Tobacco Control in Rural America

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1 Tobacco Control in Rural America

2

3 Tobacco Control in Rural America July 2009

4 Legacy s Commitment to Dissemination The American Legacy Foundation (Legacy) is committed to building a world where young people reject tobacco and anyone can quit. To urther this mission, Legacy has engaged in a comprehensive dissemination eort to share inormation about the replicable, sustainable tobacco control projects being implemented around the nation with the assistance o Legacy unding. Tobacco Control in Rural America is the seventh in Legacy s series o dissemination publications and is intended to highlight the issue o tobacco-related disparities acing rural areas in the United States. This publication examines the unique challenges to tobacco control and prevention eorts in these areas and ways in which organizations can overcome them. It includes examples o promising strategies implemented by some o our grantees to demonstrate how organizations are addressing the issue o tobacco use in rural communities across America. This publication may include certain grantee activities beyond the scope o Legacy s grants. Some o our grantees tobacco control activities have multiple unders, and it is essential to examine the ull range o program activities to explore various ways organizations are implementing tobacco control and prevention eorts in rural areas. No Legacy unds were used or lobbying or other political activities. Grassroots community-based organizations, state and local tobacco control oices, and other public health groups oten look or successul interventions that address tobacco-related disparities in rural communities; this publication helps to support that purpose. Policy makers and practitioners in oundations and nonproits in general also will beneit rom the case studies and discussion in this publication. [Legacy recognizes and honors the act that tobacco has a sacred cultural place in American Indian lie in parts o North America. Many Native American tribes use tobacco or spiritual, ceremonial and medicinal purposes. Legacy, thereore, distinguishes traditional, cultural and medicinal use o tobacco rom its commercial use. Legacy promotes tobacco control eorts that are not geared toward targeting traditional tobacco. Legacy only supports programs and activities designed to address the issue o manuactured, commercial tobacco use in communities including Native American communities in the United States.]

5 Table o Contents EXECUTIVE SUMMARY 4 CHAPTER 1: Tobacco-Related Disparities in Rural America 6 thru 13 Introduction 6 Rural : A Common Word with Many Deinitions 6 Racial and Ethnic Diversity in Rural Areas 9 High Prevalence o Smoking and Tobacco Use 9 Disproportionate Exposure o Children to Secondhand Smoke 10 Challenges to Tobacco Control and Prevention Eorts in Rural Settings 11 Rural Areas and Disprortionate Burden o Tobacco Use 12 Assets and Opportunities in Rural America 12 Key Strategies to Address Tobacco-Related Disparities in Rural America 12 CHAPTER 2: Case Studies 14 thru 36 CASE STUDY 1 Campesinos Sin Fronteras: Futuro Claro Grassroots Tobacco Education in the Borderland 15 CASE STUDY 2 Selby General Hospital Creative Outreach or a Marginalized Rural Community 20 CASE STUDY 3 Colorado Chew Tobacco Collaborative Initiative Targeting Chew Tobacco with Community-Based Participatory Research 24 CASE STUDY 4 La Crosse County Health Department: Western Wisconsin Tobacco and Alcohol Reduction Project Addressing the Dual Challenges o Tobacco and Alcohol Use 29 CASE STUDY 5 University o Maine: Tobacco Access Portal Dismantling Literacy Barriers to Tobacco Inormation 33 APPENDIX 37 thru 41 Map: New Immigration Population Change: Non-Metro Counties in the U.S. Endnotes Tobacco Control in Rural America 3

6 EXECUTIVE SUMMARY TOBACCO CONTROL IN RURAL AMERICA This publication takes a closer look at tobacco control eorts under way outside o metropolitan areas, where tobacco use is higher than in urban centers. From the outset, this report establishes a working deinition o rural beyond demographics and population density, with an eye toward cultural distinctions. A one-size-itsall approach to tobacco control can be problematic, and one must also account or vast diversity within rural areas. We explore place-based policy in this publication and conclude that a lexible and dynamic approach to tobacco control is particularly important when targeting the speciic challenges o priority population groups in rural America. The publication examines: Tobacco-related disparities acing rural areas; Socioeconomic and cultural conditions that cause these disparities in these areas; Challenges to tobacco control and prevention eorts in rural areas; and Unique assets or opportunities in rural areas or eective tobacco control interventions. A series o case studies explores eective strategies that have shown measurable outcomes in rural communities in very dierent parts o the country. Place matters: What works in southeast Ohio may not be a good it or communities in southeast Arizona. Despite the dierences among the communities presented in this publication, a broad set o promising practices has emerged. Each o the highlighted projects spends a great deal o time determining speciic and endemic contributing actors to tobacco use. Each strives to broaden its interventions and research beyond a strictly clinical approach and aims to establish nontraditional collaborations. Each takes a creative approach to acilitating the enorcement o tobacco-ree policies, reshaping norms and public opinion around tobacco use, or connecting rural tobacco users with cessation services. The U.S.-Mexico border area has high concentrations o poverty and low literacy, making the arm worker population susceptible to dramatic tobacco-related health disparities. In our irst case study, we see how Campesinos Sin Fronteras (CSF) employs a truly grassroots approach to addressing tobacco usage in that community. The borderland is a unique place or tobacco control eorts, with a transient population that is inluenced by messages rom both sides o the ence, but it occupies a subculture o its own. We highlight how CSF relies on well-established relationships, trust, and deep local knowledge to eectively promote tobacco-ree policies on arm buses and encourage cessation in the ields. Smokeless tobacco usage is a ar greater cause or concern in rural areas than in metropolitan areas, and chew usage oten comes with a higher degree o acceptance outside o urban centers. Even in rural states and counties, many public health workers ind that smokeless tobacco control has not been given adequate attention. Two programs highlighted in this report investigate the promising practices o projects in Colorado and Ohio, each taking aim at the entrenched, multigenerational tradition o smokeless tobacco use. Our second case study looks at the tobacco control program o Selby General Hospital in Appalachia s Mid-Ohio Valley. Selby ocuses on both cigarettes and smokeless products in a community with a high

