Tobacco Control in Rural America

Tobacco Control in Rural America

Tobacco Control in Rural America July 2009

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.]

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

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

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

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

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

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, http://www.carseyinstitute.unh.edu/publications/report_ 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.

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 2006. This igure has hardly changed since 1980. In contrast, the Hispanic proportion grew rom 3.1 percent in 1980 to 6.4 percent by 2006. 10 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, 2006 15 PERCENTAGE 25.1 % NOT IN MSA 22.1 % SMALL MSA 18.5 % LARGE MSA Source: Smoking Status Data CDC, National Interview Survey, 2006. Prepared by American Legacy Foundation. Tobacco Control in Rural America 9

FIGURE 2 TOBACCO PRODUCT USE IN LIFETIME, PAST YEAR AND PAST MONTH AMONG PERSONS AGED 18 TO 25, 2007 16 39.1 48.1 43.0 53.0 49.2 49.5 57.9 53.7 59.4 62.7 80.2 76.6 74.4 71.7 67.8 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 2007. 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

FIGURE 3 SMOKELESS TOBACCO PRODUCT USE IN LIFETIME, PAST YEAR AND PAST MONTH AMONG PERSONS AGED 18 TO 25, 2007 19 37.6 Large Metro 31.5 29.4 Small Metro Urbanized 21.7 21.9 Less Urbanized Completely Rural PERCENTAGE 3.4 5.9 8.9 12.4 10.8 PAST MONTH 6.3 10.1 15.8 14.2 PAST YEAR 15.7 LIFETIME Source: SAMHSA, Oice o Applied Studies, National Survey on Drug Use and Health, 2006 and 2007. 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, 22 38.1 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

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.

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

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

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 2001. 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

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

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, http://www.yumasun.com/articles/ F a pat on the back or putting down the cigarettes. arm-13398-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 18-24 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

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

F CASE STUDY NO. 1 F F labor to put resh ood on our dinner tables, but the Somehow you think that with a F services and healthcare access taken or granted in the rest o the United States are simply not available cigarette you can get things done F in places like South Yuma County. aster and it makes the tiredness go F There is a basic lack o opportunity and access in away, but it s not true. Your body will South Yuma County. These workers leave their F houses at 2 a.m., then they wait two or three hours give in either way. People smoke on the border to board arm buses to work up to F when they are tired or happy. People 12-hour days. They don t have the opportunity to F access services, and we can provide the awareness, think i they smoke when they are but we can t really get these services to them i we angry it will go away. It s not true. F don t look at the inrastructure o our communities, Redondo says. This is a very marginalized F Juan Perez, Farm Worker, South Yuma County community. F F F F F F F F F F F F F F F F F F F F F F F Lessons Learned The borderland has its own culture, separate rom both the United States and Mexico, but is inluenced by messaging rom both sides. The borderland has seasonal population surges that aect basic healthcare resources. Smoking on arm buses is not legal, but it is common, and a cause or genuine concern. The promotora model o counseling should include counselors o both genders. Awareness o the health risks o tobacco use can be alarmingly low among arm workers. Social awareness campaigns must be tailored to the literacy level o the target population. Tobacco Control in Rural America 19

Selby General Hospital Creative Outreach or a Marginalized Rural Community Program Overview Selby General Hospital is in Washington our hospital County, Ohio, which sits near the state s because they border with West Virginia, in a rural part o can park out Appalachia called the Mid-Ohio Valley. The population ront, Davis is overwhelmingly poor, with a lower per capita says. They re income 61 than the state at large, and the education not a number, and the big actor is getting over their ear o an establishment. level is also low. Among residents 25 years and over in the county, 15.5 percent have less than a Smoking prevalence rates in Washington County are high school degree. 62 Farmers in Ohio still grow very high, with use among 18- to 24-year-olds and government-subsidized tobacco, and high school 35- to 44-year-olds topping 40 percent 63 and over students in the Future Farmers o America in this part 60 percent o Selby General s inpatients identiying o southeast Ohio are still taught how to cultivate this themselves as tobacco users. Decades o heavy cash crop. Conventional wisdom here says that chew industry plastic production and carbon processing tobacco is a saer alternative to cigarettes. There is have produced chronically toxic air quality. The obesity and cancer rates are all astoundingly high in a lot o resistance here, and change is diicult until Washington County. [something] hits them personally, says Stephanie 64 Many people around here have a atalistic view o lie, Davis says. Generationally, Davis, Tobacco Prevention Program Director at Selby there is not much hope to succeed or better yoursel. General Hospital. The cycle o poverty, low education, and diminished Selby General has only 25 beds, and patients have health has a irm grip on the rural residents o the come to trust the personal nature o its care. The other Mid-Ohio Valley, and the idea o preventive healthcare hospital in town has 1,000 beds. The rural people like has little traction. 20 CASE STUDIES Selby General Hospital 20 CASE STUDY # 2

CASE STUDY NO. 2 In April 2009, the impact o tobacco use hit this They are very accepting o things population where it hurts most the wallet. Ater the increase in ederal tobacco tax, the tax per pack o that aren t necessarily healthy. It s cigarettes in Ohio increased to over two dollars. 65 generational grandpas who take Some people will have the worst health on the planet, but it s not until it s personal the money that they their grandkids out ishing when think about quitting, Davis says. Selby General they re seven and give them chew. normally runs two cessation classes each month with about a dozen participants in each class. Ater the tax Moms buying their kids cigarettes. increase, 100 people came looking or help in just a We ve seen them as young as third ew weeks. grade. Creative Marketing: From Check-Cashing Stores to Opening Day o Hunting Season Stephanie Davis, Tobacco Prevention Program Director, Selby General Hospital According to Davis, this population is reluctant to seek help and reluctant to go into a government building or a hospital. They are hesitant to call the Ohio Quitline. Washington County also has the highest number o I they call the quitline, it s routed through a national check-cashing establishments per capita in Ohio, hotline out o a dierent state, and they say, Heck, I since West Virginia has stricter regulations on these don t want to talk to you. You don t know anything payday lenders. Customers o check-cashing places about me, and you re not going to understand, tend to all into Selby General s target demographic. Masten and Davis have ound these businesses to be Davis says. She acknowledges that some aspects an ideal place to reach their patients. o the Appalachian culture present a serious public health challenge. Perhaps Selby General s most innovative community location is the deer checking stations. Davis and Only 30 percent o the population has cable television, Masten have distributed over 70 Quit Kits to deer and the majority o [the area s] target population does hunters at the places where they check in with the not read the local daily paper, the Marietta Times, Fish and Game Department ater a day s hunt. They Davis says. So purchasing advertising in these set up an outreach booth on opening day and other outlets is not really practical or the Selby General high-traic days and give out inormation on chew Tobacco Prevention Program. Instead, they turned to tobacco cessation and herbal snu. Some hunters a collection o alternative orms o marketing. We ve mix the herbal chew with their Copenhagen to wean tried the backs o register receipts, the outside o themselves o gradually. pharmacy bags we ve done the gamut, Davis says. The Bulletin Board, a local publication o buy, sell, and trade ads, is popular with their target audience o The Transportation Barrier: Taking Hospital low-income residents with low education. Most olks Services Directly to the Community in the Mid-Ohio Valley call this circular The Bible Davis and Masten get many reerrals rom within the and use it to ind good deals on livestock and arm hospital, since most o their inpatients are tobacco equipment or to look or a yard sale. They are also likely users. Anyone who indicates tobacco use can expect to see an advertisement or one o Selby General s a visit. We ve got them barred up in a hospital, and cessation classes. Demographically targeted direct sometimes they re not so happy to see us, Davis mail has also proven useul: Classes doubled in size says. Hopeully, i they can be tobacco-ree or a ew ater the mailings. We d advertise on bus lines, i we days in the hospital, they can turn that into a ew more had any, Davis says. It took us a while, but we inally days. But Davis and Masten have ound that, by and igured out a good way o communicating. large, their target population requires pursuit. Davis and her Lead Tobacco Educator, Joellen Due to the high poverty in Washington County, many Masten, have assembled a diverse collection o places residents have limited access to transportation. Selby to interace with their target demographic outside the General holds two monthly classes concurrently, hospital. They regularly leave their stickers, brochures, rotating through all the major communities in southeast and reebies, such as branded toothpick dispensers, Ohio, and actively reers about 100 tobacco users to at laundromats, tattoo parlors, and barber shops. the quitline every week since the tax increase. Tobacco Control in Rural America 21

