ARIZONA DEPARTMENT OF HEALTH SERVICES 2014 2014 B ie nn ia l E va l u ati on R e po r t A R e por t on Toba c co C on t ro l Progr am s an d Chronic Disease Prevention Services ARIZONA DEPARTMENT OF HEALTH SERVICES Division of Public Health Services Bureau of Tobacco and Chronic Disease Jan Brewer, Governor State of Arizona Will Humble, Director Arizona Department of Health Services 150 North 18th Avenue Phoenix, Arizona 85007-3228 TOBACCO FREE ARIZONA We can build a better Arizona by helping each other to make good life choices ARIZONA DEPARTMENT OF HEALTH SERVICES 2014 Ta b l e of Co nte nts Quick Guide to Content, Figures, Tables, and Charts Executive Summary..................................................................................................................................3 Introduction..................................................................................................................................................4 Youth Tobacco Use...................................................................................................................................5 Fig 1: Trends in the use of any tobacco by youth, 2000-2013 Fig 2: Trends in the use of cigarettes by youth, 2003-2013 Fig 3: Tobacco use among youth by race, 2000-2013 Fig 4: Ever use of hookah by youth, 2007-2010 Fig 5: Current use of smokeless tobacco by youth, 2004-2012 Fig 6: Any tobacco use by middle school grade, 2000-2013 Youth Access to Tobacco Products.................................................................................................7 Fig 7: Self-reported access among middle school students,2000-2013 Fig 8: Store type of student tobacco purchase, 2005-2013 Fig 9: Students asked for proof of age or refused, 2000-2013 Youth Exposure to Secondhand Smoke......................................................................................9 Fig 10: Exposure to second-hand smoke in past 7 days, 2000-2013 Fig 11: Exposure in home and car, 2013 Youth Prevention and Cessation Programs.............................................................................11 Adult Tobacco Use.................................................................................................................................14 Fig 12: Prevalence of current tobacco use among adults, 2008-2012 Table 1: Demographics of current smokers, 2013 Smoke-Free Arizona..............................................................................................................................15 ACKNOWLEDGEMENTS Wayne Tormala, Bureau Chief Bureau of Tobacco and Chronic Disease Courtney Ward, Office Chief Office of Tobacco Prevention and Cessation Programs Anna Alonzo, Office Chief Office of Chronic Disease Prevention Brandy McMahon, Epidemiologist, Office of Tobacco Prevention and Cessation Programs Benjamin Palmer, Program Manager Office of Tobacco Prevention and Cessation Programs Sage Wheeler, Intern Bureau of Tobacco and Chronic Disease Arizona Smokers’ Helpline.............................................................................................................16 Reducing Health Disparities.............................................................................................................18 Reducing the Burden of Chronic Disease...............................................................................22 BTCD Organizational Chart............................................................................................................28 Table 2: Prop 200 Expenditures and Contracts....................................................................29 Table 3: Prop 303 Expenditures and Contracts....................................................................30 Table 4: Federal Expenditures and Contracts.........................................................................31 Table 5: Community Outreach and Project Vendors........................................................31 Celebrating our Past and Present and Embracing our Future......................................32 2 Special thanks and appreciation for her contributions are also extended to: Sheila Sjolander, Assistant Director Division of Public Health Prevention Services ARIZONA DEPARTMENT OF HEALTH 2014 EXECUTIVE SUMMARY Where are we now? & Where are we going? In a series of voter-approved propositions, Arizona increased the Arizona Department of Health Services Bureau of Tobacco and state sales tax on tobacco products, required a portion of tobacco Chronic Disease (BTCD) continues to work toward reducing the taxes be spent on tobacco prevention, and banned smoking in burden of tobacco and chronic disease through youth coalition and counter-marketing activities, adult prevention and cessation almost all indoor public buildings. efforts, coordination with partners to improve the delivery of care, and reducing disparities among at-risk populations. Among youth in Arizona, 14% of high school students and 7% of Youth coalitions around the state work with BTCD in trainings middle school students are currently using some form of tobacco. and planning and executing tobacco control projects to prevent and control youth tobacco use and exposure. While 33% of underage youth who try to purchase a tobacco Along with the Division of Behavioral Health and the Attorney related product in 2013 are refused, only 7% of youth who General’s Office, BTCD went through an intense Continuous Quality Improvement project to streamline youth tobacco purchase tobacco products are asked for proof of age. programs, better collaborating on youth inspections, and eliminating duplicate efforts and costs. In Arizona, 17.1% of adults are current smokers, down from 20% BTCD utilizes its partners to serve as referral development in 2009. Smoking rates among adults in Arizona continue to liaisons in metro and rural Arizona in promotion of Arizona Smokers’ Helpline services. ASHLine offers free telephone decrease. coaching, free online quit support through WebQuit (available on ashline.org) and free over-the-counter nicotine replacement therapies for smoking cessation. Continuing its work with community organizations, BTCD works Asian-Pacific Islanders, and migrant farm workers exhibit on capacity building and program planning for the development of disproportionately high morbidity and mortality rates associated sustainable commercial tobacco cessation programs. BTCD also with tobacco use. Factors such as age, ethnicity and income can engages community partners to achieve sustainable positive change in reducing health disparities relating to tobacco-use and greatly contribute to health disparities within a given population. obesity. Certain groups including African Americans, American Indians, Chronic disease, including cancer, heart disease, chronic lower In an effort to reduce the burden of chronic disease in Arizona, respiratory disease, alzheimer’s disease, diabetes, chronic liver BTCD works with county and local partners to develop Chronic disease and cirrhosis, and hypertension and hypertensive renal Disease Self Management Programs, School Health Advisory disease, accounts for 7 of the 10 leading causes of death and Councils, improvements in the delivery and coordination of stroke and Chronic Obstructive Pulmonary Disease care, Million Hearts, 30,000 deaths in Arizona each year. Cardiopulmonary Resuscitation Dispatch, and Health in Arizona Policy initiatives, along with the Healthy Arizona Worksite Program. 3 INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 FALL 2009 2014 INTRODUCTION OVERVIEW This report contains a description of tobacco-related activities within the State of Arizona for Fiscal Years 2013 (FY13) and 2014 (FY14). Arizona Department of Health Services (ADHS) Bureau of Tobacco Chronic Disease (BTCD) has primary responsibility for its content with supplemental information from SmokeFree Arizona and BTCD partners. This report also includes key outcome indicators for youth and adult tobacco-related behavior and attitudes. Backg round In 1994, Arizona voters passed the Tobacco Tax and Health Care Act (Proposition 200) which increased the state sales tax on tobacco products. Tax revenues are used to fund several programs: health care for the medically needy, medically indigent, and low income children; tobacco education and prevention; and tobacco-related research. This began Arizona’s tobacco taxation, which increased with the 2006 vote to raise the excise tobacco tax to $2.00. Proposition 303, passed in 2002, protected the tobacco tax monies. These funds were earmarked for BTCD to address the four leading causes of death in Arizona: heart disease, cancer, chronic lower respiratory disease, and cerebrovascular disease. In May 2007, the Smoke-Free Arizona Act took effect, banning smoking in all indoor public buildings with the exception of retail tobacco stores, veteran and fraternal clubs, designated smoking hotel rooms, and outdoor patios. The ADHS Office of Environmental Health monitors compliance with the law. In FY13 and FY14, BTCD focused on youth prevention and cessation activities and chronic disease services. Youth coalitions around the state rallied around a statewide coalition branded Students Taking a New Direction (STAND) in order to work towards the prevention of youth tobacco use. Cessation activities centered around media campaigns that focused on assisting smokers in their quit attempts, which resulted in an increased number of calls by Arizona residents wanting to quit. Chronic disease services were provided by both statewide vendors and community partners focusing on disparate populations1. By focusing on these areas, BTCD was able to make strides in creating a healthier Arizona. As outlined in Proposition 303, the TRUST Commission confirms existing statutes authorizing the Arizona Department of Health Services to use portions of the tobacco tax funds for tobacco education and prevention, serves as an advisory board for the Chronic Disease Fund, including its use of funding provided through tax dollars, and submits an annual report of its activities to the President of the Senate and the Speaker of the House of Representatives. 1. See Table 5 for the list of vendors and partners funded under this provision which continued through FY13 and FY14. 