A controlled community-based trial to promote smoke-free policy in rural communities

Examining the creation of synergy in community coalitions for smoke-free environments in Armenia and Georgia

Community coalitions depend on their members to synergistically pool diverse resources, including knowledge and expertise, community connections and varied perspectives, to identify and implement strategies and make progress toward community health improvement. Several coalition theories suggest synergy is the key mechanism driving coalition effectiveness. The Community Coalition Action Theory (CCAT) asserts that synergy depends on how well coalitions engage their members and leverage their resources, which is influenced by coalition processes, member participation and satisfaction and benefits outweighing costs. The current study used mixed methods, including coalition member surveys (n = 83) and semi-structured interviews with leaders and members (n = 42), to examine the process of creating collaborative synergy in 14 community coalitions for smoke-free environments in Armenia and Georgia. Members, typically seven per coalition representing education, public health, health care and municipal administration sectors, spent an average of 16 hr/month on coalition-related work. Common benefits included making the community a better place to live and learning more about tobacco control. The greatest cost was attending meetings or events at inconvenient times. Members contributed various resources, including their connections and influence, skills and expertise and access to population groups and settings. Strong coalition processes, greater benefits and fewer costs of participation and satisfaction were correlated with leveraging of member resources, which in turn, was highly correlated with collaborative synergy. Consistent with CCAT, effective coalition processes created a positive climate where membership benefits outweighed costs, and members contributed their resources in a way that created collaborative synergy.

Community coalitions for smoke-free environments in Armenia and Georgia: A mixed methods analysis of coalition formation, implementation and perceived effectiveness

Effective models for aligning public health and civil society at the local level have the potential to impact various global health issues, including tobacco. Georgia and Armenia Teams for Healthy Environments and Research (GATHER) is a collaboration between Armenia, Georgia and U.S. researchers involving a community randomized trial testing the impact of community coalitions to promote smoke-free policy adoption and compliance in various settings. Community Coalition Action Theory (CCAT) was used to guide and describe coalition formation, implementation and effectiveness. Mixed methods were used to evaluate 14 municipality-based coalitions in Georgia and Armenia, including semi-structured interviews (n = 42) with coalition leaders and active members, coalition member surveys at two timepoints (n = 85 and n = 83), and review of action plans and progress reports. Results indicated successful creation of 14 multi-sectoral coalitions, most commonly representing education, public health, health care, and municipal administration. Half of the coalitions created at least one smoke-free policy in specific settings (e.g., factories, parks), and all 14 promoted compliance with existing policies through no-smoking signage and stickers. The majority also conducted awareness events in school, health care, and community settings, in addition to educating the public about COVID and the dangers of tobacco use. Consistent with CCAT, coalition processes (e.g., communication) were associated with member engagement and collaborative synergy which, in turn, correlated with perceived community impact, skills gained by coalition members, and interest in sustainability. Findings suggest that community coalitions can be formed in varied sociopolitical contexts and facilitate locally-driven, multi-sectoral collaborations to promote health. Despite major contextual challenges (e.g., national legislation, global pandemic, war), coalitions were resilient, nimble and remained active. Additionally, CCAT propositions appear to be generalizable, suggesting that coalition-building guidance may be relevant for local public health in at least some global contexts.

Readiness for Tobacco-Free Policy in a Statewide University System

Background. Almost 2,000 campuses have adopted tobacco-free (TF) policies across the United States. However, there is not a systematic process to help campuses implement successful policies. Readiness assessments can help provide assistance as campuses work to implement successful policies. Purpose. We assessed readiness for TF policies among campuses of a statewide university system and determined factors associated with readiness. Participants. Stakeholders from 23 campuses without 100% TF policies were invited to participate in an online survey. Method. System administrators provided contacts for five to eight stakeholders per campus. Included in the analysis were 10 of 23 campuses (43.5%) with at least three stakeholders completing the survey. Results. Of the 10 campuses, one was in Preplanning, five were in Preparation, and four were in the Initiation stage of readiness. Political Climate was the highest scored dimension on seven campuses (0.74-1.0); Resources was the lowest on eight campuses (0.0-0.67). Campus size and county rurality were each associated with one dimension score. Conclusions. Despite being part of a statewide university system, campuses are in varying stages of readiness for TF policies. Stage-based strategies to advance TF campus policies must be implemented to set campuses up for successful policies.

PhenX: Environment measures for Tobacco Regulatory Research

OBJECTIVE

A Working Group (WG) of tobacco regulatory science experts identified measures for the tobacco environment domain.

