Statewide Strategic Plan for Tobacco Prevention

1. Statewide Strategic Plan for Tobacco Prevention New Directions for 2009-2013

2. Background

3. Background

4. Background

5. Economic Cost • In 1998/1999, Texas Smoking-Attributable Costs = $10.09 billion • Direct Medical expenditures - $4.55 billion • Lost Productivity costs - $5.54 billion • In 1998, about 15% ($1,265,000,000 or $543.87 per recipient) of all Texas Medicaid expenditures were spent on smoking-related illnesses and diseases. (includes state and federal contributions to Medicaid)

6. Tobacco Industry Expenditures • In 2005 the tobacco industry spent $13.36 billion on advertising and promotion in the U.S. (more than $36.6 million per day) • Approximately $884.7 million was spent in Texas in 2005 (over $2.4 million every single day)

7. Texas Tobacco Settlement • 1998 - Texas became the 3rd state to settle with the tobacco industry • Settlement represented compensation for the state’s cost of tobacco-related disease • Texas to receive $17.3 billion over 25+ years

8. FY 00 -01 • $1.8 billion available from the settlement in FY 00-01 • Texas Department of Health appropriated the interest from a $200 million endowment ($9 million) per year to implement programs to reduce the use of tobacco products • Special attention to populations targeted by the tobacco industry

9. Texas Tobacco Task Force ReportProgram Elements and Best Practices • Community & School Programs • Media Campaigns • Cessation • Enforcement • Efforts Targeted to Diverse/Special Populations • Surveillance & Evaluation Research

10. Texas Tobacco Prevention Initiative Program Sites

12. Initial Pilot Results (Summary) • Areas with expenditures of $3 per capita, supporting high level media campaigns and combined community programs for prevention and cessation produced significant reduction in tobacco use • 40% reduction in 6th and 7th grade tobacco use • Significant increases in teen and adult cessation • Significant reductions in tobacco consumption • Lower level media campaigns and single focus community programs did not have measurable effects on tobacco use among children and adults (there is no magic bullet)

13. Latest Results • From 2000 to 2006, current use of any tobacco products in the comprehensive program area showed a 42% reduction among middle school students (from 24.8% to 14.3%) and a 36% reduction among high school students (from 40.7% to 26.2%) • The prevalence of adult smoking in the comprehensive program area decreased 26.4% (from 21.6% in 2000 to 15.9% in 2004)

14. Texas AdultCurrent Smoking Rates

15. Smoking Rates for Harris & Jefferson Counties 2000-2005 Reducing tobacco use requires a comprehensive & sustained approach. Gains in Harris County regressed as resources/efforts were reduced.

16. Health Impact Heart Attack Deaths Decline 3 Times Faster in County with Anti-Tobacco Campaign

17. Recent Developments • Increase in the state cigarette tax to $1.41 per pack • Increased compliance with youth tobacco laws (7.2% Synar buy rate for 2006) • Increased number of local secondhand smoke ordinances across state • Statewide smoking ban proposed (but not passed) • 2006 U.S. Surgeon General’s report on involuntary exposure to secondhand smoke

18. New Direction From the 80th Legislature • Create competitive statewide grant program allowing health departments and school districts in communities statewide to apply for funds. • Dedicate $3 million in tobacco settlement funds to the Texas Education Agency for tobacco education in schools statewide. • Dedicate $1 million for smokeless tobacco prevention in rural communities. • Produce resource list identifying best practice and evidence-based interventions for use by organizations receiving state appropriated funds.

19. New Direction • DSHS and grantees must use only best practice or evidence-based tobacco prevention, cessation, and enforcement interventions. • DSHS or its contractor must notify Comptroller’s tobacco law enforcement grantees and local sheriff’s departments in writing when Synar violations occur during the annual survey. • DSHS must prepare a report on the progress of the program to the legislature.

20. Synar Requirements • An agreement to continue to have in effect a State law that makes it unlawful for any manufacturer, retailer or distributor of tobacco products to sell or distribute any such product to any individual under the age of 18; and to enforce such laws in a manner that can reasonably be expected to reduce the extent to which tobacco products are available to individuals under the age of 18.

