TOBACCO USE IN RURAL AREAS
by Stacey Stevens, Brian Colwell, and Linnae Hutchison
One Healthy People 2010 goal is to reduce illness, disability, and death related to tobacco use and exposure to secondhand smoke.1 Tobacco use shared a sixth-place ranking among the Healthy People 2010 focus areas in terms of rural health priority rating, selected by an average of 26 percent of four groups of rural health leaders across the states.2
This summary addresses the following Healthy People 2010 objectives:
Seven basic components of community tobacco control have been identified. These include surveillance, problem assessment, legislation, health department and community-based programs, public information campaigns, technical information collection and dissemination, and coalition building.15 While interventions have been conducted in rural communities, applicability and feasibility of implementation in other rural communities is not known.
There is a clear difference in tobacco use prevalence among those living in rural versus urban areas, whether the individual is an adolescent, adult, or pregnant woman. Higher tobacco use in rural areas will eventually lead to increased mortality rates and to higher numbers of people with health problems that rural areas are ill equipped to handle. Past research has shown that education, enforcement of existing laws, product labeling, and anti-tobacco advertising campaigns may reduce tobacco use. More research is needed to understand the factors that contribute to higher prevalence of both smoke and smokeless tobacco use in rural areas and to understand how to effectively intervene with rural populations.
The following models for practice are examples of programs utilized to address this rural health issue.
1.
2. Gamm, L.; Hutchison, L.; Bellamy, G.; et al. Rural healthy people 2010: Identifying rural health priorities and models for practice. Journal of Rural Health 18:9-14, 2002.
3. Office of Applied Studies. National Household Survey on Drug Abuse Advance Report. 1995. <http://www. samhsa.gov/oas/nhsda/ar18t039.htm>August 10, 2001.
4.
Eberhardt, M.S; Ingram, D.D.; Makuk,
D.M; et al. Urban and Rural Health Chartbook.
5.
6.
Boyle, R.G.; Stilwell, J.; Vidlak, L.M.; et al.
“Ready to quit chew?” Smokeless tobacco cessation in rural
7. Kendell, N. Medicaid and indigent care issue brief: Youth access to tobacco. Issue Brief Health Policy Tracking Service, 2000, 1-32.
8.
16.
<http://www.healthypeople.gov/LHI/>2002.
17. McGinnis, J.M., and Foege,
W.H. Actual causes of death in the
Stevens, S.; Colwell, B.; and Hutchison, L.
(2003). Tobacco Use in Rural Areas. Rural
Healthy People 2010: A companion document to Healthy People 2010. Volume 1.
MODELS FOR PRACTICE
FOCUS AREA: TOBACCO USE
Program Name: Stickers-Suckers-Smokers Pregnancy Tobacco Cessation Program
Location:
Healthy People 2010 Objective: 27
Web Address: http://www.rmhp.org
Smoking
is associated with low birth weight infants and preterm deliveries.
Stickers-Suckers-Smokers Pregnancy Tobacco Cessation Program is a collaborative
effort to reduce the incidence of smoking-related preterm births and low birth
weight infants in rural
Blueprint: The program represents a collaborative effort between Rocky
Mountain Health Plans, Rocky Mountain Health Foundation (RMHF¾a 501[c][3]), Hilltop Community Resources B4 Babies and Beyond
program, Mesa County Tobacco Education Coalition (MCTEC), and March of Dimes.
The core staff consists of a Rocky Mountain Health Plans care coordinator and
obstetrics (
The program provides assessment, education, and incentives for patients. Caregivers get educational information, a chart sticker program that identifies smokers for follow-up and tracking, and “train-the-trainer” educational programs. Pregnant women who smoke are identified, through entry into the B4 Babies and Beyond program, by health care providers and by RMHP OB screeners.
Pregnant women who smoke and agree to participate in the program receive one-on-one assessment of stage and counseling at the point of entry (physician office, B4 Babies, or RMHP). They are sent quit kits, and their primary care providers are notified of the patient’s participation. The primary care providers play a vital role as screeners, educators, counselors, and supporters by closely tracking the patient’s progress at each prenatal visit.
