Institute for Health Promotion Research San Antonio Tobacco Prevention and Control Coalition Community-Based Needs Assessment-2008 Executive Summary

Institute for Health Promotion Research San Antonio Tobacco Prevention and Control Coalition Community-Based Needs Assessment-2008 Executive Summary

Executive Summary The purpose of this community-based needs assessment was to assess the baseline situation, short and long term goal changes, and community change related to tobacco prevention and control in San Antonio. The needs assessment was conducted by the Institute for Health Promotion Research on behalf of the San Antonio Tobacco Prevention and Control Coalition (SA-TPCC) from April 2008 through June 2008. The report included: (1) an analysis of the current situation in San Antonio regarding tobacco policies (archival data and key observer interviews), (2) organizations currently conducting tobacco prevention and control activities (organizational survey), (3) analysis of compliance with tobacco laws and policies, (4) current school activities and future plans (campus health educators survey), and (5) policy analysis (history of mass media counter-marketing, municipal clean air policies, public officials key opinion surveys). The data collected will guide the SA-TPCC to develop a comprehensive strategic plan and guide the coalition in implementing evidence-based public health programs to: (1) prevent youth tobacco use, (2) ensure compliance with state and local tobacco laws, (3) increase cessation among youth and adults, (4) eliminate exposure to secondhand smoke, (5) reduce tobacco use among populations with the highest tobacco-related disease burden, and (6) develop and maintain the capability to implement comprehensive tobacco programs. Coalition Infrastructure, Capacity and Training Currently the San Antonio Tobacco Prevention and Control Coalition is composed of approximately 50 individuals and roughly 35 organizations. An internet based survey was administered to Coalition members in order to assess the coalition infrastructure, capacity and training needs. The survey used seven key activities that are related to tobacco control and prevention as a basis for evaluating the current tobacco environment in the community. These activities included: increasing cessation among adults, preventing youth tobacco use, reducing tobacco use among groups with the highest burden of tobacco-related health disparities, ensuring compliance with state and local tobacco laws, increasing cessation among young people, eliminating exposure to secondhand smoke and ensuring adequate enforcement of state and local tobacco laws. The survey respondents were asked to evaluate the priority that was placed on each of the activities in their community, their motivation to work together on those activities and the amount of impact each of the activities is having on their community. The top three activities identified across each area were: to increase cessation among adults, to prevent youth tobacco use and to reduce tobacco use among groups with the highest burden of tobacco-related health disparities. The seven areas did not differ greatly between the three areas of priorities, motivation, and impact. Coalition members were surveyed regarding the accessibility of tobacco cessation programs for youth and adults. The majority of respondents, 56.3%, believed that cessation programs are available but not accessible to most youth and 31.3% believed programs to be available but only accessible to some youth. The Coalition respondents ranked the services for adults as more accessible where 64.7% believed the programs are available and accessible to some adults and 23.5% believed cessation programs are available and extremely accessible to all adults. Respondents were also asked to assess how supportive community leaders are of efforts to reduce tobacco use among youth and among adults, reduce tobacco use among groups with the highest burden of tobacco-related health disparities and to protect the public from secondhand smoke.

