Tobacco Use is a Tremendous Burden to All Texans
Tobacco use is the leading cause of preventable disease and death in Texas. Smoking-related illnesses cause more deaths than alcohol, car accidents, illegal drugs, suicides, homicides, driving while intoxicated, and fire – combined.
Every year more than 24,100 Texans die from a smoking-related illness such as cancer or cardiovascular and respiratory disease. Tobacco use is responsible for a wide range of other health conditions. Cigarette smoking causes many diseases and affects every organ of the body. It is estimated that in 2005, more than 27,000 Texans were diagnosed with tobacco-related cancers and approximately 17,800 Texans died from tobacco-related cancers, including acute myeloid leukemia and cancers of the lung, oral cavity and pharynx, esophagus, bladder, pancreas, kidney, cervix and stomach. The number one cause of cancer deaths among Texas men and women is lung cancer. More than 90% of lung cancers in men and 90% of all esophageal cancers are due to tobacco use.[4, 5]
Tobacco use is a major contributor to chronic lung disease. During 2005 there were 26,718 hospitalizations due to chronic lung diseases such as asthma, chronic bronchitis and emphysema in Texas. An estimated 80% - 90% of all these deaths are due to smoking.
Secondhand Smoke is a Health Threat to Nonsmokers
Secondhand smoke hurts the young, the old and everyone in between. Consider the following facts:
- Secondhand smoke contains more than 4,000 chemicals, and 69 of them are known to cause cancer. 
- Secondhand smoke is associated with an increased risk for lung cancer and coronary heart disease in non-smoking adults.[7, 8]
- Because their lungs are not fully developed, young children are more vulnerable to secondhand smoke. Children who are exposed to secondhand smoke early in life are at greater risk for asthma, middle ear infections, bronchitis and pneumonia and have an increased risk of cancer. Exposure to secondhand smoke is also associated with sudden infant death syndrome (SIDS) 
- The most common source of children’s exposure to secondhand smoke is parental smoking in homes and in cars.
- Documented health risks of persistent smoke exposure in the home have recently led courts to take parental smoking into account in custody and visitation disputes. Arkansas, California and Louisiana have enacted legislation prohibiting smoking in vehicles when a child is present.
Health Effects of Tobacco Use Not Limited to Cigarette Smoking
While the general health risks associated with cigarettes are widely known, many other tobacco products are marketed and sold, and tobacco companies are constantly developing new products to attract new users, lower the perception of risk and circumvent clean air policies. However, all tobacco products are harmful.
- Cigars, hookahs (water pipes), and smokeless tobacco – such as chewing tobacco, snuff and snus (hard snuff) – also contribute to poor health. Smokeless tobacco is associated with tooth discoloration and decay, of gum recession, periodontal disease and bad breath.
- Studies have linked smokeless tobacco use to cancers of the mouth or oral cavity. [12,13,14]
- More recent research suggests a link between snus, a smokeless tobacco product, and pancreatic cancer. 
- Smoking marijuana is not a safer alternative to cigarette smoking because it causes more severe respiratory effects than those caused by tobacco.
Tobacco Use Costs Texas Businesses and Taxpayers Money
In 1999, tobacco-related diseases cost the state approximately $10 billion ($4.5 billion in direct medical costs and an additional $5.5 billion in lost worker productivity). In 1998, about 15% ($1,265,000,000 or $543.87 per recipient) of all Medicaid expenditures were spent on smoking-related illnesses and diseases. 
Investment in Community Tobacco Control Saves Money
A 2006 report estimated that Texas could achieve significant cost savings by funding comprehensive tobacco prevention and control programs at levels recommended by state researchers. The study examined actual smoking-related costs from a Kaiser Permanente database of 440,000 smokers to estimate the potential savings.
The study concluded that a comprehensive tobacco prevention and control program would achieve almost a 40:1 return on investment over a five-year period. Savings would accumulate over time. Nonsmokers would stay healthy, and smokers who quit would be healthier, preventing costly medical care and productivity losses.
