COMMUNITY GRANTS PROGRAM

Transcription

1 OHIO DEPARTMENT OF HEALTH TOBACCO PREVENTION AND CONTROL PROGRAM COMMUNITY GRANTS PROGRAM Program Evaluation Report CYCLE III (Jan Dec, 27) Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

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3 ACKNOWLEDGEMENTS This report summarizes the tobacco prevention, cessation, and control activities provided across the state of Ohio by the grantees of the Community Grants Program (CGP) between January and December, 27. It is our hope that this report will provide the Ohio Department of Health with a comprehensive picture, based on substantive data, of what the Community Grants Program has accomplished and what it can be called upon to do in the future. We would like to thank the grantees for their willingness to embrace the statewide evaluation plan that was introduced for Cycle III in January 27. We were continually impressed with their dedication and passion for tobacco prevention and control in Ohio, and without their commitment to program fidelity, data collection and reporting, this report would not have been possible. We would also like to thank Dr. Jeff Willett and the OTPF staff for engaging us as true partners in the process of program development and evaluation. It has been an incredibly rewarding experience to observe the grassroots change that is underway in Ohio regarding this important public health issue and we are grateful to have been part of it. Finally, we would like to remind the readers of this report that the interpretations of data, conclusions, and recommendations expressed are those of the authors and may or may not represent the views of the Ohio Department of Health or those individuals and organizations that provided data. OTREC TEAM Elaine A. Borawski, Ph.D., Director, OTREC Erika S. Trapl, Ph.D., Project Director, OTREC Margaret Male, MPH Dana Jankus, MS Ebony Boyd, BS Ashley Brooks, MPH R. Scott Olds, HSD Danyel Savarda, MEd Nital Subhas, MPH ii Ohio Tobacco Research and Evaluation Center Case Western Reserve University 43 Euclid Avenue, Triangle Bldg. Cleveland, OH 446 (26) Copies of this report can be found on the following websites: Ohio Tobacco Research and Evaluation Center CASE Center for Health Promotion Research Suggested Citation: Borawski, E., Male, M., Brooks, A., Merritt, E., Jankus, D., Olds, RS., Savarda, D., Subhas, N., Trapl, E. 28. Evaluation of the Ohio Tobacco Prevention and Control Community Grants Program. 24 pages. Ohio Tobacco Research and Evaluation Center, Case Western Reserve University, Cleveland, Ohio.

4 TABLE OF CONTENTS iii Acknowledgement i Table of Contents ii iii Tables and Figures iv v Programmatic and Evaluation Overview Goal Area: Community Awareness Strategy : Community Leader Relations 2 23 Strategy 2 : Coalition Development Strategy 3: Local Tobacco Surveillance Goal Area: Cessation Strategy 4: Intensive Individual and/or Group Counseling Strategy 5: Policy and Brief Interventions Within Health Systems Strategy 6: Training Health Professionals in Brief Interventions Strategy 7: Employer Support of NRT Strategy 8: Promotion of Ohio Quits Strategy 9: Distribution of Quit Kits Goal Area: Prevention Strategy : Tobacco Free School Campus Policies 6 Strategy: & 2: School, Community & Online Youth Prevention Programming 7 26 Strategy 3: Training School Personnel in Prevention Curricula 27 3 Strategy 4 & 5: Establish and Support Local stand Teams 3 42 Goal Area: Secondhand Smoke Strategy 6: Tobacco Free Worksites Strategy 7: Outdoor Tobacco Free Environments 5 52 APPENDICES: A. G Wiz (workplan, activity report, progress report) B. OTREC DM: Instructions C. Youth Prevention Data Collection Forms (strategy ) D. Adult Cessation Data Collection Forms (strategy 4) E. Other Surveys F. Presentations G. Grantee Descriptions

5 Tables and Figures iv Strategy : Community Leader Relations.. Grantee Reach in Community Leader Relations Strategy in Grant Year Grantee Reach with Federal and State Officials in Grant Year 7 23 Strategy 2: Coalition Development 2.. Number of Coalitions Supported by a Single Agency Agency Role in Coalition at Beginning of Funding Year Status of Coalitions at Beginning of Funding Year Completion of Required Coalition Development at End of Funding Year Coalition Leader Representation Skills and Experience of the Coalition Coalition Written Plans Coalition Expectations Methods of Communication Organizational Climate Institutionalization and Sustainability 35 Strategy 3: Local Tobacco Surveillance 3.. Percentage of Adult Tobacco Use by Demographic Category Across Three Ohio Counties 4 Strategy 4: Intensive Individual and/or Group Counseling Cessation 4.. Characteristics of Cessation Counseling Participants Geographic Distribution of Adult Cessation Participants Cessation Program, Attendance, and Relapse Prevention Call Disposition of Follow Up Surveys Satisfaction with Programming at 3 and 6 month Post Initiation Agency Funding, Reach Success and Quit Rates 55 Strategy 5: Policy and Brief Intervention within Health Systems 5.. List of Local Health Systems Identified by Grantees by Types Types of Tobacco Related Policies and Interventions Provided by Each Health System Brief Interventions Within Health Systems: Program Reach by Grantee Strategy 6: Training Health Professional in Brief Interventions 6.. Number of Health Care Professionals Trained by Job Title Proposed Setting Where Trained Health Care Professionals Will Provide Brief Interv Trainees Comfort with the Brief Intervention Training Materials Provided Confidence of Trainees That They Could Successfully Implement the 5 A s Agency Funding and Reach Success 72 Strategy 7: Employer Support for NRT 7.. Grantees Efforts to Gain Employer Support for NRT Grantee Funding for Strategy 8 Strategy 8: Promotion of Ohio Quits No Tables or Figures for this Strategy

6 v Strategy 9: Distribution of Quit Kits 9.. Distribution of Quit Kits Training in Quit Kits Fax Referrals Strategy : Tobacco Free School Campus Policies.. Percent Change Over Time of Tobacco Free School Policy Work from Advocacy to Adoption and Implementation, and Enforcement 3.2. Stakeholder Involvement in Tobacco Free School Policy Advocacy 3.3. Tobacco Free School Policy Activities 4 Strategy & 2: Youth Prevention: School Based, Community Based and Online Programming.. Classes Delivered and Youth Reached: Total, By Curriculum 3.2. Agency Funding and Program Reach Description of Youth Participants 6.4. Contact Time and Fidelity Data by Curriculum 9.5. Contact Time and Fidelity Data by Agency 2.6. Classroom Teacher Satisfaction: Response Rate by Curricula 22 Strategy 3: Prevention Curricula Training 3.. Characteristics of Prevention Curricula Trainees Curriculum Delivery Setting Trainees Comfort with Material Covered in Training Trainees Confidence in Administering the Curriculum 3 Strategy 4 & 5: Establish and Support stand Teams 4.. Number of Agencies Funded to Support and/or Establish stand Teams Counties with a Grantee Supported stand Team (at least Bronze Level) Counties Where a Grantee Supported stand Team Successfully Achieved Bronze Level Status During the Grant Year Frequency of Selected stand Team Activites Reach of stand Team Activities by Agency and Team Agency Funding and Number of Supported and Established Teams 42 Strategy 6: Tobacco Free Worksite 6.. Tobacco Free Worksite Policy Progress from Advocacy to Implementation (graph) Tobacco Free Worksite Policy Progress from Advocacy to Implementation (table) Stakeholder Involvement in Tobacco Free Worksite Strategy Tobacco Free Worksite Strategy Activities Funding for Tobacco Free Worksites by Grantee: # of Worksites and # Potential Impact 49 Strategy 7: Outdoor Tobacco Free Environments No Tables or Figures for this Strategy

7 vi Community Grants Program PROGRAMMATIC AND EVALUATION OVERVIEW OVERVIEW Introduction Tobacco use is the single most preventable cause of death and disease in the United States today. Tobacco use increases the risk of lung and other cancers and also cardiovascular and respiratory diseases. It is estimated that cigarette smoking is responsible for one of every five deaths in the United States, or more than 2, 43, deaths per 2F3 year.f In Ohio, tobacco causes 8,6 deaths annually and costs more than $4 billion in 4 healthcare expenditures per year.3f Community programs are an important component to any comprehensive tobacco control program. The U.S. Centers for Disease Control and Prevention (CDC) best practices guidelines suggest that community programs 5 are an integral component of statewide efforts to reduce tobacco use.4f Under the best practices model, community programs are intended to change community norms regarding tobacco use by: increasing the number of organizations and individuals involved in planning and conducting community level education and training programs; using state and local counter marketing campaigns to place pro health messages that inform, educate, and support local tobacco control initiatives and policies; promoting the adoption of public and private tobacco control policies; and, measuring outcomes using surveillance and evaluation techniques. CDC best practices further note that to achieve the individual behavior change that supports the nonuse of tobacco, communities must change the way tobacco is promoted, sold, and used, while changing the knowledge, attitudes, and practices of young people, tobacco users, and nonusers. Effective community programs involve people in their homes, work sites, schools, places of worship and entertainment, civic 5 organizations, and other public places. 36H It is upon this framework that the Cycle III Community Grants Program was developed and launched. Community Grants Program In developing the programmatic structure for the third cycle (January December, 27) of the Community Grants Program, the Ohio Tobacco Prevention Foundation (OFTP) staff began with a careful review of the most recent clinical and community guidelines, including the CDC s Community Guide to Preventive Services5F6, Best Practices for Comprehensive Tobacco Control Programs,37H5 and the Clinical Guidelines for Treating Tobacco Use and Dependence 6F7. They also made inquiries with other states to determine the most effective prevention and cessation strategies available. The intention of the CGIII program was to strengthen tobacco control infrastructures in Ohio communities through effective programs and approaches, using a socio ecological approach. That is, in order to influence and/or change individual health behavior (e.g., tobacco use), interventions must target all layers of the system that potentially influence individual health behavior, such as interpersonal relationships (friends, family, peers, co workers), the organizations and communities in which individuals work, learn, worship, or recreate, and through the mechanisms of public policy. As shown in the

8 Community Grants Program: Evaluation Overview 2 figure below, this framework approaches tobacco prevention and control through multiple strategies and channels, targeting multiple layers of the system 8. $ TAX $ Public Policy Local, state, and federal tobacco taxes, tobacco-free policies Community Social norms, social networks, standards and practices Organizational Tobacco-free policies at work, in public buildings, sporting venues; incentives to quit Interpersonal Support/positive role modeling from family, friends, peers, co-workers Individual Education, one-on-one counseling, 5 A s SOCIO ECOLOGICAL MODEL APPLIED TO HEALTH BEHAVIOR CHANGE Focusing the programming at all five levels, the CGIII programmatic plan was developed with four overarching programmatic goals and seventeen strategies to meet those goals. Certain goals and strategies (e.g., community awareness) were required of all funded agencies; others were carried out by grantees who demonstrated capacity, through their grant application, to do so. The goals and strategies are outlined below (a graphic depiction of the goal strategies is provided following the end of this chapter): Goal : Community Awareness (programs that build community awareness and support). Community Leader Relations 2. Coalition Development 3. Local Tobacco Surveillance Goal 2: Tobacco Cessation 4. Intensive Adult Cessation Counseling (individual or group) 5. Training Health Professionals in Brief Interventions 6. Establishing Policy and Brief Interventions within Health Systems 7. Employer Support for Nicotine Replacement Therapies (NRT) 8. Promotion of Ohio Quits 9. Distribution of Quit Kits Goal 3: Tobacco Prevention. % Tobacco Free School Campus Policies. School Based Youth Prevention 2. Community Based Youth Prevention 3. Training School Personnel in Prevention Curricula 4. Establish stand (youth advocacy) Team 5. Support stand (youth advocacy) Team

9 Community Grants Program: Evaluation Overview 3 Goal 4: Reduce Exposure to Secondhand Smoke 6. Establish Outdoor Tobacco Free Environments 7. Promotion of Tobacco Free Worksite Campus Policies When these strategies are viewed within the socio ecological framework (as in the figure below), we can see the depth and breadth of the CGIII programmatic plan. As shown, some strategies are single level approaches (Cessation), while others are intentionally or inherently multi level (tobacco fee worksites or promotion of Ohio Quits). Tobacco Use and Key Outdoor Tobacco-Free Policies Indicators Surveillance Tobacco-Free Schools Comm Leader Relations Public Policy Local, state, federal govt. policies, regulations, Tobacco-Free laws Worksites Coalition Development Prevention Community Tobacco-Free Worksites Social norms, social School networks, and standards Stand and Team practices Training Health Comm Prevention Tobacco-Free Schools Professionals Policy Change within Health Systems Organizational Training School Rules, policies, procedures, incentives Tobacco-Free Worksites Promote Ohio Quits Personnel in Prev. Curric Tobacco-Free Schools Cessation Programming in Worksites Interpersonal Family, friends, peers, Stand co-workers Team The 5 A s Individual Knowledge, attitudes, values, intentions The 5 A s Intensive Prevention Cessation Promote Ohio Quits Empl Support of NRT CGIII TOBACCO PREVENTION AND CONTROL PROGRAMS WITHIN THE SOCIO ECOLOGICAL FRAMEWORK In addition to making sure that all levels of the system were addressed by the CGIII Program, a decision was made to move grantees towards evidence based programming. Thus, OTPF staff studied and evaluated many programs and approaches that had been reported to be efficacious in the scientific literature or viewed as evidence based by national accrediting organizations. In turn, CGIII grantees conducting school or communitybased youth prevention programming were limited to using one of five youth prevention programs that were either identified as a model program by the Substance Abuse and Mental Health Services Administration (SAMHSA) or identified as a promising program. Similarly, grantees wishing to conduct intensive adult cessation programs were also required to structure their program to conform to Clinical Practice Guidelines 9. Once the programmatic strategies were established, OTREC worked with Dr. Jeff Willett to develop an evaluation plan for each of the strategies, as described more fully within each respective chapter contained in the remainder of this report. This involved the establishment of outcomes for each strategy and the development of standardized data collection tools, standardized and centralized data collection mechanisms, standardized protocols, and centralized reporting system(s) through which the collection of outcome data would be gathered, summarized and reported back to OTPF staff and board and grantees.

10 Community Grants Program: Evaluation Overview 4 It is important to note that prior to the CGIII grant cycle, neither the programmatic nor the evaluation component were standardized across grantees. In the early grant cycles of the Community Grants Program, grantees proposed individualized programmatic and evaluation plans. Thus, it was anticipated that at least the first year of the CGIII cycle would be focused on standardizing and centralizing the evaluation procedures, and working with grantees to adapt to the new, more rigorous reporting requirements, as well as the more prescriptive programmatic approach. As a result, much of the CGIII evaluation involved process outcomes, such as program reach, program accountability, fidelity to the evidence based approaches, and narratives on the barriers and lessons learned with each new strategy. For the most part, the CGIII evaluation did not involve quantitative outcomes, based on the rationale that before OTPF could assume that the evidence based approach would yield similar outcomes as those found in the original efficacy studies, it first had to be determined that grantees could carry out the programmatic plan successfully with accountability, targeted program reach, and program fidelity. As revealed in the remaining chapters of this report, the CGIII grantees not only were successful in adopting the new statewide evaluation plan, but proved to be diligent and thorough reporters, providing invaluable information about the on the ground experience of what it takes to establish strong, effective tobacco prevention and control programs at the local level. Three Primary Data Collection and Reporting Systems Data needed for the CGIII evaluation were collected using three primary systems of data collection: () The Ohio Tobacco Prevention Grant Wizard, known as G Wiz; (2) the OTREC fax back system; and, (3) the OTREC Data Management System known at OTREC DM. Each are described briefly below. More information on each system is provided in Appendix A and B.. G Wiz (Ohio Tobacco Prevention Grant Wizard) Prior to CGIII, OTPF had a user friendly, online system created by Bamboo Solutions to assist them with programmatic reporting, budgeting and communication with grantees. With the CGIII cycle, the system was expanded and re branded as G Wiz, the Ohio Tobacco Prevention Grant Wizard, to serve as a centralized reporting portal for all grantees, with specific workplans and reporting/evaluation features for each funded activity. During the first two weeks of the CGIII cycle (January, 27), grantees were required to go into G Wiz and complete workplans for each of their funded strategies. Then, on a bi monthly basis (first report was due Feb 28 th ), grantees were responsible for completing progress reports and activity reports for their funded activities. The true value of G Wiz, as with the other systems described below, is that the system was designed with reporting output that permitted nearly real time data that could be used for programmatic planning or reports to the Board within days of submission. In addition to the data that grantees entered directly to G Wiz, the system was also developed so that OTREC could upload programmatic data that was collected via OTREC DM (see below) and data collected elsewhere (e.g., 3 and 6 month quit rates obtained by the survey contractor), linking it to the grantee workplans so that both programmatic staff and grantees could access them. Instructions for the use of G Wiz are included in Appendix A.

11 Community Grants Program: Evaluation Overview 5 2. OTREC Fax Back System In order to summarize program reach and activities across all grantees in a timely manner, a standardized and centralized data collection system was needed so that grantees could centrally submit data collected from their program participants and about activities in their local programs. Thus, a GWiz number of standardized surveys and data collection forms were developed OTREC for various strategies (e.g. youth prevention participant survey, prevention fidelity checklists, training satisfaction surveys). Some of the data from these forms were directly entered into OTREC s online documents management system (OTREC DM) described below, but the majority were faxed to OTREC via a secured, toll free fax line, where an automated data entry software package, Teleform, was used to scan the specially designed forms. Upon receipt, each form was examined and verified by OTREC staff. Once verified, Teleform automatically dumped the data into the permanent databases, which were then converted to a statistical package (SPSS, SAS, STATA) for cleaning and analyses. 3. OTREC DM (OTREC Documents Manager) The two strategies that promised to be the most data intensive were the school and community based youth prevention classes and the individual and group adult cessation programs. Each of these strategies had multiple data collection forms that needed to be linked not only to the grantee, but also to the class/school/site in which the program was offered. Moreover, the sheer volume of data that would be collected (e.g., nearly 4, youth surveys) warranted a centralized data portal through which data could be submitted and grantees could keep track of the data collected and submitted. Thus, OTREC DM, an online documents management system, was developed by the IT department at Case Western Reserve University. OTREC DM is a web based, interactive database that permitted grantees to log into the system and keep track of data from both youth prevention and adult cessation programs. In OTREC DM, they could establish a new class as shown in the screen shot to the right, enter youth prevention participant data from the youth survey (see screen shot to the left) directly into OTREC DM, or simply keep track of all their different youth and adult classes offered throughout the year. Enter a new youth prevention class OTREC also needed a way to communicate with the grantees regarding compliance with data collection requirements and specifically in documenting the sending and receipt of the faxed data forms described above. Thus, OTREC DM was also designed to serve as a communication tools for OTREC and grantees to inform each other of the status of data collection tools sent/received through the fax back system. Through OTREC DM, grantees

12 Community Grants Program: Evaluation Overview 6 could inform OTREC when they faxed a new form, and OTREC would confirm receipt, OR tag the record as having a problem (i.e., problem with fax transmission, used the wrong fidelity form) as shown in the screen shot below. In addition, the individual class record was color coded to reflect the status of the data collection (incomplete, problem, complete), which allowed grantees an easy visual method for checking the status of their classes. Because of the way that prevention and cessation classes were logged in, the system also provided a mechanism for OTREC to examine grantee data at the classroom or group level. A brief introduction manual of OTREC DM is included in Appendix B. Date items faxed must be entered OTREC staff notes when there is a problem with items faxed OTREC staff sends an in addition to making a note when there is a problem Pilot Testing As most of the data collection tools and protocols were new and somewhat complex in their methodology, a number of CGII grantees were asked if they would be willing to participate in a pilot study to determine the utility and feasibility of the new evaluation tools and protocols. This pilot study was conducted just prior to the CGIII launch (Sept Dec, 26). The following seven CGII grantees agreed to participate in the pilot. Holzer Medicial Center Ohio Hispanic Coalition Gurnsey Noble Monroe Tobacco Project (at the Noble County Health Department) Cuyahoga County Board of Health Hamilton County General Health District Delaware General Health District Urban Minority Alcoholsm & Drug Abuse Outreach Program (UMADAOP) Their participation and feedback was invaluable in determining the problems and concerns faced by grantees in using the tools and data reporting systems (G Wiz, fax back system, OTEC DM). Based on their feedback, the system was fine tuned and prepared for dissemination to all CGIII grantees. Grantees Fifty (5) community agencies were awarded a CGIII grant, totaling approximately $2 million for the 2 month grant cycle (Jan Dec, 27). As shown in the list below, the agencies were geographically distributed throughout the state with most of Ohio s 88 counties being served by at least one of the grantees.

13 Community Grants Program: Evaluation Overview 7 GRANTEE NAME COUNTY LOCATION OF FISCAL AGENCY STATE REGION OF FISCAL AGENCY American Lung Assoc. of Ohio Franklin Central Amethyst, Inc. Franklin Central Asian American Comm. Services Franklin Central City of Refuge Point of Impact Franklin Central Columbus State Comm. College Franklin Central Columbus Urban League Franklin Central Delaware General Health Dist. Delaware Central Fairfield Co. Dept. of Health (7 Counties) Fairfield Central Knox Co. Health Dept. Knox Central Ohio Hispanic Coalition Franklin Central Pathways of Licking Co. Licking Central Project Linden Franklin Central Recovery & Prevention Resources of Delaware & Morrow Counties Delaware & Morrow Central The Breathing Association Franklin Central Tuscarawas Co. Health Dept. Tuscarawas Central Union County Health Department Union Central Zanesville Muskingum Co. Health Dept. Muskingum Central Asian Services In Action, Inc. Summit & Cleveland Northeast Barberton Health Dist. Summit Northeast Cuyahoga Co. Dist. Board of Health Cuyahoga Northeast Family & Community Services, Inc. (Portage Co.) Portage Northeast Family & Community Services, Inc. (Wayne Co.) Wayne Northeast Greater Cleveland Health Education & Service Council Cuyahoga Northeast Lake Geauga Center on Alcoholism & Drug Abuse, Inc. Lake Northeast Lorain City Health Dept. Lorain Northeast Mahoning Co. Dist. Board of Health Mahoning Northeast Medina Co. Board of Commissioners Medina Northeast Stark Co. Health Dept. Stark Northeast Your Human Resources Center (Holmes Co.) Holmes Northeast Alpha Comm. Services Erie Northwest American Lung Assoc. of Ohio NW Region Huron Northwest Bucyrus Comm. Hospital Crawford Northwest Community Action for Capable Youth Richland Northwest Hospital Council of NW Ohio Lucas Northwest Private Duty Services, Inc. (Van Wert Co.) Van Wert Northwest UMADAOP Lucas Northwest Women & Family Services, Inc. Defiance Northwest Athens City Co. Health Dept. Athens Southeast Family Guidance Center Lawrence Southeast Holzer Medical Center Gallia Southeast Noble Co. Health Dept. Noble Southeast Selby General Hospital Washington Southeast Greene Co. Combined Health Dist. Greene Southwest Hamilton Co. General Health Dist. Hamilton Southwest Miami Valley Health Improve. Council, Inc. Montgomery Southwest Pike Co. General Health Dist. Pike Southwest Rural Opportunities, Inc. Wood Southwest The Alcohol & Chemical Abuse Council Butler Southwest Upper Valley Medical Center Miami Southwest

14 Community Grants Program: Evaluation Overview 8 Reporting and Evaluation Coordinator A unique addition to the CGIII cycle was required staffing of the Reporting and Evaluation (RE) Coordinator. Applicants were required to designate a staff person to be the primary point person for evaluation reporting and contact person for OTPF and OTREC regarding evaluation. The RE Coordinator had to be a staff member of the agency serving as the primary fiscal agent for the grant, and was required to devote a minimum of 25 percent effort (.25 FTE) towards the coordination of data collection, submission of data and completed surveys to OTREC. In addition, the RE Coordinator had to ensure that evaluation tools were properly utilized and submitted by grantee program staff, subgrantees, and subcontractors. For many of the larger grantees, the RE Coordinator dedicated a significantly larger portion of their time to fulfill these obligation. This administrative change in the CGIII cycle proved to be critical to the success of the evaluation plan. Evaluation Training In order to prepare CGIII grantees for the new evaluation requirements, OTREC in coordination with OTPF staff, held 2 day evaluation trainings at two separate Ohio locations during November and December of 26. Based on geographic location and availability, grantees were given the choice of attending one of the two trainings. The first workshop was held at the Mohican State Park Resort & Lodge on November 27 28, 26 and attended by twenty two agencies (38 individuals), seven OTPF staff, and six OTREC/Case Western Reserve University staff. The second workshop was held at the Quest Conference Center in Columbus on December 5 6, 26 and attended by twenty eight agencies (5 individuals), five OTPF staff, and five OTREC staff. The workshops began with an introduction by Dr. Jeff Willett, Director of Research and Evaluation at OTPF, and Dr. Elaine Borawski, Director of OTREC. This was followed by a two hour CGIII Evaluation Plan Overview, which presented the new statewide evaluation plan and its history and rationale, a description of each of the funded strategies, introduction to the enhanced online reporting system (G Wiz), and a general discussion of the role of the RE Coordinator and reporting expectations. Copies of the slides from these sessions are included in Appendix F. Following the opening session, grantees broke out into small group sessions, which they were assigned to based on their agencies funded strategies; that is, grantees only attended sessions relevant to their 27 funding. Five sessions were offered: () Youth Prevention Curricula Evaluation; (2) Adult Cessation Evaluation; (3) Core Components (those required of all grantees, ie., coalition development, community leaders, etc.; (4) Other Tobacco Control Evaluation; and, (5) Technical Assistance for Reporting in G Wiz. The first four training sessions covered the evaluation rationale, reporting requirements and deadlines, and evaluation materials and implementation for each applicable strategy. The Technical Assistance Training in G Wiz provided an overview on how to use the on line reporting system, and gave grantees hands onexperience to explore the system and familiarize themselves with the system while staff was available for questions.

15 Community Grants Program: Evaluation Overview 9 At the end of the trainings, grantees left with a well defined understanding of the new CGIII evaluation requirements. Additionally, each attendee was given a copy of the comprehensive evaluation manual that included an in depth description of reporting requirements, evaluation tools for each of the seventeen strategies and technical assistance for the use of G Wiz and OTREC DM (also available online at Overview of this Report This report summarizes the activities, program reach, barriers, and lessons learned for each of the CGIII strategies. Two sets of strategies were combined into single chapters in this report (School and Community Based Youth Prevention; Establishing and Supporting a stand Team). In front of each chapter is a summary page that provides a condensed version of the evaluation plan and highlighted results, as well as a listing of grantees funded for the strategy and the counties served with the particular strategy. Maps could only be created for those strategies in which the county information was collected. These pages can be used independently from the full chapter or as an overview. The chapters themselves begin with a rationale for the inclusion of the strategy in the community grants program based on the scientific evidence for its effectiveness. This is followed by a description of the evaluation plan and the data collected for the specific strategy. Results are then presented, based on the type of evaluation that was conducted (i.e., summary of program reach, program fidelity, quit rates, barriers, lessons learned), and the chapters conclude with a summary and future recommendations, if appropriate. Many of the chapters provide funding amounts for each grantee. It is important to note that these were the initial funding amounts provided to OTREC by the Foundation. Grantees were permitted to re budget throughout the year; however, this information was not shared with (or request by) OTREC. The following page contains a graphic depiction of the seventeen strategies of the CGIII, as they fall within the four primary goals of the Ohio Tobacco Prevention and Control Program. REFERENCES U.S. Department of Health and Human Services. Women and Smoking: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2 [cited 26 Sep 23]. Available from: 2 Centers for Disease Control and Prevention. Annual Smoking Attributable Mortality, Years of Potential Life Lost, and Productivity Losses United States, Morbidity and Mortality Weekly Report [serial online]. 25: 54(25) [cited 26 Sep 23]. Available from: 3 Centers for Disease Control and Prevention. Health United States, 25 With Chartbook on Trends in the Health of Americans. (PDF 9KB) Hyattsville, MD: U.S. Department of Health and Human Services, CDC, National Center for Health Statistics; 26 [cited 26 Sep 23]. Available from: 4 Toll of Tobacco on Ohio. Campaign for Tobacco Free Kids. toll.php?stateid=oh. Accessed May, 28.

16 Community Grants Program: Evaluation Overview 5 Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs 27. 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 on Smoking and Health; October Tobacco.Guide to Community Preventive Services Website. Centers for Disease Control and Prevention. Last updated: 6/4/25. Accessed on: May, Fiore MC, Bailey, WC, Cohen SJ, and et. al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. June 2. Online: 8 Glanz, K., Rimer, B.K, & Lewis, F.M. ( 22). Health Behaviour and Health Education. Theory, Research and Practice. San Francisco: Jossey Bass.

17 G-WIZ WORK PLAN MAPPING FOR OTPF COMMUNITY GRANTS II I GOAL: COMMUNITY AWARENESS (Programs that build community awareness and support) CGIII GOAL GOAL: SECONDHAND SMOKE (Programs that reduce exposure to secondhand smoke) CGIII G OAL Building Community Awareness and Support PROGRAM AREA Establishing Tobacco Free Environments PROGRA M AREA Community Leader Relations Coalition Development Surveillance Data Collection Establish outdoor tobacco-free public places Establish tobacco-free worksite campus policies Community Leader Relations Coalition Development Surveillance Data Collection Adult Survey Youth Survey Health Systems Survey Employer Survey Special Populations Survey STRATEGIES/ WORK PLANS Outdoor Tobacco-Free Environment Outdoor Policy Implementation: Advocacy for tobacco free public places Outdoor Policy Enforcement: Assistance with policy enforcement Tobacco-Free Worksites Worksite Policy Implementation: Advocacy for tobacco-free worksi campuses Worksite Policy Enforcement: Assistance with policy enforcemen te STRATEGIES / WORK PLANS CGIII GOAL GOAL: CESSATION (Cessation Programs) GOAL: PREVENTION (Youth Prevention Programs) CGIII GOAL PROGRAM AREAS Adult Cessation Intervention Promotion of Cessation Services % Tobacco Free Schools Tobacco Prevention Education Yo Empow uth erment STRATEGIES/ WORK PLANS Community- Based Youth Prevention Intensive Adult Cessation Counseling- Individual and/or Group Intensive Adult Cessation Counseling (Individual or Group) Training Health Professionals in Brief Interventions Policy and Brief Interventions in Health Systems Policy and Brief Intervention Within Health Systems Employer Support for NRT Employer Support for NRT Distribution of Quit Kits Promotion of Ohio Quits Promotion of Ohio Quits Promotion of Quit Line Promotion of local cessation services Establish Tobaccofree School Policies % Tobacco Free Schools School-Based Youth Prevention Tobacco Free Life Skills School Advocacy Project T.N.T. Implementation Project ALERT and/or Compliance Word of Mouth Stamp Implement Communit y-based Curricula Implemen t Schoolbased Curricula Train School Personnel in Prevention Curricula Prevention Curricula Training Life Skills Life Skills Project T.N.T. Project T.N.T. Project ALERT Project ALERT Word of Mouth Word of Mouth Stamp Stamp Sup Loca Te Work to Establish a New stand Team port l Stand ams Support an Existing stand Team PROGRAM AREAS STRATEGIES/ WORK PLANS t

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19 Ohio Tobacco Prevention and Control Program CGIII Evaluation (Jan Dec, 27) Strategy: Community Leader Relations Programmatic Goal Area: COMMUNITY AWARENESS OVERVIEW: The principal premise of tobacco control relies on social and cultural change. Community and thought leaders are integral to effective this change. It is essential that community grant programs work to increase the awareness and change the attitudes of its residents, and, ultimately, inspire action among this important and powerful audience on tobacco control issues. Every OTPF grantee was funded and charged with spending efforts and resources to help develop, foster, and build community leader relations on a local, state, and federal level. EVALUATION AND TOOLS: The evaluation component for this strategy was process focused, ascertaining the number and type of community leaders contacted, including community business leaders, faith based leaders, federal legislators, local government leaders, social service leaders, and state legislators. These efforts included community leader involvement in local events, coalition meetings, stand Team meetings, as well as telephone conversations, letter writing campaigns, and written quarterly updates about program activities/successes. This information was obtained from workplans and activity reports submitted by grantees. RESULTS HIGHLIGHTS: Overall, grantees made nearly, connections with community leaders between January and December, 27, on behalf of local and state tobacco and control efforts. Grantees reported 3,32 connections with community business leaders,,4 connections with faith based leaders, 9 connections with federal legislators,,458 connections with local government leaders, 2,75 connections with social service leaders, and 699 connections with state legislators (these numbers included multiple interactions with the same community leaders). General activities included contacting leaders to promote a community grantee tobacco prevention, cessation, and policy efforts and inviting leaders to tobacco coalition meetings and other tobacco related community activities. Barriers included coordination of community leaders schedules and making initial contacts with community leaders. SUMMARY: The grantees were very successful in connecting with community leaders in their area regarding local tobacco prevention and control activities. The majority of grantees surpassed their goal in reaching the number of community leaders. By being in contact with the various community leaders including faith based leaders, business leaders, and local, state and federal government officials, the grantees had a chance to voice their concerns regarding tobacco control in their area. The process of developing relationships with various community leaders can lay the groundwork for a strong movement in increasing awareness and attitudes around tobacco control issues. Funding Amount $522,667 Number of Grantees Funded for this Strategy: 5 Agencies Funded: ALL 5 GRANTEES WERE FUNDED FOR THIS STRATEGY. A map for this strategy could not be generated. However, officials representing all of Ohio s 88 counties were reached through this strategy. Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

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21 Evaluation of CGIII Tobacco Prevention and Control Efforts STRATEGY : Community Leader Relations Goal: Community Awareness Background and Rationale The principal premise of tobacco control relies on social and cultural change. Community and thought leaders are integral to this process. It is essential that community grant programs work to increase awareness and to change the attitudes of its political and community leaders, and, ultimately, inspire action among this important and powerful audience on tobacco control issues. Every OTPF grantee was funded and charged with spending efforts and resources to help develop, foster, and build community leader relations on a local, state, and federal level. These efforts included community leader involvement in local events, coalition meetings, stand Team meetings, as well as telephone conversations, letter writing campaigns, and written quarterly updates about program activities/successes. All funded agencies were required to submit workplans, describing how they would engage their local community leaders. Evaluation of Community Leader Relations Overview The evaluation component for this strategy focused on capturing the number and type of community leaders with whom the grantees met. These data were captured from both the activity reports and the quarterly written reports that grantees were required to send to state and federal legislators informing them of their local tobacco prevention and control activities. Evaluation Tools Workplan (provided prospectively): Grantees provided a summarized plan of their efforts and required activities, as well as number of state legislators, federal legislators, local government officials, business leaders, faith based community leaders, social service community leaders with whom they planned to meet Activity Reports (submitted bi monthly): Grantees reported on community leader relations efforts, including: in person meetings or phone conversations with state or federal representatives, efforts to provide state or federal representatives with written updates about program activities and successes, and participation in OTPF sponsored leader outreach. Grantees also provided a description of their activities related to this strategy, and a summary of lessons learned and barriers to achieving the goals of their workplan. CGIII Program Evaluation Report (Jan Dec, 27) June, 28

22 Strategy: Community Leader Relations 4 RESULTS The table below describes the number and type of community leaders reached by each grantee during the 27 grant year, including business leaders, faith based leaders, federal, state and local government officials and local social and community agency leaders. Contact came in the form of face to face meetings, phone calls, or through written communications, such as newsletters and written updates. The majority of grantees made far more contacts with community leaders than they had proposed at the beginning of the year. A very small number of grantees did not reach the numbers they proposed at the beginning. Overall, grantees made nearly, connections with community leaders between January and December, 27, on behalf of local and state tobacco and control efforts. With regard to the types of leaders grantees connected, the most frequently engaged community leaders were business leaders (3,32 contacts) and social service leaders (2,75 contacts). Other local contacts included faith based leaders (,4 contacts) and local governmental officials (,458 contacts). Less frequent contact was made with individual federal legislators (9 contacts) or state legislators (699 contacts); however, as seen in the next section, grantees made multiple contacts to individual federal and state representatives. The most striking finding is that grantees were far more successful than they had anticipated. Overall, grantees reported a 266% program reach. Table.. Grantee Reach in Community Leader Relations Strategy By Type (Jan Dec, 27) Grantee Business Leaders Faithbased Leaders Federal Legislators Local Govt. Officials Social Service Leaders State Legislators Recovery & Prevention Resources of Delaware & Reached Morrow Counties Proposed Community Action for Reached Capable Youth Proposed Union County Health Reached Department Proposed Holzer Medical Center Reached Proposed City of Refuge Point of Reached Impact Proposed Mahoning Co. Dist. Reached Board of Health Proposed Athens City Co. Reached Health Dept. Proposed Tuscarawas Co. Health Reached Dept. Proposed Upper Valley Medical Reached Center Proposed Columbus State Reached Comm. College Proposed The Breathing Reached Association Proposed TOTAL % reached

23 Strategy: Community Leader Relations 5 Grantee Business Leaders Faithbased Leaders Federal Legislators Local Govt. Officials Social Service Leaders State Legislators Alpha Comm. Services Reached Proposed Bucyrus Comm. Reached Hospital Proposed Greene Co. Combined Reached Health Dist. Proposed Barberton Health Dist. Reached Proposed American Lung Assoc. Reached of Ohio NW Region Proposed Medina Co. Board of Reached Commissioners Proposed Miami Valley Health Reached Improve. Council, Inc. Proposed Lorain City Health Reached Dept. Proposed Greater Cleveland Reached Health Education & Service Council Proposed Pathways of Licking Reached Co. Proposed Ohio Hispanic Reached Coalition Proposed Selby General Hospital Reached Proposed Hospital Council of NW Reached Ohio Proposed Family & Community Reached Services,Inc (Portage) Proposed Family & Community Reached Services, Inc (Wayne) Proposed Private Duty Services, Reached Inc. (Van Wert Co.) Proposed Noble Co. Health Dept. Reached Proposed Pike Co. General Reached Health Dist. Proposed Cuyahoga Co. Dist. Reached Board of Health Proposed Rural Opportunities Reached Proposed Women & Family Reached 3 24 Services, Inc. Proposed Family Guidance Ctr Reached Proposed Asian American Reached Comm. Services Proposed TOTAL % reached

24 Strategy: Community Leader Relations 6 Grantee Business Leaders Faithbased Leaders Federal Legislators Local Govt. Officials Social Service Leaders State Legislators TOTAL % reached Amethyst, Inc. Reached Proposed Hamilton Co. General Reached Health Dist. Proposed Asian Services In Reached Action, Inc. Proposed Your Human Reached Resources Center (Holmes Co.) Proposed Lake Geauga Center Reached on Alcoholism & Drug 32 Abuse, Inc. Proposed Zanesville Muskingum Reached Co. Health Dept. Proposed American Lung Assoc. Reached of Ohio Proposed Fairfield Co. Dept. of Reached Health (7 Counties) Proposed Stark Co. Health Dept. Reached Proposed Delaware General Reached Health Dist. Proposed UMADAOP Reached Proposed Columbus Urban Reached League Proposed Project Linden Reached Proposed Knox Co. Health Dept. Reached Proposed The Alcohol & Reached Chemical Abuse Council Proposed Totals Reached 3,32,4 9,458 2, ,829 Proposed, ,69 266% Contact with Federal and State Legislators The next table summarizes the total number of contacts grantees made with federal and state officials, or their aides, during the grant year. Contact came in the form of face to face meetings, phone calls, or through written communications, such as newsletters and written updates. As summarized in the table, grantees made a total of,39 connections with federal and state legislators, or their aides: 339 of these contacts were through face to face meetings; 58 through phone conversations, and, through written communications.

25 Strategy: Community Leader Relations 7 Govt. Position U.S. Senate U.S. House of Representatives Ohio Governor Ohio Lt. Gov. Table.2. Grantee Reach with Federal and State Officials (Jan Dec, 27) Individual Sherrod Brown George Voinovich John A. Boehner Steve Chabot David L. Hobson Jim Jordan Marcy Kaptur Dennis J. Kucinich Steve C. Latourette Robert E. Latta Deborah Pryce Ralph Regula Tim Ryan Jean Schmidt Zack T. Space Betty Sutton Patrick J. Tiberi Stephanie Tubbs Jones Mike Turner Charles Wilson Ted Strickland Lee Fischer # of Face to Face Meetings # of Phone Calls/ Conversations # of Written Communication (i.e. Written Update)

26 Strategy: Community Leader Relations 8 Govt. Position Ohio Senate Individual Ron Amstutz Steve Austria John Boccieri Steve Buehrer Capri S. Cafaro John Carey Gary Cates Kevin Coughlin Keith Faber Teresa Fedor David Goodman Timothy Grendell Bill Harris Jeff Jacobson Eric H. Kearney Lance T. Mason Dale Miller Ray Miller Sue Morano Larry A. Mumper Tom Niehaus Joy Padgett Tom Roberts # of Face to Face Meetings # of Phone Calls/ Conversations 3 2 # of Written Communication (i.e. Written Update)

27 Strategy: Community Leader Relations 9 Govt. Position Ohio House of Representatives Individual Tom Sawyer Tim Schaffer Robert Schuler Kirk Schuring Bill Seitz Shirley Smith Robert F. Spada Steve Stivers Mark D. Wagoner, Jr. Jason H. Wilson Linda Bolon Jon M. Peterson Jim Carmichael Matt Huffman Gerald Stebelton Randy Gardner Kenny Yuko Armond Budish Barbara Boyd Eugene Miller Sandra Williams Michael DeBose Michael J. Skindell # of Face to Face Meetings # of Phone Calls/ Conversations 2 # of Written Communication (i.e. Written Update)

28 Strategy: Community Leader Relations 2 Govt. Position Individual Michael Foley Timothy J. DeGeeter Jennifer Brady Josh Mandel Thomas F. Patton Larry L. Flowers Jim McGregor Kevin Bacon Jim Hughes Larry Wolpert Ted Celeste Daniel Stewart Tracy Heard Joyce Beatty Jim Raussen Louis W. Blessing Jr. Robert Mecklenborg Steven L. Driehaus Dale Mallory Tyrone K. Yates Tom Brinkman Jr. Michelle G. Schneider Arlene J. Setzer # of Face to Face Meetings # of Phone Calls/ Conversations # of Written Communication (i.e. Written Update)

29 Strategy: Community Leader Relations 2 Govt. Position Individual Jon A. Husted John J. White Clayton Luckie Fred Strahorn Brian G. Williams John Widowfield Steve Dyer Vernon Sykes John Otterman Barbara Sears Peter Ujvagi Edna Brown Matt Szollosi John P. Hagan W. Scott Oelslager Shawn N. Webster Courtney E. Combs Bill Coley Joseph F. Koziura Matt Lundy Matt Barrett Ron Gerberry Robert F. Hagan # of Face to Face Meetings 2 2 # of Phone Calls/ Conversations # of Written Communication (i.e. Written Update)

30 Strategy: Community Leader Relations 22 Govt. Position Individual Mark Okey Lorraine M. Fende Carol Ann Schindel Tom Letson Sandra Stabile Harwood Joseph W. Uecker Shannon Jones Kathleen Chandler William G. Batchelder Kevin DeWine Jay Hottinger Ross McGregor Jay Goyal Bruce Goodwin Lynn Wachtman Cliff Hite Jim Zehringer John Adams Diana M. Fessler Chris Redfern Jeff Wagner Stephen Reinhard Anthony E. Core # of Face to Face Meetings # of Phone Calls/ Conversations 2 2 # of Written Communication (i.e. Written Update)

31 Strategy: Community Leader Relations 23 Govt. Position Individual Chris Widener John M. Schlichter David T. Daniels Clyde Evans Danny R. Bubp Todd Book Thom Collier Dan Dodd Jimmy Stewart Jennifer Garrison James Aslanides John Domenick Allan R. Sayre Bob Gibbs Matthew J. Dolan L. George Distel # of Face to Face Meetings # of Phone Calls/ Conversations 5 # of Written Communication (i.e. Written Update) TOTAL CONTACT (ACROSS ALL TYPES) Summary The grantees were very successful in connecting with community leaders in their area regarding local tobacco prevention and control activities. The majority of grantees surpassed their goal in reaching the number of community leaders. By being in contact with the various community leaders including faith based leaders, business leaders, and local, state and federal government officials, the grantees had a chance to voice their concerns regarding tobacco control in their area. The process of developing relationships with various community leaders can lay the groundwork for a strong movement in increasing awareness and attitudes around tobacco control issues.

