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Priority Health Topic: Tobacco Use


Background & History

Tobacco use—in all its forms—is an issue of high concern in Alaska, as indicated by Health Assessment Survey respondents noting it as a significant challenge in the state. There are also notable disparities in prevalence rates in tobacco use between Alaska Native/American Indian people and non-Native people in Alaska. The HA2020 plan had two leading health indicators measuring tobacco use rates for adults and adolescents. Improvement was made on both indicators for all Alaskans. The HA2030 team decided to keep tobacco objectives in the plan to continue the progress being made and set new targets to address emerging tobacco trends.

The Behavioral Risk Factor Surveillance System (BRFSS) and the Youth Risk Behavior Surveillance System are the main data sources for the adult and adolescent tobacco use objectives. HA2030 contains updated these two objectives to address all tobacco products listed in the YRBS (cigarette use, smokeless tobacco use, electronic vapor product use, Iqmik use and Cigar use) and BRFSS (cigarette use, smokeless tobacco use (including Iqmik) and electronic vapor product use). The updated HA2030 language, “other tobacco products”, is used for both objectives to cover the rapidly changing and emerging tobacco products and trends for both adolescents and adults.

Objective 26: Reduce percentage of adolescents (high school students in grades 9-12) who have used electronic vapor products, cigarettes, smokeless tobacco, or other tobacco products in the last 30 days

Target: 32%

Strategy 1: Promote public policies that have been demonstrated to reduce tobacco use among youth

Minimum legal age for tobacco laws specify an age below which the purchase or public consumption of tobacco is illegal, often 18, 19, or 21. Some states have age restrictions for sales but have not passed laws setting a minimum consumption age. Initiatives to increase the age to 21 are often referred to as ‘Tobacco 21.’ Estimates indicate 95% of adult smokers began smoking before age 21 (CTFK-Minimum tobacco age).

Regulations that restrict tobacco marketing limit promotion, placement, flavoring, or pricing of tobacco products. Regulations can restrict point-of-sale (POS) advertising, signs, and displays (Robertson 2015), require minimum package sizes (e.g., no less than 20 cigarettes), and written warnings for tobacco products (CTFK-FDA 2010). Regulations can also prohibit sales in health-oriented facilities such as pharmacies (PHLC-Tobacco in pharmacies), prohibit daytime advertising, limit the number, size, or location of ads posted by businesses (PHLC-Tobacco advertising), and prohibit print ads in child-oriented newspapers and magazines (CTFK-FDA 2010). The federal Family Smoking Prevention and Tobacco Control Act regulates sales of cigarettes and smokeless tobacco. State and local governments can further restrict promotions and pricing of cigarettes and smokeless tobacco (CTFK-FDA 2010) and restrict sales and promotion of other tobacco products such as cigars, cigarillos, and pipe tobacco (Farley 2017), but may not restrict advertising content (CTFK-FDA 2010).

Taxes at the federal, state, or local level can increase the price consumers pay for tobacco. Revenue generated from tobacco taxes may fund tobacco prevention and control interventions.

Sources:

  • https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/minimum-tobacco-age-laws
  • https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/tobacco-marketing-restrictions
  • https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/tobacco-taxes

Action Step 1

ActionEnact a strong statewide minimum legal sales age policy of 21 for all tobacco and electronic smoking products. Although the Federal Tobacco 21 (T21) law is in place, Alaska should maintain elements of a stronger policy, such as including retailer penalties. (Not currently included in the Federal law).
MeasureStronger T21 legislation passed in Alaska (Alaska statutes)
Timeframe2020-2022
Key Partners• American Lung Association, Alaska
• American Cancer Society, Alaska
• American Heart Association

Action Step 2

ActionProvide support so that the FDA restrictions on the sale of flavored tobacco and electronic smoking products are implemented as intended.
MeasureViolations of FDA restrictions (DBH Tobacco Enforcement data)
Timeframe2020-2030
Key Partners• State of Alaska, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion, Tobacco Prevention & Control Program
• State of Alaska, Division of Behavioral Health, Tobacco Enforcement Unit