One strength of the program is providing care providers with the tools to screen and counsel patients. Counselors and providers use the 5A’s Method (Ask, Advise, Assess, Assist, and Arrange) to help patients to quit or reduce smoking. Prochaska stages of change modified for pregnancy is also used.
Making a
Difference: Birth certificate data
from 2001 in
To
date, 570 prospective clients have been seen, and 213 smokers have been
identified. Of those, 100 clients agreed to enroll in the program. Of the 100
clients, 16 percent agreed to either quit or reduce their cigarette use to under five per day. The low birth weight rate in
Beginnings: Rocky Mountain Health Plans
spearheaded the development of the smoking cessation program for pregnant women
in
The program is funded through a variety of sources. The Rocky Mountain Health Foundation obtained a grant from the March of Dimes to fund the program initially. Community businesses and organizations have also contributed to maintaining the program’s success.
Challenges and Solutions: Although the program has completed Year One, plans are underway to expand the program’s services and service area. The program hopes to expand the smoking cessation program to two additional counties.
The program has also expanded to include a dental care component specifically for pregnant women. Evidence indicates that there is a link between periodontal disease and preterm labor. Pregnant women can receive no-cost to reduced-cost dental care through the Marillac Dental Clinic.
The
program is publicized through word of mouth, brochures, community programs, and
presentations by the Rocky Mountain Health Plans case manager. She has presented
to the Colorado Care Council, a statewide organization composed of
obstetricians, perinatologists, neonatologists,
and related practitioners.
Janice Ferguson, RNC, Rocky Mountain Health Plans Perinatal Care Coordinator
Stickers-Suckers-Smokers Pregnancy Tobacco Cessation Program
Rocky Mountain Health Plans
Phone: (970) 244-7890
Fax: (970) 248-5012
E-mail: jferguso@rmhp.org
MODELS FOR PRACTICE
FOCUS AREA: TOBACCO USE
Program Name: Too Smart to Smoke Tobacco Prevention Campaign
Location:
Problem Addressed: Tobacco Use
Healthy People 2010 Objective: 27
Web Address: http://www.nchsi.org
The
vision of the Health and Traffic Safety Coalition for
Blueprint: The tobacco prevention program is spearheaded by
NCH provides a significant amount of funding and in-kind support in the form of space, supplies, supervision, and program administration. Funding is also through the Vermont Department of Health first from Centers for Disease Control (CDC) money that came to the state and since 2001, tobacco settlement money.
The goals of the program are to:
These goals are congruent with Healthy Vermonters 2010. To accomplish these goals, a variety of cessation and prevention strategies are used, aimed at changing perceptions regarding tobacco use.
The following list of events and programs are used in tandem to meet the objectives:
· recruitment of local youth and adults to write and record tobacco prevention messages that are aired on local radio stations;
· a youth summit, youth and family day sponsorship;
· poster contests in all elementary schools;
· anti-drug theatre productions at local schools;
· a “Clear the Air” program aimed at reducing exposure to second-hand smoke in the area;
· a Focus on Life photo workshop where teens learn the basics of picture-taking while focusing on healthy lifestyles. The photos are then exhibited for public viewing throughout the area; and
· support of healthy youth behaviors, such as community winter carnivals, school/community dinner dances, scholarships for local summer camps, wilderness camps and teen leadership workshops, and school projects that focus on healthy hearts, aerobic exercise, and not using tobacco.
Each of these activities is a collaborative effort between the Tobacco Prevention Program and various community members. The program attributes its success to a strong sense of cooperation and collaboration held in this rural area.
Making a
Difference:
In
1999, the state’s estimated smoking rate among eighth and twelfth graders was
22 percent and 42 percent, respectively. At the same time, twelfth graders in
two of the three school districts in
Data
from 2001 revealed significant progress toward smoking cessation in not only
These data indicate that rates of smoking for twelfth graders in these two counties have significantly declined from 1999 to 2001; rates among eighth graders reveal mixed results. Adult rates have declined as well.