METHODS

This article describes the methods by which measures were identified, selected, approved and placed in the PhenX Toolkit.

FINDINGS

The WG identified 20 initial elements relevant to tobacco regulatory science and determined whether they were already in the PhenX Toolkit or whether novel or improved measures existed. In addition to the 10 complementary measures already in the Toolkit, the WG recommended 13 additional measures: aided and confirmed awareness of televised antitobacco advertising, interpersonal communication about tobacco advertising, media use, perceived effectiveness of antitobacco advertising, exposure to smoking on television and in the movies, social norms about tobacco (for adults and for youth), worksite policies, youth cigarette purchase behaviours and experiences, compliance with cigarette packaging and labelling policies, local and state tobacco control public policies, and neighbourhood-level racial/ethnic composition. Supplemental measures included youth social capital and compliance with smoke-free air laws and with point of sale and internet tobacco marketing restrictions. Gaps were identified in the areas of policy environment (public and private), communications environment, community environment and social environment (ie, the norms/acceptability of tobacco use).

CONCLUSIONS

Consistent use of these tobacco environment measures will enhance rigor and reproducability of tobacco research.

Rural-urban disparities in tobacco retail access in the southeastern United States: CVS vs. the dollar stores

Objectives

CVS, the largest US pharmacy chain, discontinued selling tobacco products in 2014; meanwhile, Family Dollar and Dollar General, the two largest dollar store chains, began selling tobacco in 2012 and 2013, respectively. The purpose of this study is to evaluate the differential change in tobacco retailer density (TRD) by rurality throughout 12 Southeastern US states.

Methods

Tobacco retailer density was calculated for CVS and dollar store locations and combined to represent retailer density change before and after policy changes. Bivariate analyses were conducted to compare the corporate-initiated changes in county-level retailer density across rurality categories.

Results

Findings suggest a statistically significant difference (p < 0.0001) between TRD effect and rurality. Urban counties together experienced a retailer density increase of 0.4 stores per 10 k adult population, while rural counties reported a TRD increase of 2.6—eight (8) times the increase in urban areas.

Conclusions

Recent corporate policy changes on tobacco sales have increased access to tobacco retailers in rural counties considerably more than in urban counties, contributing to further disparities. CVS pharmacies discontinuing tobacco sales caused a decrease in retail density in urban areas, and the decision of the dollar stores locations initiating tobacco sales resulted in a greater burden to rural and small-metro counties.

Short- and Long-Term Effects of a Tobacco-Free Executive Order on Employee Tobacco Use

Smoke-free workplace policies encourage cessation, reduce tobacco consumption, and shift the pro-tobacco norm. However, no research exists evaluating the impact of mandated tobacco-free policies on government property. The purpose of our study was to examine short- and long-term effects of a tobacco-free policy (executive order 2014-747) implemented in November 2014, prohibiting tobacco use on state executive property. Cross-sectional online surveys were administered at two time points to a total of 27,000 employees of the executive branch of the Commonwealth of Kentucky. The short-term evaluation (March 2015) comprised 4,170 employees and the long term (August 2015) included 3,070. Tobacco use, plans to quit using tobacco, personal characteristics, whether the county of their workplace was covered by a smoke-free policy, and social norms for tobacco use were assessed 4- and 9-month post-policy implementation. Current tobacco use and plans to quit were compared between short- and long-term evaluations using multiple logistic regression with relevant covariates included. Controlling for demographics and employment location, employees reported lower rates of tobacco use and higher rates of planning to quit in the long term than in the short term. Tobacco-free policies reduce tobacco use prevalence and promote plans to quit, particularly over time. We found differences in tobacco use prevalence and plans to quit using tobacco products from 4 to 9 months after the policy took effect, as reported by employees following implementation of the tobacco-free policy. These findings support the potential for avoiding long-term health care costs as a result of reduced tobacco use from these policies. Nurses can play an important advocacy and policy evaluation role to promote and assess the impact of tobacco-free policies.

Disparities in Rural Tobacco Use, Smoke-Free Policies, and Tobacco Taxes

Tobacco use and exposure to secondhand smoke (SHS) remain leading causes of preventable disease, disability, and mortality in the United States. Rural populations are among those being left behind in the recent declining smoking rates and have become a focus of discussions on tobacco-related disparities. This article describes tobacco-related disparities in rural populations including tobacco use, exposure to SHS, smoke-free policies, and tobacco taxes. Nurses, as social justice and tobacco control policy advocates, are needed especially at the local level, where much of the policy work occurs and where nursing's voice is respected and can be powerful.

