It’s all about your health 2005 PLAN FOR A TOBACCO-FREE DELAWARE This updated plan strengthens Delaware’s efforts and renews our goals. Our work has been instrumental in raising awareness, educating people on the dangers of tobacco, developing and implementing programs to help people stop using tobacco, measuring and analyzing data, and evaluating effectiveness to keep progress on course. Our consistent pursuit of our 1999 goals and objectives has helped Delaware emerge as a leader in the nation in encouraging healthier attitudes. The passage of the Delaware Clean Indoor Air Act, which prohibits smoking in indoor public places and workplaces, is particularly noteworthy. In fact, Delaware was the second state to pass a law of its kind. A plan that’s working. The Plan for a Tobacco-Free Delaware—a coordinated effort of the IMPACT Delaware Tobacco Prevention Coalition and Delaware’s Division of Public Health—was first developed in 1999. Portions of the plan were used in Healthy Delaware 2010 and by the Delaware Advisory Council on Cancer Incidence and Mortality (now called the Delaware Cancer Consortium)—the governor’s task force that is also working to reduce cancer risks including tobacco. It is a new platform upon which more objectives can be accomplished. Continuing to reduce the use of tobacco makes all of us healthier. The coalition—which includes members of every major health system, community organizations, members of the educational community, wellness centers, service organizations, and citizens—initiated goals and objectives to improve the health of the people of Delaware. In Delaware, we’ve emerged as a clear leader in tobacco prevention and control. From the beginning, we did things right. We created a process to manage the Master Settlement Agreement (MSA) funds—the $246 billion the tobacco industry distributes to all 50 states over a period of 25 years—through the Delaware Health Fund. Delaware is one of just a few states using funds as they were intended—to support programs that include comprehensive tobacco prevention and control. We have gained national recognition, not just for the landmark passing of the Delaware Clean Indoor Air Act, but for pioneering a bold path in tobacco prevention for other states to follow. We are making a difference. Our efforts are solid and time-tested. We use best practices described in “Best Practices for Comprehensive Tobacco Control Programs,” a report published by the U.S. Department of Health and Human Services in August 1999. The report outlined efforts that were incorporated in our initial plan, including: • Community programs to reduce tobacco use. • Community programs to reduce the burden of tobacco-related illness. • School programs. • Enforcement of tobacco control laws. • Strengthening statewide partnerships. • Public education. • Helping smokers to quit. • Surveillance and evaluation. • Administration and management. The implementation of those best practices has resulted in the following accomplishments: • A comprehensive program for tobacco cessation including the creation of the Delaware Quitline—a toll-free service that helps Delaware residents who are 18 years of age or older to quit using cigarettes and chewing tobacco. Delaware Quitline also features a community partnership that makes cessation aids, such as nicotine patches and gum, available to those who can’t afford them. • Media campaigns and community outreach to support those efforts. • Development and implementation of school tobacco policies. • Education of the public and tobacco retailers to enforce youth access to tobacco laws. • Tracking and statistical analysis of state tobacco use, knowledge and behavior as well as quit rates, usage rates, and subsequent targeting of efforts or initiatives where needed. • Youth programs such as the Kick Butts Generation (KBG), Not On Tobacco (NOT), and Teens Against Tobacco Use (TATU). • Development of local coalitions and expansion of the statewide coalition. • Mini-grants to help community organizations conduct tobacco prevention programs and events. • Resources for physicians, schools, and community organizations. We consider our efforts an investment in helping people get healthier. Adult tobacco use has decreased from 25% to 22%. Prevention of tobacco sales to minors has increased from 66% to 96%. Carcinogens in indoor public areas have been reduced by 90%. Youth smoking has decreased from 32% to 23.5%. But there is still much to do. According to the latest results from the Centers for Disease Control and Prevention (CDC), the facts are still startling: • Delaware spent $222 million, or $298 per capita, on smoking-attributable, direct medical expenditures. • About 16 percent ($62 million, or $609.71 per recipient) of all Medicaid expenditures were spent on smoking-related illnesses and diseases. • One out of five deaths is tobacco-related. • Smoking is the number-one cause of preventable deaths. • The risk of heart disease increases with smoking. Delaware has come a long way. Groundbreaking laws and programs have begun to have an effect on the health of many Delawareans. We’ve influenced people in every area—in all walks of life. But there’s much left to do. Here’s a review of the newest challenges as we see them. Thanks to an increase in excise tax, we’re making the cost of tobacco products higher—which studies have shown can reduce purchases. Although our excise tax has been increased, other states have raised theirs as well. In Delaware the price of cigarettes is considerably less than surrounding states. Our new plan calls for a greater increase in the tax of tobacco products to reduce consumption and youth smoking rates. Although we have seen a dramatic decrease in smoking among young people due to our youth programs and initiatives, tobacco consumption among 18- to 24-year- olds is still high—a statistic we must work to change. We need to get more creative in our general messages—we have to get the attention of the public with studies and relevant information. We must keep policymakers centered on the health issues related to tobacco and use the data we have to enforce our message. And we must use that data to create even more opportunities to tell the story of the harmful effects of tobacco—keeping the focus on health. All of our goals and objectives must mirror tobacco industry strategies. When they up the stakes, we have to counter. And as a state, we have to stay the course on our commitment to health. We have to add our voice to other states’ voices to keep the federal government committed to health improvement. Getting everyone “on the bandwagon,” from policymakers to physicians to entire health systems, makes us a united force—a force that can make even more progress in improving the health of every Delawarean in the years to come. Critical Issues 1. Cigarette prices affect consumption. Raising our excise tax—which is still lower than surrounding states and the national average—could dramatically impact tobacco use. Studies have shown there is a direct correlation between the price of cigarettes and the number of youth who buy them. Increasing the price—by increasing the excise tax—can decrease consumption. 