Eliminating tobacco-related disparities among Pacific Islanders through leadership and capacity building - Promising practices and lessons learned

Abstract

Tobacco remains a major risk factor for premature death and ill health among Pacific Islanders, and tobacco-related disparities persist. Eliminating these disparities requires a comprehensive approach to transform community norms about tobacco use through policy change, as contained in the World Health Organization (WHO) international Framework Convention on Tobacco Control (FCTC). Three of the six US-affiliated Pacific Islands – the Federated States of Micronesia (FSM), Palau and the Marshall Islands – are Parties to the FCTC; the remaining three territories – American Samoa, the Commonwealth of the Northern Mariana Islands (CNMI) and Guam – are excluded from the treaty by virtue of US non-ratification.

Capacity building and leadership development are essential in achieving policy change and health equity within Pacific Islander communities. We describe promising practices from American Samoa, CNMI, FSM, Guam and Palau and highlight some of the key lessons learned in supporting and sustaining the reduction in tobacco use among Pacific Islanders as a first step towards eliminating tobacco-related disparities in these populations.

Introduction

Tobacco is a major risk factor for premature death and ill health among the United States-affiliated Pacific islands [USAPIs]. Studies have documented high smoking prevalence among Pacific Islander groups, including 50% for Samoan men in American Samoa and 53% for Chuukese men in the Federated States of Micronesia [FSM] (Marshall, 1991). The Centers for Disease Control and Prevention [CDC] (2004) reported that in 2002-2003, Guam had the second highest overall smoking prevalence (32.1%) among all U.S. states and territories. Within Guam, the indigenous Chamorros consistently demonstrate significantly higher smoking rates than any other ethnic group (David, 2012). Recent data for adult smoking in other Pacific Island jurisdictions confirm that tobacco consumption remains higher than the US median (World Health Organization [WHO], 2012).

Equally alarming is tobacco use among Pacific Islander youth. The latest Global Youth Tobacco Survey [GYTS] showed a high percentage of Pacific youth aged 13-15 years are current tobacco users (among boys: 58.6% in Palau, 51.9% in FSM, 43.1% in Guam and 29.4% in Marshall Islands) (WHO, 2012). In FSM and Palau, smoking among boys was higher than adult male smoking (36.9% vs. 29.9% in FSM and 52% vs. 37.2% in Palau) (WHO, 2012). In addition, the GYTS also revealed that most youth had been exposed to tobacco industry marketing while a low percentage had seen anti-tobacco messages.

Tobacco use is more than just smoking cigarettes. In the Pacific, smokeless tobacco and mixing tobacco with betel nut have become prevalent. A few studies have shown high rates of tobacco use with betel nut in Palau (Salvail, Huang, Nguyen, 2002), and FSM (FSM Department of Health and Social Affairs, 2008). Emerging data reveals that over half of youth in Guam, FSM and the Marshall Islands live in homes where others smoke in their presence, and over 60% are exposed to second hand smoke in public places (76% in Guam, 60% in the Marshall Islands and 71% in FSM) (WHO, 2012). And while some studies have uncovered the tobacco industry's role in targeting Pacific Islanders and Asian Americans (Muggli, Pollay, Lew & Joseph, 2002), additional research is needed on the role of the tobacco industry in normalizing tobacco products and promoting tobacco use among Pacific Islanders.

The high prevalence of tobacco use has contributed to significant health disparities, with undue concentration of tobacco-related diseases among the region's indigenous Pacific Islander communities. Tobacco is the major risk factor for the three leading causes of death in the USAPIs – heart disease, cancer and stroke (WHO, 2012). In Guam, tobacco use accounted for over 50% of all deaths in 2004, with a disproportionate share of the burden borne by Pacific Islanders (Guam Office of the Governor Bureau of Statistics and Plans, 2006). Cancer is the second leading cause of death, with lung cancer accounting for a significant percent (27.4%) of all cancer deaths (Guam Cancer Registry, 2007). Chamorros (Guam's indigenous Pacific Islanders) had the highest mortality rates of lung and bronchus cancer at 66.9 per 100,000 followed by other Micronesian islanders at 53.1 per 100,000. The mortality rate for Chamorros was 22% higher than the U.S. rate of 54.9 per 100,000. The same pattern is seen for mouth and pharynx cancer---Chamorros had the highest age-adjusted rate at 15.5 per 100,000, almost six times the U.S. rate, while other Micronesians came in second, with a rate of 6.3 per 100,000, more than double the U.S. rate. Even when nasopharyngeal cancers are excluded, the rates remain highest (6.4 and 6.3 per 100,000 respectively) for Chamorros and Micronesians (Guam Cancer Registry, 2007). Both groups practice chewing betel nut, with an increasing number who mix tobacco with their chew.