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33 OVERVIEW: Ohio Tobacco Prevention and Control Program CGIII Evaluation (Jan Dec, 27) Strategy: Coalition Development Programmatic Goal Area: COMMUNITY AWARENESS Community coalitions form the grassroots infrastructure of the tobacco prevention and control movement in Ohio. Collaboration and support at the community level is crucial for local and statewide initiatives to succeed. The Ohio Tobacco Prevention Foundation supports local tobacco coalitions as an essential strategy toward its mission of reducing tobacco use among Ohioans. As such, all CGIII grantees were funded under this strategy and required to dedicate efforts and resources to help develop, foster, and build coalitions in the appropriate setting of the community. Each of these community agencies established or supported one or more local area tobacco prevention coalitions. Funding Amount $724,43 Number of Grantees Funded for this Strategy: 5 (all) Agencies Funded: ALL 5 GRANTEES WERE FUNDED FOR THIS STRATEGY EVALUATION AND TOOLS: The evaluation for this strategy was primarily process outcomes, assessed through the grantees workplans and bi monthly activity reports. In addition, coalition leaders were surveyed with an online survey about the characteristics and qualities of their coalitions. RESULTS HIGHLIGHTS: A total of 74 local coalitions were supported by OTPF (some agencies supported more than one coalition and some coalitions were supported by more than one grantee). Tobacco prevention and control was the single focus for 77%of the coalitions. At the beginning of the grant year, 2% of the coalitions were getting off the ground, 3% were building internal capacity for action and about half were up and running and actively engaged in grassroots efforts to prevent and control tobacco within their community. 4% of the coalitions were started with OTPF funding. 79% of coalition leaders believe that the local tobacco coalition has helped shaped public policy in the community. Coalitions supported by OTPF appear to fall into one of three categories: () those that largely utilized their time and resources to support other OTPF funded strategies; (2) those that predominantly utilize their resources to increase awareness by participating in tobacco related community events such as a cancer walks, car cruises, health fairs, and events like Dance Your Butts Off, ; and, (3) coalitions that spent their time developing their goals or strategic plans. SUMMARY: Agencies not directly involved with a coalition at the beginning of 27 may have experienced more success by joining an established coalition, if one existed in their geographic region, rather than endeavoring to build a coalition from scratch Multiple coalitions serving the same geographic region may find greater success combining efforts. Future evaluation efforts of coalitions should be a bit more prescriptive to aid younger coalitions in their growth and dev elopement (i.e., asking them at each reporting period whether they had engaged in specific activities associated with highly successful coalitions). Counties Served: Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

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35 Evaluation of CGIII Tobacco Prevention and Control Efforts Goal: Community Awareness STRATEGY 2: Coalition Development Background and Rationale For communities, coalitions can serve as a vehicle for improving the health of its people by addressing local public health problems and advocating for change. On a grassroots level, community coalitions emphasize representation from multiple community sectors, attention to multiple community issues, active local citizen participation, and bottom up planning and decision making [with] implicit or explicit concern with diversity, participation, social justice, and personal empowerment. Case studies have shown that with strong local coalition involvement, communities can and do have significant impact on public health reform. Research has shown that community coalitions with the most significant impact are those characterized by formal rules/procedures, strong leadership, a diverse and active membership, member agency collaboration, and group cohesion. 2 Community coalitions form the grassroots infrastructure of the tobacco prevention and control movement in Ohio. Collaboration and support at the community level is crucial for local and statewide initiatives to succeed. The Ohio Tobacco Prevention Foundation supported local tobacco coalitions as an essential strategy toward its mission of reducing tobacco use among all Ohioans. As such, all 5 CGIII grantees were funded under this strategy and required to dedicate effort and resources to develop, foster, and build coalitions in the appropriate setting of the community. Each of these community agencies established or supported one or more local area tobacco prevention coalitions. Evaluation of Coalition Development Overview Prior to the CGIII cycle, OTPF had little systematic information regarding grassroots organizing around tobacco prevention and control. Thus, evaluation plan for this strategy was initially to gather qualitative information regarding the specific approaches used by grantees to establish, develop and strengthen their local coalitions. In addition, to assist the development and training needs of these coalitions across the state, OTPF was interested in gathering additional data on the characteristics and qualities of each OTPF funded coalition. Evaluation Tools Workplan (provided prospectively): All grantees were required to create a workplan for each coalition that they were involved with, providing baseline information on the structure, size, and activities of their coalition. Activity Reports (submitted bi monthly): Grantees were required to provide bi monthly reports on the following: () a summary of the lessons learned and barriers faced in achieving the goals of their CGIII Program Evaluation Report (Jan Dec, 27) June, 28

36 Strategy: Coalition Development 26 workplan; (2) a report of required activities of coalition development including: assessment of current coalition goals, developing a current strategic plan, developing a communication plan, executing a coalition strategic plan, executing a communications plan, and identifying new coalition members and their roles; and, (3) provide a copy of any coalition meeting minutes for that reporting period. Coalition Leader Survey: In February 27, OTREC conducted an online survey of the tobacco coalition leaders to understand the coalition leaders perception of important characteristics of their coalition including representation, services, and initiation. A copy of the survey can be found in Appendix E. Results Process Outcomes The fifty funded grantees submitted 92 workplans for coalition development. As shown in the table below, 38% percent of the agencies supported more than one coalition. In addition, some coalitions were supported by more than one CGIII grantee. Overall, a total of 74 unique local tobacco coalitions in the state of Ohio were supported by OTPF in 27. Table 2.. Number of Coalitions Supported by a Single Grantee (N=5) Number of Coalitions Supported Number/% of grantees Coalition supported 3 (62%) 2 Coalitions supported 6 (2%) 3 Coalitions supported 9 (8%) 4 Coalitions supported (2%) 5 Coalitions supported (2%) 6 Coalitions supported (2%) 7 Coalitions supported (2%) Within the first month of funding, grantees were asked how they planned to support their local coalition. As shown in the table below, for 93% of the supported coalitions, the grantees indicated that they would attend coalition meetings, 5% reported that they would contribute funds, and 79% reported that they would provide staff time and resources to further develop and sustain their coalition. Grantees pledged to provide a leadership position to 7% of the coalitions or to be actively involved, by sitting on a committee a committee, for example, for 79% of the coalitions. Table 2.2. Grantee Role in Coalition at Beginning of Funding Year (n=92 from workplans) Role Yes N (%) No N (%) Contribute Funding 47 (5.9%) 45 (48.9%) Combine Staff Time and Resources 73 (79.35%) 9 (2.65%) Maintain a Leadership Position 64 (69.57%) 28 (3.43%) Actively Involved 73 (79.35%) 9 (2.65%) Attend Meetings Regularly 86 (93.48%) 6 (6.52%)

37 Strategy: Coalition Development 27 Further, at the beginning of the funding year, grantees were asked to characterize the stage of development of the coalitions they worked with. As shown in the table below, it was perceived that about 2% of the coalitions were just getting off the ground, 3% were building internal capacity for action, and about half were up and running and actively engaged in grassroots efforts to prevent and control tobacco use within their community. Table 2.3. Status of Coalition at Beginning of Funding Year Initial Mobilization the coalition is just starting to gather groups and individuals around tobacco control Establishing organizational structure the coalition is working to determine its leadership and governance makeup Building capacity for action the coalition is identifying internal and external resources/abilities to ready itself for action Planning for action the coalition is preparing specific steps to take to reach coalition goals and objectives Implementation the coalition is actively participating in the early delivery of programs and/or services Refinement the coalition is working to adjust its focus on programming based on continuing data collection and feedback from all relevant groups Institutionalization the coalition s work is integrated with other agencies in the county/region, long term funding has been secured (.87%) 6 (6.52%) 4 (5.22%) 5 (6.3%) (.87%) 24 (26.9%) 3 (4.3%) Over the course of the twelve month grant cycle, all OTPF grantees were required to direct efforts and resources to help develop, foster, and build coalitions in the appropriate setting of the community. As part of this, agencies were required to move the coalition forward through a series of required activities such as assessing the coalition s goals, developing and executing a communication plan, and increasing their membership recruitment efforts. Each reporting period (bi monthly), agencies were asked to detail the progress that they made in these areas. The table below shows the percentage of funded agencies who reported completion of each required activity by the end of the grant year. The grantees were the most successful at assessing the coalition s goals (75%), identifying new members (73%), and developing a strategic plan (65%) and the least successful at developing a communications plan (42%) or executing the strategic or communications or strategic plan (37% and 32% respectively). Table 2.4. Completion of Required Coalition Development at End of Funding Year Assessment of current coalition goals 69 (75.%) Develop a coalition strategic plan 6 (65.22%) Develop a communications plan 39 (42.39%) Execute a coalition strategic plan 34 (36.96%) Execute a communications plan 29 (3.52%) Identify new coalition members and their roles 67 (72.83%)

38 Strategy: Coalition Development 28 Coalitions: Size, Composition and Attendance As reported on the bi monthly activity reports, an average coalition was comprised of about 28 individuals and 7 community organizations, with an average of 4 members attending each coalition meeting. Each coalition met an average of 7.27 times (range 54) over the course of the grant year. Agencies reporting a larger number of meetings, greater than 2, largely accomplished this by utilizing narrowly focused subcommittees such as those focused on the development of a strategic plan or design and maintenance of a website. Coalition Survey Results As stated in the overview, OTPF was interested in gathering more specific information on each coalition across the state n order to better assist the grantees in the development and training needs of these coalitions. Thus, OTREC conducted a web based survey on behalf of OTPF, gathering data on coalition leaders' perceptions of important characteristics and qualities of their coalitions. Grantees were solicited by OTREC to identify up to three formal and informal leaders for each coalition being established or supported by this strategy. 7 coalition leaders, from 7 of the 74 (94.6%) local tobacco prevention coalitions across Ohio where contacted to complete an online survey developed using a commercial online survey package (SurveyMonkey ). The response rate was high (85.4% n=46/7). Coalition leaders were asked questions about representation, skills and experience, role clarity, expectations, participation benefits, leadership, organizational structure, taskforce or meeting effectiveness, stages of coalition development, organizational climate, communication, recruitment, community linkages, policy changes, and institutionalization or sustainability. As detailed in the table below, most coalitions are represented by local health departments (75.3%), social service agencies (7.5%), and voluntary health agencies (66.4%). The majority of coalition leaders participated through paid duties from another organization/agency (58.8%). The coalitions primarily served the youth (78.5%), health care professionals (6.8%), and women (58.3%) in the population. 76.8% of the coalitions primarily focus on tobacco prevention and control and 4.7% of the organizations were started with OTPF funding. As reported by coalition leaders, each coalition served an average of 3.25 counties. Coalition leaders reported an average of 3.93 individuals attended meetings in the last three months; on average, 5.7 individuals are members of the coalition; and coalitions are comprised of an average of 5.9 organizations. Of interest is that these averages were lower than numbers reported in community agency workplans.

39 Strategy: Coalition Development 29 Table 2.5. Coalition Leader Representation Coalition Representation:* N (%) Primary Coalition Focus: N (%) City/County Health Dept. (75.3%) Tobacco Prevention & Control 6(76.8%) Social Service Agency 3(7.5%) Tobacco Control as a Part of Another Public Health Focus 32(23.2%) Voluntary Health Agency 97(66.4%) Non Profit Organization 89(6.%) Coalition Ethnicity: Hospital 87(59.6%) White 84.9% School 8(55.5%) African American 22.6% Other Local Government Agency 47(42.2%) Asian.7% Counselor/Therapist 47(32.2%) Hispanic/Latino 7.% Minority Based Organization 46(3.5%) American Indian 3.9% Local Business 43(29.5%) Other 9.9% Faith Based Organization 38(26.%) Population Coalition Serves:* Coalition Participation: Youth 3(78.5%) Part of Paid Duties 8(58.8%) Health Care Professionals 89(6.8%) Voluntary 48(35.3%) Women 84(58.3%) Other 8(5.9%) Minority Groups 79(54.9%) Policy Leaders 69(47.9%) Coalition Start: Faith Based Organizations 57(39.6%) Started with OTPF funding 55(4.7%) Other 43(29.9%) Existing, with additional OTPF monies 36(26.7%) Don t Know 3(2.%) Shifted focus to tobacco with OTPF $ 9(6.7%) Don t Know 23(7.%) Other 2 (8.9%) * Multiple response options were permitted. Coalition leaders were next asked about the skills and experiences of the coalition. The majority of coalition leaders reported that they had an excellent or very good understanding of the tobacco prevention and control needs of the population the coalition serves. The majority of tobacco coalition leaders described their professional skills as organizational (4.%), communication (29.9%), advocacy (3.4%), or motivational (8.2%) (data not shown). As shown in the next table, the majority of leaders (65.9%) felt that they had a clear understanding of their role in the coalition. However, they were less clear about the organizational roles and plans. For example, while over 7% of coalitions had a mission statement, only 52% reported having a strategic plan for carrying out this mission. When asked if the mission statement met their vision, the majority reported that it did; however a full third of the leaders reported that they were unsure. Similar results were found with regard to the strategic plan.

40 Strategy: Coalition Development 3 Table 2.6. Skills & Experience of the Coalition Leader Role Clarity: N(%) Mission Statement Meets Vision of Staff: N(%) Very Clear 87(65.9%) Very Well 5(37.3%) Somewhat Clear 3(23.5%) Pretty Well 39(29.3%) Unsure 2(9.%) Unsure 38(28.6%) Somewhat Unclear (.8%) Not So Well 4(3.%) Not Clear at All (.8%) Not Well at All 2(.5%) Has Mission Statement: Strategic Plan Meets Vision of Leader: Yes 94(7.%) Very Well 34(25.6%) No 28(2.9%) Pretty Well 37(27.8%) Don t Know 2(9.%) Unsure 48(36.%) Not So Well 7(5.3%) Has Strategic Plan: Not Well at All 7(5.3%) Yes 7(52.2%) No 45(33.6%) Strategic Plan Meets Vision of Staff: Don t Know 9(4.2%) Very Well 87(65.9%) Pretty Well 3(23.5%) Mission Statement Meets Vision of Leader: Unsure 2(9.%) Very Well 5(37.3%) Not So Well (.8%) Pretty Well 37(27.6%) Not Well at All (.8%) Unsure 39(29.%) Not So Well 6(4.5%) Not Well at All 2(.5%) As described earlier, coalitions were provided a list of expected actions of the coalition during the grant year, largely focused on the defined strategies for 27. The next table describes the leaders reporting of what their coalition had accomplished at the time of the survey, with regard to written plans around each of the strategies, such marketing and development, promotion of Ohio Quits, and tobacco free school policies. The majority of coalitions had written plans for coalition development (65.4%), youth prevention programming (63.8%), and to support or work to establish a stand team (62.3%). However, far fewer had written plans focused on broader, systems level activities or policies such as working with health systems to integrate tobacco related policies and brief interventions (35.4%), working with local employers to provide nicotine replacement therapy (NRT) to its employees (33.8%), or work with local officials to develop outdoor tobaccofree environments (25.4%). Interestingly, for many of these broader activities, many of the coalitions simply did not know whether a plan was defined by their coalition an indication that the topic may not have been discussed as often as the more familiar activities surrounding prevention.

41 Strategy: Coalition Development 3 Table 2.7. Coalition Written Plans Action Plan for: Yes No Don t Know Promotion of Ohio Quits 78(6.%) 27(2.8%) 25(9.2%) Community Leader Outreach 73(56.2%) 26(2.%) 3(23.8%) Coalition Development 85(65.4%) 22(6.9%) 23(7.7%) Local Marketing 8(6.5%) 26(2.%) 24(8.5%) % Tobacco Free Schools 78(6.%) 3(23.%) 22(6.9%) Youth Prevention Programming 83(63.8%) 29(22.3%) 8(3.8%) Prevention Curricula Training 53(4.8%) 49(37.7%) 28(2.5%) Support/Work to Establish a stand Team 8(62.3%) 28(2.5%) 2(6.2%) Intensive Adult Cessation Counseling 63(48.5%) 44(33.8%) 23(7.7%) Policy & Brief Intervention within Health Systems 46(35.4%) 44(33.8%) 4(3.8%) Employer Support for NRT 44(33.8%) 46(35.4%) 4(3.8%) Outdoor Tobacco Free Environment 33(25.4%) 59(45.4%) 38(29.2%) Tobacco Free Worksite 77(59.2%) 28(2.5%) 25(9.2%) Coalition leaders were next queried about efficacy of the coalition and their role in the coalition. A shown in the next table, a slight majority of coalition leaders were very confident that their coalition would meet its objectives (5.5%) and felt it was very likely that the coalition will fully implement its activities (56.9%) and effectively evaluate its activities in the next year (63.8%). 75.4% of coalition leaders reported that it was very likely they would still be involved with the coalition in one year s time. While 44.7% of the coalition leaders thought they could provide technical assistance to the community regarding tobacco prevention and control issues only 33.8% thought their coalition would secure financial support in the next year.

42 Strategy: Coalition Development 32 Table 2.8. Coalition Expectations Coalition Will Meet Objectives: N(%) Effectiveness at Evaluating: N(%) Very Confident 67(5.5%) Very Likely 83(63.8%) Somewhat Confident 5(39.2%) Somewhat Likely 33(25.4%) Unsure 2(9.2%) Unsure 2(9.2%) Not too Confident (%) Somewhat Unlikely 2(.5%) Not at All Confident (%) Very Unlikely (%) Coalition Will Fully Implement Activities: Likeliness of Securing Funding Next Year: Very Likely 74(56.9%) Very Likely 44(33.8%) Somewhat Likely 43(33.%) Somewhat Likely 4(3.5%) Unsure 2(9.2%) Unsure 38(29.2%) Somewhat Unlikely (.8%) Somewhat Unlikely 5(3.8%) Very Unlikely (%) Very Unlikely 2(.5%) Will Be Involved with Coalition Next Year: Can Assist Community with Tobacco Issues: Very Likely 98(75.4%) Very Well 62(44.7%) Somewhat Likely 5(.5%) Somewhat Well 37(28.5%) Unsure 3(.%) Adequately 26(2.%) Somewhat Unlikely (.8%) Inadequately 4(3.%) Very Unlikely 3(2.3%) Not Well at All (.8%) When asked about participation benefits, most coalition leaders considered the community benefits (97.7%), networking (97.7%), solidarity or being part of an organized group (89.2%), and individual input or personal development to be benefits of participation in the coalition. With regards to leadership, the majority of coalition leaders felt the local coalition staff (53.2%) and local coalition members (57.%) had a lot of influence in making decisions for the coalition. With regards to personal influence, coalition leaders reported they had a lot of influence on selecting coalition activities (45.2%) and setting the budget for coalition activities (3.2%) and only some influence in setting goals and objectivities for the coalition (49.2%) and deciding general coalition policies and actions (46.8%). 66.7% of coalition leaders reported that decisions are usually made with discussion and consensus among coalition members. When asked about their coalitions organizational structure, only 32.8% reported having written bylaws. In regards to staffing, 63.2% reported having a full time coordinator (85.% of those coordinators were paid) and 2.2% having a part time coordinator (47.8% of those coordinators were paid). With regards to meetings, 96.% of coalition leaders reported having a clear agenda and 85.5% keep minutes of meetings. Coalition leaders were also asked to identify the stage of maturity they would consider their coalition to be in at the time of the survey. As seen below:

43 Strategy: Coalition Development 33 Coalition Still Forming 2.% Implementation (just beginning to provide and/or support programming & services) 6.% Maintenance (sustaining programming and service delivery) 46.8% Institutionalization (programming and service delivery is accepted and standard practice for the coalition) 25.% Interestingly, the coalition leaders, as a group, reported that their coalitions were further along in development than grantees did in their initial workplans (see section above), where grantees reported 2% were still forming, 3% were building internal capacity and just beginning to provide services and activities and 5% were up and running. In reporting on communication, 9.2% of coalition leaders reported that communication between leaders and members was very good or good, with 7.3% of leaders reporting that is used to communicate most often. 59.8% of coalition leaders reported that their group had an electronic or paper newsletter; while, 24.6% reported their coalition had a website. In regards to other forms of communication, coalition leaders felt that group discussions (%) and verbal reports (95.9%) at meetings were very important or important. Method Mailed and Faxed Written Materials Verbal Reports at Meetings Group Discussions at Meetings Talking Outside of Coalition Meetings ing Written Materials Table 2.9. Methods of Communication within Coalitions Very Important 3 (24.6%) 95 (77.9%) 2 (83.6%) 38 (3.%) 9.8 (8.3%) Important 36 (29.5%) 22 (8.%) 2 (6.4%) 66 (54.%) 2 (6.4%) Not Very Important 44 (36.%) 5 (4.%) (.%) 7 (3.9%) 2 (.6%) Not at All Important 2 (9.8%) (.%) (.%) (.8%) 2 (.6%) Coalition leaders were asked about the organizational climate of the coalition they served. 93% of coalition leaders served agreed or strongly agreed that their coalition made an effort to keep all members engaged; while, 8.5% felt the coalition reflects the community it serves. 8.3% of coalition leaders agreed or strongly agreed that their coalition had unity and cohesion and that there was a strong emphasis on practical tasks.

44 Strategy: Coalition Development 34 Statement There is a feeling of unity and cohesion in the coalition. There is a strong emphasis on practical tasks in this coalition. There is not much group spirit among members in this coalition. This is a down to earth coalition. There is a strong feeling of belonging in this coalition. This coalition rarely has anything concrete to show for its efforts. Members of this coalition feel close to each other. This is a decision making coalition. This coalition has a hard time resolving conflicts. This coalition is reflective of the community it serves. This coalition makes an effort to keep all members engaged. Table 2.. Organizational Climate of Coalitions Strongly Agree 45 (36.6%) 45 (36.6%) 7 (5.7%) 53 (43.%) 39 (3.7%) 4 (3.3%) 23 (8.7%) 3 (24.4%) 4 (3.3%) 44 (35.8%) 5 (4.5%) Agree 55 (44.7%) 55 (44.7%) (8.9%) 56 (45.5%) 47 (38.2%) 2 (9.8%) 48 (39.%) 53 (43.%) 3 (2.4%) 55 (44.7%) 5 (4.5%) Neither Agree or Disagree 9 (5.4%) 2 (6.3%) 22 (7.9%) (8.9%) 3 (24.4%) 6 (3.%) 42 (34.%) 3 (24.4%) 2 (6.3%) 9 (5.4%) 4 (.4%) Disagree 4 (3.3%) 2 (.6%) 49 (39.8%) 3 (2.4%) 6 (4.9%) 4 (33.3%) 9 (7.3%) 8 (6.5%) 55 (44.7%) 4 (3.3%) 6 (4.9%) Strongly Disagree (.%) (.8%) 34 (27.6%) (.%) (.8%) 5 (4.7%) (.8%) 2 (.6%) 4 (33.3%) (.8%) (.8%) Coalition leaders largely reported that they had been somewhat successful (47.5%) at new member recruitment, with leaders reporting they had been very successful (2.3%) or somewhat successful (39.3%) at recruiting from the population the coalition serves. While 8.% of coalition leaders felt that the coalition links or collaborates with other community organizations or groups, only 58.6% reported that the number of new agencies who had joined the coalition had significantly increased or increased some since they had joined the coalition. With regard to policy changes, 78.5% of coalition leaders strongly agreed or agreed that the local tobacco coalition has helped shape public policies in the community (including worksites and schools) about restricting smoking. Further, 82.7% of coalition leaders strongly agreed or agreed that their local tobacco coalition has had an impact on tobacco use in their community. Finally, coalition leaders were asked about institutionalization and sustainability of their coalition. As shown in the next table, coalition leaders overall reported that approximately 24.7% of the community coalition budget is provided by sources other than the Ohio Tobacco Prevention Foundation. 48.8% of coalition leaders felt

45 Strategy: Coalition Development 35 unsure, somewhat unlikely or very unlikely that the coalition would continue after OTPF funding ends. 69.4% of coalition leaders were unsure or did not know whether their coalition had a plan for seeking funding beyond current support from OTPF; while, 59.5% of coalition leaders were unsure or did not know whether their coalition had sought financial support in addition to OTPF funding in the last two years. Finally, 77.7% of coalition leaders were unsure or did not know whether their coalition currently receives financial support beyond OTPF. Coalition Will Continue after OTPF Funding Ends: Table 2.. Institutionalization and Sustainability N(%) Coalition Has Archive of Its Work/Programs Since Start: Very Likely 26(2.5%) Yes 69(57.%) Somewhat Likely 36(29.8%) No 7(5.8%) Unsure 4(33.9%) Don t Know 45(37.2%) Somewhat Unlikely 2(9.9%) Very Unlikely 6(5.%) Plan for Seeking Funding Beyond OTPF: Yes 37(3.6%) Impact of Coalition Programs: No 33(27.3%) Significant Impact 6(87.6%) Don t Know 5(42.%) Not Much Impact 5(2.4%) No Impact at All (.%) Sought Financial Support besides OTPF: Yes 49(4.5%) Programs Monitored by Staff/Members: No 33(27.3%) Very Well 55(45.5%) Don t Know 39(32.2%) Somewhat Well 38(3.4%) Unsure 25(2.7%) Coalition Receives Funding besides OTPF: Not So Well (.%) Yes 27(22.3%) Not Very Well 3(2.5%) No 58(47.9%) Don t Know 36(29.8%) N(%) Barriers and Lessons Learned In bi monthly reports, grantees reported on successful strategies and some of the commonly encountered barriers to the coalition development process. By and large, the most common barrier faced by grantees was meeting attendance and member availability. Individual grantees reported that evenings, the summer season, weather, transportation, and holidays all led to poorer meeting attendance. Other grantees reported that a barrier for the coalition was getting representation from particular groups. The barrier of meeting attendance led one grantee to report there was inconsistency in organization representation to the coalition. A related topic reported by numerous grantees was the difficulty that many coalitions experienced in recruiting new members and staffing the coalition. As one grantee stated, small membership makes it difficult to create an effective structure. Barriers in this area ranged from competition for time and attention with

46 Strategy: Coalition Development 36 membership to multiple coalitions to staffing the coalition so that someone can run the meetings to difficulties in recruiting members from specific groups. Grantees reported low meeting attendance of school personnel, physicians, and influential people. One grantee simply stated that there was difficulty getting representation from all areas of region served by coalition. Grantees also encountered some misinformation or confusion with regard to accomplishing the required activities. Particularly, grantees struggled with development of a strategic plan. Accomplishing this step consumed the greater part of the year for many coalitions. Another grantee reported that it was difficult to get the coalition to focus on current and future goals. Yet another grantee reported that there was no consensus on strategic plan goals/coalition goals or agenda. There were a number of additional themes reported by grantees that were of note. A few grantees reported that coalitions struggled to find funding for everything from meeting refreshments to promotional materials. A number of grantees also reported that coalitions struggled with communication in the form of language, getting accurate/thorough media coverage, and computer based communication. Finally, a few grantees reported difficulty in getting noticed in the public. While many barriers related to the difficulty in recruiting members, many of the lessons learned related to the importance of recruiting the right members. One grantee reported, It is important to have a multidisciplinary coalition: educators, community leaders, business owners, etc. Another grantee noted, Bringing the right people to the table is critical to successful coalition programs. A few grantees noted that though coalition members were recruited, maintaining member involvement was an equally important lesson. As one grantee noted, Recruiting new members is easier than I thought it would be. The real challenge is keeping them engaged. A second grantee reported that it is essential to communicate with coalition members who miss meetings to assess continued interest. A number of the lessons learned were organizational and structural in nature. Grantees mentioned the importance of accurate record keeping, keeping meetings at a reasonable length, and maintaining a calendar of coalition events to aid scheduling. In relation to the coalition structure, grantees had a number of suggestions for improvement. One grantee suggested their coalition might benefit from merging with other, larger coalitions/collaborate with other agencies ; while another stressed the importance of forming subcommittees to improve coalition efficiency. Other grantees had more general ideas about coalition structure. One grantee wrote that it is important to make sure that the issues and interests of everyone at the planning table are being addressed. Summary and Recommendations At the beginning of the grant cycle, grantees reported that about 2% of their coalitions were just getting off the ground, 3% were building internal capacity for action, and about half were up and running and actively engaged in grassroots efforts to prevent and control tobacco use within their community. Unfortunately, the system did not allow us to assess their status at the end of the 2 month grant cycle and thus, we are unable

47 Strategy: Coalition Development 37 to report the progress that grantees made over the 2 months. However, a follow up coalition leader s survey was recently conducted and results will be available on the OTREC website by the end of summer of 28. The initial coalition leader survey was very informative with regard to how the coalitions varied with regard to structure, activities, leadership, and barriers faced by grantees. The coalitions varied in size and structure, with the average coalition having 28 individual members, representing an average of 7 community organizations. It appears that at the beginning of the grant cycle, most coalitions were trying to determine who to define themselves and their activities. It was very telling that over 7% of coalitions had mission statements, but only about half reported having a strategic plan for carrying out the mission. Moreover, when asked if the mission statement met their vision, the majority reported that it did; however a full third of the leaders reported that they were unsure. Moreover, when grantees were asked about the CGIII requirement to develop and execute strategic and communication plans (for reaching community thought leaders and media outlets), initially, we found that although some had strategic and communications plans in place, only about a third had actually executed them. Thus, it s clear that coalitions were struggling with how to translate their mission into practical plans for influencing the use of tobacco in their communities. The qualitative data echoed this struggle with many grantees mentioning the difficulty they had putting the strategic plan together. However, in data not shown, this struggle was highly associated with the age of coalition. Older coalitions were much more likely to have developed and executed a strategic and communication plan than those more recently established, with the clear implication that coalitions take time to mature. With regard to activities over the first 2 months, coalitions appear to fall into one of three categories. Some coalitions largely utilized their time and resources to support OTPF funded strategies (e.g. youth prevention, stand team activities). Meeting minutes described such things as strides toward % tobacco free school policy adoption or provision of adult cessation services. A second category was comprised of coalitions who predominantly utilized their resources to increase awareness by participating in community events such as a Dance Your Butts Off, cancer walks, car cruises, health fairs, etc. The third category of coalitions is those who spent the majority of the year developing their goals or strategic plans. Their efforts may have been hampered by their understanding of strategic plan requirements and inconsistent meeting attendance by members. These coalitions were largely newly formed. While some coalitions were unable to get themselves off the ground, others are poised for implementation of their strategic plan. Nonetheless, over 8% of coalition leaders believed that their coalition was having a strong impact on tobacco use in their community and nearly as many (79%) believed that their coalition helped shape public policy on restricting smoking within their community (including worksites and schools). References Berkowitz B. Studying the outcomes of community based coalitions. American Journal of Community Psychology. 2; 29(2): Zakocs RC, Edwards EM. What explains community coalition effectiveness? American Journal of Preventive Medicine. 26; 3(4):

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49 Ohio Tobacco Prevention and Control Program CGIII Evaluation (Jan Dec, 27) Strategy: Local Tobacco Surveillance Programmatic Goal Area: COMMUNITY AWARENESS OVERVIEW: Surveillance is a fundamental tobacco prevention and control activity that provides important information about target audience tobacco behaviors and attitudes through application of systematic data gathering techniques. Such approaches can yield representative data from samples drawn from the larger community populations. These data provide insight about sub groups or geographic areas that may need resource allocation as well as benchmarks for evaluation of tobacco prevention and control strategies. EVALUATION AND TOOLS: A review of OTPF funded grantees that had conducted adult tobacco surveillance projects was conducted. The review focused on methodological issues including sample sizes, question item inclusion and procedures for drawing the sample. Similarities, differences and recommendations for strengthening these approaches were identified. Funding Amount $95,74 Number of Grantees Funded for this Strategy: 3 Agencies Funded: Family & Community Services Stark County Health Department Cuyahoga County Board of Health RESULTS HIGHLIGHTS: Three grantees conducted adult tobacco surveillance projects during this reporting period (Cuyahoga, Portage and Stark). Each grantee utilized a random digit dial technique to interview adults about their tobacco use and attitudes. Sample sizes varied from 4 to 325. Because final reports were used to complete the analysis, it was difficult to judge whether consistent questions were used. Such consistency is important for comparisons across grantees and to encourage adoption of minimum principles of standardization. SUMMARY: It was surprising that only three grantees requested and committed Foundation resources to adult tobacco surveillance activities. The small number of adult tobacco surveillance projects may have either reflected a lack of appreciation of importance of such work or an unwillingness to prioritize such work in the face of providing direct prevention and treatment programming. Establishing a minimum set of standards for both data collection and presentation of adult tobacco surveillance findings would permit easy comparison across such reports and help strengthen local grantee s capacity to conduct this important work. If the low prioritization of surveillance is the explanation for low adoption by grantees the need to increase their appreciation of the importance of this work is needed. Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

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51 Background and Rationale Evaluation of CGIII Tobacco Prevention and Control Efforts STRATEGY 3: Local Tobacco Surveillance Goal: Community Awareness Public health surveillance is the ongoing systematic collection, analysis, interpretation, and dissemination of health data essential to the planning, implementation and evaluation of public health practice. Such data collection is an important and necessary requisite for tobacco prevention and control activities by monitoring tobacco use behavior and policies. Tobacco surveillance can yield prevalence estimates that serve as important markers for resource allocation and program development while providing tobacco control professionals with data on the progress in reducing the toll of tobacco on the public s health. Following scientific methodologies, data can be gathered from samples that are representative of the population from which they were drawn. Doing so is a gold standard for producing valid and reliable tobacco prevalence estimates. At the national level, tobacco surveillance is led by the U.S. Centers for Disease Control and Prevention s Office on Smoking and Health in cooperation with the National Center for Health Statistics, the National Institute on Drug Abuse, the U.S. Census Bureau, and the Substance Abuse and Mental Health Services Administration. Various surveys are used by these agencies and can be more closely examined at the Centers for Disease Control and Prevention website The primary survey tools used by states are the Behavioral Risk Factor Survey (BRFS) to measure prevalence and the Adult Tobacco Survey (ATS) to gain additional insights regarding adults attitudes and behaviors about tobacco use and exposure to secondhand smoke. The Youth Tobacco Survey (YTS) is used to assess tobacco prevalence among youth. The BRFS was established in 984, the ATS in 995 and the YTS in 998. Three local tobacco coalitions in Ohio have gathered adult tobacco surveillance data with Ohio Tobacco Prevention Foundation s (OTPF) support. This chapter examines selected findings from their most recent adult surveillance reports (See Table 3.). Further, recommendations are offered regarding methodologies and the presentation of findings that might standardize these protocols to permit easy comparison as well as enhancing capacity at the local level to conduct surveillance. Evaluation Plan for Local Surveillance To implement the strategy of local surveillance, survey items from the BRFS and the ATS were administered in Portage, Stark and Cuyahoga Counties. All three groups used random digit dial telephone interviewing of a sample of non institutionalized adults in their respective counties. Sample sizes varied considerably with Portage County sampling 4, Cuyahoga data were aggregated across four years (23 thru 26) that yielded a sample of 5,3 (mean =,325), while Stark County sampled,68 adults. Data were collected on three primary prevalence, cessation and exposure to secondhand smoke. Data were reported by age, sex, and race. CGIII Program Evaluation Report (Jan Dec, 27) June, 28

52 Strategy: Local Tobacco Surveillance 4 Results The table below provides some basic demographic and tobacco use data across the three counties conducting local surveillance. Table 3.. Percentage of Adult Tobacco Use by Demographic Category Across Three Ohio Counties. Prevalence of Current Smokers* Cuyahoga County (26) Stark County (27) Portage County (27) Total 2.3% 23.6% 6.2% Gender: Males 23 NR 6. Females 22 NR 6.4 Race: White Black 27 33*** 5.4 Other 2 NA NA Income: <$25, ** 2.3 $25, 49, ** 6. $5, 75, **. >$75, 4 4.9** 8.4 Quit Attempts in last 2 months (among current smokers) Gender: Males Females Race: White 49 NR 4.5 Black 64 NR NA* Other 67 NR NA* Income: <$25, 59 NR 4.7 $25, 49, NR 44.4 $5, 75, 53 NR 37.5 >$75, 46 NR 5. Secondhand Smoke Exposure In the Home Of those exposed, % with children Rules about Smoking in home with children Not Allowed 35 NA 32 In some places 35 NA 5 Anywhere 3 NA 8 Breathing others smoke is harmful to health Smokers Non Smokers * Current smokers are those who smoke either every day or some days; NR Not Reported; **Income increments were under $8,, $8, to $36,, $36, to $54, and greater than $54,; ***classified as people of color.

53 Strategy: Local Tobacco Surveillance 4 Activities, Barriers and Lessons Learned Activities: Each county followed a similar protocol for collecting data on adult tobacco prevalence using random digit dialing approach. Further, based on a review of the final reports, there was good consistency in the general questions categories of prevalence, cessation and exposure to secondhand smoke across all three counties, primarily because grantees used standardized measures available in the BRFSS and ATS. There was a significant difference between the sample size in Portage County (n=4) and those of Cuyahoga County (n=5,3 over four years which averages to,325 per year) and Stark County (n=,68). The Portage County ATS margin for error (standard error estimate) was ±5 % while the Cuyahoga survey was ±3% and the Stark survey was ±3%. The different sample sizes from each county were largely influenced by available resources to conduct telephone surveys. For example, Cuyahoga County received supplemental funds from a local foundation to support their surveillance work, thus permitting them to collect multiple years of comparable data, which has provided strong evidence that the local tobacco prevention and control efforts are having an impact (the smoking rate in Cuyahoga County has consistently declined each year from a high of 26.7% in 23 to 8.9% in 27). Without local surveillance, local coalitions must assume that the statewide trends apply locally in the case of Cuyahoga County, we see that this would have been a highly erroneous assumption. Barriers: No barriers were reported in the comparison of the three counties adult tobacco survey results. Lessons Learned: Framing questions in the same format is necessary in order to make cross comparisons between surveillance systems. Though this standard may not have been the intent of each of these local surveillance systems, OTPF has made important progress over the past five years by requiring local coalitions to follow such a standard. As noted in the Table of this report, some cells are not reported. This is because the data were not available from the local coalition providing the report. Given this and short of requesting the raw data from each coalition, OTPF might consider requesting standardization in reporting so that common reporting of data would permit easy comparison across coalitions that have collected adult tobacco data. Such a protocol would not prohibit coalitions from analyzing and presenting data in ways beyond those standard tables and figures. Summary and Recommendation It is worth noting that only three coalitions have elected to use OTPF funds to support adult tobacco surveillance activity. It is possible that coalitions have elected to secure alternative funds to support their surveillance activity, but it is believed this is the exception rather than rule. Because good planning is achieved with good data, surveillance is a fundamental activity in comprehensive tobacco prevention and control activities. Further, local surveillance data are often wanting. Together, these reasons provide strong justification for helping local coalitions establish their own surveillance systems. The primary recommendation of this chapter would be to encourage ODH to provide assistance to local coalitions to enable the implementation of tobacco surveillance for their local or regional community. OTPF, OTREC and coalitions already engaging in such work could provide technical assistance to coalitions in

54 Strategy: Local Tobacco Surveillance 42 achieving this end. The major challenge in achieving this recommendation is likely convincing local tobacco control professionals that the investment in such work is both necessary and essential. Second, standardized reporting of findings would permit local and state tobacco control professionals with a better opportunity to compare results between coalitions and with state ATS data. Centers for Disease Control and Prevention. Framework for evaluating public health surveillance systems for early detection of outbreaks; recommendations from the CDC Working Group. MMWR 24;53(No. RR 5):.

55 Ohio Tobacco Prevention and Control Program CGIII Evaluation (Jan Dec, 27) Strategy: Intensive Individual and/or Group Tobacco Cessation Counseling Programmatic Goal Area: CESSATION OVERVIEW: Twenty three community agencies wree funded to provide adult tobacco users with intensive cessation counseling, through either group or individual efforts. Nine agencies exclusively provided intensive group counseling, 4 agencies exclusively provided intensive individual counseling, and agencies offered both forms of tobacco cessation counseling to adults. In addition, two agencies focused on special populations (deaf adults and Hispanic adults). EVALUATION AND TOOLS: The evaluation for this strategy examined both process and outcomes, using the workplans, activity reports, data submitted to OTREC through the online data processing system, and information obtained from the survey contractor (quit rates, satisfaction with the cessation services provided). RESULTS HIGHLIGHTS: Twenty three agencies provided intensive cessation counseling to 5,574 Ohioans during the 2 month grant cycle. These adults were predominantly female (58%), white (82%), employed full time (53%), and had graduated from high school or had some college/technical school training (72%). The follow up contact rate was quite low (35% at 3 month and 3% at 6 month), likely due to the survey contractor having inadequate protocols for unreachable participants. Among those who responded at the 3 and 6 month follow up calls, 86% and 85% of respondents respectively indicated that they were either very satisfied or mostly satisfied with the services received. Across all grantees, quit rates for those responding to the survey was 44% at 3 months and 43% at 6 months post enrollment. A more conservative intent to treat approach yields overall program quit rates of 7% at 3 months and 4% at 6 months post enrollment. Intent to treat quit rates by grantee ranged from 27% at 3 months and 25% at 6 months post enrollment. SUMMARY: Grantees reached 73% (5574/7626) of the population they proposed. However, of the 23 funded grantees reached over % of their proposed numbers. According to the 26 Census data, the demographic distribution of the population served by OTPF grantees is generally representative of the population of Ohio in terms of gender, race, and education. However, in order to reduce tobacco across Ohio, future efforts should concentrate on capturing a less advantaged and/or more at risk population. Among the 3%+ of participants who were successfully contacted, the quit rate among community based cessation participants (at roughly 4%), was quite similar to national norms, and similar to rates obtained by the Ohio Quit Line. Although the follow up rate was less than desired, the centralized evaluation approach used for the CGIII grantees was a successful approach to use for obtaining real time, objective benchmarks of agency performance in reaching adult smokers who were ready to quit and providing effective cessation programming. Funding Amount $2,35,255 Number of Grantees Funded for this Strategy: 23 Agencies Funded: American Lung Association of Ohio NW Amethyst Inc. Athens City County Health Department Barberton Health Department Bucyrus Community Hospital Cuyahoga County Board of Health Family & Community Services (Wayne) Family & Community Services Family Services Association Deaf Greene County Combined Health Department Hamilton County GHD Holzer Medical Center Hospital Council of NW Ohio Ohio Hispanic Coalition Knox County Health Department Private Duty Svcs. (Van Wert Co) Stark County Health Department The Breathing Association Tuscarawas County Health Department Union County Health Department Upper Valley Medical Center Your Human Resource Center Zanesville Muskingum County Health Department Counties Served: Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

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57 Evaluation of CGIII Tobacco Prevention and Control Efforts STRATEGY 4: Intensive Adult Individual and/or Group Counseling for Cessation Goal: Cessation Background and Rationale The World Health Organization estimates that one billion people may die of tobacco related causes during the 2 st century. According to the Centers for Disease Control, smoking is the single most avoidable cause of disease, disability, and death in the United States. Research has consistently demonstrated that smoking cessation interventions can have a substantial effect on subsequent mortality Cessation strategies fall into three categories: providing brief advice (such as that provided by a physician), intensive multi session programs provided individually or in a group format, and telephone based cessation counseling. This chapter focuses on intensive adult cessation provided individually (one on one) or in a group setting. Both individual and group counseling has been shown to be effective in diverse populations, especially when combined with appropriate pharmacotherapy. According to the Clinical Practice Guideline, there is a dose response relationship between the intensiveness of tobacco cessation counseling and the effectiveness in successful long term quit rates. 2 The Clinical Practice Guideline suggests intensive cessation programming consist of sessions longer than ten minutes and four or more sessions. Effective cessation programs often include problem solving, skills training, intra treatment social support (e.g. encouragement), and extratreatment social support (e.g. support seeking behaviors). 2 Evaluation of Adult Intensive Cessation Programming Overview Grantees wishing to conduct intensive adult cessation programs were also required to structure their program to inform to Clinical Practice Guidelines 2, ensuring that the program included the components listed in the table below. Moreover, programs were to be delivered by trained and certified tobacco treatment specialists. Required Components of CGIII Adult Cessation Programs. Intake and Assessment: Collect individualized, comprehensive, and accurate data necessary to determine a course of action and treatment plan. 2. Treatment Planning: Identify goals, challenges and steps towards resolving challenges, resources and empirically based treatment strategies. Monitor and evaluate the client s progress, modifying the treatment plan as necessary. 3. Referral Services: Link clients to appropriate clinical and non clinical services to support the client s health and well being. Specifically, link clients to the Ohio Tobacco Quit Line using the fax referral system to refer interested patients to the Quit Line. Tobacco users should also be encouraged to access these services between counseling visits, throughout the course of treatment, and as a post treatment support service. Grantees must help ensure that clients who use the Quit Line for free or reduced cost NRT are also utilizing the counseling services of the Quit Line. Continued next page CGIII Program Evaluation Report (Jan Dec, 27) June, 28

58 Strategy: Intensive Adult Individual or Group Cessation Counseling 45 Required Components of CGIII Adult Cessation Programs (continued) 4. Pharmacotherapy Support and Guidance: Provide clear and accurate information about pharmacotherapy options available, their appropriate use and possible contraindications. Discuss type(s) of pharmacotherapy, encourage clients to talk with their health care provider and support clients in their use of pharmacotherapy treatments. The use of nicotine replacement therapy and other pharmacotherapy defined as first line by the Clinical Practice Guideline on Treating Tobacco Use and Dependence 2 should be encouraged, as well as any recently approved Food and Drug Administration (FDA) pharmacotherapies. 5. Counseling: Provide individual and/or group counseling as appropriate, applying accepted counseling theory and skills which facilitate treatment and recovery from nicotine addiction. a. The counseling program must include a minimum of four counseling sessions. Individual sessions should last no less than 2 minutes. Group sessions should last no less than 6 minutes. Grantees who are implementing evidence based programs, must implement the programs with fidelity in terms of number of sessions and program content. b. The sessions should be designed to build positive behavior change practices, including counseling at a minimum on the following topics: establishment of reasons for quitting, understanding nicotine addiction, various techniques for quitting and remaining a nontobacco user, discussion of stages of change, overcoming the problems of quitting (withdrawal symptoms, depression, etc.), and short term goal setting. c. Counseling on other topics such as weight management, including the importance of exercise, diet, and stress management, might also be included. d. The counseling program should operate under a written program/service outline, which, at a minimum should include: overview of service, service objectives and key topics covered, general teaching/learning strategies, clearly stated methods of assessing participant success, audio or visual materials that will be used, distribution plan for patient education materials and method for verifying enrollee attendance. e. The counseling program treatment strategies must be appropriate to the tobacco user s stage of change in the quitting process and must include services appropriate to the clients culture and language, and the social, psychological, and medical conditions that may affect tobacco use behavior. 6. Relapse Prevention: Systematically evaluate client progress after his/her quit date and provide information, guidance, and reinforcement to prevent relapse. 7. Follow up and Aftercare: Develop an aftercare plan that includes follow up to check tobacco use status at regular intervals. 8. Program Documentation and Recordkeeping: Develop a record keeping system to document patient and program progress, including the necessary forms to do so. When applicable, note patient progress in the centralized medical record (inpatient or outpatient). 9. Ensure Trained Personnel: At a minimum, cessation personnel must have one year of experience in providing direct cessation services.

