Local Tobacco Control: Application of the Essential Public Health Services Model in a County Health Department’s Efforts to Put It Out Rockland

Abstract

In 2000, Rockland County, a small suburban county north of New York City, dedicated $1 million of its Master Settlement Agreement funds to a comprehensive tobacco control program, Put It Out Rockland. Developed and implemented by the county health department, this program used an essential public health services model and an ongoing financial investment, within the context of strong statewide tobacco control efforts, to lower adult smoking rates to 9.7% and to reduce both smoking among youths and exposure to secondhand smoke over the ensuing decade. By combining state funds and local dollars for a total of $6.75 cost per capita, this comprehensive effort yielded 11 000 fewer smokers and translated to a potential savings of more than $24 million for the county.

KEY FINDINGS

• ▪ Between 2003 and 2009, Rockland County’s smoking among adults declined from 16% to 9.7%, the lowest smoking rate of all counties in New York State.

• ▪ Smoking rates among youths declined between 2000 and 2010 to less than 10% of 10th graders and to 3.3% of 8th graders smoking within the past month.

• ▪ By 2009 the percentage of homes in which smoking was prohibited increased from 77.4% to 86% of all homes and from 43% to 51% of smokers’ homes.

• ▪ Rockland County successfully invested in tobacco control by using the Essential Public Health Services model to design a comprehensive program that will potentially save the county more than $24 million in health care costs.

• ▪ Put It Out Rockland demonstrated that a local public health department, with reasonable dedicated funding, can take a comprehensive approach to address smoking by leveraging both state and regional resources toward that end.

IN 1999, CENTERS FOR DISEASE Control and Prevention (CDC)¹ published recommendations for annual per capita investments in statewide tobacco control. New York State invested heavily, spending $85.5 million annually by 2006,² albeit significantly less than the recommended investment.³ Rockland County, a diverse suburb of 298 585⁴ people north of New York City, also invested in tobacco control. In 2000, the Rockland County legislature and County Executive committed nearly $1 million of its Master Settlement Agreement (MSA) funds to comprehensive tobacco control, to be implemented by the Rockland County Department of Health. The health department used CDC’s best practices⁵ to design and implement Put It Out Rockland (PIOR), within the context of the Essential Public Health Services⁶ model by which many local public health departments operate. Put It Out Rockland was a unique approach to programs and services for a health department by virtue of its collaboration with nontraditional partners such as businesses, municipalities, schools, and media organizations.

In 2003, the county securitized MSA funds for other purposes, but sustained resources for tobacco control, dropping to a little more than $600 000 by 2006 and $325 000 by 2010. Consistent with National Association of County and City Health Officials guidelines,⁷ 10% was set aside for evaluation. In 2006, $6.75 per capita of combined state and local funds was dedicated to tobacco control in Rockland County. (The per capita rate was calculated for 2006, midpoint of the project, by adding Rockland’s $2.34 per capita to the state’s $4.41 per capita [dividing New York State’s $85.5-million tobacco investment in 2006 by the 2006 population estimate of 19 356 564].)

Young Lungs at Play campaign sign, Rockland County, New York, 2006. Design adapted from the California Department of Health Services, Tobacco Control Section.

PROGRAM ACTIVITIES

Consistent with Healthy People 2010,⁸ PIOR had 3 overarching goals: reduce the adult smoking rate to 12% or less, reduce smoking among youths by 20%, and reduce exposure to secondhand smoke by 20%. The health department engaged consultants in a strategic planning process to build theory-based interventions, by using the transtheoretical model⁹ to help smokers quit, and the social cognitive theory¹⁰ and health belief model^11,12 in media messages and programs for youths. The PIOR interventions were organized, facilitated, and implemented by the health department and included school and community youth clubs based on New York State’s Reality Check^13,14; the Environmental Protection Agency’s smoke-free home promotion¹⁵ in preschools, daycare centers, and work sites; an award-winning cessation program with free nicotine replacement therapy; targeted local media campaigns; health care provider cessation resources; and partnering with municipalities and schools to implement and support smoke-free policies. These activities functioned within the larger context of strong statewide tobacco policies and cessation resources. Rockland also benefitted from media campaigns in the nearby New York City media market.