2. Funding for tobacco, both federal and private, is slipping in priority. The effects of smoking continue to be the number one cause of preventable deaths in this country. Popularity tends to shift depending on the current “hot” health issue. We can’t afford to let our focus on tobacco issues become diffused. We must keep our sights set on eliminating tobacco from the lives of the people in our state by appropriately funding tactics that can accomplish it. 3. Prevention data must be collected. Diligence in data collection tells us where our efforts should be concentrated. It is invaluable in understanding the trends. Data shows that there are major disparities in smoking prevalence among men and women. We’ve learned male consumption overall is high—among all races and ethnicities. We’ve learned that smoking is higher among people with lower income and education levels. And that young adults smoke at a higher rate than other age groups. Only through data analysis are we able to make programs better, justify funding, and identify those programs that work. 4. The tobacco industry is increasing its efforts, targeting more youth, young adults, and minorities. We must realize that the tobacco industry, to protect its livelihood, will find new ways to target the population and change its social image. They are creating new, more clever ways to target young people. We must be aware of the tactics they’re using to make tobacco more attractive, including: – Smoking made to look “cool” by actors in movies. – The availability of cigarettes and messages about them on the Internet. – Point-of-sale displays at youth eye levels in stores. 5. Alternative products must be addressed. – Herbal cigarettes. – “Chew” or smokeless tobacco is not a safe alternative. – Nicotine additives in water and candy that keep people from fully recovering from addiction to nicotine and hamper cessation efforts. Where we were The plan you see here was initially introduced in 1999 and was the pattern we followed to make an impact on tobacco-related issues. The checkmarks ( 3 ) indicate a task that has been implemented. The five bullets ( • ) indicate a task that has yet to be implemented. The Best practices and goals defined here follow CDC guidelines. 1999 Plan for a Tobacco-Free Delaware Our Accomplishments: 1. Best Practice—Community Programs to Reduce Tobacco Use Goal 1: Prevent tobacco use among young people. Goal 2: Increase the proportion of cigarette smokers who attempt to stop smoking. Goal 4: Increase the number of Delawareans who strongly disapprove of cigarette use. We’ve accomplished all the goals we set in 1999. Successful initiatives include using CDC and Master Settlement funding to award mini-grants to community-based organizations to fund implementation of tobacco prevention and control programs. Funding has also fueled activities and programs through contracts with Organizations such as the American Lung Association, American Cancer Society, the Boys and Girls Clubs, and various other community groups. • Continue to increase the effectiveness of community groups by strengthening the state’s tobacco prevention infrastructure and providing a shared vision for all tobacco control advocates. • Expand the membership of the IMPACT Delaware Tobacco Prevention Coalition by bringing in more nontraditional partners. A larger, more diverse coalition will further influence community attitudes on tobacco use and provide communities with greater support and coordination of efforts. • Provide incentives to community organizations to implement effective programs. • Expand effective, evaluated, community youth programs reaching high-risk youth. • Expand youth-led and youth-involvement programs to all areas of the state. Examples are Teens Against Tobacco Use (TATU), the Delaware Kick Butts Generation (KBG), and an annual Youth Tobacco Conference, currently sponsored by the IMPACT Delaware Tobacco Prevention Coalition and its Tobacco-Free Delaware (TFD) project. • Implement programs targeted to help reduce geographic, racial, and ethnic disparities in smoking prevalence. Bring together community leaders to address minority health issues related to tobacco use in Delaware. • Provide training opportunities in each county for community and youth-oriented organizations on tobacco prevention and control, how to develop effective interventions, how to obtain funding, and how to evaluate a program’s effectiveness. Due to staff turnover within community organizations, training sessions will need to be conducted regularly. • Continue to develop and fund tobacco education through Internet websites, including those of the Division of Public Health, the IMPACT Coalition’s Tobacco-Free Delaware (TFD), and the A.I. duPont Hospital for Children. Provide assistance in developing interactive opportunities for youth on these sites, and ensure that the sites are marketed to schools, libraries, and the public. • Continue support of grants to community and school-based organizations. 2. Best Practice—Community Programs to Reduce the Burden of Tobacco-Related Illness Goal 2: Increase the proportion of cigarette smokers who attempt to stop smoking. In Delaware, we have established a comprehensive cancer control program to provide preventative and diagnostic services—as well as a landmark cancer treatment program—to uninsured and underinsured individuals. • Work with the American Heart Association to coordinate and implement a comprehensive cardiovascular disease program (based on the CDC model) to include education on tobacco use, nutrition, and physical fitness. • Work with the American Cancer Society to augment educational programs and materials on the relationship between tobacco use and many types of cancer. • Work with the American Lung Association to expand programs conducted on asthma, emphysema, chronic bronchitis, and sarcoidosis. • Continue to develop a comprehensive cancer control program through the Division of Public Health and its partners. • Establish a cardiovascular disease prevention and control program within the Division of Public Health. • Work with the dental community to encourage oral screening and tobacco use prevention education. • Work with the Governor’s Council on Lifestyle and Fitness to promote cardiovascular fitness. • Work with other health organizations, and encourage their support of tobacco control education. 