4 INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 FALL 2009 2014 YOUTH TOBACCO USE, ACCESS, AND EXPOSURE TOBACCO AMONG ARIZONA’S YOUTH REDUCING BURDEN OF YOUTH TOBACCO USE This section contains data relevant to the outcomes of the Arizona tobacco control program, indicators for evaluating comprehensive tobacco control programs developed by the Centers of Disease Control and Prevetion (CDC). A selection of outcome measures with the highest relevance to Arizona tobacco control activities is provided. For every outcome measure reported, the respective CDC indicator number and label are presented to ensure consistency with CDC approved standard outcome measures. Prevalence of Youth Tobacco Use High School Students CDC Outcome Indicator 1.14.1 Prevalence of tobacco use among young people 35% 29% 29% 28% According to the 2013 Arizona Youth Tobacco Survey (YTS), 7% of middle school students reported ever using any tobacco product. This represents a 53% decrease from 2003 when 15% of middle school students reported ever having used tobacco. The Youth Risk Behavior Surveillance system (YRBSS) reported that among high schools students, 14% report ever using any tobacco product, a significant decrease from only ten years ago when 29% of high school students reported ever using tobacco (See Figure 1). The YRBSS also reported that 14% of high school students had tried smoking, even 1 or 2 puffs. Additionally, 14 % are currently using some form of tobacco. YTS data also shows that the current use of cigarettes has decreased over the past decade, with cigarette use among high school students dropping from 23 to 14%, a 39% decrease. Among middle school students, current use of cigarettes has fallen from 9 to 3%, a 67% decrease in the past ten years. Fewer than one in 20 middle school students and one in 7 high school students reported current use of cigarettes (See Figure 2). The long-term trend of continued decline in the prevalence rates of cigarette use and the use of any tobacco product among youth provides evidence to support the efforts of the public health community to promote tobacco prevention and cessation among Arizona’s youth. 21% 15% 14% 28% Middle School Students 28% 28% 17% 12% 11% 10% 8% 8% 7% 2009 2011 2013 7% 0% 2000 2003 2005 2007 14% Figure  1:  Trends  in  the  use  of  any  tobacco  product  by   Arizona  middle  and  high  school  students,  2000-­‐2013 High School Students 25% 23% 21% 22% 20% Middle School Students 20% 17% 14% 15% 10% 9% 8% 7% 5% 0% 2003 2005 2007 8% 5% 2009 3% 2011 Figure  2:  Trends  in  the  use  of  cigare4es  by  Arizona   middle  and  high  school  students,  2003-­‐2013   5 2013 INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 FALL 2009 2014 YOUTH TOBACCO USE, ACCESS, AND EXPOSURE Hookah use, contrary to the general downward trend of tobacco use among middle school students, has demonstrated marked popularity since 2005. This increase is much more dramatic for high school students. Whereas ever use among middle school students in 2010 was measured at a little over 4%, it was almost 4 times that for high school, with more than 1 in 4 admitting to having ever used hookah. When broken down by grade, the increase in use among high school students is even more pronounced. (See Figure 4). Of high school seniors, 53% admitted to ever using hookah. The Arizona Youth Survey (AYS) for 2012, conducted biennially by the Arizona Criminal Justice Commission, shows a leveling off of the popularity of smokeless tobacco since 2004. (See Figure 5). The percentage of 8th graders who admitted to using smokeless tobacco—chew, snuff, plug, dipping tobacco or chewing tobacco—decreased, and is currently less than 1% more than the percentages of 8th graders who were current users in 2004. The number of current users in the 10th grade has also decreased, although it is still more than the percentage of current smokeless tobacco users in 2004. The percentage of 12th graders using smokeless tobacco has risen from 5.4 to 8.3%, a 54% increase since 2004. American Indian or Alaskan Native Black or African American 60 6th 10th 45 7th 11th 8th 12th 9th 30 15 0 2007 2008 2009 2010 Figure  4:  Percent  ever  use  of  hookah  by  middle  and  high   school  grades,  2007-­‐2010 8th grade 10th grade 12th grade 10 8 6 4 2 0 Hispanic or Latino White 2004 2006 2008 2010 2012 Figure  5:  Current  use  of  smokeless  tobacco  by  middle   and  high  school  students,  2004-­‐2012,  by  percent 30% 25% 6th grade 20% 7th grade 8th grade 60 15% 45 10% 30 5% 0% 15 2000 2003 2005 2007 2009 2011 0 2013  Figure  3:  Percent  any  tobacco  use  among  middle   school  students,  by  race,  2000-­‐2013 2000 2003 2005 2007 2009 2011 Figure  6:  Percent  any  tobacco  use  by  Arizona  middle   school  students,  by  grade,  2000-­‐2013, 6 2013 INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 FALL 2009 2014 YOUTH TOBACCO USE, ACCESS, AND EXPOSURE Susceptibility to Initiating Smoking CDC Outcome Indicator 1.13.2 Prevalence of young people who report never having tried a cigarette The YRBSS reported that 14% of Arizona high school students had tried smoking, even 1 or 2 puffs, which means that 86% self-reported never having tried a cigarette. This represents a significant increase in high school students never having tried a cigarette, up from 77% in 2003. Among middle school students surveyed in 2013, 97% report never having tried cigarettes, up from 91% who reported being lifetime free of cigarettes in 2003. 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 Youth access to tobacco products has been a major focus of concern in tobacco control efforts across the country. Federal and state laws in Arizona make it illegal for merchants to sell tobacco to youth under the age of 18. Nonetheless, students in Arizona are able to get tobacco from multiple sources, both social and commercial. Students under 18 years of age often acquire tobacco products through social networks, borrowing or bumming cigarettes from friends (See Figure 7). This is the largest identified way of acquiring tobacco products. The 2nd highest identified way method of acquiring tobacco products was giving money to someone to purchase for the student. Middle school students were asked where they last purchased the last pack of cigarettes they bought. Of the identified locations to purchase cigarettes, gas stations were identified as the most common location consistently since 2005. Fewer students reported buying cigarettes from convenience stores, smoke shops and over the Internet (See Figure 8). As of 2013, the purchase of tobacco over the Internet became illegal per ARS 36-798.06 (Arizona Revised Statute). However, questions regarding smoke shops and the Internet as purchasing sources were not asked every year. In general, drug stores, grocery stores, and convenience stores seem to be trending upward, replacing purchases previously made at smoke shops. I borrowed them or someone gave them to me I bought them I gave someone else money to them for me I took them from a store or a family member 50 40 30 20 10 0 2000 2003 2005 2007 2009 2011 Figure  7:  Self-­‐reported  access  to  cigare4es  among   middle  school  students,  2000-­‐2013,  by  percent 7 2013 INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 FALL 2009 2014 YOUTH TOBACCO USE, ACCESS, AND EXPOSURE friends, for example—and more have reported buying them directly at retailers such as gas stations. This method of obtaining cigarettes has increased significantly since 2009, with proof of age verification requests falling from 25 to 7% over the last 4 years. 30 25 20 15 10 5 0 2005 ACCESS TO TOBACCO PRODUCTS 2007 2009 2011 A convenience store A gas station A grocery store A smoke shop A drugstore 2013 Figure  8:  Store  type  where  smokers  in  middle  school   bought  their  cigare4es,  2005-­‐2013,  by  percent BEING AWARE Clamping down on tobacco sales to minors in commercial venues is extremely important but will not curtail youth’s access to tobacco as social sources are more difficult to regulate. Conducting inspections of retail tobacco vendors that are close to schools and to places where young people congregate may help. Informing the public about the extent and dangers of social sources of tobacco for youth is also needed. Consideration might be given to developing communications that would discourage sales by older to younger persons, or even to friends. Proof of age request Sale refusal to current smokers 40 32 24 16 8 The percentages for sale refusals to middle school students show a similar pattern; following a 2003 high of nearly 40%, 2005 began an upward trend. In 2013, about 33% of students indicated that they had been refused a tobacco purchase. Over time, fewer high school students have reported getting cigarettes through social means—from 0 2000 2003 2005 2007 2009 2011 Figure  9:  Self-­‐report  of  middle  school  students  who   have  been  asked  for  proof  of  age  and  sale  refusal,   2000-­‐2013,  by  percent 8 2013 INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 FALL 2009 2014 YOUTH TOBACCO USE, ACCESS, AND EXPOSURE EXPOSURE TO SECONDHAND SMOKE AT HOME AND ON THE ROAD Secondhand smoke contains cancer causing chemicals and contributes to numerous diseases in adults and children. The impact of secondhand smoke on young people’s health is heightened due to their ongoing physiological development. Young people are particularly vulnerable to exposure to secondhand smoke at home and in cars. Information about the harms of secondhand smoke is constantly being updated by researchers and scientists. The more that is discovered, especially with regard to children, the more health practitioners and public officials call for strategies to protect children and youth . There are important social and health costs to having large numbers of youth exposed to secondhand smoke. Efforts to get smokers in Arizona to refrain from smoking in the home and in cars is a good first step to alleviating those costs. Secondhand Smoke Effects E x p o s u re i n t h e H o m e According to the 2013 Arizona Youth Tobacco Survey (YTS), students were asked on how many of the past 7 days they had been in the house or the same car with someone who was smoking cigarettes. Students repor ted 20% exposure to cigarette smoke at least once in their house during the past week, and 19% also repor ted exposure at least once in a car (See Figure 10). When comparing exposure to secondhand smoke between students who live with a smoker and those who do not, differences in exposure rates between the 2 groups are high (See Figure 11). One or more exposures in the home during the past 7 days was