The responses were averaged on a supportiveness scale of one to four with reducing tobacco use among youth and adults at the highest supportiveness averages followed by reducing use among populations with the highest burden of health disparities and secondhand smoke with the lowest supportiveness average. The online survey asked respondents about the status of their community among several tobaccorelated statements. The answer options were presented on an agreement scale of one to four where four was strongly agreed. The agreement answers were then averaged and the highest averages of agreement among Coalition members included the following statements: (1) one or more wellrespected lead agencies or coalitions are active in the community, (2) health-related tobacco problems are a major concern to the community, (3) outreach is provided to diverse and special populations, (4) communication links exist locally within and across groups and agencies and (5) persons from a wide variety of cultural backgrounds are included in the decision-making process. There was least agreement among the following statements: there is little or no opposition to tobacco prevention and control and youth are included in the decision-making process. Coalition members were also asked to summarize the main factors or conditions that could influence future implementation of tobacco prevention and control programs. There were four themes among the results to this question: wide-spread support of tobacco efforts, development of the Coalition, funding sources and direct actions. Overall there was an expressed appreciation for the wide-spread support among partnering community organizations, businesses and politicians for the Coalition s work. Respondents cited buy-in from key leaders in the community and replied positively to the fact that several important organizations are cooperating together and mobilized for action. Several people commented that the Coalition itself is an asset to future implementation. The Coalition was described as strong, competent and diverse with committed leadership. The availability of funding and increased resources was cited as a contributing factor to the success of prevention and control activities. Direct actions taken by the Coalition members was the final theme presented as a positive influence. Specifically, respondents expressed an interest in creating true family-oriented events that do not allow smoking and using different venues, such as sporting events, for promoting health and prevention messages to the public. The main barriers cited that influence future tobacco programming included funding, political pressure, perception issues and a lack of community support. Twelve respondents cited funding and resources as a major concern including a fear that there is limited access to cessation resources for the Coalition. Six responses mentioned there would be competing interests or opposition among political entities, specifically city council members, regarding new policies or ordinances for secondhand smoke exposure. Some notated the difficulty in working across governmental agencies to coordinate efforts and the issue of property rights with regard to ordinances. Overall, there were numerous concerns about the priorities of the Coalition s work. People commented that adults, parents and law enforcement do not see tobacco enforcement or control as a priority and that tobacco is not considered a public health concern. There was also a fear that there is a lack of community support around this issue. People responded that there was little interest or involvement by community leaders and there is a need for more input from the community lay people who have been strongly affected by tobacco.

Respondents were asked to summarize the need for professional development and technical assistance trainings. Coalition members felt that it was important to have training on mobilizing the community around tobacco prevention and control, developing a strategic tobacco prevention and control plan and sustaining comprehensive tobacco prevention and control programs. There was little interest in development around managing volunteers, writing objectives and learning more about the problems related to tobacco use. School Analysis We contacted twelve schools districts in the city of San Antonio. San Antonio ISD was the only school district to provide a complete survey on their current school policies regarding tobacco use. North East ISD completed a partial survey. South San Antonio ISD, Edgewood ISD, and Harlandale ISD have Safe and Drug Free Coordinators or curriculum coordinators who were able to answer a partial survey. East Central ISD, Ft. Sam Houston ISD, North Side ISD, Southside ISD, Southwest ISD, Alamo Heights ISD and Judson ISD coordinators could not be reached by phone, and emails sent to the appropriate coordinators were not returned. After speaking with several health and curriculum coordinators in the different school districts of San Antonio, it became apparent that most districts do not have a standard smoking prevention and cessation program for students. The general consensus was that the individual health teachers determined how much information on smoking to include in their classroom teaching. Health courses in secondary schools occur over one semester, and the smoking prevention portion of the course is generally presented in one or two days. School districts who were able to answer the specific questions of our survey admitted that there is no district-wide policy for smoking prevention programs for students or teachers. SAISD enforces school policy through the school principals, teachers, and staff. The campuses are smokefree facilities. San Antonio ISD provides instruction in health education for grades K-12 in curriculum and in the teacher s guide. They have prevention of tobacco use in their life skills classes, Great Body Shop, and health education text books. North East ISD covers the consequences of smoking in science and health classes as well as episodic events throughout the year. Survey of Community Program Activities Six agencies currently involved in tobacco cessation and prevention were asked about community program activities. The organizations that completed this survey included: San Antonio Council on Alcohol and Drug Abuse, American Cancer Society, San Antonio Metropolitan Health District, Texas Department of State Health Services, Texas Diabetes Institute and the South Central Area Health Education Center. History of Mass Media Counter-Marketing Messages from the previously state funded Spanish media campaign that ran in East Texas, Mi Familia, have been aired in the San Antonio media market sporadically and with low frequency through limited funding from the STEPS program. The Mi Familia No Fuma campaign centers on the Hispanic family using the positive influence family plays in the Hispanic culture. The campaign portrays culturally sensitive and relevant messages to show that tobacco has no role in the family s life. It is targeted to adults and teenagers aged 9 to 17. The mass media planned for the upcoming