7 We hope the wide geographic and cultural spread o these case studies presents a broad snapshot o rural tobacco control eorts and patterns o common challenges aced, key lessons learned, and promising interventions developed. level o acceptance or tobacco usage. The Mid-Ohio Valley has high poverty, low levels o education, and degraded air quality rom decades o toxic heavyindustry emissions. Selby takes its services directly to the population, interacing with clients in checkcashing stores, tattoo parlors, and even gathering places or deer hunters. The Colorado Chew Tobacco Collaborative Initiative s ar-reaching, community-based participatory research is our third case study. This project aims to uncover the norms surrounding acceptance o smokeless tobacco throughout the rural counties o that state, using a large-scale, collaborative, ethnographic approach. Here, community members are enlisted to an out and photograph what chew tobacco looks like in your lie, thus compiling a prismatic view o this looming public health crisis. These photos showcasing a wide variety o places, rom the boys locker room to the homemaker s purse are then used as prompts to begin a community dialogue around the dangers o smokeless tobacco and approach a community policy consensus. The ourth case study looks at the work o the La Crosse County Health Department (LCHD) in Wisconsin, ocusing on the dual challenges o tobacco use and alcohol dependence. La Crosse County has one o the highest binge drinking rates in the country and an unusually high concentration o bars and taverns. Heavy drinking tends to go hand in hand with tobacco use, and one-third o Wisconsin residents between the ages o 25 and 44 without a high school diploma are tobacco users. LCHD works with employers o this population to provide targeted and tailored cessation support. This project also ocuses on La Crosse residents in alcohol recovery programs, under the premise that quitting smoking helps in maintaining sobriety. Dismantling the tobacco acceptance characteristic o support group culture is a particular challenge, but LCHD is beginning to see some results. The ith and inal case study is a departure rom the boots on the ground approach to tobacco control. The University o Maine s Tobacco Access Portal aims to improve the accessibility o web-based tobacco education resources to rural Mainers. The vast majority o these websites, the researchers ound, ailed to meet the basic guidelines o accessibility. This portal distills and simpliies, on a phrase-by-phrase and word-by-word basis, the language o tobacco education websites to be readable by tobacco users with a wide range o literacy, rom high school dropouts to highly educated immigrants with limited English acility. Dismantling literacy barriers to tobacco inormation, argue the researchers, is a human rights issue that has too long been overlooked. Tobacco Control in Rural America 5

8 CHAPTER ONE TOBACCO-RELATED DISPARITIES IN RURAL AMERICA Introduction Organizations in the ield o tobacco control and prevention generally recognize the importance o implementing culturally tailored programs to address the issue o tobacco use in high-risk populations. Some speciic population groups based on race or ethnicity, age, sex, socioeconomic status, sexual orientation, mental health, level o education, co-morbidities, and geographic location experience disproportionate eects o tobacco use. Disparities exist among these groups in terms o prevalence o tobacco use, risk o illness, mortality, and economic consequences resulting rom tobacco use. Research has established that there are also signiicant gaps among these groups in terms o tobacco control capacity and inrastructure, access to appropriate services and resources, and risk o exposure to secondhand smoke. Organizations oten make the mistake o addressing these disparities with a one-size-its-all approach to tobacco control and prevention. In order to address the unique needs o each o these populations and to create eective interventions, the tobacco control community needs to ocus on identiying speciic conditions that give rise to tobacco-related disparities in these populations and subsequently design programs adapted to these speciic conditions. This publication is part o Legacy s ongoing commitment to shine a spotlight on tobacco-related disparities. Place Matters This particular publication ocuses on disparities across geographic regions or locations and highlights disproportionate eects o tobacco use in rural areas across America. In the ollowing chapters, this report examines: Tobacco-related disparities acing rural areas; F actors or conditions that cause these disparities; Exceptional challenges to tobacco control and prevention eorts in rural areas; Unique assets or opportunities in rural areas or eective interventions; and Examples o promising interventions implemented by ive Legacy grantees to address the unique tobacco control needs o their rural constituents. This publication seeks to urther deine tobaccorelated disparities in rural America, adding to the knowledge o unique rural actors or conditions that contribute to these disparities. Legacy s ultimate goal is to encourage organizations to urther examine these disparities and identiy unique rural actors and challenges so that they are better positioned to implement eective interventions in their communities. Rural : A Common Word with Many Deinitions The word rural is generally used to describe some unique social, economic, geographic, demographic, and cultural characteristics or conditions o people and places. But there is no single, common or universal deinition o the word. What are the characteristics o a rural area? Is it the population size o a geographical region? Is it the density o population o an area? Is it a particular set o economic, social, and cultural eatures o a place? Should the relative geographical isolation o a community rom a metropolitan area be the sole deining criterion? Apart rom population size, population density, and distance rom the nearest metro area, what other conditions make an area rural? Do all rural areas have similar conditions? Answers to these questions do not usually lead to a precise and clear-cut deinition. Many regions in America are not clearly rural or urban, irrespective o what speciic criteria are being used to deine them. They