Selby s outreach booth or hunters. F F F F riends they quit. David Howell: The Story o One Less Mid-Ohio Valley Tobacco User Joellen Masten, Lead Tobacco Educator, Selby General Hospital David lives in Marietta, Ohio, and works in telecommunications. He was a pack-and-a-hal-a-day We are taking the services to them on a regular basis, smoker or 36 years and ound Selby General s services because it eliminates the excuse actor, Masten says. in a dierent way compared with most o Davis and Free nicotine replacement therapy is also a major Masten s patients: He Googled it. He dropped in on one incentive. That initial purchase is the worst part or o their tobacco use open houses and started a support them, Davis says. They can come up with $5 or a class right away. Now Howell has gone 112 days without pack o cigarettes, but it s diicult to come up with $50 lighting up. That s 3,330 cigarettes I haven t smoked, and $882 I ve saved, he says. And I ve given mysel 18 or NRT [nicotine replacement therapy]. more days o lie. They also requent health airs, where the big draw is These days he breathes a lot easier and he doesn t snore useul, ree products. They come or the rales and the nearly as much. My spouse likes that, because I used Wal-Mart git cards or the bicycle helmets and car seats, to not want to encroach on her space too much, but [it Davis says. This is where our population connects with can be hard on a relationship] when you re in separate local organizations. rooms, he says. I ve gotten my brain on the other side 22 CASE STUDIES Selby General Hospital 22 They set a goal or their Legacy grant o helping 200 You can t smoke in the woods women quit cigarettes and 50 men to quit chew because the deer will smell you. tobacco. They have ound that women are more likely to participate in cessation support and men are more likely So we see a huge number o chew to rely on an anonymous quitline. Since July o 2007, users there. We ve had them put the they have counseled 375 smokers and 63 smokeless tobacco users, with an average end-o-class quit rate herbal chew in their Copenhagen can o 43 percent. Since the program s inception in 2003, because they don t want to tell their Masten and Davis have helped over 1,000 people.

CASE STUDY NO. 2 o the process now, and I m looking at all the good things We have them do the math. that have happened since I stopped smoking. A pack a day at six dollars a day Howell says he had to get mad at himsel and his habit and had to admit that he is an addict. My whole lie was over a year, that s a house payment driven by when I was going to have that next smoke, he or a car payment. And i you ve got says. Driving his car was like passing a constant stream o messages encouraging him to smoke. I d pass a two people smoking in the house, certain street sign, I d light a cigarette. The odometer well, think about the cost. clicks another 30 miles, I d light a cigarette. I d pass the city limits, I d light a cigarette. He had to change his Joellen Masten, Lead Tobacco Educator, daily patterns and literally take dierent paths. He still Selby General Hospital avoids convenience stores, because that is where his strongest cravings emerge. I pay at the pump so I don t have to go in those places, he says. He has channeled the nervous energy into his work and an impressive array o home restoration projects. I ve accomplished more in the last three months than I have in the last three years, he says. I think o all the time I save. Assuming it takes eight minutes to smoke a cigarette, that s over two hours a day, per pack. That s rightening. Tobacco Control in Rural America 23 Lessons Learned Smaller hospitals can be better positioned to serve rural communities. Preventive healthcare is less common in marginalized rural communities. The inancial impact o a tobacco habit may be an eective incentive or quitting. Take the services directly to the target population, whether they re in a tattoo parlor or in the woods hunting. Eliminate the transportation barrier by holding regular group sessions in dispersed communities. The hospital itsel is an opportunity to conduct outreach to the target population among inpatients.

Colorado Chew Tobacco Collaborative, University o Colorado Health Center Targeting Chew Tobacco with Community-Based Participatory Research Program Overview Chew 66 tobacco use rates nationally tend to be says. Everyone you know chews. Chewing is a rite lower than smoking rates, 67 but while chew o passage here, an adult activity play acted by tobacco does not have the same secondhand children, and a cultural ixture deeply entrenched in exposure issues pervasive in tobacco smoking, it is multiple generations. a looming public health crisis, particularly in rural Seedor brought her perspective on chew tobacco communities. The tobacco industry continues to use to Legacy and was awarded an Innovative Grant to develop smokeless products that may entice younger orm the irst statewide program in Colorado ocusing and nontraditional users, as well as hold a irm grip on smokeless tobacco. According to Seedor, some on longtime users. Some public health oicials rural Colorado communities have chew tobacco and doctors actually suggest smokeless tobacco rates ar higher than rates o cigarette smoking. Chew as a harm reduction method, even though recent tobacco use in Colorado metropolitan areas is not research has indicated this to be ineective in the United States. 68 quite as prevalent, but Seedor ears new products will drive those rates up. Statewide, says Seedor, it Colorado Chew Tobacco Collaborative Initiative remains to be seen i smoke-ree ordinances and an (CCTCI) Project Coordinator Erin Seedor comes increase in the marketing o smokeless products will rom a ranching amily in Northern Colorado and lead to an increase in chew tobacco use. married into a amily o armers rom the northeastern Colorado plains. Chew tobacco use is prevalent CCTCI aimed to begin dismantling this cultural rural in her amily, and some relatives have suered the prevalence with an innovative research approach health eects o decades o chew tobacco use. It s called Community-Based Participatory Research very prevalent in these rural communities, Seedor (CBPR). 24 CASE STUDIES Colorado Chew Tobacco Collaborative 24 CASE STUDY # 3