Furthermore, access to cessation services and medication remains rudimentary in several of the. The Marshall Islands, FSM and Palau do not have toll-free access to the national quitline, and several of the outer islands in FSM and Palau do not have any trained cessation counselors (personal communication, Mr. Kerio Walliby, FSM Substance Abuse and Mental Health program and Ms. Annabel Lyman, Framework Convention Alliance, Palau, November 2012). These compound the disparities in tobacco-related adverse health impacts.

Background: Capacity Building And Leadership In Tobacco Control

Successfully combatting the tobacco epidemic in Pacific Islander communities requires a comprehensive approach to transform community norms about tobacco use through policy change. Policy change encompasses not only legislative policy at the national level, but also community policy change, mainstream institutional change and corporate policy change. The specific types of policy actions needed to eliminate tobacco use disparities are clearly outlined in the WHO international Framework Convention on Tobacco Control [FCTC] (WHO, 2005).

The FCTC is the first public health treaty developed under the auspices of the WHO. It provides a global legal framework to address the tobacco epidemic, using evidence-based demand and supply-reduction strategies. Adopted by the World Health Assembly on 21 May 2003, the treaty entered into force less than two years later, on 27 February 2005. Presently, 176 of the 193 Member States of WHO are Parties to the Convention, including three of the six US-affiliated Pacific Islands – FSM, Palau and the Marshall Islands (WHO, 2012). Among the 17 remaining countries in the world that have yet to ratify the WHO FCTC is the United States of America, which has jurisdiction over the remaining US-affiliated Pacific Islands (USAPI) of American Samoa, the Commonwealth of the Northern Marianas (CNMI) and Guam.

Capacity building and leadership development are essential in achieving tobacco control policy change and health equity within Pacific Islander communities. Before communities can comprehensively address tobacco, they need to develop community readiness and capacity on tobacco control (Robinson et al., 1995). A systematic review of community capacity to address tobacco among the four major ethnic groups in the US in the mid 1990's found that Asian Americans and Pacific Islanders had a low to very low capacity to conduct research, develop an infrastructure, create and manage programs, and develop policy initiatives on tobacco control (Robinson et al., 1995).

Recognizing the need for community capacity assessment, the Asian Pacific Partners for Empowerment, Advocacy and Leadership (APPEAL), a national non-governmental organization working to achieve health equity for Asian Americans, Native Hawaiians, Pacific Islanders, developed a Community Stages of Readiness model based on Prochaska's Transtheoretical or Stages of Change model for individual behavior change (Prochaska & Diclemente, 1983).

The APPEAL Community Readiness Model proposes that tobacco control work is best accomplished using methods tailored to a jurisdiction's specific assets, needs, and readiness to address tobacco use as a health and social justice issue. APPEAL adapted concepts from the Transtheoretical Model to identify benchmarks of community capacity building along a continuum of five stages:

1. Pre-contemplation: A community or coalition has not seriously thought about addressing an area of tobacco control

2. Contemplation: A community has thought about taking action, but has not developed plans to work in an area of tobacco control

3. Preparation: A community has thought about taking action and is developing plans to work in an area of tobacco control

4. Action: A community has taken action in an area of tobacco control

5. Maintenance: A community has been taking action in an area of tobacco control for an extended period of time and has developed a plan for sustaining its efforts

As part of the assessment process, users of the Community Readiness Model explore efforts in each of 4 tobacco control areas - (1) research and data dissemination, (2) infrastructure building, (3) programs, and (4) policy change - as well as consider relevant contextual factors before placing themselves in one of the five stages listed above (APPEAL, 2006). The model assists communities in identifying their various capacities and capacity gaps to counter the tobacco epidemic. Communities can then focus their efforts on capacity building activities in the area/s where gaps are greatest.

