Texans and Tobacco. As Required By Texas Health and Safety Code Sec

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1 Texans and Tobacco As Required By Texas Health and Safety Code Sec Department of State Health Services December 2015

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3 Table of Contents Executive Summary...1 Tobacco Use in Texas...1 Tobacco Prevention and Control Initiatives...1 Retail Cigarette and Tobacco Sales to Minors...1 Future Plans...2 Introduction...3 Background...3 Tobacco Prevention and Control Program Operations...4 Section 1: Tobacco Use...5 Youth Tobacco Use...5 Adult Tobacco Use...5 Section 2: Tobacco Prevention and Control Activities...6 Preventing Initiation of Tobacco Use...7 Statewide Comprehensive Tobacco Prevention Coalition Grant Program... 7 Youth Engagement Initiatives... 8 Cessation of Tobacco Use by Adults and Youth...10 Eliminating Exposure to Secondhand Smoke...11 Eliminating Health Disparities Related to Tobacco Use...11 Health Communications...12 Worth It? Yes You Can!/ SÍ Se Puede! Share Air Section 3: Retail Compliance and Tobacco Sales...13 Synar Authority...14 Food and Drug Administration (FDA) Authority...15 Support Activities for Enforcement of Texas Tobacco Laws...16 Retailer Community Education Texas Youth Tobacco Awareness Program Texas Tobacco Prevention Hotline Communications Strategy: Enforcing It Is Easy Section 4: Future Plans...18 Appendix A: 2014 FDA Tobacco Compliance Check Inspection Summary...19 Appendix B: Texas Tobacco Enforcement Activity...20 i

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5 Executive Summary The Texas Department of State Health Services (DSHS) presents this report in response to the requirements of Section , Texas Health and Safety Code. The report provides statistical data on current and historic tobacco use in the state. It also outlines DSHS tobacco prevention and control initiatives, including a wide range of prevention, education, awareness and cessation activities and enforcement of laws regarding sale of tobacco products to minors. Tobacco Use in Texas The use of tobacco cigarettes is continuing to decrease in both adult and youth populations in Texas. In 2013, use among adults was 15.9 percent. In 2014, use was 6.2 percent in middle school youth and 16.4 percent in high school youth. Smokeless tobacco use (dip or chew) is also decreasing. Other tobacco products, however, such as snus tobacco (spit-less tobacco in a pouch) and the use of tobacco hookahs (water pipes) have increased in the past two years. Tobacco Prevention and Control Initiatives The DSHS Tobacco Prevention and Control Branch oversees a comprehensive tobacco program that focuses on preventing the initiation of tobacco use, increasing cessation by youth and adults who use tobacco, eliminating exposure to secondhand smoke, eliminating tobacco related health disparities, and building the infrastructure needed at the state and local levels to have effective programs that are evidence-based and sustainable. DSHS funds, via contracts, local comprehensive tobacco coalitions, which serve eleven counties and one city. Local coalitions implement programs in their areas using the Centers for Disease Control and Prevention (CDC) 2014 Best Practices for Comprehensive Tobacco Control Programs and the Substance Abuse and Mental Health Services Administration (SAMHSA) Strategic Prevention Framework. The work of these coalitions is supported by DSHS-funded youth outreach, cessation services, media messages, and surveillance and evaluation systems that provide services statewide with an emphasis on the coalition areas. Retail Cigarette and Tobacco Sales to Minors Federal Synar Amendment legislation requires annual, random inspections of tobacco retailers to ensure that 20 percent or fewer retailers are in violation of tobacco laws. For federal fiscal year 2013, Texas sales-to-minors rate was 7.6 percent, a dramatic decrease since the 1998 rate of 24 percent. Tobacco sales to minors in Texas are monitored through state and federal initiatives. The state statutes are enforced by local law enforcement agencies that receive funds from DSHS to conduct inspections and enforcement activities with retailers within their jurisdictions. DSHS also has a contract with the U.S. Food and Drug Administration (FDA) to fund enforcement of federal tobacco laws regarding youth access. DSHS contracts with individual officers who are commissioned by the FDA for enforcement activities. Both of these initiatives are coordinated by the Texas School Safety Center (TxSSC) at Texas State University. 1

6 Future Plans Adult and youth tobacco use prevalence rates in the general population of Texas have dropped dramatically since To continue the decrease in prevalence, the program will focus on targeted populations that continue to have tobacco prevalence rates well above the state average. To reach these populations, the program will develop innovative methods to engage new stakeholders. The goal is to improve the capacity for the program staff and community coalitions to conduct outreach to these targeted populations and to increase clinical interventions and referrals for cessation services. In 2014, Texas youth used electronic cigarettes at higher rates than traditional cigarettes. Attention will be given to new and emerging products including electronic cigarettes and spitless tobacco products to ensure that programs and services address these new products, which are gaining popularity among adults and youth. 2