9 all somewhere along an urban-rural continuum. For example, even a county that is commonly deined as an urban or metropolitan area based on its population usually has large pockets o rural communities. Rurality may be best understood as a relative term that indicates a very complex range o possible urban-rural variations. Instead o ollowing a common measure to deine the rurality o a place, organizations should consider the context o a particular programmatic eort to determine, based on dierent rurality actors, whether their target area or population group is rural; how relatively rural the area is; and, most importantly, what rural conditions or challenges are relevant to their programs. Even within the ederal government, multiple deinitions o rural exist. 1 Oten, these deinitions do not lead to the identiication o similar regions as rural. As the U.S. Department o Agriculture (USDA) s Economic Research Service argues, Researchers and policymakers share the task o choosing appropriately rom among the more than two dozen rural deinitions currently used by Federal agencies. Furthermore, The share o the U.S. population considered rural ranges rom 17 to 49 percent depending on the deinition used. 2 Describing the importance o identiying a particular set o rural actors that are relevant to health and health care, Eric H. Larson and L. Gary Hart write, Tobacco control programs can better identiy and target a very speciic at-risk population group by incorporating the most relevant economic, social, cultural, and tobacco-related conditions into the deinition o a rural community. Deinitions o rurality are limited and approximate. Rurality is multidimensional, with many sociologic, demographic, economic, and geographic acets. The various rural concepts are oten imprecise and occasionally contradictory. Sometimes, rurality is useully understood as a continuum. Other times, it is better understood as a dichotomy. To choose a deinition o rurality that helps the health policy maker or health researcher make useul distinctions between rural and urban, or within rural areas, it is important to understand which aspects o rurality matter or health, health workorce, and the delivery o health services to rural populations. 3 Rural areas in the United States are diverse and represent a wide range o actors that contribute to the rurality o an area. According to the Institute o Medicine, Rural communities are heterogeneous in other ways as well, diering in population density, Tobacco Control in Rural America 7

10 A string o rural counties along the border o Texas and Mexico, and stretching into New Mexico and Arizona, also have experienced rapid increases in their recent immigrant populations. Given their proximity to Mexico and roots as ormer territories o Mexico, it is little surprise that they are overwhelmingly Hispanic. Seven o the eight rural counties noted on Map 2 [see Appendix A] have populations that are more than one-hal Hispanic, ive are more than 80-percent Hispanic, and Starr County, Texas, is ully 98-percent Hispanic. Lei Jensen, New Immigrant Settlements in Rural America: Problems, Prospects, and Policies, [Durham, NH: Carsey Institute, University o New Hampshire],19, Immigration.pd [accessed June 22, 2009]. remoteness rom urban areas, and economic and social characteristics. 4 Rural areas in West Virginia are dierent rom those in Texas. Similarly, the conditions that can be characterized as rural in Northern Caliornia are greatly dierent rom rural areas in Arizona or Alaska. Rural communities along the U.S.-Mexico border represent a unique set o rurality actors. Most o these communities are predominantly Hispanic or Latino and are made up o recent immigrants with strong social and cultural roots on the both sides o the border. 5 These immigrants usually cross the border in both directions on a regular basis. As Joel Rodríguez- Saldaña writes, The communities along the border are economically and socially interdependent, with more than 1 million legal northbound crossings every day. 6 Most importantly, compared to their counterparts in metropolitan areas, people living in the rural areas along the border are oten extremely disadvantaged, economically and educationally, much more so than people living in other parts o the country. According to the Pan American Health Organization, Four o the seven poorest cities and ive o the poorest counties in the United States are located in Texas along the Mexican border. Generally, counties on the U.S. side have experienced an increase in unemployment and a decrease in per capita income over the past 30 years. For example, in the city o El Paso, Texas, poverty is twice the national average and average income is onethird the national igure. The educational level o the population in U.S. border counties also is lower than elsewhere in the country. 7 A single, uniorm deinition or scheme cannot capture or represent each and every rural area o the nation. Thereore, every tobacco control intervention should be tailored to a speciic set o rural conditions o a community to eectively meet its unique tobaccorelated challenges. Highlighting the signiicance o a place-speciic approach, Lawrence C. Hamilton, et al., at Carsey Institute, University o New Hampshire, write in their report, Place Matters: Challenges and Opportunities in Four Rural Americas : Policy must become more place-based, not simply in terms o geographic location, but also with awareness o social, cultural, economic, environmental, and political characteristics. Each o the CERA [Community and Environment in Rural America] study regions is struggling with its own place-speciic issues and problems, which call or dierent policies and solutions. However, some needs appear common across all regions, such as advanced telecommunications technology, access to good education at all levels, aordable and accessible healthcare, and orward-looking transportation systems. 8 In the context o public health and tobacco control, speciic criteria to create a rural-urban deinition o an area should be based on desired program goals and outcomes. The most prudent approach or organizations is to ask what speciic rurality conditions give rise to unique tobacco-related disparities in a particular region or place and what programmatic actions they need to take to best address those disparities. County Type Deinition Adopted by the Department o Health and Human Services, Substance Abuse and Mental Health Services Administration, Oice o Applied Studies. In this report, or the purpose o analyzing the data on the prevalence o tobacco use in rural areas and highlighting how this issue has a disproportionate impact on these areas, we use the rural-urban deinition developed by the U.S. Department o Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA), Oice o Applied Studies.