reported by 47% of students living with a smoker compared to 4% of the students that do not live with a smoker. One or more exposure in a car during the past 7 days was reported by 40% of those living with a smoker compared to 8% of those who do not. The difference in repeated exposures (3 or more times) in the home and car s is par ticular ly pronounced. Repeated exposure in the home was reported by 37% of those who live with a smoker compared to 2% of those who do not. Repeated exposures in a car were reported by 24% of those living with a smoker and 3% of those who do not. Exposure in a room Exposure in a car 60 50 40 30 20 10 0 2000 2003 2005 2007 2009 2011 2013 Figure  10:  Percent  self-­‐reported  exposure  to  second-­‐hand  smoke  among  middle   school  students  during  the  past  7  days,  2000-­‐2013 9 INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 FALL 2009 2014 YOUTH TOBACCO USE, ACCESS, AND EXPOSURE Students living with a smoker Students not living with a smoker 80% 60% 40% 47% 40% 37% 24% 20% 4.3% 7.7% 2.7% 2% 0% Exposed  at  least  once  in   Exposed  at  least  3  -mes   Exposed  at  least  once  in   Exposed  at  least  3  -mes   home  in  past  7  days in  home  in  past  7  days car  in  past  7  days in  car  in  past  7  days Figure  11:  Exposure  to  Secondhand  Smoke  in  Homes  and  Cars  among  Students  Living  With  and  Without  a  Smoker,  2013 In the 2013 Arizona Youth Tobacco Survey, the frequency of students’ exposure varied with the presence of a smoker in the home. Almost 30% of students reported living with someone who smokes; students living with a smoker reported higher rates of being exposed to secondhand smoke once or multiple times in the home or a car during the previous week. Rates were reported at 8 to 10 times higher, with almost half of students living with a smoker exposed at least once in the home during the previous week. Students living with a smoker reported decreases in the number of exposures in the home and in cars during the past 7 days since 2003. Reports in the 2013 Arizona Youth Tobacco Survey showed that exposure rates among middle school students decreased in all categories from 2003. Reports of exposure at least once in a room were 49% in 2003 and decreased to 21% in 2013. Repeated exposures in the home decreased by almost half, from 28% in 2003 to 15% in 2013. Reports of single exposure in a car were lower by 16 % (35% to 19%) and repeated exposures in a car were lower by 11% (21% to 10%). 10 EMERGING TOBACCO PRODUCTS ENDS such as e-cigarettes, disposable cigarette-like, ehookah, vape pens, and refillable, personal vaporizers are battery-powered devices whose function is to vaporize and deliver to the lungs a chemical mixture that includes propylene glycol, nicotine, and other chemicals. The issue of whether e-cigarettes and similar products should be regulated as tobacco products or not has become salient in the United States. The State of Arizona is waiting the final FDA decision on the matter; however, ASHLine has begun drafting a protocol to address clients who use these products and want to quit. INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 FALL 2009 2014 YOUTH PROGRAMS AND SERVICES Students Taking a New Direction (STAND) Efforts to build a sustainable network of youth coalitions are ongoing. In FY12, BTCD awarded Pima Prevention Partnership (PPP) with a contract to serve in assisting BTCD funded partners on developing youth coalition structure and retaining youth participants. In FY12, the Join the Movement statewide youth coalition effort was branded as Students Taking a New Direction or STAND. Currently 28 coalitions exist in fourteen of Arizona’s 15 counties. Membership hovers at approximately 400 youth statewide. BTCD in conjunction with contractor PPP and its subcontractors Arizona Youth Par tnership (AzYP) and Amistades, Inc. continue to bolster youth coalition efforts statewide. Through adult and youth trainings, a planning summit held in the winter, an annual celebratory conference and an increased online presence via Facebook.com/STAND, Twitter @AZStand and www.StandAZ.com; the statewide and local initiatives are thriving in year 5. Local coalitions retain their identity but on a statewide level youth coalition activities are unified via STAND. the coalition members where needed and provide additional logistical support. Individual technical assistance is provided where needed throughout the fiscal year to both youth members and adult coalition members by PPP. Trainings for the youth include education on advocacy, public speaking, social media and message development. Additional support is provided for upcoming STAND local and statewide events such as the Great American Smoke-Out (GASO) held in November, Kick Butts Day (KBD) held in March and World No Tobacco Day (WNTD) held in May. Annual Meetings Winter Summit – held annually around the first of the year as a planning summit for coalition leadership. Planning occurs for Kick Butts Day, World No Tobacco Day and the annual summer conference. Summer Conference – held each June; over 200 youth are invited to the annual summer conference. It serves as a year end celebration with the awarding of the Arizona Youth Advocate of the Year Award (AzYAYA), Coalition of the Year, Trainings and individual coalition MVPs. National and local speakers in PPP has held trainings for adult coalition leaders as well the tobacco field challenge the youth to make positive change as youth coalition members. Trainings have been held regionally in their community. Members attend sessions designed to during both the fall and spring in Phoenix, Flagstaff, Tucson, improve their youth advocacy skills both in STAND as well as Yuma, Show Low and Sierra Vista. Adult coalition leaders learn preparing them to be future leaders. how to effectively foster youth coalition development, assist 11 INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 FALL 2009 2014 YOUTH PROGRAMS AND SERVICES Outreach: Slice of Life While members participate throughout the school year; STAND features a number of “Slice of Life” initiatives that involve non-STAND members in the promotion of the STAND message. Each initiative feature earned media opportunities and was filmed for additional online content and promotion. Art of Resistance – An annual art contest that stems from a master class given by a local artist at high schools statewide. Participants are asked to submit anti-tobacco pop art.Winning artwork has been featured on STAND collateral. Fast Forward a 40-year old smoker – Using theatrical make-up; 2 teens were aesthetically transformed into 40-year old smokers. The teens went to their regularly scheduled classes in a STAND t-shirt and read a statement regarding tobacco abstention. The ensuring transformation footage was hosted online. Spot 127 – In conjunction with KJZZ; Phoenix’s National Public Radio (NPR) affiliate; student interns created a radio ad called Private School Aids Service that focused on populations that are targeted by the tobacco industry at higher rates. Population focus included the Lesbian/Gay/Bisexual/ Transgender community, the behavioral health community and youth. Engineering Addiction – In partnership with a local robotics club; STAND created a tobacco themed trivia robot used at tobacco themed events. Youth would have to correctly answer tobacco related questions in order to operate the robot. STAND is pursuing a partnership with Arizona State University’s robotics wing (http://www.standaz.com/watch/ engineering-addiction/ ). Continued engagement and involvement with the youth help with recruitment, execution and promotion of statewide and local youth coalition efforts. Youth Cessation Counter-Marketing Get Out While You Can Beginning in mid FY13, BTCD began to formulate a plan to address tobacco cessation efforts among youth. Four hundred high school youth were surveyed on tobacco related attitudes with the aim of determining the best protocol for youth cessation. BTCD conducted a literature review and indepth interviews with 6 local and national experts on tobacco control. Youth cessation has been promoted as part of punishment for minors caught with and using tobacco, however, this form of cessation does not have a high success rate. Studies show that successful strategies require the user to be committed to quitting tobacco. With this in mind the research pointed to the formulation of a youth-friendly cessation quitline. Utilizing the highly successful ASHLine as a model; coaches from the ASHLine were trained in cessation protocol with youth clients as the primary demographic. The quitline number was retained but all callers age 24 and younger would be routed to the ASHLine’s youth cessation wing, the CIGNAL, which was developed and branded for youth and young adults ages 15-24. TheCIGNAL.com was launched to promote the a television campaign dubbed, “Get out while you can.” The challenge and focus of the 2 commercial spots was to show youth that just because they may not consider themselves tobacco users and/or addicted, they should quit and get out before it’s too late. A 2.0 version of the CIGNAL website and corresponding Facebook site launched in FY14 with more emphasis on youth engagement and viral content. The idea was that through shareable content and topical humor ; the demographic would be lured to the contemporary site and get the information needed to make an informed decision from a ‘trusted’ source that was unbranded from the ASHLine and/or ADHS. FY15 will see the revamp of the CIGNAL with new creative and renewed focus on informational content rather than a main call-to-action to the quitline. Youth Prevention Network Youth prevention has been broadened to include not only youth coalition activities but also to incorporate prevention outreach, point-of-sale (POS) efforts including the Attorney General’s sting operation, CounterStrike, and the Food and Drug Administration program. The centralized hub of activity will be StandAZ.com. Information and resources will be provided for youth and adult leaders and will house but not be limited to the aforementioned initiatives. Facebook and YouTube sites have been created to tap into the social media opportunity that presents itself when working with youth. 