August 12, 2015
Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium
Final Report
Prepared for
North Dakota Center for Tobacco Prevention and Control Policy 4023 State Street Suite 65 Bismarck, ND 58503
Prepared by
RTI International 3040 E. Cornwallis Road Research Triangle Park, NC 27709
RTI Project Number 0213456.002
RTI Project Number 0213456.002
Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium
Final Report
August 12, 2015
Prepared for
North Dakota Center for Tobacco Prevention and Control Policy 4023 State Street Suite 65 Bismarck, ND 58503
Prepared by
Betty Brown Kim Hayes Lindsay Olson Amy Henes Matt Eggers Kimberly Watson Erik Crankshaw Matthew Farrelly RTI International 3040 E. Cornwallis Road Research Triangle Park, NC 27709
______RTI International is a trade name of Research Triangle Institute.
Contents
Section Page
Executive Summary ES-1
1. Introduction 1
2. Program Context 2
3. Programmatic Approach 5
4. Program Implementation 8 4.1 State and Community Interventions ...... 8 4.1.1 Increase State Cigarette Excise Tax ...... 8 4.1.2 Increase Support for Federal Tobacco Tax Increase ...... 11 4.1.3 Increase the Percentage of Tobacco-Free K–12 Schools ...... 12 4.1.4 Increase the Number of Tobacco-Free Post-Secondary Institutions ...... 14 4.1.5 Uphold Statewide Smoke-Free Law ...... 17 4.1.6 Increase Indoor Smoke-Free Air Exempted from ND Smoke-Free Law ...... 19 4.1.7 Increase Smoke-Free and Tobacco-Free Outdoor Venues ...... 22 4.1.8 Prevent Preemption in State Tobacco Prevention and Control Laws ...... 24 4.1.9 Promote Point-of-Sale Ordinances ...... 24 4.2 Mass-Reach Health Communication Interventions ...... 30 4.3 Cessation Interventions ...... 36 4.3.1 Increase Treatment Reach of NDQuits ...... 36 4.3.2 Increase Use of U.S. Public Health Service (PHS) Guideline in Health Care Settings ...... 39 4.3.3 Increase Nicotine Dependence Interventions in Mental Health Treatment ...... 42 4.4 Surveillance and Evaluation ...... 46 4.5 Infrastructure, Administration, and Management ...... 47 4.5.1 Administration and Management ...... 48 4.5.2 Local Infrastructure and Capacity ...... 51 4.5.3 Sustain Program in Conformance with CDC Recommendations ...... 52
5. Trends in Key tobacco use Outcomes 54
6. Discussion 59
iii
7. Recommendations 61 7.1 State and Community Recommendations ...... 61 7.2 Mass-Reach Health Communication Recommendations...... 61 7.3 Cessation Recommendations ...... 61 7.4 Surveillance and Evaluation Recommendations ...... 62 7.5 Infrastructure, Administration, and Management Recommendations ...... 62
References R-1
iv
Figures
Number Page
1. Revenues and Expenditures Related to Tobacco Control and Promotion ...... 3 2. Cigarette Excise Taxes in North Dakota and Surrounding States Plus U.S. Average, 1990–2015 ...... 4 3. Predicted Smoking-Attributable Health Care Expenditures in North Dakota, 2012–2020 ...... 5 4. North Dakota Residents’ Support for Raising State Cigarette Tax, 2014–2015 ...... 10 5. Percentage of North Dakota Local Education Agencies Covered by Tobacco- Free School Policies, 2013–2015 ...... 13 6. Web Page of United Tribes Technical College Discussing the Tobacco-Free Campus Policy...... 16 7. North Dakota Residents’ Support for Statewide Smoke-Free Law, Overall and by Smoking Status, 2015 ...... 18 8. North Dakota Cities with Local Smoke-Free Ordinances ...... 20 9. North Dakota College Students’ Support for Smoke-Free Policies in Multi-Unit Housing ...... 21 10. North Dakota Tobacco-Free Parks ...... 23 11. Percentage of North Dakota Adults Somewhat or Strongly in Favor of Policies that Require that All Tobacco Products Be Kept Behind the Counter, Overall and by Smoking Status, 2015 ...... 28 12. Percentage of North Dakota Adults Somewhat or Strongly in Favor of Policies that Prohibit the Sale of Flavored Tobacco Products, Overall and by Smoking Status, 2015 ...... 29 13. NDQuits Enrollments and Broadcast Television GRPs for Center and NDDoH Campaigns, July 2010—March 2015 ...... 