Leadership in tobacco control, at all levels in society, is pivotal to successfully controlling the tobacco epidemic through policy change. This is especially true given competing health priorities and limited infrastructure and resources to respond to tobacco and the tobacco industry in Pacific Islander communities.

APPEAL has worked in partnership with various Pacific Islander communities in the US mainland and in the USAPIs to strengthen their capacity and leadership for effective tobacco control (Lew & Nakashima, 1999). In 2000 and 2008, APPEAL assisted the Palau national tobacco control program to assess Palau's community readiness and develop strategic plans for tobacco control. Similarly, in February 2004, APPEAL collaborated with FSM to develop a strategic tobacco control plan for the four FSM states. APPEAL has also convened several leadership development summits, including the landmark Guam Tobacco Control Leadership Summit in 2004, an inclusive multisectoral leadership initiative specifically focused on tobacco control (Lew, 2004). These leadership development initiatives tap recognized local tobacco control stakeholders and program staff to nominate community advocates for tobacco control who have the potential to influence policy and social norms change. Interactive learning exercises and participatory discussions channel insight and help participants acquire skills in vision setting, selecting priorities and developing action plans focused on environmental interventions to reduce tobacco use. Workshop activities are tailored for cultural relevance.

Community readiness assessment and tobacco control leadership development served as starting points for tobacco control policy change that have augmented local initiatives to curb tobacco use. The next section features selected promising practices emerging from capacity building and leadership development efforts in the USAPIs, and highlights some of the key lessons learned in supporting and sustaining the reduction in tobacco use among Pacific Islanders to eliminate tobacco-related disparities in these populations.

Strategies: Promising Practices for Tobacco Control in the Pacific

American Samoa

American Samoa is a US Territory with a population of approximately 69,000 (United Nations Economic and Social Commission for Asia and the Pacific [UNESCAP], 2012). Its tobacco control program emphasizes village-based outreach and advocacy to mobilize grassroots support for tobacco control and to increase referrals to the cessation quitline. During previous tobacco control summits hosted by APPEAL, tobacco control program staff identified capacity gaps in their cessation service delivery infrastructure and program staffing. Because of resource limitations, creating a stand-alone cessation service network and hiring additional program staff for cessation education and advocacy were not considered feasible. Instead, two strategies were identified as alternative solutions: (1) tapping into the existing village-based primary health care infrastructure for providing cessation advice and (2) partnering with relevant community organizations and opinion leaders to extend the reach of education and advocacy efforts.

Cessation services are incorporated with other health services at the local wellness clinic, which serves as a “one-stop” source for primary and preventive health care. However, because not all villages are geographically close to a wellness center, the tobacco control program partners with the American Samoa Community Cancer Coalition to conduct village health visits for sharing information about tobacco and cessation resources and building community capacity for tobacco control.

Program staff also engage with traditional Samoan leaders who are the community opinion leaders. Village chiefs and faith-based leaders open the visits with a spiritual service that incorporates both faith-based elements and traditional Samoan customs. Demonstrating respect for tradition and culture promotes a relationship of trust between program staff and villagers, and facilitates expanding the dialogue from cessation services to broader tobacco control policy issues. Since many traditional leaders also hold influential positions in the government, legislative champions can be nurtured to guide tobacco control policy change (Pacific Partners for Tobacco Free Islands, 2012). The village engagement proved crucial to mobilizing population and political support for the American Samoa Smoke-free Environment Act, which was signed into law in October 2010 (American Samoa Cancer Coalition, 2010). Today, the American Samoa Department of Health continues to utilize the village level approach to build enforcement capacity for the smoke-free law (Radio New Zealand, 2012, Nov. 12).

Commonwealth of the Northern Mariana Islands

CNMI has 14 islands and a population of approximately 53,900 (Eugenio, 2011). Its Tobacco Control Program emphasizes prevention and early education through community capacity building trainings. At an APPEAL National Leadership Summit, program staff and CNMI members of the regional consortium Pacific Partners for Tobacco Free Islands (PPTFI) identified cessation and smoke-free legislation as capacity building priorities. With technical and funding assistance from APPEAL and tobacco control counterparts in Guam, program staff and their PPTFI counterparts facilitated multiple cessation training workshops to create a critical mass of community stakeholders and health practitioners capable of delivering brief cessation advice. PPTFI sought the assistance of the Pacific islands Primary Care Association (PIPCA), which runs the Community Health Centers (CHCs), to expand cessation training to CHC front line staff.