3. Best Practice—School Programs Goal 1: Prevent tobacco use among young people. Goal 4: Increase the number of Delawareans who strongly disapprove of cigarette use. Delaware schools have adopted the CDC’s model policy for tobacco control, which prohibits smoking on school property. Master Settlement funding has been provided to schools to enforce those school tobacco policies. Funding for Lifeskills (researched tobacco prevention curriculum) has also been provided to help young people to recognize and challenge common misconceptions about tobacco, alcohol, and other drugs. • Expand the use of successful, evidence-based prevention programs, such as the CDC-approved Lifeskills and Toward No Tobacco as well as Project Alert and other research-based health education curricula in Delaware schools, both public and private. • Ensure inclusion of tobacco and substance abuse programs in the school health education standards adopted in Delaware. • Provide teachers in K-12 with ongoing training opportunities including skills accessing information, self-management, internal and external influences, interpersonal communication, decision making, goal setting, coping skills, and advocacy. • Integrate and support Comprehensive School Health Education (CSHE), a prevention strategy that gives students the skills to make health-enhancing decisions throughout their lives. • Provide assistance and incentives to maintain tobacco-free school environments. • Provide a comprehensive school health education coordinator for 20 school districts. • Enforce and strengthen school policies on tobacco use. • Involve families in support of school programs to prevent use of tobacco and other drugs. • Support development and implementation of science-based youth smoking cessation efforts. • Assess tobacco use prevention programs at regular intervals. 4. Best Practice—Enforcement of Tobacco Control Laws Goal 1: Prevent tobacco use among young people. Goal 3: Reduce routine exposure to environmental tobacco smoke. Goal 4: Increase the number of Delawareans who strongly disapprove of cigarette use. Our accomplishments include the passage of The Clean Indoor Air Act and a system through which adherence to the act can be monitored. A phone number was established for reporting violations. The Delaware Tobacco Retailer Education Packets have been translated into six languages and distributed to every merchant with a tobacco license. • Educate tobacco retailers about the Youth Access Law, FDA regulations, and other laws or regulations regarding sale of tobacco products. Specifically, provide them with educational packets, as well as information via the Internet and in appropriate business publications on a regular basis. • Work with the Delaware Division of Revenue, the tobacco industry, the county and state chambers of commerce, the FDA, and others to develop an accurate, up- to-date mailing list for the retailer education project, other enforcement activities, and compliance checks. • Provide additional resources to help coordinate compliance checks. • Strengthen existing youth access laws by prohibiting self-service displays, banning free sampling, coupons to youth and sales of single cigarettes. • Strengthen the state’s Clean Indoor Air Act. • Conduct an ongoing education/marketing campaign to promote the state’s Clean Indoor Air Act and to educate the public on how to report violations of the act. • Provide public information about state laws and the phone numbers for reporting violations. 5. Best Practice—Strengthening Statewide Partnerships Goal 1: Prevent tobacco use among young people. Goal 2: Increase the proportion of cigarette smokers who attempt to stop smoking. Goal 3: Reduce routine exposure to environmental tobacco smoke. Goal 4: Increase the number of Delawareans who strongly disapprove of cigarette use. Media campaigns educating Delawareans about the harms of secondhand smoke have been implemented. A state-wide, tobacco-prevention conference for African Americans entitled “Leaving Tobacco Road” was held in April 2000. Technical assistance workshops on grant writing, evaluating programs, and other training topics have been provided. • Continue the Tobacco-Free Delaware project funded by the Robert Wood Johnson Foundation and administered through the American Lung Association of Delaware. The organization was scheduled to end on March 31, 2001. • Develop educational and incentive programs for companies, restaurants, and other public places, encouraging them to go smoke-free, and rewarding those that do. • Develop and implement educational and marketing “Go Outside to Smoke” programs for families, encouraging smokers not to smoke in their homes, automobiles, or other enclosed areas where children and other family members would be exposed to secondhand smoke. • Target programs to help reduce geographic, racial, and ethnic disparities in smoking prevalence. Bring together community leaders to address minority health issues related to tobacco use in Delaware and receive their input on training and other needs of the communities they represent. • Provide training opportunities in each county for community and youth-oriented organizations on tobacco prevention and control, how to develop effective interventions, how to obtain funding, and how to evaluate effectiveness. Due to turnover in staff within community organizations, these training opportunities will need to be available on an ongoing basis. • Expand the existing resource centers and the capacity to provide materials to teachers, community groups, and the public; improve marketing of these services. • Complete the online Delaware Health Information Database, which will include listings of available tobacco prevention and control resources, and market this service. 