11 There are no other sources o this type o data at the national level that can establish dierences in tobacco use across geographic regions or locations. In their surveys and publications, most o the HHS agencies generally ollow this rural-urban scheme. According to SAMHSA s county type scheme, Counties were grouped based on the Rural/Urban Continuum Codes developed by the U.S. Department o Agriculture (2003). Each county is in either a metropolitan statistical area (MSA) or outside o an MSA. Large metropolitan (large metro) areas have a population o 1 million or more. Small metropolitan (small metro) areas have a population less than 1 million. Nonmetropolitan (nonmetro) areas are outside o MSAs and include urbanized counties with a population o 20,000 or more in urbanized areas, less urbanized counties with a population o at least 2,500 but ewer than 20,000 in urbanized areas, and completely rural counties are those with a population o ewer than 2,500 in urbanized areas. 9 Racial and Ethnic Diversity in Rural Areas The racial and ethnic landscape o rural America is changing rapidly. Today s rural areas are much more racially and ethnically diverse than they were in the past. Besides Whites, Blacks, and Native Americans, a growing number o Hispanics/Latinos, Asians, and Paciic Islanders constitute the rural population. Although the population in rural America is still predominantly White, these other groups now have a strong presence not only in border regions o the Southwest but also in communities in the Midwest and Southeast. According to USDA s Economic Research Center, Hispanics and Asians are the astest growing minority groups in the United States as a whole and in nonmetro areas. Blacks, concentrated in the deep South, remain the largest minority group in nonmetro areas, making up 8.4 percent o all nonmetro residents in This igure has hardly changed since In contrast, the Hispanic proportion grew rom 3.1 percent in 1980 to 6.4 percent by The Economic Research Center urther notes, Racial and ethnic minorities now make up 18.3 percent o nonmetro residents and are geographically dispersed throughout the nation. 11 Arguing that rural America will be even more diverse in the uture, Kenneth Johnson at the Carsey Institute, University o New Hampshire, notes, Data on the rates o population growth among the various racial and ethnic groups in rural America suggest that diversity is likely to increase in the uture. 12 Organizations need to recognize this changing racial and ethnic mix in rural communities and implement culturally tailored programs that can address the unique tobacco control needs o dierent minority groups. In the ollowing sections, this publication ocuses on the disproportionate impact o commercial tobacco use on rural areas, the unique set o challenges acing tobacco control eorts in these areas, and ways to address these challenges. High Prevalence o Smoking and Tobacco Use Cigarette smoking is more prevalent in rural communities compared to large and small metropolitan areas. 13 According to the Centers or Disease Control and Prevention (CDC) s 2006 National Health Interview Survey, current cigarette smoking among persons 18 and older varied signiicantly by geographic regions. The smoking rate was highest among individuals living outside o a MSA and lowest among people who were living in a large metro area. As presented in Figure 1 below, among people not living in metropolitan statistical areas, the smoking rate was 25.1 percent, compared to 18.5 percent among people in large metro areas and 22.1 percent in small metro areas. 14 FIGURE 1 AGE ADJUSTED PERCENT DISTRIBUTIONS (WITH STANDARD ERRORS) OF CURRENT CIGARETTE SMOKING STATUS AMONG PERSONS 18 YEARS OF AGE AND OVER, BY PLACE OF RESIDENCE: UNITED STATES, PERCENTAGE 25.1 % NOT IN MSA 22.1 % SMALL MSA 18.5 % LARGE MSA Source: Smoking Status Data CDC, National Interview Survey, Prepared by American Legacy Foundation. Tobacco Control in Rural America 9