CNMI tobacco control stakeholders leveraged resources from a Strategic Prevention Framework-State Incentive Grant (SPF-SIG) from the US Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Prevention (CSAP), to establish a Substance Abuse Prevention Coalition that played a central role in mobilizing community support for smoke-free legislation. PPTFI supported leadership development workshops for coalition members, who included civil society organizations, private sector groups and community volunteers. Influential community elders and youth coalition members rallied to support the bill during its passage and when it faced the threat of repeal. CNMI's Smoke-Free Act was signed into law in September 2009. While falling short of the WHO FCTC recommendations, it has helped re-shape public opinion about tobacco-free environments (Pacific Partners for Tobacco Free Islands, 2012).

Guam

Guam's tobacco control stakeholders comprise a multisectoral team working collaboratively since 2003. These stakeholders underwent an APPEAL tobacco control leadership training and were supported by APPEAL to undertake a 3-year capacity assessment and strategic planning process to develop a coordinated action plan for tobacco control. The Departments of Mental Health and Substance Abuse (DMHSA) and Public Health and Social Services (DPHSS) provide program support for cessation training and tobacco control policy technical assistance, while private sector partners like the Guam chapter of the American Cancer Society, the Noncommunicable Disease (NCD) Prevention Coalition and the Guam Comprehensive Cancer Control Coalition take the lead for advocacy and community mobilization for legislative change. The University of Guam's Cancer Research Center and the Guam State Epidemiological Outcomes Workgroup (SEOW) oversee research, data analysis and data translation. Established in 2004, the SEOW monitors trends in tobacco consumption and consequences and provides an annual data update (David, 2012), which forms the core of Guam's local evidence base.

Guam adopted key tobacco control policies restricting youth access in 1999, and raising taxes on tobacco products as a fiscal measure in 2003. In 2005, the stakeholder group provided vital technical and advocacy support to Senator Lou Leon Guerrero, an APPEAL Leadership Training graduate, when she introduced Guam's smoke-free public places bill, named the “The Natasha Protection Act” (Guam Compiler of Laws, 2005) after a local cancer victim. Putting a community “face” to the issue elicited strong support from community members. Sound local data and strategic use of media contributed to effectively counter the formidable opposition to the bill from business owners and some elected officials. The bill was enacted in 2005 and put in effect in 2006. As a policy “tipping point”, it paved the way for other tobacco-related policies, including an Executive Order that mandated all government facilities and vehicles must be 100% tobacco-free (including outdoor spaces), institutional policies creating 100% tobacco-free campuses at the University of Guam and the Guam Community College, and laws banning smoking in vehicles with children under 18 years and within 20 feet of public doorways.

In 2010, strategic stakeholder mapping enabled tobacco control partners to pinpoint legislative champions and potential opponents to a proposed tobacco tax increase. The group also utilized the heightened concern over cancer to frame the rationale for the higher taxes, by incorporating a provision that earmarks 72% of the tax revenues for prevention and education programs addressing key cancer risk factors, primarily tobacco and alcohol, and 15% of tax revenues to support the Guam Cancer Registry and the Guam Cancer Trust Fund. Using health economic data developed with Campaign for Tobacco Free Kids, community advocates successfully deflected arguments from those opposing the measure. As a result, taxes on cigarettes increased by $2.00 per pack (Public Law 30-80, 2010), the largest single-time tax increase among all US States and Territories.

Federated States of Micronesia

The Federated States of Micronesia (FSM) is an independent nation comprised of a loose federation of four states---Chuuk, Kosrae, Pohnpei and Yap. Based on the 2010 census, FSM has a population of about 102,600 (FSM Office of Statistics, Budget and Economic Management, Overseas Development Assistance and Compact Management, 2010).

In 2006, FSM established its State Epidemiological Outcomes Workgroup (SEOW) under a grant from the SAMHSA CSAP. The SEOW, comprised of data teams from the 4 States and the national government, embarked on the first ever effort to systematically collate and analyze data on substance abuse indicators, including tobacco use. The SEOW produce a Substance Abuse Epidemiological Profile for FSM (David, 2008), which provided the local evidence for tobacco control. At a data dissemination workshop in 2008, the Kosrae team developed an action plan to advocate for a ban on sales of single cigarette sticks, using local data for their advocacy messages. Implementing the action plan with community support, Kosrae's legislators enacted a ban on single stick sales. Today, it is the only State in the FSM with this law (FSM Country Presentation, 2012).