2 3 4 CASE STUDY NO. 3 Meera Viswanathan, et al., deine CBPR as a The beauty o community-based collaborative research approach that is designed to ensure and establish structures or participation by participatory research is that it really communities aected by the issue being studied, does give the communities the ability 5representatives o organizations, and researchers in all aspects o the research process to improve to own and deine their issue. Yes, health and well-being through taking action, it s overwhelming, with a culture o including social change. 69 Based on this theoretical ramework, CCTCI implemented a unique community chew tobacco in these areas that engagement strategy that empowers communities to is so supportive, but each o these collect qualitative data in the orm o photographs and oral histories to assemble a grassroots account communities got to look at one little o what chew tobacco use actually looks like, and tiny piece o what chew looks like in what challenges exist in cessation. Barriers in rural tobacco control oten actually have beneits their community. So what it s given attached, Seedor says. These are communities them is at least one very small way to within a community, and that can be hard because o the social acceptance o things. But the beneit is start addressing it. that they really do support each other, and i you get the right person in the right situation to start to make Erin Seedor, Program Manager, Cancer Center, change, it can aect the whole area really quickly. University o Colorado; Director, Colorado Chew Tobacco Collaborative Initiative Implementing the Methodology: the interesting observations was the enorcement o Photovoice and Story Circle the Colorado Tobacco-Free Schools Law as it relates The research design o CCTCI is based on to chew, Seedor says. We are hearing and seeing ethnographic documentation, a way o eectively in our research that while it is being enorced with and unobtrusively constructing surveillance o chew cigarette use on school campuses, chew tobacco tobacco use in these communities. Seedor and is being completely overlooked. We see this as an her partners trained participants to go out and take exciting possibility to address statewide change. pictures and collect stories with a general question The individual communities each own the research. in mind: What does chew tobacco look like in your Seedor returns all the photos, stories, and lie? In the Photovoice technique, participants take transcriptions or partners to share with the community pictures in their local communities and use them as and continue the process o solution building. prompts or a written account, a story describing just what those images were intended to illustrate. The Story Circle technique is similar, giving participants Forming a Statewide Rural Coalition an opportunity to create and share their own personal or Data Collection stories. Participants then share these stories and Health department oicials and academics rom pictures with the group, creating a wider dialogue research institutions can sometimes be seen as and, ideally, isolating the major community concerns. community partners in rural areas, but oten the Finally, participants are asked or solutions to the cultural distance can be an insurmountable barrier. concerns. This approach is intended not just as an Seedor knew that as a Denver person, access to educational project but also to inorm policy makers rural communities would be diicult. She set out to to create change around the community concerns. orm a project steering committee and discovered Participants shot hundreds o photographs. They an ad hoc group o county public health workers include countless images o the telltale ring in the who were inormally meeting to strategize about back pocket o a pair o blue jeans o a longtime smokeless tobacco issues in their communities. chew user, dozens o close-up shots o at, snuengorged lips, and brown-spit-illed bottles, and then aware that chew tobacco is the major tobacco A lot o our rural communities have long been the unexpected purse with a chew can inside. We ve issue in their area, Seedor says. But there has not gotten lots o pictures o what chew actually looks like been any unding or initiative statewide or them to in the community and the impact it can have. One o look at it. These olks were already meeting to see Tobacco Control in Rural America 25

Flat bed o a pick up truck covered with Copenhagen lids nailed directly into the bed o the pickup. contacted someone in a home visitation program We all associate chew with the who conducts parenting classes in seven counties in agricultural landscape and the northeast Colorado. Seedor also engaged partners who work with the collegiate rodeo program and cowboy, but the reasons or it were partners in the tobacco prevention youth advocacy very dierent rom what I expected. movement GET R!EAL(Resist! Expose Advertising It s not just a culture; it s a critical Lies, getrealcolorado.com). From this outreach, a statewide steering committee, Partners Accessing tool, some might say a drug to Chew Tobacco (PACT), was ormed or the project. stay awake. We have moms who The steering committee brimmed with ideas or use because their husbands keep data collection sites. Each member was tasked with assembling a list o possible sites, ranging rom a rural it around, and it s a way to keep vocational technical high school and a church youth group to an Air Force base and a group o student themselves awake as they ulill athletes. In the irst year o the grant period, Seedor their roles as a wie or a mother. directed the group to pick the low-hanging ruit They were hiding their use and the groups known to have a high use rate, a culture associated with chew, or groups with a strong desire nobody knew it. to participate. In the pilot year o the data collection process, 18 groups including youth, college, adults, Erin Seedor, Program Manager, Cancer Center, and military participated. University o Colorado; Director, Colorado Chew Tobacco Collaborative Initiative Preliminary Findings: A Prismatic what other people were doing and talking about View o Chew Tobacco how to try to convince the state to start looking at Seedor and her team amassed piles and piles o spit tobacco seriously. She also pulled in some data. One o the beneits o widely dispersed CBPR nontraditional partners outside o the county health is volume. Taken as a whole, a statewide picture o departments and nursing services. For example, she spit tobacco use begins to emerge. Much o the data 26 26 CASE STUDIES Colorado Chew Tobacco Collaborative Initiative

CASE STUDY NO. 3 underscored the cultural currency that chew enjoys This basic social acceptance and in these rural communities. One photo that struck bonding dynamic that happens a chord with Seedor was that o the lat bed o a pick-up truck, completely covered with Copenhagen between parents and their kids lids nailed directly into the wood slats. Another around chew tobacco is a powerully photograph showed old can lids nailed along a doorrame. I know that with people who chew, there strong norm. These olks always is an image associated with it, Seedor says. But have chew in the ridge in the I ve been working in tobacco or eight years, and I ve kitchen or out in the shed. never heard o anyone nailing cigarette packages into something. It really showed how people go to great Here, i you re a kid, it s ine. lengths to use this product as an identity piece. I you re a grandma, it s ine. Oicially, emale chew prevalence is low, but You can t put that on a graph, but the photos and stories that came back rom the now we have people rom the ninth group data collections told a dierent story. One photograph captured a massive can o chew inside a grade all the way up to guys in tiny clutch purse with bright pink polka dots. Another their seventies actually having a photograph showed a whole line o spit bottles next to a curling iron. Several discussions centered on the conversation about all this. point that it is not just something men or boys do, but that girls and women are using chew as well. Though Edward Ellis, CCTCI Steering Committee Member, Jeerson it lacks the quantitative statistical signiicance, County, Colorado this research methodology begins to get past the challenges o quantitative surveys. all corners o Colorado showed evidence o chew Many community members took photos o chew in the schools: spit-stained carpets, spit-illed water tobacco displays in convenience stores. In these ountains, and empty cans in lockers. Now CCTCI is areas, smokeless products completely overshadow collaborating with a tobacco control group working cigarettes. They say they can t even ind the with schools to explore and educate Coloradoans cigarettes in the store, Seedor says. But the chew about the school policy, to better train sta and is on the counter where it s all sel-serve, and the inorm both students and parents. posters are all over the place. This process allowed Seedor and her partners to Preliminary Solutions: Working see common themes across the state. For instance, Toward a Community Action Plan despite the tobacco-ree schools policy, photos rom PACT, the statewide steering committee, met in the spring o 2009 to begin the next phase helping One girl came rom a amily o each community distill the massive amount o data smokers, and she thought that was a down to a plan o action to conront chew prevalence and begin to dismantle the culture o acceptance. This nasty habit, so she started chewing. process will enable each community to look at its data It helps me balance with the stress, and begin to create policy directives to aect change. she said. Why should it be any Otero and Crowley counties, or example, collected data with the 4-H clubs, and the presence o dierent or the girls? One o the smokeless tobacco products at the rodeo emerged guys was a rodeo rider, so he got as as a huge concern. With the help o the CCTCI data collection, concerned citizens have set a goal to much as he wanted or ree and he encourage the local rodeo committee to adopt a said he used it to stay awake on long tobacco-ree policy and in the uture build on that trips. momentum to advocate or a city ordinance. To some extent, the movement toward building a community action plan already began in the storysharing sessions all over the state. Once they start Lori Gittings, CCTCI Steering Committee Member, Prowers County, Colorado Tobacco Control in Rural America 27

F F F F talking about chew, you hear all these perspectives beginning to chip away at one o the most F on acceptance and the social contract, says F overlooked health crises in rural communities. A steering committee member Edward Ellis. They F dialogue is under way now in these communities, but even brainstormed some practical solutions: Start F there is much work still to be done. Chew tobacco talking about this in school more oten, get cessation F is so prevalent that you just ignore it here you don t services in schools, do something about the tobacco F even see it, says steering committee member Lori displays, and boost the tobacco taxes. F Gittings. But things are starting to change now; the F CCTCI took a novel approach to studying and Colorado Rockies [baseball] team doesn t allow it. F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F 28 CASE STUDIES Colorado Chew Tobacco Collaborative Initiative F 28 F Lessons Learned Chew tobacco acceptance is generationally and geographically rooted, and intervention must be similarly oriented. New smokeless products may entice nontraditional users. Rural communities may be resistant to change, but once initiated, change can spread rapidly. Look or community partners already working toward the same goal. Community-Based Participatory Research initiates community dialogue, a necessary precursor to culture shit.