21. Synar Partners • Texas Department of State Health Services (DSHS) • Substance Abuse Prevention • Tobacco Prevention and Control Program • Comptroller of Public Accounts • Office of the Attorney General • Texas State University • Center for Safe Communities and Schools (CSCS) • Texas Statewide Tobacco Education and Prevention (TX STEP)

22. Synar Enforcement • Comptroller of Public Accounts • Responsibility for the Law • Senate Bill 55: September 1, 1997 • Texas Health and Safety Code Chapter 161 • Subchapters H, K, N, O • Texas Tobacco Tax Code Chapter 154, 155 • Grants to Local Communities • Local Law Enforcement (approx 100/yr) • School District Police (approx. 100/yr.)

23. Synar Enforcement • Office of the Attorney General • Consumer Protection and Public Health Division • Authority under the Texas Deceptive Trade Practices - Consumer Protection Act, Tex. Bus. & Com. Code Ann • Settlements: Voluntary Compliance: • Conoco Philips Company • E-Commerce Today, Ltd • The Walgreen Company • Exxon Mobil • BP Amoco

24. Synar Contractors • Texas State University – San Marcos • Center for Safe Communities and Schools • Synar Survey • Training • Texas STEP • Oversight of Comptroller grantees • Law Enforcement Training

25. Synar Retailer Violation Rates • Minors Access to Tobacco • 1995 – 53% • 1996 – 56% • 1997 – 24% (Texas law effective 9/1/97) • 1998 – 13% • 1999 – 14.6% • 2000 – 13.4% • 2001 – 12.9% • 2002 – 15.66% • 2003 – 23.8% • 2004 - 15.5% • 2005 - 12.4% • 2006 – 7.2%

26. Synar Survey • To determine the retailer violation rate (or retailer noncompliance rate) for each State based on random, unannounced inspections of a sample of tobacco outlets accessible to youth • The sample inspected must be representative of the geographic distribution of statewide tobacco outlets • Results of the survey will be used to determine whether the State has met the interim target rate • Retailer violation rates obtained over years will help assess the State’s progress toward achieving the Synar goal of a violation rate of 20% or less

27. Tobacco Outlet Inspection Survey • Using minors (ages 15-17) to conduct inspections of tobacco outlets within survey areas. Recruitment and selection of minors are demographically matched for the area being inspected • Training and technical assistance for local law enforcement and community members are provided • Inspection timeline is June-July of each year • Weights are used for the retailer violation rate estimates to reflect the statewide outlet populations

28. Sampling Frame • A list sampling frame of OTC tobacco outlets is used for Texas Synar survey • Texas Comptroller of Public Accounts (CPA) provides statewide database of licensed tobacco retailers: • License renewed every two years (even year) • Coverage study in 2007 to determine if sampling frame is accurate in terms of actually selling tobacco products and/or accurate address

29. Sampling Methodology • Over 26,600 tobacco outlets across 254 counties in Texas are eligible for 2005 survey sampling • Rationale of sampling: • Non-zero probability of selection to all outlets in the state • Spread the sample out both literally by geography and by demographic status • Use stratification and other efficiency measures to minimize any major increase in complexity and cost • A stratified two-stage cluster sampling design is developed • Stage I: selection of counties or Primary Sampling Units (PSUs) • Stage II: selection of outlets within each selected county

30. Sampling Methodology • PSUs are stratified according to the number of tobacco outlets by county. A total of 10 strata are formed: • Stratum A1-A7: counties with > 500 outlets (self-representing counties) • Stratum B: counties with 100-500 outlets • Stratum C: counties with 26-99 outlets • Stratum D: counties with < 26 outlets • Select six counties in stratum B, 4 counties in stratum C, and 2 counties in stratum D by systematic or PPS sampling • Sample size allocation across strata is based on proportional allocation method

31. 19 Sampled Counties in 2007 Texas: 254 counties/PSU clusters

32. Survey Inspection Results: Tobacco Retailer Violation Rate

33. Synar Survey Inspection Protocols • Synar Inspection Survey is conducted in a scientifically sound manner • Training of Synar inspectors (law enforcement officers) and youth inspectors ensures the same procedures and protocols are used to collect data • Protocol ensures changes in the buy rate over time or between counties are not due to extraneous factors • Youth inspectors - judged to younger than 18 years old • Equal number of male and female • Equal number of inspections • Minor asks for tobacco product • Minor doesn’t carry ID but tells the truth about their ageif asked

