Lake County Health District
Tobacco Free Living: Operationalizing evidence-based interventions thorugh expanded use of MRC volunteers and local health resources
The area of focus is Lake, Geauga and Ashtabula Counties in Northeast Ohio.
Lake County is a suburban community and has a population of 229,230 and is medically underserved with 11.87% Medicaid recipients and 7.6% uninsured. The poverty rate is 8.9% increasing to 13.4% for those under 18. Geauga County has a population of 94,295. The county has 10.2% Medicaid recipients and 5.8% uninsured. The poverty rate is 7.9% increasing to 11.5% for those under 18. Ashtabula County is a suburban Appalachian community and has a population of 98,632 and is medically underserved with 20.87% Medicaid recipients and 8.6% uninsured.. The poverty rate is 21.5% increasing to 32.1% for those under 18.
The public health issue is that tobacco use is the leading cause of preventable death around the world and secondhand smoke harms children and adults, and the only way to fully protect nonsmokers is to eliminate smoking in all multi-unit housing and outdoor areas where the community may be exposed.
Focus was on four goals as outlined in the CDC Best Practices for Comprehensive Tobacco Control Programs. 1.) Prevent tobacco use initiation among youth and young adults by promoting tobacco-free environments; 2.) Promote quitting among youth and adults through tobacco-free policies; 3.) Eliminate exposure to secondhand smoke by promoting tobacco-free environments; and 4.) Identify and eliminate tobacco-related disparities by educating the youth and adults in the community on the dangers of tobacco use.
The goals were supported by two objectives as outlined in Healthy People 2020 for tobacco use: 1.) Tobacco use prevalence: implementing policies to reduce use and initiation among the youth and adults; and 2.) Social and Environmental Change: Establish policies to reduce exposure to secondhand smoke, increase the cost of tobacco, restrict tobacco advertising, and reduce illegal sales to minors.
The Lake Geauga Ashtabula Tobacco Prevention Coalition (LGATPC) along with the assistance of MRC volunteers took a multi-faceted approach to tobacco control programs. Coalition members were chosen to work with youth to create stand groups in the community to provide tobacco prevention and education. Coalition members and MRC volunteers assisted in conducting community tobacco surveys through face-to-face interviews to evaluate perceptions on tobacco free environments. Education for the community was conducted in Lake, Geauga and Ashtabula Counties at community events, health fairs, and during the county fairs on the dangers of outdoor secondhand smoke exposure. Surveys were also conducted at public multi-unit housing. Educational materials and presentation were provided to residents on the dangers of secondhand smoke exposure in multi-unit housing.
Results and outcomes for Youth stand groups have been active in promoting tobacco counter marketing campaigns for the past three years throughout their communities.
The surveys conducted for tobacco free environments have brought attention to the community. Most recently, the Fairport Harbor Exempted Village Board of Education (FHEV BOE) has voted for the adoption of 100% smoke-free policy for all outdoor properties owned by the FHEV BOE. The policy addresses staff, faculty, students and visitors. The LGATPC and MRC will continue to work in the community to promote smoke free outdoor environments.
The work in public multi-unit housing has better prepared residents for the new HUD ruling that will be instituted. Work will continue with the housing authorities to provide education to staff and residents on the reasons why the rule is important and to assist housing authorities with the smoke free housing policy.
The objectives, thus far, have been met though there is still much work to be done with continued policies that reduce use and initiation among youth and adults. The LGATPC will continue to work with students to promote tobacco counter marketing campaigns working towards a tobacco free generations. Continued work with school districts, colleges, businesses, and government organizations to adopt 100% tobacco free environments. Assisting public housing agencies and the residents to smoothly adopt the new HUD ruling will be a focus over the next couple years.
Specific factors which led to the success of the practice were the continued and ongoing involvement of the LGATPC and MRC volunteers as well as the funding that supported the efforts.
The impact of working with youth in stand groups is the reduction of youth smoking, having them work on tobacco counter marketing campaigns, and having them support smoke-free environment policies in their communities.
100% smoke-free environments will impact school district property by providing a positive modeling for students and also eliminates the risk of secondhand smoke exposure. Continued work toward 100% smoke free environments in parks, playgrounds, fairgrounds and sporting events will protect the community from the dangers of secondhand smoke exposure.
The impact of 100% smoke-free policies in public multi-unit housing will include reduction in maintenance costs, less risk of catastrophic fires, and fewer residential complaints from residents who are impacted by secondhand smoke. Further impact will provide a healthier environment for children, adults and seniors who experience chronic illnesses. A healthier environment may reduce emergency room and doctor visits for those who experience breathing problems due to secondhand smoke exposure.