12 INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 FALL 2009 2014 YOUTH PROGRAMS AND SERVICES ASHline Counter-Marketing within DBHS and the FDA Tobacco Compliance program which is housed within the Division of Public Health Project Quit BTCD’s previous marketing efforts included a direct call- Preparedness at ADHS. to-action of contacting the quitline with a message of what the service provided (e.g. free, nicotine replacement therapy SYNAR In July 1992, Congress enacted the Alcohol, Drug Abuse, (NRT)) as well as telling the stories of real ASHLine clients. To and Mental Health Administration Reorganization Act, which tie the previous 2 campaigns messaging together, a new includes the Synar Amendment aimed at decreasing youth campaign dubbed “Project Quit” was developed. Project Quit access to tobacco. This amendment requires states to enact was a campaign that highlighted the real stories of tobacco and enforce all laws prohibiting the sale or distribution of users who quit using tobacco with the help of ASHLine. Each tobacco products to individuals under the age of 18. In of the 4 participants stories were captured with a professional Arizona, all businesses known or suspected of selling tobacco film crew on the outset, mid-point and conclusion of the 30are broken down into clusters, which are geographic units day project. The participants checked in daily with confessionalbased on zip codes with the intent of having between 20 and style cameras from their home. A 120-day check-in was done 80 retailers per cluster. Statistical analysis determines how with the participants to assess their tobacco-free status and many inspections need to be completed, and random clusters provide additional online content. are drawn until there are sufficient numbers of retailers. Two To p r o m o t e t h e c a m p a i g n , a w e b - p o r t a l , community organizations are contracted to recruit youth and ProjectQuitAZ.com, and Facebook page were launched, complete the inspections within the chosen cluster, which featuring footage of 3 series of seven webisodes each. includes canvassing the cluster for any additional retailers. Additional media was created in the form of digital ads and Youth for this program must be 16 years of age, are not able outdoor billboards. The “Project Quit Roadshow” debuted at to carry ID, and there must be an equal number of male and three Phoenix Metro malls on New Year’s and featured a female youth inspectors. In 2013, 369 inspections were video/photo booth for additional stories from new participants completed and 3.8% of stores sold to minors. In 2014, 255 as well as motivational messages from supporters. ASHLine inspections were completed and the percent of stores that referrals were made onsite to anyone who was looking to quit sold to minors was 4.0%. tobacco. Continuous Quality Improvement FDA ADHS is contracted with the Food and Drug Project Collaborating to Streamline Efforts Administration (FDA) to conduct compliance check inspections of tobacco retailers to determine compliance with federal laws and regulations, including the Family Smoking Prevention and Tobacco Control Act of 2009. For the youth inspections, counties within Arizona recruit youth to participate within their counties or in neighboring counties. For FY14, 690 undercover buys were completed with a 15% buy rate. During this same time, 543 AL (Advertising and Labeling) inspections were also completed with a 7% fail rate. Youth must be 16 or 17 years of age and are expected to carry ID although that is not required. Additionally, the FDA team conducts Advertising and Labeling inspections to ensure compliance with all regulations regarding advertising, incentive programs, labeling restrictions, and flavored tobacco products. In 2014, ADHS Bureau of Tobacco and Chronic Disease, Department of Behavioral Health Services (DBHS) and the Attorney General’s Office (AGO) went through an intense Continuous Quality Improvement (CQI) project to streamline tobacco enforcement and compliance. The intent of the project was to look at possible collaborations on youth inspections, while eliminating duplicate efforts and unnecessary costs. The programs involved in this project were the Office of Tobacco Prevention and Cessation Programs, which funds the AGO’s CounterStrike youth enforcement programs as well as holds the CDC tobacco collaborative agreement and is the office responsible for all tobacco prevention and cessation efforts in the state, and the Synar program, which is housed 13 ARIZONA DEPARTMENT OF HEALTH SERVICES 2014 ADULT PROGRAMS, ACTIVITIES AND SERVICES Prevalence of Adult Tobacco Use SEX CDC Outcome Indicator 3.14.1 Smoking Prevalence According to the 2012 Arizona Behavioral Risk Factor Surveillance Survey (BRFSS), 17.1% of respondents identified themselves as current smokers. Figure 12 retrospectively weights the data from previous year’s surveys to show what the prevalence would have been with the current weighting system. Table 1 lists demographic information about respondents who reported they are current smokers. FEMALE 14.7 AGE Prevalence of Tobacco Use in Pregnancy CDC Outcome Indicator 3.14.2 Prevalence of tobacco use during pregnancy According to the Arizona Department of Health Services Bureau of Public Health Statistics (ADHS BPHS), Health Status and Vital Statistics Section the prevalence rate of women who report tobacco use during pregnancy is 4.4 per 100 births in 2013, which is lower than 2005’s report of 5.4 per 100 births. 25 22.5 20 19.71 19.3 18.22 17.1 17.5 2008 2009 2010 2011 2012 Figure  12:  2008-­‐2012  BRFSS,  Prevalence  of  tobacco   use,  retrospecTvely  weighted MALE 19.6 18-24 18.9 Employed for wages 15.9 25-34 21.1 Self-employed 18.3 35-44 16.7 Out of work 29.7 45-54 18.6 Homemaker 10.8 55-64 19.2 Student 16.1 65 or more 9.5 Retired 10.6 Unable to work 32.1 INCOME Married 11.5 < $25,000 22.7 Divorced 27.7 $25,000-$34,999 20.3 Widowed 13.5 $35,000-$49,999 18.1 Separated 29.6 $50,000-$74,999 13.0 Never married 20.1 >$75,000 10.1 Unmarried Couple 29.2 EDUC ATION 20.01 % EMPLOYMENT MARITAL STATUS Percentage of Adults in Arizona that are Current Smokers 15 % RACE/ETHNICITY Less than High School 20.3 White, Non-Hispanic 18.2 High School Graduate/GED 22.9 Black, Non-Hispanic 24.1 Some College/ Tech School 17.1 Other race, Non-Hispanic 20.4 College Graduate 8.5 Hispanic 14.3 Table  1:  2012  Arizona  BRFSS,  demographics  of   respondents  who  are  current  smokers 14 ARIZONA DEPARTMENT OF HEALTH SERVICES 2014 SMOKE FREE ARIZONA SMOKE FREE ARIZONA On November 7, 2006, Arizona voters approved Proposition 201, the Smoke-Free Arizona Act, A.R.S. § 36-601.01 (the Act or the Law). The Law went into effect on May 1, 2007, prohibiting smoking inside and within 20 feet of entrances, open windows, and ventilation systems of most enclosed public places and places of employment, with a few exemptions. While the Act prohibits smoking inside most enclosed public places and places of employment in Arizona, smoking is allowed in establishments that meet specific exemption criteria. There are 7 exemptions, including private residences, designated smoking rooms in hotels and motels, retail tobacco stores, Veterans and fraternal clubs, smoking when associated with a religious ceremony pursuant to the American Indian Religious Freedom Act of 1978, outdoor patios, and theatrical performances upon a stage or in the course of a film or television production. Also included in Proposition 201, was the imposition of a 2-cent tax per pack of cigarettes to be deposited into the Smoke-Free Arizona Fund, which must be used to enforce the provisions of the Law. If a proprietor of an establishment does not correct violations as requested, demonstrates willful violations, or exhibits a pattern of noncompliance with the Act, (s)he is subject to enforcement action. The proprietor may receive a Notice of Violation (NOV) or an assessment of civil penalty fines between $100 and $500 for each violation. If injunctive relief is requested, the Superior Court may impose appropriate injunctive relief and civil penalty fines up to $5,000 per violation. The Arizona Department of Health Services Office of Environmental Health (ADHS) and all but one of Arizona’s counties work through delegation agreements to ensure that Arizonans are protected from secondhand smoke exposure in most enclosed public places and places of employment. The county health departments conduct consultations and on-site visits at public places and places of employment, including but not limited to local businesses, bars, and restaurants to provide education and to ensure continued compliance with the Smoke-Free Arizona Act. Between May 1, 2013 and April 30, 2014, a total of 20,202 educational visits, consultations, and onsite visits were conducted. Many business proprietors have made steps to go above and beyond the requirements of the Smoke-Free Arizona Act. In addition to making the necessary changes to comply with the Act, such as posting the required “No Smoking” signs and moving ashtrays, proprietors have also continued to build outdoor patios, provide designated smoking areas, and establish in-house policies that are more strict than the Act to accommodate their employees and customers. In 2014, Arizona earned an “A” grade on the American Lung Association State of Tobacco Control Report for maintaining a strong, comprehensive enforcement program of the Smoke-Free Arizona Act. For the 7th year in a row, the report has awarded a grade “A,” recognizing the continued success of the Smoke-Free Arizona Act. 15 ARIZONA DEPARTMENT OF HEALTH SERVICES 2014 ADULT PROGRAMS, ACTIVITIES AND SERVICES A New Call to Action ASHLine Counter-marketing ADHS BTCD funds the Arizona Smokers’ Helpline (ASHLine) to offer free telephone coaching, free online quit support through WebQuit (available on ashline.org) and free over-the-counter nicotine replacement therapies (NRTs) for tobacco cessation. Starting FY09, BTCD no longer funded community-based cessation classes, and placed the statewide focus on ASHLine for cessation services. BTCD utilizes its tobacco-funded partners to serve as referral development liaisons in metro and rural Arizona to promote ASHLine services. The goal of ASHLine is to provide access to effective, evidence-based tobacco use cessation services for all Arizona residents. In order to achieve this goal, ASHLine offers the following services: • Individual/personalized telephone counseling in English and Spanish • Web-based information/online WebQuit • Printed materials • Access to free Over The Counter Nicotine Replacement Therapies (i.e. NRT patch, gum, or lozenge) Since its inception, ASHLine has received more than 10,000 calls each year and more than 12,000 referrals. ASHLine utilizes various approaches to maximize the accessibility of tobacco cessation, including: • Individualized quit planning • Client anonymity and confidentiality • Proactive counseling • Culturally competent and sensitive counseling • Bilingual services (English, Spanish) ASHLine had a total seven-month quit rate of 30 percent in FY13 and 37% in FY14. This compares favorably to the average 20% quit rate reported by most national quitlines. Moreover, the seven-month quit rate for clients who utilized coaching and medication was 45 percent and 55 percent in FY13 and FY14 respectively. Medication to Assist in Quitting One of the most effective tobacco cessation methods is a combination of quitline coaching and FDA-approved tobacco cessation medication. In FY13 and FY14, BTCD offered a medication benefit to eligible ASHLine clients aged 18 and above that included a free two-week supply of over-thecounter nicotine replacement patch, gum or lozenge. Unlike a voucher program, ASHLine ships the two free weeks of NRT directly to clients’ homes. Arizona Health Care Cost Containment System (AHCCCS) Title 19 beneficiaries can receive up to twelve weeks of any of the seven FDA-approved tobacco cessation medications. Arizona has one of the most comprehensive and accessible NRT benefits available to its Medicaid population. 