6. Best Practice—Public Education Goal 1: Prevent tobacco use among young people. Goal 2: Increase the proportion of cigarette smokers who attempt to stop smoking. Goal 3: Reduce routine exposure to environmental tobacco smoke. Goal 4: Increase the number of Delawareans who strongly disapprove of cigarette use. Media campaigns that inform about the Delaware Quitline, Clean Indoor Air Act, and environmental tobacco smoke (ETS) have been released and include movie theater advertising that specifically target youth. A youth TV contest has been implemented to engage high school students to write and produce commercials that appeal to their own age group. Media placement in Delaware college newspapers and outreach programs have targeted those schools. • Maintain an ongoing counter-marketing campaign, including radio, television, outdoor advertising, and print media, to increase awareness of tobacco prevention issues and help create the normative changes described above. • Develop a replicable tobacco public education initiative in at least one community in each of Delaware’s three counties. • Create and expand special events that promote awareness and educate the public about the dangers of tobacco use (such as the IMPACT Delaware Tobacco Prevention Coalition’s annual Wilmington Blue Rocks event, the Doctors Ought to Care, and the Division of Public Health’s student competition to develop anti-tobacco spots). • Maintain a central clearinghouse and online health information database of programs, services, contacts, and support materials related to tobacco. • Work with the American Cancer Society to offer a movie theater public education campaign. • Develop a public awareness campaign targeting college students in Delaware, a population in which smoking has increased dramatically in recent years. • Using the growing youth movement, including Kick Butts Generation (KBG) and Teens Against Tobacco Use (TATU) groups, increase the number of youth-created and youth-led media education activities. Provide funding for these groups to develop materials. 7. Best Practice—Helping Smokers Quit Goal 2: Increase the proportion of cigarette smokers who attempt to stop smoking. NOT (Not On Tobacco) programs have been funded. The Delaware Quitline has been established, and all materials have been translated into Spanish. College outreach has been performed. Pharmacist training and outreach to healthcare providers through printed materials has been accomplished. • Develop or replicate a successful teen smoking cessation program (such as NOT, the American Lung Association’s Not On Tobacco program) in high schools, through school-based wellness centers and/or school health facilities. • Continue to utilize behavior change cessation programs offered by the American Lung Association and the American Cancer Society. • Increase access to cessation services, especially in underserved areas such as Sussex County, for cigarette smokers who want to quit; train additional cessation leaders in underserved areas. • Work with the state’s colleges and universities to develop effective smoking cessation services and/or programs for students and graduates. • Develop a replicable tobacco control model in at least one university, and promote that model in other institutions of higher learning. • Work with professional organizations to provide ongoing in-service, Internet, and other training opportunities about smoking cessation to physicians, dentists, nurses, and other health-care professionals. • Enhance smoking cessation efforts for pregnant women through Division of Public Health clinics and other public clinics, provide advice and targeted quit-smoking packets to all pregnant women who smoke. Ensure that smoking status and education are tracked on all patient records. • Continue to support the American Cancer Society’s “Make Yours a Fresh Start Family” with the City of Wilmington, which assesses smokers on their readiness to quit and provides interventions. • Assess barriers to smoking cessation services in Kent and Sussex counties. • Develop or expand a toll-free telephone smoking-cessation hotline. • Ensure that such services are bilingual and that the personnel are well trained. 8. Best Practice—Surveillance and Evaluation Goal 1: Prevent tobacco use among young people. Goal 2: Increase the proportion of cigarette smokers who attempt to stop smoking. Goal 3: Reduce routine exposure to environmental tobacco smoke. Goal 4: Increase the number of Delawareans who strongly disapprove of cigarette use. • The following surveys have been conducted: • The Youth Tobacco Survey (YTS)—a survey of middle and high school youth that started in 2000—has been conducted during even years,. • The Youth Risk Behavior Survey (YRBS)—a survey of high school students grades 9 through 12—during odd years. The Behavioral Risk Factor Surveillance Survey (BRFSS)—a telephone survey of adults—takes place every year. Adult Tobacco Survey (ATS) adds more data to the evaluation process. All programs are committed to evaluation to help us determine the success of each outreach effort, media campaign or program. • Continue to monitor changing behaviors and attitudes through surveillance systems like the BRFSS (Division of Public Health), the YRBS (Department of Education), the special Alcohol, Tobacco and Other Drugs School Survey (Office of Prevention and the Department of Services for Children, Youth and their Families). • Conduct the Youth Tobacco Survey. • Select existing programs in communities, schools, and volunteer and state agencies and ensure periodic evaluations are conducted to improve their effectiveness. • Develop evaluation components for all newly developed and/or implemented programs. • Develop a mechanism for evaluation of awareness and attitudes regarding tobacco, using a private survey research firm. 9. Best Practice—Administration and Management Goal 1: Prevent tobacco use among young people. Goal 2: Increase the proportion of cigarette smokers who attempt to stop smoking. Goal 3: Reduce routine exposure to environmental tobacco smoke. Goal 4: Increase the number of Delawareans who strongly disapprove of cigarette use. Through Master Settlement funds, staffing assistance has been provided to community organizations to provide tobacco prevention programs. The state added people in departments including the Division of Public Health, the Department of Education, and the Department of Public Safety and Homeland Security to handle the staffing needs of related tasks. Two positions are funded by the Master Settlement to coordinate and evaluate our efforts. • Develop and implement an infrastructure adequate to handle the facilitation of the tobacco control plan, hiring additional administrative and management staff as required. • Review staff job responsibilities and needs. • Develop policies and procedures to ensure coordination of efforts between all key partners. • Continue training opportunities for all tobacco control personnel. Where we need to go 2005 Plan for a Tobacco-Free Delaware This newly revised plan has been created to move our tobacco prevention and control efforts into areas where there is identified need. It has been based on the same best practices formula as the initial plan. The subsequent pages describe the objectives and actions needed to reach these goals. 