Variations in support for secondhand smoke restrictions across diverse rural regions of the United States

Significant disparities exist between rural-urban U.S.

POPULATIONS

Besides higher smoking rates, rural Americans are less likely to be protected from SHS. Few studies focus across all regions, obscuring regional-level differences. This study compares support for SHS restrictions across all HHS regions.

DATA

2014/15 TUS-CPS; respondents (n = 228,967): 47,805 were rural residents and 181,162 urban. We examined bi-variates across regions and urban-rural adjusted odds ratios within each. Smoking inside the home was assessed along with attitudes toward smoking in bars, casinos, playgrounds, cars, and cars with kids. Urban respondents were significantly more supportive of all SHS policies: (e.g. smoking in bars [57.9% vs. 51.4%]; support for kids in cars [94.8% vs. 92.5%]. Greatest difference between urban-rural residents was in Mid-Atlantic (bar restrictions) and Southeast (home bans): almost 10% less supportive. Logistic regression confirmed rural residents least likely, overall, to support SHS in homes (OR = 0.78, 95% CI 0.74, 0.81); in cars (OR = 0.87, 95% CI 0.79, 0.95), on playgrounds (OR = 0.88, 95% CI.83, 0.94) and in bars OR = 0.88, 95% CI 0.85, 0.92), when controlling for demographics and smoking status. South Central rural residents were significantly less likely to support SHS policies-home bans, smoking in cars with kids, on playgrounds, in bars and casinos; while Heartland rural residents were significantly more supportive of policies restricting smoking in cars, cars with kids and on playgrounds. Southeast and South Central had lowest policy score with no comprehensive state-level SHS policies. Understanding differences is important to target interventions to reduce exposure to SHS and related health disparities.

Readiness to Adopt Physical Activity Policies in Rural Communities

The purpose was to explore community readiness to adopt physical activity (PA) policies by adapting and pilot testing an online survey (Physical Activity Readiness Survey [PARS]). PARS was adapted from the previously tested Community Readiness Survey-Short. In February/April 2016, key informants (N = 17) involved in PA activities from two rural communities were invited to complete the PARS, representing six dimensions: knowledge, leadership, resources, community climate, existing voluntary PA policies, and political climate. First, participants were asked to respond to a presurvey to screen for overall readiness for up to four evidence-based PA policies. A main survey readiness score (0-6) was determined by averaging the key informants' ratings across items: Raw scores were rescaled to range from 0 to 1, and dimension scores were summed. Participants identified two PA policies in the presurvey: neighborhood availability and point-of-decision prompts. For both policies, political climate had the highest dimension score (1.0) and the knowledge dimension scored lowest (0.05-0.38). Overall readiness scores ranged from 3.19 to 3.62, revealing the preparation stage for both policies. Readiness for the two PA policies were similar, but specific dimension scores varied by policy type and community, reinforcing the need for tailored interventions.

A Social-Ecological Review of Cancer Disparities in Kentucky

Cancer continuously ranks among the top 10 leading causes of death in the United States. The burden of cancer is particularly elevated in the Commonwealth of Kentucky and its 54-county Appalachian region, where cancer is the leading cause of death. Kentucky's high rates of cancer have been attributed to a wide range of socioeconomic, behavioral, environmental, and policy influences, resulting in numerous disparities. The present review specifically evaluates the burden of lung, colorectal, cervical, and head and neck cancers in Kentucky, along with resultant cancer control research and community outreach efforts conducted by the state's only National Cancer Institute-designated cancer center using an adapted version of McLeroy's Social-Ecological Model. Here, we categorize disparities and identify relevant intervention approaches based on their level of influence (ie, individual, community, and policy).

Key Factors Inhibiting Legislative Progress Toward Smoke-Free Coverage in Appalachia

The Appalachian Region has among the highest rates of smoking and smoking-related illness in the United States. Strong smoke-free legislation could help protect nonsmoking residents from the harmful effects of secondhand smoke. However, there is a dearth of state, county, city, and subcounty smoke-free law coverage throughout Appalachia. As of July 2016, only 21% of Appalachian residents were covered by comprehensive smoke-free laws (i.e., 100% coverage for workplaces, restaurants, and bars). Only 46% of Appalachians lived in places with 100% smoke-free workplace laws, only 30% lived in places with 100% smoke-free restaurant laws, and only 29% lived in places with 100% smoke-free bar laws. Reasons for this lack of smoke-free law coverage include socioeconomic disadvantage, the historical importance of tobacco in Appalachian economies, and preemptive state legislation. By understanding the contextual issues that have inhibited smoke-free legislation, smoke-free advocates will be better prepared to lead efforts that expand smoke-free coverage in this region.