In 2009, the FSM Tobacco Control Program facilitated a capacity building workshop for tobacco control program staff from all 4 States in brief tobacco cessation, partly funded by APPEAL (David, 2009). Today, it operates a cessation quitline and counseling services in the state of Pohnpei. At the same time, program staff worked with traditional and faith-based leaders, many of whom were participants in previous APPEAL and PPTFI-hosted tobacco control leadership workshops, to build their capacity for tobacco control policy interventions. The late Mr. Koismy Hadley, Narhnmwarki of Madolenihme Municipality, was an early champion and the first traditional leader to ban smoking in traditional ceremonies (Pacific Partners for Tobacco Free Islands, 2012). In 2011, Mr. Herbert Mikel, village Chief of Enupein Powe, announced a village-wide ban on tobacco use in public functions – the first village to do so in the entire country (Jaynes, 2012, Nov. 12). With the increasing attention on tobacco as a major risk factor for noncommunicable diseases, and with the support of influential traditional leaders, Kosrae and Yap both passed Clean Indoor Air Acts in 2010 (Government of the Federated States of Micronesia, 2012, Nov. 12).

The Republic of Palau

The Republic of Palau, an archipelago in the North Pacific Ocean, has a population of approximately 20,600 (UNESCAP, 2012). The Palau delegation played a pivotal role in rallying the other Pacific Islands to support the development of the WHO FCTC: Palau was among the first 40 countries to ratify the treaty (David & da Costa e Silva, 2010). Until recently, however, Palau had a number of disjointed tobacco control laws that were not based on the WHO FCTC recommendations.

The Coalition for a Tobacco Free Palau (CTFP) has been advocating for comprehensive tobacco control legislation since 2004. Working in partnership with the Ministry of Health's Tobacco Control Program and APPEAL, they created a National Strategic Plan on Tobacco Control (Republic of Palau, 2008), in line with the WHO Regional Plan and the Palau National Non-communicable Disease Strategic Implementation Plan.

The Plan highlighted comprehensive legislation as a priority. Coalition members and tobacco control program staff provided technical assistance to legislators during the drafting of the comprehensive tobacco control bill. House Bill 8-8-1 was proposed in 2009, but encountered stiff opposition from several political leaders. The coalition conducted grassroots mobilization simultaneously with high-level advocacy and capacity building among Palau's Council of Chiefs, representing the traditional leadership in the country. They anchored their advocacy on Palau's available data showing rising tobacco consumption (both smoking and chewing tobacco with betel nut) among youth. This culminated in a Declaration by the Council of Chiefs that tobacco use, in any form, is not part of Palauan culture and “...should not receive any protection and respect to be preserved or maintained as a part of our cultures and traditions” (Declaration 12-001 2012, p. 1) The Declaration proved pivotal in countering political opposition to the proposed legislation from elected officials who persisted in characterizing tobacco use as a “personal choice.” The coalition also used media strategically, emphasizing the youth data and increasing airtime for public service announcements at crucial periods, such as when the proposed tobacco control bill was up for endorsement by the President.

Despite numerous legislative battles, Republic of Palau law 8-27 (RPPL no. 8-27, 2011), the first comprehensive tobacco control legislation in Palau, was finally passed on 19 August 2011. Although the current law lacks a number of important components required for alignment with Palau's FCTC obligations, it represents a significant improvement over the previous set of disjointed laws. The law bans tobacco advertising, including at point of sale. The point of sale ban was an exceptional win; Palau is the first, and to date, only Pacific Island nation and one of very few countries globally to have this key provision.