16 ARIZONA DEPARTMENT OF HEALTH SERVICES 2014 ADULT PROGRAMS, ACTIVITIES AND SERVICES AHCCCS members made up 23% and 29% of ASHLine’s client population in FY13 and FY14 respectively. State quitlines and tobacco control programs have a long history of partnership with state Medicaid agencies on: • Expanding coverage (and decreasing barriers) for tobacco cessation services to Medicaid members • Promoting existing cessation coverage and the availability of free quitline services to Medicaid members • Gaining some level of funding and/or reimbursement for delivery of quitline services to Medicaid members. Arizona has also partnered with AHCCCS to secure the Centers for Medicare and Medicaid Services administrative match for Quitline Services, one step toward ensuring sustainability of the ASHLine as well as providing quit tobacco services to underinsured populations. ASHLine Counter-Marketing During FY13 and FY14, ASHLine clients reported a diverse array of formal and informal advertising regarding how they heard about ASHLine services. The most common way clients reported hearing about ASHLine services during FY13 was through television, by a wide margin. During FY14, the most common way clients reported hearing about ASHLine services remained television; however, the margin decreased significantly partially due to a reported increase in clients hearing about ASHLine within healthcare settings. Increased provision of training and technical assistance around tobacco assessment, intervention and referral via community development – especially among medical and behavioral health partners – may be contributing to the significant increase in clients who report hearing about ASHLine services in healthcare settings. Fur thermore, ASHLine has placed an increased emphasis on improving a reengagement of ASHLine services during follow-up, which may account for the significant increase in former clients reengaging in services from FY13 to FY14. 17 HOW ASHLINE CLIENTS HEARD ABOUT SERVICES Media  Source FY13  (%)   FY14  (%)   TV 55.7% 34.1% Radio 1.2% 2.1% Billboards  or Other  media 2.6% 3.9% Friends  and  Family 9.0% 8.6% Doctor  or Healthcare  Facility 18.2% 32.7% Client   Reengagement 9.2% 11.2% Workplace 0.5% 1.4% Other 3.7% 6.0% YOU CAN QUIT WE CAN HELP Prior to ASHLine’s commitment to focusing on establishing Public-Private Partnerships with employers, only a small fraction of clients reported hearing about ASHLine services via the workplace. The percentage of clients hearing about ASHLine services in the workplace nearly doubled, however, between FY13 and FY14. This may be partially attributable to efforts on behalf of the Public-Private Partnership initiative. INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 SERVICES FALL 2014 2009 REDUCING HEALTH DISPARITIES IDENTIFYING AND ELIMINATING TOBACCORELATED DISPARITIES Certain groups exhibit disproportionately high morbidity and mortality rates associated with tobacco use. Factors include but are not limited to, an individual’s age, ethnicity, education, income, and sexual orientation. These factors can greatly contribute to health disparities within a given p o p u l a t i o n . To b a c c o - re l a t e d disparities are demonstrated by increased prevalence of tobacco use, greater exposure to secondhand smoke, limited access to educational information and prevention/cessation programming, among other considerations. In FY13 and FY14, BTCD continued its work with community organizations on capacity building and program planning for the development of sustainable commercial tobacco prevention programs. The contracts with these organizations were through September of 2013. BTCD also engaged community partners to achieve sustainable positive change in reducing health disparities relating to diabetes, tobacco-use, and obesity. The funded organizations conducted work in various communities throughout the state in these population groups: African American, American Indian, AsianPacific Islanders, and migrant farm workers. Integ ration of Tobacco and Chronic Disease Services - Community Health System In 2011, BTCD initiated the Integration of Tobacco and Chronic Disease Services - Community Health System by procuring Request for Grant Applications (RFGAs).The purpose of the grant was to improve the health status of people by supporting the integration services to build a community health system that will support the utilization of tobaccocessation, cancer, cardiovascular disease/stroke, pulmonar y disease services in communities. The gr ant-funded project focused on communities in 1 of 5 counties in Arizona: Gila, Graham, La Paz, Mohave, and Navajo. These counties were chosen based on their rankings on health outcomes (mortality and morbidity) and health factors (health behaviors, clinical care, s o c i a l a n d e c o n o m i c , p hy s i c a l environments) according to the report, County Health Rankings – Mobilizing Action Toward Community Health, 18 prepared by the Robert Wood Johnson Foundation and University of Wisconsin. The grant required the use of funds for the integration of services that improved their effectiveness. Examples of integration areas include: • Development of interagency coordination mechanisms and partnerships with community partners for increased/improved service delivery (e.g. building provider networks, building functional and sustainable linkages among service partners; • Development of procedural processes to suppor t needed collaborative ser vice systems improvement (e.g. change in standards of practice, data sharing); • Training/workforce development to assist staff or other providers in the community provide effective services consistent with the purpose of the grant program; and redesigning processes, as needed, to enhance effectiveness, efficiency and optimal collaboration between service providers. INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 SERVICES FALL 2014 2009 REDUCING HEALTH DISPARITIES Asian Pacific Community in Action: Asian Pacific Islanders door or window of the rental units. Through youth coalitions, the tribal housing authority worked with proper ty management to complete the language necessary for the leasing agreement. Additionally, they refurbished the units to remove odors and make the units more desirable. Additionally, contractors worked with housing authority programs and community leaders to implement smoke-free housing policies, worked on ASHLine referrals and assisted healthcare facilities in revising intake forms to enable referrals; the tribal programs diligently reached out to their local programs to implement changes in their intake processes to include the “Ask, Advise, Refer” (AAR) process to identify individuals using commercial tobacco. To date, a total of 32 programs have revised their intake forms. Lastly, contractors also collaborated with other counties and additional programs to promote and implement chronic disease self-management programs. All eight tribal subcontractors were trained in CDSMP in February 2013. The Inter-Tribal Council of Arizona, Inc. completed its grant work in 2013. During FY13 and FY14 Asian Pacific Community in Action (APCA) continued to promote the UC Davis California Asian Quitline to refer AAPI clients to quitline services. The California Quitline has the capacity to provide services in many AAPI languages the ASHLine is unable to provide at this time. APCA reached out to the community at health fairs, workshops, cultural events and by working with several healthcare providers who work with the AAPI community. APCA is also an active member of the Arizona Smoke Free Living Coalition. Through the coalition, a tobacco survey was completed of persons living in multi-unit housing and the coalition worked to promote multi-unit smoke-free housing policies in Maricopa County. APCA also reached out to several managers’ of multi-housing complexes where members from AAPI community reside to discuss this initiative. APCA provided workshops based on the Stanford – Chronic Disease Self-Management (CDSMP) Curriculum. They successfully recruited and trained several Master Trainers who in turn trained members of the community to become lay leaders to conduct CDSMP workshops. Due to this endeavor they held several workshops in the AAPI community. They also worked with several providers in the area to educate them about the availability of the workshops and established a referral system for CDSMP workshops. The Asian Pacific Community in Action grant was completed in the second quarter of FY13. Inter-Tribal Council of Arizona, Inc. (ITCA): Five Tribal Nations a nd Three Urban Centers ITCA and their subcontractors, which includes five Tribal Nations and three Urban Indian Centers, worked on the several tobacco control activities, including youth coalitions to implement smoke-free policies. One grantee, Kaibab Paiute Tribe (KPT), through the Kaibab youth coalition, passed an ordinance for their twenty five rental units to go smoke-free with plans for