59 Strategy: Intensive Adult Individual or Group Cessation Counseling 46 A number of cessation programs have been identified as meeting the above requirements, and were provided to the grantees for consideration:. University of Massachusetts 2. Fresh Start 3. Quitting Tobacco: A Life Changing Decision 4. Quit For Good 5. Mayo Clinic Model 6. Integrated Tobacco Treatment 7. Freedom From Smoking 8. Better Breathing Solutions 9. Cooper/Clayton Method. Freshmore Tobacco Program. Quit You Can/PAH 2. Win by Quitting In cycle III, 23 community agencies were funded to provide adult tobacco users with intensive cessation counseling, through either group or individual efforts. Nine agencies exclusively provided intensive group counseling, 4 agencies exclusively provided intensive individual counseling, and agencies offered both forms of tobacco cessation counseling to adults. In addition, two agencies focused on special populations (deaf adults and Hispanic adults). Evaluation Protocol Each class or group receiving cessation counseling was given a unique identifier. Agencies were asked to batch groups of individual counseling clients and attach a unique identifier to the batch. Agencies determined the most meaningful approach for batching individual counseling clients. Some batched individuals enrolling in counseling in a calendar week, while other batched by counselor. The unique class/batch identifiers were obtained by accessing a web based document management system called OTREC DM (see description in first chapter; screen shots in Appendix B). OTREC DM was designed to provide a means for tracking the voluminous amount of evaluation data in the CGIII evaluation effort: over 6, surveys for this strategy alone. The tracking provided was transparent to both the agencies and OTREC so that all parties could see what data had been received by OTREC and which evaluation data was still outstanding. All evaluation data were tracked on the individual class/batch level by agency. In addition to a clear, real time method of communication, OTREC DM proved a vital tool in obtaining complete data for accurate program evaluation. At enrollment, participants completed a baseline survey capturing demographic information, smoking history and readiness for behavioral change ( stage of change ) 3. Participants were also asked to provide OTPF, via its survey contractor, permission to be re contacted at 3 and 6 months after the completion of counseling. The 3 and 6 month telephone surveys ascertained current tobacco use status, satisfaction with services, whether the client used NRT, and quit intention for those not yet tobacco free. Results of the telephone survey were provided electronically to OTREC by Pegus for assimilation with other cessation data.

60 Strategy: Intensive Adult Individual or Group Cessation Counseling 47 Agencies provided OTREC with data on the type of counseling each individual received (group or individual) and indicated the setting of the services: business, community setting, hospital, health clinic, or health department. Agencies were required to provide relapse prevention telephone calls to clients 3 days after the initiation of programming to offer encouragement or additional services if needed. The programmatic approach was slightly altered for those serving special populations and one agency. Evaluation data collection tools (e.g., the adult baseline survey) were translated into Spanish for the Hispanic population and into a format more useful for signing to the deaf population. There were no follow telephone surveys conducted for either of the special populations due to language barriers. Therefore, we cannot report quit rates or satisfaction for the two special populations. At the request of OTPF, OTREC created a modified evaluation protocol for on grantee, The Breathing Association. The Breathing Association had an electronic data capture system in place prior to the implementation of the community grants centralized evaluation approach. OTREC adjusted the evaluation approach to accommodate electronic data transfers from The Breathing Association. Due to a serious breach in protocol in early 27, 69 Breathing Association clients were not consented for follow up telephone contact resulting in a deficit of quit rate and satisfaction data for this agency. Evaluation Tools Workplan (provided prospectively): Workplan data included the county or counties where cessation counseling was provided, indication of group or individual counseling, name of cessation program used, proposed reach, whether or not program facilitators were certified tobacco specialists or trained by certified tobacco specialists, whether or not free or reduced cost NRT was provided, percent of programming that was educational in nature, and topics covered in treatment program. Each agency was required to submit a separate work plan for group counseling and individual counseling. Activity Reports (submitted bi monthly): Activity reports included a description and approach to training or certification deficiencies, description of activities related to the cessation strategy, barriers, and lessons learned. Adult Baseline Survey and Follow Up Consent Form: The consent page contains the cessation participant s name, contact information, and a legal release allowing the OTPF survey contractor to contact the participant by phone following the first cessation program. The questionnaire, completed by each participant captures demography, stage of change, and tobacco use history. Both pages are faxed to OTREC using the fax back system as described in the first chapter.

61 Strategy: Intensive Adult Individual or Group Cessation Counseling 48 Class/Batch Info Sheet: A class/batch sheet was completed for each class of group counseling clients or each batch of individual counseling clients. A unique identifier, obtained via OTREC DM, was attached to each class for tracking purposes. The class/batch sheet listed the unique participant identification numbers for each individual in the class/batch and the site of the cessation counseling. Attendance log: Facilitators used the attendance log to record the number of counseling sessions (i.e., intervention dosage) received by each client as well as whether they conducted the 3 relapse prevention call. Results Process Outcomes 94% of workplans reported that all facilitators were trained by a certified cessation trainer. 36% of the workplans reported that all facilitators were certified tobacco treatment specialists. 64% of the workplans included provision of free NRT or other medications The average program was 4% educational (+ 25%, range 8%) with the remaining portion of the programming assumed to be counseling in nature. 94% of the workplans included post program relapse prevention follow up counseling. Program composition o % included weight management and the importance of exercise o 97% included stress management o 8% included carbon monoxide testing o 97% included proper use of NRT Population Served From January to December, 27, the community agencies provided intensive group and individual cessation services to 5,574 individuals within their local communities across the state. Table 4. below further describes the population, based on the 5557 adult baseline survey received (7 were not submitted). Slightly more men than woman received cessation counseling and the average age of participants was 45. (standard deviation = 2.4; range = 2 to 86). Eighty two percent identified themselves as white. While this number may seem high, according to the 26 Census, 84.5% of Ohioans are white. The majority of the population (72%) graduated high school or had some college/technical school training. A little less than half of the participants were

62 Strategy: Intensive Adult Individual or Group Cessation Counseling 49 married and 27% indicated that they were in fair or poor health. Seventy three percent had some form of health insurance coverage. Less than half (37%)of the participants had a least one child (<7 yrs) living in their home, and nearly half (46%) lived with a tobacco user. Table 4.. Characteristics of Cessation Counseling Participants Reached Jan Dec, 27 (n=5557)

63 Strategy: Intensive Adult Individual or Group Cessation Counseling 5 Twenty of these individuals were under the age of 8. It is likely that minors receiving cessation services were referred through the judicial or educational system. These minors are reflected in the reach numbers; however, they are not accounted for in the quit rates. Minors are unable to provide consent for follow up contact; this consent would have to have been obtained from a parent or guardian. Individuals from special populations, the deaf and the non English speaking Hispanic population, were also excluded from follow up telephone survey due to language barriers. Nearly all (99%) individuals benefiting from cessation counseling were Ohio residents. The remaining % is comprised of adults from Michigan (n=27), West Virginia (n=26), Kentucky (n=8), Indiana (n=), Florida (n=) and Minnesota (n=). Based on zip codes, geographic distribution of participants was mapped, as shown below. The darker the area, the more participants from that specific geographic area. The map below reveals the broad geographic reach of the OTFP community grants program. Figure 4.2. Geographic Distribution of Adult Cessation Participants According to Prochaska s Transtheoretical Model of Change 3, 47% of the adults entering into one of the community based cessation counseling programs were considered to be in preparation stage of behavioral change, as suggested by their reported intention to stop smoking in the next 3 days and having made at least one quit attempt in the past 2 months. Another 47% of individuals were considered to be in contemplation phase, as suggested by their intentions to quit in the next six months. The high prevalence of smokers with an intention to quit is not unexpected as it was recommended that agencies identify individuals in the preparation phase to enter counseling. The stage of change distribution was monitored over the course of the

64 Strategy: Intensive Adult Individual or Group Cessation Counseling 5 year. It was noticed midway through the grant year that agencies were not identifying the targeted number of individuals in the preparation change. The program staff relayed this to the agencies, and collectively the agencies were able to shift their reach more toward the desired population. Attendance Efforts were made to capture the number of counseling sessions attended by each client. This effort did prove to be challenging in some regards. A subset of clients attended the orientation session, completed the baseline demographic/consent survey and never returned for the intensive counseling. It was difficult at times to quantify the number of counseling sessions within the context of individual counseling because the number of sessions provided is determined by the number of sessions the individual client requires. The client may choose to return to the tobacco treatment specialist multiple times for boosters or continued support. Table 4.3 below provides estimates of attendance by cessation program and agency. Agencies were required to provide a relapse prevention call to clients 3 days after the initiation of cessation counseling. This was an opportunity to provide additional support or services to individuals still struggling with tobacco use. Table 4.3 also displays the degree to which agencies were able to provide the 3 day relapse prevention call. Table 4.3. Cessation Program, Attendance, and Relapse Prevention Call Status (Jan Dec, 27) Agency Program # Served Average Attendance Mean + SD (Range) % Who Received Relapse Prevention Call ALA of Ohio NW (Ayres) Freedom From Smoking ( 8) Amethyst Inc. Integrated Tobacco Treatment ( ) * Athens City County Health Department Freedom From Smoking ( 7) Barberton Health Department Freedom From Smoking ( ) Bucyrus Community Hospital Freedom From Smoking ( 8) Cuyahoga County Board of Health Freedom From Smoking ( 9) Family & Community Services (Portage) Freedom From Smoking ( ) 6 Family & Community Services (Portage) Mayo Clinic Model (2 8) 39 Family & Community Services (Wayne) Mayo Clinic Model ( 9) Family Service Assoc Deaf Quit You Can PAH! 3 *(*) * Greene County Combined Health Department Freedom From Smoking ( 8) Hamilton County General Health Department Win By Quitting ( 9) Holzer Medical Center Freedom From Smoking ( 8) 6 Holzer Medical Center Mayo Clinic Model ( ) 4

65 Strategy: Intensive Adult Individual or Group Cessation Counseling 52 Agency Program # Served Hospital Council of NW Ohio Better Breathing Solutions Average Attendance Mean + SD (Range) % Who Received Relapse Prevention Call (2 7) 96 Hospital Council of NW Ohio Freedom From Smoking ( 8) 37 Hospital Council of NW Ohio Knox County Health Department Medina County Board of Commissions University of Massachusetts ( ) 62 Mayo Clinic Model ( ) Freedom From Smoking ( 8) Ohio Hispanic Coalition Freedom From Smoking (4 7) Private Duty Services Mayo Clinic Model ( ) Stark County Health Department Freedom From Smoking ( 6) Stark County Health Freshmore Tobacco Department Program ( 4) Stark County Health University of Department Massachusetts (2 ) 9 The Breathing Association Quit For Good ( ) Tuscarawas County Health Department Freedom From Smoking ( 7) 44 Tuscarawas County Health Department Mayo Clinic Model ( ) 56 Union County Health ( 7) Freedom From Smoking 26 Department Upper Valley Medical Center Mayo Clinic Model ( 6) Your Human Resource Center Freedom From Smoking 6. + (6 6) Zanesville Muskingum County Quitting Tobacco: A Life Health Department Changing Decision ( 9) SD=standard deviation Satisfaction with Services Cessation counseling participants were contacted at 3 and 6 months after the initiation of programming to ascertain their smoking status and level of satisfaction with services provided. Approximately 2 weeks prior to the telephone survey, participants received a letter from OTPF notifying them that they would be called for the follow up survey and reminding them of the time and location of their cessation counseling. The survey contractor began survey calls approximately 2 weeks after the letters were mailed. The percent of individuals that the survey contractor was able to reach was disappointing. At 3 months, the contractor was able to survey 35% of the population attempted and 3% at 6 months. This response rate was impacted by the survey contractor s lack of a protocol for researching or updating unreachable participants. Respondents did have the opportunity to complete the survey via the internet, but this approach only yielded a 2% completion rate. Table 3 below further describes the outcome of follow survey call attempts.

66 Strategy: Intensive Adult Individual or Group Cessation Counseling 53 Table 4.4. Outcome Disposition of Follow Up Surveys Final Disposition Month 3 Calls Frequency N(%) N=2545 Generally, adults were satisfied with the counseling they received. Figure 4.5 below depicts participant satisfaction levels. At the 3 month follow up survey, 86% of the individuals surveyed indicated that they were either very satisfied or satisfied with the services provided to them and 85% at the 6 month survey. Only 2% of the respondents indicated that they were not at all satisfied with their cessation counseling at the 3 month call and only 3% were not at all satisfied at the 6 month call. Figure 4.5. Satisfaction with Programming at 3 and 6 Months Post Initiation Month 6 Calls Frequency N(%) N=595 Total completes Phone and Web 888 (35%) 492 (3%) Respondent refusal Hung up, refused, please never call 356 (4%) 247 (5%) Problem with contact information Wrong number, disconnected, moved, fax 546 (2%) 365 (23%) Respondent unreachable No answer, busy, answering machine, call back, deceased 72 (28%) 4 (25%) Barrier to survey completion Language, physical/mental, error 22 (%) 8 (%) Quit Rates Across all grantees, the average quit rate for individuals surveyed was 44% at month 3 and 43% at month 6. An intention to treat approach of all attempted contacts yields an overall quit rate of 7% at month 3 and 4% at month 6. These rates were determined based on the individual response when asked if they have used any form of tobacco in the last 7 days in any amount. Table 4.6 on the next page details the agency specific quit rates at both time points. As shown in the table, the two agencies with the most consistently effective

67 Strategy: Intensive Adult Individual or Group Cessation Counseling 54 cessation programming were Bucyrus Community Hospital (ITT=27% and 2% at 3 and 6 months respectively) and Zanesville Muskingum Co Health Dept (ITT=24% and 25%). OTREC is currently analyzing the full 8 month cessation data with follow up to examine which factors are most associated with successful outcomes (6 month quit rates), including type of cessation program, type and training of facilitator, dosage (number of sessions), participant characteristics, and use of NRT. Results will be posted to when completed. Summary and Recommendations Overall grantees reached 73% (5574/7626) of the population they proposed. However, of the 23 funded grantees reached over % of their proposed numbers. According to the 26 Census data, the demographic distribution of the population served by OTPF grantees is generally representative of the population of Ohio in terms of gender, race, and education. However, in order to reduce tobacco across Ohio, future efforts should concentrate on individuals with lower socioeconomic status (i.e., less educated, lower income). The true quit rate for the community based cessation participants is difficult to determine with the extremely low responder rate (i.e., % of people who follow up survey contractor actually talked to). This promises to be greatly improved for the six month extension of the CGIII program due to the replacement of the survey contractor in January, 28. The new contractor, SRG, has already reported contact rates that are twice that of Pegus, which conducted the follow up calls for the 27 program year. Among the 3%+ of participants who were successfully contacted, the quit rate among community based cessation participants (at roughly 4%), was quite similar to national norms, and similar to rates obtained by the Ohio Quit Line. Although the follow up rate was poor, the centralized evaluation approach used for the CGIII grantees was a successful approach to use for obtaining real time, objective benchmarks of agency performance in reaching adult smokers who were ready to quit and providing effective cessation programming. REFERENCES Anthonsen NR, Skeanns MA, Wise RA, Manfreda J, Kanner RE, Connett JE. The Effects of Smoking Cessation Intervention on 4.5 Year Mortality. Ann Inter Med. 25: 42: Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 28 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May Prochaska, J. O., & Velicer, W. F. (997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 2,

68 Table 4.6. Agency Funding, Reach Success and Quit Rates.* Agency Funding Reach (n, % of proposed) Month 3 Quit Rate Month 6 Quit Rate Group Individual Responder ITT Responder ITT ALA of Ohio NW (Ayres) $8, (58%) 23/57 (4%) 23/78 (3%) 7/22 (32%) 7/7 (%) Amethyst, Inc $5,78 68 (5%) 5/5 (%) 5/36 (4%) 5/5 (%) 5/24 (2%) Athens City County HD $53, (54%) 7 (34%) 2/5 (3%) 2/39 (5%) 4/2 (33%) 4/3 (3%) Barberton HD $5,677 9 (76%) 22/45 (49%) 22/ (2%) 3/3 (42%) 3/76 (7%) Bucyrus Community Hospital $26, (9%) 53/85 (62%) 53/97 (27%) /4 (79%) /56 (2%) Cuyahoga Co. Board of Health $67,76 47 (9%) 42/2 (4%) 42/246 (7%) 23/52 (44%) 23/49 (5%) Family & Comm Svcs (Wayne) $62, 75 (58%) 5 (3%) /3 (33%) /77 (3%) /3 /5 Family & Community Services (Portage) $3,7 27 (29%) 6 (7%) 5/34 (44%) 5/78 (9%) 8/2 (38%) 8/55 (5%) Family Service Assoc. Deaf $78,523 3 (52%) * * * * Greene Co. Combined HD $43, (2%) 9 (9%) 3/35 (37%) 3/92 (4%) /4 /7 Hamilton Co. General Health District $3,87 89 (45%) 9/8 (5%) 9/4 (23%) 4/ (4%) 4/44 (9%) Holzer Medical Center $24, 69 (56%) 64 (%) 28/72 (39%) 28/98 (4%) 2/38 (53%) 2/35 (5%) Hospital Council of NW Ohio $92, (56%) 52 (22%) 7/49 (48%) 7/398 (8%) 56/5 (48%) 56/38 (8%) Knox Co. HD $45, (66%) (25%) 9/32 (28%) 9/66 (4%) 6/6 (38%) 6/34 (3%) Medina Co. Board of Commissioners $46,48 37 (43%) ** ** ** ** Ohio Hispanic Coalition $26,73 75 (47%) * * * * Private Duty Services (Van Wert Co) $6, 39 (7%) 5 (85%) 8/46 (39%) 8/ (6%) 6/22 (27%) 6/55 (%) Stark Co. HD $27, 37 (37%) /3 / /3 /3 The Breathing Association $56,9 393 (7%) 46/2 (38%) 46/375 (2%) 27/84 (32%) 27/33 (8%) Tuscarawas Co Health Dept. $6,93 7 (82%) 2 (33%) 9/38 (5%) 9/92 (2%) 9/6 (56%) 9/49 (8%) Union County Health Department $9, (3%) 4/7 (57%) 4/5 (26%) /4 / Upper Valley Med Center $98, (95%) 9/4 (46%) 9/3 (5%) 5/28 (54%) 5/79 (9%) Your Human Resources Center $,576 ( proposed) (%) ** ** ** ** Zanesville Muskingum Co Health Dept $48, 2 (4%) 3 (3%) 3/2 (62%) 3/54 (24%) /2 (52%) /44 (25%) * Follow up telephone survey was not conducted for special populations **No participants enrolled before September 27 therefore no follow up data are available. CGIII Program Evaluation Report (Jan Dec, 27) June, 28

69 OVERVIEW: This strategy is one component of institutionalizing cessation interventions in health systems. By screening all patients for tobacco use, providing brief cessation interventions to tobacco users, documenting tobacco use status in patient medical records, and/or making referrals to appropriate quit services, more tobacco users receive the treatment needed for tobacco cessation. EVALUATION AND TOOLS: The evaluation component for this strategy assessed the extent to which grantees were working with their local health systems to establish policies to screen all patients for tobacco use, to provide brief cessation interventions to tobacco users, to document tobacco use status in patient medical records, and/or to make referrals to appropriate quit services. RESULTS HIGHLIGHTS: Fourteen community agencies were funded to establish policies in 57 health systems throughout the state of Ohio, including 25 hospitals, 8 other health systems, 2 public health clinics, one outpatient hospital site, and one private health clinic or office. Through the community grants program, 54 health systems received brief cessation intervention counseling, 7 of the health systems received bedside consultations, and 47 of the health systems used the Ohio Tobacco Quit Line s fax referral process to enroll patients into the Quit Line. 4,23 (25% of target) patients received brief intervention counseling and 3, 59 (25% of target) patients received bedside cessation counseling within health systems across the state. SUMMARY: Ohio Tobacco Prevention and Control Program CGIII Evaluation (Jan Dec, 27) Strategy: Policy and Brief Interventions Within Health Systems Programmatic Goal Area: CESSATION In 27, CGIII grantees provided brief intervention and bedside consultations to 43,82 patients in 55 health systems across Ohio, with many health systems well surpassing their original targeted reach. Through these efforts, agencies worked with health systems to help institutionalize brief intervention cessation services for patients throughout the state of Ohio. More importantly, the effort highlights the growing willingness of health care systems to screen patients for tobacco and look for ways to institutionalize the screening and brief interventions into their regular clinical practices. Funding Amount $562,776* Number of Grantees Funded for this Strategy: 4 Agencies Funded: Amethyst Inc. Barberton Health Department Bucyrus Community Hospital Cuyahoga County Board of Health Delaware Gen. Health Department Fairfield County Department of Health Hamilton County GHD Holzer Medical Center Hospital Council of NW Ohio Lake Geauga Ctr. On Alcoholism & Drug Abuse Upper Valley Medical Center Tuscarawas County Health Department The Breathing Association Women & Family Services *Funding amount includes this strategy & Trainingin health Professionals in Brief Interventions Counties Served: Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

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71 Evaluation of CGIII Tobacco Prevention and Control Efforts STRATEGY 5: Policy & Brief Interventions within Health Systems Goal: Cessation Background and Rationale The most recent version of the Clinical Guidelines for Treating Tobacco Use and Dependence, best summarizes the rationale behind Strategies 5 (Policy & Brief Interventions within Health Systems) and 6 (Training Health Professionals in Brief Cessation Interventions): The goal of.these guidelines is to change clinical culture and practice patterns to ensure that every patient who uses tobacco is identified, advised to quit, and offered scientifically sound treatments. The strategies underscore a central theme: it is essential to provide at least a brief intervention to every tobacco user at each health care visit. Responsibility lies with both the clinician and the health care system to ensure that this occurs Brief cessation interventions, which usually take 2 3 minutes, are an effective way for clinicians to identify smokers and assess their readiness to change. The 5 A s model states the patient should be: Asked about their smoking status, Advised to quit smoking if they are current smokers, Assessed for willingness to quit, Assisted with quitting, and Arranged for follow up with the patient. Most tobacco users visit some type of health care professional on a regular basis and yet this intervention is not routinely used. Tobacco control policy advocates and researchers suggest that if health care systems would institutionalize the use of a method to identify smokers, such as the 5 A s, they would have a large impact on the public s health, both with regard to the smoker and those exposed to the smoker s secondhand smoke. The goal of Strategy 5 was to direct the community based grantees that either were health care systems themselves or worked directly with local health care systems (broadly defined as (including hospitals, health departments, treatment programs, dentist offices, etc.) to work towards the goal of institutionalizing cessation interventions within the system. Specifically, OTPF was interested in learning to what extent grantees could succeed in assisting the health systems establish policies to screen all patients for tobacco use, to provide brief cessation interventions (5 A s) to tobacco users, to document tobacco use status in patient medical records, and/or to make referrals to appropriate quit services. Evaluation of Adult Intensive Cessation Programming Overview: The evaluation component for this strategy assessed the extent to which grantees have established policies to screen all patients for tobacco use, to provide brief cessation interventions to tobacco users, to document tobacco use status in patient medical records, and/or to make referrals to appropriate quit services. Data were collected for each health system that received funding or housed services through the OTPF grant. Evaluation Tools: The evaluation tools and respective data collected via this tool are outlined below: Workplan (provided prospectively): County or counties where health system is located, annual inpatient admissions, annual outpatient admissions, annual clinic visits, type of health system, and CGIII Program Evaluation Report (Jan Dec, 27) June, 28

72 Strategy: 7/3/28 Policy & Brief Interventions within Health Systems 58 services provided at health system. Grantees also reported on the presence of tobacco free policy that prohibits the use of all tobacco products in all indoor and outdoor locations, campus wide smokefree policy that prohibits smoking in all indoor and outdoor locations, or designated smoking areas for employees, patients, or visitors on each health system s workplan. Finally, grantees reported on whether or not they would be administering brief cessation intervention counseling, providing bedside consultations, and/or using the Ohio Tobacco Quit Line s fax referral process to enroll patients into the Quit Line for each health system. Each agency was required to submit a separate work plan for each health system. Activity Reports (submitted bi monthly): Description and approach to ensure all patients are screened for tobacco use, patient medical records are flagged for tobacco use, brief cessation interventions are provided to tobacco users, and referrals are made to intensive cessation services at the health system. Grantees also provide a description of activities related to the policy and brief intervention within health systems, barriers, and lessons learned. Results Progress Reports (submitted bi monthly): Reach of patients that received brief cessation intervention counseling and bedside consultations. Process Outcomes OTPF funded 4 community agencies to provide 57 health systems with patient screening for tobacco use, providing brief cessation interventions to tobacco users, documenting tobacco use status in patient medical records, and/or making quit service referrals. Twenty five of the health systems served were hospitals, 8 of the health systems served were other health systems, 2 of the health systems served were public health clinics, one of the health systems served was an outpatient hospital site, and one of the health systems served was a private health clinic or office. Table 5.. List of Local Health Systems Identified by Grantees by Types Grantee Funding Health System Type Private Health Clinic Holzer Clinic Holzer Medical Center $2,. or Office Holzer Consolidated Health Systems Hospital Carroll County Health Department Public Health Clinic Tuscarawas County Health Holmes Health Clinic Public Health Clinic Department $49,64. Tuscarawas County Health Clinic Public Health Clinic Twin City Hospital Hospital Upper Valley Medical Center $2,85. Upper Valley Medical Center Hospital The Breathing Association $4,. Columbus Children's Hospital Hospital Columbus Public Health Other Health System Delaware General Health District Public Health Clinic Fairfield Medical Center Hospital

73 Strategy: 7/3/28 Policy & Brief Interventions within Health Systems 59 Grantee Funding Health System Type Licking Memorial Health Systems Hospital Maryhaven Other Health System Mount Carmel Health Systems Hospital Columbus Neighborhood Health Centers Hospital OhioHealth Doctors Hospital Hospital OhioHealth Grant Hospital Hospital OhioHealth Riverside/McConnell Heart Health Center Outpatient Hospital Site The Breathing Association Other Health System Union County Health Department Other Health System Bucyrus Community Hospital $2,38. Bucyrus Community Hospital Hospital Galion Community Hospital Hospital Akron General Medical Center Hospital Barberton Health District $7,984. Barberton Citizens Hospital Hospital Summa Health Systems Hospital Fisher Titus Medical Center Hospital Mercy Health Partners Hospital Hospital Council of Northwest Ohio $35,79.5 St. Luke's Hospital Hospital St. Rita's Medical Center Hospital The Toledo Hospital Hospital Wood County Hospital Hospital Cuyahoga County Board of Health $77,69.92 Lakewood Hospital Hospital MetroHealth Medical Center Hospital Northwest Ohio Regional Dental Clinic Other Health System Fulton County Health Department Other Health System Henry County Health Department Other Health System Women and Family Services, Inc. Other Health System Women & Family Services, Inc. $48,9. Help Me Grow Defiance County Other Health System Help Me Grow Putnam County Other Health System Help Me Grow Fulton County Other Health System Help Me Grow Henry County Other Health System Help Me Grow Paulding County Other Health System Help Me Grow Williams County Other Health System Amethyst, Inc. $2,634. Amethyst, Inc. Other Health System Price Hill Clinic Public Health Clinic Hamilton County General Health $66,465. NORCEN Behavioral Health Systems, Inc. Other Health System District Talbert House Other Health System Lake Geauga Center on Alcoholism & Drug Abuse, Inc. $34,836. Lake Hospital System Hospital Fairfield County Department of $44,62.7 Fairfield Department of Health Public Health Clinic Health Hocking County Health Department Public Health Clinic

74 Strategy: 7/3/28 Policy & Brief Interventions within Health Systems 6 Grantee Funding Health System Type Delaware General Health District $8,26. Licking Policy and Brief Intervention Perry County Health Department Pickaway County General Health District Ross County Health District Vinton County Health Department Delaware General Health District Grady Memorial Hospital Ohio Health Public Health Clinic Other Health System Public Health Clinic Public Health Clinic Public Health Clinic Public Health Clinic Hospital Health systems varied in the services they provided their patients. Forty health systems provided primary care; 28 health systems provided prenatal care; 26 health systems provided pediatric care; 7 health systems provided mental health services or treatment; 4 health systems provided substance abuse treatment; and 2 health systems provided routine dental care. Twenty seven of the health systems have a campus wide tobacco free policy that prohibits the use of all tobacco products in all indoor and outdoor locations. Of the thirty health systems without a campus wide tobacco free policy, five of these health systems had a campus wide smoke free policy that prohibits smoking in all indoor and outdoor locations. Of the thirty health systems without a campus wide tobacco free or smoke free policy, twenty health systems had designated smoking areas for employees, patients, or visitors. As a part of the grant, 54 of the health systems will be receiving brief cessation intervention counseling, 7 of the health systems will be receiving bedside consultations, and 47 of the health systems will be using the Ohio Tobacco Quit Line s fax referral process to enroll patients into the Quit Line. Table 5.2. Types of Tobacco Related Policies and Interventions Provided by Each Health System Grantee Holzer Medical Center Tuscarawas County Health Department Upper Valley Medical Center The Breathing Association Health System Quit Line Referral Bedside Consult Brief Intervention Designated Areas Smoke Free Policy Tobacco Policy Pediatric Care Dental Care Prenatal Care Mental Health Substance Abuse Primary Care Holzer Clinic Y Y Y Y Y Y Y Y Holzer Consolidated Health Systems Y Y Y Y Y Y Carroll County Health Department Y Y Y Y Y Y Holmes Health Clinic Y Y Y Y Y Y Y Tuscarawas County Health Clinic Y Y Y Y Y Y Y Y Twin City Hospital Y Y Y Y Y Upper Valley Medical Center Y Y Y Y Y Y Y Y Y Columbus Children's Hospital Y Y Y Y Y Y Y Columbus Public Health Y Y Y Y Y Y Y Y Delaware General Health District Y Y Y Y Fairfield Medical Center Y Y Y Y Y Y Y Licking Memorial Health Systems Y Y Y Y Y Y Y Y

75 Strategy: 7/3/28 Policy & Brief Interventions within Health Systems 6 Grantee Health System Maryhaven Y Y Y Y Y Y Mount Carmel Health Systems Y Y Y Y Y Columbus Neighborhood Health Ctrs Y Y Y Y Y Y Y Y OhioHealth Doctors Hospital Y Y Y Y Y Y OhioHealth Grant Hospital Y Y Y Y Y Y OhioHealth Riverside/McConnell Heart Health Center Y Y Y Y The Breathing Association Y Y Y Y Union County Health Department Y Y Y Y Y Bucyrus Community Bucyrus Community Hospital Y Y Y Y Y Hospital Galion Community Hospital Y Y Y Y Akron General Medical Center Y Y Y Y Y Y Y Y Barberton Health Barberton Citizens Hospital Y Y Y Y Y Y Y District Summa Health Systems Y Y Y Y Y Y Y Y Y Fisher Titus Medical Center Y Y Y Y Y Y Mercy Health Partners Y Y Y Y Y Y Hospital Council of St. Luke's Hospital Y Y Y Y Northwest Ohio St. Rita's Medical Center Y Y Y Y Y Y Y Y The Toledo Hospital Y Y Y Wood County Hospital Y Y Y Y Y Y Cuyahoga County Lakewood Hospital Y Y Y Y Y Y Y Y Y District Board of Health MetroHealth Medical Center Y Y Y Y Y Y Y Y Northwest Ohio Regional Dental Clinic Y Y Y Y Fulton County Health Department Y Y Y Y Henry County Health Department Y Y Y Y Women and Family Services, Inc. Y Y Y Y Women & Family Help Me Grow Defiance County Y Y Y Services, Inc. Help Me Grow Putnam County Y Y Y Help Me Grow Fulton County Y Y Y Help Me Grow Henry County Y Y Y Help Me Grow Paulding County Y Y Y Help Me Grow Williams County Y Y Y Amethyst, Inc. Amethyst, Inc. Y Y Y Y Price Hill Clinic Y Y Y Y Y Y Y Hamilton County NORCEN Behavioral Health Systems Y Y Y Y General Health District Talbert House Y Y Y Y Y Lake Geauga Ctr on Alc & Drug Abuse, Inc. Lake Hospital System Y Y Y Y Y Y Y Y Primary Care Substance Abuse Mental Health Prenatal Care Dental Care Pediatric Care Tobacco Policy Smoke Free Policy Designated Areas Brief Intervention Bedside Consult Quit Line Referral

76 Strategy: 7/3/28 Policy & Brief Interventions within Health Systems 62 Grantee Health System Fairfield Department of Health Y Y Y Y Hocking County Health Department Y Y Licking Policy and Brief Intervention Y Y Y Fairfield County Perry County Health Department Y Department of Health Pickaway County General Health District Y Y Ross County Health District Y Vinton County Health Department Y Y Delaware General Delaware General Health District Y Y Y Health District Grady Memorial Hospital Ohio Health Y Y Y Y Y Y Primary Care Substance Abuse Mental Health Prenatal Care Dental Care Pediatric Care Tobacco Policy Smoke Free Policy Designated Areas Brief Intervention Bedside Consult Quit Line Referral Population Served Within Health Systems: From January December, 27, grantees (primarily through subgrantees affiliated with the health system) provided brief intervention counseling to 4,23 patients and bedside consults to 3,59 patients within health systems across the state. Of the 55 health systems where grantees administered brief cessation intervention counseling, 29 health systems achieved a 75% or more of their targeted reach with many health systems far exceeding their targeting reach. Only ten health systems achieved less than a quarter of their target reach with three health systems not administering brief cessation intervention counseling. Of the 7 health systems where grantees provided bedside consultations, 5 health systems achieved a 75% or more of their targeted reach with four health systems far exceeding their targeting reach. Only one health systems achieved was unable to provide bedside consultations. Table 5.3. Brief Interventions Within Health Systems: Program Reach by Grantee (Jan Dec, 27) Grantee Holzer Medical Center Tuscarawas County Health Department Health System Target Patient Counseling Number of Patients Counseled % Target Bedside Consults Number of Bedside Consults Holzer Clinic 2, 8, % Holzer Consolidated Health Systems Carroll County Health Department,932 2,735,25.% % 4, % Holmes Health Clinic, % Tuscarawas County Health Clinic 4, 4,63 4.% Twin City Hospital 5, 3, % %

77 Strategy: 7/3/28 Policy & Brief Interventions within Health Systems 63 Grantee Upper Valley Medical Center The Breathing Association Bucyrus Community Hospital Barberton Health District Hospital Council of Northwest Ohio Health System Upper Valley Medical Center Columbus Children's Hospital Columbus Public Health Delaware General Health District Fairfield Medical Center Licking Memorial Health Systems Target Patient Counseling Number of Patients Counseled % Target Bedside Consults Number of Bedside Consults 75,6 66.3% % % % % % % Maryhaven % Mount Carmel Health Systems Columbus Neighborhood Health Centers OhioHealth Doctors Hospital OhioHealth Grant Hospital OhioHealth Riverside/McConnel l Heart Health Center The Breathing Association Union County Health Department Bucyrus Community Hospital Galion Community Hospital Akron General Medical Center Barberton Citizens Hospital Summa Health Systems Fisher Titus Medical Center Mercy Health Partners % % % % % % 38.% % 7 7.% % % 2, %,.% 2,4 7, % 4, % St. Luke's Hospital 4,5, % St. Rita's Medical Center 4,928 4, % %

78 Strategy: 7/3/28 Policy & Brief Interventions within Health Systems 64 Grantee Cuyahoga County District Board of Health Women & Family Services, Inc. Health System Target Patient Counseling Number of Patients Counseled % Target Bedside Consults Number of Bedside Consults The Toledo Hospital Wood County Hospital, % Lakewood Hospital 3, % MetroHealth Medical Center Northwest Ohio Regional Dental Clinic Fulton County Health Department Henry County Health Department Women and Family Services, Inc. Help Me Grow Defiance County Help Me Grow Putnam County Help Me Grow Fulton County Help Me Grow Henry County Help Me Grow Paulding County Help Me Grow Williams County 2, 24, % % % % % % % % % % % Amethyst, Inc. Amethyst, Inc % % Hamilton County General Health District Lake Geauga Center on Alcoholism & Drug Abuse, Inc. Fairfield County Department of Health Price Hill Clinic 4, % NORCEN Behavioral Health Systems, Inc. 33, % Talbert House % Lake Hospital System Fairfield Department of Health Hocking County Health Department Licking Policy and Brief Intervention Perry County Health Department 2,5 2,796.8% 2, 2, %, 2, % 2, 5, %, 6,6 66.% %

79 Strategy: 7/3/28 Policy & Brief Interventions within Health Systems 65 Grantee Delaware General Health District Health System Target Patient Counseling Number of Patients Counseled % Target Bedside Consults Number of Bedside Consults Pickaway County General Health 2, % District Ross County Health District 7, % Vinton County Health Department % Delaware General Health District % Grady Memorial Hospital Ohio 3,35.% 7.% Health Totals,676 4, % 2,445 3,59 25.% % Barriers and Lessons Learned: In bi monthly reports, grantees reported on successful strategies and some of the commonly encountered barriers. Scheduling and Competing Priorities Several grantees identified scheduling and competing priorities as barriers to implementing patient screening for tobacco use, brief cessation interventions to tobacco users, documentation of tobacco use status in patient medical records, and/or quit service referrals in health. Capacity Building Several of the grantees implemented a funded policy and brief interventions within health systems for the first time during this grant cycle. Some grantees noted that they were not prepared to implement brief intervention and bedside consultations in some health systems. As a result, three health systems were unable to achieve any of their targeted reach. Summary and Recommendations In 27, CGIII grantees provided brief intervention and bedside consultations to 43,82 patients in 55 health systems across Ohio with many health systems well surpassing their original targeted reach. Through these efforts, agencies worked with health systems to help institutionalize brief intervention cessation services for patients throughout the state of Ohio. More importantly, the effort highlights the growing willingness of health care systems to screen patients for tobacco and look for ways to institutionalize the screening and brief interventions into their regular clinical practices. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 28 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 28.

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81 Ohio Tobacco Prevention and Control Program CGIII Evaluation (Jan Dec, 27) Strategy: Training Health Professionals in Brief Interventions Programmatic Goal Area: CESSATION Funding Amount $562,776* Number of Grantees Funded for this Strategy: 4 RATIONALE: Most tobacco users visit some type of health professional on a regular basis and yet brief interventions are not routinely used. Tobacco control policy advocates and researchers suggest that if health care systems institutionalized the use of a method to identify smokers, such as the 5 A s, they could have a large impact on the public s health, both with regard to the smoker him/herself and those exposed to the smoker s secondhand smoke. Thus, this strategy is one component of a large OTPF goal of institutionalizing cessation interventions in health systems. EVALUATION TOOLS: The evaluation component for this strategy was process focused, identifying the number of persons trained, the estimated number of patients who will benefit from the trainings, and the satisfaction level of those trained. This information was obtained from workplans, activity reports, and satisfaction surveys completed by trainees. RESULTS HIGHLIGHTS: Fourteen agencies were funded to provide brief intervention training to workers in their local health systems using the 5 A s model. The most frequently trained health care professionals were nurses (45.6% of all trainees). In addition to nurses, physicians, dentists, respiratory therapists, social workers, volunteers, and other support staff were also trained. Based on survey information, trainees estimated they would provide brief interventions to approximately 444,54 people, located in 35 counties across the state, primarily in a hospital or clinic. Agencies Funded: Holzer Medical Center Tuscarawas Upper Valley Medical Center The Breathing Association Bucyrus Community Hospital Barberton Health District Hospital Council of Northwest Ohio Cuyahoga County Board of Health Women and Family Services, Inc. Amethyst, Inc. Hamilton County General Health District Lake Geauga Center on Alcoholism and Drug Abuse, Inc. Fairfield County Department of Health Delaware General Health District * Funding amount includes this strategy as well as Policy and Brief Interventions Within Health Systems Counties Served: SUMMARY: As a result of the grantees efforts, 2,55 health care professionals were trained during the 27 grant period. Recommendations for the future would be to assess the current level of brief interventions currently being conducted in health systems, and assessing these practices for thoroughness, consistency & effectiveness, and the degree to which they are providing refresher training for those already trained. In addition, grantees reported a desire from various hospitals and medical offices to receive free or low cost cessation services for their lower SES patients (as a higher number of their smokers met these criteria); recommendations on how grantees can address these issues might prove beneficial. Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

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83 Evaluation of CGIII Tobacco Prevention and Control Efforts STRATEGY 6: Training Health Professionals in Brief Cessation Interventions Goal: Cessation Background and Rationale Research finds that over two thirds of smokers see a physician each year, and almost a one third see a dentist., 2. However, smokers also see physician assistants, nurse practitioners, nurses, physical and occupational therapists, pharmacists, counselors, and other clinicians 3. Therefore, virtually all clinicians are in a position to intervene with patients who use tobacco. Going hand in hand with Strategy 5, this strategy focuses specifically on educating and training health professionals on the importance and effectiveness of brief cessation counseling with all smoking patients within its system, as well as providing brief intervention training using the 5 A s model, all intended ensure that tobacco use is systematically assessed and treated at every clinical encounter. Evaluation Plan for Training in Brief Interventions Overview: Fourteen agencies were funded to provide brief intervention training to workers in their local health systems using the 5 A s model. The evaluation component for this strategy was process focused, identifying the number of persons trained, the estimated number of patients who will benefit from the trainings, and the satisfaction level of those trained. Evaluation Tools: Workplan (provided prospectively): Grantees reported on the county or counties where trainings were to be provided, how many workers were to be trained by type (e.g., physicians, nurses, social workers, etc), and whether or not the OTPF Physician Quit Kit would be a part of the training. Reach Reports and Activity Reports (submitted bi monthly): Grantees reported on the number of individuals trained during that reporting period, as well as any changes made to the program, barriers, and lessons learned. Satisfaction Surveys: RE Coordinators were provided with evaluation materials to create packets for each individual training session (survey administration instructions, surveys, and packet labels). Each packet was to include survey implementation instructions and enough copies of the satisfaction survey for each individual to be trained. The survey was to be administered at the end of the training session. The survey assessed the characteristics of the individuals being trained to deliver the 5 A s, the potential number of patients who will benefit, comfort level with the material provided in the training, and confidence in delivery of the 5 A s. All surveys were to be returned in the packet to the RE coordinator within 48 hours. The RE Coordinator then faxed the completed surveys to the OTREC Fax Data Entry Line. A copy of the survey is included in Appendix E. CGIII Program Evaluation Report (Jan Dec, 27) June, 28

84 Strategy: 7/3/28 Training Health Professional in Brief Cessation Interventions 68 Results Fourteen agencies provided brief intervention training, of which 3 indicated they used the OTPF Physician Quit Kit as a component of the training. Grantees originally proposed training,955 health professionals; however, 2,55 health care professionals were trained, representing 28.3% of the expected program reach. The figure below depicts the number of people trained by job title. The most frequently trained health care professionals were nurses (45.6% of all trainees). Figure 5.. Number of health care professions trained by job title (n=255) The health care professionals were asked to provide an estimate of the number of individuals they would conduct the 5 A s training within in the next year, as well as the location (health care setting and Ohio counties) where the brief interventions would take place. The 2,55 trained individuals estimated that they would provide the brief interventions with 444,54 people, located in 35 counties across the state. With regard to health care setting, most reported the intervention would take place in a hospital or clinic, followed by a more modest estimate for other settings, such as practitioner office, community setting, or worksite. This distribution is depicted in the figure below. Figure 5.2. Proposed setting where trained health care professionals will provide brief interventions

85 Strategy: 7/3/28 Training Health Professional in Brief Cessation Interventions 69 At the completion of the training, individuals were first asked how comfortable they were with the materials presented as part of the training. As shown in the figures below, the vast majority (77.8%) reported being very comfortable with the training materials provided. However, when asked how confident they felt in being able to provide the 5 A s intervention at their respective institution, they were less confident. Nonetheless, nearly all of the respondents reported being very or somewhat confident, with over half (6.%) feeling very confident that they could put the 5 A s into practice what they learned in the training. Figure 5.3: Trainees Comfort with the Brief Intervention Training Materials Provided Figure 5.4: Confidence of Trainees That They Could Successfully Implement the 5 A s Intervention. Summary of Activity Reports Activities at a Glance: Hiring staff, networking, planning/preparation, scheduling training dates Prior to providing any of the trainings, grantees had to ensure that they were equipped with the staff necessary to prepare for and provide training. Preparation for training included tasks such as developing policies & procedures for providing training, creating databases to track contacts & trainings, reviewing and preparing Ohio Quit Kits physician manuals, & creating presentation materials. Grantees also had to determine which sites were a target for providing the 5 A s training. This involved networking & meeting with various people and organizations in addition to assessing the current treatment plans for patients who are tobacco users. Once these steps were taken, training regarding use of the 5 A s, including instructions on how to make a proper referral, could begin. Physician pocket cards with the 5 A s, pharmacotherapy and dosing, quit kits, and program marketing materials were often given out at trainings. Barriers at a Glance: Time, weather, creating training materials, obtaining support for the 5 A s, competing priorities While examining barriers reported in the activity reports, time was frequently noted as a barrier to providing training to health professionals. Planning and setting up for trainings was often very time consuming and for some grantees, staff time to plan and train professionals was limited. Working with various departments procedures for managing documents required more staff time as they needed to take different approaches and create new proposals and outlines. Several grantees noted difficulty scheduling times with health care professionals as many had competing obligations or were difficult to reach (holidays, bad weather, and family

86 Strategy: 7/3/28 Training Health Professional in Brief Cessation Interventions 7 emergencies of staff made scheduling trainings difficult as well). The following , sent to a grantee, was included in the activity report and exemplifies the struggle with scheduling trainings: I am sorry that it has taken so long to reply but it has been absolutely crazy around here lately. Unfortunately, we have not been able to arrange a meeting room and it really doesn t look like we will have the time to host any in service times either due to the increase demands on our unit. We need to concentrate on patient care and getting ready for Joint Commission and would not be able to devote the attention your educational offering would need. There is a possibility that our nursing education department would be interested. Otherwise we can aim for the first of next year. Thank you for your generous offer. Providing training for the 5 A s was hindered by several other factors such as health care professionals in hospital systems who did not believe in nicotine replacement therapy, skepticism about the fax referral system, and lack of familiarity with the Quit Line and with other local resources. Clinical Health Services was on board with the 5 A s at first, then the department heard that the program was unallowable for the child and family health services grant. The Clinic felt it could not make a commitment due to staffing. During a meeting with the Director of Operations, it was made clear that the clinical health services department would only be responsible for 3 A s and an R. The Director of Operations met with the Director of Clinical Health Services to explain the brief intervention process. This meeting assisted with Clinical Health Services willingness to become trained. Other barriers included finding ways to identify health care professionals that would be interested in learning about the 5 A s brief intervention. Once they were identified, they had to find ways to educate professionals in a way that was easy, accessible, and convenient for professionals. It also proved difficult to get support from physicians and departments throughout hospitals to provide training during work hours and to obtain permission to do random chart audits. Lessons Learned: Partnerships, incentives, preparation, & patience Grantees shared insights into what they learned to help make training professionals a success. The general themes were partnerships, incentives, preparation and patience. Agencies reported that it took not only time but patience and effort in order to be able to provide such a service. Being patient and willing to work on the timeline of others was important. As stated by one grantee: Don t underestimate how much time is needed in the planning stages of setting up trainings. Various meetings and phone calls take much time and are imperative to planning a successful training. When partnering with so many agencies to offer such training, much time is needed so individuals have time to complete various tasks. Grantees learned several ways to increase the number of attendees at trainings, such as offering continuing education credits, providing food/beverages at trainings, and promotion of the event through fliers. When providing the actual trainings, grantees learned to keep them brief as limited time was a major factor for lack of attendance and to tailor their presentation based on the audience. Grantees also learned that forming

87 Strategy: 7/3/28 Training Health Professional in Brief Cessation Interventions 7 partnerships and working with others was beneficial to gaining entry to various health systems and getting things done. Summary and Recommendations In the beginning of the grant year, fourteen agencies were selected to provide training in brief interventions to health care professionals. Providing training and implementing the 5 A s in a health system requires staff, time, resources, and patience. As a result of the grantees effort, 2,55 health care professionals were trained during the 27 grant period. Physicians represented only a small number (n=23) of health care professionals trained, fitting with the lack of physician time that grantees reported on. While nurses were the largest group of professionals trained, there were a substantial number of individuals who classified themselves as other. These individuals included administrators, supervisors, volunteers, transporters, and office support staff such as unit secretaries. This could have been due to the fact that some health systems required all staff (even those who had no contact with patients) to attend the trainings provided. Other health care professionals that attended training sessions included health educators, nurse s assistants, medical assistants, technicians, and dietitians. In addition to training professionals, it would be recommended that in the future the interventions being conducted in health systems be assessed for thoroughness, consistency and effectiveness, and the degree to which they are providing refresher training for those already trained. In addition, grantees reported a desire from various hospitals and medical offices to receive free or low cost cessation services for their lower income patients (as a higher number of their tobacco users met these criteria); recommendations on how grantees can address these issues might prove beneficial. References Centers for Disease Control and Prevention. Physician and other health care professional counseling of smokers to quit United States, 99. MMWR 993;42: Drilea SK, Reid BC, Li CH, et al. Dental visits among smoking and nonsmoking US adults in 2. Am J Health Behav 25;29: Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 28 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 28.