7 Introduction Tobacco use among adults and youth in Texas, though currently in decline, remains a serious public health problem that contributes to or causes many preventable illnesses and deaths. This report details the steps that DSHS is taking to reduce and eliminate tobacco use statewide, presents statistical data on current and historic tobacco use, and outlines the progress of various programs. This report, Texans and Tobacco, is presented pursuant to the requirements of Section , Texas Health and Safety Code and contains information on the following: Tobacco use prevalence [Health and Safety Code (b)(6)] Tobacco initiatives [Health and Safety Code (b)(3)] Education programs [Health and Safety Code (b)(5)] Retail compliance with state statutes [Health and Safety Code (b)(1)] Tobacco sales and enforcement actions [Health and Safety Code (b)(2)] Future plans [Health and Safety Code (b)(4)] DSHS staff would like to acknowledge the assistance of the staff from the Texas Comptroller of Public Accounts and the TxSSC at Texas State University in creating this report. Background Tobacco use is the leading preventable cause of death in Texas and the United States, causing more than 20.8 million premature deaths since 1965 according to the 2014 Surgeon General's Report: The Health Consequences of Smoking 50 Years of Progress 1. While most of these deaths were in adults with a history of smoking, nearly 2.5 million were nonsmokers who died from heart disease or lung cancer caused by exposure to secondhand smoke. Another 100,000 were children who died from Sudden Infant Death Syndrome (SIDS) or complications related to parental smoking, particularly by the mother, which included premature birth and low birth weight. Confirming the findings of the June 2006 Surgeon General s Report that secondhand smoke is a serious health hazard, the December 2010 Surgeon General s Report describes in detail the multiple ways that tobacco smoke damages the body and results in disease and death. 2 In the report, former Surgeon General Regina Benjamin states, There is no safe level of exposure to tobacco smoke. Every inhalation of tobacco smoke exposes our children, our families, and our loved ones to dangerous chemicals that can damage their bodies and result in life-threatening diseases such as cancer and heart disease. According to the American Cancer Society, within 12 hours of quitting, the carbon monoxide level in a smoker s blood drops to normal. Within nine months of quitting, shortness of breath and coughing decrease, and the lungs have repaired their ability to function. After just one year 1 U.S. Department of Health and Human Services. The Health Consequences of Smoking 50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014, Surgeon General's Report How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease, 3

8 of not smoking, the risk of coronary heart disease decreases by half, compared to a smoker's risk. 3 According to a study by the Center for Health Research at Kaiser Permanente, for every Texan who quits smoking, there is a five-year savings of $7,027 in medical costs and lost productivity. 4 It is because of the significant risk to the population that DSHS, in concert with federal, state and local partners, focuses significant effort on reducing the prevalence of adult tobacco use, preventing the initiation of tobacco use by Texas youth, and reducing exposure to secondhand smoke. Tobacco Prevention and Control Program Operations The DSHS Tobacco Prevention and Control Branch oversees tobacco prevention education and cessation interventions. The program coordinates with other DSHS divisions to implement a tobacco use reduction and cessation strategy that involves multiple state agencies, local and regional governments, volunteer organizations, universities, and local community coalitions. DSHS tobacco coordinators in each of the eight DSHS Health Service Regions conduct the following activities: community mobilization and training activities; environmental and policy change activities to reduce exposure to secondhand smoke and support tobacco-free living; educational activities; cessation activities; and activities targeted to populations with a disproportionate health burden from tobacco, such as minorities, persons in rural areas, persons diagnosed with mental health and substance abuse problems, and the state s lesbian, gay, bisexual and transgendered populations. To provide training and support for specific program activities, in addition to those listed above, DSHS contracts with: A nonprofit agency, Texans Standing Tall, for coalition training The University of Texas at Austin for coalition evaluation and clinical cessation efforts related to electronic health records The University of Houston for evaluation of municipal ordinances Texas A&M University for youth tobacco prevalence surveys. DSHS will continue to provide statewide and targeted community surveillance through participation in state and national surveillance systems including the Behavioral Risk Factor Surveillance System, and the Youth Risk Behavior Surveillance System. 3 American Cancer Society, 4 The Return on Investment from Reducing Cigarette Smoking in Texas, Jeffery L. Fellows, PhD, The Center for Health Research, Kaiser Permanente. Submitted to the Tobacco Research and Evaluation Team, University of Texas at Austin, Austin TX, August 30,

9 Section 1: Tobacco Use Youth Tobacco Use The findings from the 2014 Texas Youth Tobacco Survey conducted by the Public Policy Institute at Texas A&M University are reflected below in Table 1. The annual survey of approximately 8,000 students is designed as a random sample of all public school students in the sixth through twelfth grades within each of the nine coalition service areas and throughout the state. It is an eight-page questionnaire designed to assess the students general exposure to and use of tobacco, plans to quit smoking, and beliefs about the health effects of tobacco. These data indicate a continued decrease in cigarette and traditional smokeless tobacco products since The data also show an increase in newer tobacco products, such as snus, orbs, and hookah that are now available to Texas youth. Information about use of electronic cigarettes became available in Table 1. Percentages of Youth Using Tobacco Products Grades 6-8 and 9-12 in Texas, Texas Youth Tobacco Survey 2012 and 2014 Grades 6-8 Grades Current use (past month) of cigarettes 7.4% 6.2% 17.3% 16.4% Current use (past month) of smokeless tobacco 4.2% 3.1% 13.7% 13.2% Current use (past month) of snus/spit-less tobacco 0.6% 1.6% 4.3% 8.1% Current use (past month) of tobacco in a hookah 0.9% 4.5% 2.8% 13.1% Current use (past month) of e-cigarettes na 8.1% na 19.2% Electronic cigarettes are not classified as tobacco products under statutes in either the Texas Tax Code or the Health and Safety Code. These products do, however, deliver nicotine and are being used by Texas youth. In 2014, 8.1 percent of Texas middle school students and 19.2 percent of Texas high school students reported using electronic cigarettes and similar devices within the past month, which is greater than the percent of students who reported using traditional cigarettes. While electronic nicotine delivery devices do not produce the side effects that come from combustion, research shows they do include some of the same chemicals found in traditional cigarettes. 5 However, these devices are so new to the U.S. market that there is no research showing the long-term health effects. Adult Tobacco Use Table 2 shows the prevalence of tobacco use as reported by the Texas Behavioral Risk Factor Surveillance System in 2012 and Nationally there was a decrease in current smoking among adults from 18.9 percent in 2012 to 18.2 percent in In Texas the decrease was from 18.2 percent in 2012 to 15.9 percent. 5 Besaratinia A., Tommasi S, Electronic cigarettes: the road ahead, Preventive Medicine, 2014, Sept.; 66:

10 Table 2. Percentages of Adult Tobacco Users in Texas by Sex, Race, Education, Income, Insurance Status, and Age, Behavioral Risk Factor Surveillance System, 2012 and Adult smoking prevalence All Texas adults 18.2% 15.9% Males 23.4% 18.7% Females 13.1% 13.1% Race White only 18.9% 16.5% Black only 18.7% 18.7% Hispanic 16.7% 13.6% Education Less than high school 23.4% 18.6% High school graduate 22.8% 19.8% College graduate 8.1% 8.3% Income Less than $25, % 21.2% $25,000 to $49, % 15.8% $50, % 13.1% Insurance Status Have health insurance 14.9% 13.9% No health insurance 25.9% 20.9% Age years of age 20.2% 17.6% years of age 20.8% 17.6% years of age 18.6% 16.9% 65 years of age and older 9.7% 8.6% Section 2: Tobacco Prevention and Control Activities DSHS tobacco prevention and control activities are guided by goals and objectives developed through a statewide strategic planning process that included regional and local stakeholders and partners. These goals continue to echo the historic Texas Interagency Tobacco Task Force Legislative Plan presented to the Texas Legislature in 1998, as well as the comprehensive approach promoted by the CDC s Best Practices for Comprehensive Tobacco Control Programs manual revised in The goals for comprehensive tobacco prevention programs are: To prevent initiation of tobacco use; To increase cessation of tobacco use by youth and adults; 6

11 To eliminate exposure to secondhand smoke in public places; and To eliminate disparities among diverse and special populations. DSHS promotes each of these goals with media campaigns that educate the public regarding the risks of tobacco use and the strategies to successfully stop using tobacco. Preventing Initiation of Tobacco Use Statewide Comprehensive Tobacco Prevention Coalition Grant Program In fiscal year 2014, DSHS issued a competitive request for proposals to fund organizations to manage and support community coalitions implementing a comprehensive tobacco program (prevention, cessation, secondhand smoke exposure, and addressing health disparities) within their community as part of their local Tobacco Prevention Comprehensive Coalition (TPCC) initiative. The nine contractors selected, representing 12 individual coalitions, will be funded through fiscal year Organizations and communities selected for the five years of annual funding include: Bay Area Council on Drugs and Alcohol serving Galveston County Brazos Valley Council for Alcohol and Substance Abuse serving Brazos County Council for Alcohol and Drug Abuse Coastal Bend serving Nueces County Drug Prevention Resources, Inc., serving Waxahachie East Texas Council for Alcohol and Drug Addiction serving Lamar, Red River and Rusk Counties Greater Houston Area Health Education Council serving Waller County The Coalition serving Angelina and Nacogdoches Counties Rio Grande Valley Council, Inc. serving Hidalgo County Wichita Falls/Wichita County Public Health District serving Wichita County The purpose of these coalitions is to provide comprehensive, evidence-based, culturally competent, tobacco prevention and control activities that meet the DSHS tobacco program s strategic plan goals. To guide their planning and implementation, the coalitions use the CDC s Best Practices for Tobacco Prevention and Control and SAMHSA s Strategic Prevention Framework (SPF). The Texas SPF adds addressing tobacco-related health disparities as a core concept to the federal models to ensure that those disproportionately impacted by tobacco use are included in coalition programs and activities. 7