As per Figure 1, program activities covered the range of essential public health services: diagnosis, education, partnerships, policy, enforcement, health care, workforce development, evaluation, and monitoring. The activities included direct services (e.g., smoking cessation classes) and strong collaboration, cooperation, and facilitation of activities with nontraditional partners. Such partnered activities included local media (secondhand smoke and cessation messages in the large multiplex theater, indoor and outdoor billboards, busses, newspaper, and radio); municipalities (smoke-free “Young Lungs at Play” ordinances); the county’s 9 school districts and network of preschools (strong tobacco policy, school-based Reality Check clubs, Environmental Protection Agency smoke-free home campaign); businesses (cessation classes and resources on-site for employees); and health care providers (“tobacco detailing” to encourage the use of the New York State Quitline and Fax to Quit programs, and training in brief cessation counseling).

FIGURE 1—

The Essential Public Health Services Model applied to Put It Out Rockland (PIOR).

Note. ATUPA = Adolescent Tobacco Use Prevention Act; DOH = Department of Health; eBRFSS = Expanded BRFSS; EPA = Environmental Protection Agency; NRT = nicotine replacement therapy; NYS = New York State.

PUT IT OUT ROCKLAND (PIOR) PROGRAM HIGHLIGHTS IN ESSENTIAL PUBLIC HEALTH SERVICES CONTEXT

Diagnose and investigate

• Reviewed statewide data and local surveys to set realistic goals and objectives for PIOR

• Used a logic model and strategic planning process

Inform, educate, and empower

• Facilitated Reality Check youth clubs in 4 middle schools and 8 of the county’s 11 high schools, which focused on students advocating against tobacco industry strategies

• Conducted media campaigns in local newspapers, cable TV, radio, billboards, busses, local ad frame at the mall, and rotating ads in multiplex movie theater, including smoking information and messages, reports on PIOR successes, and announcement of cessation programs

• Distributed EPA smoke-free home campaign at Head Start, preschools, day care centers, schools, work sites

Mobilize community partnerships

• Served as a founding member of POW’R Against Tobacco, a 4-county coalition

• Partnered with Community Awareness Network for a Drug-Free Life and Environment, Head Start of Rockland, Rockland Medical Association, Gay Pride Rockland, Journaleros Project (day laborers), Healthy Neighborhoods Program, the Haitian American Community Service Organization, Quisqueya (social club), Mental Health Association, Board of Cooperative Educational Services, ESL program, and other community organizations and coalitions

• Collaborated with nontraditional partners including businesses, school districts, municipalities

Develop policies

Within the context of NYS’s Clean Indoor Air legislation, PIOR worked with, advocated, and supported:

• Smoke-Free Campus Policies on the 2 major hospital campuses

• Rockland’s Kids in Cars Smoking Safety Act, the first of its kind in the nation

• Young Lungs at Play policy, which made playgrounds and parks free of tobacco

• Rockland Housing Action Coalition, which made 88 multifamily housing units smoke-free

• Village of Haverstraw’s groundbreaking legislation prohibiting tobacco displays in local businesses

Enforce laws

The Environmental Health Division of the NYS DOH conducted compliance checks:

• At all retail tobacco facilities in the county, pursuant to NYS Public Health Law, Article 13-F, Adolescent Tobacco Use Prevention Act

• At residential and commercial facilities in response to complaints, and weekly checks at bars and food service establishments, pursuant to NYS Public Health Law, Article 13-E, Clean Indoor Air Act.