88 Table 5.5. Brief Interventions: Grantee Funding and Program Reach Success (Jan Dec, 27) Agency Funding Counties Physicians Nurses Dentists Reach (N, % of proposed) Respiratory Therapists Social Workers Holzer Medical Center $2,. Gallia, Jackson, Meigs 76(76%) 392(96%) 6(2%) 28(28%) 3(%) Tuscarawas $49,64. Upper Valley Medical Center The Breathing Association $4,. Bucyrus Community Hospital Carroll, Holmes Tuscarawas $2,85. Miami Delaware, Fairfield, Franklin Licking, Union 5(93%) 6(38%) (9 proposed) 98(27%) 5(5%) (4%) $2,38. Crawford (2%) (6%) Barberton Health District $38,62. Summit 64(75%) 95(58%) Hospital Council of NW Ohio Cuyahoga County Board of Health Women & Family Services, Inc Amethyst Hamilton County General Health District Lake Geauga Center on Alcoholism and Drug Abuse, Inc. Fairfield County Health Department Delaware General Health District $35,79.5 Lucas Wood $77,69.92 Cuyahoga $48,9. $2,634. Defiance, Fulton, Henry, Paulding Putnam, Williams Athens, Coshocton, Cuyahoga, Defiance, Delaware, Franklin, Geauga, Licking, Lorain, Portage, Tuscarawas, Van Wert 5 ( proposed) (5 proposed) 75(875%) 26(2%) ( proposed) 4(93%) (5 proposed) (3 proposed) (2 proposed) ( proposed) ( proposed) (5 proposed) ( proposed) ( proposed) ( proposed) (3 proposed) ( proposed) (4 proposed) 5(25%) 4(7%) 4(2%) 2(8%) (%) (2%) (3 proposed) Other 347 (,735%) 3 (5%) 44 (628%) 3 (6%) /5 proposed) 8(6%) 3(65%) 28(2%) 27(54%) (3 proposed) ( proposed) $66,465. Hamilton (6%) 2(5%) (25%) ( proposed) $34,836. $44,62.7 $8,26. Ashtabula, Geauga, Lake Fairfield, Hocking, Licking, Perry Pickaway, Ross, Vinton 3(2%) (73%) (2 proposed) 28(93%) Delaware (5 proposed) (66%) ( proposed) ( proposed) ( proposed) ( proposed) ( proposed) 89 ( proposed) (2 proposed) 2(2%) 29(29%) (4%) (2%) 4(4%) ( proposed) 24(6%) 24(8%) 3(6%) 44(92%) ( proposed) 5(83%) 29(3%) (2 proposed) 2(33%) 6(2%) CGIII Program Evaluation Report (Jan Dec, 27) June, 28

89 OVERVIEW: Nicotine replacement therapy (NRT) products provide users with nicotine without the harmful carcinogens or gases found in tobacco products. They come in the form of gum, patches, inhalers, nasal sprays, and lozenges and aid in reducing withdrawal symptoms faced by smokers attempting to quit. Research has shown that NRT coupled with smoking cessation counseling increases the likelihood of a successful quit attempt. This CGIII strategy was intended to increase program sustainability by obtaining local employer support for NRT. EVALUATION PLAN: To collect qualitative information regarding the specific approaches grantees intended to use to obtain local employer support for providing NRT and to examine their successes, barriers, and experiences to provide future programmatic recommendations with regard to this strategy. RESULTS HIGHLIGHTS: Ohio Tobacco Prevention and Control Program CGIII Evaluation (Jan Dec, 27) Strategy: Employer Support for NRT Programmatic Goal Area: CESSATION Seven grantees indicated they would advocate for employer support for NRT (without providing on site cessation services); ten grantees stated they would recruit employers to become a part of the OTPF NRT Employer Partnership Program, and ten of the seventeen grantees indicated they would work with employers to provide NRT for workers who participated in the grantee conducted cessation programs. General activities included contacting employers to promote a smoke free workplace, informing them of the Quitline, smoking cessation classes, and NRT. Barriers included lack of interest at times by both employers and employees as well as the cost of NRT. Funding Amount $358,387 Number of Grantees Funded for this Strategy: 7 Agencies Funded: Bucyrus Community Hospital Community Action for Capable Youth Cuyahoga County Board of Health Delaware General Health District Family and Community Services Holzer Medical Center Hospital Council of NW Ohio Knox County Health Department Lake Geauga Center on Alcoholism and Drug Abuse Medina County Board of Commissioners Rural Opportunities Inc Selby General Hospital The Breathing Association Tuscarawas County Health Department Union County Health Department Upper Valley Medical Center Your Human Resource Center Counties Served: SUMMARY: Qualitative data collected from activity reports showed the primary factors which drove efforts of grantees were aggressive marketing and promotion as well as continued communication with businesses. Grantees compiled local business information, prepared mailings which included various information regarding cessation and NRT, and attended employer and community health fairs as well as company meetings to increase visibility and awareness. These efforts combined contributed to the grantees success in obtaining employer support for NRT. Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

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91 Evaluation of CGIII Tobacco Prevention and Control Efforts STRATEGY 7: Employer Support for NRT Goal: Cessation Background and Rationale Nicotine replacement therapy (NRT) provide users with nicotine without the harmful carcinogens or gases found in tobacco products. NRT comes in the form of gum, patches, inhalers, nasal sprays, and lozenges and aid in reducing the withdrawal symptoms smokers face when attempting to quit smoking. Research has shown that NRT coupled with smoking cessation counseling increases the likelihood of a successful quit attempt, 2. This CGIII strategy was intended to increase cessation program sustainability by obtaining local employer support for NRT. Seventeen agencies were funded for this strategy. Evaluation Plan for Employer Support for NRT Programmatically, it was unclear as to how the grantees could best approach this strategy. A number of grantees had proposed partnering with the Quit Line and the OTPF sponsored Employer Partnership Program that worked with leading healthcare insurance plans, employers, and pension funds to provide qualified callers with free NRT. However, the approaches and methods were far from standard and as a result, the evaluation plan for this strategy was to collect qualitative information regarding the specific approaches grantees intended to use to obtain employer support and to examine their successes, barriers, and experiences to provide future programmatic recommendations. At the beginning of the funding year, grantees completed work plans in G Wiz that outlined their proposed efforts toward gaining employer support for NRT during the grant year. Grantees also submitted bi monthly activity reports, which allowed them to report on progress, significant changes, barriers, and lessons learned during the reporting periods. Results Activities: Plans for promoting the benefits of supporting NRT General activities included contacting employers to promote a smoke free workplace, informing them of the Quit Line, smoking cessation classes, and NRT. As shown in the graph below, 7 of the 7 grantees stated that they would advocate for employer support for NRT (without providing any cessation services); of the 7 stated that they would recruit employers to become a part of the OTPF NRT Employer Partnership Program, and of the 7 stated that they would work with employers to provide NRT for employees who participated in the grantee conducted cessation program. * As indicated initially on the work plan CGIII Program Evaluation Report (Jan Dec, 27) June, 28

92 Strategy: Employer Support for NRT 8 Barriers: Un preparedness, Lack of interest, Lack of Participation, Cost of NRT As somewhat expected, grantees faced numerous issues in their attempt to engage local employers in providing their workers with NRT. For at least one agency, Quit Kits & Employer Tool Kits were not received in the beginning of the grant year delaying progress toward this strategy. Some agencies also faced changes in staffing. A delay in the budget process slowed down the hiring process for staff that would recruit employers and coordinate cessation services to them. In addition, several grantees underestimated the amount of staff, as well as time necessary, to move forward with this strategy. Some grantees reported that promoting a tobacco free worksite as well as support for NRT was met with resistance by employers for a variety of reasons. For some businesses and companies, tobacco cessation was simply not high on their priority list. Some grantees reported that they met with employer representative who were smokers themselves, and were resistant or unwilling to share NRT partner information with major decision makers for the worksite. Often, the people that staff work with are not the level of management that make a decision as to whether or not the business can become an NRT partner shares the information and benefits of the program to the contact person, and stresses the importance of having upper management support the program. However, it often seems the discussion ends as it has to be discussed at length (due to the financial commitment) with other staff who are not present. Another common frustration of grantees was the amount of time and effort spent recruiting employers, only to find that, in the end, the employer was unwilling to make a commitment to provide NRT to their workers. The perception of grantees was that this often reduced the time available to reaching out to other potential employers. During discussions with local employers, grantees often found employers unwilling to address policy change, and a lack of familiarity with or understanding of NRT. Once an employer did agree to offer the services, grantees faced additional barriers. Employees were not taking advantage of the services offered. Some employees were just not interested in the cessation classes. Grantees surmised that employees who were not willing to take advantage of the free classes were not likely take advantage of NRT. Other reasons for lack of attendance from interested employees included work schedules or a busy family life, as well as lack of transportation. Some agencies worked towards eliminating this barrier by bringing the classes to interested employees. Cost was another common barrier grantees reported when trying to recruit employers to provide services. They all say they will consider helping with the costs, but do not follow through. This issue needs to be addressed. Perhaps the foundation can give tips in how to effectively succeed with this task. Our main goal is to help the smokers by providing onsite classes and NRT s, but we don t want to upset their employer by asking them to cover the costs of NRT s. How far do we take this? There was a drastic difference in the amount of financial help employers were willing to provide in order to help their employees quit smoking. Some employers would only provide time and space for the cessation

93 Strategy: Employer Support for NRT 8 classes while others allowed up to $8 for each employee to use for tobacco cessation. It was difficult for several grantees to try to convince employers that the long run NRT costs would be far less than health care costs of an employee with lung cancer. Without financial support for NRT many employees could not afford it. One grantee offered NRT free with attendance at the Fresh Start classes to eliminate this problem. Lessons Learned: Building connections, alternatives to NRT, insurance changes Grantees learned the value of making connections. First, grantees found it was helpful to build a relationship with businesses before attempting to offer them services. Developing a good relationship with businesses was important to determine if they were ready to make a commitment. This also allowed grantees to learn who the real decision makers were for the company. Second, developing a connection with smokers was crucial as grantees could not rely on human resources and management alone to ensure employee interest in services. Through providing these services, grantees learned of additional reasons for lack of interest in NRT. Some employees did not want any nicotine in their body; other employees who were prescribed Chantix did not believe they needed NRT because they reported no cravings. Chantix was also seen as a better alternative since many insurance companies are now covering the cost. Grantees also learned that changes in insurance, refusal to insure or increasing premiums for smokers, affected attempts to quit smoking. While some agencies believe it caused many to consider quitting, one agency felt the opposite was occurring more people were hiding the fact that they were smokers. One company began giving discounts to their health insurance premiums for being tobacco free; since then, the number of employees coming forward to receive cessation services have dropped. Table 7.2. Agency Funding for Employer Support of NRT Agency Funding Bucyrus Community Hospital $2,38. Community Action for Capable Youth $7,57.52 Cuyahoga County Board of Health $,44.5 Delaware General Health District $3,966. Family and Community Services (Portage) $6,8. Holzer Medical Center $2,. Hospital Council of NW Ohio $53,79.5 Knox County Health Department $8,48. Lake Geauga Center on Alcoholism and Drug Abuse $6,4. Medina County Board of Commissioners $67, Rural Opportunities Inc $3,96. Selby General Hospital $9,5. The Breathing Association $23,4. Tuscarawas County Health Department $4,227. Upper Valley Medical Center $2,95. Your Human Resource Center $3,572.4

94 Strategy: Employer Support for NRT 82 Summary and Recommendations Grantees initially indicated they would advocate for employer support for NRT without providing on site cessation services, recruit employers into the OTPF NRT Employer Partnership Program, and/or advocate for employers to pay for NRT for onsite cessation programs grantees facilitated. In the beginning of the grant year it was unclear exactly how grantees would achieve these goals. Qualitative data collected from activity reports showed the primary factors which drove their efforts were aggressive marketing and promotion, as well as continued communication with businesses. Grantees compiled local business information; mailed packets which included information on the Quit Line, Issue 5, services available, and who to contact for services; and, attended employer and community health fairs as well as company meetings (where appropriate) to increase visibility and awareness. These efforts combined contributed to the grantees success in obtaining employer support for NRT. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 28 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May Tinkelman, D, Wilson, SM, Willett, J, Sweeney, CT 27. Offering free NRT through a tobacco quitline: impact on utilisation and quit rates. Tobacco Control, 6: i42 46.

95 Ohio Tobacco Prevention and Control Program CGIII Evaluation (Jan Dec, 27) Strategy: Promotion of Ohio Quits Programmatic Goal Area: CESSATION Funding Amount $769,784* Number of Grantees Funded for this Strategy: 5 OVERVIEW: Increasing tobacco users awareness of cessation services is a vital component to any successful tobacco control program. Ohio Quits is the umbrella term that OTPF uses to refer to all of its supported cessation services. Including the Ohio Quit Line, the faxreferral system used by health professionals, community based cessation classes, and individualized cessation counseling provided through the health systems. EVALUATION & TOOLS: The evaluation component for this strategy was largely qualitative, designed to provide OTPF with information regarding specific approaches used by grantee used promote Ohio Quits, as well as the barriers they faced in its promotion. The actual documentation of how many Quit Kits were distributed or the number of health care professionals trained are included in the next strategy, Distribution of Quit Kits. The promotion of Ohio Quits was also addressed through the grantee s Marketing Plan, which is being evaluated by another OTPF evaluator and is not included in this report. Agencies Funded: ALL 5 GRANTEES WERE FUNDED FOR THIS STRATEGY. *Funding amount includes Distribution of Quit Kits & Promotion of Ohio Quits RESULTS HIGHLIGHTS: General activities within this strategy included community promotional efforts and contacting healthcare workers and workplaces to promote the Ohio Quits program using the Quit Kits provided to them by OTPF, informing them of 8 QUIT NOW and smoking cessation programs. Barriers included contacting, scheduling, and getting physicians interested in the Quit Kit program and getting workplaces to use the QuitLine. SUMMARY: While agencies were largely successful at promoting cessation services to their community, grantees struggled with outreach to area healthcare facilities, workplaces, and citizens due to scheduling difficulties and interest in services. The primary factors which drove efforts of grantees were aggressive marketing and promotion as well as continued communication with businesses, healthcare settings, and involvement in community events. Grantees compiled local business information, prepared mailings which included Quit Kit information, and attended employer and community health fairs, as well as conducting office visits with area employers and healthcare workers. Many agencies struggled in defining the goals of the strategy and determining how to best implement promotion in their community. Many agencies felt that more direction was needed for this strategy. Counties Served: Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

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97 Evaluation of CGIII Tobacco Prevention and Control Efforts STRATEGY 8: Promotion of Ohio Quits Goal: Cessation Background and Rationale Increasing tobacco users awareness of cessation services is a vital component to any successful tobacco control program. During the past decade, the number of alternative cessation approaches has grown significantly, with one of the fastest growing approaches being telephone based counseling offered through toll free quitlines. Recent research confirms that value of these approaches with studies showing that individuals using quitlines being significantly more successful at long term (more than six months) cessation than those receiving minimal (self help), or no counseling.,2 Research further confirms that individuals who combined medication (nicotine replacement, pharmacological therapies) and counseling report some of the highest success rates. Ohio Quits is the umbrella term that OTPF uses to refer to all of its supported cessation services. During the CGIII cycle (Jan Dec, 27), Ohio Quits currently includes the Ohio Tobacco Quit Line ( 8 QUIT NOW) and local cessation programs facilitated by OTPF grantees. a All grantees were required to promote Ohio Quits services in their communities. Promotion of Ohio Quits for CGIII grantees included: promotion of the Quit Line and 8 QUIT NOW in the community; promotion of existing cessation services in the community; distribution of Quit Line physician quit kits that include the grantee ID; training health care professionals in the use of Quit Line fax referral processes; and, participating in future Ohio Quits initiatives and promotion of future Ohio Quits services. Evaluation of Promotion of Ohio Quits The evaluation component for this strategy was largely qualitative, designed to provide OTPF with information regarding specific approaches used by grantee used promote Ohio Quits, as well as the barriers they faced in the promotion. The actual documentation of how many Quit Kits were distributed or the number of health care professionals trained are included in the next strategy, Distribution of Quit Kits. The promotion of Ohio Quits was also addressed through the grantee s Marketing Plan, which is being evaluated by another OTPF evaluator and is not included in this report. Evaluation Tools: Workplan (provided prospectively): Grantees proposed the county or counties where the Ohio Tobacco Quit Line and cessation services would be promoted. a In 28, Ohio Quits was recently expanded significantly to offer a coordinated, centralized process by which individuals seek and receive cessation treatment and support. However, activities related to this expanded program are not included in this report. CGIII Program Evaluation Report (Jan Dec, 27) June, 28

98 Strategy: Promotion of Ohio Quits 85 Activity Reports (submitted bi monthly): Grantees reported on any significant changes from the proposed workplan, summary of strategy activities, lessons learned and barriers to achieving the goals of their workplan. Barriers and Lessons Learned In bi monthly reports grantees reported on some of the commonly encountered barriers to the promotion of Ohio Quits strategy. In the first reporting period, many of the agencies reported that their primary barrier was receiving the new Quit Kits in time to promote the materials in their community. In fact, all 5 of the agencies were delayed in this strategy as Quit Kits were not distributed by OTPF until the end of the first reporting period. In following reporting periods, many grantees stated that getting additional Ohio Quit materials was a problem. Some grantees noted having to make photocopies of Quit Kit materials while waiting for orders to arrive. Other grantees reported that materials were incorrect or missing from subsequent orders. One grantee reported the following situation, Ohio Tobacco Quit line pamphlets were requested and pamphlets for the Colorado Quit line were received. When a call was made to the Ohio Tobacco Quit Line about the error, they said that someone would call back and no one did. The pamphlets were finally received but with delay. Pamphlets were ordered again and 3 were requested, only were received with no explanation for the low number received. In addition to getting materials, more than one agency reported that their marketing plan had not been approved at the end of the first reporting period. As one grantee noted during the first reporting period, Waiting to meet with the marketing specialist and review the action plan has taken a considerable amount of time and has limited our time to implement this goal. Establishing contact with the marketing firm was also problematic. One grantee reported, We have contacted Clary Communications by several times to review our marketing plan and provide us with feedback and have not received that feedback yet. Additionally, other agencies felt that once the marketing plan had been developed, it took a great deal of time to develop advertisements to use for marketing. Many agencies reported that working with the uninsured was a barrier as nicotine replacement therapy could only be offered to individuals with health insurance using Ohio Quits. As one grantee reported, One of the huge barriers that the coordinator is finding is that people with no insurance cannot receive the nicotine patches through the Ohio Quit Line The coordinator has referred a lot to the Ohio Quit Line, but some have been told that because they do not have insurance, they do not qualify. Those are the people we are trying to reach and help in this battle. Some agencies had to develop individualized procedures for working with the uninsured. Related to this, when working in the low socioeconomic population, utilizing a program that is dependent on individuals having a telephone can also be very difficult. One agency wrote, The low SES [often] do not have a telephone or a friend is their message telephone or they get a new boyfriend and live at a home with a different phone number. They are difficult to contact for follow up.

99 Strategy: Promotion of Ohio Quits 86 While working with underserved populations, agencies experienced a variety of barriers. For one agency, the need for an interpreter made working with the deaf population a barrier. In working with youth, one agency wrote, There are no cessation opportunities for teenagers. I frequently have parents asking [about] programs for kids, but, unfortunately, we don't have anything available The pamphlets do not appeal to younger smokers i.e years old. Another grantee experienced difficulty in the Latino population, Latino smokers have been rejecting to be referred to [the] Ohio Quit Line because they are afraid to provide personal contact information. For another agency working with Ohio s Asian population, they stated, many of the promotional materials may be better received if translated or presented more culturally appropriate images. This continues to be a major challenge for promoting the Ohio Quits line in AAPI communities. Finally, for non native English speakers, utilizing the Quit Line can be a difficult process, as described below: The initial conversation had to be in English to ask for an [language] interpreter. The Ohio Quits Line person had not heard of the language [that was requested] but put the conversation on hold and got an AT&T interpreter for a 3 way conference call There is a lot of personal information asked (address, age, education, date of birth, phone number, marital status, if caller is pregnant, etc.) and the client felt a little uneasy giving the information in a conference call situation. The initial phone call information session lasted about 45 minutes(twice as long as normal with the interpreting time). Then the Ohio Quits Line person said he would get a counselor and call the client back in a few minutes. He called back in approximately 5 minutes and transferred the client to a counselor and new interpreter. The new interpreter was not as good as the first one. Some translation was lost and at times the information was not accurately transferred to the counselor and client The counseling session took hour and minutes With the interpreting time, it would be hard to shorten the time of the sessions. However, one agency highlighted an advantage for pregnant women: working with new mothers was also problematic, one grantee noted, New mothers (parents) can participate in the Ohio Quit Line without leaving the home, which is usually difficult after the new baby goes home In the past we have not had much success with pregnant women or post delivery parents. Many agencies reported having difficulties in getting other workplaces to utilize the Quit Line. Some worksites were willing to display project materials, but would not personally promote the Quit Line. One agency reported this barrier as a human resources issue, [It is] difficult to get businesses to utilize the fax referral form. It is not likely that this will be added to the job of Human Resource Department [employees]. Even [businesses with] a nurse onsite, do not see the fax referral as their job. Additionally, a few agencies reported that worksites were resistant to promote the Quit Line if the organization already had an established cessation program. Grantees themselves thought this was an issue. As one agency stated, It appears that there is a competition between the Quit Line and the Grantees local tobacco cessation programs. Also, the Outreach Program and the Quit Line seem to be competing for the Grantees referrals. For some agencies, the promotion of Ohio Quits was met with opposition by worksites that were not enforcing the newly passed Smokefree Ohio Law. As the Ohio government had to establish policies for enforcement and

100 Strategy: Promotion of Ohio Quits 87 a penalty schedule in the months after the law was passed, some businesses were still allowing patrons and employees to smoke. Businesses that were not enforcing the Smokefree Ohio Law were also not supportive of efforts to promote Ohio Quits. In bi monthly reports grantees reported on successful strategies and lessons learned in the Promotion of Ohio Quits process. For many grantees, the most common lesson learned was one of patience, flexibility, and preparation. As one grantee noted, It is important to promote the Quit Line in multiple types of settings, where some of the same tobacco users might hear the information multiple times the consistent message moves them closer to quitting. Another agency added, Use any opportunity available to work with groups or individuals to promote cessation efforts. Numerous grantees also mentioned the importance of following up with initial contacts and maintaining contacts with area businesses and health professionals. As one grantee noted, Keep businesses and health professionals aware of tobacco cessation programs that are available and ways to incorporate them in a company wellness program. A few grantees reported that in establishing contact with area physicians or worksites, telephone calls were more effective than sending letters or visiting places without appointments. Many grantees noted that if connections to physicians or worksites were not successful, other avenues of entry could be pursued. Some agencies noted that working with office managers and human resource departments were more effective than trying to contact the physicians or dentists themselves. When these strategies have been exhausted, agencies turned to alternative points of outreach. Grantees turned to other healthcare, social service, and other nonhealthcare organizations, with one grantee finding success in nursing home setting. As one grantee stated, Medical personnel are very busy and it is nearly impossible to meet with them one on one. Therefore we will market these in May June on the radio show and other public areas for interest where we can get the word out in our rural setting. Another grantee looked to nursing homes as a method of community outreach. Many grantees looked for ways to maximize community outreach. When visiting offices to schedule Quit Kit trainings, some grantees leave promotional materials for Ohio Quits in the waiting area. Another agency distributed promotional materials at worksite scheduling and policy meetings. Many agencies utilized colleagues and co workers to disseminate information about the Quit Line to the public through word ofmouth and promotional materials. In an effort to reach all area county employees, one grantee used payroll stuffers with promotional materials. Agencies reported the promotion of Ohio Quits at community events was an effective way to reach the public. I have the best success with promoting the Quit Line when I am in community settings actually talking to and interacting with people in attendance. The grassroots approach may not bring huge numbers at each event, but I believe people are being reached that may not otherwise be 'found'. Also, they tell their family members, who tell their friends, etc. I believe that being where they worship, where they shop, where they go to school, etc. is most effective for hard to reach groups. Even community outreach to other agencies was important, Collaborating with other community agencies allows me to discuss the Quit Kits with large numbers of staff, answer questions, and engage them in the

101 Strategy: Promotion of Ohio Quits 88 process. A few agencies reported promoting the Quit Line as an adjunct to the cessation classes currently being taught in their community. For many grantees, accessing or working directly with the Quit Line helped them to promote it more effectively in their community. One grantee noted that by contacting Ohio Quits, they were able to learn the exact procedures for those who are referred. Another grantee added, We contacted Ohio Quit Line to have a better understanding of it. It is going to be helpful for us and our clients because we are going to explain them clearly how to access and take advantage of this service. In regards to insurance efforts, one agency stated, We learned during this period information about how insurance carriers who are partners with the Quit Line promote this partnership. The impression of several employers whose insurance carriers are partners is that the insurance carrier does only minimal promotion of this service to its members/employees. As a result, we determined that periodic updates provided to employees would serve the important purpose of reminding employees of the Quit Line and the resource that is available to them and their family members. Yet, other agencies felt that more information was still needed. As one agency noted, I've learned, unfortunately, that even though the quality of the counseling service may be effective and of a high quality, the process for referring and enrolling participants is very problematic and ineffective and the representatives at the Quit Line don't seem to have any interest in solving the problems. Another grantee felt that more information was needed from insurance companies partnering with Ohio Quits, stating, It would be helpful to know what sort of promotion the insurance companies who are partnering with the Ohio Quit Line are doing so that our promotion with entities using these insurance companies can complement other promotional activities. Summary and Recommendations In the beginning of the grant year, fifty agencies were asked to promote Ohio Quits services in their communities. While agencies were largely successful at promoting cessation services to their community, grantees struggled with outreach to area healthcare facilities, workplaces, and citizens due to scheduling difficulties and interest in services. Further, many agencies struggled in defining the goals of the strategy and determining how to best implement promotion in their community. Many agencies felt that more direction was needed for this strategy. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 28 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May Tobacco.Guide to Community Preventive Services Website. Centers for Disease Control and Prevention. Last updated: 6/4/25. Accessed on: May, 28.

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103 Ohio Tobacco Prevention and Control Program CGIII Evaluation (Jan Dec, 27) Strategy: Distribution of Quit Kits Programmatic Goal Area: CESSATION OVERVIEW: Research has shown that physicians and other health professionals can be highly instrumental in moving smokers along the pathway to cessation. One successful and cost effective way is for health professionals to guide their patients to the statewide tobacco quit lines. Thus, like other states, OTPF developed a fax referral system, whereby physicians and other health professionals could fill out a referral form on behalf of a patient who expressed a desire to quit, and fax it to the Ohio Quit Line. Upon receipt, the Quit Line then contacts the individual to encourage them to enroll in the telephone cessation counseling program. In order to encourage physicians and health professionals to use the fax referral system, OTPF then created Quit Kits, or packets of promotional materials (e.g., brochures, posters), instructions (for both the referring physician or health professional and the smoker) and a tablet of fax referral forms. EVALUATION & TOOLS: The evaluation component for this strategy identified the number of Quit Kits distributed and assessed the training that was provided to health professionals receiving the Quit Kits. The primary outcome indicator for performance on this strategy was the total number of physician fax referrals received by the Quit Line, with the attributable grantee identification number. RESULTS HIGHLIGHTS: A total of 8,845 Quit Kits were distributed in the state of Ohio over the course of the year, including 28.2% (2,494) to physician s offices, 9.8% (,576) to community based organizations, 4.5% (,286) to hospitals,.8% (,49) health clinics, 7.7% (683) to health departments, 9.9% (,757) of the Quit Kits were distributed to other locations. A total of 7,95 health professionals were trained in the use of Quit Kits over the course of the year, including 27.5% (2,79) who were nurses, 9.3% (,529 physicians, 2.2% (,6) other health professionals, 6.3% (,288) community agency representatives, 6.% (475) dentists, and.% (884) other professionals. A total of,838 fax referrals were received statewide via the Quit Kit Referral System over the course of the year. Of those referred, 25.4% (466) were contacted and patients enrolled in cessation programming, 3.8% (253) were reached, but declined cessation programming, and 4.% (76) were reached, but elected to receive information only, and 56.7% (,83) were unreachable after five attempts. Barriers included contacting, scheduling, and getting health care professionals interested in the Quit Kit program. A few grantees reported that all of their referrals were not received or counted. SUMMARY: The distribution of Quit Kits strategy was an important component of the Ohio Quits Program, increasing physician and other health professionals awareness of the Quit Line and the role they could play in their patient s tobacco cessation. Over 8, kits were distributed and nearly as many professionals were trained, potentially reaching tens of thousands of smokers. However, less than 2, referrals were received by the Quit Line and far fewer patients actually enrolled in the cessation program. Future efforts must be spent on determining how to better engage physician practices, as well as ensuring successful delivery of all fax referrals. Funding Amount $769,784* Number of Grantees Funded for this Strategy: 5 Agencies Funded: ALL 5 GRANTEES WERE FUNDED FOR THIS STRATEGY. *Funding amount includes Distribution of Quit Kits & Promotion of Ohio Quits Counties Served: Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

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105 Evaluation of CGIII Tobacco Prevention and Control Efforts STRATEGY 9: Distribution of Quit Kits Goal: Cessation Background and Rationale Research has shown that physicians and other health professionals can be highly instrumental in moving smokers along the pathway to cessation. One successful and cost effective way is for physicians and other health professionals to guide their patients to the statewide tobacco quit lines. Thus, like other states, OTPF developed a fax referral system, whereby physicians and other health professionals could fill out a referral form on behalf of a patient who expressed a desire to quit, and fax it to the Ohio Quit Line. Upon receipts of the fax referral form, the Quit Line contacted the individual and engaged them in the telephone cessation counseling program, making up to five attempts to contact the patient. In order to encourage physicians and health professionals to use the fax referral system, OTPF then created Quit Kits, or packets of promotional materials (e.g., brochures, posters), instructions (for both the referring physician or health professional and the smoker) and a tablet of fax referral forms. Every CGIII grantee was funded to distribute the Quit Kits at various community locations (physician offices, health clinics, health departments). An essential component of the distribution of Quit Kits was to ensure that the recipient, physician/health professional understood the fax referral process and were able to identify patients who were ready to quit (e.g., expressing a desire to quit in the next 3 days). Thus, this strategy involved both the distribution of the kits, as well as training the individuals who would use the system. Fax referral forms were marked with a grantee specific number so that successful faxed forms could be tracked and attributed to a particular grantee. Evaluation of Distribution of Quit Kit Overview: The evaluation component for this strategy identified the number of Quit Kits distributed and assessed the training that was provided to health professionals receiving the Quit Kits. The primary outcome indicator for performance on this strategy was the total number of physician fax referrals received by the Quit Line, with the attributable grantee identification number. Another goal of the evaluation of this strategy was to provide OTPF with information regarding the success of the fax referral system. It was unknown whether () physicians and health professionals would use the system, and (2) whether patients would actually enroll in the telephone cessation counseling programs offered by the Quit Line. Evaluation Tools: Workplan (provided prospectively): Grantees reported on data included anticipated number of Quit Kits to be distributed in physician offices, hospitals, health clinics, health departments, communitybased organizations, and other locations and projected number of physicians, nurses, dentists, other health professionals, community agency representatives, and other recipients to be trained in use of Quit Kits. The work plan also included a description of the training Quit Kit recipients would receive and county or counties where Quit Kits would be distributed. CGIII Program Evaluation Report (Jan Dec, 27) June, 28

106 Strategy: Distribution of Quit Kits 9 Activity Reports (submitted bi monthly): Grantees reported on changes in settings or sites as proposed in their workplan, other significant changes from workplan, summary of strategy activities, lessons learned and barriers to achieving the goals of their workplan. Results Progress Reports (submitted bi monthly): Grantees reported on the number of Quit Kits distributed in physician offices, hospitals, health clinics, health departments, community based organizations, and other locations and number of physicians, nurses, dentists, other health professionals, community agency representatives, and other recipients trained in use of Quit Kits during the bi monthly reporting period. Evaluation Reports (submitted bi monthly): The Quit Line provided OTREC with grantee specific information on the number of fax referrals received, the number of individuals enrolled, number of individuals unreachable, number who declined to participate, and the number who requested to receive information only from the Quit Line, declining to participate in the full telephone cessation counseling program. Process Outcomes: Distribution of Quit Kits A total of 5 grantees submitted 5 workplans for distribution of Quit Kits. As shown in the table below, a total of 8,845 Quit Kits were distributed in the state of Ohio over the course of the year. Of the distributions, 28.2% (2,494) of the Quit Kits were distributed to physician s offices. 9.8% (,576) to community based organizations, 4.5% (,286) to hospitals,.8% (,49) health clinics, 7.7% (683) to health departments, and finally, 9.9% (,757) of the Quit Kits were distributed to other locations. Agency Name Table 9.. Distribution of Quit Kits by Grantees (Jan Dec, 27) Doctor s Office Hospital Health Clinic Health Dept. Comm. Org. Alpha Comm. Services American Lung Assoc. of Ohio American Lung Assoc. of Ohio NW Region Amethyst, Inc Asian American Comm. Services Asian Services In Action, Inc Athens City Co. Health Dept Barberton Health Dist Bucyrus Comm. Hospital City of Refuge Point of Impact Columbus State Comm. College Columbus Urban League Community Action for Capable Youth Cuyahoga Co. Board of Health Delaware General Health Dist Fairfield Co. Dept. of Health (7 Counties) Family & Community Services, Inc. (Portage Family & Community Services, Inc. (Wayne ) Other Total

107 Strategy: Distribution of Quit Kits 92 Agency Name Doctor s Office Hospital Health Clinic Health Dept. Comm. Org. Family Guidance Center Family Service Assoc. Comm. Services for the Deaf/Deaflink Greater Cleveland Health Education & Service Council Greene Co. Combined Health Dist Hamilton Co. General Health Dist Holzer Medical Center Hospital Council of NW Ohio Knox Co. Health Dept Lake Geauga Center on Alcoholism & Drug Abuse, Inc Lorain City Health Dept Mahoning Co. Dist. Board of Health Medina Co. Board of Commissioners Miami Valley Health Improvement Council Noble Co. Health Dept Ohio Hispanic Coalition Pathways of Licking Co Pike Co. General Health Dist Private Duty Services, Inc Project Linden Recovery & Prevention Resources Rural Opportunities, Inc Selby General Hospital Stark Co. Health Dept The Alcohol & Chemical Abuse Council The Breathing Association Tuscarawas Co. Health Dept UMADAOP ,937 Union County Health Department Upper Valley Medical Center Women & Family Services, Inc Your Human Resources Center (Holmes Co.) Zanesville Muskingum Co. Health Dept Statewide Totals: 2,494,286,49 683,576,757 8,845 Other Total Process Outcomes: Training Health Professionals in Use of Quit Kits Grantees were responsible not only for distribution of the Quit Kits, but also to provide training to the health professionals on the use of the referral system, and to encourage health professionals to assess patients for readiness to quit, referring only those who have an intention to quit in the near future. As shown in the table below, a total of 7,95 health professionals were trained in the use of Quit Kits over the course of the year. Of the training sessions, 27.5% (2,79) of the health professionals trained were nurses,

108 Strategy: Distribution of Quit Kits % (,529) were physicians, 2.2% (,6) were other health professionals, 6.3% (,288) were community agency representatives, 6.% (475) were dentists, and finally,.% (884) were other professionals. Table 9.2. Training Provided to Health and Other Professionals in Use of Quit Kits (Jan Dec, 27) Agency Name Doctor Nurse Dentist Other Prof. Comm Rep. Alpha Comm. Services American Lung Assoc. of Ohio American Lung Assoc. of Ohio NW Region Amethyst, Inc Asian American Comm. Services Asian Services In Action, Inc Athens City Co. Health Dept Barberton Health Dist Bucyrus Comm. Hospital City of Refuge Point of Impact Columbus State Comm. College Columbus Urban League 6 8 Community Action for Capable Youth Cuyahoga Co. Board of Health Delaware General Health Dist Fairfield Co. Dept. of Health (7 Counties) Family & Community Services, Inc. (Portage Co.) Family & Community Services, Inc. (Wayne Family Guidance Center Family Service Assoc. Comm. Services for the Deaf/Deaflink Greater Cleveland Health Education & Service Council Greene Co. Combined Health Dist Hamilton Co. General Health Dist Holzer Medical Center Hospital Council of NW Ohio Knox Co. Health Dept Lake Geauga Center on Alcoholism & Drug Abuse, Inc Lorain City Health Dept Mahoning Co. Dist. Board of Health Medina Co. Board of Commissioners Miami Valley Health Improvement Council, Inc Noble Co. Health Dept Ohio Hispanic Coalition Pathways of Licking Co Pike Co. General Health Dist. Private Duty Services, Inc. (Van Wert Co.) Project Linden Recovery & Prevention Resources 58 8 Other Total

109 Strategy: Distribution of Quit Kits 94 Agency Name Doctor Nurse Dentist Other Prof. Comm Rep. Rural Opportunities, Inc Selby General Hospital Stark Co. Health Dept The Alcohol & Chemical Abuse Council The Breathing Association Tuscarawas Co. Health Dept UMADAOP Union County Health Department Upper Valley Medical Center Women & Family Services, Inc Your Human Resources Center (Holmes Co Zanesville Muskingum Co. Health Dept Statewide Training Totals:,529 2,79 475,6, ,95 Other Total Fax Referral: A total of,838 fax referrals were received statewide via the Quit Kit Referral System over the course of the year. Of the,838 patients referred, 25.4% (466) were contacted and patients enrolled in cessation programming, 3.8% (253) were reached, but declined cessation programming, and 4.% (76) were reached, but elected to receive information only, and 56.7% (,83) were unreachable after five attempts. Table 9.3. Outcomes of Fax Referrals by Grantee (Jan Dec, 27) Grantee Enrolled Unreachable Declined Info. Only Total Alpha Comm. Services 3 American Lung Assoc. of Ohio American Lung Assoc. of Ohio NW Region Amethyst, Inc Asian American Comm. Services Asian Services In Action, Inc. Athens City Co. Health Dept Barberton Health Dist Bucyrus Comm. Hospital City of Refuge Point of Impact Columbus State Comm. College 2 8 Columbus Urban League Community Action for Capable Youth Cuyahoga Co. Dist. Board of Health Delaware General Health Dist Fairfield Co. Dept. of Health (7 Counties) Family & Community Services, Inc. (Portage Co.) Family & Community Services, Inc. (Wayne Co.) 2 3 Family Guidance Center 4 6 Family Service Assoc. Comm. Services for the

110 Strategy: Distribution of Quit Kits 95 Grantee Enrolled Unreachable Declined Info. Only Total Deaf/Deaflink Greater Cleveland Health Education & Service Council Greene Co. Combined Health Dist Hamilton Co. General Health Dist Holzer Medical Center Hospital Council of NW Ohio Knox Co. Health Dept. Lake Geauga Center on Alcoholism & Drug Abuse, Inc Lorain City Health Dept Mahoning Co. Dist. Board of Health Medina Co. Board of Commissioners Miami Valley Health Improvement Council, Inc. Noble Co. Health Dept Ohio Hispanic Coalition Pathways of Licking Co. Pike Co. General Health Dist. 3 6 Private Duty Services, Inc. (Van Wert Co.) Project Linden Recovery & Prevention Resources Rural Opportunities, Inc Selby General Hospital Stark Co. Health Dept. 7 9 The Alcohol & Chemical Abuse Council The Breathing Association 2 3 Tuscarawas Co. Health Dept UMADAOP Union County Health Department 4 4 Upper Valley Medical Center 3 8 Women & Family Services, Inc Your Human Resources Center (Holmes Co.) Zanesville Muskingum Co. Health Dept Statewide Totals: ,838 Barriers and Lessons Learned In bi monthly reports grantees reported on some of the commonly encountered barriers in the distribution of Quit Kits. In the first reporting period, many of the agencies reported that their primary barrier was receiving the new Quit Kits in time to distribute at trainings. As one grantee stated in the first reporting period, [We are] waiting on new Quit Kits to be distributed. Until we know what the kits will look like it is difficult to provide trainings. Another grantee added, New Quit Line resources are not yet available. [We are] distributing existing Quit Kits. Requested but have not received 5 brochures. Once received, one grantee reported, The Ohio Quit Line packet came with a pad of fax referral forms. These did not have our grant number. The number needs to be on all forms so the physician offices' do not have to look up the number.