Action Step 3

ActionIncrease the price of all tobacco products, including e-cigarettes.
• Build capacity of local coalitions to promote tax increases and create tax parity. Garner support for youth tobacco prevention.
• Provide evidence and technical assistance to local coalitions on effective pricing strategies to prevent youth initiation. Use national resources to calculate specific information for varying price increases.
• Advocate for price increases and tax parity for all tobacco products using evidence and Alaska specific impacts.
• Create tax parity to include e-cigarettes.
• Assess coalitions for youth partners
Measure• Relevant trainings provided, # attendees (Program records)
• Tax legislation passed in Alaska (Alaska statutes)
Timeframe2020-2030
Key Partners• State of Alaska, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion, Tobacco Prevention & Control Program
• Alaska Native Tribal Health Consortium
• American Lung Association, Alaska
• American Cancer Society, Alaska
• American Heart Association

Strategy 2: Support evidence-based tobacco cessation interventions for youth

Quitlines provide behavioral counseling to tobacco users who want to quit. Cessation specialists schedule follow-up calls after the specialist or tobacco user makes initial contact using a proactive quitline; reactive quitlines rely solely on tobacco users to make future contact. Some quitlines provide additional interventions such as mailed materials, web-based support, text messaging, or tobacco cessation medications (CG-Tobacco use). Many quitlines offer services in multiple languages (NAQC-US)

Tobacco cessation therapies such as nicotine replacement therapy (NRT) and individual, group, and telephone counseling often include out-of-pocket costs for patients. Efforts to increase affordability of cessation therapies can include eliminating patients’ out-of-pocket expenses or reducing patients’ expenses by eliminating co-payments, limits on duration of treatment, prior authorization, or annual limits on quit attempts (CG-Tobacco use). As of 2016, the US Food and Drug Administration (FDA) has approved nine therapies for tobacco cessation: individual counseling, group counseling, nicotine patches, nicotine gum, nicotine lozenges, nicotine nasal sprays, nicotine inhalers, Bupropion, and Varenicline (CDC-MMWR-DiGiulio 2016).

Sources:

  • https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/tobacco-quitlines
  • https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/tobacco-cessation-therapy-affordability

Action Step 1

ActionExpand Alaska’s Tobacco Quit Line to include education and cessation interventions for youth under 18 years. Continue to review research on youth treatment of nicotine addiction
MeasureEligibility criteria for Alaska’s Tobacco Quit Line (Program records)
Timeframe2020-2025
Key Partners• State of Alaska, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion, Tobacco Prevention & Control Program

Action Step 2

ActionTrain school professionals, behavioral health providers, and healthcare providers in evidence-based tobacco cessation referral processes for youth under 18 years, including for e-cigarette use.
• Provide the tools available to assist in screening.
• Provide evidence based cessation resources available for providers/clients/patients.
MeasureRelevant trainings provided, # attendees (Program records)
Timeframe2020-2030
Key Partners• State of Alaska, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion, Tobacco Prevention & Control Program
• Alaska Native Tribal Health Consortium

Strategy 3: Implement counter marketing, mass-reach health communication interventions to the public

Mass media campaigns use television, print, digital or social media, radio broadcasts, or other displays to share messages with large audiences (Cochrane-Carson-Chahhoud 2017). Tobacco-specific campaigns educate current and potential tobacco users about the dangers of tobacco and often include graphic portrayals or emotional messages to influence attitudes and beliefs about tobacco use (CG-Tobacco use).