Lake County General Health District https://www.lcghd.org/
The public health issue is that tobacco use is the leading cause of preventable death around the world and secondhand smoke harms children and adults, and the only way to fully protect nonsmokers is to eliminate smoking in all multi-unit housing and outdoor areas where the community may be exposed. In 2014, 10% of Lake County youth grades 6-12 were smokers, increasing to 19% of those who were over the age of 17 (Lake County 2014 Youth Health Status Assessment, 2014). Geauga County identified that 15% of youth ages 12 - 18 were smokers increasing to 26% when including only 17-18 year olds (Geauga County Community Health Assessment).The current percentage of adult smokers in Ashtabula County is 22.1%. Youth smokers aged 12-17 is at 9.5%, with current smoking prevalence at 23.8%.
Everyone is affected by creating 100% smoke-free environments. Smokers who want to quit receive positive reinforcement by not seeing another individual smoking; which can trigger tobacco use. Nonsmokers benefit from a healthy environment where they do not have to be subjected to secondhand smoke incursion. Lastly, the environment is impacted due to less tobacco product waste left on the ground.
Target population is youth in Lake, Geauga and Ashtabula Counties. Though only a few stand groups have been created there have been over 200 students impacted over the past three years.
The work on smoke-free environments affects everyone who lives, works, and visits communities that have 100% smoke-free environments.
The target population for smoke free multi-unit housing is the residents in public housing. Presently, Lake County has 468 and Ashtabula County has 483 residents that will be directly impacted by the new HUD ruling. The impact of the work will reach Ashtabula County residents and could eventually impact those in section 8 and subsidized housing.
The outreach to youth is difficult to determine as to how many youth were directly impacted by the activities of the stand groups activities.
There were 1,378 community tobacco surveys conducted in Lake Geauga and Ashtabula Counties. Additionally, about 10,000 individuals were impacted during outreach efforts to provide education for community members in Lake, Geauga and Ashtabula Counties.
Lake County had 195 available occupied public housing units with 135 of those units surveyed. Geauga County had 125 available occupied units with 103 units surveyed. Of the units surveyed 58% wanted at least a smoke free building.
Working with youth has been primarily done for the past three years. However, very little has been done to address the issue of public multi-unit housing and outdoor tobacco smoke. Though many states have adopted smoke free workplaces, many public housing and outdoor environments still remain problematic.
Working with youth is not new, but involving coalition members and MRC volunteers in the tobacco counter marketing activities should be considered a cost effective solution to funding programs. Conducting community surveys is just one piece of the 10 essential public health services. The assessment phase provides the needed information to inform policy makers and community members on perceptions on the adoption of smoke-free environments.
The current practice of working with community partners involved in coalitions is not new, but utilizing MRC volunteers to conduct non-emergency services is a cost effective solution for health departments who often have limited funding resources to conduct surveys, evaluations and policy implementation.
Conducting health assessments is not new to public health but for the Lake Geauga and Ashtabula County area, no surveys have been conducted to evaluate the community's perceptions and support for smoke free multi-unit housing and smoke-free environments. MRC volunteers should be utilized for non-emergency purposes to support community efforts that contribute to positive health behaviors.
The use of coalition members and MRC volunteers to assist in the survey delivery and education of the community provides a much needed assistance to public health agencies who have limited funding to deliver services.
The Community Action Model was utilized due to it being developed as a model for tobacco-related health disparities (Lavery, et.al, 2005).
Step 1 involves organizing a group of 5 â€“ 15 community members. The Lake Geauga Ashtabula Tobacco Prevention Coalition (LGATPC) was originally created to address the issues of youth smoking and has been in existence since 1995 and continued until 2005 when funding ended. Members of the coalition include public health organizations and mental health and addiction services. Step one began the process of addressing the issue of concern: smoking in public housing and outdoor environments.
Step 2 A community assessments were conducted working with the Metropolitan Housing Authority in Lake and Geauga counties to collect information as part of the community diagnosis. The primary research focused on interviews with MHA management and surveying residents of multi-unit public housing. Research was conducted to assess the relevant smoke-free policy for PHAs as well as a literature review on smoke-free issues and other jurisdictions working to implement smoke-free public housing. Additional research was conducted with community members in Lake, Geauga and Ashtabula Counties to gather perceptions of creating 100% tobacco free environments at parks, playgrounds, beaches, fairgrounds and outdoor sports facilities.