Discussion: Lessons Learned and Future Directions

These experiences highlight some of the lessons learned about re-shaping the social and policy environment to reduce tobacco-related disparities within the Pacific Islander context. Community capacity building and leadership development are the common themes propelling action to control tobacco across these settings. Key insights include:

1. Effective tobacco control requires a comprehensive mix of evidence-based interventions embodied in the WHO FCTC. The success of tobacco control in the Pacific will largely depend upon aligning national and community policies with WHO FCTC recommendations. Three Pacific Island nations have ratified the treaty – FSM, Palau and the Marshall Islands – and are obligated to fulfill the treaty's provisions. However, American Samoa, Guam and CNMI are US jurisdictions and fall outside the FCTC by virtue of the USA's non-ratification. Thus, the three US jurisdictions must rely on local drivers of policy change to voluntarily adhere to the standards set by the treaty; in this context, capacity building for effective tobacco control policies is crucial. Exclusion from the FCTC in itself is a cause for disparity because the FCTC Conference of Parties negotiations are a powerful capacity building process for legislative leaders. Recognizing this, Guam's legislature sent a resolution to the US government calling for speedy ratification of the treaty because “only ratification can obligate nations to implement its provisions” (Resolution 211-31, 2011, p. 5).

2. Investments in leadership development can yield significant benefits for tobacco control. Political and legislative solutions at the national level are among the most effective tobacco control interventions; but effective leaders and champions are necessary to ensure adoption of these proven interventions. Champions are also needed to counter opposition from the tobacco industry, including tobacco distributors and retailers and pro-tobacco elected officials. CNMI, Guam and FSM benefitted from APPEAL-sponsored leadership workshops; some of the workshop graduates were early tobacco control legislative champions in these islands. Policymakers as champions are vital, but because influencing social norms related to tobacco use requires culturally appropriate interventions, community champions are equally important. The experiences in American Samoa, FSM, and Palau underscore the value of having champions among traditional leaders, identified and cultivated through a systematic leadership development process.

3. Partnerships are essential. Given the broad nature of tobacco control, it is critical to expand the participation beyond the usual group of stakeholders in public health. Engaging civil society and community partners facilitates the mobilization process, as shown by CNMI's coalition, and expands the reach of tobacco control program staff, as demonstrated by the American Samoa experience. Building capacity on an ongoing basis among all tobacco control stakeholders is pivotal to the successful translation of polices into population behavioral change. At the regional level, partnerships across the various Pacific Islands are accelerating, as evidenced by the formation of the PPTFI (Pacific Partners for Tobacco Free Islands, 2012). In the future, global partnerships between Asia and the Pacific will also strengthen capacity to a) assist one another with tobacco control strategies; and b) to voice concerns about the devastating impact of U.S. and other tobacco companies worldwide.

4. Local data is crucial to inspire policy action against tobacco. The power of local data to convince policy leaders can surpass even the best data imported from outside the Region. Kosrae's ban on sales of single sticks of cigarettes, Palau's Tobacco Control Act and Guam's recent tobacco tax increase resulted in part because local data were used to justify legislative action. Investments in capacity building for surveillance and data infrastructure are essential to further strengthen the local evidence base and, as policies are enacted, to monitor the impact of policy change on tobacco use and its consequences.

5. Community engagement ensures broad ownership of tobacco control and facilitates policy and social norms change. American Samoa demonstrates the effectiveness of the village approach in ensuring broad delivery of cessation services. It also provided the entry point to engage influential village leaders in supporting the adoption of a smoke-free law. Community-based tobacco-free policies, such as Pohnpei, FSM's “Tobacco-free Village” policy, may be limited in scope, but these initiatives set the stage for a community-led process to adopt tobacco-free social norms. This eventually expedites successful passage and implementation of national tobacco control policies.

What impact, if any, have these policy changes had on tobacco consumption in the Pacific? Data are limited, but Guam has demonstrated measurable reductions in youth smoking in direct temporal association with tobacco control policy adoption (David, 2010). It is anticipated that similar reductions will be shown in the other Pacific Islands as their data capacity improves.

Conclusion

The process for eliminating tobacco-related disparities in the Pacific has begun. Investments in leadership development and capacity building for strategic planning and implementation of a comprehensive mix of tobacco control policies are starting to yield positive results. Increasingly, the Pacific Islands are moving towards achieving policy environments and community norms that are intolerant of tobacco use. Continued support from the international community and technical assistance partners will reinforce the current momentum towards broader policy interventions. The USAPIs are beginning to make inroads towards reducing tobacco use among Pacific Islanders and eliminating tobacco-related disparities. We are nearing that point in time when we no longer need to remind ourselves that “Tobacco is not Pacific-ly Correct.”