Source:

  • https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/mass-media-campaigns-against-tobacco-use

Action Step 1

ActionUse social marketing tactics to reach youth with media to change social norms around tobacco use. Campaigns will focus heavily on e-cigarette use.
MeasureMedia metrics, flights, placement, etc. (Program records)
Timeframe2020-2030
Key Partners• State of Alaska, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion, Tobacco Prevention & Control Program
• Alaska Native Tribal Health Consortium

Objective 27: Reduce the percentage of adults (aged 18 and older) who currently smoke cigarettes or use electronic vapor products, smokeless tobacco, or other tobacco products

Target: 25%

Strategy 1: Adopt and implement comprehensive tobacco‐free post‐secondary and healthcare campus policies, and smoke free multi‐unit housing policies

Smoke-free policies for indoor areas prohibit smoking in designated enclosed spaces. Private sector smoke-free policies can ban smoking on worksite property or restrict it to designated, often outdoor, locations. Smoke-free state laws and local ordinances can establish standards for all workplaces, designated workplaces, and other indoor spaces. Policies can be comprehensive, prohibiting smoking in all areas of workplaces, restaurants, and bars, or limit smoking to designated areas via partial bans (Cochrane-Frazer 2016). Restrictions may also extend to adjacent outdoor areas (CG-Tobacco use). Some local governments cannot enact smoke-free measures due to state preemption legislation (Grassroots Change).

Smoke-free multi-unit housing policies prohibit smoking in apartments, duplexes, and similar residences. Policies can apply to both common areas and individual units, and often include adjacent outdoor areas. Private sector rules apply to privately owned rental properties and owner-occupied units such as condo complexes; state and local ordinances apply to public and subsidized housing. Non-smoking residents of multi-unit housing are often exposed to secondhand smoke (SHS) in their homes from other units or common areas (Snyder 2016). The US Surgeon General indicates there is no risk-free level of SHS exposure (US DHHS SG-Smoking 2014). Residents, especially children, can also be exposed to thirdhand smoke (tobacco residue on surfaces and furnishings), in their home (Bartholomew 2015, Matt 2011).

Sources:

  • https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/smoke-free-policies-for-indoor-areas
  • https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/smoke-free-policies-for-multi-unit-housing

Action Step 1

ActionAdvocate for comprehensive tobacco‐free post‐secondary and healthcare campus policies, and smoke free multi‐unit housing policies.
MeasureRelevant policies passed in Alaska (Campus and organization policies, available online or as program records)
Timeframe2020-2030
Key Partners• State of Alaska, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion, Tobacco Prevention & Control Program and grantees

Action Step 2

ActionProvide education and support for policy implementation and enforcement, using local resources tailored to each organization
MeasureRelevant trainings provided, # attendees (Program records)
Timeframe2020-2030
Key Partners• State of Alaska, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion, Tobacco Prevention & Control Program
• American Lung Association, Alaska

Action Step 3

ActionDistribute funding to local and statewide organizations to implement and enforce smoke free or tobacco‐free policies.
Measure# of communities that have funding (as TPC grantee or through tax revenue) dedicated to implementation or enforcement of smoke free or tobacco-free policies; TPC grantee self-efficacy to address secondhand smoke in their communities (Community of Practice evaluation survey).
Timeframe2020-2030
Key Partners• State of Alaska, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion, Tobacco Prevention & Control Program

Strategy 2: Support evidence-based changes to behavioral health, health systems and reimbursement policies that enhance tobacco cessation interventions

Provider reminder systems remind or encourage health professionals to support tobacco cessation among their patients. Such systems can include provider trainings, organizational protocols or referral processes, financial remuneration for providers, and materials such as self-help pamphlets and pharmacotherapy (e.g., nicotine replacement therapy (NRT)) (Rosseel 2012). A 2013 survey suggests that physicians are more likely to advise quitting than to discuss cessation strategies or medications (NCQA 2013).