12 FIGURE 2 TOBACCO PRODUCT USE IN LIFETIME, PAST YEAR AND PAST MONTH AMONG PERSONS AGED 18 TO 25, Large Metro Small Metro Urbanized Less Urbanized Completely Rural PERCENTAGE PAST MONTH PAST YEAR LIFETIME Source: SAMHSA, Oice o Applied Studies, National Survey on Drug Use and Health, 2006 and Prepared by American Legacy Foundation. As shown in Figure 2 above, tobacco use by adults aged 18 to 25 is highest in rural areas compared to those who live in large or small metro areas. The rates o tobacco use in nonmetro areas or past month, past year and lietime are all higher than the rates in metro areas. According to SAMHSA, Oice o Applied Studies, Past-month prevalence reers to using a type o tobacco product (any tobacco product, cigarettes, cigars, smokeless tobacco, and pipes) at least once during the 30 days preceding the survey interview date. This prevalence type is also reerred to as current use. Past-year prevalence reers to using a speciic type o tobacco product at least once during the 12 months preceding the interview date. Lietime prevalence reers to a respondent reporting use o a speciic type o tobacco product at least once in their lietime. 17 High Prevalence o Smokeless Tobacco Use in Rural Settings Use o smokeless tobacco is most common in rural areas. Various national surveys have clearly shown that the use o smokeless tobacco is undeniably high in rural areas versus small and large metropolitan areas. According to the 2006 and 2007 National Survey on Drug Use and Health, the use o smokeless tobacco is two to three times higher in less urbanized and completely rural areas o the country (see Figure 3, page 11) compared to large and small metropolitan areas. Combined 2002 to 2007 data also indicate that past-month smokeless tobacco use is highest among persons who live in completely rural and less urbanized counties in nonmetropolitan areas and lowest among persons who live in large metropolitan areas. 18 Smokeless tobacco use is entrenched in the social and cultural norms and practices o many rural communities. Moreover, the manuacturers o smokeless tobacco products have exploited these social and cultural aspects o tobacco use and targeted these rural areas with persistent marketing campaigns to promote smokeless tobacco products. Tobacco companies sponsorships o rural sporting events such as rodeos demonstrate this kind o culturally targeted marketing campaign. Disproportionate Exposure o Children to Secondhand Smoke Exposure to secondhand smoke is hazardous to human health. Studies have shown that children are highly vulnerable to the negative eects o secondhand smoke including acute respiratory inections, ear problems, and more severe asthma. 20 According to the CDC, exposure

13 FIGURE 3 SMOKELESS TOBACCO PRODUCT USE IN LIFETIME, PAST YEAR AND PAST MONTH AMONG PERSONS AGED 18 TO 25, Large Metro Small Metro Urbanized Less Urbanized Completely Rural PERCENTAGE PAST MONTH PAST YEAR 15.7 LIFETIME Source: SAMHSA, Oice o Applied Studies, National Survey on Drug Use and Health, 2006 and Prepared by American Legacy Foundation. to secondhand smoke is associated with higher rates o sudden inant death syndrome, asthma, bronchitis, and pneumonia in young children. 21 Since smoking is more common in rural areas, children in rural America are more oten exposed to secondhand smoke in the household. Based on the National Survey o Children s Health conducted by the National Center or Health Statistics, percent o children in small rural areas and 37 percent o children in large rural areas live with a smoker, compared to 27.5 percent in metropolitan areas. Among children in rural areas, in general, older children, children with lower amily income, and White and American Indian/Alaska Native children are most likely to be exposed to smoking in the household. 23 In terms o race and ethnicity, 46.5 percent o American Indian/Alaska Native children in small rural areas live with a smoker, compared to 30.4 percent o urban White, 27.7 percent urban Black, and 20.6 percent urban Hispanic children. 24 By implementing community-based, culturally tailored programs to address these disparities, organizations can close the gaps in prevalence o tobacco use, increase access to evidence-based prevention and cessation services, and minimize the disproportionate impacts o tobacco use on the health o people living in rural areas o the country. Challenges to Tobacco Control and Prevention Eorts in Rural Settings In addition to a very high prevalence o tobacco use, rural communities ace a number o challenges to tobacco control eorts. These challenges consist o the ollowing: Lack o appropriate tobacco control programs 25, 26 and services Lack o or very limited transportation Low income 30, 31 Lower rates o insurance coverage Minimal access to tobacco cessation 32, 33, 34 27, 28, 29 35, 36 Limited access to health care services 37 Proximity to tobacco growers 38 Limited media resources on tobacco 39, 40 prevention Inadequate enorcement o laws against tobacco 41, 42 sales to minors Lack o eective compliance o smoke-ree policies 43 Limited research on the question o how dierent rural conditions lead to higher tobacco use in rural areas 44 Culturally and socially entrenched use o tobacco 45, 46 products Tobacco Control in Rural America 11