La Crosse County Health Department: Western Wisconsin Tobacco and Alcohol Reduction Project Addressing the Dual Challenges o Tobacco and Alcohol Use Program Overview The alarming alcohol La Crosse, Wisconsin, a city o just over 50,000, abuse rate also goes has roughly 250 bars and taverns, making their hand in hand with high prevalence o tobacco bar-to-resident ratio one o the highest in the use. Nearly one-third o country. Two universities and one college all sit within adults aged 25 to 44 with a short walk o the pub-congested downtown area. less than a high school Breweries and drinking establishments have long education in Wisconsin are been a primary engine o the economy in this part o current smokers. 72 Al Bliss the Midwest, and particularly in La Crosse County. and the La Crosse County Health Department (LCHD) For example, La Crosse is home to the world s largest set out to break the strong correlation between a six-pack, located at the City Brewery downtown. culture o alcohol abuse and a high smoking rate Wisconsin leads the country in binge drinking, among residents with less than a college education. according to the 2008 Behavioral Risk Factor They turned to Legacy or project unding to launch Surveillance System. Binge drinking is deined by the their Tobacco and Alcohol Reduction Program to Centers or Disease Control and Prevention as having address this problem o co-morbidity o tobacco use ive or more drinks on one occasion within the past with alcohol abuse. 30 days or males, our or more drinks or emales. 70 LCHD decided to target both active binge drinkers In 2008, 22.8 percent adults in Wisconsin reported and people in recovery programs or aggressive binge drinking in the last 30 days. This is the highest cessation education. Up to 75 percent o patients rate o binge drinking in the United States. 71 La Crosse in treatment or alcoholism are tobacco-dependent County is near the top o the list or the state. and about hal o them are heavy smokers, according Tobacco Control in Rural America 29 CASE STUDY # 4

drinking and tobacco dependence. While interacting Approximately 75,766 alcohol- with the participants at the recovery centers, Al Bliss attributable deaths and 2.3 million talked about the co-morbidities and the higher rates years o potential lie lost, or o cancer. Many o his clients are unemployed or underemployed. Many people in substance abuse approximately 30 years o lie lost programs are stressed out and without employment on average per alcohol-attributable and a permanent residence, and it exacerbates the problems o addiction, Bliss says. death, were attributable to The smoking rate in Wisconsin just dipped below excessive alcohol use in 2001 in the 20 percent, 75 he says. So people recognize that the smoking rate in the general population has dropped, but United States. what they don t realize is the great disparity in the other population, particularly the population we are working Alcohol-Attributable Deaths and Years o Potential Lie Lost with. Up to 80 percent o people in recovery programs United States, 2001, MMWR, September 24, 2004 / 53(37); 866-870. express interest in quitting smoking, 76 but Bliss does not believe that implementing a smoke-ree policy beore to the National Institute on Alcohol Abuse and assisting tobacco users interested in quitting would be eective. Sta o recovery centers have a great ear Alcoholism. 73 These rates are nearly as high as the that their clients would not attend treatment and get rates or the co-occurrence o tobacco dependence the help that they need i a complete smoking ban and serious mental illnesses. 74 was in place, Bliss says. We start with educating the sta themselves, some o whom are smokers. De-normalizing Smoking at Recovery We provide the training and technical assistance to Centers and 12-Step Meetings help them quit. We are inding that the socialization LCHD s initial outreach strategy was to access the associated with smoking is a big part o it. recovery client s interest in quitting; provide motivation A large part o the support culture o people in through ree nicotine patches, gum, or lozenges; and recovery involves gathering beore and ater meetings provide evidence on the serious health risks o heavy or a chat and a smoke. Studies have shown that 30 CASE STUDIES LaCrosse County Health Department 30

F F CASE STUDY NO. 4 F F F alcoholics who quit smoking have a better chance F Alcohol and nicotine are triggers o maintaining their long-term sobriety, and that F encouraging cessation does not threaten the priority or each other. There are a couple o F o sobriety. F 77 The recovery centers try to integrate schools o thought on this, but some smoke-ree activities into the daily routine. F treatment centers say to hit them all F One o the regular stops on LCHD s recovery center F rotation is the Coulee Council on Addictions (CCA), at once. I you re going into recovery F located a short distance rom downtown La Crosse. or alcoholism, you might as well go F CCA implements the entire spectrum o addiction F support, rom preventive to end-stage substance or the nicotine as well. We just put F abuse. CCA has a drop-in center or anyone looking it out there, and kind o meet them F or help, a meal, and some support with their F addictions. Bliss is oten on hand to oer ree nicotine where they re at. F replacement therapy (NRT) and cessation support. F We ve got to dispel that myth that you should quit Pat Ruda, Executive Director, Coulee Council on Addictions F alcohol irst and then just keep smoking, says Pat F Ruda, the Executive Director o CCA. That s old relationships with a diverse array o employers, rom F thinking. We need to help people become healthy car dealerships to telemarketing companies. It s F in all aspects. amazing how many HR managers and employees are F Equal access to an array o services that promote not aware o their cessation and tobacco treatment F wellness and recovery is the LCHD mission coverage or medications, Bliss says. It might be F statement. There is a tremendous amount o work in a 30-page book, and you ve never read it. Now, F that could be done in cost savings or local health many businesses promote this beneit regularly and F departments to provide and integrate tobacco oer the opportunity or LCHD sta to meet with F treatment in their services, particularly in mental smokers one-on-one to develop an individualized F illness, clinical services, and economic support, quit plan and select appropriate medication. F Bliss says. F LCHD surveys workers to identiy the binge drinkers F but does not disqualiy workers who are not binge Targeting the Binge-Drinking Population F drinkers. It s not that diicult to identiy them based Fat Workplaces and in Jail on our intake survey, Bliss says. Well over hal o F Another part o LCHD s Tobacco and Alcohol the individuals that we reach through businesses can F Reduction Program ocuses on area businesses. be identiied this way, and most o these adults we F To access the employed, binge-drinking segment talk to do not identiy themselves as binge drinkers F o the local population with less than a college or heavy drinkers. For example, employees might F degree, LCHD works directly with local employers believe that binging is having more than 10 drinks F and human resource managers. Bliss has developed during an evening. F LCHD s goal or the term o the Legacy grant is to F During 2000-2004, cigarette enroll 320 total participants, with a little over one-third F F smoking and exposure to tobacco F smoke resulted in at least 443,000 F F premature deaths, approximately F 5.1 million years o potential lie F F lost, and 96.8 in productivity losses F annually in the United States. F F Smoking-Attributable Mortality, Years o Potential Lie Lost, F and Productivity Losses United States, 2000-2004, MMWR, F November 14, 2008 / 57(45);1226-1228 LCHD s lyers to promote the tobacco cessation services F F F Tobacco Control in Rural America 31 F