Quitlines provide behavioral counseling to tobacco users who want to quit. Cessation specialists schedule follow-up calls after the specialist or tobacco user makes initial contact using a proactive quitline; reactive quitlines rely solely on tobacco users to make future contact. Some quitlines provide additional interventions such as mailed materials, web-based support, text messaging, or tobacco cessation medications (CG-Tobacco use). Many quitlines offer services in multiple languages (NAQC-US)

Sources:

  • https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/health-care-provider-reminder-systems-for-tobacco-cessation
  • https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/tobacco-quitlines

Action Step 1

ActionTrain behavioral health and healthcare providers on evidence-based tobacco cessation referral processes, including for e-cigarette use.
• Provide the tools available to assist in screening.
• Ensure that evidence-based cessation resources are available for providers/clients/patients.
MeasureRelevant trainings provided, # attendees (Program records)
Timeframe2020-2030
Key Partners• State of Alaska, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion, Tobacco Prevention & Control Program
• Alaska Native Tribal Health Consortium

Action Step 2

ActionWork with behavioral health and healthcare leadership to implement documentation systems and reimbursement protocols within health systems. Support use of:
• Electronic referral to Alaska’s tobacco quit line
• EHR to ensure tobacco screening and referral happens with every patient
Measure# of e-referrals to Alaska’s Tobacco Quit Line (Quit line reports); Participation of TPC in collaborative planning efforts related to systematizing e-referral (program records)
Timeframe2020-2030
Key Partners• State of Alaska, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion, Tobacco Prevention & Control Program
• Alaska Native Tribal Health Consortium

Action Step 3

ActionSupport evidence-based tobacco cessation treatment coverage and reimbursement by working with payers to:
• Allow tobacco cessation treatment to be a reimbursable service for substance abuse and mental health providers
• Expand insurance coverage of proven cessation treatments (dropping co-pays, paying right providers)
Measure# of different payers TPC is working with to expand coverage (program records)
Timeframe2020-2030
Key Partners• State of Alaska, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion, Tobacco Prevention & Control Program

Strategy 3: Implement counter marketing, mass-reach health communication interventions

Because youth and adults continue to be heavily exposed to pro-tobacco media, advertising, and promotion, public education campaigns are needed to prevent tobacco use initiation and to promote cessation (CDC, Best Practices, 2014). Mass media campaigns use television, print, digital or social media, radio broadcasts, or other displays to share messages with large audiences (Cochrane-Carson-Chahhoud 2017). Tobacco-specific campaigns educate current and potential tobacco users about the dangers of tobacco and often include graphic portrayals or emotional messages to influence attitudes and beliefs about tobacco use (CG-Tobacco use).

Sources:

  • https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/mass-media-campaigns-against-tobacco-use
  • https://www.cdc.gov/tobacco/stateandcommunity/best_practices/pdfs/2014/comprehensive.pdf

Action Step 1

ActionImplement campaigns, which may include:
• A focus on e-cigarette use, (e.g., “Switching is Not Quitting” theme)
• Promotion of evidence-based cessation services
• A focus on mental health and quitting
MeasureMedia metrics, flights, placement, etc. (Program records)
Timeframe2020-2030
Key Partners• State of Alaska, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion, Tobacco Prevention & Control Program
• Alaska Native Tribal Health Consortium

Strategy 4: Promote public policies that have been demonstrated to reduce tobacco use

Taxes at the federal, state, or local level can increase the price consumers pay for tobacco. Revenue generated from tobacco taxes may fund tobacco prevention and control interventions. Some local governments cannot enact such measures due to state preemption legislation (CG-Tobacco use).

Source:

  • https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/tobacco-taxes

Action Step 1

ActionIncrease the price of all tobacco products, including e-cigarettes.
• Build capacity of local coalitions to promote tax increases and create tax parity. Garner support for youth tobacco prevention.
• Provide evidence and technical assistance to local coalitions on effective pricing strategies to prevent youth initiation. Use national resources to calculate specific information for varying price increases.
• Advocate for price increases and tax parity for all tobacco products using evidence and Alaska specific impacts.
• Create tax parity to include e-cigarettes
MeasureRelevant trainings provided, # attendees (Program records); Tax legislation passed in Alaska (Alaska statutes)
Timeframe2020-2030
Key Partners• State of Alaska, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion, Tobacco Prevention & Control Program
• Alaska Native Tribal Health Consortium
• Health Care Services
• American Lung Association, Alaska
• American Cancer Society, – Cancer Action Network
• American Heart Association

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Wellness and Prevention
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Alaska Native Tribal Health Consortium
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