111 Strategy: Distribution of Quit Kits 96 For the few grantees who had been distributing the Quit Kits in the previous year, there were concerns that health professionals would not need new Quit Kits. One grantee stated, Many departments/services do not need new Quit Kits as we have been distributing them for many months under prior grants. In the first reporting period, many agencies also commented on the difficulties in receiving trainings for the strategy. One grantee wrote, Grantees have not received adequate training in distribution of Quit Kits. We have not received the kits; therefore, we are unable to train in the distribution of the kits. Another grantee added, In all 3 counties we haven't started this yet due to not receiving Quit Kits to distribute. Also, we haven't received training on protocol on how to distribute the kits. Once trained, some agencies continued to have difficulties understanding some of the facets of the Quit Kit distribution strategy. As one grantee simply stated, More guidance is needed in distribution of kits. Another grantee described their issues in more detail, We are still uncertain of some of the definitions to be used for the categories in this section and what those should include. We could have reported some numbers in several different categories. It is only important if the Foundation wants grantees across the state to report consistently in the proper categories. Other agencies had criticisms of the strategy and its protocol. Regarding the flip chart, one grantee wrote, The flip chart is small and limited for use during trainings, while another wrote, A laptop would be [simpler] to use than a homemade flip chart. Other materials in the program were also critiqued, All marketing materials for physician s offices promote the Quit Line and does not promote having their [referring] doctor sign the fax form. Further, some grantees felt the program materials were underutilized. One grantee stated, Clinical staff taking the TIME to read the educational poster could be a barrier, and, Any large complex organization has many hoops to jump through before a plan can be implemented. Additionally, for the grantees who ordered maternal health Quit Kits, some agencies had specific barriers related to their distribution, Maternal clinics do not feel it is appropriate to give a smoking pregnant woman NRT. This has provided some challenge in getting them to use the fax referral system or using Ohio Quits. While an effort was made to adapt to Quit Kit distribution program to other non healthcare community organizations, the transition was not without its problems. As one grantee stated, Quit Kits are probably better offered through medical facilities or through grantees who work with adult smokers on a continuum. In transitioning to faith based organizations, one agency wrote, The process of Ohio Quits Fax Referral program is originally designed for physicians the adaptation for faith based organizations is somewhat confusing. For other worksites, agency comments included: Quit Kit distribution was not possible at some worksite locations due to HR staff/liaison not being equipped to provide this service to employees. Company has no previous history of doing referrals and Some worksites, even those who have nurses, do not see the quit kits/fax referral as their job If an employee is interested they are instructed to call the Quit Line. There were also problems in using the Quit Line program for non native English speakers. As one grantee noted, The immigrant population does not deal with using the phone well, does not adhere to scheduling appointment times well, and at times does not have access to a phone or cell phone minutes. The Quit Line presents translation issues and the length of the phone calls is doubled making the time needed a hardship on the client. They do better with one on one counseling sessions. Another noted, One of the main barriers

112 Strategy: Distribution of Quit Kits 97 that we continue to face with the non English speaking Asian population is cultural norms and barriers regarding regular access of traditional medical services. Many of these individuals are not able to access or even know about cessation services offered in their area. Gaining access to and scheduling time with health care professionals was a major barrier for many of the funded agencies. Not all agencies were connected to health agencies prior to OTPF Funding. As one agency noted, Our staff does not have a lot of contact with physician offices nor does our agency offer medical services. In trying to make contact with health professionals, many agencies had similar statements. While one grantee wrote, Scheduling conflicts, on the part of the healthcare providers, made it difficult to schedule trainings/meetings with them. Scheduling issues could often cause agencies valuable time. One grantee highlighted this issue: When we do the follow up the physicians and doctors' office who received the Quit Kits is not available and we have to make another trip to doctors' office. The person who received the Quit Kits on behalf of the physician does not communicate to the doctor. Additionally, because of scheduling issues, many grantees reported training one or two members of the office staff in use of the Quit Kits. Agencies would then depend on those trained staff members to train the rest of the office at a later, more convenient time. In addition to problems with contacting and scheduling, getting physicians and their staff interested in the Quit Kit program was also difficult for many agencies. Agencies reported, Office staff [members] are frequently not willing to add another step/paperwork to their routines, and that some office managers were not convinced of the benefits of discussing cessation with their patients or how smoking affects different parts of the body. It seems that it is still a hot topic for some and they are hesitant to address it in their practice. Yet, once scheduling and buy in are achieved, success in the strategy occurs. As one agency highlighted, Once they hear what I have to offer in the way of the kits, they are more interested in listening, and I try to keep the presentation very brief and factual. With regards to the fax referral service, a number of agencies had criticisms. Agencies noted a number of problems, including: One case manger has reported that her clients have not been contacted by the Quit Line, The inability of the Quit Line to denote our Grant ID number when people who learned about the Quit Line call the 8 number instead of using the fax referral process. In bi monthly reports grantees reported on successful strategies and lessons learned in the Quit Kit process. For many grantees, the most common lesson learned was one of persistence. Many grantees reported that assigning multiple staff and coalition members to the strategy and individuals often had to make multiple phone calls to establish contacts with physician offices and hospital systems. As one grantee noted, Persistence reaps benefits both for project staff and trainees. Another added, Be willing to use a variety of strategies to distribute the kits. Be very creative. Work smarter not harder. With the barriers many grantees found in accessing and scheduling visits with physicians, many of the lessons learned dealt with how to connect with the doctors in the area. Yet, successful strategies were not the same

113 Strategy: Distribution of Quit Kits 98 for all grantees. While, one grantee found that phone calls prior to visiting locations led to more scheduled trainings, a couple other grantees found face to face efforts led to more scheduled trainings. As one grantee stated, I find that showing up in person is effective even if I have initially received a "Not interested" type of reply. Once I'm in the door, with the Quit Kit's contents open and in my hand, they become more interested. A few agencies reported that phone calls were more effective entry to offices than letters. Some agencies had important notes about information that should be included on the office phone calls. Agencies reported that mentioning the brevity of the training up front and remaining flexible to physicians schedules all helped to set up trainings with physicians. Many grantees noted that if connections to physicians were not well made, other avenues of entry could be pursued. A few grantees mentioned that nurses and dental hygienists were often more receptive than doctors and dentists. Other agencies noted that working with office managers was more effective than trying to contact the physicians at offices and working with human resources was more effective at hospitals and businesses. One grantee contacted Community Colleges to identify respiratory therapists, licensed practitioner nurses, radiology technicians, and other non physician health care workers in the area. Other grantees looked to the more junior members of the medical community. Two agencies reported that medical students or nursing students were more willing to utilize Quit Kits than more senior staff. As one grantee noted the advantage of using this population, Training this group will be the catalyst for change. They do not have to "unlearn" old procedures and implement the training from day one. When these strategies have been exhausted, agencies turned to alternative points of outreach. Grantees turned to other healthcare, social service, and other non healthcare organizations, with one grantee finding success in nursing home setting. As this grantee reported, More nursing homes want information for patients and follow up training for staff. Another found drug treatment centers to be very receptive. This grantee stated, The drug treatment centers where they don't have a lot of funding are welcoming with open arms. The free service is very helpful for the social workers helping their clients with the addiction. In discussing strategies for the scheduling of presentations, many grantees mentioned the importance of linking the training with other meetings and food as a way to draw an audience. As one grantee noted, Bring in breakfast or lunch act as a pharmaceutical sales rep and they will be more apt to come. Brevity of the presentation is also important. Many grantees felt that shorter presentations led to more attendees. Summary and Recommendations The distribution of Quit Kits strategy was an important component of the Ohio Quits Program. Grantees delivered Ohio Quits promotional materials and fax referral forms to physician offices and other health and community locations. Grantees trained the health professionals in the fax referral process and in assessing patient readiness to quit. All grantees were funded to distribute Quit Kits although the proposed and achieved reach numbers varied greatly across grantees. Nearly 8, health professionals were trained in the use of the Quit Kits and more than 8, kits were distributed across the state during the 27 program year. In spite of this potential program reach, the Quit Line reported that less than 2, (n=,838) of the fax referrals marked with a grantee ID were actually received during the 27 grant year. A number of grantees complained that

114 Strategy: Distribution of Quit Kits 99 the number of reported referrals by the Quit Line did not match their records of referrals faxed, suggesting that there may have been some problems with the delivery, acceptance, or follow through on some of the referrals sent by grantees. However, no information was available to explore this discrepancy. It is also important to note that the distribution of Quit Kits began with a slow start due to the delay in grantees receiving the promotional materials and receiving training in this strategy. Grantees provided a wealth of information about the pitfalls of working with physicians and other health professionals as well as techniques to successfully achieve the goal of the workplan. References Bentz, C., Bayley, K. Bonin, K., Fleming, L., Hollis, J., McAfee, T. 26. The Feasibility of Connecting Physician Offices to a State Level Tobacco Quit Line. American Journal of Preventive Medicine, 3, : 3 37.

115 Ohio Tobacco Prevention and Control Program CGIII Evaluation (Jan Dec, 27) Strategy: Tobacco Free School Campus Policies Programmatic Goal Area: PREVENTION OVERVIEW: Of all the approaches to combat the impact of tobacco on the public s health, tobacco policy offers much promise. Such policy can help shape behavior by supporting norms that discourage youth initiation and encourage cessation by current users. Of the multiple channels for policy efforts (worksite, media, communities, health care settings and schools), schools present a unique prevention opportunity because they provide ready access to nearly all school age children. Thus, they are ideal venues for developing, implementing and enforcing % tobacco free policies that restrict tobacco use of all forms by students, faculty, staff and all visitors at all school sponsored functions. The targets for such policy expand beyond students because of the modeling effect that adults can have on youth. EVALUATION AND TOOLS: Grantees funded to support % tobacco free school campuses at the school district level created an annual work plan for each district and submitted monthly activity reports on the progress toward work plan goals. The evaluation of the grantees activities includes the following components: tracking of the status of the school policy and progress towards passing and implementing policies, list of the school stakeholders involved in the effort, the type of activities completed, and the number of students and school personnel protected by the policy. Grantees also provided a summary of lessons learned and barriers to achieving the goals of their work plan. RESULTS HIGHLIGHTS: A total of 34 grantees, in 259 public and private school districts in 6 counties were funded to work towards model tobacco free schools policy adoption and enforcement. Districts working in all phases of the policy process were protecting a total of 232,672 children and 32,983 school personnel from secondhand smoke exposure at school. Approximately two thirds (64.2%) of the participating districts were advocating for tobaccofree policy adoption in the beginning of the year while at the end this dropped to 5.2%. At the same time, there was an increase from 7.% of districts implementing and enforcing tobacco free policies at the beginning of the school year to 35.% doing so at the end of the reporting period. Districts were most often in the advocacy mode most often. Policy work is arduous and time consuming. A total of 4 districts had policies reviewed and acted upon by school boards. Results indicate that 3 (2.4%) passed a modified policy that fell short of the % tobacco free desired goals while (78.6%) adopted the model policy. This represents a high success rate but a low overall number of districts that made decisions on this policy matter. The passage in 26 of the Smokefree Workplace Act and delayed but subsequent enforcement guidelines from the Ohio Department Health has likely caused some districts to move more quickly and others to be confused about the role this act has on their policy work. SUMMARY: Much work lies ahead on the tobacco free school policy front. The need to establish important ground work of identifying stakeholders, recruiting their participation and crafting a plan is necessary to assist local tobacco coalition members in the policy arena. Provision of technical assistance is likely to assist local coalition in successfully lobbying their district officials to seriously examine, adopt, implement and enforce a % tobacco free school policy. Funding Amount $653,226 Number of Grantees Funded for this Strategy: 34 Agencies Funded: American Lung Association of Ohio American Lung Association of Ohio NW Athens City County Health Department Barberton Health Department Community Action for Capable Youth Cuyahoga County Board of Health Delaware General Health Department Fairfield County Department of Health Family & Community Services (Wayne) Family & Community Services (Portage) Family Guidance Center Greater Cleveland Health Education & Services Council Guernsey Noble Monroe Tobacco Project Hamilton County General Health District Holzer Medical Center Hospital Council of NW Ohio Knox County Health Department Lake Geauga Center on Alcoholism & Drug Abuse Lorain City Health Department Mahoning County Board of Health Medina County Board of Commissions Miami Valley Health Improvement Council Inc. Pathways of Licking County Pike County General Health District Private Duty Services Project Linden Recovery & Prevention Resources Rural Opportunities Inc. Selby General Hospital Stark County Health Department UMAPDAOP Lucas County Women & Family Services Your Human Resources Center Zanesville Muskingum County Health Department Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

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117 Evaluation of CGIII Tobacco Prevention and Control Efforts STRATEGY : Tobacco Free School Campus Policies Goal: Prevention Although Ohio s Smokefree Workplace Act prohibits smoking inside school buildings by everyone, only students are prohibited by state law from using or possessing tobacco products on outdoor school property. This law does not apply to staff and visitors. Students may be exposed to secondhand smoke if individuals are permitted to smoke on school grounds, and students often look to adults as role models, particularly those they observe in the school environment when it comes to tobacco use. (OTPF, 27). Background and Rationale % Tobacco free school campus policies help reduce youth exposure to secondhand smoke and the concomitant health risk such exposure pose. Further, these policies reinforce classroom strategies that emphasize non tobacco use and help strengthen norms that non smoking/no tobacco use is the desired and common behavior. Students and adults alike often exaggerate the level of tobacco use by youth and adults. Youth who misperceive the norm are at an increased risk of adopting tobacco use. Tobacco free policies are an important strategy for correcting these misperceptions and establishing a non tobacco use environment and delivering a pro health normative message. Further, research suggests that tobacco free school policies are associated with lower rates of youth smoking. 2 Three steps for advocating a % tobacco free school campus policy include adoption; implementation and enforcement; and evaluation. 3 Policy adoption is the responsibility of the school board; however, advocating for such a policy ideally involves local school wellness committee members, parents, students and tobacco coalition participants coming together to persuade board members and school administrators that such a policy adoption is positive for students health and academic achievement. 4 Some districts have been reluctant to adopt such a policy either because they perceive the issue as non integral to their educational mission or they have other more pressing matters to address. Further, some administrators are reluctant to adopt the % policy because it would mean asking community members at athletic events and other school sponsored activities to not use tobacco products. They anticipate such an adoption would create unnecessary friction between the district and the community and could undermine their efforts to persuade the same community to support school levies. The passage of the Smokefree Workplace Act of 26 in Ohio has gone a long way to persuading some districts to move toward a % tobacco free policy. This is an excellent example of how policy development can positively influence tobacco norms to shift toward an environment of non use. The second step in advocating for a % tobacco free school policy is implementation and enforcement. Prior to implementation, frequent and advance communication to all parties (students, staff, parents and visitors) needs to occur so that these groups are aware of the impending policy change. Anticipated implementation obstacles (athletic and other school sponsored activities) should be addressed through clear language in all communication media including signage, print, web and public address systems about the policy and the request for compliance. Further, the enforcement of the policy, as noted above, is perhaps the most challenging aspect of this work. The school district, has a responsibility to follow through on the policy CGIII Program Evaluation Report (Jan Dec, 27) June, 28

118 Strategy: Tobacco Free School Campus Policies 2 enforcement/compliance and should do so with a supportive rather than punitive approach. Most people are willing to be compliant when asked politely to follow the policy and they understand that doing so is in the best interests of the students. Districts do need to identify responses when individuals are not willing to comply. The third step in advocating for a % tobacco free school policy is evaluation. Evaluation provides feedback about how the policy is being received, what is working, what is not working and how that information might be used to more effectively deliver the policy in the future. An evaluation of the policy should include the following components: prohibition of all tobacco products for all people at all school sponsored activities; communication of the district s policy to all constituents through a variety of formats (signage, school website, newsletter, stipulations in vendor contracts, announcements at school events, letter to parents); the degree to which the district is implementing effective tobacco prevention educational curricula as well as cessation support for faculty, staff and students; level of community support for the policy; and future steps to improve the policy. Evaluation Plan for Tobacco Free School Campus Policies Workplan (provided prospectively): Grantees funded to support % tobacco free school campuses at the school district level created an annual workplan for each district, providing the counties in which the district was located, the number of students, faculty, and staff to be impacted by the policy. Activity Reports: Grantees submitted bi monthly activity reports on the progress toward workplan goals. The evaluation of the grantees activities includes the following components: tracking of the status of the school policy and progress towards passing and implementing policies, list of the school stakeholders involved in the effort, the type of activities completed, and the number of students and school personnel protected by the policy. Grantees also provided a summary of lessons learned and barriers to achieving the goals of their workplan. Results Process Outcomes All grantees funded to deliver prevention programming were required to advocate for % tobacco free school campuses through policy development, implementation and enforcement. Additional agencies were funded to work on this strategy without providing prevention curricula. A total of 34 grantees, in 259 public and private school districts in 68 counties, were funded to work towards model tobacco free schools policy adoption and enforcement. The desired tobacco free policy should advocate that all school districts in Ohio adopt, implement and enforce policies that prohibit tobacco use of any kind on all school property, in school vehicles, at school sponsored events (on and off campus), by students, staff, faculty and visitors at all time. At the beginning of the grant year in January of 27, a total of 259 public and private school districts were partnering with OTPF grantees to adopt % tobacco free policies. Based on estimates of students, faculty, and staff in the districts, grantees estimated that the policy either was or had the opportunity to protect a total

119 Strategy: Tobacco Free School Campus Policies 3 of 232,672 children and 32,983 school personnel from secondhand smoke exposure at school. When asked to list the stakeholders involved in advocating, implementing or enforcing the tobacco free policies (see table. below), the most frequently listed was school principals (48.7%), followed by district superintendents (43%), teachers (42.3%) and students (3.5%). Interestingly, not one grantee mentioned parents or a parent organization (e.g. PTA). Table.. Stakeholder involvement in tobacco free school policy advocacy Stakeholders Number (%) of districts engaging stakeholders Students 88 (3.5) Parents/PTA (.) Teachers 8 (42.3) Teachers union ( 3.9) School nurses 87 (3.2) Guidance counselors 65 (23.3) Other school personnel (.4) School principals 36 (48.7) District superintendent 2 (43.) School board members 44 (5.8) Health care providers (.4) Law enforcement (.4) 2 month Progress Approximately two thirds (64.2%) of the participating districts were advocating for tobacco free policy adoption in the beginning of the year while at the end this dropped to 5.2%. At the same time, there was an increase from 7.% of districts implementing and enforcing tobacco free policies at the beginning of the school year to 35.% doing so at the end of the reporting period. This trend is illustrated in Figure below. As the figure illustrates, by far districts were in the advocacy mode most often. Figure also indicates there was very little movement over the 2 month reporting period for adoption and implementation.

120 Strategy: Tobacco Free School Campus Policies 4 While grantees strived for passage of % comprehensive, or model, tobacco free policies, this goal was not always achieved. A total of 4 districts had policies reviewed and acted upon by school boards. Results indicate that 3 (2.4%) passed a modified policy that fell short of the % tobacco free desired goals while (78.6%) adopted the model policy. This represents a high success rate but a low overall number of districts that made decisions on this policy matter. The passage in 26 of the Smokefree Workplace Act and delayed but subsequent enforcement guidelines from the Ohio Department Health has likely caused some districts to move more quickly and others to be confused about the role this act had on their policy work. Based on the OTPF Tobacco free Schools Toolkit, there are several activities that are suggested as best practices to aid in the process of passage of a % tobacco free school policy. These activities were tracked in the bi monthly grantee activity reports. The table below presents the frequency that these activities were employed. Curiously in spite of the changes that were reported (see above), the majority of activity reports revealed many months of non activity, as shown in the table below. Rather, grantees appeared to be report one of three predominant (and general) activities: assessing the policy, presenting the policy to school personnel, and supporting enforcement, once the policy was passed. Table.3. Tobacco free school policy activities Activity Number (%) of school districts Establish a committee 7 ( 2.5%) Assess existing policy 22 ( 7.9%) Hold a community forum 5 (.8%) Present model policy to superintendent 8 ( 6.5%) Present model policy to school board 28 (.%) Adoption of model policy 8 ( 2.9%) Ensure adequate signage 5 ( 5.4%) Develop communications plan 9 ( 3.2%) Implement communications plan 4 (.4%) Support policy enforcement 38 (3.7%) No activity was taken 65 (59.4%) Barriers and Lessons Learned In bi monthly reports grantees reported on successful strategies and some of the commonly encountered barriers to the advocacy process. Grantees reported on barriers as basic as a difficulty scheduling meetings during summer break to the political complexities of school board elections and timing of ballot levies. Grantees encountered some misinformation or confusion among school staff and administrators. For example, Most schools think that because they have a written policy, they are a % tobacco free school. Most schools have policies, but they are either not enforced or not completely tobacco free, and simply because a model policy is in place does not mean school staff are aware of policy. Communication is key. With this last excerpt in mind it may not be surprising that school administrators reported some difficultly with policy enforcement, particularly with staff and at school functions and sporting events.

121 Strategy: Tobacco Free School Campus Policies 5 Grantees also reported that barriers most often faced were lack of administrative support and difficulty coordinating calendars to meet with school officials. Grantees suggested that helping administrators appreciate the value and importance of a % tobacco free policy was challenging in light of the varied tasks and responsibilities that school personnel face. Factors that were reported to facilitate the process of policy adoption included finding a champion within the school district who was able to push the issue. Sometimes the champion could be a group of youth, as reported by one grantee, Youth can sometimes open doors and bring light to important facts about tobacco Looking back, it seems the youth were the natural way to approach this district. The closed system would have been hard to crack through traditional adult channels. It was a challenge to get the stand Team started in the [district], but once the challenge was met, the youth have started a fire! Before the stand events, not a single school staff member was willing to talk about a % Tobacco free policy. Grantees also reported that it was important to, develop strong communication levels within school districts, it's important to be able to talk to board members and school personnel. They acknowledged that school administrators are busy individuals with many competing priorities. For this reason it was important to efficiently use their time. Grantees also found it helpful to learn from the successes of others. For example, it is very useful to use model policies from other states who have already adopted % tobacco free schools. The language is correct, they have identified all tobacco products and explained rules for enforcement. Summary and Recommendations It is not uncommon for school districts to have an existing tobacco free school policy, sometimes a comprehensive or nearly comprehensive policy. However, as described in the results section above, compliance is not always complete. The following observations were made regarding tobacco free school campus policies: The passage of Issue 5, the statewide smoke free law, has not lessened the need for continuing work in this area. Tobacco free school policy work goes hand in hand with other youth prevention activities. Establishing committee structures to examine district policy was slow. Grantees seemed to lean heavily on school principals, superintendents and teachers as gatekeepers to the school policy process. Because resistance was met as evidenced by lack of administrative support by many grantees, it may be necessary to seek leverage for policy work by alternate means. For example, recruiting community members, including parents who were strikingly absent from this

122 Strategy: Tobacco Free School Campus Policies 6 process during the reporting period, might go a long way to garnering the attention of school officials and board members about this important policy work. Policy votes should not occur unless advocates are certain that passage is likely. No policy advocate wants to have a negative vote on their records for which they will always be associated. Distribution of the Foundation s tobacco free school policy manual and support materials should occur with follow up training and technical support to guide local tobacco control professionals in the very challenging work of % tobacco free school policy work. References Olds RS and Thombs DL (2).The relationship of adolescent perceptions of peer norms and parent involvement to cigarette and alcohol use.josh. 7 (6) Pentz MA, Brannon BR, Charlin VL, Barrett EJ, MacKinnon DP, Flay BR. The power of policy: the relationship of smoking policy to adolescent smoking. AJPH. 989;79(7): Ohio Tobacco Prevention Foundation [OTPF] (27). Creating a Tobacco Free School District. Columbus, Oh. 4 Olds RS and Rubin M (25).Tobacco Free Schools Policy Study. Funded by the Ohio Tobacco Prevention Foundation. Columbus, Oh.

123 Ohio Tobacco Prevention and Control Program CGIII Evaluation (Jan Dec, 27) Strategy: School Based Youth Prevention Programming Programmatic Goal Area: PREVENTION OVERVIEW: An essential component of a community based comprehensive tobacco control program is the implementation of evidence based youth prevention programming. To prevent youth initiation, it is important that youth be educated about the harmful effects of tobacco use. Most people initiate smoking before the age of 9 and it is critical that prevention education begin during adolescence. Fundable curricula was limited to five evidence based or promising youth prevention programming: Life Skills Training (LST); Project Alert (PA); Project TNT (TNT); Project STAMP (STMP); and Word of Mouth (WOM). Four of the five (LST,PA, STMP, TNT) had been empirically tested and shown to be effective at impacting youth behavior, the fourth (WOM) viewed as a promising program. EVALUATION TOOLS: There were three main sources of information for this strategy: fidelity information provided by the facilitator; classroom information provided by the teacher; and demographic information provided by the students. From these three sources information was collected on the school district and school name, class period, number of students receiving youth prevention, number of youth prevention sessions and session length, number of activities completed per session, teacher satisfaction with the curriculum, student demographic information and exposure to tobacco use. RESULTS HIGHLIGHTS: Youth prevention curricula were implemented in,66 school based classrooms across Ohio with 36,989 youth enrolled in these classes. Almost half of the youth reported that they live with a smoker and 4% reported that they had tried smoking cigarettes. Program reach ranged from 32.4% to 28.9%, with nine agencies achieving a reach greater than % of their proposed reach. Average activity completion (i.e., fidelity) ranged from 64% to 92%. In general, the average percent of curriculum specific activities completed was higher for the programs requiring fewer sessions. 96% of the teachers who completed the online survey indicated that they were satisfied or very satisfied with the tobacco prevention programming and the curriculum content provided to their students. SUMMARY: In 27, OTPF funded agencies have provided tobacco use prevention programming to 36,989 youth across Ohio. The programming was comprised of evidenced based and promising tobacco prevention curricula implemented at reasonable levels of fidelity. Based on reported exposure to tobacco within the home, nearly 5% of the students who received programming are not only presumably exposed to secondhand smoke, but experiencing a social norm suggestive of the acceptability of tobacco use. The programming appears to be reaching a diverse group of students from different racial and socioeconomic backgrounds and from different geographic regions of the state. Funding Amount $,966,76 (combined amount for school and community based) Number of Grantees Funded for this Strategy: 23 Agencies Funded: ALA of Ohio ALA of Ohio NW Athens City County Health Department Community Action for Capable Youth Cuyahoga County Board of Health Fairfield County Dept of Health Family Guidance Center Greater Cleveland Health Education & Service Council Hamilton County Health Dept Holzer Medical Center Hospital Council of NW Ohio Lake Geauga Center on Alcoholism and Drug Abuse Lorain City Health Dept Pathways of Licking Co Private Duty Services Project Linden Recovery and Prevention Resources Rural Opportunities Inc.. Selby General Hospital Stark County Health Department UMAPDAOP of Lucas County Your Human Resource Center Zanesville Muskingum County Health Dept. Counties Served: Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

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125 Ohio Tobacco Prevention and Control Program CGIII Evaluation (Jan Dec, 27) Strategy: Community Based Youth Prevention Programming Programmatic Goal Area: PREVENTION OVERVIEW: While schools offer the most efficient method for delivering tobacco prevention programming to youth, there are many opportunities to reach youth in communitybased settings such as after school programs, youth enrichment programs, and through faith based organizations. For some youth, the anti tobacco message may resonate more strongly when delivered within a more social environment. As with school based prevention programming, fundable curricula were limited to five evidence based or promising youth prevention programming: Life Skills Training (LST); Project Alert (PA); Project TNT (TNT); Project STAMP (STMP); and Word of Mouth (WOM). Four of the five (LST,PA, STMP, TNT) had been empirically tested and shown to be effective at impacting youth behavior, the fourth viewed as a promising program (WOM). EVALUATION TOOLS: There were three main sources of information for this strategy: fidelity information provided by the facilitator; classroom information provided by the community leader in charge of the activity or overall program; and demographic information provided by the students. From these sources information was collected on the number of students receiving youth prevention, number of youth prevention sessions and session length, number of activities completed per session, community leaders satisfaction with the curriculum, student demographic information and exposure to tobacco use. RESULTS HIGHLIGHTS (with exception of reach, data combined with school based) Youth prevention curricula were implemented in 84 community based setting across Ohio with,588 youth reached by this programming. Almost half of the youth reported that they live with a smoker and 4% reported that they had tried smoking cigarettes. Agencies reach ranged from 32.4% to 28.9%, with nine agencies achieving a reach greater than %. Average activity completion ranged from 64% to 92%. In general, the average percent of curriculum specific activities completed was higher for the programs requiring fewer sessions. 96% of the teachers (66) indicated that they were satisfied or very satisfied with the tobacco prevention programming and the curriculum content provided to their students. SUMMARY: In 27, OTPF funded agencies have provided tobacco use prevention programming to 36,989 youth across Ohio in both school and community settings. The programming was comprised of evidenced based and promising tobacco prevention curricula implemented at reasonable levels of fidelity. Based on reported exposure to tobacco within the home, nearly 5% of the students who received programming are not only presumably exposed to secondhand smoke, but experiencing a social norm suggestive of the acceptability of tobacco use. The programming appears to be reaching a diverse group of students from different racial and socioeconomic backgrounds and from different geographic regions of the state. Funding Amount $,966,76 (combined amount for school and community based curricula) Number of Grantees Funded for this Strategy: 5 Agencies Funded: Alpha Community Services Asian American Community Services ASIA, Inc. City of Refuge, Point of Impact Columbus State Community College Fairfield County Dept of Health Family Guidance Center Hamilton County Health District Lake Geauga Center on Alcoholism and Drug Abuse Mahoning County District Board of Health Ohio Hispanic Coalition Project Linden Rural Opportunities Inc. Stark County Health Department UMAPDAOP of Lucas County Counties Served: Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

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127 Evaluation of CGIII Tobacco Prevention and Control Efforts STRATEGY & 2: Youth Prevention: School Based, Community Based and Online Programming Goal: Prevention Background and Rationale An essential component of a community based comprehensive tobacco control program is the implementation of evidence based youth prevention programming. To prevent youth initiation, it is important that youth be educated about the harmful effects of tobacco use. Most people initiate smoking before the age of 8 and it is critical that prevention education begin during adolescence. Specifically, youth prevention programs are most effective when evidence based curricula are implemented. As reported in the CDC s Best Practices for Comprehensive Tobacco Control Programs, Although rates of youth smoking increased dramatically in the early 99s, after increased implementation of evidence based interventions, youth smoking declined 4% from 997 to 23. In support of this, The Ohio Tobacco Prevention Foundation funded grantees to implement one of five evidence based or promising youth prevention curricula. The curricula included, Life Skills Training (LST); Project Alert (PA); Project TNT (TNT); STAMP (STMP); and Word of Mouth (WOM). Four of the five (LST, PA, STAMP, TNT) had been empirically tested and shown to be effective at impacting youth behavior, the fifth viewed as a promising program (WOM). It is important that community programs and school based policies and interventions are implemented across the community and school environments. In order to meet these guidelines and reach the diverse population of youth in Ohio, grantees were funded to implement youth prevention programs in public and private schools, as well as in community based youth programs. With this approach, the intention is to reach youth across the state through youth tobacco prevention programming. In November 26, the Ohio Tobacco Prevention Foundation (OTPF) funded 23 agencies to provide schoolbased and community based youth prevention programming throughout Ohio during a 2 month grant running January through December of 27. Evaluation of School Based and Community Based Youth Prevention Typically, evaluations of prevention programs involve collecting data through surveys, reports, or observations on program participants (and often a control group who did not receive the program) before and after the intervention, with the assumption that any observed change in these indicators (above and beyond the change observed in the controls) is attributed to the health intervention. Prior to the CGIII grant cycle, the evaluation of the school based prevention programs funded through OTPF involved such pre and post intervention testing. However, these results were deemed meaningless due to the vast variation across programs offered by grantees with regard to structure, dosage, emphasis, and facilitator training. As a result, it was decided that the first step was to put into place a more standardized, CGIII Program Evaluation Report (Jan Dec, 27) June, 28

128 Strategy: School, Community and Online Youth Prevention Programming best practice approach to prevention programming, and dedicating the CGIII cycle to better understanding the programmatic and delivery aspects of the programs. This decision was based on the assumption underlying best practice guidelines that if an evidence based intervention (i.e., one that has been published and shown to be effective with rigorous study) is conducted with fidelity (i.e., with the same dosage, content, and structure) and to a similar population, the results should be the same as those found in the published studies. Fundable curricula were limited to five evidence based or promising youth prevention programming, as shown in the table below: CGIII Approved Youth Prevention Curricula SAMHSA Model Programs Promising Programs o Life Skills Training LST (3 rd to 9 th grade) o Word of Mouth (WOM)(4 th 8 th grade) o Project TNT (TNT)(5 th 8 th grade) o STAMP (STMP)5 th 8 th grade) o Project ALERT (PA)(6 th 8 th grade) Three of the five (LST, PA, TNT) had been empirically tested and shown to be effective at impacting youth behavior, and two (STMP and WOM) are viewed as a promising program (WOM). All of the curricula chosen have a tobacco prevention focus. Two of the programs (TNT, PA) are single packaged curricula aimed at multiple age groups; the other two (LST, WOM) are grade specific curricula. For example, OTPF funded seven versions of LST (3 rd /4 th ; 4 th /5 th ; 5 th /6 th ; Middle School ; Middle School Tobacco Focus; Middle School 2; Middle School 3) and five versions (grades 4 through 8) of the WOM program. While these curricula contain similar topics, they tend to vary in the number of sessions and the specific activities implemented within the curriculum. Thus, separate fidelity checklists were prepared for each version of the programs. In addition to fidelity data, information was collected from classroom teachers and participating youth to provide a fuller picture of the programmatic efforts. Below is a brief description of the tools utilized to evaluate school based youth prevention programming. Examples of the fidelity checklists for each curricula group (LST,TNT,PA,WOM,STMP) are include Appendix C. Evaluation Tools Workplan (provided prospectively): Grantees submitted a work plan into G Wiz for each curriculum they would be implementing. Separate workplans were submitted for community based and private schoolbased, and public school based curriculum. Workplans identified curriculum to be implemented; the counties, school districts, and schools to receive youth prevention; the training and certification status of prevention facilitators; whether the full number of curriculum sessions would be completed; whether the curriculum would be substantially modified to be culturally appropriate for target audience or to address tobacco related topics not covered by core curriculum; and whether schools were committed to implementing the recommended number of sessions and session length. Activity Reports (submitted bi monthly): Activities related to the strategy, as well as any changes made to the program, barriers, and lessons learned.

129 Strategy: School, Community and Online Youth Prevention Programming OTPF Youth Prevention Survey (administered last day of program): This single page survey collects demographic information (gender, age, grade, race), as well as tobacco prevalence and exposure (e.g., whether student lives with a smoker, ever offered tobacco, lifetime cigarette use, current cigarette use, lifetime cigar use, current cigar use, lifetime smokeless tobacco use, and current smokeless tobacco use) for each program participant. This anonymous survey was completed by each youth receiving a tobacco prevention curriculum. Third grade students did not complete section on tobacco use. The data were entered by the RE Coordinators into OTREC DM, which was then summarized and uploaded into G Wiz by OTREC. Teacher Reporting Form (completed by classroom teacher, not the facilitator): This single page form allows the classroom teacher to provide feedback on program delivery and class characteristics. The OTPF Teacher Reporting Forms also provides an avenue to capture teacher e mail address which will be used to ask the teachers to complete the Online Teacher Satisfaction Survey (description follows) at a later time. Facilitator name, school district and school name, class period, teacher address, number of students receiving youth prevention, number of youth prevention sessions and session length, number of students by grade level, and teacher consent to receive teacher satisfaction survey. Facilitator Fidelity Checklists: The Facilitator Fidelity Checklist assesses how closely the Facilitator was able to comply with the selected prevention curriculum. These checklists are specific to the prevention curriculum used and, where appropriate, the grade (form to right is example of one such checklist). Data collected include: grantee and subgrantee name; facilitator name, gender, phone number, and ; teacher last name; grade levels, class period; session date, session length, self reported fidelity (how closely did you keep to the published curriculum), the checklist of specific activities that were expected to be covered under each classroom session, as printed in the published curricula (completed after each classroom session); and notes.

130 Strategy: School, Community and Online Youth Prevention Programming 2 Online Teacher Satisfaction Survey: This survey assesses classroom teacher or site representative satisfaction with tobacco prevention curriculum and facilitator. The teacher/representative providing consent on the teacher reporting form is contacted via e mail by OTREC to illicit completion of this web based survey. A $5 bookstore giftcard incentive was used to increase response rate. This survey collects the following information: type of curriculum received, school or community setting, student grade levels, number of classrooms receiving programming, type of youth prevention facilitator, teacher presence during youth prevention administration, overall satisfaction with programming, satisfaction with curriculum content, satisfaction with number of sessions, satisfaction with length of sessions, satisfaction with curriculum and content, satisfaction with facilitator, and qualitative feedback regarding curriculum, content, and facilitator. Fax Back System and OTREC DM: The data collected on the above three forms are either faxed to OTREC through the fax back system or online using OTREC DM (see appendix A for description of these two systems). The graphic below provides a overview of how these data are entered and summarized by OTREC. Fidelity Checklist Teacher Reporting Form Student Surveys GWiz OTREC Results Data from the three primary data sources described above (youth one page survey, teacher reporting form, and curriculum specific fidelity checklist) were merged into a single analytic dataset. Once compiled, these data were used to construct summary tables detailing the youth population, program reach, and curriculum fidelity. Implementation of school based curricula Youth prevention curricula were implemented in,7 school based and community based classrooms across Ohio, with 36,989 youth enrolled in these classes. As shown in Table.. below, Word of Mouth 4 th grade. Project TNT (which is not grade level specific), and Life Skills Training Middle School, which targets 6 th and 7 th grade youth, were the most widely implemented curricula during this period.

131 Strategy: School, Community and Online Youth Prevention Programming 3 Table.. Classes Delivered and Youth Reached: Total, By Curriculum Curriculum Number of Classes Delivered Number of Youth Reached TOTAL,7 36,989 School Based,66 35,4 Community Based 84,588 Life Skills Training 3 rd /4 th 3 2,586 Life Skills Training 4 th /5 th 69,543 Life Skills Training 5 th /6 th 76,737 Life Skills Training Middle School 339 7,572 Life Skills Training Middle School ,68 Life Skills Training Middle School 3 78,734 Project Alert 233 Project TNT 238 5,46 STAMP 4 47 Word of Mouth 4 th 283 6,54 Word of Mouth 5 th 5 3,396 Word of Mouth 6 th 74,56 Word of Mouth 7 th Word of Mouth 8 th Word of Mouth 4 th Online Word of Mouth 5 th Online 8 83 Word of Mouth 6 th Online 4 53 Program Reach Agencies were funded for particular curriculum within school based, community based, or both settings. As shown in table.2. below, grantees program reach ranged from 32.4% to 28.9%, with nine agencies achieving a reach greater than %. Table.2. Strategy Funding, Program Setting, Curricula, and Program Reach By Grantee Agency Approved Funding Amount Setting Curriculum Total Youth Reached Proposed Reach % of Proposed Reach ALA of Ohio $54,966. School Word of Mouth,57,9 79.8% ALA of Oho NW $45,47.74 School Word of Mouth,972,5 3.5% Alpha Community Services $24,55. Community Life Skills Training % ASIA, Inc. $26, Community STAMP %

132 Strategy: School, Community and Online Youth Prevention Programming 4 Agency Asian American Community Services Athens City County Health Department City of Refuge, Point of Impact Columbus State Community College Community Action for Capable Youth Cuyahoga County District Board of Health Fairfield County Department of Health Approved Funding Amount Setting Curriculum Total Youth Reached Proposed Reach % of Proposed Reach $42,85. Community Project TNT % $6,. School $5,38. Community $,47. Community $59, School $3,929.8 School $3, Family Guidance Center $2,893. Greater Cleveland Health Education and Service Hamilton County General Health District School Community School Community Life Skills Training Life Skills Training Life Skills Training Life Skills Training Life Skills Training* & Word of Mouth Life Skills Training Life Skills Training % % % 693 2, % 3,823 4, %,28, % % $48, School Project TNT,552, % $9,55. School Community Life Skills Training, % Holzer Medical Center $2,. School Project Alert % Hospital Council of NW Ohio Lake Geauga Center for Alcoholism and Drug Abuse Lorain City Health Department Mahoning County District Board of Health $325,783. School $2,522. School Community $5,863. School Ohio Hispanic Coalition $2,85.9 Community Pathways of Licking County Private Duty Svd Van Wert County Project Linden $49,567. Recovery and Prevention Resources Rural Opportunities, Inc $54,679. Life Skills Training & Word of Mouth Life Skills Training Life Skills Training 9,879 9,64 2.8% % % $74,25. Community Project TNT % $25,882. School $93,2. School School Community $2, School School Community Life Skills Training Life Skills Training Life Skills Training % % 2,93 2,87 4.4% Project TNT % Life Skills Training Life Skills Training % %

133 Strategy: School, Community and Online Youth Prevention Programming 5 Agency Approved Funding Amount Setting Selby General Hospital $,9. School Stark County Health Department UMADAOP of Lucas County Your Human Resource Center Zanesville Muskingum County Health Department $3,. $92,97. School Community School Community $6,95. School $9,826. School Curriculum Life Skills Training Total Youth Reached Proposed Reach % of Proposed Reach % Word of Mouth 2,256,8 28.9% Project TNT 2,56 2, % Life Skills Training & Word of Mouth Life Skills Training %,68 2, 77.% * Life Skills Middle School was taught in an approved, modified form where only 9 of the 5 sessions and certain activities were required for program administration. Additionally, one agency, ALA of Ohio, created and administered a Word of Mouth web version to three schools in two school districts. An additional 728 students in grades four through six received this programming. As reported by the agency, Overall, students respond well to the Word of Mouth web programs. They are comfortable with computers and work well independently. The only barriers we have encountered were [in one school district]. They often do not have enough computers for all of their students, requiring them to complete the lessons in shifts or spread out to multiple rooms (i.e. library and classrooms) so that everyone can complete the lesson. They also need to schedule their lessons with the school librarian and work around an already busy library schedule. The web lessons offer students a chance to improve their computer skills, practice reading skills and work at their own pace. Many schools are looking for opportunities to work on computer skills and reading so this fits in well with their curriculum requirements. Description of Youth Participants Of the 36,989 students who received programming, 34,42 students (92.3%) completed the one page youth survey. (Note: The survey was completed only by youth present in the class on the day of survey administration, yielding less than % completion.) As shown in Table.3., the youth were evenly divided by gender, with most in the 4 th or 6 th grades, and predominantly White/Caucasian (57.9%) or African American/Black (9.8%). Seventy two percent of youth were in districts deemed to be of low socioeconomic status, based on median district income (half of households with incomes below; half with incomes above) a When using the mean (i.e., average), district income, 9.4% of students were located in a district less than 2% of the poverty level, suggesting that many of the districts were economically diverse. While programming was offered throughout the state, grantees in the Northwest and Northeast regions of the state reached just under 74% of all Ohio youth receiving OTPF funded programming. a Low socioeconomic status defined as having a median/mean income less than or equal to 2% of the poverty level using 24 tax return data collected by the Ohio Board of Education.