14 Rural Areas and Disproportionate Burden o Tobacco Use As highlighted in the previous sections, tobacco has a disproportionate impact on rural areas because o their unique geographic, cultural, social, and economic conditions. In addition, many rural areas lack adequate access to an eective, evidence-based tobacco prevention and cessation inrastructure. Many national and state surveys have shown that rural areas generally have higher tobacco prevalence. Individuals living in these areas have limited access to appropriate, eective services compared to their counterparts living in metropolitan areas o America. To address this tobacco-related disparity, organizations need to identiy rural areas and understand the unique public health and tobacco control challenges they ace in order to implement comprehensive, systemic tobacco control programs that address the underlying social, economic, cultural, and geographic conditions o these areas. The ollowing sections highlight some unique ways to address tobacco-related disparities in rural America. Assets and Opportunities in Rural America Rural areas oer unique assets and opportunities that organizations can leverage to implement tobacco control programs. Generally, rural areas are made up o closely knit communities and strong amilies. They demonstrate a sense o social trust and neighborliness. Many residents in rural areas are involved in local aith-based and other communitybased organizations. These organizations play an important role in all aspects o people s day-to-day lives in these communities. By examining the data gathered in 2007 rom a representative survey o 8,000 rural Americans selected rom nine clusters o 19 rural counties across the United States, Lawrence C. Hamilton, et al., o the Carsey Institute at the University o New Hampshire ound that more than 75 percent o the residents in these communities agreed with the statements People around here are willing to help their neighbors ; People in this community generally trust one another and get along ; and I this community were aced with a local issue such as the pollution o a river or the possible closure o a school, people here could be counted on to work together to address it. 47 The Carsey Institute s survey also showed that residents participation in local organizations was high. 48 These inormal social networks and institutions oer unique opportunities or organizations to enhance the impact o their tobacco control programs. By tapping into the robust social capital in rural areas, organizations can earn the trust o the community, mobilize and gain support o local stakeholders, and expand the reach o their initiatives. KEY STRATEGIES TO ADDRESS TOBACCO-RELATED DISPARITIES IN RURAL AMERICA Identiy and adapt to speciic rural actors or conditions o a region. A wide variety o conditions contributes to the exceptionally high prevalence o tobacco use in a rural area. As discussed above, rural communities vary in terms o their social, economic, cultural, and geographic characteristics. In addition, each community has a speciic combination o actors that may give rise to the high prevalence o tobacco use and/or create barriers to eective tobacco control and prevention eorts. Organizations need to identiy speciic conditions that contribute to the problem o tobacco use in their target communities. In order to create strategies to match these conditions, organizations need to examine them in depth and thereby gain a practical understanding. In this way, organizations can create a communitybased, culturally tailored approach to tobacco control and prevention that both its the speciic set o rural conditions and meets the unique challenges acing their communities. Foster broad-based collaboration to engage multiple stakeholders. Organizations may ail to address a host o challenges to tobacco control in a rural area without irst engaging diverse, local stakeholders in their interventions. Tobacco use is a culturally entrenched behavior in rural populations. Without long-term and comprehensive interventions, organizations cannot successully address the issue o tobacco use in a rural setting. Moreover, designing and implementing a holistic, multiaceted intervention to address diverse systemslevel issues deriving rom a lack o transportation, communications, smoke-ree policies, and education requires a signiicant amount o resources and broadbased collaboration among all major decision makers and resource holders in the community. A mere clinical approach, ocused exclusively on helping individuals quit without multipronged, community-wide engagement, cannot address the exceptionally high rate o tobacco use in rural populations.

15 Enact and enorce smoke-ree policies. Many small rural areas lack smoke-ree policies that not only protect nonsmokers rom secondhand smoke but also help reinorce smoke-ree social norms in a community. Where such policies exist, enorcement is not always very eective. According to Stacy Stevens, et al., While the number o community prevention policies has increased in the past decade, rural communities do not necessarily comply with these policies. 49 Illegal tobacco sales, especially to minors, are more prevalent in rural settings. 50, 51 Small businesses, arms, and other places o employment in rural areas oten either are not covered by a robust policy 52 or they do not eectively comply with such policies that may already exist. 53 Thereore, both enactment and enorcement o robust smoke-ree policies is undamental to addressing tobacco-related disparities in rural settings. Implement public awareness campaigns targeting smokeless tobacco in rural settings. As presented earlier, the use o smokeless tobacco is exceptionally high in rural areas. Over the years, it has become an inherent part o rural culture and social norms. Even though cultural or social use o tobacco is decreasing in rural communities, in many areas, the cultures o mainstream rodeos, ranching, and arming still galvanize tobacco use. Smokeless tobacco companies target this population through aggressive marketing o their products. Through sponsorships o rural sporting events and various orms o targeted messaging, these companies try to reinorce the culture o smokeless tobacco use. 54 Culturally tailored public education campaigns are needed to counter the tobacco industry s marketing strategies and to promote a new, smoke-ree culture in rural America. Case Studies This publication highlights ive case studies that demonstrate how organizations across America are addressing the issue o tobacco use in rural communities. These case studies relect a broad range o tobacco control, prevention, and cessation programs implemented by Legacy grantees to deal with the tobacco-related disparities acing their rural communities. Through these case examples, Legacy seeks to highlight the unique barriers to tobacco control and prevention eorts in rural areas and ways in which organizations can address those challenges. These examples show that by creating program interventions tailored to the speciic rural conditions and tobacco control needs o a rural community, organizations can provide eective, accessible tobacco control and prevention services or people living in rural areas. Legacy hopes that other organizations involved in tobacco control and prevention will learn rom these case examples, identiy unique rural conditions that create tobacco-related disparities and challenges, and develop program strategies to achieve eective and sustainable tobacco control and prevention outcomes or their rural communities. Create alternative ways to provide aordable, accessible tobacco treatment and counseling. Organizations need to develop program strategies to make tobacco cessation services more aordable and accessible to individuals who live in rural areas. Interventions proven to be eective in metropolitan areas may not be eective in rural areas, i implemented in the exact same ormat. These interventions can be tailored to meet the unique needs o the people in rural areas. Speciic outreach, enrollment, retention, ollow-up, and relapse prevention techniques grounded in rural settings are key to eective tobacco cessation programming. Tobacco Control in Rural America 13