implementation and enforcement of policy being finalized by program lead and tribal council. Youth made public comment to tribal council by presenting a PowerPoint which showcased how secondhand smoke was drifting into the rental units. The youth took pictures of the designated smoking areas and captured how close they were to either a 19 INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 SERVICES FALL 2014 2009 REDUCING HEALTH DISPARITIES other agencies, such as hospitals and medical providers to increase referrals of patients to the ASHLine. Due to the completion of the grant, Campesinos Sin Fronteras no longer received funding after the second quarter of FY13. Tanner Community Development Corporation: African American Campesinos Sin Fronteras: Hispanic and Mig rant Farmworkers During FY13 and FY14, Campinas Sin Fronteras (CSF) collaborated with various faith groups to provide training and education on chronic disease prevention and tobacco prevention activities. CSF utilized the “Tu Corazon, Tu Vida” curricula for disease prevention and the AAR process for brief tobacco intervention. Each faith based group identified a member to be trained to provide education and information to their members on these activities. They also trained various community service agencies on the brief tobacco intervention and how to refer to ASHLine for tobacco cessation services. CSF worked with their Students Taking A New Direction (STAND) youth coalition to work towards smoke-free parks in San Luis and Somerton Arizona. CSF youth participated in statewide activities like Kick Butts Day, World No Tobacco Day, and regional youth trainings, attending statewide conferences and working within their community to promote tobacco prevention. CSF worked with apartment complex management and housing authorities to work towards smoke free housing policies and were able to assist in some multi-family units in going smoke-free. Additionally, CSF actively promoted tobacco cessation through community events and by working with Tanner Community Development Corporation (TCDC) faith based youth groups continued to have strong support and interest in the statewide youth coalition called STAND. Youth from several churches participated in youth groups who received training in public speaking and leadership skills giving them the ability to talk to their peers and members of their community regarding tobacco issues. TCDC youth groups participated in regional youth trainings as well as participated in the planning of STAND’s Summer Conference. They worked to develop an initiative around a smoke-free park within their community. TCDC also participated as a member of the Arizona Smoke Free Living Coalition. Through the coalition a tobacco survey was completed of persons living in multi-unit housing and the coalition worked to promote multi-unit smoke free housing policies to those interested in Maricopa County. TCDC has worked with several multi-unit housing complexes that have implemented either smoke-free policies for their units or have a designated smoking area. TCDC is highly invested in the Stanford Chronic Disease Self- Management curriculum. Since the inception of this endeavor TCDC has worked with ten churches to identify leaders to act as advocates for this initiative. They have trained several lay leaders who provide the CDSMP workshops within the faith community. Through this initiative, they were able to assist 8 churches to become “Smoke Free” Campuses and several other developed designated smoking areas. Due to the completion of the grant, TCDC no longer receives funding after the second quarter of FY13. However, BTCD solicited an RFGA for youth anti-tobacco efforts and awarded the RFGA to TCDC starting in January 2014. TCDC continues to work on STAND tobacco prevention efforts which include policy work around smoke-free parks and smoke-free multi-unit housing, peer-to-peer education, and participation in state tobacco surveillance and enforcement efforts. 20 INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 SERVICES FALL 2014 2009 REDUCING HEALTH DISPARITIES L a P a z R e g i o n a l H o s p i t a l : STAND tobacco prevention efforts include policy work around smoke-free parks and smoke-free multi-unit housing, Community Health System La Paz Regional Hospital (LPRH) worked to enhance their peer-to-peer education, as well as, participate in state tobacco existing ASHLine referral process and CDSMP referral process surveillance and enforcement efforts. BTCD is working to within the hospital. They also implemented the “No Place Like secure other tribes through IGAs in the coming years. Home” program which tracked readmissions and followed up with discharged patients at 2- days, 30- days, and 60- days to STAND YOUTH COALITIONS provide case management assistance. As a result of this HOPI AND KAIBAB-PAIUTE program, patients were more likely to follow up with a The Hopi Tribe and Kaibab-Paiute Tribe each received doctor’s appointment, more likely to fill and take prescriptions, funding through ITCA to create an anti-tobacco youth and reported appreciating having someone call to check up on coalition. Once the funding cycle from ITCA was them. Additionally, readmission rates at LPRH were reduced. completed, BTCD contracted with Hopi and KaibabLPRH continued to work on their health needs Paiute to continue their youth coalition efforts. The assessment, which focused on Tobacco and other Substance youth coalition works in their community to educate Abuse, Adult Obesity, Lack of Exercise, and Screening youth and adults about the dangers of commercial Utilization Rates. The hospital worked with Cenpatico, a local tobacco use and is working towards enacting improved behavioral health provider in La Paz County, to help with tobacco policy in their communities. improvement of their approach to older patients regarding management of their disease. Funding ended for most community organizations starting in the second quarter of FY14. BTCD decided to direct funds to community or ganizations directly through Intergovernmental Agreements (IGAs) or through Request For Grant Applications (RFGAs). To date, two tribes, the Hopi Tribe and the Kaibab Paiute Tribe, have established IGAs with BTCD. All contracted work is specific to youth anti-tobacco efforts. STUDENTS TAKING A NEW DIRECTION 21 ARIZONA DEPARTMENT OF HEALTH SERVICES 2014 REDUCING THE BURDEN OF CHRONIC DISEASE CHRONIC DISEASE ACCOUNTS FOR 30,000 DEATHS EACH YEAR IN AZ OBESITY AFFECTS 1 IN 4 ARIZONANS STROKE AZ’S 6TH LEADING CAUSE OF DEATH 76,000 HOSPITALIZATIONS 10,000 DEATHS & IN AZ EACH YEAR DUE TO HEART DISEASE CARDIOVASC U LAR DISEASE AZ’S 2ND LE AD IN G C AUSE OF DEATH CANCER HEART DISEASE CHRONIC LOWER RESPIRATORY DISEASE ALZHEIMER’S DISEASE DIABETES CHRONIC LIVER DISEASE+ CIRRHOSIS HYPERTENSION+ HYPERTENSIVE RENAL DISEASE CHRONIC DISEASE = 7 OF THE 10 LEADING CAUSES OF DEATH IN AZ C ANC ER CAUSES MORE THAN 10,000 DEATHS IN AZ EACH YEAR NEARLY 1 IN 10 ARIZONANS HAS DIABETES BUT WE ARE WORKING TO G E T H E R TO M A KE A DIFFERENCE 22 ARIZONA DEPARTMENT OF HEALTH SERVICES 2014 REDUCING THE BURDEN OF CHRONIC DISEASE FACILITATING SELF-MANAGEMENT AND CREATING LINKAGES The program consists of workshops conducted once a Chronic Disease and Tobacco Use According to the US Department of Health and Humans week for 2 and a half hours over 6 weeks in communitybased settings such as senior centers, congregate meal programs, faith-based organizations, libraries, YMCAs, YWCAs, and senior housing programs. In addition to the Diabetes and Chronic Pain Self-Management Programs, Arizona offers the Spanish programs Tomando Control de su Salud and Programa de Manejo Personal de la Diabetes. The Arizona Department of Health Services partners with the Arizona Living Well Institute and Yavapai County Health Department to coordinate the delivery of the Healthy Living: Self-Management of Chronic Conditions workshops throughout the state. The Arizona Living Well Institute is the lead agency that facilitates communication, coordination, and coaching for organizations and individuals, collects program data and ensures program fidelity. Since 2010, our partners have reached 5,203 community members with 74% completing the program statewide. Services, about 8 out of 10 of all deaths from chronic obstructive pulmonary disease (COPD) are caused by smoking and tobacco use. Among current smokers, chronic lung disease accounts for 73 percent of smoking-related conditions. Even among smokers who have quit, chronic lung disease accounts for 50 percent of smokingrelated conditions. Research from the Centers for Disease Control and Prevention has shown a direct correlation between tobacco use and chronic diseases such as lung, larynx, esophageal, and oral cancers, heart disease and chronic lower respiratory disease. Chronic Disease Self Management Education Prog rams ADHS contracts with county health departments to implement Chronic Disease Self Management Education Programs (CDSME/P). This has resulted in a well-defined CDMSE/P statewide infrastructure that has proven to be extremely effective in assisting people with ongoing chronic disease problems such as heart disease, chronic lower pulmonary disease and other on-going health problems. CDSME/P helps participants deal with difficult emotions, manage symptoms, set goals, problem-solve, nutrition, understanding medications, make informed treatment decisions, increase strength and stamina through better fitness, and communicate more effectively with health care providers. Participants develop action plans related to these topics through structured planning and feedback exercises. CDSME/P teaches consumers skills to manage their conditions and build self-confidence so they can be successful in adopting healthy behaviors, improve communications with their physician, and enhance their quality of life. School Health Index/ Advisory Councils ADHS has made funding available to Arizona counties to implement the School Health Index (SHI), a self-assessment and planning tool in elementary and high schools located in their communities. This tool will allow School Health Advisory Councils (SHACs) to be formed for the purpose of discovering what their school or school district is already doing to support student health and to identify areas of improvement. SHACs are comprised of a group of individuals representing the school and the community, acting collectively to provide advice to schools or districts on aspects of school health policies and programs. In Arizona, five counties have been working with school districts in their areas to implement the School Health Index/School Health Advisory Council Strategy through Prop 303 funds. 