In
designing the various programs and events, program organizers also consider the
Developmental Assets as one mechanism to improve program effectiveness. The
Developmental Assets were developed by the Search Institute and are now used by
the state of
Beginnings: The Health and Traffic
Safety Coalition for
NCH
provided tobacco prevention/cessation assistance through its
Challenges and Solutions: The primary challenges to the HTS ONE coalition are continued funding. As the program has expanded, funding has expanded from both the national level as well as the local level, including grants from NCH and HTS ONE. The program utilizes a variety of communication channels to disseminate information on the program including newspapers, newsletters to students, press releases, radio, and informational booths at numerous community events.
Joanne Fedele, RN, MS, Community Health Planner
Too Smart to Smoke Tobacco Prevention Campaign
Phone: (802) 334-3208
MODELS FOR PRACTICE
focus area: TOBACCO USE
Program Name: Tobacco Intervention and Prevention Strategy
Location: Prosperity,
Problem Addressed: Tobacco Use
Healthy People 2010 Objective: 27
Web Address: Under Construction
Tobacco
Intervention and Prevention Strategy (TIPS) is a tobacco education, prevention,
cessation, policy development, and community empowerment program implemented in
rural
Blueprint: The Tobacco Intervention and Prevention Strategy program is multifaceted and delivered in a variety of settings including worksites, schools, the health department (during prenatal and Women, Infant, and Children [WIC] program visits), and the physician’s office. TIPS is a coalition between the Lovelace Family Medicine Practice and the South Carolina Department of Health and Environmental Control (SC DHEC). Community empowerment is achieved through the development of a TIPS task force, which is comprised of local community leaders. The program is designed around the Stages of Change Theory and Clinical Practice Guidelines. The components of TIPS include smoking cessation, education, and prevention; policy development and change; and community empowerment.
The program office is located in the Lovelace Family Medicine Practice. Staffing includes one full-time program manager, and Dr. Lovelace acts as the principle investigator. Volunteer and donated staff are also utilized. The program manager, office space, computer equipment, and telephone lines are provided as an in-kind donation by the Lovelace Family Medicine Practice. As a 501(c)(3) organization, the program is eligible to receive funding from a variety of sources, including its original funder¾the Lovelace Family Medicine Practice, as well as the South Carolina Department of Health and Environmental Control, the American Cancer Society, the March of Dimes, the Tobacco Free Midlands Coalition, and various pharmaceutical companies and community members.
The
program is designed as a comprehensive approach to combating tobacco use.
Smoking cessation interventions include the Stages of Change assessment, health
education, stress management, and behavior modifications. Worksite and prenatal
cessation is a primary focus of the cessation component. Free bassinets (paid
for by a grant from the March of Dimes) are provided to pregnant women who
complete the program. Smoking prevention is delivered through strategies
targeting youth and adolescents, including programs such as the National Lung
Association’s NOT (Not on Tobacco) program and Tar Wars (a program endorsed by
the
Making a Difference: Both process and outcome measures are utilized to determine the program’s effectiveness. During workshops, presentations, and training events, participants are given evaluation forms that include qualitative and quantitative questions. Data on participant demographics, opinions, program delivery, and logistics are collected at each activity.
Beginnings: Dr. Oscar Lovelace, MD, an
established
The program was developed to respond to the county’s
alarming tobacco use statistics when compared to state data. The smoking rate
for
Challenges and
Solutions: Transportation is a hurdle that is overcome by delivering
the program to the people in worksite, school, and community settings.
Enlisting the help of other physicians requires the program manager to build
relationships with providers. The
The program manager acts as the community liaison and is responsible for community awareness. In addition to local newspaper advertising, billboards, and public service announcements to the community, TIPS is promoted at the state and national levels through abstracts, policy papers, and a policy advocacy video. Dr. Lovelace also promotes the program through presentations at the state level.
The program received the National Tar Wars Star Award
through the
Renee Martin, TIPS Project Coordinator
Tobacco Intervention and Prevention Strategy
Phone: (803) 364-1011 ext. 197
Fax: (803) 364-2014