing 12 10 8 6 AZ tax stamps per person 4 US tax stamps per person 2 1983 1984 1985 1986 1987 1988 1990 1991 1992 1993 1994 1995 1997 1998 1999 2000 2001 2002 2004 2005 Year CDC Outcome Indicator 3.9.2. Proportion of adults who have been asked by a health care professional about smoking CESSATION CDC Outcome Indicator 3.8.3. Proportion of smokers who intend to quit CDC Outcome Indicator 3.9.3. Proportion of smokers who have been advised to quit smoking by a health care professional Reported intentions to quit smoking are known to be precursors of actual quit attempts. Knowing the percentage of adult smokers who are ready to quit suggests the numbers who may be receptive to tobacco control services such as quit classes and help-line coaching. In 2005, 61 percent of current smokers reported that they are seriously considering stopping smoking within the next six months and 21 percent report planning to stop in the next 30 days. This suggests that about 690,000 Arizona smokers could be receptive to messages urging them to take steps to quit and providing them with evidence-based approaches to do so. There was an increase from 2002 to 2005 in the percentage of respondents who reported having been asked about tobacco use by a healthcare provider (Fig. 20). No change from 2002 occurred in the reported rate of health care providers recommending that respondents stop tobacco use (about seventy percent in both years), nor in the percentage of respondents who reportedly tried to attempted to quit after being advised to do so (about one out of four respondents). 59 Figure 20. Medical Care Provider’s Tobacco Use Counseling, Reported by ATS 2005 Respondents M e dical care prov ide r's tobacco use counse ling, re porte d by ATS 2005 re sponde nts Source: ATS 02 & 05 2002 100 73 Percent 80 2005 71 72 63 60 40 25 24 20 0 A sked about tobacco use Recommended to stop A ttempted to stop CDC Outcome Indicator 3.9.5. Proportion of smokers who have been assisted in quitting smoking by a health care professional EXPOSURE TO & ATTITUDES TOWARDS SECONDHAND SMOKE (SHS) About 51 percent of smokers who report that their health care providers recommended that they quit using tobacco also report being offered cessation assistance such as medication, information about classes, materials, or being urged to set a quit date. This rate is similar to what was reported in 2002 (50 percent). CDC Outcome Indicator 2.4.1. Proportion of jurisdictions with public policies for tobacco-free workplaces and other indoor and outdoor public places The map below highlights Arizona counties and municipalities that have enacted an ordinance or law that bans smoking 100 percent in workplaces, bars or restaurants. The database for the map is derived from data published by the American Nonsmoker’s Rights Foundation5 and was current as of October, 2006. CDC Outcome Indicator 3.11.1. Proportion of adult smokers who have made a quit attempt Forty-six percent of current smokers reported on the ATS 2005 that they had tried to quit for 24 hours or longer during the past year. This percentage is slightly higher than the 43 percent reported by current smokers in 2002. 5 60 http://www.no-smoke.org/ Figure 21. Jurisdictions with Tobacco Laws or Ordinances. CDC Outcome Indicator 2.3.4. Proportion of the population willing to ask someone not to smoke in their presence CDC Outcome Indicator 2.3.5. Proportion of the population that thinks secondhand smoke is harmful Twenty-five percent of AZ ATS 2005 respondents report that they ever asked a stranger not to smoke around them in the past year. Of those who have a friend or family member who smokes, 73 percent have encouraged them to stop smoking. Of those who have a friend or family member who chews, 40 percent of respondents have encouraged them to stop chewing. For smokers, 60 percent reported that they were asked (by anyone) not to smoke in the past 12 months. The majority of adult Arizonans believe that breathing other people’s tobacco smoke is very harmful to one’s health (63 percent). Another 30 percent reported that they believe breathing other’s tobacco smoke is somewhat harmful. Only 7 percent reported believing that breathing other’s tobacco smoke is not very or not at all harmful. Among youth, the majority (70 percent) reported that they believe smoke from other people’s cigarettes is definitely harmful to them. Nineteen percent reported thinking that smoke from other 61 support for complete smoking bans in various locations (Fig. 22). The highest gain occurred for restaurants, with a total increase of 7 percentage points from 2002 to 2005. This indicates growing support of the general Arizonan public for establishments and public places being completely smoke-free. people’s cigarette is probably harmful to their health. Roughly ten percent of young people reported that smoke from other people’s cigarettes is probably or definitely not harmful to them. CDC Outcome Indicator 2.3.7. Level of support for creating tobacco-free policies in public places and workplaces Slight to moderate increases were observed from 2002 to 2005 in the level of Figure 22. Support for Complete Smoking Bans in Various Locations Support for complete smoking bans in various locations Source: ATS 02 & 05 2002 100 87 Percent 80 59 2005 89 66 64 69 74 75 60 40 27 32 20 0 Res taurants Public Buildings Private Buildings Indoor Sports Events Outdoor Sport Events smoke than children not protected by such bans. This is especially true in households with at least one resident smoker. In 2005, the vast majority (85 percent) of adult Arizonans reported that smoking was not allowed anywhere in the home. Seven percent reported smoking was restricted to some places in the home or only permitted at some times, and the remaining 8 percent reported that smoking was allowed anywhere in the home. CDC Outcome Indicator 2.4.3. Proportion of the population that works in environments with tobacco-free