An Intervention to Promote Smoke free Policy Development in Rural Kentucky

1. An Intervention to Promote Smoke free Policy Development in Rural Kentucky Ellen Hahn, DNS, RN, Principal Investigator University of Kentucky College of Nursing National Heart, Lung, and Blood Institute (NHLBI) RO1 HL086450 October 8, 2008 PAR-06-039 Dissemination and Implementation Research in Health

2. Study Purpose • To test the effects of a community intervention on smoke-free policy outcomes in rural underserved communities. • To accelerate the ‘diffusion-of-innovations curve’ in rural communities through tailored, evidence-based dissemination and implementation efforts.

3. Long-term Goal • To develop a best practices framework for disseminating the information on the state of scientific knowledge about the effects of secondhand smoke and smoke-free laws and implementing effective community policy change and maintenance strategies in rural underserved communities.

4. Background • Enacting smoke-free laws typically depends on the readiness of local people who have the greatest and most sustainable impact in solving local problems. • Rural residents more likely to be exposed to secondhand smoke than those living in urban areas, reflecting a major rural-urban disparity in smoke-free laws.

5. Lexington Georgetown* Letcher County Morehead* Frankfort Ashland* Elizabethtown* Paducah Hardin County* (unincorporated areas) Madison County* Louisville* Danville* 4/27/04 10/1/05 7/1/06 8/1/06 8/22/06 10/1/06 12/1/06 4/1/07 4/1/07 6/11/07 7/1/07 and 1/11/08 8/8/08 Kentucky Communities with 100% Smoke-free Workplace* and/or Public Place Ordinances or Regulations

6. Primary Hypotheses • Controlling for contextual factors: • H1: The overall change in stage of readiness for smoke-free policy will be greater for Treatment than Control communities; • H2: Media coverage will be more favorable toward smoke-free environments in Treatment than Control communities; and • H3: Treatment communities will be more likely than Control communities to demonstrate initial, intermediate, and final smoke-free policy outcomes.

7. Secondary Aims • Test the effects of community readiness assessment on stage of community readiness and smoke-free policy outcomes; • Evaluate the implementation of the intervention; and • Test for the influence of secular trends in diminishing the difference between Treatment and Control communities in change over time.

8. Research Design

9. Study Counties • Treatment (n = 22) • Readiness Assessment Annually and Intervention • Control I (n = 8) • Readiness Assessment Annually • Control II (n = 10) • Readiness Assessment Year 5 Only *Note. The PRC CAB is taking a leadership role in Perry County, an Eastern Kentucky county.

10. Study Intervention

11. Translation & Dissemination of Science • Policymaker Assessments • Public Opinion Studies • Air Quality Studies • Smoke-free Toolkit

12. Building Capacity • Coalition Building • Building Organizational Capacity • Basic Legal Information • Growing Legislative Champions • Training on local policymaking process • Leveraging funds (each county awarded mini-grant, $2500 per year x 5 years)

13. Building Demand • Build on the existing rural infrastructure • Media advocacy • Advocacy: grassroots and grasstops • Branding a smoke-free campaign

14. Primary Measures • Community Readiness • 3-5 Key Informants (community advocates) • Mayors and County Judge Executives • Print Media Evaluation • NewsClipz • Smoke-free Outcomes • No policy outcomes (0); work group or resolution (1); draft ordinance (2); ordinance enacted (3); comprehensive ordinance (4)

15. Project Staff • Community Advisors • Shevawn Akers/Heather Robertson • Carol Riker • Brenda Vestal • Carol Whipple/Sarah Cavendish • Community Liaisons • Baretta Casey, MD, Director, UK Center for Rural Health • Peggy Lewis, State Office of Rural Health • James Rousey, Public Health Director, Madison County Health Department

16. Project Consultants • Judy Owens, JD, Legal Consultant • Collaborates with the Tobacco Control Legal Consortium at the University of Minnesota. • Todd A. Warnick, MA, MHA, CADC, Smoke-free Campaign Consultant

17. Key Support Staff • Kathy Begley, Data Management Coordinator • Karen Arrowood, Research Assistant • Amanda Fallin, Research Associate • Erin Lee, Project Assistant • Kiyoung Lee, Assistant Professor and Environmental Scientist, UK College of Public Health • Mary Kay Rayens, Professor and Mei Zhang, Data Analyst • Heather Robertson, Manager, Clean Indoor Air Partnership

18. 5-Year Project Summary • Readiness Interviews (Spring/Summer) • Advocates • Elected Officials (County Judge Executives and Mayors) • Readiness Reports to Communities (September) • Community Advisors serve communities as they develop/revise a tailored roadmap for next steps or review existing plans (ongoing) • Community and Community Advisor prepare scope of work for mini-grant contract with UK (annually) • Community advocates use roadmap to take action based on stage of readiness (ongoing, regular contact with Community Advisor as needed)

19. What Have We Learned? • The community with the highest overall baseline readiness score at baseline (Year 1) enacted a comprehensive smoke-free ordinance in Year 2. • Communities with more Capacity for tobacco control (i.e., leadership, numbers of personnel committed to tobacco control as well as linkages between key agencies and advocacy groups) are more ready for smoke-free policy. • Communities that report more Efforts related to tobacco control (i.e., time spent on media advocacy, training and technical assistance, policy advocacy) are more ready for smoke-free policy.

20. Average readiness scores by group, with comparisons based on two-sample t-tests for means (N = 30) Note. The community with the highest baseline readiness score enacted a comprehensive smoke-free ordinance in Year 2.

21. Lessons Learned • Tailoring interventions • Popular, low-cost communication channels (e.g., weekly shopper bulletins and weekend ‘trader’ radio shows) • Opposition tactics (e.g., ‘little tobacco’) • Air quality monitoring • Special concerns in small communities where everyone knows everyone • Concerns that businesses do not have advance notice when monitoring conducted

22. Summary • The RuralSmoke-free Communities Project assists rural partners and acts as a value-added resource as they work toward implementing comprehensive smoke-free policies in their communities. • We believe that successfully moving toward smoke-free policy goals needs to be a carefully planned, community driven effort by committed local advocates.