A Policy Analysis of Smoke-Free Legislation in Kentucky

This article presents a policy analysis of proposed smoke-free legislation in Kentucky during the 2015 General Assembly. Kingdon's three streams model of agenda setting is used to analyze the failure to pass HB145. Secondhand smoke exposure and related deaths are a significant public health problem in Kentucky, a state with one of the highest smoking rates in the U.S. HB145, a comprehensive smoke-free bill, was designed to protect workers and the general public from secondhand smoke and e-cigarette aerosol in enclosed workplaces and public places, with few exemptions. The bill faced intense criticism from opponents who were concerned about violation of personal and business rights and the belief that the decision should be addressed on a local level. HB145 passed the House with amendments but failed to receive a hearing in the Senate. Failure of the smoke-free legislation was due to partisanship, fragmentation of advocacy groups, lack of political bargaining, and conflict of values. As in past years, the policy window did not open for state smoke-free legislation in 2015.

Recall and Effectiveness of Messages Promoting Smoke-Free Policies in Rural Communities

INTRODUCTION

Low-cost media campaigns increase demand for smoke-free policies in underserved rural areas. The study examined the impact of loss- and gain-framed smoke-free print ads on recall and perceived effectiveness in rural communities, controlling for personal characteristics.

METHODS

Following 6- to 9-month print media campaigns in three rural counties, recall and perceived effectiveness of loss-framed (ie, targeting dangers of secondhand smoke [SHS]) and gain-framed (ie, highlighting positive aspects of smoke-free air) ads were assessed using random-digit-dial phone surveys. Respondents were asked if they remembered each ad, whether they liked it, whether they were prompted to contact a smoke-free coalition, whether the ad made them think, and whether it prompted emotion. Mixed modeling assessed whether personal factors predicted ad recall or perceived effectiveness.

RESULTS

Loss-framed ads were less likely to be recalled but more likely to prompt emotion. For ads of both frame types, females reported greater recall and perceived effectiveness than males. Those with less education reported higher perceived effectiveness of the ads but lower recall. Nonsmokers were more likely than smokers to perceive the ads as effective. Knowledge of SHS risk and support for smoke-free workplaces were positively associated with recall and effectiveness.

CONCLUSIONS

Ad recall and perceived effectiveness were associated with framing and demographic and personal characteristics. Smoke-free efforts in rural areas may be bolstered by continuing to promote benefits of smoke-free workplace policies and educate on SHS risks. Rural areas may need to provide a combination of ad types and framing strategies to appeal to a wide audience.

IMPLICATIONS

Rural communities are disproportionately affected by SHS and less likely to be protected by smoke-free policies. This study adds evidence-based guidance for tailoring rural smoke-free media campaigns using different framing: gain-framed messages (ie, benefits of smoke-free environments) to promote recall and loss-framed content (ie, dangers of SHS) to prompt emotion. Further, gain-framed messages that are localized to the rural community may be especially effective. Findings support designing smoke-free campaigns in rural communities with the audience in mind by tailoring messages to age, sex, and education level.

Creating Effective Media Messaging for Rural Smoke-free Policy

OBJECTIVES

Objectives were to (1) explore perceived effectiveness of existing smoke-free print advertisements in rural communities and (2) generate message content, characteristics, and media delivery channels that resonate with residents.

DESIGN AND SAMPLE

Qualitative methods design. Thirty-nine rural adults recruited by community partners.

MEASURES

Content analysis of findings from individuals in four focus groups who participated in general discussion and reviewed eight print ads related to secondhand smoke (SHS) and smoke-free policy.

RESULTS

Six content themes were identified: smoking/SHS dangers, worker health, analogies, economic impact, rights, and nostalgia. Seven message characteristics were recognized: short/to the point, large enough to read, graphic images, poignant stories, statistics/charts/graphs, message sender, and messages targeting different groups. Four media delivery channels were considered most effective: local media, technology, billboard messages, and print materials.

CONCLUSIONS

Seeking input from key informants is essential to reaching rural residents. Use of analogies in media messaging is a distinct contribution to the literature on effective smoke-free campaigns. Other findings support previous studies of effective messaging and delivery channels. Further research is needed to examine effectiveness of themes related to message content in smoke-free ads and delivery strategies. Effective media messaging can lead to policy change in rural communities to reduce exposure to SHS.