134 Strategy: School, Community and Online Youth Prevention Programming 6 Table.3. Description of Youth Participants Total Number of Youth Surveys Received 34,42* Gender n (%) Female 7,36 (46.5%) Male 6,85 (45.45%) Missing 9 (<%) Grade in School n(%) 3 rd Grade,653 (4.46%) 4 th Grade 7,922 (2.4%) 5 th Grade 5,765 (5.58%) 6 th Grade 8,95 (24.9%) 7 th Grade 4,28 (.57%) 8 th Grade 4,4 (.89%) 9 th Grade 764 (2.6%) Missing 36 (<%) Racial/Ethnic Distribution n(%) White/Caucasian 2,428 (57.93%) African American/Black 7,335 (9.83%) Hispanic 2,55 (5.82%) Asian or Pacific Islander 5 (.37%) Native American or Alaskan Native 526 (.42%) Other,66 (4.34%) Missing 482 (.3%) Students in Low SES School Districts based on median income n(%)** 25,33 (7.5%) Students in Low SES School Districts based on average income n(%)** 6,7 (9.39%) Geographic Location n(%)*** Northwest Ohio 5,6 (42.82%) Northeast Ohio,8 (3.53%) Central Ohio 3,447 (9.73%) Southwest Ohio,95 (5.5%) Southeast Ohio 3,234 (9.3%) Live with Smoker n(%) 7,274 (48.88%) Ever offered cigarette n(%)**** 8,54 (24.9%) Tried cigarettes n(%)**** 5, (4.7%) Tried cigars, cigarillos, or little cigars n(%)**** 3,45 (8.9%) Tried chewing tobacco n(%)****,54 (4.28%) Any tobacco use in last 3 days n(%)**** 2,373 (6.7%) *The number of students in this table is less than the previous table because this table is based on the number of youth surveys received, whereas the previous table is based on the number of student reported by the facilitator **low SES based on family income at or above 2% of poverty line for family of 3 in 24: (2*5,67)=$3,34, only for school based data ***Data only for school based data, based on school building locations ****Data not collected from 3 rd grade students

135 Strategy: School, Community and Online Youth Prevention Programming 7 Lastly, over half of the youth (48.9%) reported that they live with a smoker, an interesting finding when considering that far fewer (~22%) of Ohio adults report to be smokers. Approximately 4.2% reported that they had tried smoking cigarettes; 4.3% reported trying cigars, cigarillos, or little cigars; and 4.3% reported trying smokeless tobacco. Overall, 6.7% reported using any tobacco in the previous 3 days. Exposure to tobacco in the home clearly influences usage among youth as children who reported living with a smoker were six times more likely to have tried and to use tobacco than those who did not live with an adult smoker (data not shown). Contact Time and Curriculum Fidelity As state in the overview, a primary focus of the evaluation of the school and community youth prevention programming was on programmatic fidelity could the community based agencies conduct the intervention with high fidelity to ensure effectiveness?? Owing to the fact that different curricula had different dosage levels (i.e., number of required sessions), fidelity was examined within the context of contact time. Table.4. summarizes contact time across curricula and curriculum fidelity. Contact time for each class was calculated based on the sum of minutes reported by the facilitator for each session in the fidelity checklist. These totals were summed and averaged across each curriculum and are reported in Table.5. As expected, the curricula with the most sessions had the highest average total contact minutes per classroom, with Life Skills Training Middle School averaging 474 contact minutes and Project TNT averaging 436 contact minutes. As the Word of Mouth curricula are only four sessions, these curricula had the lowest average total contact minutes per classroom, ranging from 68 contact minutes to 74 contact minutes. It is also noted that the more sessions a curriculum had, the less likely that the facilitators are able to conduct all the sessions. For example, most grantees implementing WOM were able to administer over 9% of the sessions, while those conducting the most time intensive LST (5 sessions) were typically able to administer 75 8% of the sessions. Table.4. also summarizes data obtained from the curriculum specific fidelity checklists. Two primary measures of fidelity were used: average percentage of activities completed and a fidelity rating. Average percentage of activities completed was calculated by summing the total number of activities implemented across all sessions and dividing by the total number of activities possible. Average activity completion ranged from 64% (Life Skills Training Middle School 2) to 92% (Word of Mouth 8). In general, the average percent of curriculum specific activities completed was higher for the programs requiring fewer sessions. As might be expected, there appeared to be a relationship between average number of minutes per session and the average percent of activities completed, with more activities completed where more time was available. To provide an alternative examination of fidelity, a fidelity rating of high, medium, or low was assigned using a two step process. First, the average proportion of activities completed within each curriculum session was calculated. Second, the session averages were summed and divided by the total number of curriculum sessions. The subsequent scores were split into high fidelity (more than 75%), medium fidelity (5 75%), and low fidelity (less than 5%).

136 Strategy: School, Community and Online Youth Prevention Programming 8 As shown in Table.4., on the next page, of the thirteen (of 4) curricula examined, over half of the classes were rated as being implemented with high fidelity (fidelity ratings are bolded in Table.4.). Of the remaining LST MS, over half of the classes were rated as being implemented with either high or medium fidelity. It is important to point out that in providing training to the agencies, OTREC assured the agencies that the fidelity checklists were tools to assess the real life implementation of the curricula, and not intended to be punitive assessments. OTREC stressed the importance of honest reporting in order to provide the most accurate description of youth prevention programming to OTPF. The distribution in fidelity measures reported below suggests an honest assessment of program implementation by the facilitators.

137 Table.4. Contact Time and Fidelity Data By Curriculum Fidelity Rating Number of Fidelity Checklists Received Number of Sessions Required by Curriculum Average % of curriculum Activities Completed Average Number of Sessions Completed Mean ± SD Average Total Contact Minutes per Session Mean ± SD High: Average, >75% of each session activities completed Medium: Average, 5 75% of each session activities completed Low: Average, <5% of session activities completed Life Skills 3/ ± ± ± Life Skills 4/ ± ± ± Life Skills 5/ ± ± ± Life Skills MS ± ± ± Life Skills MS Modified ± ± ± Life Skills MS ± ± ± Life Skills MS ± ± ± Project ALERT ±.96. ± ± Project TNT ± ± ± STAMP 4 9. ± ±. 5. ± Word Of Mouth 4* ± ± ± Word Of Mouth 5* ± ± ± Word Of Mouth 6* ± ± ± Word Of Mouth ± ± ± Word Of Mouth ± ± ± * Word of Mouth web version not included CGIII Program Evaluation Report (Jan Dec, 27) June, 28

138 Strategy: School, Community and Online Youth Prevention Programming 2 Contact Time and Curriculum Fidelity We next examined contact time and curriculum fidelity across agencies, as shown in Table.5. Contact time for each class was again calculated based on the sum of minutes reported by the facilitator for each session in the fidelity checklist. These totals were summed and averaged across each agency and are reported. Table.5. also summarizes data obtained from the curriculum specific fidelity checklists. Two primary measures of fidelity were used: average percentage of activities completed and a fidelity rating. Average percentage of activities completed was calculated by summing the total number of activities implemented across all sessions and dividing by the total number of activities possible. Average activity completion ranged from 37% (Community Action for Capable Youth) to 98% (Recovery & Prevention Resources of Delaware & Morrow Counties). In general, the average percent of curriculum specific activities completed was higher for the agencies implementing programs requiring fewer sessions (i.e. Word of Mouth). To provide an alternative examination of fidelity, a fidelity rating of high, medium, or low was assigned using a two step process. First, the average proportion of activities completed within each curriculum session was calculated. Second, the session averages were summed and divided by the total number of curriculum sessions. The subsequent scores were split into high fidelity (more than 75%), medium fidelity (5 75%), and low fidelity (less than 5%). As shown in Table.5., among 8 of the thirty examined, over half of the classes were rated as being implemented with high fidelity (fidelity ratings are bolded in Table.5), with six agencies achieving % high fidelity. Of the remaining agencies, 27 of the thirty agencies were rated as having more than half of their classes implemented with either high or medium fidelity. It is important to point out that in providing training to the agencies, OTREC assured the agencies that the fidelity checklists were tools to assess the real life implementation of the curricula, and not intended to be punitive assessments. OTREC stressed the importance of honest reporting in order to provide the most accurate description of youth prevention programming to OTPF. The distribution in fidelity measures reported below suggests an honest assessment of program implementation by the facilitators.

139 Strategy: School, Community and Online Youth Prevention Programming 2 Table.5. Contact Time and Fidelity Data By Agency Number of Fidelity Checklists Received Average % of curriculum Activities Completed Average Total Contact Minutes per Session Mean ± SD High: Average, >75% of each session activities completed Fidelity Rating Medium: Average, 5 75% of each session activities completed Low: Average, <5% of session activities completed Recovery & Prevention Resources of Delaware & Morrow Counties ±.4... Community Action for Capable Youth ± Holzer Medical Center ± City of Refuge Point of Impact ± Mahoning Co. Dist. Board of Health ± Athens City Co. Health Dept ± Columbus State Comm. College ± Alpha Comm. Services ± American Lung Assoc. of Ohio NW Region ± Lorain City Health Dept ± Greater Cleveland Hlth Educ & Serv Council ± Pathways of Licking Co ± Ohio Hispanic Coalition ± Selby General Hospital ± Hospital Council of NW Ohio ± Private Duty Services, Inc. (Van Wert Co.) ± Cuyahoga Co. Dist. Board of Health ± Rural Opportunities, Inc ± Family Guidance Center ± Asian American Comm. Services ± Hamilton Co. General Health Dist ± Asian Services In Action, Inc ± Your Human Resources Center (Holmes Co.) ± Lake Geauga Center on Alcoholism & Drug ±.... Abuse, Inc. Zanesville Muskingum Co. Health Dept ± American Lung Assoc. of Ohio* ± Fairfield Co. Dept. of Health (7 Counties) ± Stark Co. Health Dept ± UMADAOP ± Project Linden ±.58...

140 Strategy: School, Community and Online Youth Prevention Programming 22 Teacher Satisfaction Survey Responses Tobacco prevention programming was provided to the classrooms of,34 unique teachers across the state of Ohio from January to December 27. Of these, 647 (62.57%) provided an address and consented to be contacted at a later time to complete an on line survey which elicited their degree of satisfaction with the programming provided. Teachers were surveyed only once in a school year, regardless of how many of their classes received youth prevention programming. Initially, teachers were incentivized with inclusion in a quarterly raffle. However, due to low response rates, the protocol was changed such that each responding teacher received a $5 gift card after completion of the online satisfaction survey. As a result, 74 teachers completed the online survey for a response rate of 26.89%, with response rates were similar across curricula. Of the 74 teachers who completed the on line survey, 52 (87.6%) teachers reported on youth prevention programming delivered in the school setting. As shown in the table below, most of the teachers reported on Word of Mouth and Life Skills. Most interestingly, however, was that a full third (6 fo the 74 teachers) reported that they were unsure of the name of the prevention program offered in their classroom. Table.6. Teacher Response by Curricula CURRICULUM (ALL LEVELS) Number of Teachers Reporting Word of Mouth N=73 (4.9%) Life Skills N=44 (25.3%) TNT N= ( 6.3%) Project Alert N=3 (.7%) STAMP N=3 (.7%) Unsure of curriculum name N=6 (34.5%) The vast majority (n=5; 86.8%) of the classes were taught by outside facilitators, with 7 (.9%) teachers reporting they or another teacher administered the prevention programming. An overwhelming 96% of the teachers (66) indicated that they were satisfied or very satisfied with the tobacco prevention programming and the curriculum content provided to their students. Teachers reported that the students were engaged in the presentations and particularly enjoyed the hands on activities. Teachers appreciated the valuable information provided to the students and felt it was important for the students to learn the benefits of a tobacco free lifestyle from someone other than school personnel to reinforce the message. Barriers and Lessons Learned: Scheduling and Competing Priorities Several grantees identified scheduling and competing priorities as barriers to implementing school based prevention curricula in schools. Due to extremely harsh weather conditions in January and February, 27,

141 Strategy: School Based and Community Based Youth Prevention 23 many school districts cancelled or delayed classes. Subsequently, scheduled classroom implementation was also cancelled and had to be renegotiated. Grantees generally approached this issue by securing additional classrooms days for implementation or condensing sessions into the time provided. Grantees also reported that the school cancellations impacted grantee recruitment of schools as it was difficult to gain access to school administrators to discuss scheduling of classroom instruction. Additionally, the cancellation of classes created competition for the spring semester class time as teachers prepared students for the administration of the Ohio Achievement Tests. Scheduling or re scheduling of prevention curricula instruction became a low priority to the teachers and the administration. Further contributing to limited classroom access was poor communication with school staff and administration regarding other events occurring within the school day, such as end of the year events or field trips. However, some grantees noted that maintaining strong and consistent contact with school teachers and administration and proactively seeking information on competing priorities allowed the grantee to more successfully navigate program scheduling. A key piece of advice was provided by one grantee, who wrote in their activity report: It is important to stress and gain commitment of the school regarding programming fidelity. Once you have gained commitment, regardless of any event that happens on the day of your programming (snow day or an unexpected field trip) the teacher is aware that you still have to implement the rest of the curriculum as outlined. Grantees provided other tips to overcome recruitment and scheduling barriers, such as attending parent meetings and networking within the school to promote implementation of the prevention curriculum. Grantees also suggested working with the schools over the summer or early in the school year to ensure adequate scheduling time to implement all curriculum material. Finally, to encourage successful communication, grantees suggested the facilitator follow up with teachers at the end of the day to remind them of the next scheduled session. Capacity Building Several of the grantees implemented a funded tobacco prevention curriculum for the first time during this grant cycle. Some grantees noted that they were not prepared to implement school based programming due to the OTPF training requirement (i.e. facilitators must be trained by certified trainers). Other grantees reported issues with classroom management and successfully managing class time to allow completion of session activities. Lastly, some grantees reported difficulties in gaining a commitment from facilitators to comply with the evaluation protocols. Class management and student engagement can greatly impact successful implementation of the curriculum. One grantee provided the following feedback: If it is your first time in a district, you may want to introduce yourself to the staff and students before you do any programming. We took ten minutes to let the students know who we were and what we would be doing with them two weeks before the program started.

142 Strategy: School Based and Community Based Youth Prevention 24 Program Overlap Finally, agencies identified competing tobacco prevention program providers as a barrier. At times, agencies identified other OTPF funded agencies that were also providing tobacco cessation curricula to the same schools as well as agencies funded by other sources bringing similar programming to the schools. In this case, one agency suggested the following: identify any additional programs that are in schools your (sic) selected to do school based curriculum. There may be a duplication of services and administration does not know until you are standing in the door ready to begin your program. Summary and Recommendations In 27, OTPF funded agencies have provided tobacco use prevention programming to 36,989 youth across Ohio. The programming was comprised of evidenced based and promising tobacco prevention curricula implemented at reasonable levels of fidelity. Based on reported exposure to tobacco within the home, nearly 5% of the students who received programming are not only presumably exposed to secondhand smoke, but experiencing a social norm suggestive of the acceptability of tobacco use. The tobacco prevention programs funded by OTPF have exposed Ohio youth to activities which educate them on the harmful effects of tobacco use and provide them skills and strategies to avoid tobacco use in the face of social norms, peer pressure and tobacco industry marketing. The programming appears to be reaching a diverse group of students from different racial and socioeconomic backgrounds and from different geographic regions of the state. For example, although 27% of Ohio middle and high school students are from minority backgrounds, 43% of all students receiving OTFP funded programming were African American, Hispanic, Asian or Pacific Islander or other minority. Moreover, over 7% of the youth attend schools districts where the median income is within 2% of the federal poverty level (approximately $4, for a family of four). With regard to geographic distribution, there was a predominance of programming in the northern part of the state, with over 7% of programming occurring in northeast and northwest Ohio. Overall, grantees should be recognized for successfully transitioning to the OTPF approved curricula. For the most part, grantees did well implementing the curricula with fidelity given real life restrictions, with average activity completion ranging from 64% (Life Skills Training Middle School 2) to 92% (Word of Mouth 8). While the briefer curricula had better fidelity, the longer curricula allowed more contact time. The implementation rate among the longer curricula may seem problematic; however, they are similar to what has been reported in the literature. Gil Botvin, the developer of LST has found that when implemented by classroom teachers, the average implementation of the curriculum topics was around 48% 2, and that was with the teachers knowing that they were being observed. Ideally, however, the goal for real world implementation of evidenced based curricula is above 75% for those with ten or more sessions, higher for those with fewer sessions. In particular, with curricula comprised of more sessions, activity and content is frequently repeated

143 Strategy: School Based and Community Based Youth Prevention 25 as repetition is a key to making the point ; thus, when pressed for time, it s possible that facilitators are cutting content that has already been covered in order to present a wider range of topics. With regards to the teacher satisfaction survey, 74 teachers completed the online survey for a response rate of 26.9%, a response rate typical of online survey administration. Of the 74 teachers who completed the online survey, 96% of the teachers (66) indicated that they were satisfied or very satisfied with the tobacco prevention programming and the curriculum content provided to their students. Our expectation was that those teachers who felt strongly that they had an important comment to share would respond, and the data to date reflect this with many teachers reporting strong positive feedback regarding the prevention programming. The information gathered from grantees bi monthly activity reports has provided additional insight into the process of school based program implementation by community agencies. Many grantees had very similar experiences with scheduling difficulties due to inclement weather and the competing priorities of preparing Ohio youth for standardized tests. Moreover, many grantees provided valuable lessons learned in dealing with these same problems. It would be quite beneficial for grantees to share of this information. In considering the future prevention programming, OTREC would make the following recommendations:. Curricula Implementation It is recommended that OTPF continue to require grantees to use published, evidenced based programs for the school based and community based prevention programming and to strongly encourage program fidelity. It has been consistently shown to be the best way to influence community wide preventive behaviors such as tobacco prevention. However, this does point out the problem with the lack of published evidence related to the Word of Mouth program. To the best of our knowledge, this program has not been evaluated and reported in peer review publications as the other four programs have. Nonetheless, it is a well liked and well used program, and therefore, it is strongly recommended that the Word of Mouth program be evaluated. With the large number of schools that are currently conducting the WOM curriculum across Ohio, and the strong relationships that grantees have with local school districts, it would be relatively easy to design and conduct a rigorous effectiveness study of WOM in Ohio. It is also important to point out that no evaluation of a program aimed at children (most WOM participants are age 9 or ) will have the power to yield significant behavioral outcomes, such as reductions in smoking initiation or smoking prevalence. The prevalence of tobacco related behaviors at this age is simply too low. Rather, an efficacy study would be aimed at observed changes in cognitive factors theoretically assumed to precede behavior, such as knowledge, self efficacy, intentions, and perceptions of peer norms. In order to study behavioral outcomes, a longitudinal study would be needed and preferred for the WOM program since the program was designed to be multi year and progressive (i.e., each year building off the prior year). In this case, evaluators would have to engage a limited number of school districts across the state that would be willing to participate in a multi year study where individual students would be followed over a longer period of time (2 3 years). Again, there appears to be a number of current grantees that could provide the access and support needed for such as study should OTPF choose to pursue it.

144 Strategy: School Based and Community Based Youth Prevention Geographic distribution of prevention programming Examination of the youth surveys reveal that over 7% of prevention programming occurred in the northern parts of the state, provided primarily by two of the largest grantees (Cuyahoga County and Hospital Council of Northwest Ohio). This was likely influenced by the fact that these two grantees were already providing evidenced based programming in many of their school districts prior to the funding for 27. For other grantees around the state, the capacity to provide such programming may have been limited and thus it required more effort and time to get into the schools and to train and implement a different curricula than they had in the past. However, during the past year there have been many more opportunities for grantees to be trained in the four OTPF sanctioned programs and therefore, the concern should be must less going forward. Nonetheless, it is recommended that in the future, steps be taken to increase prevention programming in the southern parts of the state. 3. Fidelity and Dosage One of the primary barriers that grantees faced with regard to fidelity was the resistance from some schools to commit to the more intensive tobacco prevention curricula, such as Life Skills, which commits up to three weeks of daily class time. For this reason, many of the grantees chose to deliver curricula with fewer sessions (i.e.,word of Mouth). It would be important going forward to assess the impact of dosage of the recommended programs. For example, if class time is limited, is it more effective to conduct the shorter dosage curricula or reduce the number of sessions for the more intensive curricula? And if you are going to reduce the number of sessions, is there a cutoff at which the program is no longer effective? With the large number of classrooms involved in the Community Grants Program and the data collection infrastructure (i.e., standardized tools and protocols, and OTREC DM) in place, it would be relatively easy to step up the evaluation next year to include a pretest and posttest that captured factors that were immediately sensitive to programmatic influence (i.e., knowledge, attitudes, intentions). Along with measures of fidelity (number and type of sessions completed) of each curricula, the impact of curricula and curricula X dosage could be assessed. The results from this type of study would be highly beneficial not only for future tobacco prevention programming in Ohio, but across the country. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs 27. 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 on Smoking and Health; October Botvin GJ, Baker E, Dusenbury L, Botvin EM, Diaz T. Long term follow up results of a randomized drug abuse prevention trial in a white middle class population. Journal of the American Medical Association.995;273(4): 6 2.

145 Ohio Tobacco Prevention and Control Program CGIII Evaluation (Jan Dec, 27) Strategy: Train School Personnel in Prevention Curricula Programmatic Goal Area: PREVENTION OVERVIEW: A long term strategy of the Community Grants Program is to implement evidencebased youth prevention curricula to all Ohio youth in order to reduce the prevalence of tobacco use and to prevent or increase the age of tobacco use initiation. To increase program sustainability it is important to institutionalize prevention curricula within school systems whenever possible. Training teachers, school nurses, guidance counselors, community educators, etc. can enhance local capacity to reach youth with prevention curricula. Funding Amount $6,62 Number of Grantees Funded for this Strategy: 2 Agencies Funded: Family & Community Services (Wayne) Your Human Resources Center EVALUATION AND TOOLS: The evaluation component for this strategy identifies the number of persons trained, the estimated number of youth who will benefit from the trainings and the satisfaction levels of those trained, using workplans, reach reports, activity reports, and a satisfaction survey completed by all trainees. RESULTS HIGHTLIGHTS: Two agencies were funded to provide Life Skills curriculum training to 4 persons reaching approximately 5,92 youth in Holmes and Wayne counties. Trainees were predominantly white, males, and those with a college degree or more, and included teachers, school nurses, safe and drug free counselors, guidance counselors and community agency representatives. The vast majority of trainees were satisfied with the training and over 6% high confidence in their ability to teach the curriculum following the training. Counties Served: SUMMARY: The goal for the next grant cycle would be to increase the number of school districts that train their own teachers in the delivery of evidenced based tobacco preventin programming or order to sustain a statewide effort to reach all Ohio youth. Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

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147 Evaluation of CGIII Tobacco Prevention and Control Efforts STRATEGY 3: TRAINING SCHOOL PERSONNEL IN YOUTH PREVENTION CURRICULA Goal: Prevention Background and Rationale Youth tobacco prevention curricula are implemented to reduce the prevalence of tobacco use among Ohio youth and increase the age of tobacco use initiation. To increase program sustainability it is important to institutionalize proven and promising prevention curricula within school systems whenever possible. Training teachers, school nurses, guidance counselors, and community educators can enhance local capacity to reach youth with proven and promising prevention curricula. Grantees funded for this strategy could provide training on any of the following programs: Life Skills Training (3 rd 9 th ), Project ALERT (6 th 8 th ), Project TNT (5 th 8 th ), WOM (4 th 8 th ) & STAMP (5 th 8 th ). Two agencies were funded to provide prevention curricula training in Wayne and Holmes counties. Evaluation of Prevention Curricula Training The evaluation component for this strategy identifies the number of persons trained, the estimated number of youth who will benefit from the trainings and the satisfaction levels of those trained. The evaluation tools and respective data collected via this tool are outlined below: Results Workplan (provided prospectively): Grantees identified curriculum for which training(s) would be provided and proposed number of individuals to be trained on the curriculum. Reach Reports and Activity Reports (submitted bi monthly): Number of individuals that were trained during that reporting period, as well as any changes made to the program, barriers, and lessons learned. Satisfaction Surveys: The agency training coordinator was responsible for administering a survey at the end of each training session. RE Coordinators were provided with evaluation materials to create packets for each individual training session (survey administration instructions, surveys, packet labels) and the survey was to be completed by each individual receiving training. The survey assessed the characteristics of the individuals being trained to deliver youth prevention curricula, the potential number of youth reached by the newly trained facilitator, and their comfort level with the material provided in the training. The completed surveys were faxed to OTREC using the fax who compiled the data and uploaded the results into G Wiz. Process Outcomes The agencies funded for this strategy provided training for the Life Skills Training Middle School (LST MS) (6 th 9 th ) curriculum by either sub contracting with an external agency to provide training or using certified members of their own staff to provide the training.

148 Strategy: Training School Personnel in Youth Prevention Programming 29 A total of forty one persons were trained on LST MS (6 th 9 th ) in 27. Table 3. provides a description of the 4 individuals trained through this strategy. The most frequently trained persons were teachers (32%), followed by community volunteers (24%). Most were female (73%), white (85%), with a distribution regarding age. Most had either a bachelor s degree (49%) or more (24%). Table 3.. Characteristics of Prevention Curricula Trainees (N=4) Number (%) Gender Male 9 (22%) Female 3 (73%) Missing 2 (5%) Race/Ethnicity White 35 (85%) African American 3 (7%) Hispanic (3%) Asian or Pacific Islander Native Amer/Alaskan Native Other 2 (5%) Missing Age (46%) (42%) 55 and older 5 (2%) Missing Highest Level of Education High School Some College 6 (5%) Associate's Degree 5 (2%) Bachelor's Degree 2 (49%) Professional Degree (24%) Missing Occupation Teacher 3(32%) School Nurses 2(5%) Safe and Drug Free Coordinators 2(5%) Guidance Counselors (2%) Community Agency Representative (24%) Other (2%) Missing 2(27%) When asked, twenty five percent indicated they would culturally tailor or adapt the curriculum for a special population. Trainees were also asked to estimate the number of students they expected to reach with the curriculum an estimated 5,92 youth would benefit as a result of the training provided by OTPF. Trainees were also asked where they would provide the training: in school, after school, or in a community setting. As shown in Table 3.3, most reported they would provide LST MS (6 th 9 th ) curriculum in a school.

149 Strategy: Training School Personnel in Youth Prevention Programming 3 Table 3.3. Curriculum Delivery Setting n(%) In School 33 (8%) After School ( 2%) Community Setting 7 (7%) Missing At the completion of training individuals were asked how comfortable they were with the training session. No one expressed discomfort with the material covered in training or lack of confidence in their ability to deliver the curriculum. In fact, 73.2% of trainees were very comfortable with the material covered in training and 58.5% were very confident in their ability to deliver the Life Skills Curriculum. Figure 3.4. Trainees Comfort with material covered in training Figure 3.5. Trainees Confidence in administering the curriculum Activities at a Glance: Securing someone to provide trainings, scheduling training dates The first step for grantees was to secure someone to provide training. Each agency s coordinator was trained in March to train other facilitators according to National Health Promotion Associates standards. After certification of an in house trainer, grantees began compiling the necessary materials for training as well as scheduling dates for training sessions. Both grantees also teamed up with the National Health Promotion Associates to provide additional trainings. Barriers& Lessons Learned at a Glance: weather, scheduling conflicts, duplication of services Activity reports acknowledged several barriers faced by grantees. These barriers were weather, scheduling conflicts, and duplication of services which delayed training. After one agency discovered it was duplicating services being provided by another organization, the two agencies decided to work together. Re evaluation of services was completed to see where gaps still existed and both organizations worked together to fill these gaps without duplicating services. Another agency had trouble retrieving surveys from participants and opted to give the surveys out at the events instead of sending them afterwards. Summary and Recommendations Two agencies provided Life Skills curriculum training to 4 persons reaching approximately 5,92 youth in Holmes and Wayne counties. While the number of grantees who undertook this strategy was few, it clearly is an efficient and sustainable way in which to provide Ohio youth with tobacco prevention education.

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151 Ohio Tobacco Prevention and Control Program CGIII Evaluation (Jan Dec, 27) Strategies: Establish and Support Stand Teams Programmatic Goal Area: PREVENTION OVERVIEW: Tobacco counter marketing campaigns have been found to be associated with an increase in anti tobacco attitudes and beliefs among adolescents and with a decrease in tobacco use and tobacco use initiation. In 22 OTPF partnered with Northlich to launch the stand campaign, an interactive, youth led anti tobacco counter marketing campaign. The centerpiece of the stand campaign are the youth driven stand teams that participate in promoting the anti tobacco message, particularly to younger children in their local community. While stand teams originated separate from the community grants program, in the CGIII cycle many of the community grantees were awarded funds to support existing stand teams and establish new stand teams, particularly in counties where there were fewer stand teams. EVALUATION AND TOOLS: Community grantees funded to establish and support existing stand teams created an annual workplan for each team and submitted ongoing activity and reach reports on the team activities and progress toward workplan goals. For each of the activities, grantees reported on the date, youth attendance, attendance of community leaders and partnering organization, and other relevant information such as the amount of stand gear distributed and attendance by non team members events. Grantees also provided a summary of lessons learned and barriers to achieving the goals of their workplan. RESULTS HIGHLIGHTS: By the end of the grant year there were a total of 84 active teams (including both previously established teams and new teams established in 27) with 77 of these reaching bronze status. A total of 53 counties had at least one grantee supported stand team of at least bronze level status. Counties with large populations such as Cuyahoga (Cleveland), Franklin (Columbus), Hamilton (Cincinnati), and Montgomery (Dayton) generally had more stand teams than less populated counties. There were a total of 7 occurrences of team participation in one of the three statewide campaigns. SUMMARY: There is a large range in the participation, reach, and accomplishments of the grantee supported stand teams. In general, grantees made significant progress toward establishing active stand teams in the areas they proposed. Most stand teams planned and successfully executed numerous activities and events, engaging anywhere from dozens to thousands of members of the community. Future evaluations of stand teams could further develop standardized definitions such as what constitutes an active team or an active team member and how to measure the number of individuals reached by a stand team activity. Funding Amount $84,35 Number of Grantees Funded for this Strategy: 42 Agencies Funded: American Lung Association of Ohio American Lung Association of North West Ohio Alcohol & Chemical Abuse Council Alpha Community Services ASIA Inc. Asian American Community Services Athens City County Health Department Barberton Health Department Columbus State Community College Columbus Urban League Community Action for Capable Youth Cuyahoga County Board of Health Delaware Health Department Fairfield County Department of Health Family & Community Services (Wayne) Family & Community Services (Portage) Family Guidance Center Family Service Association Greater Cleveland Health Education & Service Council Greene County Combined Health Department Guernsey Noble Monroe Tobacco Project Hamilton County GHD Holzer Medical Center Hospital Council of NW Ohio Knox County Health Department Lake Geauga Ctr. On Alcoholism & Drug Abuse Lorain City Health Department Mahoning County Board of Health Medina County Board of Commissions Miami Valley Health Improvement Council Pathways of Licking County Pike County General Health Distirct Private Duty Services Project Linden Recovery & Prevention Resources Rural Opportunities Inc. Selby General Hospital Stark County Health Department UMAPDAOP Lucas County Women & Family Services Your Human Resources Center Zanesville Muskingum County Health Department Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

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153 Evaluation of CGIII Tobacco Prevention and Control Efforts STRATEGY 4 & 5: Establish and Support stand Teams Goal: Prevention Background and Rationale Tobacco counter marketing campaigns have been found to be associated with an increase in anti tobacco attitudes and beliefs among adolescents and with a decrease in tobacco use and tobacco use initiation. In the Guide to Community Preventive Services, the Task Force on Community Prevention Services found strong evidence for the effectiveness of mass media campaigns when combined with other tobacco prevention strategies. Several states, including California, Massachusetts and Florida, have implemented integrated counter marketing campaigns and found success in slowing the increase in tobacco initiation. Integrated, mass media, counter marketing campaigns often include strategies such as paid advertising, event sponsorships, local media advocacy and public relations, and youth empowerment. In 22, OTPF partnered with Northlich to launch the stand campaign, an interactive, youth led anti tobacco counter marketing campaign. The campaign combines grass roots, community based efforts with commercials, billboards, other marketing materials, and public relations. The centerpiece of the stand campaign is the more than 7 stand teams across the state of Ohio. A stand team is a group of youth, age 2 7, who plan events in their community to spread tobacco prevention messages to their peers, adults, and community leaders. Currently, there are more than 2, youth actively participating as members of stand teams. While stand teams originated separate from the community grants program, in 26 many of the community grantees were awarded funds to support existing stand teams and establish new stand teams, particularly in counties where there were fewer stand teams. This coincided with the beginning of the DEBUNKIFY campaign, which had a special emphasis on reaching young adults. Teams are designated as bronze, silver, or gold, according to activities they accomplish. To be considered an active stand team, the team must meet all the requirements of the bronze level. These include requirements such as the following: participate in SUSO Remix a, hold a DEBUNKIFY event, hold an activist event, contact a legislator, hold recruitment events, post updates on the team web page, designate team leaders or the adult advisor participate in regional conference calls. This report will focus on those stand teams supported by the community grants program, which is a part of the larger stand campaign, and will have an emphasis on the activities accomplished by teams that are at least bronze level status. Evaluation of Establishing and Supporting stand Teams Overview: An in depth longitudinal evaluation of the stand counter marketing campaign was previously commissioned by the Ohio Tobacco Prevention Foundation and conducted by Research Triangle Institute. In contrast, this a SUSO REMIX was a contest held by Northlich that challenges stand Teams to uncover the cultural infiltration of tobacco in Ohio.

154 Strategy: Establish and Support stand Teams 33 evaluation is limited in scope to process outcomes related to the reach and range of stand activities completed by grantee supported stand teams during the 27 grant year. The evaluation of the grantees activities includes the following components: number of stand team meetings, activities, and events; number of new and returning youth attending events; and a summary of the meetings and activities. Evaluation Tools Workplan (provided prospectively): Community grantees funded to establish and support existing stand teams created an annual workplan for each team. Agencies were required to fill out separate workplans for each team they were supporting or establishing. Workplan data included: county in which the stand team was primarily located, stand team advisor name and contact information, and number of current members (if the team was already established). For the strategy, Establish a stand Team, agencies were asked to indicate which steps they had already completed toward establishing the team. Reach Reports and Activity Reports (submitted on going or at least bi monthly): Reporting differed if grantees were working to establish a new team, as compared to supporting an existing team. If the team was in the process of being established, grantees reported on the progress made in recruiting youth members and organizing the team in bi monthly activity reports. The grantees classified the progress as either still working to establish a stand team, established a local youth team which is pursuing bronze level stand status, or team achieved bronze level stand status. They were also asked to describe the next steps related to establishing a team, barriers experienced, and lessons learned. Once a team was established, grantees were asked to create a new workplan for supporting an existing team. This workplan allowed more reporting options and were submitted on an on going basis. Grantees submitted descriptive activity reports following each of several types of stand team events. stand team activities were divided into three main categories: activist event, meeting, and training. stand team activist events were further characterized as one of the following events: DEBUNKIFY, Great American Smokeout, Through With Chew, Kick Butts Day, team recruitment, legislative event, Prom Raiders, media coverage, letter to the editor, submitted YAYA candidate, smoke free workplace thank you event, friend of stand, SUSO Remix, activist event with another team, or other (unspecified) event a. Similarly, team trainings were further characterized as one of the following: media training, regional training, statewide training, or other (unspecified). Finally, stand team meetings were considered one of the following: team meeting, legislative meeting, or other unspecified meeting. For each of the activities, trainings, or meetings described above, grantees reported on the date, youth attendance, attendance of community leaders and partnering organization, and other relevant information such as the amount of stand gear distributed and attendance by non team members at an activist event. Grantees also provided a summary of lessons learned and barriers to achieving the goals of their workplan. a Details regarding these events can be found at

155 Strategy: Establish and Support stand Teams 34 Results Process Outcomes A total of 39 of the 58 community grantees were funded to either support an existing stand team or work to establish a new team a. Of those agencies, 2 were funded to support existing stand teams, 9 were funded to both support existing teams and to establish new teams, and agencies were funded to establish new teams (see Figure 4.). There were a total of 54 teams that existed prior to the CGIII grant period, and 35 new teams proposed. Of the 35 new teams, 23 (66%) achieved bronze level status by the end of the grant year. Of the proposed teams that did not achieve bronze level status, 7 teams were established but still actively pursuing the requirements of bronze level status. The remaining 5 were still working to establish a stand team at the end of the grant cycle. The pre established teams and the successfully established new teams together were a total of 77 bronze level status teams by the end of the grant year and a total of 84 active teams. Figure 4.. Number of agencies funded to support and/or establish stand teams 39 funded agencies 2 agencies supporting existing teams 9 agencies supporting existing teams and establishing new teams agencies establishing new teams Total existing teams: 35 Total existing teams: 9 Total proposed teams: 7 achieved bronze status: Total proposed teams: 8 achieved bronze status: 2 Total proposed teams: 35 achieved bronze status: 23 Previously existing teams: 54 Total bronze teams by end of grant year: 77 a Three additional agencies were funded to support local stand teams via a financial role only, not directly as an adult advisor role. When these agencies are included a total of 42 of the community grantees were funded in this strategy.

156 Strategy: Establish and Support stand Teams 35 Population Served Active stand teams were widely distributed across the state (see Table 4.2 below). A total of 53 counties had at least one grantee supported stand team that reached bronze level status or higher. Counties with large populations such as Cuyahoga (Cleveland), Franklin (Columbus), Hamilton (Cincinnati), and Montgomery (Dayton) generally had more stand teams than less populated counties. Table 4.2. Counties with a Grantee Supported stand Team (at least bronze level) Allen Fairfield Lorain (2) Perry Ashland Fayette (2) Lucas (2) Pickaway Ashtabula Franklin (3) Mahoning Portage Athens (2) Gallia Medina Putnam Butler Guernsey Meigs Richland Clarke Greene Miami Ross Clinton Hamilton (3) Monroe Stark Columbiana Henry Montgomery (3) Summit (3) Coshocton Hocking Morrow Trumbull (2) Cuyahoga (6) Huron Noble Van Wert Darke Jackson Ottawa Vinton Delaware Knox Lake Washington Defiance Licking (2) Lawrence (5) Wood Wyandot * Number in parentheses indicates the number of teams in the county. There is one team unless otherwise indicated. Of particular interest are the teams that successfully achieved the bronze level requirements during the 27 grant year. These represent an extended reach for the stand campaign into previously underserved counties. As previously mentioned, a total of 23 teams were successfully organized and met bronze level requirements during the grant year. These teams were also distributed across the state in 6 counties with multiple teams established in Cuyahoga, Franklin, Hamilton, Lorain, and Montgomery counties (see Table 4.3). Table 4.3. Counties where a grantee supported stand team successfully achieved bronze level status during the grant year Ashtabula Jackson Clarke Licking Clinton Lorain (2) Cuyahoga (2) Montgomery (2) Fayette Putnam Franklin (2) Ross Greene Summit Hamilton (3) Trumbull * Number in parentheses indicates the number of teams in the county. There is one team unless otherwise indicated.

157 Strategy: Establish and Support stand Teams 36 stand Team Activities The stand campaign included several state wide campaigns and contests. During 27, these included DEBUNKIFY, SUSO Remix, and Prom Raiders. There were a total of 7 occurrences of team participation in one of the three state wide campaigns. In addition to participating in these state wide campaigns, teams were encouraged to hold a variety of local events and meetings such as meetings with local community leaders and legislators, and recruitment of new team members. Table 4.4 below describes the most common types of stand team activities and the number of times these activities were held in 27. By far the most common events were recruitment events and team meetings. Event Type SUSO (Stand Up Speak Out ) Remix DEBUNKIFY Prom Raiders Thank You Section Great American Smokeout Kick Butts Day Recruitment event/meeting Meet with friend(s) of stand Team meeting Meet with another team/youth group Table 4.4. Frequency of selected stand team activities Description A state wide contest to document the cultural infiltration or presence of tobacco in daily life, teams won points and prizes by completing challenges A state wide campaign and mobile bus tour focused on debunking the myths about tobacco use State wide contest to win an all expense paid prom by painting the school orange through decorations and events at a participating high school Event held at a local restaurant or other commercial establishment to recognize the smoke free environment Annual anti tobacco holiday developed by the American Cancer Society and held in November with the goal of encouraging people to quit tobacco use Annual anti tobacco holiday developed by the Campaign for Tobacco Free Kids and held in April to encouraging youth activism for tobacco use prevention Any team event or meeting with the purpose of recruiting new team members Any team event or meeting with a local supporter ( friend ), usually a community leader Any team meeting not categorized as any other type of activity, typically held to plan for other activities Any team event or meeting with another stand team or other youth group Number of events in 27 Regional training Training organized and led by a team for other teams in the area 3 News story/letter to the editor Letter to the editor from a stand team member or coverage of a team event by local media Legislative event Contact with a legislator such as a letter, phone call, or meeting

158 Strategy: Establish and Support stand Teams 37 stand Team Profiles The next table (Table 4.5) provides information specific to each stand team by agency. The table includes the total number of new members that attended any meeting or event throughout the year and the total number of pieces of stand branded items that were distributed at events. There is also an estimate of the range of number of teen members at team meetings and events, as this number fluctuated greatly during the year. The numbers in the table below provides an overall impression of the level of activity of the team during the year. Direct comparisons across teams should be made with caution because of differences in the way reach numbers are counted and differences in the degree of impact of any given event. For example, a team that did a television interview may estimate the number of viewers and count those as the number of youth and adults reached, in contrast to a team that holds and an all day training and counts the number of youth who attended. Additionally, there may be some overlap in the number of youth reached if teams participated in events together and both counted the number of non member youth in attendance. Most teams reported a wide range of membership attendance, often ranging from one member at a poorly attended meeting to several dozen members participating in a large event. The ratio of number of new members to regularly attending members provides an indication of the stability of team membership and team turnover. Agency Table 4.5. Reach of stand team activities by agency and team County (team*) Range of members attending New members Youth reached Adults reached 7 3 Morrow (Morrow County stand Team) Richland (Richland County stand Team) 5 2, Gallia (Gallia County stand Team) Jackson (Jackson County stand Team) , 35 Meigs (Meigs County stand Team) Columbiana (Columbiana County stand Team) 3 2,5 2,2 33,58 Trumbull (Trumbull County stand Team) Mahoning (Youngstown stand Team) Athens (Athens stand Team) 5 2, Athens (Nelsonville) Family Service Association for the Deaf Franklin** Fayette Erie ** Clarke (Clarke County stand Team) 6 32,572,3 4 Greene (Greene County stand Team) Fayette (Washington Crthouse stand Team) Clinton (Wilmington stand Team) Summit (Summit County stand Team) Ashland (Ashland County stand Team) Wyandot (Wyandot County stand Team) gear

159 Strategy: Establish and Support stand Teams 38 Agency Table 4.5. Reach of stand team activities by agency and team County (team*) Range of members attending New members Youth reached Adults reached Medina (Medina County stand Team) ,493, Montgomery (MVHIC Dayton stand) Preble ** Darke (Arcanum stand) 4 Miami (Troy stand) 8, Lorain (Lorain County stand Team) Cuyahoga (ATEEM) Cuyahoga (Spanish speaking team)** Licking Washington , Huron ,723, Lucas (Mercy Health Partners) , Ottawa 2 2 Wood Portage (stand Portage) Wayne** Van Wert (Van Wert County stand Team) 7 38,89 2, Guernsey (Guernsey County stand Team) 2 3 2,338, Monroe (Monroe County stand Team) Noble (Noble County stand Team) Pike ** Cuyahoga (Cleveland Eastside stand Team) ,533 2, 68 Cuyahoga (JFK SHOUT stand Team) Cuyahoga (SW Cleveland stand Team) Henry (Henry County stand Team) Henry ** Putnam** Defiance Lawrence (Chesapeake stand Team) 6 5 Lawrence (Dawson Bryant stand) 3 8 Lawrence (Ironton stand) 2 Lawrence (Lawrence stand) 2 4 6,259 9,35 4,65 Lawrence (Rock Hill stand) Hamilton (Hamilton County stand Team) Summit (Akron AAYAT stand Team) Hamilton (Cincinnati AAYAT stand Team) 6,32 2, 75 Cuyahoga (Cleveland AAYAT stand Team) , Franklin (Columbus AAYAT stand Team) Montgomery (Dayton AAYAT stand Team) Holmes** Lake Ashtabula** Coshocton (Coshocton County stand Team) 8 Coshocton** Fairfield (Fairfield County stand Team) ,28 6 Hocking (Hocking County stand Team) 2 2 2,38,22 2 gear

160 Strategy: Establish and Support stand Teams 39 Agency Table 4.5. Reach of stand team activities by agency and team County (team*) Range of members attending New members Youth reached Adults reached Licking (Licking County stand Team) 5 9, Perry (Perry County stand Team) 5 2,9 276 Pickaway (Pickaway County stand Team) Ross (Ross County stand Team) 4 5 Vinton (Vinton County stand Team) Stark (Stark County stand Team) , Delaware Summit (Akron UMADAOP stand Team) Hamilton (Cincinnati UMADAOP stand Tm) Allen (Lima UMADAOP stand Team) Cuyahoga (Cleveland UMADAOP stand Tm) Franklin (Columbus UMADAOP stand Team) Lucas (Toledo UMADAOP stand Team) Montgomery (Dayton UMADAOP stand Tm) Lorain (Lorain UMADAOP stand Team) 2, Trumbull (Warren stand Team) Franklin (African American Peer Leadership alliance Against Tobacco) Knox (Knox County stand Team) ,395 3, Butler (Butler County stand Team) 5 3 TOTALS 322 8,483 52,48 45,648 * stand team name may not be exact **Differences in reporting for these teams prevent their direct comparison with other teams in the table. These teams started were established at some point during the grant year rather than being an existing team from the start of the grant year. gear Barriers and Lessons Learned Barriers: The most consistent barriers reported by grantees focused on logistical barriers to holding stand team events and meetings. Perhaps the most commonly reported barrier was transportation for team members. Related to the issue of transportation is the challenge of finding a location for team meetings and events that is centrally located and convenient for all team members. Many teams strive to serve an entire county and this geographic distance can be a barrier for teams where many of the youth do not have cars or drivers licenses. Some teams struggled to meet anywhere outside of school. Several factors affected this, including transportation difficulties, lack of time outside of school due to competing activities, and team members who were not willing to make the extra effort to attend meetings held outside of school. Another commonly reported barrier is team membership. Some teams had so many members that organizing meetings and engaging members proved to be highly challenging. In contrast, some teams struggled to retain consistent members and/or recruit sufficient numbers of youth to have an effective team. Some adult advisors observed that many of the youth team members were actively involved in several other extracurricular activities which made it difficult to sufficiently commit to being involved in stand.