23 ARIZONA DEPARTMENT OF HEALTH SERVICES 2014 REDUCING THE BURDEN OF CHRONIC DISEASE PROPOSITION 303 CHRONIC DISEASE STRATEGIES · Contracting with 14 of 15 county health departments to create a well-defined Chronic Disease Self-Management infrastructure Million Hearts Initiative Strategies to Prevent Heart Disease and Stroke BTCD has made available funding for Arizona counties to support the Million Hearts Initiative. The Million Hearts® initiative will focus, coordinate, and enhance cardiovascular disease prevention activities across the public and private sectors in an unprecedented effort to prevent one million heart attacks and strokes by 2017 and demonstrate to the American people that improving the health system can save lives. Million Hearts® will scale-up proven clinical and community strategies to prevent heart disease and stroke across the nation. In Arizona, 14 counties have agreed to support the Million Hearts Initiative through leveraging their local partners and opportunities to help increase community/ clinical linkages to improve care in their counties. FOCUS · Increasing the number of Chronic Disease SelfManagement workshops in English and Spanish for people experiencing ongoing chronic disease problems · Implementing the School Health Index in elementary and high schools throughout Arizona to improve health and safety policies and programs · Establishing School Health Advisory Councils to support student health and identify areas of improvement · Funding county health departments to implement clinical and community strategies to prevent heart disease and stroke COORDINATE 24 ENHANCE ARIZONA DEPARTMENT OF HEALTH SERVICES 2014 REDUCING THE BURDEN OF CHRONIC DISEASE CPR Dispatch Initiative Improving CPR care and outcomes with the Guidelines (GWTG) program is an evidence-based quality improvement program which utilizes a patient management tool to improve the quality of care, per CDC guidelines, for stroke patients. Stroke is the 4th leading cause of chronic disease death in Arizona and the leading cause of long-term disability. Through the GWTG quality improvement program, hospitals in Arizona will improve delivery of stroke care, thus reducing death and long-term disability. As of 2014 there are 29 hospitals participating in its quality improvement program state-wide. Heart-related deaths are the leading cause of mortality in the U.S. An estimated 424,000 annual out-of-hospital cardiac arrests (OHCAs) make OHCA a major public health problem. While most occur in adults, OHCA can strike all ages and is a significant problem in children. It results in death in all but 7.6% of cases nationally, but a 500% regional variation in survival suggest that system factors have profound impacts on outcomes. BTCD is currently funding a statewide public health initiative to improve care and evaluate OHCA outcomes. This program is called the Arizona TARGET (Telephone-Assisted Resuscitation Gains Essential Time) Initiative. It implements the latest American Heart Association guidelines for telephone CPR. A three-year study evaluating more than 2,600 OHCAs in Arizona finds that survival and survival with positive neurologic outcome improved by factors of 1.5 and 1.7, respectively, among 9-1-1 agencies adopting the program's protocols, training, and quality-improvement tools. Stroke System of Care Responding to the call for a non-profit AZ Stroke System of Care The 2011 House Bill 2157 required ADHS to create an infrastructure to coordinate stroke care statewide through the establishment of protocols and national standards for care. The Stroke Systems of Care in Arizona continues to grow with the expansion of Stroke Centers, improved data collection, quality management programs and use of tele-stroke (telemedicine for stroke patients). There are currently 25 Accredited Stroke Centers in Arizona, up from 12 in 2011. Future plans include Get with the Guidelines the development of a self-sustaining stroke organization tasked Improving delivery of care in AZ hospitals The ADHS Office of Chronic Disease is funding a quality with the oversight and expansion of the statewide stroke improvement program which improves the delivery of stroke system of care as it continues to grow to provide improved care in Arizona hospitals. The American Heart Association Get care and patient outcomes for Arizonans. QUALITY IMPROVEMENT SUSTAINABILITY 25 ARIZONA DEPARTMENT OF HEALTH SERVICES 2014 REDUCING THE BURDEN OF CHRONIC DISEASE HAPI STRATEGIES “A TRUE HEALTH IN ALL POLICY” Health in Arizona Policy Initiative (HAPI) In January 2012, ADHS created the Health in Arizona Policy Initiative (HAPI) to achieve the goals of coordinated chronic disease. HAPI is a Division of Public Health Services’ collaboration that leverages tobacco tax and lotter y funding with federal funding to address social determinants of health through a “health in all policies” approach within worksites, communities, schools and health systems. The goal of HAPI is to provide infrastructure and implementation funding to local county health departments that choose to participate in the initiative. Program staff and leadership from ADHS, including the Office of Chronic Disease provide technical assistance to the HAPI contractors on implementing policy, system and environmental change. HAPI is built upon the leveraging of resources, development of relationships, and engagement of all populations on advancing efforts which make the healthy choice the easy choice for populations. Each county has the option to work within the following five areas: Worksite Wellness, School Health, Healthy Community Design, Clinical Care, and Procurement Policy. Counties are given the option of incorporating policy approaches which impact children and youth with special health care needs into their activities. ADHS is currently exploring ways in which it can leverage funding sources to increase the utilization of evidence-based community preventative ser vices (worksite wellness, school health, & community design) as well as clinical preventative services (use of electronic health systems to increase screenings, engagement of promotoras and patient navigators, use of clinician reminders around screening and clinician referrals to community programs around disease self-management, etc.). ADHS staff is working with the HAPI contractors to identify evaluation strategies for both the output and intermediate outcomes and for those of the larger initiative. Over the next several months ADHS will be identifying the major outcomes it would like to see out of both the HAPI contracts and the larger initiative. 26 • Focusing on children and youth with special health care needs when considering healthy community design implementation by Maricopa and Mohave Counties. • Increasing opportunities for physical activity in the workplace in Yavapai and Navajo County • Providing disease selfmanagement classes to employees in Yuma County • Increasing policies and practices to support breastfeeding in the workplace in Greenlee County, • Increasing access to physical activity for county employees in Gila County • Establishing healthy community design standards to make streets safe for pedestrians, bicyclists, and users of public transit in Coconino County. • Establishing healthy community design protocols to improve community health and wellbeing in Maricopa County • Establishing sites for community gardens in institutional settings and/or underserved areas in Pima and Graham Counties ARIZONA DEPARTMENT OF HEALTH SERVICES 2014 REDUCING THE BURDEN OF CHRONIC DISEASE Healthy Arizona Worksite Prog ram (HAWP) This award recognizes businesses in Arizona that are making efforts to positively affect the health and well-being of their Funding has been made available to assist Arizona employees, their families and their communities through employers on the development and implementation of evidence-based worksite health initiatives. evidence-based worksite wellness programs. Comprehensive worksite wellness programs are proven to not only help Chronic Lower Pulmonary Disease organizations control healthcare costs, including those Through a contract with the American Lung Association, associated with chronic conditions such as heart disease, BTCD is promoting improvements in the system of care for diabetes, and pulmonary disease, but they also increase individuals diagnosed with COPD by working to productivity among employees. Many employers, however, do • Promote the prevention and early detection of lung disease not have an understanding of how to implement such a • Collect surveillance data to determine the impact of indoor worksite wellness program, often neglecting the connection air quality as it effects COPD and other chronic respiratory between prevention initiatives and health plan benefit design conditions in Arizona and utilization. ADHS contracts with the Maricopa County • Educate the public, people living with COPD, healthcare Department of Public Health and the Arizona Small Business community, and decision makers about the risks for chronic Association to help employers successfully implement lung disease and relevant resources evidence-based healthy worksite initiatives to improve the • Build awareness of indoor air quality issues through a social health of their employees and businesses. media campaign, collateral materials and website The Healthy Arizona Worksites Program (HAWP) provides • Provide a statewide forum for individuals living with lung tools, resources and technical assistance to employers to disease, medical professionals, members of the healthcare design, implement, and evaluate healthy worksite initiatives industry and community agencies invested in respiratory throughout Arizona. HAWP also works to create linkages issues between Arizona businesses engaging in healthy worksite • Build relationships with decision makers in the multi-housing efforts so they can learn from each other and share community to assist in creating smoke-free policies in experiences. Employers that participate in HAWP and meet communities throughout Maricopa County certain other criteria are eligible to receive the Healthy • Develop and implement a Contractor Action Plan in Arizona Worksite Award. conjunction with BTDC and implement the Action Plan. WORKSITE WELLNESS “Comprehensive Worksite Wellness Programs...not only help organizations control heatlhcare costs...but they also increase productivity among employees.” 