The Big Picture – Ending the Tobacco Use Problem
In 1998, strategies for addressing the tobacco use problem changed dramatically when Texas and other states reached court settlements with the tobacco industry over the costs incurred to treat tobacco-related illnesses. In many states and in selected areas of Texas, these settlements were used to create successful comprehensive tobacco control programs.
The Texas Legislature set aside a portion of the settlement money to fund tobacco prevention and control programs and instructed the state health department to determine the most effective way to use the limited funds, which were not enough to provide programs statewide. The Texas Department of Health (now Department of State Health Services) formed the Texas Tobacco Prevention Initiative to conduct a pilot study. The researchers determined that the population in southeast Texas experienced the greatest incidence of tobacco-related illnesses, such as heart disease and lung cancer. The project then tested varying levels of tobacco prevention and control programs in pilot sites selected from this region. The area that received the most comprehensive programming demonstrated significant reductions in tobacco use; partial and low-intensity programs did not yield results. Therefore, DSHS established a comprehensive tobacco prevention and control program in Beaumont/Port Arthur, the area of greatest need.
States that made larger investments in comprehensive tobacco programs have seen cigarette use drop more than twice as much as the national rate. At the same time, lung cancer and heart disease rates have dropped proportionately. The mission of the Texas tobacco prevention and control program is to create healthy communities by expanding comprehensive programs through coalitions that will leverage local resources and sustain the effort. The end result is not only healthier Texans, but also cost savings to businesses and taxpayers.
DSHS Tobacco Prevention and Control Program Strategic Plan Goals
- Prevent tobacco use among young people.
- Ensure compliance with state and local tobacco laws with adequate enforcement.
- Increase cessation among young people and adults.
- Eliminate exposure to secondhand smoke.
- Reduce tobacco use among populations with the highest burden of tobacco-related health disparities.
- Develop and maintain statewide capacity for comprehensive tobacco prevention and control.
Laws Regulate Access to Tobacco Products
In July 1992, Congress enacted a law that included an amendment aimed at decreasing access to tobacco products among individuals under age 18. Texas’ Senate Bill 55, one of the strongest and most comprehensive youth-access-to-tobacco laws in the nation, went into effect in 1997. The Synar Amendment required all states to have laws in place prohibiting the sale and distribution of tobacco products to persons under 18 and to enforce those laws effectively. Texas tobacco law restricts minors’ access to tobacco products and provides penalties to youth who possess tobacco products and retailers who sell to underage youth. Under the Synar Amendment, states can also be penalized if the rate of retailer sales to minors rises above 20 percent a year. Texas has made great strides in reducing retailer violations. In 1996, before SB 55 went into effect, the state rate of illegal sales to minors was 56%. In 2006, the Texas retailer violation rate was 7%.
Building Healthy, Tobacco-Free Communities
Healthy, tobacco-free, communities don’t just happen. Research has identified evidence-based strategies and processes that build healthy communities – areas where tobacco use is less desirable, less accepted and less accessible. These strategies include comprehensive tobacco prevention and control programs and a public health approach called the Strategic Prevention Framework (SPF).
Comprehensive Tobacco Prevention and Control Programs
A comprehensive tobacco prevention and control program is a coordinated effort to establish smoke-free policies and social norms, to promote and assist tobacco users to quit, and to prevent initiation of tobacco use. This approach combines educational, clinical, regulatory, economic and social strategies. 
Comprehensive programs include five basic components:
- State and community interventions
- Health communications
- Cessation services
- Surveillance and evaluation
- Administration and management
A single organization can create a comprehensive program, or it can result from independent activities conducted by different groups working in together toward a common goal.
Research shows that laws and policies in a comprehensive tobacco prevention and control effort are effective in the following ways:
- protecting the public from secondhand smoke
- promoting cessation
- preventing initiation
- providing insurance coverage for tobacco use treatment
- limiting minors’ access to tobacco products
Research also shows greater success when partners work together to influence social norms, systems and networks.
State and community interventions include programs and policies that create environments supporting tobacco-free norms. The “social norm change” model assumes that long-lasting change occurs through shifts in the social environment at the grassroots level across communities. State and community interventions unite a range of program activities, including local and state policies and programs, initiatives to prevent and reduce chronic disease and tobacco-related health disparities, and activities to influence youth.