34. Synar Challenges • Size, diversity & location of Texas presents logistical challenge • Texas law does not penalize courts for not following through in processing Final Proceeding Report for disposition of violations/penalties • Staff shortages are an obstacle to departments’ tobacco enforcement programs • School Resource Officers (SRO’s) in the school/education environments are reluctant to write MIP tobacco citations • Language barrier is a major challenge in training retail employees in some areas • Financial resources to provide a comprehensive approach in Texas are lacking

35. Strategic Plan Process • DSHS staff, partners and stakeholders met to assess program and develop future direction • Evaluated progress, areas for improvement and available resources • Drafted strategic plan for 2009-2013 • Your input is encouraged

36. Goal 1: Prevent Tobacco Use Among Young People • Educate young people & families about effects of tobacco use. • Increase compliance with tobacco laws and policies. • Support increased enforcement of minor access laws. • Decrease tobacco industry influence on youth. • Mobilize communities to prevent tobacco use. • Use evidence-based, culturally appropriate programs. • Evaluate changes in youth’s knowledge, skills and attitudes about tobacco use.

37. Goal 2: Promote Compliance and Enforcement of Tobacco Laws • Educate communities on youth access laws, retailer regulations and local clean indoor air ordinances. • Support Comptroller and local law enforcement agencies in enforcement and compliance activities to reduce minors’ access to tobacco. • Increase number of law enforcement agencies actively enforcing tobacco laws. • Support enforcement and compliance activities to reduce public exposure to secondhand smoke.

38. Goal 3: Increase Cessation • Educate youth and adults on benefits of quitting tobacco and resources for quitting. • Increase awareness, availability and access to cessation resources. • Increase number of health professionals who assess, counsel, refer and treat patients for cessation. • Increase social support for youth cessation.

39. Goal 3: Increase Cessation • Mobilize youth-serving organizations to promote tobacco cessation activities. • Work with Texas Medicaid/Medicare and Texas Department of Insurance for increased coverage for cessation services. • Implement evidence-based, culturally appropriate programs to increase tobacco cessation.

40. Goal 4: Eliminate Exposure to Secondhand Smoke • Educate the public about the harmful effects of secondhand smoke and clean indoor air laws. • Educate health professionals to assess and counsel patients/clients about eliminating secondhand smoke exposure. • Increase enforcement and compliance with federal, state and local secondhand smoke laws. • Implement evidence-based, culturally appropriate programs to reduce exposure to secondhand smoke.

41. Goal 5: Reduce Tobacco Use Among Disparate Populations • Educate populations with the highest burden of tobacco-related health disparities about tobacco prevention, cessation, secondhand smoke hazards, and clean indoor air laws. • Increase awareness, availability and access to cessation resources among populations with tobacco-related health disparities. • Provide technical assistance for local organizations that serve populations having the highest burden of tobacco-related health disparities.

42. Goal 5: Reduce Tobacco Use Among Disparate Populations • Mobilize key stakeholders to develop partnerships to promote elimination of tobacco-related health disparities. • Enhance data systems to capture information on priority populations. • Identify populations with the greatest burden of tobacco-related health disparities.

43. Goal 6: Develop and Maintain Statewide Infrastructure • Build and sustain state, regional and local capacity for effective tobacco prevention and control initiatives. • Maximize capacity by integrating with the state’s substance abuse prevention services delivery system. • Identify and distribute information about evidence-based tobacco prevention and control activities, resources and opportunities. • Provide training and technical assistance to communities on programs that build local tobacco control infrastructure.

44. Goal 6: Develop and Maintain Statewide Infrastructure • Use research findings to plan and implement effective initiatives. • Maintain and enhance surveillance of tobacco use among youth and young adults, adults and high-risk populations. • Use evaluation findings to modify programs. • Evaluate use of the statewide strategic plan.

45. Questions/Comments

46. Contact Information Joe Vesowate Assistant Commissioner Division for Mental Health and Substance Abuse Services (512) 206-5797 Phil Huang, MD, MPH Medical Director, Chronic Disease Prevention Branch Division of Prevention and Preparedness (512) 419-2290