2005 Plan for a Tobacco-Free Delaware Prevent tobacco use among young Delawareans through age 24. Increase tobacco cessation among Delawareans. Reduce routine exposure to environmental tobacco smoke. Decrease the social acceptability of tobacco use. Maintain leadership position to sustain progress of tobacco prevention. Goal 1: Prevent tobacco use among young Delawareans through age 24. Rationale: A solid body of scientific evidence indicates that tobacco use and addiction usually take root in adolescence. An overwhelming majority of adults who have ever smoked daily tried their first cigarette before age 18. Over the past few years, the smoking prevalence rate in Delaware has been highest among young adults (age 18-24). Preventing initiation to tobacco use among youth and young adults will have the greatest effect on reducing future health, economic and social burdens associated with tobacco. Objective 1 Enforce laws that prohibit the sale of tobacco to minors so, by 2007, 98 percent or more of minors who attempt to buy cigarettes are denied. [As evidenced by the Department of Safety and Homeland Security Compliance Check Data: 1999 baseline: 66 percent; 2004: 95 percent.] Objective 2 Increase the number of judgments against owners of retail establishments found to be selling tobacco to minors. [As evidenced by review of the Department of Public Safety DELJIS records for arrests since the enactment of HB440; July 1996–December 1998; baseline: 11 judgments at or above minimum penalty.] Objective 3 Increase the number of schools, K-12, that faithfully implement a skills-based substance-use prevention program that includes tobacco and has been scientifically demonstrated to result in behavior change. [As evidenced by review by the Department of Education; baseline: to be determined.] Objective 4 Reduce the prevalence of smoking among youth under age 18. [As evidenced by the YRBS survey(high school): 1999 baseline—32 percent; 2003—23.5 percent. YTS survey (middle school): 2000 baseline—15 percent; 2002—11 percent.] Objective 5 Reduce the prevalence of smoking among adults, ages 18 to 24, to 20 percent by 2007. [As evidenced by the BRFSS; 1998 baseline: 28 percent; 2003: 27 percent.] Objective 6 Increase the number of community agencies faithfully implementing skills-based prevention programs that include tobacco. [As evidenced by survey; baseline: to be determined.] Objective 7 Increase the excise tax on tobacco to at least $1 per pack of cigarettes by 2007, and the tax on smokeless tobacco products from 15 percent to 30 percent of the wholesale price index by 2007. [1999 baseline: Delaware’s cigarette excise tax was 24 cents; smokeless tobacco, 15% wholesale price index. As of Jan. 2005, Delaware’s cigarette excise tax was 55 cents. The average tax of the three surrounding states is $1.58 per pack: Maryland $1.00; Pennsylvania, $1.35; and New Jersey, $2.40.] Action Steps: • Use evaluation and surveillance data to identify disparities and knowledge gaps so targeted messages and programs can be developed to reduce those disparities. • Advocate against any attempts to weaken youth access law or eliminate owner liability if their establishment has been found to sell tobacco to minors. • Strengthen youth access laws. • Continue to collect data on sales to minors and compliance checks. • Advocate for restrictions on self-service displays of tobacco products to discourage youth from obtaining tobacco products. Tobacco products should only be obtained from the sales clerk. • Develop point-of-sales devices which will require that an ID be shown to purchase tobacco products. • Develop a uniform survey used to obtain data on young adults (ages 18-24). • Develop marketing strategies that target workplaces, colleges, and military to reach 18-to-24-year-olds. • Provide funding and technical support for science-based programs that (as shown by existing models) result in behavior change. • Advocate for increasing the excise tax and use a portion of that tax for tobacco prevention and control efforts. • Ensure evaluation is conducted on all programs and activities. 2005 Plan for a Tobacco-Free Delaware Prevent tobacco use among young Delawareans through age 24. Increase tobacco cessation among Delawareans. Reduce routine exposure to environmental tobacco smoke. Decrease the social acceptability of tobacco use. Maintain leadership position to sustain progress of tobacco prevention. Goal 2: Increase tobacco cessation among Delawareans. Rationale: There are many people who have become addicted to tobacco products who want to quit but need help. Close to half of Delaware smokers have attempted to quit at least once and were not successful. Comprehensive cessation interventions are needed to reduce smoking prevalence, morbidity, mortality and economic impact of tobacco use in Delaware. Resources and opportunities must continue to be provided to tobacco users to assist them in their efforts. Smoking cessation counseling is one of the most effective health interventions from a physical and economic standpoint. The sooner a person quits tobacco use, the less damage they do to themselves and others. Objective 1 Increase the percentage of tobacco-using patients who are routinely advised of cessation by their healthcare providers and receive assistance and follow-up. [Survey of Health Care Providers and BRFSS; baseline: 2002 Physicians’ survey: “Most physicians replied that they discuss with their smoking patients the ill effects of smoking (86%), the need to stop smoking (91%), and smoking cessation techniques 58%) during every office visit. BRFSS 2000: 48% respondents indicated that their healthcare provider advised them to quit smoking. This figure increased to 79% in 2002. Objective 2 Increase the proportion of tobacco users who receive or use cessation services. [Delaware Quitline Fiscal Year 2004: July 1, 2003–June 30, 2004: 2,111 people enrolled in cessation services.] Objective 3 Increase the number of