12 Figure 1: Texas Strategic Prevention Framework Utilizing the SPF model, the TPCCs collected, analyzed, and interpreted tobacco use data in their communities to identify specific tobacco-related problems and set priorities to help mobilize the community and build capacity in the coalition. The TPCCs mobilize community stakeholders to develop an annual strategic plan for comprehensive evidence-based interventions to be implemented by coalition partners and contractors in the following year. The TPCCs promote community interventions, including social norm changes, youth engagement activities, promotion of cessation services, and health communications. DSHS has contracted with the University of Texas at Austin to conduct a cross-community evaluation of these coalitions to document program outcomes for future use by both local coalitions and DSHS. This evaluation focuses on processes necessary to create a sustainable coalition with widespread community involvement as well as outcomes measured by changes in tobacco use prevalence for adults and youth, reduction in exposure to secondhand smoke and addressing locally identified tobacco related health disparities. In addition, DSHS has contracted with a nonprofit organization, Texans Standing Tall, to provide intensive technical assistance and training to these coalitions on coalition development, environmental change, and sustainability to ensure that the activities conducted by these coalitions will continue after the funding ends in fiscal year Youth Engagement Initiatives The TxSSC at Texas State University in San Marcos conducts youth engagement initiatives through a contract with DSHS. These include the Say What! Youth Movement, Teen Ambassador Program, teen summits, Texas Tobacco-Free Kids Day activities, and a tobacco prevention conference. Say What! Youth Movement The Texas youth leadership initiative Say What! is implemented in coordination with TPCCs and other existing youth tobacco prevention stakeholders. The initiative s goal is to support local school and community efforts to create tobacco-free social norms among youth. Following the CDC s Best Practices User Guide: Youth Engagement State and Community Interventions, 8

13 DSHS provides mini-grants to local youth-led school groups, which conduct recommended youth activities to engage with the school and community to promote tobacco free lifestyles. The Say What! movement was created and designed by young people from across Texas to link students who actively strive to eliminate tobacco from their schools and communities and is coordinated by the TxSSC at Texas State University. 6 By joining the Say What! movement, local groups have the opportunity to connect to other youth and organizations across the state, access ideas and events hosted by other Say What! partners, and actively promote efforts to reduce tobacco use. During fiscal year 2013 and fiscal year 2014, DSHS awarded 250 minigrants of $500 each to local Say What! groups across Texas that reached 383,066 youth and adults in tobacco prevention, awareness and education efforts. By the end of fiscal year there were 376 registered Say What! groups around the state. Texas Teen Ambassador Program The Texas Teen Ambassadors are a network of approximately 20 well-trained, educated, and committed high school-aged youth who represent the diversity of the state of Texas. These teens have an in-depth understanding of tobacco-related issues. Many of them have directly experienced the adverse effects of tobacco through illnesses and deaths of family members. Teen Ambassadors provide guidance to the DSHS tobacco program on the state s tobacco prevention efforts through formal and informal focus groups and provide peer-to-peer guidance to local school groups on various aspects of the state s prevention program, including tobacco prevention media campaigns aimed at pre-teens and teens. They also serve as representatives and spokespersons for the State s tobacco prevention efforts at the state and local levels. They appear on television and radio talk shows and newscasts, and speak at public events. In fiscal year 2013 and fiscal year 2014, the TxSSC reported that the Teen Ambassadors reached 42,368 individuals (30,072 youth and 12,296 adults) through local prevention activities. Regional Texas Teen Tobacco Summits Regional Texas Teen Tobacco Summits are weekend summits in the fall that provide training and resources to youth from community and school-based organizations to create a positive social change at the local level. In fiscal year 2013 and fiscal year 2014, summits were conducted for 1,135 people (889 youth and 246 adults). Summit participants receive prevention training to address local community conditions that contribute to youth tobacco use, preparing them to actively promote Texas Tobacco-Free Kids Day. Texas Tobacco-Free Kids Day Texas Tobacco-Free Kids Day is held each spring in conjunction with the national Kick Butts Day event sponsored by the Campaign for Tobacco-Free Kids. This tobacco awareness day encourages students of all ages to live tobacco-free lifestyles. Youth trained at the Texas Teen Tobacco Summits engage with schools and other local organizations to select and implement locally appropriate options from the activity guide provided by DSHS. During fiscal year 2013 and fiscal year 2014, 70,762 youth and 17,760 adults participated in local Tobacco-Free Kids Day events

14 Say What! Texas Tobacco-Free Prevention Conference The Say What! Texas Tobacco-Free Prevention Conference, held each July, provides best practice training for effective tobacco use prevention and cessation programming for youth and adults who work with youth. This conference brings in state and national speakers to provide youth with the current evidence-based practices and strategies for prevention and leadership for reaching other youth. In fiscal year 2013 and fiscal year 2014, a total of 569 youth and 233 adults attended this conference; they went on to implement activities within their schools and communities to prevent tobacco use by youth. Cessation of Tobacco Use by Adults and Youth Texas Quitline Activities DSHS has funded the telephone Texas Quitline since 2000 to provide telephone counseling to tobacco users who want support to quit and to provide nicotine replacement therapy (NRT) to Texas residents. Since fiscal year 2011, DSHS has contracted with Alere Wellbeing, Inc. (formerly Free & Clear) to provide Texas Quitline services. Alere Wellbeing has a 25-year history of operational expertise and clinical experience to handle all cessation service delivery, promotional support, account management, and reporting. Individuals who use Texas Quitline services double their chance of successfully quitting. During fiscal year 2013 and fiscal year 2014, 32,729 individuals registered to receive services from the Texas Quitline. A majority of those registrants, 22,654 were tobacco users who enrolled in telephone counseling services. The remainder was friends, family members, and clinicians who requested information about quitting and the services available from the Texas Quitline. Texas Quitline data show that the comprehensive coalitions have a significant impact on the number of individuals who attempt to quit through this service by creating an environment in the community that supports being tobacco free. Texas Quitline data shows that the comprehensive coalitions have a significant impact on the number of individuals who attempt to quit using tobacco by creating an environment that supports being tobacco free. From 2008 through 2013, the number of callers to the quitline from the coalition counties ranged from % to 1,101.23% higher than the number of calls from non-coalition counties. Annual evaluations conducted by the Quitline contractor show that 27 percent of those who receive services through the quitline are no longer using tobacco products seven months after entering the program. Tobacco Cessation in Clinical Settings DSHS also supports cessation efforts in the clinical care setting (physician offices, clinics, etc.). DSHS developed and disseminates the Yes You Can Cessation Tool Kit specifically for healthcare providers to increase their role in patient cessation. This kit promotes system changes in clinical settings to ensure all patients are assessed regarding tobacco use and provided appropriate counseling and resources. It is directly linked to the Yes You Can media campaign. The Yes You Can Cessation Tool Kit is available for downloading on the YES QUIT website. 7 In addition, DSHS collaborated with the University of Texas at Austin to develop referral systems that use technology, including electronic health records and cell phone applications, to make it easier for Texas clinicians to treat tobacco dependency in their patients