year includes the DUCK smoking prevention youth campaign and the Yes You Can adult smoking cessation campaign in English and Spanish (also on radio). Compliance with Tobacco Laws and Policies From September 1, 2005 to May 1, 2008 the overall percent of tobacco sales to minors in Bexar County was 2.27%. Out of 1,640 currently active tobacco retailer permits, there were 1,588 "controlled buy" attempts with only 36 of those attempts resulting in the failure of the tobacco retailer to restrict sales of tobacco products to the underage minor decoy. The percent of youth monitors whose ages was not questioned in a successful buy was 72.23%. Out of 1,588 "controlled buy" attempts, 26 of 36 violations included a failure of the clerk to request identification from the underage minor decoy. In 10 cases the clerk asked for identification and still sold to the underage minor decoy. Bexar County is above average in compliance with the restriction on sales to minors with a compliance rate of 97.73%. There were 36 violations out of 1,588 "controlled buy" attempts. The state average for the same time period is 90.44% compliance rate with 1,918 violations out of 20,066 "controlled buy attempts. There were no businesses identified by the Comptroller s Office for consistently being out of compliance. The Bexar County Sheriff's Office has conducted activities including "controlled buys" using minor decoys during this time period and they are contracted to enforce the law restricting minors access to tobacco. Through the third quarter of fiscal year 2008, 51 youth in Bexar County enrolled in the Texas Youth Tobacco Awareness Program and 48 completed. No minor in possession charges were reported in Bexar County during fiscal year 2008 and none were reported in Bexar County since September 1, 2005. The Justice of the Peace Precinct #4 was contacted regarding MIPs. The Justice of the Peace receives all records from smoking violations at school districts; however they are not recorded by offense. Therefore, there is no distinction between smoking offenses and other offenses on school property, and no data could be gathered. Tobacco Cessation Services The Coalition organizations were asked about the availability of local services to people who want to quit smoking. The respondents of this survey included: San Antonio Council on Alcohol and Drug Abuse, American Cancer Society, San Antonio Metropolitan Health District, Texas Department of State Health Services, Texas Diabetes Institute and the South Central Area Health Education Center. It was estimated that among those organizations, they served 502 clients through the clinician s use of the 5A s (Ask, Advise, Assess, Assist, and Arrange) in 2007 and 2,602 clients in the past 3-5 years. They also promoted the American Cancer Society telephone Quitline (1-877-YES-QUIT) and reached 16,610 clients in 2007 and 44,300 in the past 3-5 years. From January 1, 2007 to December 31, 2007, 426 community members called the Texas American Cancer Society Quitline in Bexar County. The organizations reached 1,038 clients through group classes and support groups in 2007 and 2,730 in the past 3-5 years. Through the distribution of cessation aids (Nicotine Replacement Therapy), they reached 2.048 clients in 2007 and 3,602 in the most recent 3-5 years.