33 14. Monthly NDQuits Telephone and Web Enrollments, July 2007—March 2015 ...... 38 15. North Dakota Reports of Health Care Providers Asking Them about Tobacco Use, Advising Them to Quit, Assisting Them with Quit Efforts, and Referring Them to a Smoking Cessation Class, Program, Quitline, or Counseling, among Smokers Who Visited a Health Care Provider in the Past 12 Months, North Dakota ATS 2009–2012 ...... 41 16. Percentage of North Dakota Mental Health and Substance Use Treatment Facilities Reporting Prohibition of Smoking, Other Tobacco Products, and E-cigarettes, 2014 ...... 44 17. Percentage of North Dakota Mental Health and Substance Use Facilities That Have a Written Policy or Protocol on Tobacco-Related Screening and Treatment, 2014 ...... 45 18. Web Sites of the Center for Tobacco Prevention and Control Policy and the North Dakota Department of Health Tobacco Prevention and Control Program ...... 49 19. CDC Tobacco Control Program Funding Recommendations and North Dakota Comprehensive Tobacco Prevention and Control Program Funding by Component, 2013–2015 Biennium ...... 54
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20. Adult Smoking Prevalence in North Dakota, Official Estimates (BRFSS) and Adjusted Estimates, 2005–2013 ...... 55 21. Adult Smoking Prevalence among Selected Groups with Prevalence Higher than the State Average in North Dakota, BRFSS 2011–2013 ...... 57 22. High School Youth Smoking Prevalence, North Dakota and Nationally, YRBS 1999–2013 ...... 57 23. Percentage of High School Students Who Currently Use Tobacco Products, ND YTS 2003–2013...... 58 24. Percentage of High School Youth Who Smoked a Whole Cigarette before Age 13, North Dakota and Nationally, 1999–2013 ...... 59
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Tables
Number Page
1. North Dakota Comprehensive Tobacco Prevention and Control Program Objectives by Goal and CDC Best Practices Component ...... 7 2. North Dakota Colleges and Universities’ Tobacco-related Policies ...... 15 3. City Ordinances Prohibiting E-cigarette Sales to Minors, Restricting E-cigarette Self-Service, and Requiring a License for Sale of E-cigarettes, 2013–2015 Biennium ...... 26 4. North Dakota Television Health Communication Campaigns ...... 31 5. Average Quarterly GRPs, by Campaign Type, FY 2014–2015 ...... 35 6. Documentation of Ask-Advise-Refer among Active Client Records at North Dakota LPHUs, 2014–2015 ...... 41 7. Services and Staffing Related to Tobacco Dependence Screening and Treatment in North Dakota Mental Health and Substance Use Treatment Facilities, 2014 ...... 45 8. CDC Tobacco Control Program Funding Recommendations and North Dakota Comprehensive Tobacco Prevention and Control Program Funding by Component, 2013–2015 Biennium ...... 53
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EXECUTIVE SUMMARY
Nearly 119,000 adults in North Dakota currently smoke. Every year in North Dakota, cigarette smoking is responsible for 1,000 deaths, in addition to more than $442 million in smoking-attributable health care and lost productivity costs. The tobacco tax is disproportionately low even though increasing the price of tobacco is one of the most effective tools to prevent initiation and promote cessation. Furthermore, the tobacco industry spends approximately $34 million in the state annually to promote tobacco products. In response, North Dakota has implemented a comprehensive statewide Tobacco Prevention and Control Program comprising the funding and activities of the North Dakota Center for Tobacco Prevention and Control Policy (the Center) and the North Dakota Department of Health (NDDoH) Tobacco Prevention and Control Program. These two agencies implement state and community interventions, cessation interventions, and health communication interventions to achieve the program goals of preventing initiation of tobacco use, eliminating exposure to secondhand smoke, promoting cessation, and building program infrastructure and capacity.