Health communications deliver strategic, culturally appropriate, and high-impact messages in sustained and adequately funded campaigns to support and complement tobacco control efforts. Communications strategies use a wide range of tactics, including paid television, radio, billboard, print and web-based advertising; media advocacy through press releases, local events, media literacy education, and health promotion activities; and efforts to reduce or replace tobacco industry sponsorship and promotions. Messages should focus on high-risk audiences. Target audiences should participate in message development and distribution through appropriate channels.
Cessation services include a broad array of policy, system, and population-based measures. Initiatives should insure that all patients seen in health care systems are screened for tobacco use, receive brief interventions to help them quit, and are offered more intensive counseling services and FDA-approved cessation medications. Quit line counseling should be made available to all tobacco users willing to access the service. Quit lines are effective and have the potential to reach large numbers of tobacco users. Quit lines also serve as a resource to busy health care providers who provide the brief intervention and discuss medication options and then link tobacco users to quit line services for more intensive counseling.
Evaluation and surveillance is the process of monitoring tobacco-related attitudes, behaviors, and health outcomes at regular intervals. Statewide surveillance should monitor the achievement of overall program goals. Evaluation is used to assess the implementation and outcomes of a program, increase efficiency and impact over time, and demonstrate accountability. A comprehensive state tobacco prevention and control plan – with well-defined goals, objectives, and short-term, intermediate and long-term indicators – requires appropriate surveillance and evaluation data systems. Program results are measured by comparing baseline data for each objective and performance indicator to similar data at a later point in time. Surveillance and evaluation systems must have high priority in the planning process.
Administration and management is essential for program sustainability, efficacy and efficiency. Sound fiscal management is critical since substantial funding is needed to implement effective tobacco prevention and control programs. Sufficient capacity enables programs to plan their strategic efforts, provide strong leadership, and foster collaboration between state and local tobacco control communities. An adequate number of skilled staff is also necessary to provide or facilitate program oversight, technical assistance and training.
Strategic Prevention Framework
The Strategic Prevention Framework is a five-step planning process used by community coalitions to develop the infrastructure required to support community-based public health approaches to tobacco prevention and control. This framework is supported by three core concepts that bind the planning process to community realities: tobacco-related heath disparities, cultural competency, and program sustainability. Addressing these core concepts in each step of the planning process helps assure that the outcomes of the coalition’s processes are broad-based, far reaching, encompass input from the community and are designed to have lasting effects.
Community level tobacco prevention and control coalitions operate within a context of individuals, families, peer groups, organizations, businesses and political systems. No single individual and no single organization has the capacity to create or sustain the level of changes needed to create healthy communities. Successful community programs are not one-shot events – they are built over a period of time through a process that is strategic and builds community infrastructure.
The National Coalition Institute defines a coalition as a formal arrangement for collaboration among groups in which each keeps its own identity but all agree to work toward a common goal. Implementation of effective, population-based community initiatives requires collaboration across a broad range of community sectors. Underlying each step in the strategic prevention framework are the core concepts of eliminating tobacco-related health disparities, cultural competency and sustainability.
Tobacco-Related Health Disparities
Health disparities are differences in the health status and outcomes among different population groups when compared to the general population. Several factors influence health disparities. These factors can include barriers to access of health services, age, gender, language, economic and social inequities, inequitable distribution of health care resources, and insensitivity to the health care concerns that arise in special populations, such as sexual minorities or people with disabilities. Other issues that influence tobacco-related health disparities include disproportionate tobacco use among certain populations, as well as tobacco industry marketing that targets specific populations.
Tobacco-related health disparities can be further defined as the differences among populations in the 1) patterns of tobacco use, 2) access to prevention and treatment for tobacco-related illnesses, 3) and protection by environmental smoking policies in public places and at the worksite. These differences frequently result in higher medical care costs for the public and a lower quality of life for the affected populations.
