Innovative Approaches to Reducing the Tobacco Burden Among Low SES Populations A National Review

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Innovative Approaches toReducing the Tobacco
Burden Among Low SES PopulationsA National
Review

• Craig Mosbaek, MPH and Maureen Rumptz, PhD
• Program Design Evaluation Services
• Multnomah Co. HD/OR Public Health Division
• Janet Porter, MPH
• National Network on Tobacco Prevention and
  Poverty
• Health Education Council
• Health Equity for All A Leadership Summit to
  Reduce the Burden of Tobacco Use among Low SES
  Populations
• November 5-6, 2008

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Overview

• 5 overarching approaches to reducing the burden
  of tobacco on low SES populations
• Specific strategies undertaken by the National
  Network on Tobacco Prevention and Poverty

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Methods

• Literature review
• Behavioral Risk Factor Surveillance System
  (BRFSS) data analysis
• Key informant interviews
• WA tobacco program staff (n9)
• Other health department staff - WIC, Medicaid,
  drug and alcohol, chronic disease (n6)
• Service providers to low SES communities in WA
  (n5)
• Tobacco program staff and service providers in
  other states (n9)
• National experts American Legacy Foundation,
  NNTPP, National Cancer Institute, CDC (n8)

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Definition of low SES

• No consensus definition of low SES, but
  definitions often include
• Income Federal poverty level or eligibility for
  certain programs
• Education usually 12 years of education or less
• Occupation
• Where low SES populations can be reached
• Enrolled in government programs WIC, Head Start,
  Medicaid, Food Stamps
• Served by agencies or institution homeless
  shelters, incarcerated, substance abuse and
  mental health treatment
• Others worksites that employ low-wage workers,
  blue collar, out of school youth

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1. Social Determinants of Health

• The economic and social conditions under which
  people live which determine their health, e.g.
• Education
• Employment
• Housing
• Food security
• Healthcare services

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Social Determinants of Health

• The causes of disease in low SES populations are
  pervasive and complex
• Even if we eliminate disparities in tobacco use,
  there will still be disparities in
  tobacco-related health outcomes
• Must CHANGE the social determinants of health in
  order to eliminate all health disparities
• Thinking about social determinants can lead to
  better tobacco control interventions 

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Social Determinants of Health

• There are a number of social/economic policies
  that work within the social determinants of
  health
• Examples of tobacco-specific polices
• Smokefree workplaces and other worksite wellness
  programs
• Smokefree homes (multi-unit housing)
• Smokefree public transportation
• Medicaid coverage of cessation treatment services

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Social Determinants of Health

• Tobacco is not the leading concern for low SES
  communities so we need to integrate tobacco into
  other issues of concern
• Smoking and diabetes impact heart disease
• Partner with health and non-health agencies that
  work with low SES communities and where there is
  a trusted relationship

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2. Targeting Best Practices

• Apply the best practices for comprehensive
  tobacco control
• Make sure each strategy is
• Designed to impact low SES populations.
• Example - TV ads should have actors that look
  like smokers
• Reaching low SES populations.
• Example - TV ads should be placed in shows that
  smokers are watching
• View each strategy with an equity lens
• Seattle/King, Multnomah
• e.g., smokefree workplace laws originally
  exempting bars/restaurants

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Population-Wide Strategies

• Population-wide strategies have the potential for
  greater impact on low SES
• Before comprehensive smokefree workplace laws,
  low SES were more likely to be exposed to
  secondhand smoke at work
• Increasing tobacco taxes leads to greater
  reductions in use by low-income (increased tax
  revenue must go to services for the populations
  most affected by tobacco use)
• Analyze population-wide strategies with an equity
  lens

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3. Changing Social Norms

• Changing social norms and the social
  acceptability of tobacco use is important
• It is harder to quit if your family, friends,
  workmates use tobacco
• Stigmatizing tobacco users is not a good strategy
  and may be particularly ineffective with
  populations that are already marginalized

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4. Tobacco and Social Service Agencies Tobacco
programs can