up could be challenging. The irst thing they want Many people eel that it is too much to do when released is to light up, he says. But we to ask someone to quit tobacco at the are at least reaching out to them, and that has been another area o opportunity or us and could be or same time they are quitting drugs many health departments. and alcohol. I tell them i you want to out, your housing in place, and your not be the ashtray o the Midwest, 78 and i past is initial treatment done, then maybe prologue, the prevalence o tobacco use will begin to there is a better time to do this. diminish. We may not catch them at the right time, but maybe a couple months later, they re ready to think about quitting. Al Bliss, LCHD, Health Educator coming rom recovery centers and the rest via local businesses. At 18 months in, over 300 individuals have been enrolled. LCHD oers both one-to-one and group cessation support classes in La Crosse and our surrounding rural counties where tobacco cessation eorts are ew and ar between. Bliss considers two o the biggest barriers to cessation to be ear o quitting tobacco use while in recovery and lack o aordability o the seven approved FDA medications. There is a myth that quitting smoking costs too much that it costs more than smoking, Bliss says. LCHD makes ree starter quit kits available, which include nicotine patches, gum, or lozenges, and reers participants to the Wisconsin Tobacco Quitline or additional ree NRT. Most o the employers with whom Bliss works have indoor smoke-ree policies, which help to diminish tobacco use. But he inds that businesses are oten hesitant to oer cessation classes during work time, though they are not as reluctant to allow individual meetings o a hal hour or a brie intervention and NRT dispersal. Besides a healthier workorce, another incentive or employers is a more productive sta with ewer sick days and less disability leave. Bliss also sought his target demographic within the inmate population, successully counseling 27 prisoners, many o whom were serving sentences or alcohol-related oenses. Unortunately, Bliss cannot provide inmates with NRT without violating prison contraband policies. He conceded the ollow- 32 CASE STUDIES LaCrosse County Health Department 32 Wisconsin Governor Jim Doyle signed a smoking ban participate in our program once you on May 18, 2009, making the state the 27th to clear have some o your inances worked the air or employees in all public spaces and patrons o eating and drinking establishments. Wisconsin will Lessons Learned Binge drinking is culturally endemic to La Crosse County, Wisconsin. Binge drinkers are much more likely to smoke than the average population and are an overlooked group or tobacco cessation. Providing ree nicotine replacement therapy increases the cessation rates among clients. Educating smokers on the inancial beneits o quitting is eective. Breaking the socialization o recovery around smoking is necessary. Intervention services must come to the client rather than vice versa. Quitting tobacco increases the likelihood o maintaining sobriety.

University o Maine: Tobacco Access Portal Dismantling Literacy Barriers to Tobacco Inormation Program Overview Maine leads the states in tobacco control risk o prolonged unding, but smoking rates remain at tobacco use and crisis levels or certain segments o its consequences, as they are not able the population, raising the concern that tobacco to access important cessation inormation is not trickling down to its inormation on cessation techniques. residents eectively or equally. 79 Data show that 17.5 83 percent o Maine women smoke while pregnant. O Alarming statistics such as these encouraged Drs. those, 83.3 percent receive MaineCare or Medicaid Stephen Gilson and Liz DePoy to apply or a grant assistance. 80 Maine also has a high number o rom Legacy. Gilson and DePoy are co-directors o residents with disabilities a population both more the Prevention Center o Excellence located in the likely to use tobacco and less likely to quit. 81 Twice as Center or Community Inclusion and Disability Studies (CCIDS) at the University o Maine and have built many Mainers earning less than $25,000 use tobacco considerable capacity or improving health inormation compared to residents who earn over $50,000, and access or diverse populations. The original idea three times as many o those with a high school came rom their intent to develop a web-based tool degree use tobacco compared to those with a college that renders text rom tobacco inormation websites degree. 82 For people with literacy barriers, reading a into readable inormation or mostly rural Mainers with text on the web - a dynamic multimedia platorm - is limited literacy and English proiciency. When they more diicult than reading a text in printed materials. tested the top ten Google search results ound by Because reading is urther complicated on the using the key words quit smoking, they ound only Internet, those with reading challenges are at greater one the Centers or Disease Control and Prevention Tobacco Control in Rural America 33 CASE STUDY # 5

developed until the University o Maine created the Maine is a poor rural state. It s a TAP project. Existing tools such as English language border state, where many people parsers and thesauruses work toward this aim, but no existing sotware could ilter a health-based speak Acadian French as their irst website to be readable to a low-literacy population. A language. Low literacy here in a particular challenge is that many topical areas, such as tobacco control, have specialized lexicons that do rural area is an issue or dierent not lend themselves to easy translation. reasons than it is in, say, New York, Initially, the process was a labor-intensive, line-by-line, word-by-word tinkering with the language. Gilson and where an immigrant might come to DePoy worked with a handul o graduate students the city and never learn to speak who developed a matrix to check and doublecheck each word as the portal was being built and English. That s dierent than i you improved. What do you do when the title o a website never went to school or you went to says smoking cessation? asked Gilson. We had to develop a program that dierentiated between a one-room schoolhouse, which is ormal names and text describing quitting smoking. still the case here in a lot o places. The process uncovered kinks in their sotware that produced problematic translations o some phrases. For instance, people with special needs became Liz DePoy, Developer and Researcher, University o Maine Tobacco Access Portal special people in an early iteration o the portal. The current version o TAP translates the six major website that met basic accessibility guidelines. tobacco prevention sites serving the state o Maine. The idea or the prototype Tobacco Access Portal This has never been a project with the intention o (TAP) was born rom DePoy s personal experience, doing an I gotcha against the designers o these when she became sick with encephalitis and had websites, Gilson says. We just lipped our brains and temporarily lost her eyesight. Walking into the started thinking dierently. Web authors and designers doctor s oice and not being able to read anything, didn t write those sites to exclude people. she says, led to her interest in developing tools or A local journalist interviewed Gilson and DePoy soon people with limited access to print inormation. While ater they received the Legacy grant. The journalist went TAP addresses visual challenges, it also includes 47 and pulled up those six sites and told them he couldn t percent o American adults who have trouble reading see how the inormation was diicult to understand. English in the dynamic and oten distracting webbased ormat. He was reading through a lens o someone with a 84, 85 While taking into account that individuals access We thought that low literacy was and comprehend inormation in a variety o ways, low literacy. It never dawned on us Gilson and DePoy aimed to build a bridge to tobacco cessation inormation or those who do not use the that there would be dierences in web in standardized ways. It s ludicrous, DePoy the nature o literacy even at the says. The people who need the inormation the most those who tend to be lower in literacy same level. I somebody speaks can t access it. From a human rights perspective it English as a second language just makes perect sense that something should be written at a literacy level that can be both read and but is very literate in his/her irst orally rendered. language, that was a very dierent Building the Portal Word by Word picture than someone who never Sotware like Babel Fish 86 is designed to translate learned to read in the irst place. blocks o text rom one language to another, but a web portal capable o distilling and simpliying language Liz DePoy, Developer and Researcher, to a literacy level below its original had not been University o Maine Tobacco Access Portal 34 CASE STUDIES University o Maine: Tobacco Access Portal 34