16 CHAPTER TWO CASE STUDIES No. 1 Campesinos Sin Fronteras: Futuro Claro Grassroots Tobacco Education in the Borderland No. 2 Selby General Hospital Creative Outreach or a Marginalized Rural Community No. 3 Colorado Chew Tobacco Collaborative Initiative Targeting Chew Tobacco with Community-Based Participatory Research No. 4 La Crosse County Health Department Western Wisconsin Tobacco and Alcohol Reduction Project Addressing the Dual Challenges o Tobacco and Alcohol Used No. 5 University o Maine: Tobacco Access Portal Dismantling Literacy Barriers to Tobacco Inormation

17 Campesinos Sin Fronteras: Futuro Claro Grassroots Tobacco Education in the Borderland Program Overview C ampesinos Sin Fronteras (CSF) has built 17 years old compared a reputation as a trusted one-stop shop to only 34.8 percent in or migrant arm workers seeking health, non-border regions. 57 education, and economic services in South Yuma Border counties would County, Arizona, an agricultural region that hugs the be ranked 50th in U.S.- Mexico border. Founded by ormer arm workers insurance coverage in 1997, CSF connects campesinos (migrant arm or adults and children. 58 Not considering the workers), a dramatically marginalized community, with economies o San Diego and Pima, in 2004, the everything rom reproductive services and domestic unemployment rate or the remaining 22 border abuse counseling to housing advocacy. They began counties was more than double the rate o the rest 59, 60 tobacco education work in o the United States. The U.S.-Mexico border region has culture, norms, According to Flor Redondo, director o CSF, South and language distinct rom both Mexico and the Yuma County imports over 10,000 arm workers United States. Awareness o these dierences is daily rom November to April. In the winter, the area crucial to building an eective public health initiative. becomes the lettuce-producing capital o the world, I treated as the 51st state, the border areas (excluding with more than 50,000 arm workers picking the San Diego County, Caliornia) would be dead last in greens that become the nation s salads. We don t have per capita income 55 and last in terms o access to the resources to serve the population that lives here primary medical care. 56 In this region, 43.2 percent o year round, and imagine in the winter when it triples, the total population living in poverty is between 0 and Redondo says. We cannot respond to all the needs. CASE STUDY # 1 Tobacco Control in Rural America 15

18 F F They call us pochos. For us in Redondo remembers a decade ago, when she rode F those buses to pick lettuce in the ield. Everybody the border area, pocho means F smoked, she says. It was really hard or us who hal-mexican/hal-american. didn t [smoke], but it was just part o lie. You didn t F even think o the possibility o asking people not to People see you as a mix o both. smoke. But Arizona smoking laws make that illegal F It suggests that we are not really now, and CSF aims to educate both the campesinos and their bosses that smoke-illed buses are F a part o the Mexican culture. We detrimental to workers health. Despite new signs F learned Spanish when we were in the buses, awareness and enorcement o the smoking regulations are slow to trickle down. F young and then we came to the U.S. Rosario Sanchez, also a ormer arm worker and now F lead promotora (peer health counselor) or CSF, oten and learned English, but we don t heads out into the cold, dark night to give inormal master any language at all. But we F tobacco education to campesinos at the San Luis speak Spanglish luently, the border bus stop. People ask me i I am araid to go here at F 3 a.m. all by mysel, she says. I m not araid, language. because they know me and respect me, and that F opens a lot o doors. Sanchez also makes regular F Flor Redondo, CSF Programs Director rounds in the ields promoting smoking cessation and reerring any identiiable smokers to the Arizona state F The borderland receives tobacco messages quitline (ASHLine). rom both sides o the ence. Mexican television The promotora model employs community members F broadcasts its telenovelas and ilms 50 miles deep to transmit health education to underserved, into South Yuma County. Television programs that F low-income Spanish speakers. We can talk to them normalize and glamorize tobacco use are popular at their educational and proessional level, says Luis F with campesinos. The luidity o the population Vazquez, CSF Tobacco Use Prevention Program compounds the challenges o eective tobacco Coordinator. We may encounter people at the stores F control. We can do all the prevention and reerrals to the quitline, but at the end o the day they come rom F Mexico, and they may have a home there to return to every weekend, Redondo says. It s cheap and easy Campesinos Sin Fronteras F to buy tobacco there and bring it back or the week. It Key Achievements F can be really challenging to get a program going with these kinds o barriers. But despite these challenges, 21 agriculture companies have F our program has been successul in reaching our implemented a no-smoking target group, Redondo says. policy on their arms. F 2,901 arm workers have received F Farm Buses: A Secondhand Smoke Frontier education on tobacco prevention and Arizona s no-smoking laws. Thousands o migrant workers start gathering in San F Luis, Arizona, at 3 a.m. every morning to board one o CSF has reerred 55 individuals to F approximately 300 old school buses, which transport Arizona s state quitline, the ASHline. them to the ields. In the winter, all the windows are F closed because there is no heat in these buses. Each 20 participants have joined the bus carries 30 to 40 campesinos to their job sites. CSF s cessation support group. F These buses are oten thick with smoke or the our CSF s peer educators have to ive hours o transportation each day, even though F reached 1,609 young adults. only a ew riders may be smokers. For years, CSF F has received reports o chronic respiratory diseases rom the campesinos. A grant rom Legacy allowed F them to begin to address this serious public health concern. F F 16 CASE STUDIES Campesinos Sin Fronteras: Futuro Claro 16