• Find out how tobacco fits into the agencys core
  mission, e.g.
• tobacco is bad for health
• effect of secondhand smoke on others, especially
  children
• employers dont want to hire smokers
• disadvantaged populations are targeted by the
  tobacco industry
• Make it easy for the agency to integrate tobacco
  control

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Working w/ Social Service Agencies Agencies can

• Support and equip staff
• e.g., train staff to do brief interventions
  (M.I), address concerns that staff has to quit,
  support them when they are ready to quit
• Add questions to intake forms
• Do you smoke cigarettes? Do you want to quit?
• Create smokefree facilities
• Start with a pilot project and build champions

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5. Surveillance and Evaluation

• There are data on effective interventions with
  low SES populations
• e.g., taxes, smokefree environments, cessation
  services
• Need to evaluate other interventions to determine
  what works and disseminate findings

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Summary

• Effective policies and interventions to reduce
  inequalities in health must address fundamental
  non-medical determinants
• Use best practices for tobacco control
• Tailor (designed to impact/reaching?) and view
  each with an equity lens
• De-normalize tobacco without stigmatizing low SES
  smokers
• Work with agencies serving low SES populations
  and integrate tobacco control into other concerns
• Conduct evaluations and disseminate findings

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• National Network on Tobacco Prevention and
  Poverty
• Janet Porter, MPH
• Program Director

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NNTPP Mission

• To identify resources and advocate for the
  elimination of tobacco use among populations of
  Low SES

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6 Priority Populations for National Tobacco
Networks

• American Indians / Alaskan Natives
• Asian Americans / Pacific Islanders
• African Americans
• LGBT
• Hispanics / Latinos
• Low Socioeconomic Status

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What We Do

• Collaborate with partner organizations who serve
  low SES populations to
• Build their institutional capacity in tobacco
  control
• Assist with tobacco control, education,
  activities and policy development
• Work with states/collaborate with other networks

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NNTPP Stakeholder Body
WISCONSIN TOBACCO PREVENTION AND POVERTY NETWORK
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• How has the NNTPP succeeded in gaining access to
  partners and populations for our work?

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• Historically, the NNTPP has focused efforts on
  populations of low income, or those living in
  poverty.
• Indicators
• Income level
• Circumstance

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Tobacco Use PrevalenceSelected Populations
Homeless
Substance Abusers
Incarcerated
All Adults
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NNTPP Strategies

• Engaging Non-Traditional Partners
• Systems Change Approaches
• Cessation
• Advocacy

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Engaging Non-Traditional Partners

• Identify those who have access to the populations
  we are trying to reach
• Build their capacity in tobacco control
• Provide support in developing interventions

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Systems Change Approaches

• Change the social norm organizational policies
  compliance with existing policies
• Create environments that support cessation

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Tobacco Cessation

• Development of APPROPRIATE cessation resources
  access to resources
• Brief interventions/counseling
• Access to nicotine replacement therapies

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• Correctional Populations
• Young Adults in Community Workforce Development
  Programs
• Association of Gospel Rescue Missions
• Rural Alaska Community Action Program

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Advocacy

• Support programming for low SES populations
• Encourage statewide, regional and local
  networks to address tobacco use among low SES.

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Closing

• Evaluation we need more data, so the more you
  can evaluate, the better!
• Focus for the National Networks has shifted
  less focus on programming
• Link to resources and expertise
• Expansion new stakeholders
• Development of recommendations/guidelines

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Final Word

• Policies and interventions must address
  fundamental social determinants
• Equity lens
• Gaining access to partners and populations is key
  
• NNTPP is a resource
• Best practices work!

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Contact Information

• Janet Porter, MPH, Program Director
• National Network on Tobacco Prevention and
  Poverty
• 916-556-3344 jporter_at_healthedcouncil.org
• Maureen Rumptz, PhD and Craig Mosbaek, MPH
• Program Design Evaluation Services
• 971-673-0606 maureen.h.rumptz_at_state.or.us
• 971-673-0610 craig.mosbaek_at_state.or.us