policies A moderate increase was found from 2002 to 2005 for the rate of respondents reporting that smoking was completely banned at their worksite, from 42 percent to 50 percent. CDC Outcome Indicator 2.4.4. Proportion of the population reporting voluntary tobacco-free home or vehicle policies Evidence shows that children living in households with smoking bans are exposed to substantially less secondhand 62 In 2005, 21 percent of all ATS respondents reported exposure to smoking in a car in the seven days prior to the survey. This is a slight decrease from the 25 percent of respondents who reported car exposure in 2002. Non-smokers report much lower exposure to smoking in a car than current smokers (for 2005, 12 percent of non-smokers versus 60 percent for smokers). CDC Outcome Indicator 2.7.1. Proportion of the population reporting exposure to secondhand smoke in the workplace Prior to being asked about their exposure to secondhand smoke in the workplace, respondents to AZ ATS were asked if they work primarily indoors, outdoors or equally indoors and outdoors. There was considerable variation depending on primary place of work. Among those working primarily indoors, 14 percent reported having been exposed to secondhand smoke within the last seven days. This rate almost quadrupled to 55 percent for those working primarily outdoors. Thirty-seven percent of individuals who work equally indoors and outdoors reported exposure to secondhand smoke in the workplace within the seven days prior to the survey. Amongst youth, 36 percent reported being exposed to secondhand smoke in a car at least once during the seven days prior to the survey. CDC Outcome Indicator 2.7.5. Proportion of nonsmokers reporting overall exposure to secondhand smoke Among all respondents categorized as former or never smokers (current nonsmokers) in the 2005 ATS, 14 percent reported being exposed to secondhand smoke either inside their home or in a car within the last seven days, at least once. Amongst youth, 50 percent of those categorized as non-smokers reported to having been in the same room or in a car with someone who was smoking cigarettes within the last seven days at least once. CDC Outcome Indicator 2.7.3. Proportion of the population reporting exposure to secondhand smoke at home or in vehicles Only eight percent of all ATS respondents in 2005 said that they were exposed to tobacco smoke in their home one day or more in the past seven days. This rate is down from the 18 percent reported in 2002. 63 CONCLUSIONS AND RECOMMENDATIONS Tobacco control is a complex and difficult challenge. The Centers for Disease Control and Prevention (CDC) have urged the development of a nine-part effort directed at prevention and cessation of smoking and elimination of secondhand smoke exposure. The Arizona Department of Health Services Office of Tobacco Education and Prevention (ADHS TEPP) has used this framework to develop, maintain, and control a wide range of initiatives, programs, and activities in order to further its mission and progress toward the ultimate goal of enhancing the health and welfare of the people of Arizona by bringing commercial tobacco use to minimum. These efforts require that ADHS TEPP be active in a wide range of venues, including schools, healthrelated organizations, community organizations, businesses, and personal, private settings. ADHS TEPP activities include educational interventions, smoking cessation counseling, media campaigns, and production of reports relevant to tobacco control policies and legislation. It is important to note that assessing the overall effectiveness of ADHS TEPP programs is made difficult by the fact that it is not possible, at least with present methods and resources, to measure the counter-control activities of the tobacco industry. It is very likely that the industry is spending more money in promoting tobacco in the state than ADHS TEPP is spending on enhancing tobacco control. Unless and until a better understanding of the level and effectiveness of tobacco promotion efforts is achieved, it will be difficult to produce a definitive judgment on the absolute level of effectiveness of ADHS TEPP. PREVENTING YOUTH INITIATION School-based prevention services are reaching a large proportion of Arizona school-aged youth. Nearly half of all public schools in Arizona that serve the current ADHS TEPP target grades of 4 through 8 are receiving intensive services, and many others are receiving brief educational interventions. Youth smoking rates in Arizona continue to be slightly lower than national rates, and an increasing percentage of Arizona schoolaged youth are reporting never having tried a cigarette. Variations within and between communities in terms of the nature of the tobacco problem, public reaction to it, and support for various interventions make it necessary for ADHS TEPP to take into account the differences between communities, the preferences of diverse citizens, and the extent of local human resources in making decisions about which specific tobacco control efforts to support and in what communities they might be most effective. The following provides a summary of some of the results of the programming and of the programming directions identified for ADHS TEPP to pursue in the next years to refine their efforts. In order to strengthen their programming in relation to CDC best practices, and to continue to make gains in preventing youth initiation, ADHS TEPP has identified the following areas for program planning and development. SERVICE DELIVERY FOR PREVENTION ƒ 64 Continue to target schools with youth at higher risk of tobacco use ƒ Increase programming in middle schools relative to the earlier grades ƒ Conduct pilot prevention and cessation interventions for high school students, focusing on higher-risk schools such as charter and alternative high schools with large proportions of youth at risk of dropping out ƒ Assure