15 Eliminating Exposure to Secondhand Smoke Strategies recommended by the CDC to reduce the exposure to secondhand smoke include: Enforcing federal, state, and local secondhand smoke laws; Educating the public (including parents), business owners, and community leaders about the harmful effects of secondhand smoke and the laws prohibiting or restricting smoking; Providing technical assistance to offer evidence-based programs and strategies to communities; Educating health professionals on how to assess and counsel regarding situations where secondhand smoke should be eliminated; and Conducting research on the lack of adverse economic impact on communities that have passed strong smoke-free laws and ordinances. DSHS staff work with community-based coalitions and local community organizations to educate the public about the health effects of secondhand smoke. This education targets students, parents, faith communities, local governments, employers, and employees. Local efforts of the regional tobacco staff, contractors, and coalitions, as well as state-wide efforts facilitated by partners such as the American Cancer Society, American Heart Association, and the American Lung Association, have resulted in policy changes that impact exposure to secondhand smoke. An effective strategy to limit exposure to secondhand smoke is to place restrictions upon smoking in public places. The University of Houston maintains the Texas Smoke Free Ordinance Database website with DSHS support. 8 This website tracks and details all known Texas municipal ordinances enacted to reduce or eliminate exposure to secondhand smoke. Local communities may create reports from the website s database to review local ordinances. The website provides short summaries of ordinances in cities throughout Texas. The University of Houston examines the five general settings that may be covered by local ordinances: municipal worksites, private worksites, restaurants, bars in restaurants, and bars not in restaurants. Ordinances with all five settings smoke-free are categorized as strong or 100 percent smoke-free; three or more smoke-free settings are classified as moderate smoke-free; and no smoke-free settings or lack of an ordinance are classified as not smoke-free. At the end of fiscal year 2013, the percent of the Texas municipal population living in communities with strong smoke-free policies increased to 44 percent, and the percent of the population living in areas with moderate smoke-free policies increased to 57 percent. As of August 2011, all of the major municipalities had enacted a comprehensive smoke-free ordinance. Eliminating Health Disparities Related to Tobacco Use Tobacco-related health disparities refer to differences in health status, disease burden, and death rates in certain population groups when compared to the general population. Tobacco-related health disparities include differences among various priority population groups with respect to mortality, morbidity, exposure to secondhand smoke, as well as access to and use of cessation

16 resources. These groups exhibit higher prevalence of tobacco use and/or greater incidence of tobacco related death and disease. Overall DSHS focuses on initiatives that can address health disparities across racial and ethnic lines primarily by targeting low-socioeconomic populations identified as having low-income, low education, and lack of health insurance with targeted initiatives where there is opportunity to have long-term impacts. One high priority group currently includes persons with substance abuse and mental health conditions. According to the 2007 A Best Practices Toolkit Promoting Wellness and Recovery by the National Association of State Mental Health Program Directors, research shows that 44 percent of all cigarettes smoked in the U.S. are consumed by individuals with a psychiatric or substance abuse disorder. Half of all smoking-related deaths each year are among this priority population, who are reported to die 25 years younger than the general population, largely due to smoking-related illnesses. In January 2012, DSHS hosted a Tobacco Leadership Academy sponsored by SAMHSA and facilitated by the Smoking Cessation Leadership Center at the University of California-San Francisco. This academy brought together experts and decision makers from public health, mental health, and substance abuse organizations throughout the state. The result of this academy is ongoing partnerships between these organizations to address the use of tobacco in behavioral health treatment settings. One example of this is the collaboration between DSHS and the Association of Substance Abuse Programs (ASAP). With assistance from DSHS, ASAP applied for and received funding from Pfizer, Inc. to develop a train-the-trainer program through which DSHS regional tobacco coordinators and DSHS-funded substance abuse treatment providers were trained in best practices for treating tobacco dependence in individuals with addiction disorders. Individuals who received the training went on to provide training to the treatment providers within their respective regions. This collaboration has brought together public health, substance abuse, and academic partners to develop solutions to the barriers faced by treatment providers in implementing changes that support tobacco cessation efforts by clients and staff. Health Communications DSHS contracts with EnviroMedia Social Marketing to develop targeted media campaigns supporting tobacco prevention and cessation efforts in Texas. The media campaigns described below directly address the four strategic goals of the Comprehensive Tobacco Prevention Program described in the previous pages. The number of Texans reached with tobacco prevention advertising through these campaigns is estimated based on Nielsen and/or Arbitron ratings, and indicates the number of persons who see or hear the health promotion information. Placements include purchased air time on television and radio stations, purchased online ad space, and billboards. Impressions are the viewing or exposure to each of the messages. The paid media campaigns described below are supplemented through the efforts of the Tobacco Prevention and Control Coalitions, community groups, and volunteer agencies that work to raise public awareness through press releases, letters to the editor, and public service announcements. Stations that run paid media schedules typically provide further exposure for campaigns by running additional public service announcements free of charge. 12