Municipal Clean Air Policies San Antonio passed a smoking ordinance on August 7, 2003. The ordinance prohibited smoking in municipal and private worksites (100% smoke-free). There is limited protection in restaurants and bars, with designated smoking areas allowed and/or required. Fire officers, health officials, private individuals, and other authorities are enforcers. There are smoke-free policies on all university campuses and junior colleges in San Antonio (AACD, OLLU, St. Mary s University, Trinity University, University of Incarnate Word, UTHSCSA and UTSA), which prohibit smoking in buildings, dormitories and University vehicles. The UTHSCSA campus is the only campus that is 100% smoke-free and prohibits smoking on all campus property. There are currently no smoke-free multi-unit housing options in Bexar County. Public Officials Key Opinion Leaders Several efforts were made by the American Cancer Society and the University of Texas Health Science Center San Antonio to survey the elected city council about their position on smoke-free communities and policies. Only two city council members in San Antonio responded to the survey asking about public policy and second-hand smoke. They both believed all workers, regardless of the type of work site, should be protected from exposure to secondhand smoke. One city council member strongly agreed and the other somewhat agreed with the statement that local government has an obligation to protect public health, including restricting smoking. Both city council representatives would support a health regulation or an ordinance to protect residents, including children, in their community from the health hazards of secondhand smoke. Statistical Characteristics of Population and Epidemiology of Tobacco Use Data from the San Antonio STEPS 2007 Behavioral Risk Factor Surveillance Survey was used to determine relationships between current smoking and other behavioral risk factors. This analysis includes estimations for current and prior adult smokers, and current smokers only. Only 31% of the respondents had smoked regularly and 69% had never smoked more than 100 cigarettes in their lifetime. Among those who have tried over 100 cigarettes in their lifetime: - 28% of them are daily smokers, 20% some-days smokers, and 53% quitters. - Mean age of daily smokers = 51.6; some-days smokers = 45.7; non smokers = 59.8. - Separated and singles are less likely to be non-smokers, more likely to smoke frequently. - People with lowest education are more likely to smoke, and do it more frequently. - People earning more than $75,000/year smoke at rates half of those smoking. - People earning less than $20,000 are more likely to be smokers at rates twice as high as those making more than $75,000. - People who feel they have more emotional support are less likely to be smokers. - People who feel they have less emotional support are more likely to be smokers and smoke daily (23% in average). - People who are more satisfied with their lives are less likely to be current smokers.

- People who are less satisfied with their lives are more likely to be current smokers (53% in average). This is stronger for some-day smokers than for everyday smoker. - Among smokers who do not have access to health care, 62% are current smokers, compared to 43% among those who have access. - Income and age can be used to predict smoking status (logistic regression): Older individuals and individuals with higher incomes are less likely to be smokers. In summary, non smokers are older, have higher income, higher education, are more satisfied with their lives, more likely to be married or living in a stable couple, and more likely to have access to health care. Among current smokers: - The mean age of everyday smokers was 51.6, of some-day smokers was 45.7. - Over 1 out of 4 smokers do not have access to health care and can t pay for it. - Latinos are more likely to be some-day smokers than non-latinos (53% vs. 26%). - Among adult smokers, 2 out of 3 students are some-day smokers, half of employed with wages and self-employed are every-day smokers. Most (80%) of retired smokers are everyday smokers. - Among current smokers, 51% have made an attempt to quit in the last 12 months; 42% of daily smokers, and 63% of some-days smokers. - Over 80% of smokers have never been told by a doctor that they need to quit. - Opportunities lost: over 2/3 of smokers have some type of health coverage. - Some-day smokers are more likely to have made a quit attempt in the 12 months. - Age, and ethnicity can be used to predict the probability of a person smoking every day, smoking some day or no smoking at all. In summary, someday smokers are more likely to be younger and Latinos, and are more likely to have made a quit attempt in the past 12 months. Among smokers, students are more likely to be some-day smokers. Although 2/3 smokers have some type of health coverage, over 80% have never been told by a doctor that they need to quit. Youth tobacco use The 2006 Youth Tobacco Survey was administered in schools in San Antonio. Among middle school students, there were an estimated 13.6% of students who reported cigarette use, which was slightly higher than the state prevalence of 9.5%. Of those 13.6% in San Antonio, there were 15.2% females and 12.1% males. The middle school prevalence for girls differed greatly from that in the state (15.2% compared to 8.0%). The high school use of cigarettes was lower in San Antonio than the state (22.4%, 24.7%). There were more male high school smokers (23.4%) than female high school smokers 921.4%).

Selected Tobacco-Related Mortality and Morbidity The estimated number of new cases of lung cancer for Public Health Region 8 was 1,233 cases in 2007. The estimated number of deaths from cardiovascular disease for Bexar County in 2004 was 2,723. There were 721 deaths attributed to strokes in Bexar County in 2003. No recent data was available. The hospitalization discharge data was used to determine the number of number of hospitalizations due to Chronic Obstructive Pulmonary Disease in Bexar County. 2006 was the most recent year for which the data was available and there were 1,333 hospitalizations.