CASE STUDY NO. 5 master s degree, and those words seemed common It would be a dream come true i to him, Gilson says. It is easy or most members o this could be an overlay or any sort the population to take their basic literacy or granted. o website. It s really easy to see Accounting or a Low-Literacy the potential o making the Internet Population That Is Not Homogeneous accessible. We see people all the In the rural communities o Maine, low literacy takes time who simply can t understand many orms. Roughly 25% o Mainers are o French or French-Canadian ancestry. the health inormation that many 87 This population grows up speaking Franglais, much like the residents o the U.S.- o us take or granted, and it s clear Mexico border are luent in Spanglish. The Chinese that low literacy translates into low immigrant population is on the rise in Maine, particularly health. in and around Bangor, as is the Spanish-speaking population in the agricultural areas. 88 Gilson and DePoy Mary Lyon, Executive Director, Literacy Volunteers o Bangor had not anticipated their tool becoming useul or the English-as-a-second-language (ESL) population until Testing the Portal and Building they entered the testing phase. Creative Partnerships That was a big a-ha or us that we hadn t considered, Gilson and DePoy had a TAP testing site in place DePoy says. So we began looking at the dierences through the Literacy Volunteers o Bangor (LVB) even between what people want rom a website, how they beore they submitted their grant application. LVB s goal read it, and ultimately how they can learn rom it. We is to reduce the disparity o access to social, economic, really had to look at the multiple explanations o why they and educational resources or adults with identiiable don t read well and what that means or the development low literacy skills. Mary Lyon, the LVB executive o a web portal. In other words, the conceptualization director, and her sta serve roughly 200 people every and learning process or an immigrant highly educated year, mostly within a 25-mile radius o Bangor. The in his or her native language may be quite dierent rom population served at LVB is roughly 40-percent native that o a Franglais speaker or a high school dropout. English speakers and 60-percent ESL. Tobacco Control in Rural America 35

Gilson and DePoy arranged or a testing group o 20 Looking Forward with a Sustainable Initiative at LVB to receive stipends or their participation and Gilson and DePoy are now looking to broaden also donated a set o PCs to the center or ongoing the geographic reach o their innovative tool. They assistance. Our students would have done it even are developing a version that will ilter the tobacco without the stipends, because they are all so appreciative education sites in any state. We started with Maine as o what we do, Lyon says. It is a orgotten population, and this helps to remove barriers and level the playing a ramework to igure out the issues in development o ield. The testing process helped Gilson and DePoy this portal, Gilson says. Now we re ready to have it polish the portal by honing in on some language that work anywhere. Whether you re urban or rural, in North remained diicult or unamiliar and moved the prototype Carolina, Wyoming, or Los Angeles, you ll be able to to a level where it could be unveiled. plug in a cessation site and have it do the translation. At the time o this publication, the Maine Adult Education I am really excited about this next phase that will allow Association has developed a growing interest in us to extend beyond the boundaries o Maine. implementing the portal or a wider audience. Ater a Gilson and DePoy see a paradigm shit on the presentation at the American Public Health Association horizon. As the chair-elect o the Disability Section o annual conerence in 2008, immigrant service providers the American Public Health Association, Gilson eels in New York have expressed interest. This has sparked that the conversation around web-based inormation something or us, Gilson says. We had originally access is gaining traction. That is part o how policy conceived o this as a tool or olks with some sort o diagnostic circumstance or why they are not reading, thinking takes place, Gilson says. It gets on people s people who are in rural areas with problematic access, radar, and they begin looking at it and thinking or or people who had schooling curtailed. dierently. Lessons Learned Maine s adult smoking rate and literacy rate made it an ideal testing ground or the Tobacco Access Portal. Those who can least understand text-based health inormation are oten the ones who most need it. A tool like TAP requires many rounds o patient, diligent revision to distill language and simpliy specialized language while retaining accuracy. Vast dierences in the nature o literacy exist (even at the same level), and must be accounted or: regional dialects, ESL populations, and dierences o conceptual ability. The TAP model could be widely applied to improve literacy access or a range o sites across geographic boundaries. Innovative projects require creative partnerships. 36 CASE STUDIES University o Maine: Tobacco Access Portal 36

APPENDIX A NEW IMMIGRATION POPULATION CHANGE: NON-METRO COUNTIES IN THE U.S. Less than 1.2 1.2-3.5 3.5-6.5 6.51-13 Greater than 13.01 [Durham, NH: Carsey Institute, University o New Hampshire] P. 18, available at http://www.carseyinstitute.unh.edu/publications/report_immigration.pd. Source: Lei Jensen, New Immigrant Settlements in Rural America: Problems, Prospects, and Policies, Tobacco Control in Rural America 37

APPENDIX B ENDNOTES 1 USDA, Economic Research Service, Rural Deinitions: Data Documentation and Methods, Economic Research Service, http://ers.usda.gov/data/ruraldeinitions/ documentation.htm [accessed May 18, 2009]. 2 USDA, Economic Research Service, Deining the Rural in Rural America, Economic Research Center, http://www.ers. usda.gov/amberwaves/june08/features/ RuralAmerica.htm [accessed May 18, 2009]. 3 Eric H. Larson and L. Gary Hart, Rural Health Workorce Methods and Analysis, in State o the Health Workorce in Rural America: State Proiles and Comparison, ed. Eric H. Larson et al., [Seattle, WA: WWAMI Rural Health Research Center, University o Washington, 2003], 18, http://depts.washington.edu/wwamiric/ pds/monograph/ruralch3methods. pd [accessed May 22, 2009]. 4 Institute o Medicine, Quality through Collaboration: Future o Rural Health Care, Executive Summary [Washington, DC: The National Academies Press, 2005], 1. 5 U.S. Census Bureau, U.S. Census 2000, County Factsheets, http://actinder.census.gov/home/sa/ main.html?_lang=en [accessed June 29, 2009]. 6 Joel Rodríguez-Saldaña, Challenges and Opportunities in Border Health, Preventing Chronic Disease 2, no. 2 [January 2005], http://www.cdc.gov/pcd/issues/2005/ jan/04_0099.htm [accessed June 5, 2009]. 7 Pan American Health Organization (PAHO), Health in the Americas, [Washington, DC: PAHO, 2007], Vol. 2, http://www.paho.org/hia/archivosvol2/paisesing/ United%20States%20Mexico%20Border%20 Area%20English.pd [accessed June 5, 2009]. 8 Lawrence C. Hamilton et al., Place Matters: Challenges and Opportunities in Four Rural Americas, [Durham, NH: Carsey Institute, University o New Hampshire, 2008], 4, http://carseyinstitute.unh.edu/publications/report_ PlaceMatters.pd [accessed May 28, 2009]. 9 USDHHS, Substance Abuse & Mental Health Services Administration, Oice o Applied Studies, National Survey on Drug Use & Health: National Results, Appendix C: Key Deinitions, 2006, Substance Abuse and Mental Health Administration, http:// www.oas.samhsa.gov/nsduh/2k6nsduh/ AppC.htm [accessed May 28, 2009]. 10 USDA, Economic Research Center, Racial and Ethnic Diversity Is Increasing in Rural America, Economic Research Center, http://www.ers.usda.gov/publications/eib48/ spreads/7/index.htm [accessed June 1, 2009]. 11 USDA, Economic Research Center, Rural Population and Migration: Trend 5 Diversity Increases in Nonmetro America, http:// www.ers.usda.gov/brieing/population/ Diversity.htm [accessed June 1, 2009]. 12 Kenneth Johnson, Reports on RURAL AMERICA: Demographic Trends in Rural and Small Town America, [Durham, NH: University o New Hampshire, Carsey Institute, 2006], 24, http:// www.carseyinstitute.unh.edu/publications/report_ Demographics.pd [accessed June 1, 2009]. 13 USDHHS, Oice o Applied Studies, National Household Survey on Drug Abuse Advance Report 1995, http://www.samsha.gov.oas/ nhsda/ar18t039.htm, August 10, 2001. 14 USDHHS, CDC, National Center or Health Statistics, Summary Health Statistics or U.S. Adults: National Health Interview Survey 2006, Vital Health Statistics 10(235), [Washington, DC: National Center or Health Statistics, CDC, 2007] Table 25, 69, http:// www.cdc.gov/nchs/data/series/sr_10/ sr10_235.pd [accessed May 28, 2009]. 15 Ibid. 16 USDHHS, Substance Abuse & Mental Health Administration (SAMHSA), Oice o Applied Studies, Results rom the 2007 National Survey on Drug Use and Health: Detailed Tables, SAMHSA, Table 2.49B, 80402, http:// oas.samhsa.gov/nsduh/2k7nsduh/tabs/ Sect2peTabs47to51.pd [accessed May 28, 2009].