Step 3 involves analyzing the results and presenting the findings.
Step 4 is the selecting, planning, and implementing activities to address concerns of a smoke-free policy. The coalition members have worked with management to set up educational forums with public housing residents on the dangers of smoking, secondhand smoke exposure, and potential for dangerous fires. The forums provided a platform for residents to voice their opinion and ask questions concerning a smoke-free policy. Working in the community for 100% smoke-free environments involved working at community events to promote policies that protect nonsmokers.
Step 5 primarily focuses on enforcement and maintaining of smoke-free policies. This will become an increasing challenge for residents in multi-unit housing and for community members when 100% tobacco free environments are adopted.
The community guide provides a systematic review of comprehensive tobacco control programs that effectively reduce tobacco use and secondhand smoke exposure. Evidence indicates that programs that reduce the prevalence of tobacco use among adults and young people, reduce tobacco product consumption, increase quitting, and contribute to reduction in tobacco-related disease and deaths are cost-effective and create a cost savings from averted healthcare costs.
The strategy of using coalitions and MRC volunteers is a combined approach to integrate evidence-based educational, regulatory, economic and social strategies to change behaviors. The comprehensive tobacco control program used in Lake, Geauga and Ashtabula Counties include administrative support, surveillance, evaluation and program monitoring. Lake County General Health District worked with our coalition and MRC volunteers to create a mass-reach effort to inform youth, adults, multi-unit residents and the entire community about tobacco use and secondhand smoke exposure.
The goal of all the activities was to change perceptions with youth, adults and residents in the community and in multi-unit housing on the importance of implementing tobacco free policies. Objectives were to; 1.) Work with youth in the community on tobacco counter marketing campaigns; 2.) Survey the community on tobacco free environments at parks, playgrounds, fairgrounds, beaches, and outdoor sports facilities; and 3.) To evaluate managers and residents perception on implementation process of smoke-free policies in public multi-unit housing.
The Lake Geauga Ashtabula Tobacco Prevention Coalition (LGATPC) has been in existence since 1995. In 2003 â€“ 2005, the Coalition established STAND teams in Lake and Geauga counties and held many events throughout the year. The Lake County General Health District has always been the leader among the group of agencies. If a request was submitted from the general public, the Health District would fulfill the request or ask for assistance through the Coalition. Current partners in the LGATPC are: Ashtabula City Health Department, Ashtabula County Health Department, Crossroads, Geauga County Health Department, Lake Area Recovery Center, Lake County Alcohol, Drug Addiction and Mental Health Services (ADAMHS) Board Lake Geauga Recovery Center, and Lake Health System.
The Lake County General Health District and its partners are committed to ensuring that its staff and its partners, as well as its policies and infrastructure, are attuned to meeting the diverse needs of the community. This includes those who face challenges of the English language, disabilities and/or cognitive impairments that impede their communication with staff, or other cultures that view health-related behaviors and health care differently than the dominant culture. Some come from ethnically, racially, and economically disadvantaged segments of society that have faced longstanding barriers to good health.
The Lake Geauga Ashtabula Tobacco Prevention Coalition (LGATPC) received $30,000 in funding in March of 2014 to work with youth to create stand teams. Stand teams were comprised of students attending middle and high school. Most of the work with the students revolved around the school year with little to no interaction during the summer months. Meeting with coalition members were held at least once a month to discuss activities conducted in the tri-county region with the stand teams. During high profile counter marketing activities such as Great American Smoke out and Kick Butts Day, the coalition members and MRC volunteers would assist with the events.
In the fall of 2015, partners in the coalition received $100,000 funding to continue the work with youth, plus work with creating tobacco free environments with business and working with the Metropolitan Housing Authorities on adopting multi-unit housing smoke-free policies.
The community tobacco surveys were conducted by LGATPC coalition members and MRC volunteers starting in October of 2015. These surveys were to be used to influence decision makers on the community's acceptance of creating tobacco-free environments. While most nonsmokers and former smokers were very supportive of the tobacco free environments, not all smokers agreed. But surprising, smokers were very supportive of creating tobacco-free environments at playgrounds; this provides support that communities should begin to consider tobacco free environments in areas were children play.