healthcare providers and institutions providing cessation services that adopt and follow The U.S. Department of Health and Human Services. [Survey of Health Care Providers; baseline to be determined.] Objective 4 Increase the percentage of Delaware citizens who have insurance coverage for tobacco cessation programs. [Baseline to be determined.] Action Steps: • Use evaluation and surveillance data to identify disparities and knowledge gaps so targeted messages and programs can be developed to reduce those disparities. • Continue to collect data on smoking prevalence, knowledge, and attitudes. • Collect information on the habits, demographics, and attitudes of “some day” smokers and develop programs and messages to help them quit using tobacco. • Continue to market Delaware Quitline, N-O-T, and other tobacco cessation programs. Marketing will be accomplished using various media venues (both general and target audience), healthcare providers, professional organizations, and community organizations. • Advocate for healthcare providers to identify their patients who smoke and advise them to quit smoking. • Increase the cessation services available to underserved areas/populations. • Educate employers about the social and economic benefits of employee cessation programs. • Advocate for comprehensive cessation coverage in public and private insurance plans. • Eliminate barriers to receiving coverage. • Use and recommend only evidence-based cessation programs and products. • Ensure evaluation of all programs and activities. 2005 Plan for a Tobacco-Free Delaware Prevent tobacco use among young Delawareans through age 24. Increase tobacco cessation among Delawareans. Reduce routine exposure to environmental tobacco smoke. Decrease the social acceptability of tobacco use. Maintain leadership position to sustain progress of tobacco prevention. Goal 3: Reduce routine exposure to environmental tobacco smoke. Rationale: Environmental tobacco smoke (ETS) is a known cause of several serious health problems and death. ETS is classified as a human carcinogen. Research has shown that there are more than 4,000 chemicals in tobacco smoke, many of which are known to cause cancer. By limiting or eliminating exposure to ETS, the less likely people will be impacted by its harmful effects. Objective 1 Increase the number of Delaware schools, pre-K-12 (including non-public schools), that have and enforce policies that include prohibiting smoking at school-related events, in facilities, on property, and in vehicles. [As evidenced by school health reports.] Objective 2 Sustain and enforce the Delaware Clean Indoor Air Act. Objective 3 Reduce number of locations where smoking is currently allowed. Objective 4 Increase the percentage of pediatric and family healthcare practitioners who inquire about secondhand smoke exposure in the home and advise reduction in secondhand smoke exposure for patient and family. [Baseline: Survey of Health Care Providers.] 2002 Physicians’ survey: 13% initial visit only; 36% almost every visit; 14% when symptomatic. Action Steps: • Use evaluation and surveillance data to identify disparities and knowledge gaps so targeted messages and programs can be developed to reduce those disparities. • Advocate for all school districts to adopt the Delaware model policy and enforce the policy. • Advocate for all private and parochial schools to adopt and enforce the Delaware model policy. • Reduce exemptions that are allowed in the Clean Indoor Air Act (CIAA). • Adopt policies that would not allow smoking in front of building entrances. • Increase resources available for enforcement for the CIAA. • Advocate for businesses and workplaces to develop and adopt policies that are stronger than the CIAA (e.g., smoke-free grounds, no smoking near entrances, smoke-free policies in organizations that are currently exempt • Conduct marketing campaigns and educational programs to reduce/eliminate smoking in the home and vehicles. • Encourage agencies that have regulatory authority over youth, elderly, and people with severe medical conditions to develop policies to reduce or restrict exposure to environmental tobacco smoke (ETS). • Advocate for physicians to strongly advise against exposure to ETS. • Educate the public, community, state leaders and healthcare providers about dangers of ETS. • Ensure evaluation is conducted on all programs and activities. 2005 Plan for a Tobacco-Free Delaware Prevent tobacco use among young Delawareans through age 24. Increase tobacco cessation among Delawareans. Reduce routine exposure to environmental tobacco smoke. Decrease the social acceptability of tobacco use. Maintain leadership position to sustain progress of tobacco prevention. Goal 4: Decrease the social acceptability of tobacco use. Rationale: For many years tobacco use was seen as an acceptable “social norm.” Smoking has been marketed as glamorous, sophisticated, cool, sensuous and something that most adults do. Even today most people tend to overestimate the smoking prevalence rates. Today the majority of people don’t smoke; an overwhelming majority does not want to be in places where others do smoke. Through education, social marketing and changing attitudes, tobacco use has become less desirable, less acceptable and less accessible. Objective 1 Reduce the percentage of middle and high school students who perceive that smoking is acceptable. [Youth Tobacco Survey; baseline to be determined.] Objective 2 Reduce the percentage of adults, ages 18 to 24, who think that smoking is acceptable. [Adult Tobacco Survey; baseline to be determined.] Objective 3 Decrease the proportion of middle and high school children who overestimate the percentage of peers who smoke. [Youth Tobacco Survey (middle school): 2002—70 percent significantly overestimate the smoking prevalence of their peers. Youth Tobacco Survey (high school): 2002—60 percent significantly overestimate the smoking prevalence of their peers.] Objective 4 Decrease the proportion of young adults, ages 18 to 24, who overestimate the percentage of peers who smoke. [Adult Tobacco Survey: baseline for ages 18 to 24—to be determined. ATS 2003: baseline for all adults surveyed—54 percent significantly overestimated the percentage of Delawareans who smoke.] Objective 5 Increase the proportion of Delawareans who report having seen or heard anti- tobacco messages within the past month. [Adult Tobacco Survey: 2002—70 percent have heard secondhand smoke messages; 2004—74 percent. Youth Tobacco Survey survey (high school): 