As required by the legislation that supports the program, this biennial report describes the program’s implementation of the comprehensive state plan and consistency with the Centers for Disease Control and Prevention’s (CDC’s) (2014) Best Practices for Comprehensive Tobacco Control Programs (Best Practices). Highlights include the following:
. The program’s comprehensive plan and its implementation are consistent with CDC Best Practices.
. The state’s 2012 implementation of a statewide comprehensive smoke-free air law was a significant success for the program, continues to be widely supported by North Dakotans, and has not negatively affected bar and restaurant employment.
. Ongoing efforts by community-level grantees continue to expand smoke-free policy coverage to indoor areas not protected by the statewide law, including multi-unit housing, as well as outdoor venues and campuses of K–12 schools and post- secondary institutions.
. North Dakota passed a law prohibiting the sale of e-cigarettes to minors and requiring childproof packaging for liquid nicotine. Prior to the state law, 23 cities adopted ordinances prohibiting the sale of e-cigarettes to minors and defining e-cigarettes as tobacco products, with some ordinances also restricting self-service of e-cigarette sales and/or requiring e-cigarette vendors to be licensed.
. The program educated decision makers and the public about the benefits of increasing the cigarette excise tax, which is supported by the majority of North Dakota adults and recommended by CDC Best Practices and a 2014 state auditor’s report.
ES-1 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium
. North Dakota has seen declines in youth tobacco use prevalence over time, and the percentage of youth who smoked a whole cigarette by age 13 has decreased by 64% from 1999 to 2013.
Successful implementation of North Dakota’s comprehensive plan over time will reinforce a tobacco-free norm, reduce the economic toll of tobacco use, and improve the health and quality of life of North Dakotans. Recommendations to further enhance the program’s effectiveness and efficiency include the following:
. Continue to emphasize initiatives most likely to impact tobacco use behavior and ultimately prevalence rates, particularly educating policy makers and key stakeholders about the benefits of a tax increase. CDC prioritizes adequately funded programs, comprehensive smoke-free air laws, and tobacco pricing that discourages youth initiation. North Dakota has two of these three and should continue to collaborate with its grantees and partners to mobilize key stakeholders and highlight existing support. Activities during the 2013–2015 biennium that helped lead to the proposal of two separate bills can serve as a foundation for future efforts.
. Continue to adapt media plans collaboratively to meet the updated Best Practices recommendations regarding gross rating point (GRP) levels and ad themes. Continue the coordination between the Center and NDDoH, and enhance efforts to achieve a more comprehensive media approach.
. Continue promoting health systems change via written policies and improvements in documentation and referral systems, supported by training of health care providers and staff.
. Adapt and improve systems to track grantee activities and outcomes achieved. Enhancing data reporting systems can ensure that data are collected in a standardized, efficient manner to minimize user burden; improve accountability; and facilitate data aggregation, grant monitoring, and evaluation efforts.
. Recognize, assess, and address the impact of new and emerging products, such as e-cigarettes, on tobacco use in North Dakota.
. Continue funding the comprehensive program at CDC Best Practices recommended levels.
ES-2
1. INTRODUCTION
Tobacco use is the leading preventable cause of death and disease in the United States (USDHHS, 2004). Fifty years after the first report on smoking and health, the U.S. Surgeon General described progress made in tobacco control and highlighted the ongoing problem of tobacco use in the United States (USDHHS, 2014). The Surgeon General’s report details the grave and wide-ranging effects of tobacco use on the human body. It also summarizes new evidence of harm from tobacco use, including adding two types of cancer to the long list of cancers that are caused by smoking and establishing smoking as a cause of diabetes and rheumatoid arthritis. Tobacco use also affects nonsmokers, causing serious illness and death in children and adults (USDHHS, 2004, 2012). In North Dakota, approximately 119,000 adults currently smoke (Campaign for Tobacco-Free Kids [CFTFK], 2015a), and cigarette smoking is responsible for 1,000 deaths every year (CDC, 2014), in addition to more than $442 million in smoking-attributable health care and lost productivity costs (CDC State System, 2004). The Centers for Disease Control and Prevention (CDC) recommends reducing the toll of tobacco use by funding comprehensive tobacco control programs to implement evidence-based interventions (CDC, 2014).