17 Andrea Kopstein, Tobacco Use in America: Findings rom the 1999 National Household Survey on Drug Abuse, [Rockville, MD: Substance Abuse and Mental Health Services Administration, Oice o Applied Studies, 2001], DHHS Publication No. SMA 02-3622, 15, http://www.oas.samhsa.gov/nhsda/tobacco/ tobacco.pd [accessed June 1, 2009]. 18 USDHHS, Substance Abuse and Mental Health Services Administration, Oice o Applied Studies, The NSDUH Report: Smokeless Tobacco Use, Initiation, and Relationship to Cigarette Smoking: 2002 to 2007, [Rockville, MD: Substance Abuse and Mental Health Services Administration, Oice o Applied Studies], http:// www.oas.samhsa.gov/2k9/smokelesstobacco/ smokelesstobacco.htm [accessed June 1, 2009]. 19 USDHHS, Substance Abuse and Mental Health Services Administration, Oice o Applied Studies, 2007 National Survey on Drug Use and Health: Detailed Table, [Rockville, MD: Substance Abuse and Mental Health Services Administration, Oice o Applied Studies], Table 2.59, http://www. oas.samhsa.gov/nsduh/2k7nsduh/tabs/ Sect2peTabs43to84.htm [accessed June 1, 2009]. 20 UDHHS, CDC, The Health Consequences o Involuntary Exposure to Tobacco Smoke: A Report o the Surgeon General, [Atlanta, GA: USDHHS, CDC, Oice on Smoking and Health, 2006]. 21 USDHHS, CDC, Smoking and Tobacco Use, Secondhand Smoke Fact Sheet, September 2006, http://www.cdc.gov/tobacco/data_ statistics/act_sheets/secondhand_smoke/ secondhandsmoke.htm [accessed June 1, 2009]. 22 USDHHS, The Health and Well-Being o Children in Rural Areas: A Portrait o the Nation 2005 US DHHS, Health Resources and Services Administration, Maternal and Child Health Bureau. The National Survey o Children s Health 2003, [Rockville, MD: U.S. Department o Health and Human Services, 2005], http://www.mchb.hrsa.gov/ruralhealth/ amily/18sh.htm [accessed June 1, 2009]. 23 Ibid. 24 Ibid. 25 Tresza D. Hutcheson et al., Understanding Smoking Cessation in Rural Communities, The Journal o Rural Health, Spring 2008, 117. 26 Stacy Stevens, Brian Colwell, and Linnae L. Hutchison, Tobacco Use in Rural Areas in Rural Healthy People 2010: A Companion Document to Healthy People 2010, Vol. 1, ed. Larry D. Gamm, et al., [College Station, TX:, School o Rural Public Health, Southwest Rural Health Research Center,The Texas A&M University System Health Science Center, 2003]. 27 Ibid. 28 Hutcheson et at., 122. 29 USDA, Economic Research Service, Rural America at a Glance, [Washington, DC: USDA, Economic Research Service, 2006], Economic Inormation Bulletin 18, http:// www.ers.usda.gov/publications/eib18/ eib18.pd [accessed June 1, 2009]. 30 Hutcheson et at., 122. 31 Stevens, Colwell, and Hutchison. 32 Hutcheson et at., 122. 33 Stevens, Colwell, and Hutchison 34 USDA, Economic Research Service. 35 Hutcheson et at., 122. 36 Stevens, Colwell, and Hutchison. 37 Hutcheson et at., 122. 38 Stevens, Colwell, and Hutchison. 39 Ibid. 40 Hutcheson et at., 122. 41 Stevens, Colwell, and Hutchison. 42 Bradley Gray and Frank J. Chaloupka, Do State Policies Aect Tobacco Sales to Minors?, Policy Forum, no. 16, [November 2003], Institute o Government and Public Aairs, IGPA University o Illinois, 3, http://tigger.uic. edu/~jc/presentations/scans/final%20pdfs/ IGPA_2003.pd [accessed June 1, 2009]. 43 Stevens, Colwell, and Hutchison. 44 Ibid. 45 Ibid. Tobacco Control in Rural America 39

ENDNOTES, CONTINUED 46 Jeanette Treiber, Tobacco Control Evaluation with Rural Populations, [Davis, CA: UC Davis, Tobacco Control Evaluation Center, 2007], Culture in Evaluation # 2: Rural, http:// tobaccoeval.ucdavis.edu/iles/culture_ Rural.pd [accessed June 1, 2009]. 47 Lawrence C. Hamilton et al., Place Matters: Challenges and Opportunities in Four Rural America, [Durham, NH: Carsey Institute, University o New Hampshire, 2008], 17, http:// carseyinstitute.unh.edu/publications/report_ PlaceMatters.pd [accessed May 28, 2009]. 48 Ibid. 49 Stacy Stevens, Brian Colwell, and Linnae L. Hutchison, Tobacco Use in Rural Areas in Rural Healthy People 2010: A Companion Document to Healthy People 2010, Vol. 1, ed. Larry D. Gamm, et al., [College Station, TX: School o Rural Public Health, Southwest Rural Health Research Center,The Texas A&M University System Health Science Center, 2003]. 50 Ibid. 51 Bradley Gray and Frank J. Chaloupka, Do State Policies Aect Tobacco Sales to Minors? Policy Forum, no. 16, [November 2003], Institute o Government and Public Aairs, IGPA University o Illinois, http://tigger.uic. edu/~jc/presentations/scans/final%20pdfs/ IGPA_2003.pd [accessed June 1, 2009]. 52 Robert McMillen, Julie Breen, Arthur G. Cosby, Rural-Urban Dierences in the Social Climate Surrounding Environmental Tobacco Smoke: A Report From the 2002 Social Climate Survey o Tobacco Control. Journal o Rural Health, December 2004, 7-16. 53 Stevens, Colwell, and Hutchison. 54 The Family Smoking Prevention and Tobacco Control Act gives new authority to the Food and Drug Administration (FDA) to put restrictions on the sponsorships o athletic or other entertainment events by tobacco product manuacturers, distributors, or retailers. The speciic restrictions on sponsorships and other areas will be determined through the regulations process. 55 US/Mexico Border Counties Coalition, Income, in At the Cross Roads: US/Mexico Border Counties in Transition, http://www.bordercounties.org/ vertical/sites/%7bb4a0f1-7823-4c95-8d7a- F5E400063C73%7D/uploads/%7B00C192A3- E3F0-4E3F-B33A-F819997BF3F2%7D. PDF [accessed June 24, 2009]. 56 Ibid., Health, Chapter 9. 57 Ibid., Income, Chapter 4. 58 Ibid., Health, Chapter 9. 59 Ibid., Labor Force, Labor Pool and Unemployment, Chapter 5. 60 USDOL, Bureau o Labor Statistics, http://data. bls.gov/pdq/servlet/surveyoutputservlet?data_ tool=latest_numbers&series_id=lns14000000 [accessed June 30, 2009]. 61 Ohio Department o Development, Ohio County Indicators, Table 17, http://www. development.ohio.gov/research/iles/ s100.pd [accessed June 22, 2009]. 62 Ohio Department o Development, Oice o Strategic Research, Ohio County Proiles- Washington County, 2002, http://www. development.ohio.gov/research/iles/s0/ Washington.pd [accessed June 22, 2009],. 63 Ohio Department o Health, Ohio Comprehensive Tobacco Use Prevention, Strategic Plan 2004-2008: 2007 Update, Ohio Department o Health, 40, http://www.odh.ohio.gov/assets/ F11C7C900CAD48BAA7678F146DD42815/ SPlan07.pd [accessed June 22, 2009]. 64 American Cancer Society Ohio Division, Ohio Department o Health, Ohio State University, Ohio Cancer Facts & Figures 2008, [Columbus, OH: American Cancer Society, 2008], http://www.cancer.org/downloads/com/ Ohio2008.pd [accessed June 22, 2009]. 65 Wendy Koch, Biggest U.S. Tax Hike on Tobacco Takes Eect, USA Today, April 3, 2009, http://www.usatoday.com/money/ peri/taxes/2009-03-31-cigarettetax_n. htm#table [accessed June 25, 2009]. 66 The terms spit, chew, and smokeless tobacco are oten used interchangeably.