19 F CASE STUDY NO. 1 F F F F F F F F F F F F F F F Lead Promotora, Rosario Sanchez Chayito, conducts outreach sessions to educate armworkers at the pick up sites. F or church or the park and we talk to them about F About 55,000 arm workers labor in their smoking. Even on a Saturday or Sunday we are Fproviding education. This truly grassroots approach Yuma County between October and has generated positive results in many communities, F March, the peak season or lettuce, including South Yuma County, Arizona. Campesinos still light up cigarettes rom time to time on the arm said Janine Duron, supervisor o the F buses, but ar less than just a ew years ago. Migrant and Seasonal Farm Worker F Juan Perez: 58-Year-Old Farm Program or the Arizona Department F Worker, 30-Year Smoker o Economic Security. FJuan Perez has been smoke-ree or two months. Vazquez convinced him to call the state quitline and Fcome to a CSF cessation support group where 15 Paige Lauren Deiner, By the Dawn s Early Light, Yuma other arm workers gather weekly to give each other Sun, April 23, 2005, F a pat on the back or putting down the cigarettes. arm workers-canal.html [accessed June 24, 2009]. FPerez has been telling all his riends in the ields that Futuro Claro: Young Adult Peer Counseling they should come to the group, too. The support Fgroup is providing the human touch through this hard Young adults in South Yuma County are at an elevated quitting process, Vazquez says. I m so glad to see risk o becoming lietime smokers, and prior to the F Juan quitting. Legacy grant, no outreach or this population existed. FJuan s our daughters are grateul that he has Low education, low literacy, high unemployment, and stopped smoking. It s helped me change the way I easy access to cheap tobacco all contribute to a high Fthink about my health, he says. I ve learned how to rate o tobacco use in the year old population. keep my mind busy with other positive things rather In 2008, CSF hosted Desaio de Bandas (Challenge F than smoking. Some people get o the bus to smoke, o the Bands), a youth event in San Luis. The event and some people get o the bus to get away rom the was ocused on providing prevention education on F smokers. That s what I do. violence and drug use to youth on both sides o the F Tobacco Control in Rural America 17

20 F F F F F F F F F F F F F F F Lead Promotora, Chayito, conducts early morning sessions to provide inormation to armworkers on the prevention o tobacco use and the F harmul eects o second hand smoke. F border. Hundreds o young people came across the I a person wants to smoke in the border and joined the local kids to hear the music. F Some o the kids were smoking, Redondo says. buses now, the other workers tell F Many o them came rom the Mexican side, where them get out o here, cause we it s part o the culture to be chic and smoke. know about the law and we have F Carlos Sanchez has been a peer counselor in the Futuro Claro project team or two years. He noticed the right not to have smoke in here. F that arm workers are in the ields as young as Our inormation is really making a F 17 years old. He, too, worked in the local citrus groves in the summers when he was in high school, picking dierence. F ruit. It s really hard work, he says. I understand how diicult it is. It took me like our hours to do three Flor Redondo, CSF Programs Director F trees. He realized he wasn t cut out or picking in the F hot sun, but he did have a knack or talking to people Currently the Futuro Claro team is working on a and helping them improve their lives. photonovela, a comic strip-like book intended to F The problem is they just don t know what s out there ease comprehension o tobacco education. These or health services, he says. With tobacco, a lot o photonovelas are a series o photos eaturing actors F people don t know the health impacts. I ve talked to telling a story about tobacco cessation. CSF has F lots o young women who have chronic asthma or used this strategy or diabetes and HIV education. have lost babies to premature birth. One time this It is a useul tool or our population, Redondo says. F young husband started crying, because they had lost a child, and he said he used to smoke in the house all F Rural Roadblocks and Borderland Barriers the time. He just didn t know. He had no idea. F Carlos says it is important to have promotoras o both Since the time o the Bracero program in the 1940s, genders. They oten want to ask questions about through the ormation o the United Farm Workers, F pregnancy, but they don t want to ask me, he says. the needs o these laborers who toil in the shadows They want to talk to a woman o their own age. have been long overlooked. We rely on migrant F F 18 CASE STUDIES Campesinos Sin Fronteras: Futuro Claro 18

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