North Dakota’s comprehensive statewide tobacco control program is founded on CDC’s Best Practices for Comprehensive Tobacco Control Programs (Best Practices). North Dakota is one of only two states that meets the CDC recommended funding level (CFTFK, 2015c). Allocation of funding for the program at this level was made possible by Initiated Measure 3, passed by North Dakota voters in 2008. Measure 3 enacted a new law to establish and fully fund a comprehensive statewide Tobacco Prevention and Control Program and created a Tobacco Prevention and Control Executive Committee to administer the program. The North Dakota Center for Tobacco Prevention and Control Policy (the Center) is a division of the Tobacco Prevention and Control Executive Committee. The comprehensive statewide tobacco control program comprises the funding and activities of the Center (whose funding makes up approximately three-quarters of the program budget) and the North Dakota Department of Health (NDDoH) Tobacco Prevention and Control Program (which is funded with one-quarter of the program allocation). The program’s comprehensive plan, Saving Lives—Saving Money: North Dakota’s Comprehensive State Plan to Prevent and Reduce Tobacco Use (North Dakota Tobacco Prevention and Control Advisory Committee, 2013), outlines key goals, objectives, and strategies. The goals of the program are to
1. prevent the initiation of tobacco use among youth and young adults, 2. eliminate exposure to secondhand smoke, 3. promote quitting tobacco use, and 4. build capacity and infrastructure to implement a comprehensive evidence-based tobacco prevention and control program.
1 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium
RTI International began conducting an independent evaluation of the comprehensive program in 2012. RTI prepared this report to describe the program’s efforts and consistency with CDC’s Best Practices for the 2013–2015 biennium. The program’s current funding allocation and state plan were developed in 2013 based on CDC’s 2007 Best Practices document. However, an update to CDC’s Best Practices was released in 2014, and this report describes the program’s alignment with the 2014 update. Using the updated Best Practices allows us to highlight the program’s consistency with the most recent recommendations and identify possible areas for improvement, to facilitate adjustments to the programmatic approach. The report also describes trends in key outcomes and offers recommendations for the program.
To review the comprehensive plan’s consistency with CDC’s (2014) Best Practices, Measure 3 requires an audit of the North Dakota Tobacco Prevention and Control Program:
At least once a biennium, the executive committee shall provide for an independent review of the comprehensive plan to assure that the comprehensive plan is consistent with the [C]enters for [D]isease [C]ontrol and [P]revention best practices. The executive committee shall report the results of that review to the governor and to the state health officer on or before September first in each odd-numbered year (North Dakota Century Code 23-42-07).
This report fulfills this requirement by providing an independent review. The Center contracted with RTI International to conduct an independent evaluation of the comprehensive program and to summarize findings in a biennial report. The following sections of this report summarize the program context (Section 2) and programmatic approach (Section 3) and review the comprehensive plan (Section 4). This report also describes key outcomes (Section 5), synthesizes and discusses the findings (Section 6), and offers recommendations for the program (Section 7).
2. PROGRAM CONTEXT
In this section, we put North Dakota’s efforts in context. This summary describes the health and economic burden of tobacco use; tobacco industry advertising and promotions; state revenue from tobacco taxes and payments; and indicators of the tobacco control environment, such as funding for tobacco control and level of cigarette excise taxes in North Dakota compared with the U.S. average and surrounding states.