27 28 BRANDY MCMAHON EPI SPCT II AUN04687 20 SHS000002394 ERICA FERGUSON HEALTH PLANNING CONSULTANT AUN06838 20 SHS000001906 VACANT HEALTH PROGRAM MANAGER AUN04842 21 SHS000001809 BELEN TRUJILLO COORDINATOR ADMV SECRETARY III ACV31213 14 SHS000000300 DIANE WILLIAMS *(TRAVEL)* AUN04463 SHS000001862 THOMAS BINGER ENVRNMNTL HLTH SPCT HLTH PRG MNGR I AUN06656 20 SHS000001132 ANTHONY DEBENEDETTO ENVRNMNTL HLTH SPCT HLTH PRG MNGR I AUN06656 20 SHS000002641 HEATHER MCALISTER HLTH PRG MGR II AUN09027 21 SHS000002653 DIANE BURKETT HLTH PRG MNGR III AUN04496 22 SHS000003061 STACY GREEN PROGRAM MANAGER I AUN06656 20 SHS000000040 BENJAMIN PALMER HEALTH PROG MNGR III AUN04774 22 SHS000002253 COURTNEY WARD OFFICE CHIEF TOBACCO ADMV OFCR IV AUN09005 23 SHS000003083 VACANT PROGRAM ADMINISTRATOR AUN06932 22 SHS000001928 SHARON JAYCOX CHRONIC DISEASE COMMUNITY COORDINATOR HLTH PRG MGR I AUN06656 20 SHS000001004 YANITZA SOTO COMMUNITY HEALTH WORKER PREVENTION HLTH PRG MNGR III AUN04496 22 SHS000002127 RJ SHANNON MINORITY LIAISON HS HLTH PLNG CONSULTANT AUN06838 20 SHS000002258 BABAK NAYERI ALZHIEMERS PROGRAM MANAGER II HS EXEC CONSULTANT II AUN05814 22 SHS000001069 VACANT EVALUATION MANAGER / EPIDEMIOLOGIST II 20 DAVID HEATH CHRONIC DISEASE PREVENTION SPECIALIST HS HLTH PRG MGR III AUN04496 22 SHS000002434 ANNA ALONZO OFFICE CHIEF CHRONIC DISEASE AUN04496 23 SHS000002645 OMAR CONTRERAS CHRONIC DISEASE PREVENTION SPECIALIST HS HLTH PRG MGR III AUN04496 22 SHS000002227 BUREAU CHIEF AUN03932 26 SHS000001605 WAYNE TORMALA SHEILA SJOLANDER ASSISTANT DIRECTOR PUBLIC HEALTH PREVENTION SERVICES CARA CHRIST DEPUTY DIRECTOR PUBLIC HEALTH SERVICES WILL HUMBLE DIRECTOR ARIZONA DEPARTMENT OF HEALTH SERVICES BYRON HOMER FISCAL MANAGER HS ADMV SVS OFR III AUN04638 22 SHS000002082 KAREN BOSWELL OFFICE CHIEF OPERATIONS AUN07388 24 SHS000002216 CURRENT 9-15-2014 Bureau of Tobacco and Chronic Disease DEBRA REARDON PRG IMPROVEMENT COORD HEALTH PRG MNGR II AUN09027 21 SHS000001818 TIANA GALINDO DATA INTEGRATION COORD HEALTH PROG MNGR II AUN09027 21 SHS000001819 CHELLY WEBER BUDGET ANALYST AUN04357 21 SHS000002357 ANN GARDNER HIV TESTING/LINKAGE TO CARE COORD HEALTH PRG MNGR II AUN09027 21 SHS000002664 JOHN SAPERO OFFICE CHIEF HIV PREVENTION SERVICES AUN06750 23 SHS000000548 9/15/2014 INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 FALL 2009 2014 FIGURE 13: BTCD ORGANIZATIONAL CHART INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 FALL 2009 2014 TABLE 2: PROP 200 EXPENDITURES AND CONTRACTS PROJECTS EXPENDITURES FY13 EXPENDITURES FY14 Local Partners Apache County $144,081 $173,390 Cochise County $312,922 $275,803 Coconino County $340,523 $351,827 Gila County $137,529 $125,920 Graham County $111,244 $120,730 Greenlee County $59,559 $70,837 $165,113 $118,817 $1,702,939 $2,348,730 $91,663 $129,588 Mohave County $336,725 $346,487 Navajo County $163,863 $161,860 Pima County $955,146 $1,052,501 Pinal County $320,294 $348,368 Yavapai County $281,075 $341,883 Yuma County $257,918 $265,109 $5,380,594 $6,231,850 Administrative $381,383 $791,171 Community Outreach $185,857 $85,778 $56,606 $31,532 $636,904 $231,130 $3,191,668 $3,329,409 $452,805 $11,581 $3,855,246 $3,746,078 $14,141,063 $14,458,529 La Paz County Maricopa County Mariposa Community Hlth Cntr Total Local Partners Evaluation Licensing – Empower Marketing and Communication Native American Outreach Statewide Projects Total Tobacco Expenditures Table 2: BTCD expenditures and contracts from Prop 200 funds, FY 2013-14 29 INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 SERVICES FALL 2014 2009 TABLE 3: PROP 303 EXPENDITURES AND CONTRACTS EXPENDITURES FY13 PROJECTS EXPENDITURES FY14 Local Partners Apache County $6,017 $1,720 $287,036 $20,121 Cochise County $13,997 $1,391 Coconino County $16,446 $14,659 $386,450 $24,780 Graham County $5,421 $228 Greenlee County $2,982 $1,851 La Paz County $6,130 $6,365 Lung- COPD $355,595 $149,882 Maricopa County $109,149 $53,874 Mohave County $14,203 $1,012 Navajo County $7,367 $247 Pima County $57,678 $6,547 Pinal County $7,644 $6,593 $12,993 $8,954 $6,146 $962 $1,295,254 $299,186 Administrative $211,929 $386,865 Community Outreach $131,128 $186,791 $42,932 $13,693 Health in Arizona Policy Initiatives $439,468 $439,468 Healthy Arizona Worksite Project $184,860 $275,567 Marketing and Communication $492,177 $134,397 Statewide Projects $542,513 $384,449 $3,340,261 $2,120,416 Breast Cancer Screening Colorectal Cancer Screening Yavapai County Yuma County Total Local Partners Evaluation Total Chronic Disease Expenditures Table  3:  BTCD  expenditures  and  contracts  from  Prop  303  funds,  FY  2013-­‐14 30 INVESTOR DEPARTMENT ARIZONA NEWSLETTER OF ISSUE HEALTH N°3 SERVICES FALL 2014 2009 TABLE 4: FEDERAL EXPENDITURES AND CONTRACTS EXPENDITURES FY13 PROJECTS EXPENDITURES FY14 ADMINISTRATIVE $648,742 $503,247 COMMUNITY OUTREACH $528,960 $384,297 $0 $0 MARKETING AND COMMUNICATION $186,382 $439,468 NATIVE AMERICAN OUTREACH $171,422 $144,052 STATEWIDE PROJECTS $539,839 $633,429 $2,075,345 $2,057,895 EVALUATION TOTAL FEDERAL EXPENDITURES Table  4:  BTCD  expenditures  and  contracts  from  federal  funds,  FY  2013-­‐14 TABLE 5: COMMUNITY OUTREACH AND PROJECT VENDORS Community Outreach Vendors, FY13 Community Outreach Vendors, FY14 Asian Pacific Community in Action Campesinos Sin Fronteras Inter-Tribal Council of Arizona La Paz Regional Hospital Tanner Corporation Development Community Pima Prevention Partnership Asian Pacific Community in Action Campesinos Sin Fronteras Inter-Tribal Council of Arizona La Paz Regional Hospital Hopi Tribe and Kaibab Paiute Tribe Tanner Corporation Development Community Pima Prevention Partnership Statewide Projects Vendors, FY13 Statewide Projects Vendors, FY14 AHCCCS Attorney General Office BeBetter Networks Health Care Excel Quality Quest University of Arizona Pima Prevention Partnership Community Bridges AHCCCS Attorney General Office University of Arizona Health Care Excel Quality Quest Pima Prevention Partnership Community Bridges 31 ARIZONA DEPARTMENT OF HEALTH SERVICES 2014 Celebrating our Past and Present…..Embracing Our Future! Thanks to the combined efforts of our many partners at the local, state, and national levels, we stand proud of our efforts to build on the successes of the past as we put forth many new initiatives over the past 2 years. At a time when the prevalence of tobacco use was at a standstill across the nation, we embraced the fact that continued improvements in the health of Arizonans would require new ways of thinking and doing, with several milestones being achieved: Tobacco Prevalence Continued to Drop! Arizona continued to make strides in lowering tobacco use among both adults and youth. CDC released findings indicating a drop in adult use from 19% to 17%, which translates to over 72,000 Arizonans quitting tobacco use. Even more profound, youth prevalence fell from 17.3% to 14.1%, for an estimated 110,000 fewer smokers today than four years ago. Such reductions translate into tens-of-millions dollars saved in healthcare costs and work productivity. Centers for Medicare and Medicaid Services (CMS) Reimbursement. The Bureau of Tobacco & Chronic Disease secured federal participation in the partial funding of quitline expenditures, allowing Arizona to a claim 50% administrative match for services to Medicaid (AHCCCS) members. Arizona was only the 10th state to receive approval from the Centers for Medicare and Medicaid Services and can use the funds to extend tobacco cessation services to the Medicaid population while at the same time bolstering the long-term sustainability of tobacco control. STAND (Students Taking a New Direction). STAND conducted its first legislative day in March, 2014. Over 300 students from across Arizona met at the State Capitol to showcase their efforts to prevent and reduce tobacco use among youth, and eliminate exposure to secondhand smoke. Joined by the Office of the Attorney General, Arizonans Concerned About Smoking, American Heart Association, American Cancer Society Cancer Action Network, and American Lung Association, STAND ranks among the nation’s largest and most organized youth-driven efforts in reducing the health and cost burdens of tobacco use. Youth Cessation. In July, 2013, the Bureau of Tobacco & Chronic Disease premiered CIGNAL, the first youth cessation quitline in Arizona. This pilot program targets smokers who are 15-26 years of age, the program utilizes college age, trained quit coaches to help young people quit before they develop lifelong addictions. ASHLine Re-Organization. To maximize program scalability, sustainability, and the overall public health impact of cessation services, the University of Arizona, Canyon Ranch Center for Prevention and Health Promotion, implemented a comprehensive re-organization of the ASHLine to improve its overall capacity to engage health plans and other payers of tobacco cessation services. Tobacco and Behavioral Health. Arizona has been among the nation’s leaders in addressing the high prevalence of tobacco use among people with a mental illness. By training behavioral health professionals and establishing systems linkages between clinical providers and the ASHLine, referrals from behavioral health locations have skyrocketed, and the “quit rate” among people living with a serious mental illness is now on a par with the general population; a feat that was considered “impossible” by national tobacco control authorities just two years ago. Today, while we recognize success on many levels, and Arizona has retained its position as one of our nation’s leaders in tobacco control, the ADHS Bureau of Tobacco & Chronic Disease remains committed to its core concern: Too many Arizonans will suffer needlessly and die prematurely as a result of tobacco use! Working alongside our many partners across the state, a recently-formed Sustainability Work Group, and the oversight of the TRUST Commission, we are confident that further reductions in tobacco use among adults and youth across all populations will be reported, and that lower disease and financial burdens of tobacco use will be self-evident! Wayne Tormala, Chief Arizona Department of Health Services Bureau of Tobacco & Chronic Disease October 2014 32