17 Worth It? The Worth It? campaign targets teenagers aged and has a secondary audience of adults. Worth It? presents the facts about tobacco use and its consequences, and challenges teens to decide for themselves. As part of an overall media strategic plan, the Worth It? brand will incorporate the previously used DUCK Tobacco is Foul pre-teen media and the Spit It Out smokeless tobacco media into a single campaign. See Yes You Can!/ SÍ Se Puede! The Yes You Can!/ SÍ Se Puede! campaign encourages Texas adults to take the first steps to quit tobacco by seeking the support and information they need through family, healthcare providers, the Texas Quitline, and the web-based Tobacco Cessation Program (for Quitline clients who prefer communicating via computer instead of telephone). The target audience is adults aged While this campaign targets the coalition areas, as funding is available it is also run statewide and is distributed as a public service announcement statewide. See Two additional campaigns under this umbrella include the Talk to Your Doctor campaign that urges tobacco users to discuss quitting with their doctors and Quit for Your Child which targets mothers with young children. During fiscal year 2013 and fiscal year 2014, these cessation messages reached 25,281,748 people who were exposed by broadcast placement between two and three times each; 167,754,666 impressions were seen through broadcast, digital, and out-of home placements; and 960,000 impressions were seen through placement in print media. Share Air The Share Air media campaign educates people about the dangers of secondhand smoke. In fiscal year 2013, 1,717,613 people were exposed to messages through broadcast placements an average of 2.9 times. See Section 3: Retail Compliance and Tobacco Sales Texas law enforcement agencies use the state s model for tobacco enforcement developed by the Comptroller and Texas State University in the 1990s. This model includes education of retailers who sell tobacco products, the public, and youth; inspections of retailers; and enforcement of the state s retail sales and minor-in-possession laws through undercover compliance checks. This model has provided the core of tobacco law enforcement since the law passed in 1997; the model has since become a model for other states. It emphasizes voluntary compliance created through the partnership between local law enforcement agencies and local retailers. The Texas tobacco laws are enforced by the collaborative efforts of the following entities: Office of the Attorney General Comptroller of Public Accounts Department of State Health Services Texas School Safety Center at Texas State University Federal Drug Administration The Office of the Attorney General (OAG) has been an active partner in reducing youth tobacco access. Through its Consumer Protection and Public Health Division, and under authority of the Texas Deceptive Trade Practices Consumer Protection Act, the OAG has negotiated voluntary 13

18 compliance settlements with several large retail companies that include a provision that these companies will not hire minors to sell tobacco. The OAG implemented innovative strategies to new challenges, such as restricting Internet sales of tobacco by negotiating settlements with credit card companies to prohibit online tobacco purchases using these cards; this was negotiated with Visa, MasterCard, and American Express. Synar Authority Federal legislation, known as the Synar amendment, requires states to outlaw tobacco sales to persons under the age of 18 and to conduct an annual random inspection of tobacco retailers. States that have a sales rate of more than 20 percent (meaning that one in five tobacco retailers inspected sold tobacco to a minor) face stiff sanctions including the potential loss of federal funds for substance abuse prevention and treatment. Through an interagency agreement with the Comptroller s office, DSHS conducts the Synar Survey, analyzes the survey data to determine the state s rate of illegal sales to minors, and submits the Annual Synar Report to SAMHSA. DSHS contracts with the TxSSC at Texas State University to oversee the Synar Survey field inspections. The Synar Survey is conducted according to research protocols approved by SAMHSA s Center for Substance Abuse Prevention to ensure the findings are scientifically valid. Since passage of the state s comprehensive tobacco control laws in 1997, Texas tobacco sales to minors have dramatically decreased from 24 percent in 1998 to 7.6 percent in The Annual Synar Report is for the federal fiscal year following the calendar year in which the inspections were conducted. (See Appendix A 2014 FDA Tobacco Compliance Check Inspection Summary) In Texas, the Comptroller of Public Accounts is responsible for compliance with the Synar amendment as the permitting and regulatory agency for tobacco retailers. The State of Texas requires tobacco retailers to obtain permits from the Comptroller to sell tobacco products to consumers. Each tobacco retailer must renew its permit every two years in even numbered years. Additionally, a permit holder must have an active sales tax permit for each business location from which tobacco products are sold. The Comptroller s office conducted a study during 2010 that determined the Comptroller s database of tobacco retailers was 98.9 percent accurate for use in the Synar Survey. The Texas tobacco tax retailers list consisted of approximately 27,988 tobacco retailers in 254 counties. DSHS has established a protocol to alert the Comptroller s office during the annual Synar Survey to ensure local law enforcement is notified of local retailer violations. One hundred and twentyfour retailer violations during the 2013 Synar Survey were reported to local law enforcement for follow-up enforcement activities. The Comptroller also conducts its own inspections of tobacco permit holders to ensure compliance with the law. The Comptroller s enforcement and criminal investigation divisions conduct comprehensive misdemeanor and administrative inspections of thousands of retailers annually, with the following result: 14