2000—86 percent have seen or heard anti-smoking messages; 2002—89 percent. Youth Tobacco Survey (middle school): 2000—81.1 percent have seen or heard anti-smoking messages; 2002—84 percent.] Action Steps: • Use evaluation and surveillance data to identify disparities and knowledge gaps so targeted messages and programs can be developed to reduce those disparities. • Conduct tobacco prevention social marketing efforts that offer strong clear messages to target audiences. • Increase public awareness of the fact that 25 percent or less of adult Delawareans smoke. The perception is that smoking prevalence is much higher. • Educate the public and community leaders on the deceptive marketing and promotional strategies of the tobacco industry. • Place strong restrictions on tobacco advertising and promotion. • Encourage organizations, agencies, and leaders not to accept tobacco industry funding and seek alternative sources of funding. • Ensure evaluation is conducted on all programs and activities. 2005 Plan for a Tobacco-Free Delaware Prevent tobacco use among young Delawareans through age 24. Increase tobacco cessation among Delawareans. Reduce routine exposure to environmental tobacco smoke. Decrease the social acceptability of tobacco use. Maintain leadership position to sustain progress of tobacco prevention. Goal 5: Maintain Delaware’s position of leadership in comprehensive tobacco prevention to sustain existing progress and efforts. Rationale: Delaware has been recognized as exceeding national standards for Clean Indoor Air efforts, for preventing youth from smoking, for reducing youth access to tobacco, and for providing services to help people quit using tobacco. Delaware has served as a model by providing substantial resources to conduct comprehensive programs. In order to continue to maintain the significant strides in tobacco prevention and control attained in Delaware over the past few years, significant efforts must continue. Tobacco use is not a health problem that can be eradicated or cured overnight. Objective 1 Ensure resources (public and private) are available to develop and maintain quality, innovative and comprehensive approaches (human, financial, etc.) to tobacco control. [In 2003 and 2004, Delaware was one of three states to meet or exceed CDC’s minimum guidelines for funding tobacco prevention and control programs.] Objective 2 Expand statewide and local coalitions to advocate and promote tobacco prevention programs. Objective 3 Conduct ongoing monitoring and evaluation of the Plan for a Tobacco-Free Delaware. Action Steps: • Partner with other organizations and participate in Delaware’s initiative to eliminate health disparities. • Ensure that tobacco prevention funding is maintained at effective levels. • Access and pursue new funding opportunities. • Encourage community organizations and agencies that do not address tobacco prevention to include tobacco prevention and control as part of their agenda and policy. • Educate and inform community and state leaders on tobacco issues in Delaware and the nation. • Encourage community and state leaders to actively support tobacco prevention programs and policies. • Expand current successful programs and develop new programs, activities, and policies. This includes development of “pilot projects.” • Participate in national tobacco prevention programs and initiatives. This includes evaluation activities. • Integrate tobacco prevention and control into other health and community programs. • Ensure that the state tobacco prevention coalition and partnerships developed over the years remain strong. • Expand coalition membership and develop more partnerships. • Use this tobacco plan as a guide to help develop objectives, programs, and policies. • Ensure evaluation is conducted on all programs and activities. Appendix Name of Data Source: Behavioral Risk Factor Surveillance System (BRFSS) Description: The BRFSS is a joint effort of the Delaware Division of Public Health and the U.S. Centers for Disease Control and Prevention (CDC), and is funded by a CDC cooperative agreement. The BRFSS is an annual survey of Delaware’s adult population about behaviors which affect risk of disease and disability. Delaware’s BRFSS is conducted by the University of Delaware’s Center for Applied Demography & Survey Research for the Delaware’s Division of Public Health. The BRFSS is a random sample telephone survey of adults statewide, and has been administered in Delaware since 1990. The Behavioral Risk Factor Surveillance System monitors health-risk behaviors among adults. It includes behaviors that are linked with the leading causes of death—heart disease, cancer, stroke, diabetes, and injury—and other important health issues. These behaviors include level of physical activity, body weight, seatbelt use, tobacco and alcohol use, and receiving preventive medical care—as well as preventive use of mammograms, Pap smears, colorectal cancer screening tests, and flu shots— known to save lives. Tobacco-Related Data: The BRFSS is the main source of tobacco-related data on prevalence of tobacco use among adults. Web Address: http://www.state.de.us/dhss/dph/dpc/brfsurveys.html Name of Data Source: Youth Risk Behavior Survey (YRBS) Description: The YRBSS consists of a national school-based survey (all 50 states and DC) conducted by the Centers for Disease Control and Prevention as well as state and local school surveys conducted by education and health agencies. Delaware’s YRBS is conducted by the University of Delaware, Center for Alcohol and Drug Studies for the Delaware Department of Education. The surveys have been administered to a sample of public and private school students in grades 9–12 every two years (odd years) since 1997. The Youth Risk Behavior System (YRBS) monitors six categories of priority health-risk behaviors among youth and young adults: behaviors that contribute to unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection, unhealthy dietary behaviors, and physical inactivity, plus being overweight. Tobacco-Related Data: The YRBS is the main source of tobacco-related data on prevalence of tobacco use among high school students. Web Address: http://www.cdc.gov/healthyyouth/yrbs/index.htm Name of Data Source: Tobacco Attitudes and Media Survey a.k.a. the Adult Tobacco Survey (ATS) Description: The Tobacco Attitudes and Media Survey (ATS) was developed by the Division of Public Health to assess public attitudes towards tobacco media campaigns and changes in public policy addressing tobacco