that youth at higher risk of using tobacco are receiving prevention education across the K to 12 continuum ƒ Expand school policy assessments and technical assistance to assist schools in maintaining tobacco-free campuses ƒ Conduct inspections of retail tobacco vendors that are close to schools and places where students and youth congregate HELPING TOBACCO USERS QUIT About one out of five Arizona adults continues to smoke, but the amount they are smoking is decreasing. Almost half of all current smokers have tried to quit in the past year, and the majority of smokers report that they are planning a quit attempt within the next six months. Support for smoke-free environments is growing, and more municipalities, worksites and homes are enforcing smokefree policies. This suggests that there is an unprecedented opportunity to inform smokers of resources that can aid them in quitting. Smoking rates are highest amongst young adults and those with the least education, yet those are the groups least likely to take up existing ADHS TEPP services. In order to most effectively leverage resources in assisting smokers in quitting, ADHS TEPP has identified the following areas for program planning and development. SOCIAL MARKETING FOR PREVENTION ƒ ƒ Promote public messages about refraining from smoking in the home and in cars ƒ Develop messages targeting parents who smoke about the impact of secondhand smoke on their preteen and adolescent children and how their smoking makes it much more likely that their children will smoke ƒ SERVICE DELIVERY FOR CESSATION Develop a strong anti-tobacco marketing campaign for youth that is tied to prevention education programming Develop public messages, especially to smokers, about the extent and harm of youth acquiring tobacco through friends, acquaintances, family members, and other social networks 65 ƒ Disseminate information on cessation resources and services to high schools, particularly in higher-risk schools such as charter and alternative high schools with large proportions of youth at risk of dropping out ƒ Develop services targeted to 18 to 24 year olds to assist them in quitting before they become established smokers ƒ Develop services and messages to young adults 25 to 34 years old to capture pregnant women, and families with young children in the home ƒ Maintain and refine systems to give health care providers information about resources and services to make it easier for them to inform and refer patients ƒ Encourage health care providers to provide cessation information and referral services to smoking parents during pediatric visits ƒ Continue collaborations with the Arizona Health Care Cost Containment System in order to better serve low-income tobacco users ƒ Facilitate the use of pharmaceutical aids in conjunction with behavioral support services to improve cessation rates completely banned in their home. Half of Arizona workers, however, still report that smoking is allowed in their workplace, and about one in five adults-and one in three youth--report having been exposed to smoke in a car in the week prior to being surveyed. In order to reduce the number of Arizonans exposed to secondhand smoke, ADHS TEPP has identified the following service and marketing areas for program planning and development. SERVICE DELIVERY FOR REDUCING SECONDHAND SMOKE ƒ Continue to provide information and technical assistance to worksites in creating and maintaining smoke-free policies ƒ Consider expanding pilot programs of providing information on the dangers of secondhand smoke through day cares and hospital neonatal units SOCIAL MARKETING FOR CESSATION ƒ Use a comprehensive marketing campaign to encourage quitting and to advertise cessation services ƒ Focus messages on young adults to encourage them to quit smoking before becoming established smokers ƒ SOCIAL MARKETING FOR REDUCING SECONDHAND SMOKE Provide information on the effectiveness and appropriate use of pharmaceutical aids in conjunction with behavioral support services to support quitting REDUCING EXPOSURE TO SECONDHAND SMOKE ƒ Continue to provide information on the benefits of developing and maintaining in-home rules about smoking. ƒ Develop messages encouraging youth and adults not to smoke in cars IDENTIFYING AND ELIMINATING TOBACCO-RELATED DISPARITIES The United States Surgeon General released a report in 2006 detailing the health consequences of secondhand smoke, and the vast majority of Arizona adult and youth residents report that they are aware of the harmful effects. Support for smoking bans in public places and workplaces has been increasing, and most Arizonans report that smoking is Tobacco use is highest among males, and among those with low education. American Indians have the highest reported prevalence among ethnic groups in both youth and adult reports. Residents who report being gay, lesbian, 66 bisexual or transgendered also report high tobacco use rates. tobacco-related prevention and cessation services to the lesbian, gay, bisexual and transgendered population In order to continue to serve diverse communities, ADHS TEPP have identified the following areas for program planning and development. ƒ SERVICE DELIVERY FOR ELIMINATING DISPARITIES ƒ Continue to provide support to grassroots organizations to help reduce tobacco-related disparities ƒ Support American Indian programs for adults and youth by providing additional technical assistance to help in program development and evaluation ƒ Use findings from the recent community assessment to provide appropriate information about Use findings from the recent community assessment to tailor tobacco control efforts to socioeconomically disadvantaged Arizona residents SOCIAL MARKETING FOR ELIMINATING DISPARITIES ƒ 67 Continue to develop campaigns that are integrated with the general market campaigns, but that are adapted to address the particular communication needs of communities with health disparities