Work began in mid-October 2015 with the Lake and Geauga Metropolitan Housing Authorities, through email contacts with the management over a three month time period to set meeting dates. Meetings were held with both Lake Metropolitan Housing Authority (Lake MHA) and Geauga Metropolitan Housing Authority (Geauga MHA) to discuss HUDs proposed rule for smoke-free public housing. Management surveys for Lake MHA were conducted at a face-to-face meeting on January 6, 2016 and Geauga MHA was conducted during a face-to-face meeting on February 9, 2016. The process of adopting a policy can be daunting, especially one that is seen as taking away the rights of an individual to do what they want in their own homes. During the meeting the management was asked questions about smoke-free policy adoption and they agreed to allow the residents to be surveyed. There was one face-to-face management meeting with Lake MHA and multiple meetings with Geauga MHA both had multiple email correspondences.
Over the course of four months, five public housing complexes were surveyed from March until May of 2015. As part of the process it was important to provide educational forums to the residents on why smoke-free policies were being implemented. Presently, two of the five complexes have received educational information with further education to be completed at the other resident complexes.
Youth involvement in stand groups was strictly evaluated on the number of students attending the meetings, number of tobacco counter marketing activities, and the reach those activities had on others in the community. The data was compiled by the respective stand coordinators in their county.
The tobacco community surveys collected 1,378 responses. The current study is an analysis of a cross-sectional study conducted of residents in Ashtabula, Geauga and Lake Counties, during a one year period (September 2015 to September 2016). Eligible participants included those ages eleven and up. The primary aim was to examine perceptions of smoke-free policies in outdoor environments. A face-to-face qualitative survey was given to residents during community events and at organizations through the counties. The survey assessed sociodemographic characteristics such as age, sex, race/ethnicity, and smoking status, and favorability in tobacco free policies at beaches, fairgrounds, hiking/biking trails, parks, playgrounds and outdoor sports facilities. Of those surveyed 841 were non-smokers, 185 were smokers and 187 were former smoker. Survey results provided substantial data that majority of non-smokers and former smokers agree or strongly agree that the above mentioned venues should be tobacco free environments. Smokers were not as supportive but did however respond favorably to supporting tobacco free environments at playgrounds. Survey results evaluating responses to agree/strongly agree with tobacco-free policies were as follows: Beaches support was nonsmokers 73%, smokers 24%, and former smokers 64%. Fairgrounds support was nonsmoker 74%, smokers 26%, and former smokers 69%. Hiking/biking trails support was nonsmoker 69%, smokers 27%, and former smokers 67%. Parks support was nonsmoker 76%, smokers 28%, and former smokers 68%. Playgrounds support was nonsmoker 88%, smokers 64%, and former smokers 87%. Outdoor sports facilities support was nonsmoker 79%, smokers 34%, and former smokers 74%.
This data provides evidence that there is strong support by the community to adopt 100% tobacco free environments at playgrounds. Areas such as playgrounds should be targeted for policy development to not only protect our children from secondhand smoke exposure but create a positive modeling environment by adults.
Responses from surveys in public multi-unit housing provided strong support for smoke-free housing. Lake County has a total of four complexes with 263 occupied units. Surveys were conducted of three complexes with a total of 195 occupied units, of those 135 (69.2%) were surveyed. The resident survey rate for each complex was 36% (9/25) for Parkview Place in Willoughby, 71% (71/100) for Jackson Towers in Painesville, and 79% (55/70) for Washington Square in Painesville. Lake County households units surveyed had 116 (86%) with one resident and 19 (14%) with two or more household members.
Geauga County has a total of five complexes with 242 occupied units, surveys were conducted of two complexes with a total of 125 occupied units, of those 103 (82.4%) were surveyed. The resident survey rate was 78.9% (61/76) for Murray Manor in Chardon and 86% (43/ 50) for Harris House in Chardon. Geauga County household units had 91 (88%) with one resident and 12 (12%) with two residents.
Findings suggest that there was no statistically significant relationship between smoking and chronic disease based on this study (p>0.05). This may be due to the fact that approximately half of US adults have at least one chronic condition (Ward, Schiller & Goodman, 2014). Chronic conditions include hypertension, coronary heart disease, stroke, diabetes, cancer, arthritis, hepatitis, weak or failing kidneys, current asthma, or chronic obstructive pulmonary disease (COPD) (Ward, Schiller & Goodman, 2014). Furthermore, 1 in 4 adults also have multiple chronic conditions (Ward, Schiller & Goodman, 2014). Chronic disease is not solely dependent on whether an individual smokes, thus leading to the assumption that there are multiple chronic diseases that are not necessarily associated with smoking.