Link to or provide care

• Offered PIOR group classes and one-on-one counseling, with free NRT, in multiple languages at the health department, schools, work sites, and local college campuses

• Trained local health care providers to use the NYS “Fax to Quit” program to link their smoking patients to the NYS Quitline or refer them to PIOR cessation services

Ensure competent workforce

• Trained medical and dental specialists via the local medical society in brief cessation counseling

• Conducted tobacco “detailing” to provide materials and support at individual provider offices

• Trained specialists to recruit participants and conduct cessation services for special populations—mental health, LGBT, Spanish, Yiddish, Creole, and school communities

Evaluate

• Conducted local annual computer-assisted telephone survey, longitudinal follow-up of PIOR cessation group participants, and documentation of all program activities

• Reviewed and discussed data with staff monthly and annually, and used for program modifications

Monitor

• Monitored tobacco behaviors and attitudes through statewide expanded BRFSS and health department’s 5-year Community Health Assessment, under the direction of the Commissioner of Health and the County Epidemiologist

Note. BRFSS = Behavioral Risk Factor Surveillance System; DOH = Department of Health; EPA = Environmental Protection Agency; ESL = English as a second language; LGBT = lesbian, gay, bisexual, or transgender; NRT = nicotine replacement therapy; NYS = New York State.

EVALUATION ACTIVITIES

Program evaluation began during the strategic planning process, by using logic models to define each program component. Data for outcome evaluation included the annual New York State Expanded Behavioral Risk Factor Surveillance System (eBRFSS),¹⁶ the Pride¹⁷ youth survey conducted in schools every 3 years, and a local computer-assisted random-digit-dial telephone survey conducted annually between 2003 and 2008. The local survey focused on smoking behavior and exposure to secondhand smoke, attitudes about local and state tobacco policy or legislation, and awareness of local and regional media campaigns. (The local evaluator compared data for 800 respondents in 2003 and 1000 respondents in 2008, weighted for age, gender, and ethnicity, with the New York State eBRFSS for those same years. Smoking status on the local survey was within the margin of error for the eBRFSS at both time frames, with a 16% smoking rate in 2003 on the local survey and 11.4% at 2008. In a similar way, the local survey compared favorably with the eBRFSS data on smoking rules in the home for those same years.)

Program and evaluation staff reviewed local survey and eBRFSS data annually for program improvements. Evaluation of the PIOR cessation intervention included pre and post surveys, and 3-, 6-, and 12-month telephone follow-up of every participant, including program drop-outs. The project evaluation team conducted surveys of participants in all program components, and shared data with program staff, who used the data for program improvements. For example, interpretation of attendance data and qualitative feedback from cessation participants helped to reduce program drop-out and led to tailored dosing of nicotine replacement therapy, for 10 weeks, when needed, instead of the typical 8 weeks.

PUT IT OUT ROCKLAND (PIOR): A POPULAR AND EFFECTIVE CESSATION PROGRAM

Put It Out Rockland’s smoking cessation program received the National Association of County and City Health Officials Model Practice Award in 2004.24 Developed by trained health department cessation specialists, it built on the Centers for Disease Control and Prevention’s best practices model, specifically based on the understanding that:

• Some smokers need a longer course of nicotine replacement;

• Duration of NRT should be tailored to meet individuals’ needs; and

• Combining the patch with either nicotine gum or lozenge may increase long-term abstinence rates over those produced by a single form of NRT.25

Thus, PIOR cessation used an individualized dosing approach:

• Offering 10 weeks of NRT for those who needed it, instead of the standard 8-week course;

• Tailoring of weekly dosage on the basis of pretest Fagerstrom scores26,27 and weekly ratings of difficulty and success; and

• Providing either or both nicotine lozenges or gum as part of the tailoring, when needed.

PIOR education and support

• Were offered in a group format, for 10 sessions over 8 weeks and in an individualized counseling model, called PIOR One-on-One;

• Were offered free by health department staff or their trained facilitators at the health department and at work sites, schools, hospitals, and community organizations; and

• Attracted smokers who were nonnative English speakers, with materials and messages about smoking and NRT safety in the county’s adult ESL classes.