According to CDC, 1,000 North Dakota adults die prematurely each year because of smoking, and 14,000 youth who are currently younger than age 18 are projected to die prematurely from smoking (CFTFK, 2015a). Smoking-attributable health care costs in North Dakota are estimated at $326 million annually (CFTFK, 2015a). Of that, nearly 17.5%, or $56.9 million, was covered by the state’s Medicaid program. Annual productivity losses as a result of smoking are estimated at $232.6 million (CFTFK, 2015a).
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North Dakota has two significant sources of tobacco-related revenue: Master Settlement Agreement (MSA) funds and excise taxes. The MSA, a 1998 settlement between tobacco companies and 46 states, paid North Dakota $30.7 million in fiscal year (FY) 2015 (unpublished data, North Dakota Office of Management and Budget, 2015) and has paid out a total of $463.9 million to date (NAAG, 2015). North Dakota has also generated $30.7 million in cigarette and tobacco excise taxes in FY 2015 (unpublished data, North Dakota Office of Management and Budget, 2015). A portion of the MSA payments, along with CDC grant funding, makes possible North Dakota’s Tobacco Prevention and Control Program, which works to decrease the health, economic, and social burden of tobacco use in the state. Tobacco Prevention and Control Program funding allocation is approximately $10.7 million annually in the current biennium (Figure 1), making North Dakota one of only two states to reach the CDC-recommended funding level (CFTFK, 2015b).
Figure 1. Revenues and Expenditures Related to Tobacco Control and Promotion
$40 $34.1 $35 $30.7 $30.7 $30
$25
$20
Millions $15 $10.7 $10
$5
$0 ND revenue from ND revenue from ND tobacco control Estimated annual state cigarette MSA payments (FY program budget cigarette advertising excise tax (FY 2015) 2015) (FY 2015) and promotions in ND (CY 2012)
Note: FY = fiscal year; MSA = Master Settlement Agreement; ND = North Dakota. Source: Unpublished data, North Dakota Office of Management and Budget, 2015; CTFTK, 2015b
The Federal Trade Commission’s (FTC’s) Cigarette Report for 2012, released in 2015, shows that tobacco companies spend $9.7 billion annually nationwide on marketing, including price discounts and coupons (FTC, 2015). In North Dakota alone, tobacco companies spend an estimated $34.1 million on marketing each year (CFTFK, 2015a). Approximately 93% of this spending went toward promotions aimed at wholesalers and consumers to reduce the price of cigarettes for consumers and make the products more attractive (FTC, 2015).
3 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium
The tobacco control environment in North Dakota is influenced by tobacco-related policy and state and local activities. North Dakota’s 2012 smoke-free air law transformed the tobacco control policy landscape, covering nearly all workplaces, including bars and restaurants, and many other previously exempted locations. Another major factor in the tobacco control environment is the amount of tax applied to tobacco products. With a cigarette excise tax of $0.44 per pack, North Dakota ranks 47th in the nation, lower than some major tobacco- producing states and only $0.27 above the lowest rate ($0.17 in Missouri) (CFTFK, 2015b; North Dakota Office of the State Tax Commissioner, 2015). North Dakota’s cigarette excise tax has remained unchanged since 1993 and is significantly lower than tax rates in the surrounding states (Figure 2).
Figure 2. Cigarette Excise Taxes in North Dakota and Surrounding States Plus U.S. Average, 1990–2015
Source: Orzechowski & Walker (2014). Note: Minnesota also charges a wholesale tax of 52.6 cents per pack in lieu of a sales tax. The U.S. average shown here is weighted for population and is not yet available for 2015.
RTI conducted analyses to explore the likely impact of a cigarette tax increase on adult smoking prevalence and smoking-attributable personal health care expenditures in North Dakota. If North Dakota had increased the state cigarette excise tax to $2.00 per pack in 2015, our model predicts that smoking prevalence in the state would have decreased from 21.2% to 16.7%, a decrease of 24,238 adult smokers. This decrease in prevalence would
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have been expected to result in a projected savings of $560 million in personal health care costs from 2015 to 2020 (Figure 3).