We can conclude that there is a slight relationship between those who regularly or occasionally smoke in this group (p<0.05). There is significant data to show that most smokers do smoke at least regularly or occasionally in their unit, while nonsmokers do not permit others to smoke in their unit. Though the significance level may be underestimated for smokers who say they occasionally smoke as opposed to those who regularly smoke. Questions should identify the amount of smoking in units as it pertains to a day or week.
We can conclude that there is a relationship between the residents who smell secondhand smoke in this group (p<0.05). It was noted by some who smoke that they smell SHS due to being able to smoke in their units, while other smokers could not discern if they smelled SHS. Most of the nonsmokers were very consciences of being able to smell SHS or not and responded whether it bothered them/made them ill or not. It may be pertinent for future questions to strictly target nonsmokers who smell SHS, but the significance of the question is whether those who do not smoke are exposed to secondhand smoke; whether it bothers them or not.
When data from Lake County nonsmokers and smokers is combined there were 46 (19.3%) residents who wanted a completely smoke-free building and grounds, 32 (13.5%) said they wanted the building to be smoke-free but allow smoking outside in designated areas, and 57 (23.9%) did not want smoke-free building/grounds or had no preference. The total number of individuals in Lake MHA MUH who want at a least a smoke-free building is 78 (32.8%) as compared to 57 (23.9%) who do not want a smoke-free policy.
When data from Geauga County nonsmokers and smokers is combined there were 26 (10.9%) said they wanted a completely smoke-free building and grounds, 34 (14.3%) said they wanted the building to be smoke-free but allow smoking outside in designated areas, and 43 (18.1%) did not want smoke-free building/grounds or had no preference. The total number of individuals in Geauga MHA MUH who want at a least a smoke-free building is 60 (25.2%) as compared to 43 (18.07%).
Of the 238 residents a total of 138 (57.9%) wanted at least a smoke-free building, while 100 (42.1%) did not want a smoke-free policy or had no preference. We can conclude that there is a statistically significant relationship between smokers and wanting a smoke-free building and/or grounds in this group (p<0.05). There were a significant number of smokers who reported wanting at least a smoke-free building to help in their quit attempts.
Results of the survey from Lake MHA and Geauga MHA management provide support for adopting smoke-free policies in MUH. Messaging strategies for smoke-free policy implementation need to include individual rights and responsibilities, health benefits, and the economic impact. Most importantly, the study from residents shows support for smoke-free policies but critical factors remain. When the data from Lake and Geauga Counties is analyzed together, results show that 138 (61.9%) residents want a smoke-free building with 85 (38.1%) residents either preferring smoking in the building or no preference. Smoking residents are going to be faced with difficult choices of quitting, staying and smoking outside, or leaving with great concern for those who are disabled and unable to leave their unit. Addressing issues for those who suffer from disabilities and mental health issues will be the challenge of public housing agencies.
The current findings have an important implication for research and practice. Further research should examine the process that impedes the adoption of comprehensive tobacco-free policies. Determining ways to build coalitions and foster community engagement is critical in advancing tobacco-free policy legislation. Research will also be needed to examine the impact of tobacco free policies beyond the self-report of persuasiveness. As a public health practitioner, strategies for garnering support should include, tobacco control advocates focusing on tobacco-free policies that provide a message of the positive health impacts of tobacco-free policies, the protection of vulnerable populations through implementation of tobacco-free policies, and the positive economic impact of tobacco-free policies. These survey findings provide a foundation to inform public health practitioners and policy makers to further the agenda of tobacco-free policy adoption.
The Lake Geauga Ashtabula Tobacco Prevention Coalition (LGATPC), established in 1995, meets monthly to support a shared vision of a tobacco free community. The LGATPC shall continue to work with community members to support youth initiatives for tobacco free environments and multi-unit housing. Funding sources have been made available through 2019 and with the adoption of HUD's new ruling; further funding may be made available to work with residents to deliver cessation services.
Though sustainability is not a guarantee, many of the community partners within the coalition receive funding from other sources to continue their work in the community. Data collection is ongoing through the CDCs Youth Risk Behavior Surveillance System, Lake County Youth Health Status Assessment, and county Community Health Assessments.
Lessons learned are that one organization cannot take on a huge undertaking without the support of community partners. Funding must continue to combat the deadliest behavior around the world. Tobacco prevention and education is paramount to prevent those who are contemplating tobacco use. More importantly, policy development that creates healthier indoor and outdoor environments must be implemented. Policies limiting where an individual can smoke will achieve a number of goals. It will prevent tobacco use initiation among youth and young adults; 2.) Promote quitting among youth and adults; and 3.) Eliminate exposure to secondhand smoke.
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