From 2001 to 2010, PIOR provided cessation services to 1399 adults in PIOR group programs and 517 in PIOR One-on-One.

• Telephone follow-up surveys of the group cessation program showed quit rates of 57%, 47%, and 46% at 3, 6, and 12 months, respectively.

• When more conservatively counting every person not reached as a smoker, telephone follow-up demonstrated quit rates of 53%, 39%, and 32%, at 3, 6, and 12 months.

Note. ESL = English as a second language; NRT = nicotine replacement therapy.

FINDINGS

The data suggest that PIOR had met its primary goals. By 2009, the smoking rate in Rockland (FIgure 2) declined by more than those of the nation¹⁸ (22% to 17.9%, an 18.6% decrease) and New York State (21.6% to 18%, a 16.6% decrease).^19,20 Between 2003 and 2009, current smoking among adults had dropped by 39% in Rockland, from 16% (95% confidence interval [CI] = 12.7, 19.3) to 9.7% (95% CI = 6.6, 12.8), the lowest rate of New York State counties,²¹ reflecting nearly 12 000 fewer smokers in Rockland since 2003. As noted previously, Rockland’s smoking rates on the eBRFSS were consistent with data from the county’s local tobacco survey.

FIGURE 2—

Percentage of adults who smoke: New York State Expanded Behavioral Risk Factor Surveillance System, 2003 and 2009.

Note. eBRFSS = Behavioral Risk Factor Surveillance System; NYS = New York State. Whiskers indicate 95% confidence intervals.

PUT IT OUT ROCKLAND (PIOR): PUBLIC HEALTH POLICY FOCUS

Put It Out Rockland had strong collaborations with municipalities, schools, businesses, and elected officials, through which it spearheaded and advocated meaningful policy changes, within a context of strong statewide tobacco control policies:

• Young Lungs at Play,28a an effort of PIOR and the NYS Steps to a Healthier Rockland grant, created 89 municipal tobacco-free zones in parks, pools, and playgrounds, along with tobacco-free play spaces outside 15 childcare centers, 13 apartment complexes, 5 day camps, 7 faith-based organizations, and 31 school buildings.

• In 2010, Rockland Kids in Cars Local Law 6 made it “unlawful for the operator or any passenger in a vehicle to smoke when any child is present … punishable by a fine of between $75.00 and $150.00. A second or subsequent violation shall be a criminal violation, punishable by a fine of between $150.00 and $250.00.”28b Rockland County was the first county in the nation to prohibit smoking in cars where children are present.

• The Village of Haverstraw is a small village in which nearly two thirds of its residents are of Hispanic origin, many speaking only Spanish. In 2011, Haverstraw become the first location in the nation to ban tobacco displays at retail shops, gas stations, groceries, and convenience stores. The Tobacco Display Regulation29 prohibited “display of any tobacco product in a manner that permits the consumer to view any tobacco product before purchase.” This small village was no match for the tobacco industry. The law was rescinded after the threat of a lawsuit,30 although local media coverage drew great attention to the issue of tobacco industry marketing to children, and was recently reignited by Mayor Bloomberg’s proposal to pass a similar law in NYC.31

Note. NYS = New York State.

Smoking bans in the home (Figure 3) increased to 86.3% (95% CI = 82.6, 90) of all homes, from 77.4% (95% CI = 73.7, 81.1) in 2003, an 11.5% increase. Half (50.9%) of smokers on the local survey reported home smoking bans, increasing from 43% in 2003. Between 2000 and 2010, data from unpublished reports of the Pride youth survey, conducted every 3 years in schools countywide, showed that past-30-day smoking had declined from 5.4% to 3.3% of 8th graders, and from 16.8% to 9.5% of 10th graders (Walter Schneider, PhD, and Christina Pratt, PhD, Center to Study Recovery in Social Contexts, Rockland County, NY, March 2, 2011, written communication). The local annual survey demonstrated increasing support for smoke-free policies, 79.4% supporting New York State’s Clean Indoor Air Act in 2006, up from 67.5% in 2003. By 2008, Rocklanders supported bans on smoking in bus shelters (76%), outdoor dining areas (71%), and playgrounds and parks (69%). The PIOR cessation program served more than 1900 smokers, with quit rates of 39% and 32% at 6 and 12 months, respectively.