To eliminate tobacco-related heath disparities, a community coalition must first identify the disparities as well as the community assets that can be used to address them. A comprehensive and strategic plan to address tobacco-related health disparities should include:
- Assessment Although addressing diversity within the coalition is important, addressing tobacco-related health disparities requires a deeper look into who is really most burdened by tobacco use, exposure and the context of that tobacco use and exposure. Some disparities will be hard to document and others will require resources to address them that are not currently developed in the community.
- Capacity Building Community involvement strategies which are diverse and culturally competent engage the affected population from the beginning. Interventions will be more successful when the affected populations are empowered to make change happen from assessment to evaluation. Educating the coalition as well as affiliated agencies on tobacco-related health disparities is vital.
- Strategic Planning Developing a strategic plan involves documenting the tobacco-related health disparities and prioritizing strategies to address them. Strategies must consider the differing capacities, assets and resources that facilitate successful implementation as well as any barriers that need to be overcome. The strategic plan should describe the kinds of programs and communications that are successful at creating change in the affected communities.
- Implementation Evidence-based strategies must be adapted to reach disparate population groups.
- Evaluation The community coalition must evaluate appropriate goals and effective strategies to reduce tobacco-related health disparities. Appropriate goals and objectives should be clearly defined, specific, measurable and attainable for reducing disparities in tobacco-related health status and outcomes.
Cultural Competency for Community Coalitions
As our world expands and health disparities grow, it is important that community coalitions are culturally competent. Tobacco prevention and control coalitions work by influencing the social norms of a community and those norms are driven by culture. Culture shapes how people see their world and participate in community and family life. Broader than race and ethnicity, culture can include geography, lifestyle, age, disabilities, religious affiliation and any other characteristics that affect attitudes and beliefs toward tobacco use.
Cultural competence refers to the blend of academic and interpersonal skills that foster understanding and appreciation for cultural differences and similarities between groups. It is the knowledge, awareness, sensitivity, and skills individuals and organizations need to operate effectively and respectfully for the benefit of the entire community. Neither a one shot class nor a single policy can instantly make a coalition culturally competent.
The National Coalition Institute suggests key strategies for creating culturally competent coalitions:
- Invest time and resources in training staff and volunteers in cultural competence Carefully examine population structure, practices and policies to ensure that these elements truly facilitate effective cultural interactions
- Display respect for differences among cultural groups
- Expand cultural knowledge and pay attention to the dynamics of culture
- Solicit advice from diverse communities regarding all activities
- Hire employees who respect unique aspects of different cultures
Coalitions that operate with these principles can have a powerful influence on the level of cultural competence of the individuals and member organizations that are involved. The institute also suggests these guidelines:
- Culture first, last and always Culture has an impact on how a person thinks, believes and acts. Acknowledge culture as a predominant and effective force in shaping behaviors, values and institutions.
- One goal—many roads Every group has something to share. Acknowledge that several paths can lead to the same goal.
- Diversity within diversity Recognize the internal diversity and complexity of cultural groups. Remember that one individual cannot speak for all.
- People are unique People have both group and personal identities. Acknowledge group identities and treat people as individuals.
- Viewpoint shift The dominant culture serves the community with varying degrees of success. Acknowledge that what works well for the dominant group may not serve members of other cultural groups. Try viewing issues from alternative viewpoints.
Securing the resources and support to accomplish the work of the coalition –human, social and material resources - needs to begin immediately and continue throughout the life of the coalition. This also applies to communities lucky enough to have received seed money need to plan for sustainability. Regardless of how much funding is available in the early stages, it will eventually be used up. Changing priorities and other life events will also take a toll on even the most dedicated coalition leaders and members. Effective coalitions understand that recruiting and engaging new members must become an “obsession”. If the problem is important enough to address it is just as important to maintain the effort until its goals can be achieved.
The first step in building sustainability is identifying what needs to be sustained. Sustainability is not just about money. Everything the coalition will need to achieve its goals, from space, time, technology and training, to public relations, information and technical assistance need to be assembled. Even if the coalition has substantial funds, some resources could be provided by member organizations with little or no financial burden. In-kind donations often serve a double value in sustaining efforts by reinforcing relationships among coalition partners.