67 CDC, Oice on Smoking and Health, Smoking and Tobacco Use: Adult Data, CDC, http:// www.cdc.gov/tobacco/data_statistics/by_topic/ adult_data/index.htm [accessed June 22, 2009]. 68 Shu-Hong Zhu, et al., Quitting cigarettes completely or switching to smokeless tobacco: do US data replicate the Swedish results? Tobacco Control 18 [January, 2009]: 82-87. 69 Meera Viswanathan, et al., Community- Based Participatory Research: Assessing the Evidence, AHRQ Publication 04-E022-2 [NC: RTI-University o North Carolina, 2004], 3, http:// www.ahrq.gov/downloads/pub/evidence/pd/ cbpr/cbpr.pd [accessed June 1, 2009]. 70 CDC, BRFSS, Alcohol Consumption 2008, Binge Drinkers, Wisconsin, http://apps.nccd. cdc.gov/brss/sex.asp?cat=ac&yr=2008&qke y=7307&state=wi [accessed June 16, 2009]. 71 CDC, BRFSS, Alcohol Consumption 2008, Binge Drinkers, Wisconsin, http://apps.nccd. cdc.gov/brss/list.asp?cat=ac&yr=2008&qkey =7307&state=WI [accessed June 23, 2009]. 72 BRFSS, Wisconsin-2008, Tobacco Use, Adults who are current smokers, http://apps.nccd.cdc. gov/brss/education.asp?cat=tu&yr=2008&qk ey=4396&state=wi [accessed June 16, 2009]. 73 John R. Hughes, Treating Smokers with Current or Past Alcohol Dependence, American Journal o Health Behavior 20, [1996]. 74 National Institute o Mental Health, Expert Panel Addresses High Rates o Smoking in People with Psychiatric Disorders, http://www.nimh.nih.gov/ science-news/2009/expert-panel-addresseshigh-rates-o-smoking-in-people-with-psychiatricdisorders.shtml [accessed June 23, 2009]. 75 Wisconsin Department o Health and Family Services, Tobacco Prevention and Control Program, Wisconsin Tobacco Facts 2006, [Madison, WI: DHS]. 76 Judith J. Prochaska, Kevin Delucchi, and Sharon M. Hall, A Meta-analysis o Smoking Cessation Interventions with Individuals in Substance Abuse Treatment or Recovery, Journal o Consulting and Clinical Psychology 72, 2004, 1144-1156. 78 Oice o the Governor Jim Doyle, Press Release, Governor Doyle Urges Legislature to Make Wisconsin Smoke-ree, January 9, 2008, http://www.wisgov.state.wi.us/ journal_media_detail.asp?locid=19&prid=3087 [accessed June 26, 2009]. 79 Diana Bowser and Paul Campbell, Inluencing State Policy on Tobacco Settlement: The Experience in Maine. [Augusta, ME: Maine Center or Public Health, 2005]. 80 Department o Health and Human Services, Maine, 2005 Pregnancy Risk Assessment System, http://www.maine.gov/dhhs/bohodr/tables2005/ smokeduring05.htm [accessed June 26, 2009]. 81 Partnership or Tobacco-Free Maine, Fact Sheet, Disabled, http://www.tobaccoreemaine. org/explore_acts/documents/disabled. pd [accessed June 26, 2009]. 82 Partnership or Tobacco-Free Maine, Fact Sheet, Low Socio-Economic Status, http://www. tobaccoreemaine.org/explore_acts/documents/ LowSES_001.pd [accessed June 26, 2009]. 83 Elizabeth DePoy and Stephen Gilson, Universal Web Access, The International Journal o Technology, Knowledge & Society, Vol. 1, 2005/2006. 84 Institute o Medicine (2004) Speaking o Health: Assessing Health Communication Strategies or Diverse Populations [Washington, DC: National Academic Press, 2002]. 85 Stephen Gilson and Elizabeth DePoy, (2006) Explanatory Legitimacy: A Theory o Diversity Applied to Disability, in Encyclopedia o Disability, ed. Gary L. Albrecht [Thousand Oaks, CA: Sage Publications Inc. 2006]. 86 Yahoo! Babel Fish, http://babelish.yahoo.com/. 87 U.S. Census Bureau, Selected Social Characteristics: Maine, http://actinder. census.gov/home/sa/main.html?_ lang=en&_ts= [accessed June 22, 2009]. 88 Ibid 77 Ibid. Tobacco Control in Rural America 41

American Legacy Foundation The American Legacy Foundation is dedicated to building a world where young people reject tobacco and anyone can quit. Located in Washington, D.C., the Foundation develops programs that address the health eects o tobacco use with ocus on vulnerable populations disproportionately aected by the toll o tobacco through grants, technical assistance and training, partnerships, youth activism, and counter-marketing and grassroots marketing campaigns. The Foundation s programs include: truth, a national youth smoking prevention campaign cited or its contributions to signiicant declines in youth smoking; EX, an innovative public health program designed to speak to smokers in their own language and change the way they approach quitting; research initiatives that explore the causes, consequences, and approaches to reducing tobacco use; and a nationally-renowned outreach program to priority populations. The American Legacy Foundation was created as a result o the November 1998 Master Settlement Agreement reached among attorneys general rom 46 states, ive U.S. territories and the tobacco industry. For more inormation about the oundation please visit www.americanlegacy.org. Acknowledgements We acknowledge and thank the ive grantees whose work has been eatured in this publication. We are grateul to them or providing inormation about their initiatives and reviewing manuscript drats. Kabi Pokhrel is the principal architect and author o this publication. We are grateul to Zachary Slobig, who created the case studies. Legacy sta colleagues Amber Hardy Thornton, Laura Hamasaka, Katherine Wilson, Michael Wood, Benjamin Frey, Robin Scott, and Alesia Brody contributed to this publication and served as reviewers. Kaye Placeres directed the graphic design o this publication. Building a world where young people reject tobacco and anyone can quit. americanlegacy.org

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