use. The survey is conducted by the Center for Applied Demography & Survey Research for Delaware’s Division of Public Health. Beginning in 2001, the random-sample telephone survey has been administered annually to 1,100 – 1,600 adults statewide. The survey provides information used by both public and private health providers on use of tobacco products, knowledge and attitudes toward tobacco use, and attitudes about policies such as the Clean Indoor Air Act, and to gauge the success of anti-tobacco media campaigns. Tobacco-Related Data: The ATS is the main source of data on public attitudes toward tobacco use, exposure to secondhand smoke, and their exposure and attitudes towards tobacco company advertising and anti-tobacco public education and programming. Web Address: http://www.cadsr.udel.edu Name of Data Source: Youth Tobacco Survey (YTS) Description: The Youth Tobacco Survey is a nationally developed survey that is administered on a state-by-state basis. Delaware has participated in the YTS since 2000, with surveys conducted every two years (even years). The survey is conducted by the Center for Drug and Alcohol Studies at the University of Delaware, and sponsored by Delaware’s Division of Public Health with funding from the Centers for Disease Control and Prevention. The surveys have been administered to a sample of Delaware students in grades 6– 12 and provide information on the use of tobacco products, students’ attitudes toward tobacco use, and their exposure to media and programming related to tobacco use. Tobacco-Related Data: The YTS is the main source of tobacco-related data on students’ attitudes toward tobacco use, exposure to secondhand smoke, and their exposure and attitudes toward tobacco company advertising and anti-tobacco media and programming. Web Address: http://www.state.de.us/drugfree/ Name of Data Source: Delaware School Survey on Alcohol, Tobacco and Other Drugs (DSS/ATODA) Description: The DSS/ATODA is conducted by the University of Delaware, Center for Drug and Alcohol Studies, and The Center for Community Development, in cooperation with the Department of Education, all 19 school districts, and participating middle and high schools, with web support from the Department of Services for Children, Youth and their Families. The Delaware School Survey has been conducted annually since 1989, with support from various state and federal agencies. This survey is currently supported by a cooperative agreement with Delaware’s Division of Substance Abuse and Mental Health, with funding from the Delaware State Legislature, Delaware Health Fund, and federal Substance Abuse Prevention and Treatment Block grant. Since 1999, the survey sample has been expanded to include most 5th, 8th, and 11th graders in the Delaware public schools. The DSS/ATODA provides information on alcohol, tobacco, and other drug use incidence, prevalence, abuse, and dependence among Delaware students as well as attitudes toward the use of alcohol, tobacco, and other drugs. Tobacco-Related Data: The DSS/ATODA provides trend data on tobacco use, perceived risk and access to cigarettes, and other risk and protective factors in the school and living environments of middle and high school students. Web Address: http://www.state.de.us/drugfree/data.htm#atd Tobacco Prevention Data and Program Sources: National Sources: American Cancer Society: http://www.cancer.org American Heart Association: http://www.americanheart.org American Legacy Foundation: http://www.americanlegacy.org American Lung Association: http://www.lungusa.org Campaign for Tobacco Free Kids: http://tobaccofreekids.org Center for Tobacco Cessation: http://www.ctcinfo.org Centers for Disease Control and Prevention: http://www.cdc.gov/tobacco Guide to Community Preventive Services: http://www.thecommunityguide.org North American Quitline Consortium: http://www.naquitline.org Tobacco Cessation Guidelines: http://www.surgeongeneral.gov/tobacco Tobacco Control Archives (Tobacco Industry Documents): http://www.library.ucsf.edu/tobacco Tobacco News and Information: http://www.tobacco.org State and Local Sources: American Lung Association of Delaware: http://www.alade.org Delaware Association for Health, Physical Education, Recreation and Dance: http://dahperd.org Delaware Health Fund Advisory Committee: http://www.state.de.us/dhss/healthfund Delaware Kick Butts Generation: http://ysmoke.org Delaware’s Division of Public Health Tobacco Prevention & Control Program: http://www.state.de.us/dhss/dph/dpc/tobacco.html Healthy Delaware 2010: http://www.healthydelaware.com Phone Numbers: American Cancer Society (Delaware Office): 302-324-4227 American Heart Association: 302-454-0613 American Lung Association of Delaware: 302-655-7258 (1-800-LUNG-USA) Clean Indoor Air Act Report Line: 1-800-297-5926 Delaware Department of Education: 302-739-4676 Delaware Division of Alcoholic Beverage Control & Tobacco Enforcement: 302-577- 5210 Delaware Division of Public Health: 302-744-4700 Delaware Quitline: 1-866-409-1858 Impact Coalition: 1-800-lung-usa (586-4872) 1-800-586-4872 Report sales of tobacco to minors: 1-800-EYES-EARS (800-393-7327) Tobacco Prevention & Control Program: 302-741-2900 (temp. number) Thanks to the following individuals for their contributions: Darrin W. Anderson, MSc, CSCS Director of Health Initiatives and Public Advocacy American Heart Association Fred Breukelman, CHES Director of Health Education Delaware Division of Public Health Deborah P. Brown Director of Programs and Advocacy American Lung Association of Delaware J. Thomas Butler, EdD, CHES Delaware State University Jean Chiquoine Collaboration Manager American Cancer Society Elizabeth Dubravcic, MLHR Tobacco Prevention Evaluator Delaware Division of Public Health Mawuna Gardesey Director of Minority Health Delaware Division of Public Health Ferdinando Gatto Tobacco Prevention Administrator Delaware Division of Public Health Suchitra Hiraesave Proposal Writer/Grants Administrator Boys & Girls Clubs of Delaware Cathy Scott Holloway Government Relations Manager American Cancer Society Summer Jopp Tobacco Prevention Outreach Coordinator Delaware Division of Public Health Lisa McKenzie, MPA Tobacco Prevention Coordinator Delaware’s Division of Public Health John Ray Education Specialist, Tobacco Prevention and Coordinated School Health Delaware Department of Education Rob Simmons, DrPH, MPH, CHES Health Promotion Consultant and Instructor in Public Health Theresa Strawder School Based Health Centers Delaware Division of Public Health