Once it is clear what needs to be sustained, case-statements that clearly explain the importance of having organization around will help rally community support for your coalition’s efforts. Effective case statements:
- Are written in a style that you would use to explain an issue to a neighbor or friend
- Describe why the coalition exists
- Explain the value of the coalition to the community and the consequence of it going away
- Identify resources that are required for success
- Can be used repeatedly to spread the word about your group to potential donors, volunteers and partners
If the work of the coalition is perceived as being valuable to the community, resources will emerge. Building partnerships and leveraging resources are critical to not only promote a comprehensive approach, but also to achieve sustainability for long term reductions in tobacco use. Several Texas communities are leading the way in protecting their citizens and planning for sustainability. The Amarillo Hospital District is the first hospital district in the state to use its tobacco settlement funds for a comprehensive tobacco control program. This program has been in continuous operation since 2001. http://www.tfreeamarillo.com El Paso, through the Paso del Norte Health Foundation created a Smoke Free Paso del Norte as one of its primary funding priorities. http://www.pdnhf.org
The Strategic Prevention Framework Process
The Strategic Prevention Framework process is a community-based, public health approach used to develop the infrastructure for effective and sustainable reductions in tobacco use. Each stage builds upon another, and the entire process is built around the core concepts of tobacco-related health disparities, cultural competence and sustainability.
Texas Strategic Prevention Framework
Step 1 – Assessment Evaluators collect and review data from many sources to define the community’s tobacco-related problems, resources already in place to address them and additional resources that are needed. Data include tobacco use and lung cancer rates by various groups in the community, compliance with retailer and youth tobacco access laws, as well as secondhand smoke policies in schools, worksites, restaurants, bars and other public places. The sequence of actions in the assessment phase includes 1) collecting data to identify the problem of local tobacco use and tobacco-related health consequences, 2) identifying local resources to address the problems, 3) analyzing the data, 4) prioritizing tobacco-related problems and their causes, and 5) sharing the data.
Step 2 – Capacity Building To build capacity, the coalition must pool resources with community stakeholders who have the capability to address the tobacco use problems identified in the assessment phase. The coalition develops and strengthens partnerships and examines cultural competence. Training enhances the group’s capacity to develop and implement an effective community strategic action plan. The main elements of capacity building are 1) identifying capacity to address prioritized problems, 2) mobilizing community capacity, 3) reaching out to new partners and 4) nurturing members of the coalition.
Step 3 – Planning During the planning stage, the coalition creates logic models and selects evidence-based programs, practices and policies linked to each goal. They use this model to set goals and measurable outcomes as part of a strategic plan to address the problem(s) identified during the assessment phase. Planning includes 1) identifying and prioritizing factors contributing to the problem, 2) identifying specific goals, 3) establishing benchmarks, 4) expanding capacity to achieve the goals, 5) preparing an evaluation plan and 6) developing an implementation plan.
Step 4 – Implementation This stage involves putting the plan into action with evidence-based strategies that were identified in the planning stage. It also means documenting and measuring how the plan is carried out and how well it works, making course corrections as needed and finalizing the evaluation plan. The basic elements of this step include 1) carrying out planned services, 2) documenting what is done and 3) evaluating the implementation process.
Step 5 – Evaluation During this stage, the coalition measures what has been done and the effects it has had on the community. Evaluation findings tell us how programs, policies or practices might be improved to achieve better outcomes. Key activities under evaluation include 1) implementing the evaluation plan, 2) collecting data, 3) analyzing data, 4) reporting outcomes to create a common understanding of what the numbers mean and 5) using the evaluation outcomes to make needed changes in programs, activities and services. For more information on the Strategic Prevention Framework contact firstname.lastname@example.org.
Tools & Quick Tips
Milestones In Community Tobacco Prevention & Control
Community tobacco prevention and control is a marathon – not a sprint. The first few months need to be spent building the community infrastructure for creating change. The coalition needs to invest time in collecting local data to inform future program development, as well as identifying volunteers and community partners and educating them on local issues in tobacco use prevention, cessation and policy development.