19 In 2013, there were 3,815 inspections with 43 violations. These inspections resulted in collection of civil penalties of $135, ($54, for Comptroller violations and $80, for the Criminal Investigation Department [CID] follow-up on sale to minor citations issued by local law enforcement). In 2014, there were 3,489 inspections with 39 violations. These inspections resulted in collection of civil penalties of $184, ($110, for Comptroller violations and $73, for CID follow-up on Sale to Minor Citations issued by local law enforcement). These penalties are assessed against store owners. For fiscal year 2013 and 2014, the Comptroller s office reported 661 minors in possession of tobacco in addition to other sources of citations/violations. (See Table 3) Table 3. Comptroller of Public Accounts Retailer Compliance Reported Violations Violations FY 2013 FY 2014 Sales to Minor Vendor Sales Access 4 3 Warning Signs Employee Notification Prohibition of Signage 2 1 Source: Comptroller of Public Accounts Food and Drug Administration (FDA) Authority DSHS has administered the FDA Tobacco Retail Inspection Contract since The TxSSC at Texas State University contracts with DSHS to conduct retail compliance check inspections in each health and human services region using 23 inspectors and 46 minors. Intensive training for inspectors and minors on the protocols of conducting the inspection activities required by FDA is provided annually and is supplemented by technical assistance throughout the year. In fiscal year 2014, 6,700 retail outlets were inspected with 3,018 being undercover buys using minors and 3,019 being advertising and labeling inspections. (The remaining inspections were follow-up inspections after violations were found on the original inspection.) Of the 6,700 retail outlet, the violation rate among retail outlets checked was 5.24 percent. (See Appendix B 2014 FDA Tobacco Compliance Check Inspection Summary) Texas Enforcement Program: Texas School Safety Center DSHS allocates state tobacco control funding from the Tobacco Settlement Fund for youth access enforcement through the Texas Enforcement Program, which is implemented through a contract with the TxSSC. Law enforcement agencies who apply and are approved to participate are provided with a web-based training to conduct on-site controlled buys (also called stings) and follow-up controlled buys involving the use of minors as decoys. Training ranges from six hours (for new agencies) to three hours (for agencies previously funded). In fiscal year 2014, 64 law enforcement agencies and 197 officers conducted 12,462 controlled buys statewide and issued 669 citations. 15

20 Support Activities for Enforcement of Texas Tobacco Laws Retailer Community Education During the period between the 2013 and 2014 Synar Survey, DSHS and the Comptroller conducted a number of outreach activities to educate Texas law enforcement, judicial officials, tobacco retailers, and local communities about the state s tobacco laws, the importance of complying with these laws, and potential consequences for failure to comply. When a tobacco retailer is established, or when it renew its permit, it receives a packet of information from the Comptroller s office describing the retailer s role in enforcing tobacco laws in Texas. The packet contains multiple components, including: a booklet that summarizes the Texas law, a four page information sheet for the tobacco retailers permit requirements, an employee booklet that provides information on how employees can comply with the law, a flyer that details the quickest way to check ID, rules explaining penalties and warning sign requirements, cigarette and tobacco products retail employee notification form, two copies of the state required warning signs in English and Spanish, warning stickers for vending machines, and cash register stickers with the new logo that says, I check ID. The Comptroller's office sent out 1,250 Certificates of Recognition to local law enforcement agencies to award retailers who did not sell to a minor during a controlled buy. In addition, the Comptroller s office approves independent (i.e., not state-funded) seller training programs that provide classes to merchants and their employees. To become an approved program, providers must meet specific criteria in their courses. There were over 30 tobacco seller education programs located across the state at the end of fiscal year Community Education DSHS-funded substance abuse prevention programs, chronic disease programs, and school districts across the state include minors and tobacco information in their educational presentations. Aimed at youth and adults, these presentations provide the message that tobacco is harmful and addictive, as well as information concerning state laws. Using SAMHSA block grant funds, DSHS funds 11 Substance Abuse Prevention Resource Centers (PRC), one in each health service region to provide substance abuse prevention materials, training, and collaborating on local tobacco activities. Each PRC is required by SAMHSA to hire one full-time Tobacco Prevention Specialist who educates tobacco retailers to gain voluntary compliance with the Texas tobacco laws. In addition, the PRCs are required to provide the retailers with information regarding responsibility and liability pertinent to their establishments, and to make compliance kits, signs, and training available to retailers and their employees. The PRC Tobacco Prevention Specialists are also required to conduct follow-up visits to retailers that were not in compliance during a voluntary compliance visit or to retailers that received a violation citation as reported by the Comptroller's office. In addition to these compliance related activities, these Tobacco Prevention Specialists reached 162,436 Texas youth by making youthspecific tobacco presentations that highlight both health and legal issues. 16