Figure 3. Predicted Smoking-Attributable Health Care Expenditures in North Dakota, 2012–2020
The health and economic burden of tobacco use in North Dakota is significant. Although the program is funded at the CDC-recommended level and the state recently implemented a comprehensive smoke-free air law, the tobacco industry spends an estimated $34.1 million in the state annually, the tobacco tax is disproportionately low, and approximately 119,000 North Dakotans smoke.
3. PROGRAMMATIC APPROACH
North Dakota’s comprehensive Tobacco Prevention and Control Program uses a multipronged evidence-based approach to develop and implement its state plan. The three main areas of focus of the program’s efforts are state and community interventions, cessation interventions, and health communication interventions.
. State and community interventions in North Dakota include promotion of tobacco- free K–12 and higher education campus policies, education about the health and economic benefits of a tobacco tax increase, education regarding retail point-of-sale policies, promotion of smoke-free multi-unit housing and tobacco-free outdoors policies, and other public education and policy efforts. . Cessation interventions include NDQuits, the state quitline service available via telephone and online, as well as implementation of U.S. Public Health Service (PHS)
5 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium
guidelines regarding cessation interventions in health care organizations. The program also conducts activities intended to increase tobacco dependence screening and treatment in mental health facilities. . Health communication interventions include public education media campaigns to denormalize tobacco use, promote cessation, educate about the impact of tobacco use in North Dakota, and communicate about the accomplishments and benefits of fully sustaining the comprehensive Tobacco Prevention and Control Program.
The Center and NDDoH comprise the comprehensive statewide Tobacco Prevention and Control Program. The Center funds grantees that help carry out the programmatic efforts, including Local Public Health Unit (LPHU) grantees throughout the state; Special Initiative Grantees (SIGs) that focus on statewide activities; and the Public Health Law Center, which provides technical assistance to inform the legal defensibility of model tobacco control policies. NDDoH provides cessation services, administers Million Hearts “S” grants that promote health systems change focused on smoking cessation, and funds tribal tobacco control programs on American Indian reservations in North Dakota.
The comprehensive program’s efforts are guided by an evidence-based comprehensive state plan. Measure 3 required that the newly formed comprehensive Tobacco Prevention and Control Program develop and implement a comprehensive plan consistent with CDC Best Practices recommendations. Based on CDC’s 2007 Best Practices for Comprehensive Tobacco Control Programs, the Tobacco Prevention and Control Advisory Committee’s 2009 comprehensive plan described the program’s goals, objectives, and action steps and has served as a guiding document for the program (North Dakota Tobacco Prevention and Control Advisory Committee, 2009). The Committee released updated versions in 2012 and 2013 to adapt to changes in the tobacco control environment, include new areas of focus, and change the target levels for objectives that had already been met. The program maps each objective to one or more of the program goals and to one of the CDC Best Practices overarching components (Table 1).
This report provides a summary of the state plan and its implementation during the 2013– 2015 biennium. Although the state plan and its activities are based on CDC’s 2007 Best Practices document (the most updated at the time the state plan was revised), this report uses the 2014 version to discuss each objective’s consistency with Best Practices. The evaluation is tasked with reviewing the program’s consistency with the most updated Best Practices, and we believe that this approach provides the most useful reflections and recommendations to the program.
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Table 1. North Dakota Comprehensive Tobacco Prevention and Control Program Objectives by Goal and CDC Best Practices Component
Program Goal
Eliminate Secondhand Build Capacity CDC Best Prevent Smoke Promote and Practices Objective Initiation Exposure Quitting Infrastructure Component
Increase state cigarette excise tax State and community
Increase federal cigarette excise State and tax community
Increase percentage of tobacco- State and free K–12 schools community
Increase percentage of tobacco- State and free college and university community campuses
Restrict point-of-sale youth access State and to tobacco and nicotine products community
Uphold smoke-free statewide law State and community
Prevent preemption in state State and tobacco control laws community
Increase smoke-free policies in State and areas not covered by state law community
Increase tobacco-free outdoor State and public venues community
Increase treatment reach of Cessation NDQuits
Increase and enhance PHS Cessation guideline systems approach in health care settings
Provide nicotine dependence Cessation interventions in mental health/ addiction treatment
Maintain and enhance Infrastructure, administrative structure to manage administration, comprehensive program and management
Build local infrastructure and Infrastructure, capacity administration, and management
Implement health communication Health initiative communication
Conduct surveillance and evaluation Surveillance and evaluation
Sustain program in conformance Infrastructure, with CDC Best Practices administration, and management
7 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium
4. PROGRAM IMPLEMENTATION
This section describes the North Dakota Tobacco Prevention and Control Program’s implementation of its state plan, by objective. Objectives are organized by CDC Best Practices component: state and community interventions; mass-reach health communication interventions; cessation interventions; surveillance and evaluation; and infrastructure, administration, and management.