While timelines will vary by community the objective is to build an infrastructure and engage the coalition in development of products consistent with key steps in the strategic prevention framework. By the end of the first year the coalitions should have completed their community tobacco needs assessment; developed strategic program plans; and recruited, trained and organized local action committees.
|Step 1 Assessment
- Form community evaluation workgroup
- Conduct community needs assessment
- Analyze data
- Develop problem statements
- Identify possible geographical target areas & populations
- Report outcomes of community Needs assessment
- Clear, concise, data-driven problem statements
- Data sources
- Baseline gap analysis of community programs, resources and services
|Step 2 Capacity Building
- Create and develop partnerships
- Conduct meetings with stakeholders, service providers and potential coalition members
- Recruit & develop leadership
- Train to promote leadership, cultural competence and evaluation capacity
- Letters of agreement
- Members & stakeholder directory
- Organizational chart
- Membership plan & pitch by constituency
- Leadership development & cultural competency plans
|Step 3 Planning
- Conduct planning & strategy meetings
- Organize action teams
- Develop logic models from local data
- Draft 3-5 year strategic plan
- Review evidence-based interventions
- Create action & evaluation plans
- Logic models by goal
- Strategic plan
- Action plans by goal
- Measurable outcome objectives
- Evaluation plan
|Step 4 Implementation & Sustainability
- Action teams meet to
- Implement action plans by program goal
- Assemble materials for implementing evidence-based strategies, policies and practices
- Develop & implement sustainability plan
- Collect process data
- Evidence-based strategies, policies, programs & practices
- Process evaluation plan
- Sustainability plan
- Program/process documentation
|Step 5 Evaluation
- Consultations between coalition & community evaluation workgroup on initial outcomes
- Review & use process data to assess fidelity of implementation, develop recommendations
- Evaluation reports for internal & external audiences
- Recommendations to improve program delivery
Quick Tips for Community Tobacco Prevention and Control Coalitions
|Identify and collect non-traditional data to get a more complete & accurate understanding of tobacco use in your community.
||Use only the data you prepared in submitting an earlier grant proposal.
|Recruit new faces and build your coalition to include people representative of your community.
||Form your coalition with the “usual” agency partners.
|Collaborate with a broad range of partners, including non-health related organizations such as Texas County Extension Cooperatives or substance abuse prevention programs, employers, faith-based and civic organizations, law enforcement officers and educational institutions at all levels.
||Do it on your own.
|Contact your Regional Tobacco Coordinator for additional training and technical assistance. email@example.com.
||Assume that your coalition has all the knowledge and skills it needs.
|Contact your Regional Education Service Center School Health Specialist and Prevention Resource Center staff to find out how they can assist. firstname.lastname@example.org.
||Do it on your own.
|Use already developed, tested materials for community cessation and prevention activities.
||Create your own materials from scratch.
|Ask representatives of high risk groups to help tailor your programs to their peers.
||Approach high risk populations without an understanding of their culture and norms.
|Use evidence-based strategies and best practices in conducting prevention and cessation programs.
||Start coalition activities without reading the CDC’s 2007 Best Practices document.
|Work on creating change at local, city or community levels.
||Wait for changes from the state or national level.
|Appeal to employers, insurance companies and others in terms of their economic interests as well as the health benefits to their employees and policy holders.
||Base the appeal for tobacco prevention and control only on health improvement or disease reduction.
|Reach out with prevention and cessation programs to high risk populations.
||Focus prevention and cessation efforts only on “easy to reach” populations.
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- Miller L, Zhang X, Novotny T, Rice D, Max W. State estimates of Medicaid expenditures attributable to cigarette smoking, fiscal year 1993. Public Health Reports 1998;113(2):140–51
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- Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health; October 2007. Available at http://www.cdc.gov/tobacco/tobacco_control_programs/stateandcommunity/best_practices/index.htm
Developed by Sneden GG, Robertson TR, Loukas A, & Gottlieb NH Department of Kinesiology and Health Education University of Texas at Austin