161 Strategy: Establish and Support stand Teams 4 Lessons Learned: The stand campaign is designed so that the youth are expected to generate ideas for activities and provide most of the team leadership. The adult advisor s role is to support the youth in achieving their team goals. Several advisors commented on strategies of engaging the youth and supporting youth leadership. Examples of lessons learned included encourage youth to run meetings and [keep] all members involved in events and meetings. When meetings and events were executed with in this way the results were encouraging. For example, one advisor wrote the following about a Great American Smoke Out event, The event was very successful due to the team members taking ownership over the event. They provided several great ideas in the planning process. They were involved with the event from the beginning to the end. Some team advisors reported on successful methods of communication. One advisor noted, It is helpful to use multiple ways to communicate with youth text messages, s, cell phones, etc. Agency Funding: The table at the end of the chapter lists the approved funding for stand activities based on grantee proposals. During the grant year grantees were permitted to submit budget revisions which may have reduced or increased these amounts. Quarterly budget reports were organized by categories of expenditures rather than by programming strategy so the exact amount spent on stand activities during the grant year is not available. Summary and Recommendations The stand counter marketing campaign represents an important component of a comprehensive approach to community tobacco prevention and control. Grantees supported the stand campaign by establishing new youth led stand teams and/or supporting existing teams. A total of 39 grantees worked to establish new teams or support existing teams during the 27 grant year. A total of 53 counties had at least one grantee supported stand team of at least bronze level status. Counties with large populations such as Cuyahoga (Cleveland), Franklin (Columbus), Hamilton (Cincinnati), and Montgomery (Dayton) generally had more stand teams than less populated counties. The existing teams and the successfully established teams made up a total of 77 bronze level status teams by the end of the grant year and a total of 84 active teams. There were a total of 7 occurrences of team participation in one of the three state wide campaigns during the grant year. There was a large range in the participation, reach, and accomplishments of the grantee supported stand teams. In general, grantees made significant progress toward establishing active stand teams in the geographic areas they proposed. Most stand teams planned and successfully executed numerous activities and events, engaging anywhere from dozens to thousands of members of the community. stand team activities were primarily reported in Activity Reports. Due to the qualitative nature of this reporting system there was a wide variety in how teams described their activities. Future evaluations of stand teams could further develop standardized definitions such as what constitutes an active team or an active team member and how to measure the number of individuals reached by a stand team activity. The varied nature of the stand team activities may require several definitions of reach from 'brief exposure to stand team promotional materials' to 'in depth training.' We also recommend that future evaluate work take a closer look

162 Strategy: Establish and Support stand Teams 4 at the pattern of youth involvement in counter marketing campaigns such as stand. A longitudinal evaluation of what youth join programs like stand, their reasons for involvement, and degree of involvement over time would provide important information for program designers. For more information about stand teams, stand, and stand activities, please visit stand online at References Strategies for Reducing Exposure to Environmental Tobacco Smoke, Increasing Tobacco Use Cessation, and Reducing Initiation in Communities and Health Care Systems: A Report on Recommendations of the Task Force on Community Preventive Services. Centers for Disease Control and Prevention. MMWR. 2: 49 (No. RR 2);.

163 Table 4.6. Agency Funding and number of supported and established teams ** Funding was used to support a team in the area but the agency was not responsible for advising the team Grantee Funding Number of supported teams Establishing teams Achieved bronze level or active team Working to establish team ALA of Ohio $6,98.** ALA of Oho NW $23, Alpha Community Services $28,3.84 ASIA, Inc. $28, Asian American Community Services $2,.** Athens City County Health Department $8,. 2 Barberton Health Dist. $28,3.84 Columbus State Community College $7,282.2 Columbus Urban League $6,. Community Action for Capable Youth $28,3.84 Cuyahoga County District Board of Health $28, Delaware General Health Dist. $3,37. Fairfield County Department of Health $28, Family & Community Services, Inc. (Portage Co.) $5,2. Family & Community Services, Inc. (Wayne Co.) $6,63. Family Guidance Center $4,89. 5 Family Service Association for the Deaf $6,64. 2 Greater Cleveland Health Education and Service $2,483.8 Greene Co. Combined Health Dist. $7, Hamilton County General Health District $4,6. Holzer Medical Center $,. 2 Hospital Council of NW Ohio $28, Knox Co. Health Dept. $,58. Lake Geauga Center for Alcoholism and Drug Abuse $27,22. Lorain City Health Department $7,23. Mahoning County District Board of Health $24,85. 3 Medina Co. Board of Commissioners $2,689.7 Miami Valley Health Improve. Council, Inc. $25,5. 3 Noble Co. Health Dept. $,5. 3 Pathways of Licking County $5,985. Pike Co. General Health Dist. $3,79. Private Duty Svd Van Wert County $8,8. Project Linden $,379.** Recovery and Prevention Resources $23,585.5 Rural Opportunities, Inc $5,778. Selby General Hospital $9,5. Stark County Health Department $4,447. The Alcohol & Chemical Abuse Council $9,. UMADAOP of Lucas County $28, Women & Family Services, Inc. $9,87. 2 Your Human Resource Center $5,82. Zanesville Muskingum County Health Dept. $7,24. 2

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165 Ohio Tobacco Prevention and Control Program CGIII Evaluation (Jan Dec, 27) Strategy: Tobacco Free Worksites Programmatic Goal Area: SECONDHAND SMOKE OVERVIEW: Tobacco free worksites are important for reducing exposure to secondhand smoke and for supporting positive social norms regarding tobacco use. Grantees strived for model policies to be adopted and enforced by partnering worksite. A model policy is one that includes all tobacco products, including smokeless products, and comprises the entire worksite campus, indoors and out. Grantees were required to advocate for tobacco free worksite policies at any worksite housing an agency of the grant or worksites serving as the location for cessation or prevention services. In addition, grantees could choose to advocate and support tobacco free worksite policies at other worksites in the community. EVALUATION AND TOOLS: Grantees funded to support tobacco free worksites created an annual workplan for each target worksite and submitted monthly activity reports on the progress toward the workplan goals. The evaluation of the grantees activities included the following components: tracking of the status of the progress towards passing and implementing a policy, the stakeholders involved in the advocacy efforts, the scope of advocacy activities completed, and the number of employees protected by a successfully adopted policy. Grantees also provided a summary of lessons learned and barriers to achieving the goals of the workplan. RESULTS HIGHLIGHTS: From January to December of 27 OTPF funded 33 grantees to partner with 325 worksites across the state to pursue adoption and implementation of comprehensive tobacco free worksite policies. At the end of 27, a total of 244,994 adults were employed at worksites partnering with OTPF grantees to advocacy, adopt or implement a tobacco free worksite policy At the beginning of the grant year a large majority of worksites were in the beginning phase of advocacy for policy adoption (6.8%). By the November/December reporting period this had fallen to 26.%. This is because worksites progressed to policies being implemented and continually enforced, which doubled from 2.5% in January/ February to 43.5% in November/December. Moreover, approximately a fifth of the initiatives had been abandoned, presumably due to lack of success. Grantees frequently engaged wellness coordinators and human resource representatives to support policy adoption, implementation and compliance. SUMMARY: With the passing of the smoke free worksite law in late 26, grantees worked with worksites to adopt, implement, and enforce even more comprehensive policies, covering all tobacco products, and the entire worksite campus. A large proportion of grantees did not utilize (or report) the recommend strategic activities to achieve their successes in policy adoption and implementation. However, those who did not use the recommended activities were no less successful than those who did. Funding Amount $382,252 Number of Grantees Funded for this Strategy: 33 Agencies Funded: American Lung Association of Ohio NW (Ayres) Alpha Community Services Amethyst Inc. Asian American Community Services Barberton Health Department Bucyrus Community Hospital City of Refuge Point of Impact Cuyahoga County Board of Health Delaware Gen. Health Department Fairfield County Department of Health Family & Community Services (Wayne) Family & Community Services (Portage) Family Guidance Center Greene County Combined Health Department Guernsey Noble Monroe Tobacco Project Hamilton County GHD Hospital Council of NW Ohio Holzer Medical Center Knox County Health Department Lake Geauga Ctr. On Alcoholism & Drug Abuse Lorain City Health Department Medina County Board of Commissions Miami Valley Health Improvement Council Ohio Hispanic Coalition Recovery & Prevention Resources Rural Opportunities Inc. Stark County Health Department The Breathing Association Tuscarawas County Health Department Union County Health Department Upper Valley Medical Center Your Human Resources Center Zanesville Muskingum County Health Department County of Worksites was not collected; therefore, a map of program reach could not be generated. Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

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167 Evaluation of CGIII Tobacco Prevention and Control Efforts STRATEGY 6: Tobacco Free Worksites Goal: Secondhand Smoke Background and Rationale Tobacco free worksite policies offer employees protection against secondhand smoke exposure at work. Not only does this provide a health benefit by decreasing exposure to secondhand smoke, there is an economic benefit by decreasing health care utilization and absenteeism. Additionally, smoke free and tobacco free worksites have been found to encourage smoking cessation and a reduction in tobacco consumption among smokers. 2,,3,4 Over half of adults in Ohio are employed outside of the home, spending a large portion of their day at their place of work. Tobacco free worksites are important for reducing exposure to secondhand smoke and for supporting positive social norms regarding tobacco use. Worksites that adopt comprehensive tobacco free policies (e.g., adopting a model policy) communicate a commitment to the health and wellness of their employees. A model policy is one that includes all tobacco products, including smokeless products, and comprises the entire worksite campus, indoors and out. Just prior to the CGIII cycle beginning, Ohio voters passed the Ohio smoke free workplace law that required, with very few exceptions, worksites to be smoke free indoors and areas immediately adjacent to of entrances. The law contained no restrictions on smokeless tobacco use. Turning their efforts from advocating for the law, OTPF grantees served an important role during the rollout of the statewide law by working with local employers to communicate, implement, and enforce the new restrictions. Moreover, grantees funded for this strategy worked encourage employers to not only enforce the state wide law, but also adopt and enforce a comprehensive % tobacco free worksite (model policy). Grantees had various reasons for choosing worksites with which to partner. First of all, grantees were required to advocate for tobacco free worksite policies at any worksite housing an agency of the grant or worksites serving as the location for cessation or prevention services. In addition, grantees could choose to advocate and support tobacco free worksite policies at other worksites in the community. Evaluation of Tobacco Free Worksite The Tobacco Free Worksite strategy consists of two major components: advocacy for passage of a comprehensive tobacco free worksite policy and support for implementation and enforcement of the policy. Workplan (provided prospectively): Grantees funded to support tobacco free worksites created an annual workplan for each target worksite. Activity Reports: Grantees submitted bi monthly activity reports on the progress toward the workplan goals. Grantees reported on the following components: tracking of the status of the progress towards passing and implementing a policy, the stakeholders involved in the advocacy efforts, the scope of CGIII Program Evaluation Report (Jan Dec, 27) June, 28

168 Strategy: Tobacco Free Worksites 45 advocacy activities completed, and the number of employees protected by a successfully adopted policy. Grantees also provided a summary of lessons learned and barriers to achieving the goals of the workplan. Results From January to December of 27 OTPF funded 33 grantees to partner with 325 worksites across the state to pursue adoption and implementation of comprehensive tobacco free worksite policies. At the end of 27, a total of 244,994 adults were employed at worksites partnering with OTPF grantees to advocacy, adopt or implement a tobacco free worksite policy. Although a workplan could start at any phase, it was anticipated that most workplans would start by advocating for policy adoption (listed as still advocating in tables and figures). From there the next step would be for the model policy to be adopted ( adopted ) and finally grantees would work on continued implementation and compliance ( implemented ). If grantees encountered significant barriers to policy adoption or implementation they could cease partnering with the worksite and reported the initiative had been abandoned ( abandoned ). While there were 325 workplans created in 27, only 235 of those had consistent bi monthly activity reports and therefore could be included in the analysis in this chapter. Of those, 22 were created in the first two months of the grant year (January or February 27) and the remaining 5 were created after this time period. During the course of the grant year, significant progress was made towards policy adoption and implementation. Figure 6.. below and Table 6.2. on the next page show the movement from advocating for a tobacco free worksite policy, to policy adoption, and finally to implementation for worksites that had workplans submitted in January or February, 27. At the beginning of the grant year a large majority of worksites were in the beginning phase of advocacy for policy adoption (6.8%). By the November/December reporting period this had fallen to 26.%. This is because worksites progressed to policies being implemented and continually enforced, which doubled from 2.5% in January/February to 43.5% in November/December. Figure 6.. Tobacco free worksite policy progress from advocacy to implementation

169 Strategy: Tobacco Free Worksites 46 Unlike the latter two categories (i.e. advocating for policy adoption and working toward implementation) which are both ongoing processes, adopting the tobacco free worksite policy is a point in time occurrence. Therefore, the proportion of worksites in this category does not cumulate over time the way the other two categories increase and decrease in proportion. ` Table 6.2. Tobacco free worksite policy progress from advocacy to implementation (n=22) Completed activity Jan/Feb March/ April May/June July/Aug Sept/Oct Nov/Dec Still advocating 6.8% 5.7% 46.2% 39.6% 33.% 26.% Adopted 6.8% 6.% 9.% 7.6% 6.6% 7.7% Implemented 2.5% 26.% 35.2% 4.6% 44.3% 43.5% Abandoned.% 5.7% 9.5% 2.3% 6.% 22.7% We next looked at the type of stakeholders that were involved in the implementation of this strategy. As shown in the following table, (Table 6.3.), grantees most frequently engaged wellness coordinators and human resource departments to support policy adoption and implementation, followed by employees directly. Although it was recommended that grantees involved stakeholders such as maintenance personnel or safety officers, these individuals were not engaged in the process. Table 6.3. Stakeholder involvement in tobacco free worksite strategy Completed activity Jan/Feb (n=22) Mar/ April (n=25) May/June (n=22) July/Aug (n=224) Sept/Oct (n=225) Nov/Dec (n=22) Employees 42.7 (94) 5.2 (8) 45.5 () 4.5 (93) 44.9 () 4.6 (92) Human Resources 52.3 (5) 65.6 (4) 59.5 (3) 54. (2) 53.3 (2) 49.3 (9) Union.5 ().9 (4) 3.6 (8) 4.5 () 3.6 (8) 2.3 (5) Maintenance personnel Other Safety officers Depending on the policy and status of the policy, grantees may employ different strategies to achieve the goals of the workplan. Table 6.4. lists the activities that have been found to be useful in adopting a tobacco free policy, such as establishing an advocacy committee to developing an enforcement plan. Surprisingly few of these activities were completed by the grantees, with approximately 4% of grantees reporting that they completed none of these activities in each of the six activity reports. Given that grantees went months without completing any of the suggested strategic activities, it is surprising how many worksite policies progressed to the implementation phase during the 27 grant year. Of the 235 workplans included in the analysis, 54 completed one or more of the strategic activities listed in Table 4.4. The remaining 8 did not report completing any activities (i.e. missing) or reported that they completed nothing. Of the 235 workplans submitted, 6 had achieved the implementation, or final stage, by the end of the grant year and 9 had not. Surprisingly, those worksites that achieved implementation were not more likely to have completed the strategic activities (χ2 = 2.75, p=.).

170 Strategy: Tobacco Free Worksites 47 Table 6.4. Tobacco free worksite strategy activities Completed activity Jan/Feb (n=22) Mar/ April (n=25) May/June (n=22) July/Aug (n=224) Sept/Oct (n=225) Nov/Dec (n=22) Established advocacy committee 5.5 (2).9 (4). (2) 2.2 ().5 () Developed strategic plan and timeline.4 (3).5 ().5 ().4 (). (2) Assessed existing policy.4 (25) 4.2 (9) 8.2 (8) 4.5 () 3. (7). (2) Presented policy to personnel 3.6 (4) 7.4 () 3.2 (7) 4. (9) 2.2 (5) 3.6 (8) Adopted model policy 2.3 (5).4 (3) 2.7 (6). (2).5 () Ensured appropriate signage.4 (3) 2.3 ().5 ().3 (3).8 (4) 2.3 (5) Developed communications plan. (2) 4.6 () 3.6 (8) 3. (7). (2) Implemented communication plans.5 () 2.2 (5).8 (4).8 (4) Held forums to discuss policy.5 (). (2). (2) Developed enforcement plan.4 (3). (2) 7.6 (7).4 (3) Ensured the policy was enforced.4 () Completed nothing 4.8 (92) 3.2 (67) 43.6 (96) 44.6 () 44. (99) 45.7 () Barriers and Lessons Learned According to submitted activity reports, grantees encountered some barriers to passing a comprehensive, or model, tobacco free worksite policy. These barriers were responsible for no policy being adopted or a weaker than desired policy. Examples of structural barriers were worksites located in shared facilities with multiple tenants, or limited local decision making power because the building was owned by another entity. Reasons for delay in policy adoption included resistance from top administration, competing worksite priorities, and a desire to hear a persuasive economic rationale for the policy change. Grantees found that large organizations were particularly slow in adopting policy changes. Administration and employee perceptions were also limitations to adoption of a comprehensive policy. One mental health facility decided that an entirely tobacco free campus would be too extreme for the patients/residents who were overcoming other substance use additions. The grantee agency reported, The decision by [the worksite] was not to have a campus wide policy, allowing for tobacco use in parking lots and one other specific location away from building entrances and exits. Reasons given for this decision included the belief that certain, vulnerable clientele would not be amenable to total prohibition. [The worksite] believed that to best serve their population, it would limit rather than prohibit tobacco use. Although adoption of a comprehensive policy was the goal, several worksites struggled to enforce the statewide worksite law, at a minimum, which includes a prohibition of smoking within feet of an entrance. Some worksite characteristics that were reported to make enforcement more difficult included the following: a large campus, frequent visitors, and limited staffing or security available for enforcement. When there were no designated personnel to enforce the policy some grantees reported a reluctance of staff to confront those not following policies and signs posted for no smoking on property. A couple grantees mentioned that weekends, evenings, or third shifts when more difficult times to enforce the policy.

171 Strategy: Tobacco Free Worksites 48 Grantees also reported on factors that facilitate progress in this strategy. Having a previous relationship with the worksite and stakeholders was helpful to the process. Worksites were more receptive to policy changes when there was a give and take partnership with the local OTPF grantee. For example, some grantees were funded to provide worksite cessation. The combination of these two strategies presented a special opportunity to leverage the provision of cessation services with the request for policy changes. One grantee reported, getting staff assistance with quitting and involving them in the process is critical to help enforce policy. As described in the results section above, many worksites adopted a policy during the grant period. One grantee wrote, in general, people are very compliant and understanding of the Tobacco Free Campus Policy. We had very little negativity surrounding the changes. Successful grantees suggested that is important to make slow and steady progress. When a compromise or less than ideal policy was adopted, they worked to keep the issue on the table in hopes that the policy would later be strengthened. Summary and Recommendations At the beginning of the grant year in January, 27, the state wide smoke free worksite law had just recently been passed by voters. OTPF grantees worked with 325 worksites to adopt, implement, and enforce even more comprehensive policies, covering all tobacco products, and the entire worksite campus. There was moderate successes in progressing tobacco free initiatives from advocating for policy adoption, to policy adoption, and finally to implementation and compliance. By the end of the grant year in November/December 27, approximately 4% of the workplans were working on policy implementation, which is the final stage. However, approximately a fifth of the initiatives had been abandoned, presumably due to lack of success. A large proportion of grantees did not utilize (or report) the recommend strategic activities to achieve their successes in policy adoption and implementation. However, those who did not use the recommended activities were no less successful than those who did. References McGhee SM, Adab P, Hedley AJ, Hing Lam T, Ming Ho L, Fielding R, Ming Wong C. Passive smoking at work: the shortterm cost. J Epidemiol Community Health. 2;54: Bauer JE, Hyland A, Li Qiang, Steger C, Cummings KM. A longitudinal assessment of the impact of smoke free worksite policies on tobacco use. AJPH. 25;95(6): Fichtenberg CM, Glantz SA. Effect of smoke free workplaces on smoking behavior: systematic review. BMJ. 22;325:88. 4 Brownson RC, Hopkins DP, Wakefield MA. Effects of smoking restrictions in the workplace. Annu Rev Public Health. 22;23:

172 Strategy: Tobacco Free Worksites 49 Funding Table 6.5. Funding for Tobacco Free Worksites by Grantee: # of Worksites and # Potential Impact Grantee Agency Approved funding Total number of workplans Total employees at workplan worksites 7 3 Recovery & Prevention Resources $3, Union County Health Department $5,69. 3, Holzer Medical Center $ 3 2, City of Refuge Point of Impact $7, Tuscarawas County Health Department $, Upper Valley Medical Center $7,5. 8 3, The Breathing Association $4, , Alpha Community Services $3, Bucyrus Community Hospital $2, Greene County Combined Health District $4, , Barberton Health Department $7, , ALA of NW Ohio $5, , Medina Board of Commissioners $2,. 27 6,57 Miami Valley Health Improvement Council $2, , Lorain City Health Department $2,., Ohio Hispanic Coalition $ Hospital Council of NW Ohio $ 36 36, Family & Community Services (Portage) $ 3 36, Family & Community Services (Wayne) $6, , Guernsey Noble Monroe Tobacco Proj. $, Cuyahoga County Board of Health $ 6 67, Rural Opportunities $8, Family Guidance Center $, Asian American Community Services $ Amethyst, Inc. $5, Hamilton County Health Department $87, , Your Human Resource Center $4,5. 5, Lake Geauga Center $9, ,24 Zanesville Muskingum County Health Dept. $4, Fairfield County Health Department $2, Stark County Health Department $5,4. 4 2, Delaware County Health Department $2, Knox County Health Department $5, ,994 CGIII Program Evaluation Report (Jan Dec, 27) June, 28

173 Ohio Tobacco Prevention and Control Program CGIII Evaluation (Jan Dec, 27) Strategy: Outdoor Tobacco Free Environments Programmatic Goal Area: SECONDHAND SMOKE Funding Amount $3,95 Number of Grantees Funded for this Strategy: OVERVIEW: A smoke free environment is the only way to fully protect non smokers from the dangers of secondhand smoke. Establishing outdoor tobacco free public places was one of the approved strategies for reducing exposure to second hand smoke. At a minimum, grantees funded for this strategy were expected to: assess current policies, establish an outdoor tobacco free policy advocacy committee or coalition, develop an outdoor tobacco free policy advocacy plan, and begin to execute the plan. Agencies Funded: Your Human Resource Center EVALUATION PLAN: The evaluation component for this strategy assessed, using work plans and activity reports, grantee progress towards passing and implementing tobacco free policies for outdoor public events and places. Once policies have been adopted, grantees will identify the estimated number of persons protected by the policy. RESULTS HIGHLIGHTS: One grantee was funded for this strategy and had identified four sites with which to initiate an outdoor tobacco free policy. The grantee s focus was on advocating for policy adoption with the potential of saving an estimated,54 lives. At the end of the grant year, two of the outdoor sites had been abandoned and the grantee was still advocating for a tobacco free policy for the other two outdoor sites. Counties Served: SUMMARY: The OTPF grantee worked with four outdoor sites to pass, adopt, and implement tobacco free policies for outdoor public events and places. Despite the grantee s resilience, resistance from management prevented the execution of a policy advocacy plan for any outdoor sites. Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

174

175 Evaluation of CGIII Tobacco Prevention and Control Efforts STRATEGY 7: Outdoor Tobacco Free Environments Goal: Secondhand Smoke Background and Rationale The EPA and several other agencies have designated second hand smoke as a known human carcinogen. Secondhand smoke, from the burning of a cigarette and smoke exhaled by the smoker, contains hundreds of toxic chemicals, of which about fifty can cause cancer, exposing nonsmokers to similar risks as smokers. The surgeon general reported that there is no level of second hand smoke that is risk free. Despite current policy changes in Ohio (passage of Issue 5) many nonsmokers continue to be affected by second hand smoke at many public outdoor places and events. A smoke free environment is the only way to fully protect non smokers from the dangers of secondhand smoke. Establishing outdoor tobacco free public places was one of the approved strategies for reducing exposure to second hand smoke. The main purpose of this strategy was to advocate for policy change. Grantees were encouraged to advocate for tobacco free fairs, sporting events, zoos and playgrounds. At a minimum, grantees funded for this strategy were expected to: assess current policies, establish an outdoor tobacco free policy advocacy committee or coalition, develop an outdoor tobacco free policy advocacy plan, and begin to execute the plan. If the grantee was ready, they were encouraged to move forward with achieving policy change, implementation & enforcement. Evaluation Plan for Outdoor Tobacco Free Environments The evaluation component for this strategy assesses grantee progress towards passing and implementing tobacco free policies for outdoor public events and places. Once policies have been adopted, grantees will identify the estimated number of persons protected by the policy. Grantees were responsible for creating a work plan in G Wiz. The work plan contained information on county location of outdoor sites, how many lives could be potentially protected, stakeholders, and which steps related to implementing the policy have already been completed. Activity reports were submitted bimonthly on a work plan to assess progress throughout the year. Grantees could be at any of the following stages: researching existing outdoor policies, establishing an outdoor tobacco free policy advocacy committee or coalition, developing an outdoor tobacco free policy advocacy plan, or executing the advocacy plan. Within progress reports grantees also reported on any significant changes, barriers, and lessons learned. Results At the beginning of 27 one grantee had identified four sites with which to initiate an outdoor tobacco free policy. Of these two sites, the reported stake holders were local health departments and in all except one site, the grantee was in the stage of assessing existing tobacco policies. Within all four sites, the grantee was focusing on advocating for policy adoption with the potential of saving an estimated,54 lives. None of the sites went beyond advocating for a tobacco free environment. In fact, within two of the sites advocating for an outdoor tobacco free environment was abandoned. CGIII Program Evaluation Report (Jan Dec, 27) June, 28

176 Strategy: Outdoor Tobacco Free Environments 52 Activities The grantee engaged in hiring staff, scheduling meetings with management to discuss policy changes, and creating presentation materials to explain the model policy. Whenever possible, educational display booths were set up at outdoor locations to increase awareness of the need for tobacco free outdoor environments. Barriers Staff encountered a variety of issues from limited staff time, an inability to contact people responsible for site policy to resistance to adopt the policy. As stated in the activity report management does not see as useful or important issue. One site obtained a new manager and under the new ownership was no longer considered a public outdoor environment causing the grantee to have to abandon the initiative. Lessons Learned Through advocacy it was learned that many felt the passage of Issue 5 was enough, not everyone supported change, and many become irritated or irate if you tried. Summary At the beginning of the grant year in January, 27, the state wide smoke free worksite law had just recently been passed by voters. The OTPF grantees worked with four outdoor sites to pass, adopt, and implement tobacco free policies for outdoor public events and places. Despite the grantee s resilience, the resistance from management proved too trying and prevented the execution of a policy advocacy plan for any outdoor sites. At the end of the grant year, two of the outdoor sites had been abandoned and the grantee was still advocating for a tobacco free policy for the other two outdoor sites.

177 APPENDICES APPENDIX A: G Wiz Manual (login, workplan, activity report, progress report)

178 Ohio Tobacco Prevention Foundation Community Grants III Reporting Manual Overview of G-Wiz NOTE: A fully functioning G-Wiz will be available for grantee use beginning January, 27. G-Wiz training is being conducted on a test site. Community Grants III Evaluation Manual G-Wiz Overview Logging on to G-Wiz Open Internet Explorer (G-Wiz may have problems with other internet browsers so it is best to use Internet Explorer). Type in the web address for G-Wiz: Upon successful access of the site, the following login box will appear. Enter the user name and password that has been assigned to you. Your user name and password will be assigned and provided to you. This will log you into the Grantees Workspace. Click on the name of your grant to go to your grant s homepage. Click on the name of your grant listed here. Ohio Tobacco Research and Evaluation Center (OTREC) G-Wiz Overview -- at Case Western Reserve University

179 Community Grants III Evaluation Manual G-Wiz Overview Your homepage will look similar to the one shown below. Notice the various tabs across the top. As a default you are taken to the Summary tab. You will use many of these tabs. However, this manual focuses on the Work Plan tab where you enter work plans and do most of the reporting. Click on the Work Plan tab. Click on the Work Plan tab. Now you are in the Work Plan tab (note highlighted tab). The sample shown below already has entered work plans. Your created work plans will be listed here. Ohio Tobacco Research and Evaluation Center (OTREC) G-Wiz Overview -2- at Case Western Reserve University Community Grants III Evaluation Manual G-Wiz Overview Overview of Work Plans First we ll review some of the features you will use in the Work Plan tab. The sample below has many features labeled. This toolbar is the same on every page. Search help topics To Bamboo Help Desk The name of your grant is listed here. This is the name you give your work plans. Be careful to name your plans so that you can identify them later! You can sort your work plans by these categories (e.g. Title, Date Submitted, Status, etc.) Click on the name of the category to sort. A small arrow appears to the right of the category to show either ascending or descending order. This description is automatically created by G-Wiz names the specific goal and strategy of the work plan Ohio Tobacco Research and Evaluation Center (OTREC) G-Wiz Overview -3- at Case Western Reserve University

180 Community Grants III Evaluation Manual G-Wiz Overview Creating a Work Plan To create a work plan, first make sure that you are in the Work Plan section of the Work Plan tab rather than the Progress, Activity, and Evaluation Reports section. The section that is active will appear in purple rather than light green. Make sure the Work Plans is active by clicking on it. If active, the words appear in purple. Click on New Plan Click on New Plan to create a new work plan. Building a Work Plan First choose one of the four goals in which your strategy is linked. For an example, we will create a work plan for Community Leader Relations, which is listed under the goal Community Awareness. Descriptions are provided at each step.. Select Community Awareness 2. Select Next Ohio Tobacco Research and Evaluation Center (OTREC) G-Wiz Overview -4- at Case Western Reserve University Community Grants III Evaluation Manual G-Wiz Overview Next, choose your strategy. In this example, the strategy is Community Leader Relations. (note: for some strategies, this is a two-step process). Select Community Leader Relations Select Next Your work plan will appear. The work plan for Community Leader Relations is shown below. Now we will enter example information into the work plan. It is important that the title have meaning to you and your Program Manager. Note: After you save a work plan you will not be able to change your title. In addition to the RE Coordinator, who else will have reporting capabilities for this work plan? The list is automatically created from the contacts listed in the Contacts tab. Do not use dollar signs ($) when entering program costs. Provide general start and end dates for each work plan. Example reach numbers have been entered here. As you will see in the reporting section, you will be asked about your progress towards meeting these specific target reach goals. Ohio Tobacco Research and Evaluation Center (OTREC) G-Wiz Overview -5- at Case Western Reserve University

181 Community Grants III Evaluation Manual G-Wiz Overview Note: Before you enter a work plan, it is a good idea to have all the information you will need in front of you. In the following sections of this manual we have included every work plan and question that you will encounter. Click here to scroll to the top of the page for saving options. When you finish entering the information for the work plan you can click Go to Top of Form or scroll to the top for saving options. NOTE: The remainder of this manual provides detailed instructions on how to complete a work plan and report on each of the strategies. Please consult the appropriate tab. Ohio Tobacco Research and Evaluation Center (OTREC) G-Wiz Overview -6- at Case Western Reserve University Community Grants III Evaluation Manual G-Wiz Overview Saving a Work Plan There are three saving options at the top of each work plan: Cancel, Save and Close, and Save and Submit.. Cancel will end your session without saving any information you entered. 2. Save and Close will save the information entered into the work plan and will allow you to return to edit before submitting it to OTPF. If you think it will take you a long time to enter the work plan or you need to leave your desk, it is a good idea to SAVE AND CLOSE so you can save what you have entered so far and come back to it later. G-Wiz will time out after 2 minutes of no activity. 3. Save and Submit will save the information entered into the work plan AND will submit it to OTPF for review. It will be available for viewing but WILL NOT be available for further editing. Do not save and submit until you are completely finished and you are satisfied with what you have entered. The saving options are typically placed at the top of each work plan and reporting form. For your convenience there is usually a Go to Top of Form on long plans or forms. The save options are located at the top of each work plan. After choosing a save option, you will be taken back to the Work Plan tab. If you were saving a new work plan or report, you will see it listed with the word NEW next to it. Here is the work plan we just created. Next to it says New! Ohio Tobacco Research and Evaluation Center (OTREC) G-Wiz Overview -7- at Case Western Reserve University

182 Community Grants III Evaluation Manual G-Wiz Overview If you saved this new work plan using Save and Close you will see your plan listed, but there is no date listed under Date Submitted and it will say NE W under Sta tus. If you saved this new work plan using Save and Submit you will see our plan listed, with the data you submitted and a Status of under review (awaiting approval from your OTPF program manager). If you choose Save and Close and you then went back into your work plan, you would see that the heading now tells you that you are in edit mode (as shown below). Ohio Tobacco Research and Evaluation Center (OTREC) G-Wiz Overview -8- at Case Western Reserve University Community Grants III Evaluation Manual G-Wiz Overview Overview of Reporting For most strategies you will need to submit a Progress Report and Activity Report every other month. Refer to the Strategies Overview Page for specific reporting requirements. There are three different types of reporting forms in G-Wiz. Some strategies use all three reporting forms, others may only use one. A brief description of each:. Progress Report: Program reach (e.g., number of students taught, professional trained, Quit Kits distributed) is reported in the Progress Reports. The forms and target numbers are automatically generated based on the estimates you enter into the work plan. 2. Activity Report: Each Activity Report contains a series of strategy-specific questions regarding progress that you made during the reporting period. Worksheets are available for each strategy (see second section of Manual). It is recommended that you complete the worksheets prior to completing the Activity Reports. 3. Evaluation Report: A few of strategies have an Evaluation Report, which is where you will find summaries of data that is collected/coordinated by someone other than the grantees (e.g., OTREC, the Quit Line Call Center or Northlich (stand team)). To create and submit reports, log in to G-Wiz, following the steps at the beginning of the Overview: o Log in to G-Wiz o Select the name of your grant o Select the Work Plan tab o Select Progress, Activity, and Evaluation Reports tab Select Progress, Activity, and Evaluation Reports to access the reporting section of the Work Plan tab. Under Approved Plans you will see each of the work plans you created. Ohio Tobacco Research and Evaluation Center (OTREC) G-Wiz Overview -9- at Case Western Reserve University

183 Community Grants III Evaluation Manual G-Wiz Overview Submitting a Progress Report Under the Work Plan tab, Select Progress, Activity, and Evaluation Reports. The section will turn from purple to green once activated. Under Approved Plans you will see each of the work plans you created. To enter a Progress Report for a particular work plan, click on the box next to it and the box will become checked once selected. Ohio Tobacco Research and Evaluation Center (OTREC) G-Wiz Overview -- at Case Western Reserve University Community Grants III Evaluation Manual G-Wiz Overview Once selected, scroll down to the heading Progress Reports for the Selected Plan and click on New Report. Enter your Progress Report information and comments. For instructions on completing a Progress Report for a particular strategy, please consult the appropriate tab following this section. Click Save and Close or Save and Submit as appropriate. See prior section on Saving a work plan for detailed description of each of these options. Ohio Tobacco Research and Evaluation Center (OTREC) G-Wiz Overview -- at Case Western Reserve University

184 Community Grants III Evaluation Manual G-Wiz Overview Submitting an Activity Report Just as for Progress Reports, when you are in the Work Plan tab, make sure that Progress, Activity, and Evaluation Reports is active (it should be green, not purple). Under Approved Plans you will see each of the work plans you created. To create an Activity Report for a particular work plan, click on the box next to it and the box will become checked once selected. Once selected, scroll down to the bottom of the screen to the heading Activity Reports for the Selected Plan and click on New Report. Note that this time, you are selecting new report under Activity Reports rather than Progress Reports. Ohio Tobacco Research and Evaluation Center (OTREC) G-Wiz Overview -2- at Case Western Reserve University Community Grants III Evaluation Manual G-Wiz Overview Below is a sample of what the Activity Report will look like. Confirm that you are in the correct Activity Report Note: Just like with entering information for the work plans, it is a good idea to have all the information you will in need in front of you before completing your progress and activity plans. Use the worksheets in Section 2 of the Manual to help you with this process. Takes you to the top of the page for Saving Options For instructions on completing an Activity Report for a particular strategy, please consult the appropriate tab following this section. Ohio Tobacco Research and Evaluation Center (OTREC) G-Wiz Overview -3- at Case Western Reserve University

185 APPENDICES APPENDIX B: OTREC DM: Instructions

186 Community Grants III Evaluation Manual OTREC-DM OTREC Document-Manager (OTREC-DM) OTREC-DM can be accessed through the OTREC website at and then clicking on OTREC-DM, or it can be accessed directly at Once you enter OTREC-DM, you will be asked for your username and password. If you do not have your username and password, you can contact your agency s OTREC Statewide Field Coordinator. System is used for both prevention and adult cessation data collection Ohio Tobacco Research and Evaluation Center (OTREC) OTREC-DM - - at Case Western Reserve University Community Grants III Evaluation Manual OTREC-DM ADDING A NEW YOUTH PREVENTION CLASS Ohio Tobacco Research and Evaluation Center (OTREC) OTREC-DM at Case Western Reserve University

187 Community Grants III Evaluation Manual OTREC-DM ENTERING DATA FOR YOUTH PREVENTION CLASSES Enter dates that teacher form and fidelity checklist was faxed Once OTREC confirms receipt, date is entered into OTREC-DM Ohio Tobacco Research and Evaluation Center (OTREC) OTREC-DM at Case Western Reserve University Community Grants III Evaluation Manual OTREC-DM CREATING AN ADULT CESSATION CLASS/BATCH Enter info on each class or group of individuals ENTERING DATA FOR ADULT CESSATION CLASSES/BATCHES Enter dates that forms and surveys were faxed Once OTREC confirms receipt, date is entered into OTREC-DM Ohio Tobacco Research and Evaluation Center (OTREC) OTREC-DM at Case Western Reserve University

188 Community Grants III Evaluation Manual OTREC-DM CHECKING ON DATA ENTERED IN OTREC-DM Date items faxed must be entered OTREC staff notes when there is a problem with items faxed OTREC staff sends an in addition to making a note when there is a problem When prevention and cessation classes are created, they will appear yellow and their status will be labeled incomplete When there is a problem with a class it is shaded in red Ohio Tobacco Research and Evaluation Center (OTREC) OTREC-DM at Case Western Reserve University Community Grants III Evaluation Manual OTREC-DM When prevention and cessation classes are complete, class rows will appear beige Ohio Tobacco Research and Evaluation Center (OTREC) OTREC-DM at Case Western Reserve University

189 APPENDICES APPENDIX C: Youth Prevention Data Collection Forms Youth Participant Survey Teacher Reporting Form Fidelity Checklists (one example per curricula) Teacher Satisfaction Survey

190 3277 This survey will ask you a few questions about who you are and what you do. DO NOT WRITE YOUR NAME ON THIS SURVEY. The answers you give will be kept private and no one will know how you answer the questions. Answering the questions on this survey will not impact your grades in any of your classes. If you are not comfortable answering a question, just leave it blank. Today's Date / / OTPF YOUTH PREVENTION SURVEY (3rd Grade and Up) PART : ABOUT YOU. Are you a boy or a girl? Boy Girl 2. How old are you? 8 or younger 2 years old 9 years old 3 years old years old 4 years old years old 5 or older 3. What grade are you in? PART 2:TOBACCO USE 7. Have you ever tried cigarette smoking even one or two puffs? Yes No 8. During the past 3 days, on how many days did you smoke cigarettes? days or 2 days 3 to 5 days 6 to 9 days to 9 days 2 to 29 days all 3 days 3rd grade 4th grade 5th grade 6th grade 7th grade 8th grade 9th grade Other 9. Have you ever tried cigars, little cigars, or cigarillos (e. g. Black & Milds), even one or two puffs? Yes No 4. Which of these best describes you? White (not Hispanic). During the past 3 days, on how many days did you smoke cigars, cigarillos, or little cigars? Black/African-American (not Hispanic) Hispanic Asian or Pacific Islander Native American or Alaskan Native days or 2 days 3 to 5 days 6 to 9 days to 9 days 2 to 29 days all 3 days Other, please specify: 5. Do you live with anybody who smokes, including cigarettes, cigars or little cigars (e.g., Black & Milds), or a pipe? Yes No 6. Has anyone ever offered you a cigarette, little cigar, or chew? Yes No OFFICE USE ONLY. Have you ever used chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Coppenhagen? Yes No 2. During the past 3 days, on how many days did you use chewing tobacco, snuff, or dip? days or 2 days 3 to 5 days 6 to 9 days to 9 days 2 to 29 days all 3 days Thank you for completing this survey!