FIGURE 3—

Percentage of homes in which smoking is prohibited: New York State Expanded Behavioral Risk Factor Surveillance System, 2003 and 2009.

Note. eBRFSS = Behavioral Risk Factor Surveillance System; NYS = New York State. Whiskers indicate 95% confidence intervals.

CHALLENGES MET AND LESSONS LEARNED IN A DECADE OF PUT IT OUT ROCKLAND (PIOR)

Challenges Met

• The biggest challenge was and will continue to be maintaining the county’s commitment to PIOR, helping lawmakers understand the long-term benefits of investing in tobacco control. It took tremendous effort to encourage the legislature to continue its commitment to tobacco control when it securitized MSA funds. A dedicated campaign of local community groups, along with presentation of the local evaluation data, helped to convince them to continue to dedicate funds to tobacco control.

• The cost of a comprehensive tobacco program can be a significant challenge to localities. The success of PIOR has demonstrated the effectiveness of using local dollars in combination with existing state resources to increase local capacity. This reduces the financial cost to localities and allows implementation of a comprehensive program.

• It is difficult to attribute the impact of local programming, distinct from that of statewide and broader regional campaigns. To that end, the project used extensive local data collection, which we believe allowed improved monitoring and evaluation and more meaningful interventions. The local survey asked questions about the localized media messages to determine which messages had been seen and remembered.

• Despite their general use as a “gold standard” for comparison, and in planning, initiating, and supporting local, state, and federal health promotion and disease prevention programs, BRFSS data may not adequately reflect local trends and subgroups. The local tobacco survey provided additional information, as well as support for the application of the eBRFSS data for Rockland County.

• Much of the PIOR work involved the health department’s engagement of nontraditional partners (municipalities, schools, businesses)—entities that had not previously worked with a government agency in this way. Though challenging, these efforts ultimately expanded the health department’s influence into nontraditional venues and set the stage for subsequent similar efforts around obesity, diabetes, and other health issues.

Lessons Learned

• PIOR set the stage for transformational thinking on how a local health department can operate to improve health status, include all aspects of the essential public health services model, and involve organizations, businesses, media, schools, and community members in strong collaborative efforts.

• Incorporating evaluation from the outset of the program enabled the county to examine and improve individual program components, and to provide feedback to local legislators, whose continued commitment was critical to sustaining PIOR.

• Committed funding gave the county the capacity to leverage and build on the resources of the state, making PIOR a locally focused campaign within an existing strong context for tobacco control. When one looks at these investments as combined efforts by state, regions, and local governments, anything is possible!

Note. BRFSS = Behavioral Risk Factor Surveillance System; eBRFSS = Expanded BRFSS; MSA = Master Settlement Agreement.

Put It Out Rockland was a long-term local investment that leveraged funding and support already available statewide and in nearby media markets, used strong theoretical and practical foundations and ongoing evaluation, emphasized policy initiatives, and implemented localized community, school, business, media, and health care components in the context of the Essential Public Health Services Model. This cumulative effort met Healthy People 2010 tobacco goals,⁸ at relatively low cost, in terms of CDC and National Association of County and City Health Officials²² recommendations. With an estimated return of $4²³ to $5³ for every dollar spent on tobacco control, Rockland’s total $6 million investment between 2000 and 2010, added to the state’s investment, translated to a potential $24 million to $30 million savings in tobacco-related costs for Rockland County.