21 Texas Youth Tobacco Awareness Program In 1995 and 1997, the Texas Legislature passed laws that prohibit tobacco possession and use at school-related events and that prohibit purchase, consumption, possession, or receipt of tobacco products by anyone younger than 18. In 1995, the adopted law contained changes to the Education Code ( Sec ), prohibiting use of tobacco products by adults and possession of tobacco products by minors at school-related or school-sanctioned events on or off school property. In 1997, the adopted law modified the Health & Safety Code ( Sec , , and ) prohibiting the sale of tobacco to minors and minor s possession of tobacco products. The 1997 law also requires DSHS to provide a tobacco awareness program for youth who have received a minor-in-possession of tobacco citation. The Texas Youth Tobacco Awareness Program provides minor-in-possession classes to raise awareness of the dangers of tobacco use and provide minor tobacco users with cessation assistance. A train-the-trainer program has been developed to sustain the program. DSHS certifies instructors for the program who are trained to use the approved curriculum and maintains a current database of available instructors through the Texas tobacco law website In fiscal year 2014, 539 of the 698 youth cited for possessing tobacco products enrolled in Texas Youth Tobacco Awareness Program classes. These classes are administered by DSHS through an interagency contract with the Comptroller s office. Classes consist of eight hours of classroom instruction provided in two hour blocks, twice a week for two weeks, using the Texas Adolescent Tobacco Use and Cessation curriculum developed by Texas A&M Health Science Center and the University of Houston. Texas Tobacco Prevention Hotline DSHS contracts for the services of a tobacco prevention hotline ( ) for reporting possible violations of tobacco laws related to minors. Citizens can call toll-free to report a merchant selling tobacco products to minors, tobacco advertising within 1,000 ft. of a church or school, cigarette vending machines accessible to minors, and other infractions. Once the service determines the caller s particular need, the caller is transferred to the proper authority. The service is available 24 hours per day and is bilingual. During fiscal year 2013, the hotline received 1,227 calls and during fiscal year 2014, 1,204 calls came to the hotline. Communications Strategy: Enforcing It Is Easy The Enforcing It Is Easy campaign targets tobacco retailers, parents, and other Texas adults. It is intended to remind adults of their responsibilities under Texas tobacco law, which prohibits the sale or distribution of tobacco products to minors. This campaign places messages on television, radio, on-line, billboards, and in convenience stores. In fiscal year 2013 and 2014, this campaign exposed 1,717,613 people to messages an average of 2.9 times per person. The estimated number of total impressions included: 24,130,875 broadcast, outdoor advertising, and digital placements; 3,767,198 on-line impressions; 5,999,677 radio impressions; 37,598,364 convenience store impressions; and 275,249,820 billboard impressions. 17

22 Section 4: Future Plans The mission of the DSHS Tobacco Prevention and Control Branch is to reduce disease, disability, and death related to tobacco use in Texas. A comprehensive approach includes educational, clinical, regulatory, economic, and social strategies. The strategies are best practices designed to maximize effectiveness of interventions that eliminate both the health and cost burden of tobacco use on Texans. The Department of State Health Services, working in concert with local communities and stakeholders from across the state, continues to reduce the prevalence of smoking and smokeless tobacco use among youth and adults in Texas. With the introduction of new products to the Texas markets, DSHS and its partners must remain vigilant to ensure that the gains in previous years are not reversed. Likewise, to continue the decrease in prevalence rates, new initiatives targeting high-risk groups must be developed and implemented. This will require the development of new partnerships with non-traditional partners in order to serve those that have not been served through traditional means to create a more effective and inclusive tobacco initiative. 18

23 Texas School Safety Center/Texas State University FDA Tobacco Compliance Check Inspection Program Summary for FY FDA Tobacco Compliance Check Inspection Summary Number of retail outlets on Comptrollers Retail Tobacco List (CRTL) 27,988 Number of Inspectors Number of DSHS Regions Inspected Total Number of Inspections Conducted # of Routine Undercover Buy Inspections # of Routine Advertising and Labeling Inspections # of Compliance Follow-up Inspections # of Complaint Follow-up Inspections Percentage of Inspections Conducted Compared to CRTL % of Routine Undercover Buy Inspections % of Routine Advertising and Labeling Inspections % of Compliance Follow-up Inspections % of Complaint Follow-up Inspections Total Number of Potenial Violations # of Routine Undercover Buy Inspections # of Routine Advertising and Labeling Inspections # of Compliance Follow-up Inspections # of Complaint Follow-up Inspections Percentage of Potenial Violations % of Routine Undercover Buy PVO % of Routine Advertising and Labeling PVO % of Compliance Follow-up Inspections % of Complaint Follow-up Inspections ,700 3,018 3, % 45.04% 45.06% 9.85% 0.04% % 7.46% 2.35% 8.18% Potential Violation Rates by Region Potential Violations by (UB and A&L) Assignent Type Region # of Violations % of Violations Assignment Type # of Violations % Routine UB % Routine A&L % CFU-UB % CFU-A&L % Complaint UB % % % % % % TOTAL % Page 19