191 OTPF TEACHER REPORTING FORM Facilitator First Name Facilitator Last Name Class ID - CLASSROOM TEACHER: PLEASE COMPLETE THE INFORMATION BELOW. School District Name: School Name: Teacher Last Name: Class Period: Teacher Address: (ex. jjones@standohio.org). How many students are enrolled in this class? students 2. How many classroom sessions of the tobacco prevention program were presented to this class? sessions 3. On average, about how many minutes was each classroom session? minutes 4. How many students are in each grade in this class? If there are no students in a particular grade, please write "" in the boxes at the right. Please be sure that the sum of the boxes is equal to the number of students enrolled in your class. 4th graders 5th graders 6th graders 7th graders 8th graders graders 5. Who taught the tobacco prevention programming? I taught the sessions Another teacher in my school taught the sessions An outside facilitator taught the sessions We would like to ask you to complete a 7 question survey on-line which will help us better evalute the smoking prevention programming that was provided to your class or group. We will send you an with a link to the survey. The survey should take no more than 5 minutes of your time. You will receive a $5. Borders giftcard via as a thank you for your valuable feedback. Sure, I'll complete the brief on-line survey. No, I do not wish to participate. Signature: Date: : Created by the Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

192 OTPF LifeSkills Training: Middle School Year (6th/7th) Facilitator Fidelity Checklist Grantee Name Subgrantee Name Class ID - Facilitator First Name Facilitator Last Name Facilitator Sex Male Facilitator Phone Facilitator Female ( ) - School District School Teacher Which grades are participating in this class? Grade Grade Grade Period Instructions: Please complete the appropriate section after completion of each session. Indicate the date the session was completed, how many minutes were spent on covering that session, and indicate which of the sessioin objectives were completed. If any session objectives were not completed, please explain why. In the notes section at the end of the survey, please include any comments you have about any session including changes you may have made to the curriculum materials. SESSION DATE COMPLETED TOPICS/ACTIVITIES COVERED CURRICULUM ATTAINMENT TIME TO COMPLETE (MIN) Yes No Session : Self-Image and Self-Improvement Date Completed / / Minutes Ground Rules How I See Myself (WS) Taking Stock (WS2) Setting and Achieving Personal Goals Self Improvement Project Recording My Progress (WS3) Session Summary How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Created by the Ohio Tobacco Research and Evaluation Center at Case Western Reserve University LifeSkills 6/7 Fidelity Page of 4 3 October 6

193 OTPF LifeSkills Training: Middle School Year (6th/7th) Facilitator Fidelity Checklist SESSION DATE COMPLETED TOPICS/ACTIVITIES COVERED CURRICULUM ATTAINMENT TIME TO COMPLETE (MIN) Yes No Everyday Decisions (WS4) How closely did you keep to the 3 C's of Effective Decision Making curriculum as written for this lesson? Session 2: Macking Date Completed Minutes Putting the 3 C's into Practice (WS5) Decisions My Decision Makig Planner (WS6) Not at all close Somewhat close / / Group Conformity Experiment Pretty close Exactly Session Summary Session 3: Smoking Myths and Realities Date Completed / / Minutes Who's Using Drugs (WS7) Smoking Prevalence Smoking Myths and Realities The Cost of Smoking Smoking and Your Body My Reasons for Not Smoking (WS8) Session Summary How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 4: Smoking and Biofeedback Date Completed / / Minutes Long-term Effects of Smoking How to Take Someone's Pulse Class Experiment Class Experiment 2 Smoking Word Puzzle Session Summary How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 5: Alcohol: Myths and Realities Date Completed / / Minutes Behavioral Effects of Alcohol Reasons Why Some People Become Problem Drinkers My Reasons for Not Drinking (WS9) Session Summary How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 6: Marijuana: Myths and Realities Date Completed / / Minutes Prevalence of Marijuana Use Pros and Cons of Smoking Marijuana Marijuana and Other Drugs My Reasons for Not Smoking Marijuana (WS) Session Summary How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 7: Advertising Date Completed / / Minutes Practice Analyzing Ads (WS) Practice Analyzing Alcohol and Tobacco Ads (WS2) Counterarguements to T&A Ads Session Summary How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly LifeSkills 6/7 Fidelity Page 2 of 4 3 October 6

194 OTPF LifeSkills Training: Middle School Year (6th/7th) Facilitator Fidelity Checklist SESSION DATE COMPLETED TOPICS/ACTIVITIES COVERED CURRICULUM ATTAINMENT TIME TO COMPLETE (MIN) Yes No How closely did you keep to the Minutes curriculum as written for this lesson? Session 8: Violence and the Media Session 9: Coping with Anxiety Date Completed / / Date Completed / / Minutes Watching TV (WS3) Reality Checks (WS4) Session Summary Anxiety Experiment Identification of Anxiety Signs Situations Making Me Feel Nervous (WS5) Rating How Anxious You Feel (WS6) How to Decrease Your Anxiety: Demonstration of Techniques Relaxation Tape Session Summary Not at all close Pretty close Somewhat close Exactly How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session : Coping and Anger Date Completed / / Minutes What Really Bugs Me (WS7) Techniques for Controlling Anger Session Summary How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session : Communication Skills Date Completed / / Minutes Telephone Game Communication Activity Recent Misunderstandings (WS8) Skills for Avoidinig Misunderstandings Practice Applying Comm Skils (WS9) The Value of Asking Questions Activity Session Summary How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 2: Social Skills (A) Date Completed / / Minutes Getting Over Being Shy Conversational Skills Activity: Tennis Ball Toss Developing Social Skills Scripts (WS2) Social Activities (WS2) Session Summary How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 3: Social Skills (B) Date Completed / / Minutes Social Activities (WS2) Group Brainstorming of Social Activities Develop/Rate "Social Scripts" for Asking Someone Out Asking Someone Out and Being Asked Out Session Summary How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly LifeSkills 6/7 Fidelity Page 3 of 4 3 October 6

195 OTPF LifeSkills Training: Middle School Year (6th/7th) Facilitator Fidelity Checklist SESSION DATE COMPLETED TOPICS/ACTIVITIES COVERED CURRICULUM ATTAINMENT TIME TO COMPLETE (MIN) Yes No Session 4: Assertiveness Date Completed / / Minutes Handling Difficult Situations (WS22) Define Passive, Aggressive and Assertive Reasons for Not Being Assertive Benefits of Being Assertive List 'High Risk' Situations Practice Ways of Saying 'No' Assertive Action Plan (WS23) Session Summary How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 5: Resolving Conflicts Date Completed / / Minutes Results of Reactions to Conflicts Behavioral Rehearsal Session Summary How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Notes: LifeSkills 6/7 Fidelity Page 4 of 4 3 October 6

196 OTPF Project TNT: Towards No Tobacco Facilitator Fidelity Checklist Grantee Name Subgrantee Name Class ID - Facilitator First Name Facilitator Last Name Facilitator Sex Male Facilitator Phone Facilitator Female ( ) - School District School Teacher Grade Period Instructions: Please complete the appropriate section after completion of each session. Indicate the date the session was completed, how many minutes were spent on covering that session, and indicate which of the session objectives were completed. If any session objectives were not completed, please explain why. In the notes section at the end of the survey, please include any comments you have about any session including changes you may have made to the curriculum materials. SESSION DATE COMPLETED TOPICS/ACTIVITIES COVERED CURRICULUM ATTAINMENT TIME TO COMPLETE (MIN) Yes No Session : Effective Listening & Tobacco Information Date Completed / / Minutes Introduction Memory Quiz Tips for Effective Listening Listening Paragraph Demonstration Tobacco Project Information & Prevalence Introduce and Play the TNT Game How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly 955 Created by the Ohio Tobacco Research and Evaluation Center at Case Western Reserve University TNT Fidelitey Page of 3 4 Sept 6

197 OTPF Project TNT: Towards No Tobacco Facilitator Fidelity Checklist SESSION DATE COMPLETED TOPICS/ACTIVITIES COVERED CURRICULUM ATTAINMENT TIME TO COMPLETE (MIN) Yes No TNT Game Review of Session How closely did you keep to the Date Completed Minutes TNT Word List: Consequence curriculum as written for this lesson? Demonstration Activity: Stages of Addiction / / Consequences & Decision Making Not at all close Somewhat close Pretty close Exactly Session 2: The Course & Consequences of Tobacco Use Session 3: Self-Esteem Date Completed / / Minutes Homework: Consequences of Tobacco Use Session Summary TNT Game (Optional) TNT Game Review of Session 2 TNT Word List: Self-Esteem Building Self-Esteem Worksheet I'm Special Worksheet Pass a Compliment Game and Discussion Homework: Feeling Good About Myself WS Session Summary TNT Game (Optional) How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 4: Being True to Yourself & Changing Negative Thoughts Date Completed / / Minutes TNT Game Review of Session 3 Disscussion of Peer Pressure & TNT Word List: Peer Pressure (Indirect & Direct) Special Qualities in Friendship Worksheet What's In My Head? Session Summary TNT Game (Optional) How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 5: Effective Communication Date Completed / / Minutes TNT Game Review of Session 4 TNT Word List: Communication Verbal & Nonverbal Communcation Worksheet Observational Skills Open-Ended Questions Homework: Interviewing a Smoker Session Summary TNT Game (Optional) How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 6: Assertiveness Training & Refusal Date Completed / / Minutes TNT Game Review of Session 5 Indirect vs. Direct Pressure Avoiding and Escaping the Situation Refusal Techniques Practicing Assertive Refusals Homework: Saying No Session Summary TNT Game (Optional) How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 7: Assertive Refusal Skills Practice Date Completed / / Minutes TNT Game Review of Session 6 Standing Up For Yourself Assertive Refusal Skills Practice Session Summary TNT Game (Optional) How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly 955 TNT Fidelitey Page 2 of 3 4 Sept 6

198 OTPF Project TNT: Towards No Tobacco Facilitator Fidelity Checklist SESSION DATE COMPLETED TOPICS/ACTIVITIES COVERED CURRICULUM ATTAINMENT TIME TO COMPLETE (MIN) Yes No TNT Game Review of Session 7 Date Completed Minutes TNT Word List: Social Image How closely did you keep to the Tobacco Awareness curriculum as written for this lesson? / / Advertising Pitches Tobacco in the Media Not at all close Somewhat close Pretty close Exactly Session 8: Advertising Images Homework: Anti-Tobacco Advertisement Session Summary: TNT Game (Optional) Session 9: Social Activism-Advocating for No Tobacco Use Date Completed / / Minutes TNT Game Review of Session 8 Writing a Letter Preparation for Last Day of Project TNT Session Summary: TNT Game (Optional) How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session : Public Commitment & Video Taping Date Completed / / Minutes TNT Commitment Certificate Videotaping How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Notes: 955 TNT Fidelitey Page 3 of 3 4 Sept 6

199 OTPF Project ALERT Facilitator Fidelity Checklist Grantee Name Subgrantee Name Class ID - Facilitator First Name Facilitator Last Name Facilitator Sex Male Facilitator Phone Facilitator Female ( ) - School District School Teacher Which grades are participating in this class? Grade Grade Grade Period Instructions: Please complete the appropriate section after completion of each session. Indicate the date the session was completed, how many minutes were spent on covering that session, and indicate which of the session objectives were completed. If any session objectives were not completed, please explain why. In the notes section at the end of the survey, please include any comments you have about any session including changes you may have made to the curriculum materials. SESSION DATE COMPLETED TOPICS/ACTIVITIES COVERED CURRICULUM ATTAINMENT TIME TO COMPLETE (MIN) Yes No Session : Introduction to Project ALERT Date Completed / / Minutes Introduce Program Develop Ground Rules Make Reasons List Compare Marijuana and Alcohol Show and Discuss Video: Let's Talk About Marijuana Wrap Up How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly 8345 Created by the Ohio Tobacco Research and Evaluation Center at Case Western Reserve University ALERT Fidelity Page of 4 3 October 6

200 OTPF Project ALERT Facilitator Fidelity Checklist SESSION DATE COMPLETED TOPICS/ACTIVITIES COVERED CURRICULUM ATTAINMENT TIME TO COMPLETE (MIN) Yes No Introduce Lesson Date Completed Minutes Immediate and Later Consequences of Smoking How closely did you keep to the Compare Cigarettes and Smokeless Tobacco curriculum as written for this lesson? / / Immediate and Later Consequences of Marijuana Review Consequences Not at all close Somewhat close Pretty close Exactly Session 2: Consequences of Smoking Cigarettes & Marijuana Show Video: Pot the Party Crasher Post-Video Discussion Wrap-Up Session 3: Drinking Consequences & Alternatives Date Completed / / Minutes Introduce Lesson List of Reasons Why People Drink List Consequences of Drinking Discuss How Alcohol is Used to Cover Feelings Discuss Alternatives to Drinking Alcohol Facts Game Wrap-Up How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 4: Introduction to Pressures Date Completed / / Minutes Introduce Lesson Introduce Pressures Discuss Prevalence of Substance Use Discuss Substance Advertising Identify Ad Messages Re-write Substance Ads Wrap-Up How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 5: Social Pressures to Use Drugs Date Completed / / Minutes Introduce Lesson Review Homework Partial Video: Lindey's Choice Prepare Skits Act Out Skits Show Remainder of Video: Lindsey's Choice Discuss Video Solutions Wrap-Up How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 6: Resisting Internal & External Pressurs to Use Drugs Date Completed / / Minutes Introduce Lesson Review & Practice Saying "No" to External Pressures Introduce Ways to Say "No" to Internal Pressures Practice Saying "No" to Internal Pressures Generalize Pressures and Resistance Techniques Wrap-Up How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly 8345 ALERT Fidelity Page 2 of 4 3 October 6

201 OTPF Project ALERT Facilitator Fidelity Checklist SESSION DATE COMPLETED TOPICS/ACTIVITIES COVERED CURRICULUM ATTAINMENT TIME TO COMPLETE (MIN) Yes No Session 7: Practicing Resistance Skills Date Completed / / Minutes Introduce Lesson Show Partial Video: Pot or Not? Prepare Skits Act Out Skits Show and Discuss Rest of Video: Pot or Not? Review: Parent/Adult Interview: Peer Pressure Wrap-Up How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 8: Inhalant Abuse Date Completed / / Minutes Introduce Lesson Introduce Concept of Body Pollution Reinforce Oxygen's Importance to the Body Distinguish Between Inhaling Nonpoisonous Substances vs. Toxic Chemicals Discuss Poisoning by Breathing Chemical Fumes Discuss Protection From Toxic Chemicals in Inhalants Discuss How Toxic Chemicals Harm the Body Reasons Not to Inhale Toxic Fumes Wrap-Up How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 9: Review & Practice of Resistance Techniques Date Completed / / Minutes Introduce Lesson Review Pressures Prepare Resistance Skits Act Out Resistance Skits Play the Benefits Game Wrap-Up How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session : Smoking Cessation Date Completed / / Minutes Introduce Lesson Complete Visual: Why It's Hard to Quit Smoking Show and Discuss Video: Cleaning the Air Making Quitting Lists Prepare Making Changes in My Life Sheets Wrap-Up How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session : Benefits of Not Using Drugs Date Completed / / Minutes Introduce Lesson Play the Information Review Game Show and Discuss Video: Saying "No" to Drugs Write & Discuss Commitments to Choose a Healthy Lifestyle Free From Drugs Wrap-Up How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly 8345 ALERT Fidelity Page 3 of 4 3 October 6

202 OTPF Project ALERT Facilitator Fidelity Checklist SESSION DATE COMPLETED TOPICS/ACTIVITIES COVERED CURRICULUM ATTAINMENT TIME TO COMPLETE (MIN) Yes No Introduce Curriculum and Lesson Minutes Discuss Problems with Cigarettes How closely did you keep to the Discuss Problems with Marijuana and Alcohol curriculum as written for this lesson? Booster Lesson : Motivating Resistance to Drugs Date Completed / / Review Sources of Pressure to Use Drugs Play Resisting Pressure Lines Game Discuss Other Drug Facts & Prevalence of Drug Use Wrap-Up Not at all close Pretty close Somewhat close Exactly Booster Lesson 2: Practice Resisting Internal & External Pressures Date Completed / / Minutes Introduce Lesson and Review Saying "No" Show Partial Video: Paul's Fix (Problem) Discuss Video Write Ways of Saying "No" Show and Discuss Rest of Video: Paul's Fix (Solution) Review Internal Pressures Prepare and Act Out Internal Pressure Skits Wrap-Up How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Booster Lesson 3: Benefits of Resisting Drugs Date Completed / / Minutes Introduce Lesson and Review Homework Introduce Direct Pressures Discuss How Friends Can Help Each Other Resist Pressures Discuss Benefits of Resistance Show and Discuss Video: Resisting Peer Pressure Review Benefits of Resistance Wrap-Up How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Notes: 8345 ALERT Fidelity Page 4 of 4 3 October 6

203 OTPF STAMP Facilitator Fidelity Checklist Grantee Name Subgrantee Name Class ID - Facilitator First Name Facilitator Last Name Facilitator Sex Male Facilitator Phone Facilitator Female ( ) - School District School Teacher Grade Grade Grade Period Instructions: Please complete the appropriate section after completion of each session. Indicate the date the session was completed, how many minutes were spent on covering that session, and indicate which of the session objectives were completed. If any session objectives were not completed, please explain why. In the notes section at the end of the survey, please include any comments you have about any session including changes you may have made to the curriculum materials. SESSION DATE COMPLETED TOPICS/ACTIVITIES COVERED CURRICULUM ATTAINMENT TIME TO COMPLETE (MIN) Yes No Lesson Plan Date Completed / / Minutes Introduction Student Pre-Test Ground Rules "Non-Smoker" Handout Activity : Reasons Teens Use & Do Not Use Tobacco Activity 2: Tobacco Jeopardy How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Created by the Ohio Tobacco Research and Evaluation Center at Case Western Reserve University STAMP Fidelity Page of 2 22 October 6

204 OTPF STAMP Facilitator Fidelity Checklist SESSION DATE COMPLETED TOPICS/ACTIVITIES COVERED CURRICULUM ATTAINMENT TIME TO COMPLETE (MIN) Yes No Introduction How closely did you keep to the Date Completed Minutes Activity : Stress Causes/Stress Signals List curriculum as written for this lesson? Lesson Plan 2 Activity 2: Nicotine and Your Brain Handout / / Nicotine and Your Brain Q & A Not at all close Somewhat close Activity 3: Stress Management Skills List Pretty close Exactly Activity 4: Skits and Skit Handout There are Lots of Ways to Say "No" Handout Lesson Plan 3 Date Completed / / Minutes Introduction Activity, Part Sneaky Nicotine: Smokeless Tobacco Q & A Activity, Part 2 Sneaky Nicotine: Other Tobacco Products Activity 2: The Cost of Tobacco Worksheet Adult-Student Survey How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Lesson Plan 4 Date Completed / / Minutes Survey Discussion Questions Activity : Adverstising Methods - Handout Activity : Adverstising Methods - Worksheet Activity 2: Advocacy - Letter Worksheet Classroom Session Review Student Post-Test Teacher Evaluation Form How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Notes: STAMP Fidelity Page 2 of 2 22 October 6

205 OTPF Word of Mouth 4th Grade Facilitator Fidelity Checklist Grantee Name Subgrantee Name Class ID - Facilitator First Name Facilitator Last Name Facilitator Sex Male Facilitator Phone Facilitator Female ( ) - School District School Teacher Grade Period Instructions: Please complete the appropriate section after completion of each session. Indicate the date the session was completed, how many minutes were spent on covering that session, and indicate which of the session objectives were completed. If any session objectives were not completed, please explain why. In the notes section at the end of the survey, please include any comments you have about any session including changes you may have made to the curriculum materials. SESSION DATE COMPLETED TOPICS/ACTIVITIES COVERED CURRICULUM ATTAINMENT TIME TO COMPLETE (MIN) Yes No Session : Smoking is Gross Date Completed / / Minutes Review of Respiratory System Effects of Tobacco Sponge Lungs Tar Jar Emphysema Demonstration (Bubble Wrap) Coffee Straw Breathing Exercise Smoking is Gross! Quiz How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly 582 Created by the Ohio Tobacco Research and Evaluation Center at Case Western Reserve University Word of Mouth Grade 4 Page of 2 4 Sept 6

206 OTPF Word of Mouth 4th Grade Facilitator Fidelity Checklist SESSION DATE COMPLETED TOPICS/ACTIVITIES COVERED CURRICULUM ATTAINMENT TIME TO COMPLETE (MIN) Yes No Progress Report How closely did you keep to the Date Completed Minutes Just the Facts Worksheet curriculum as written for this lesson? Session 2: You Can Brown Bag Exercise Decide / / You Can Decide Worksheet Not at all close Somewhat close Progress Report Pretty close Exactly Session 3: Refusal Power Date Completed / / Minutes Progress Report Wanted: Good Friends Worksheet Review of Refusal Skills Green-Yellow-Red Refusal Activity Green-Yellow-Red Refusal Activity 2 Green-Yellow-Red Refusal Activity 3 Green-Yellow-Red Refusal Activity 4 Green-Yellow-Red Refusal Activity 5 Progress Report How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Session 4: Grab Your Goal Date Completed / / Minutes Progress Report Getting to Know Yourself Worksheet Grab Your Goal Worksheet Progress Report How closely did you keep to the curriculum as written for this lesson? Not at all close Pretty close Somewhat close Exactly Notes: 582 Word of Mouth Grade 4 Page 2 of 2 4 Sept 6

207 557 Class ID - OTPF Evaluation of Word of Mouth On-line Implementation Fidelity Checklist Which on-line Word of Mouth curriculum was implemented? Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 School: District: Facilitator First Name Facilitator Last Name Facilitator Facilitator Phone ( ) - Facilitator Sex Male Female Did every student have their own computer? Yes No What time did the class begin? : AM PM Number of students enrolled: Number of computers available: Session Date Duration (minutes) Any technical difficulties? How many students completed the lesson?. / / Yes No 2. / / Yes No 3. / / Yes No 4. / / Yes No Comments:

208 Teacher Satisfaction Survey (School). Introduction Thank you for agreeing to take this brief survey about your experiences with the tobacco prevention curriculum delivered under your supervision. After you complete the survey we will mail you a $5. giftcard to Borders/Borders.com. Please remember to provide your mailing address so we can send you the giftcard. Please allow 7- days to receive the giftcard. If you have any questions or concerns about the survey or giftcard, please feel free to contact the Ohio Tobacco Research and Evaluation Center at (This contact information will also be provided at the end of the survey.) Please click "Next" to continue. 2. General Questions *. Which curriculum was presented to your students? (Check all that apply.) gfedc Word of Mouth gfedc Life Skills Training gfedc Project Alert gfedc Say No to Tobacco gfedc STAMP gfedc Project TNT gfedc Unsure of the name gfedc Other (please specify) * 2. Was the curriculum delivered in a school or a community setting? School setting (including afterschool) Community setting 3. General Questions Page Teacher Satisfaction Survey (School) * 3. In what grade(s) are the students who received the curriculum? (Check all that apply) gfedc K-2nd grade gfedc 3rd grade gfedc 4th grade gfedc 5th grade gfedc 6th grade gfedc 7th grade gfedc 8th grade gfedc 9th grade gfedc th-2th grade 4. General Questions, cont. * 4. How many different classrooms received the curriculum programming? (If the programming occurred in a community setting please understand "classroom" to mean a group of youth). One Classroom Two classrooms, separately Two classrooms, merged to receive programming Three or more classrooms, separately Three or more classrooms, merged to receive programming Other (please specify) 5. Facilitator * 5. Who facilitated the programming? I taught the sessions Another teacher in my school (or adult from our community organization) taught the sessions An outside facilitator taught the sessions More than one outside facilitator taught the sessions Other (please specify) Page 2

209 Teacher Satisfaction Survey (School) * 6. Were you present in the room during the programming? All of the time Most of the time Some of the time Hardly at all 6. Overall Satisfaction * 7. Overall, how satisfied were you with the tobacco prevention program that was brought into your classroom (or community site)? Very Satisfied Somewhat satisfied Neither satisfied nor unsatisfied Somewhat dissatisfied Very dissatisfied * 8. How satisfied were you with the content of the curriculum? Very satisfied Somewhat satisfied Neither satisfied nor unsatisfied Somewhat dissatisfied Very dissatisfied 7. Curriculum Satisfaction * 9. What did you think about the number of sessions? Were they... Too many Just right Too few *. What about the length of each program session? Were they... Too long Just right Too short Page 3 Teacher Satisfaction Survey (School) 8. curriculum cont. *. The following questions ask your opinion about the curriculum and its content. Please rate each statement on a scale of "strongly agree" to "strongly disagree" Activities were exciting and engaging Activities were age appropriate Curriculum helped meet state academic standards (or the goals of our community organization) Students responded positively to the curriculum Students enjoyed the activities in the curriculum Students learned something Neither agree nor Strongly agree Agree Disagree Strongly disagree Don't Know disagree 9. Facilitator * 2. The next questions ask about the facilitator who presented the curriculum to your students. Please rate the following statements on a scale of "strongly agree" to "strongly disagree." Facilitator was knowledgeable Neither agree nor Strongly agree Agree Disagree Strongly disagree Don't Know disagree Facilitator was prepared Facilitator was organized Facilitator was professional Facilitator engaged the students Facilitator managed the class well. Short answer * 3. What did you like most about your experience with this tobacco prevention program? * 4. What did you like least about your experience with this tobacco prevention program? Page 4

210 Teacher Satisfaction Survey (School). Short Answer * 5. What did you like most about your experience with the facilitator? * 6. What did you like least about your experience with the facilitator? 2. final page * 7. Have you considered teaching this curriculum to your students in the future? Yes, I would be interested I might be interested I have not given it much thought I'm not sure if I would be interested No, I would not be interested 8. Are there any other comments or suggestions that you would like to share with the organization that funds the tobacco prevention program given to your class? 3. The End 9. Thank you for completeing this survey. Please enter your name and mailing address below where you would like us to send your $5. gift card to Borders/Borders.com. After entering this information, click "Done" to finish. If you have any questions or concerns about the survey or giftcard, please feel free to contact the Ohio Tobacco Research and Evaluation Center at Page 5

211 APPENDICES APPENDIX D: Adult Cessation Data Collection Forms Class/Batch Information Form Participant Consent and Baseline Survey Participant Program Attendance & Relapse Call

212 269 OTPF Adult Cessation Class Information/Batch Sheet For group cessation classes, please complete this form after the first adult smoking cessation group session. This form must be faxed to OTREC at or toll-free , along with the completed Adult Baseline Cessation Survey for this class, within 48 hours of the first cessation class session. For individual cessation programs, plesae use this form to "batch" transmission of Adult Baseline Cessation Surveys according to your internal protocol. Grantee Name Facilitator First Name Facilitator Last Name Class/Batch ID - Facilitator Facilitator Phone ( ) - Are the participant ID's below from a cessation class or a batch of individuals? Class or Group Cessation Batch of Individuals Please indicate the type of site where the programming has occurred. Business Community Setting Hospital Health Clinic Health Department Below please provide the unique participant ID number for each adult sessation class participant or for each individual cessation participant in the batch. This unique number can be found on the Adult Baseline Cessation Survey Created by the Ohio Tobacco Research and Evaluation Center at Case Western Reserve University

213 9592 OTPF Adult Ce s s ation Surve y S urvey Purpos e and Confide ntiality S tate m e nt: Your re s pons e s to this s urve y will be us e d to e valuate the pe rformance of tobacco ce s s ation programs funde d by the Ohio T obacco Pre ve ntion Foundation. Foundation grante e s are re quire d to provide the following information in orde r to re ce ive funding that will he lp continue this important program. Your re s pons e s are s trictly confide ntial and will be groupe d with thos e of othe r individuals prior to analys is. Surve y re s pons e s will be re porte d in a way that make s it impos s ible to de te rmine the ide ntity of individual re s ponde nts. Contact Waiver: In orde r to be tte r e valuate this program, the Ohio T obacco Pre ve ntion Foundation would like to contact you in the future to determine the extent to which this program helped you to quit using tobacco and your statisfaction with the services received. Ple as e provide your contact information and s ign the s tate me nt be low to allow us to contact you after the program. Contact Inform ation: First Name Last Name Telephone Number ( ) - Address Address City State Zip Code I he re by authorize the Ohio T obacco Pre ve ntion Foundation and its e x te rnal e valuation contractors to contact m e about s e rvice s re ce ived through this program. I unde rs tand that inform ation colle cte d through follow - up calls w ill only be us e d to e valuate this program and that ne ithe r the Foundation nor its re pre s e ntatives w ill re le as e m y contact inform ation to any othe r partie s. S ignature : Today's Date / / Adult Cessation Survey Page of 3 27 September

214 9592 Ins tructions : Your ans we rs are ve ry important. Ple as e ans we r e ach que s tion care fully and hone s tly. Be s ure to comple te ly fill in the circle ne xt to your s e le cte d re s pons e. Part : DEMOGRAPHICS. Are you: Male Female 2. How old are you? Years 7. Would you say your general health is: Excellent Very good Good Fair Poor 3. How did you hear about this tobacco cessation program? Please fill the circle for all that apply. Newspaper advertisement or article Radio advertisement Flyers or brochures Referral from health provider Referral from employer Referral from friends or family Other, please list 4. Are you participating in an individual or group smoking cessation program? Individual Group 5. Are you Hispanic or Latino? No 8. Are you: Married Divorced Widowed Separated Never Married A member of a unmarried couple 9. Are there any children age 7 or younger living in your household? No Yes. Do you live with a tobacco user? No Yes Yes 6. Which one of these groups would you say best represents your race? (choose only one) White Black or African-American Asian American and Pacific Islander American Indian or Alaskan Native Other, please specify. What is the highest grade or year of school you completed? Grade 8 or less Grades 9 through (Some high school) High school graduate or GED Some college or technical school 4-year college degree Graduate or professional degree Adult Cessation Survey Page 2 of 3 27 September

215 Which best describes your current employment status? Employed full-time Employed part-time Employed but temporarily laid off Unemployed (not including homemaker) Homemaker Retired Unable to work because of health/disability 7. How soon after you wake up do you smoke, dip or chew? Within 5 minutes 6 to 3 minutes 3 to 6 minutes After 6 minutes Part 3: Tobacco Us e 3. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare? No 8. Do you currently smoke cigarettes? Everyday Some days Not at all Yes 9. How many cigarettes do you smoke per day on the days that you smoke? Part 2: Stage of Change 4. During the past 2 months, have you stopped using tobacco for one day or longer because you were trying to quit? cigarettes per day Fill in this circle if you did not smoke in the past 3 days No Yes 5. Are you seriously considering quitting tobacco use within the next six months? 2. Do you currently use chewing tobacco or snuff? No Yes No Yes 6. Do you intend to quit using tobacco within the next 3 days? No Yes 2. Do you currently smoke cigars (either full-size cigars or little cigars/cigarillos)? No Yes Thank you for comple ting this s urve y! Adult Cessation Survey Page 3 of 3 27 September

216 OTPF Adult Cessation Class Attendance Sheet Please use this form to record participant attendance for adult group smoking cessation classes. Please ACCURATELY record the unique participant ID for each class participant immediately following administration of the baseline survey. This number can be found on the bottom of the partipant's baseline survey. This form must be faxed to OTREC, at or toll-free , at the completion of the cessation programming. Total Number of Classes Offered Class ID - Participant ID Participant Name Please Mark the Box Bellow for Each Session Attended 3 Day Call Made Yes No 2. - Yes No 3. - Yes No 4. - Yes No 5. - Yes No 6. - Yes No 7. - Yes No Please use additional forms as needed. Created by the Ohio Tobacco Research and Evaluation Center at Case Western Reserve University Cessation Class Attendance Log September 26

217 APPENDICES APPENDIX E: Other Surveys Coalition Leader Survey Brief Intervention Training Survey Youth Prevention Curricula Training Survey

218 Coalition Leaders Survey Coalition Leaders Survey Thank you for taking a few brief minutes to complete this survey on tobacco coalition leadership. You have been identified as a leader from your tobacco coalition whose insights about the coalition's work are important to learn more about. Supported by the Ohio Tobacco Prevention Foundation, we hope to learn more about what is working, not working, and how coalitions are organized and function so that continued successful tobacco prevention and control activities can be delivered at the local level. Since there are no right or wrong answers please provide your honest responses to each of the items. Thank you in advance for completing this survey. Part : Coalition Leaders Characteristics and Perceptions Part of the survey will ask you questions about the characteristics of the coalition and your perceptions of the coalition. Click Next to begin Part. Representation *. Which of the following organizations/groups participates in the coalition on a regular basis (i.e. regularly attend meetings and/or participate in coalition activities)? Check all that apply. gfedc Voluntary Health Agency (such as American Heart Association, American Cancer Society, American Lung Association) gfedc Hospitals gfedc Schools gfedc Social Service Agencies gfedc City/County Health Departments gfedc Other Local Government Agencies gfedc Counselors/Therapists gfedc Faith-based Organizations gfedc Minority-based Organizations gfedc Local Businesses gfedc Non-Profit Organizations gfedc Health Care Professional gfedc Law Enforcement gfedc Don't Know gfedc Other (please specify) Representation (cont.) Page Coalition Leaders Survey * 2. What population groups does the coalition serve? (Check all that apply) gfedc Minority groups gfedc Faith-based organizations gfedc Women gfedc Youth gfedc Policy leaders gfedc Health care professionals gfedc Don't Know gfedc Other (please specify) * 3. On average, how many individuals attended the regularly scheduled meetings over the last 3 months? # of individuals Representation (cont.) * 4. How many individuals are active members of the coalition (i.e. regularly attend meetings and/or participate in coalition activities)? # of individuals * # of organizations 5. How many organizations are currently part of the coalition? * 6. What is the primary focus of the coalition? Tobacco prevention and control Chronic diseases (cancer, heart disease, lung disease, other) Children and youth Mental Health Health Care Don't Know Other (please specify) Representation (cont.) Page 2

219 Coalition Leaders Survey * 7. Please indicate what percentage of coalition membership is represented by each ethnic group. % White % African American % Asian % American Indian % Hispanic/Latino % Other * 8. Is your participation in the coalition: Voluntary, not paid for by any group or organization Part of your paid duties for an organization/agency Other * # of counties 9. Approximately how many counties does the coalition membership represent? Representation (cont.) *. How did the current coalition begin? It was an existing coalition that received additional monies from OTPF It started with OTPF funding It started with a focus other than tobacco but has shifted its focus with funding from OTPF Don't Know Other (please specify) Skills and Experience * Years. How long have you been a member of this coalition? Months Page 3 Coalition Leaders Survey * 2. What term best describes your understanding of the tobacco prevention and control needs of the populations the coalition serves? Excellent understanding Very good understanding Fair understanding Poor understanding * 3. Which of the following best describes your skills as a professional leading the tobacco coalition? Advocacy (encouraging policy change) Organizational (pulling groups together and providing direction for the coalition) Communication (oral and written exchanges with individuals and groups) Motivation (encouraging others to complete tasks in a timely and capable manner) Other (please specify) Role Clarity * 4. Does the coalition have a clear... Yes No Don't Know... Mission Statement *... Strategic Plan 5. How well do you think the coalition's MISSION STATEMENT meets its vision? Very well Pretty well Unsure Not so well Not well at all Role Clarity (cont.) Page 4

220 Coalition Leaders Survey * 6. How well do you think the coalition's MISSION STATEMENT meets the vision of the staff/volunteers? Very well Pretty well Unsure Not so well Not well at all * 7. How well do you think the coalition's STRATEGIC PLAN meets its vision? Very well Pretty well Unsure Not so well Not well at all Role Clarity (cont.) * 8. How well do you think the coalition's STRATEGIC PLAN meets the vision of the staff/volunteers? Very well Pretty well Unsure Not so well Not well at all * 9. How clear are you about your role with the coalition? Very clear Somewhat clear Unsure Somewhat unclear Not clear at all Role Clarity (cont.) Page 5 Coalition Leaders Survey * 2. Does the coalition have a written action plan related to: Yes No Don't Know Promotion of Ohio Quits Community Leader Outreach Coalition Development Local Marketing % Tobacco Free Schools Youth Prevention Programming Prevention Curricula Training Support/Work to Establish a stand Team Intensive Adult Cessation Counseling Policy and Brief Intervention Within Health Systems Employer Support for NRT Outdoor Tobacco-Free Environment Tobacco-Free Worksite Expectations * 2. How confident are you that the Coalition will achieve its objectives? Very confident Somewhat confident Unsure Not too confident Not at all confident * 22. How likely do you think it is that the coalition will fully implement its activities? Very likely Somewhat likely Unsure Somewhat unlikely Very unlikely Expectations (cont.) Page 6

221 Coalition Leaders Survey * 23. How likely is it you will be involved with the coalition next year at this time? Very likely Somewhat likely Unsure Somewhat unlikely Very unlikely * 24. How likely do you think it is that the coalition will be effective at evaluating its activities this year? Very likely Somewhat likely Unsure Somewhat unlikely Very unlikely Expectations (cont.) * 25. How likely do you think it is that the coalition will secure financial support in the next year? Very likely Somewhat likely Unsure Somewhat unlikely Very unlikely * 26. How well does the coalition provide technical assistance to the community regarding tobacco prevention and control issues? Very well Somewhat well Adequately Inadequately Not well at all Participation Benefits Page 7 Coalition Leaders Survey * 27. Which of the following do you consider benefits of participating in the coalition? Yes No Material benefits Solidarity (being part of an organized group) Strengthening my organization's capacity Personal benefits (individual input or personal development) Community benefits Networking Access to resources (financial, human, materials, equipments) Part 2: Coalition Organizational or Group Characteristics Part 2 of this survey will ask you questions related to the organizational or group characteristics of the coalition. Click Next to begin Part 2. Leadership * 28. How much influence do local coalition staff and coalition members have in making decisions for the coalition? Using the scale from "a lot of influence" to "no influence", describe how much influence each group has on deciding the actions and policies of the coalition. Not much influence A lot of influence () Some influence (2) No influence (4) Not Applicable (5) (3) Local coalition staff * Local coalition members 29. How much influence do YOU have in making decisions for the coalition? Using the same response categories, tell us how much influence you have on making the following types of decisions. Setting goals and objectives for the coalition Selecting coalition activities Setting the budget for coalition activities Deciding general coalition policies and actions Not much influence A lot of influence () Some influence (2) No influence (4) Not Applicable (5) (3) Leadership (cont.) Page 8

222 Coalition Leaders Survey * 3. How are decisions usually made in this coalition? Select the one main way you think decisions are usually made: Voting, with majority rule Discussion and consensus among coalition members The chair listening to discussion and making final decisions for the coalition The staff making the decisions Don't Know Other (please specify) Organizational Structure * 3. Does the coalition have any of the following? Yes No Don't know written bylaws written mission statement * written strategic plan 32. List out the names of the task forces or committees that your coalition currently has. * 33. Does the coalition have a full-time coordinator? Yes No Don't Know Organizational Structure (cont.) * 34. If Yes, is this person paid or a volunteer? Paid Volunteer Don't Know Organizational Structure (cont.) * 35. Does the coalition have a part-time coordinator? Yes No Don't Know Organizational Structure (cont.) * 36. If Yes, is this person paid or a volunteer? Paid Volunteer Don't Know Page 9 Coalition Leaders Survey Organizational Structure (cont.) * 37. Do new members of the coalition receive an orientation and training to the coalition's plan? Yes No Don't Know Task Force/Meeting Effectiveness * 38. Do coalition meetings have a clear agenda? Yes No Don't Know * 39. Is a distinction made in meetings among items that are: Yes No Don't Know Information only Discussion only * Action only 4. Does the coalition keep written minutes? Yes No Don't Know Part 3: Group Processes and Climate Part 3 of this survey will ask you questions regarding the processes and climate of your coalition. Click Next to begin Part 3. Stages of Coalition Development * 4. Which of the following stages best describes the current coalition? Formation-still forming Implementation-just beginning to provide and/or support programming and services Maintenance-sustain programming and service delivery Institutionalization-programming and service delivery is accepted and standard practice for the coalition Organizational Climate Page

223 Coalition Leaders Survey * 42. How much do you agree or disagree with the following statements about the coalition: There is a feeling of unity and cohesion in this coalition There is a strong emphasis on practical tasks in this coalition There is not much group spirit among members of this coalition This is a down to earth coalition There is a strong feeling of belonging in this coalition This coalition rarely has anything concrete to show for its efforts Members of this coalition feel close to each other This is a decision-making coalition This coalition has a hard time resolving conflicts This coalition is reflective of the community it serves This coalition makes an effort to keep all members engaged Neither agree nor Strongly agree () Agree (2) Disagree (4) Strongly disagree (5) disagree (3) Communication * 43. How would you describe the quality of communication between the coalition leadership and coalition members? Very good Good Unsure Bad Very bad Page Coalition Leaders Survey * 44. What forms of communication does the coalition use? (Check all that apply) gfedc Paper newsletter gfedc Electronic newsletter gfedc Electronic listserv gfedc Website gfedc Phone gfedc Communication (cont.) * 45. Which form of communication does the coalition use most? Paper newsletter Electronic newsletter Electronic listserv Website Phone * 46. How important or unimportant to the coalition is each of the following ways of communication? Mailed and faxed written materials Verbal reports at meetings Group discussions at meetings Talking outside of coalition meetings ing written materials Very important () Somewhat important (2) Not very important (3) Not at all important (4) Recruitment * 47. What steps has the coalition taken to recruit new members? Page 2

224 Coalition Leaders Survey * 48. How successful has the coalition been at recruiting new members? Very successful Somewhat successful Neither successful or unsuccessful Somewhat unsuccessful Unsuccessful * 49. How successful has the coalition been at recruiting new members from the populations being served by the coalition? Very successful Somewhat successful Neither successful or unsuccessful Somewhat unsuccessful Unsuccessful Part 4: Impact and Outcomes the Coalition Creates Part 4 of this survey will ask you questions about what impact and outcomes your coalition is able to create. Click Next to begin Part 4. Community Linkages * 5. How well do you believe the local tobacco coalition links or collaborates with other community organizations or groups? Very well Pretty well Adequately Not so well Not well at all * 5. Would you say since you have been involved with the coalition, the number of new agencies joining the coalition has: Significantly Increased Increased some Stayed about the same Decreased some Significantly Decreased Page 3 Coalition Leaders Survey * 52. Have you grown as a professional because of your involvement with the coalition? Yes No Policy Changes * 53. To what extent do you agree that the local tobacco coalition has helped shape public policies in the community, including worksite and school, about restricting smoking? Strongly agree Agree Unsure Disagree Strongly disagree * 54. To what extent do you agree that the local tobacco coalition has had an impact on tobacco use in your community? Strongly agree Agree Unsure Disagree Strongly disagree Institutionalization/Sustainablility * 55. How likely is it that the local tobacco coalition will continue its work after funding from the Ohio Tobacco Prevention Foundation ends? Very likely Likely Unsure Unlikely Very unlikely Page 4

225 Coalition Leaders Survey * 56. How much impact would you say that programs delivered by the coalition have had over the time you have participated in the coaltion: A significant impact Not much impact No impact at all Institutionalization/Sustainability (cont.) * 57. Does the coalition have an archive (stored records) of the work it has accomplished and programs delivered or supported since it began? Yes No Don't Know * 58. How well do you believe coalition programs are monitored by coalition staff and/or members? Very well Somewhat well Unsure Not so well Not very well * 59. Does the coalition have a plan for seeking funding beyond the current support from the Ohio Tobacco Prevention Foundation? Yes No Don't Know Institutionalization/Sustainability (cont.) * 6. Over the last two years, has this coalition actively sought financial support in addition to OTPF funding? Yes No Don't Know Page 5 Coalition Leaders Survey * 6. Does the coalition currently receive financial support beyond OTPF? Yes No Don't Know Institutionalization/Sustainability (cont.) * 62. What percentage of the tobacco coalition's budget is provided by external sources to OTPF? % of budget End of Survey Thank you for completing the survey. We will compile the data and prepare a report to be shared with OTPF coalitions and leaders across the state. Page 6

226 5258 OTPF Training Survey: Cessation Brief Interventions. Date / / 6. Approximately how many clients/patients do you plan to provide this program to in the next 2 months? 2. Are you: Male Female 3. How old are you (years)? 4. Which of these best describes you? White African-American Hispanic Native Hawiian or Pacific Islander American Indian or Alaskan Native Other 5. What is your current position? Physician Nurse Dentist Respiratory Therapist Social Worker Other 7. Where do you plan to implement this intervention? Hospital/clinic (check all that apply) Practitioner office Community setting Work sites Other 8. After receiving the training today, how confident do you feel in your ability to deliver this intervention? Very confident Somewhat confident Not very confident Not confident at all 9. How comfortable do you feel with the material that was covered today? Very comfortable Somewhat comfortable Not very comfortable Not comfortable at all Office Use Only: Agency ID Page of Created by the Ohio Tobacco Research and Evaluation Center at Case Western Reserve University Brief Intervention Training Page of March 27

227 44944 OTPF Training Survey: Youth Prevention Curriculum. Date / / 2. Please indicate which curriculum you received training for today. LifeSkills Training Project ALERT STAMP Word of Mouth Project TNT 3. Are you: Male Female 4. How old are you (years)? 9. Approximately how many youth do you plan to provide this program to in the next 2 months? 5. Which of these best describes you? White African-American Hispanic Native Hawiian or Pacific Islander American Indian or Alaskan Native Other. Do you pledge to deliver this curriculum with fidelity, as it is designed to be delivered? Yes No. Do you intend to culturally tailor or adapt the curriculum for a special population? Yes No If yes, please explain. 6. What is your highest level of education? High School Some College Associate's Degree Bachelor's Degree (BA/BS) Graduate or Professional Degree 7. What is your current position? Teacher School Nurse Safe and Drug-free School Coordinator Guidance Counselor Community Agency Representative Other School Personnel Other 2. After receiving the training today, how confident do you feel in your ability to deliver this curriculum? Very confident Somewhat confident Not very confident Not confident at all 3. How comfortable do you feel with the material that was covered today? Very comfortable Somewhat comfortable Not very comfortable 8. Where will you deliver this curriculum? Not comfortable at all School-based, in a classroom School-based, in an after school program Office Use Only: Community setting Agency ID Page of Created by the Ohio Tobacco Research and Evaluation Center at Case Western Reserve University Youth CurriculumTraining Page of March 27

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229 APPENDICES APPENDIX F: PRESENTATIONS

230 Welcome SLIDES FROM THE OPENING SESSION OF THE COMMUNITY GRANTS PROGRAM EVALUATION TRAINING WORKSHOPS NOVEMBER 27 28, 26 MOHICAN STATE PARK DECEMBER 5 6, 26 QUEST CONFERENCE CENTER OTPF Evaluation Workshop Jeff Willett, Ph.D. OTPF Director of Evaluation and Research Thank you for all your hard work! 26.6% to 22.4% adult smoking prevalence 32.6% to 28.7% high school tobacco use 5.% to.6% middle school tobacco use Congratulations! Ohio is a smoke-free state There is more work to be done! Estimated Prevalence of Current Smokers by Income Level, Estimated Prevalence of Current Smokers by Education, 25 Community Grants III Percent Prevalence 45% 4% 35% 3% 25% 2% 5% % 5% % 35.% 3.% 28.5% 24.6% 23.6% 2.4%.4% Under $5,- $2,- $25,- $35,- $5,- $75,+ $5, $9,999 $24,999 $34,999 $49,999 $74,999 Current Smokers Percent Prevalence 45% 39.7% 4% 35% 3.9% 3% 25% 9.8% 2% 5% 9.5% % 5% % Less than High High School Some College College Graduate School Graduate or GED Current Smokers Includes 5 CGI, CGII and HR grantees. Introduces a statewide evaluation framework. Introduces the Reporting and Evaluation (RE) Coordinator. Represents a show me year for the OTPF Board. Source: 25 Behavioral Risk Factor Surveillance System, Chronic Disease and Behavioral Epidemiology, BHSIOS-Prevention, Ohio Department of Health, 26. Source: 25 Behavioral Risk Factor Surveillance System, Chronic Disease and Behavioral Epidemiology, BHSIOS-Prevention, Ohio Department of Health, CGIII Program Framework CGIII Program Framework Grantee Evaluation Capacity Required Activities Prevention Adult Cessation Special Populations Secondhand Smoke Required Activities Coalition Development Local Marketing Communication Efforts Community Leader Relations Promotion of Ohio Quits Youth Prevention Curricula school and community-based Training % Tobacco Free Schools stand Adult Cessation Quit Programs Intensive Adult Cessation Institutionalization in Health Systems Supports by Employers Special Populations Either prevention curricula or quit programs Secondhand Smoke Worksites and Outdoor Experience tells us that 3 things happen when program staff are actively engaged in evaluation: ) Data quality improves 2) Data is more likely to be used for program planning and refinement 3) Grantees are more accountable to evaluation and reporting requirements Capacity building is a key goal of this workshop!