4.1 State and Community Interventions
CDC’s (2014) Best Practices recommends implementing state and community interventions in the form of programs and policies that encourage and support tobacco-free behavior and tobacco-free norms. State and community interventions that shift the social environment at the local level are an important part of a comprehensive program. Many of North Dakota’s state plan objectives involve state and community interventions. The following sections define these objectives, describe the program’s activities and progress, and reflect on the consistency of the objectives and their implementation with Best Practices.
4.1.1 Increase State Cigarette Excise Tax
Objective Progress
By June 30, 2015, increase the The program implemented a range of cigarette excise tax to a minimum of activities to educate policy makers and $2.00 per pack and a proportional the public about the benefits of amount of the other tobacco products increasing the state cigarette excise tax for other tobacco and nicotine tax, public support for raising the tax products. increased, and two tax bills were introduced and considered, but ultimately the tax was not increased.
Cigarette taxes are applied at federal and state levels, in addition to any state and local sales taxes and local cigarette-specific taxes. Evidence shows that increasing the unit price of cigarettes prevents youth from starting to smoke and encourages smokers to consume fewer cigarettes or quit (Guide to Community Preventive Services, 2012). This objective aims to increase the current $0.44 cigarette excise tax by $1.56 so that the state tax becomes $2.00. This objective also aims to increase the tax on other tobacco and nicotine products by a proportional amount.
Activities and Progress During the 2013–2015 biennium, SIGs and LPHU grantees funded by the Center educated policy makers and the public about the benefits of increasing the cigarette excise tax. Two SIGs, Tobacco- Free North Dakota and American Lung Association–ND, and a partner, the American Cancer Society Cancer Action Network,
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launched the Raise It for Health North Dakota campaign. This campaign invited organizations and individuals to get involved in educating decision makers about the benefits of a tax increase. This group conducted monthly teleconferences, hosted a Facebook page, and educated other organizations and individuals about the benefits of raising the tobacco tax in North Dakota. The coalition comprised 35 partner organizations, including health centers, the March of Dimes North Dakota Chapter, Boards of Health, and state medical and dental associations. LPHU grantees conducted education through coalition meetings; participated in health fairs and other events; disseminated newsletters and materials; sought resolutions in support of a tax increase; and provided public education through news stories, ads, and letters to the editor in local newspapers. Grantees reported 14 Board of Health resolutions and five resolutions from other organizations supporting an increase in the cigarette excise tax during the 2013–2015 biennium. In addition, a 2014 report from the Office of the State Auditor recommended that the program encourage the state to raise the cigarette excise tax to the national average (Office of the State Auditor, 2014).
Although the state cigarette tax has remained unchanged since 1993, adults in North Dakota support a tax increase. A telephone survey of North Dakota residents found that, in 2015, 59.9% of North Dakotans supported raising the cigarette tax, with nearly half of adults in the state saying that they are strongly in favor of increasing the cigarette excise tax (Figure 4). More North Dakotans supported a tax increase in 2015 compared with 2014. An even greater proportion of North Dakota adults (69.7%) reported support for a cigarette tax if it reduced youth smoking by 25%, an estimate of the likely impact of such a tax. A statewide survey conducted for the American Cancer Society Cancer Action Network in December 2014 also found significant support for a tobacco tax increase, regardless of party affiliation (data not shown) (Bolger, Clark, & Geroux, 2014).
During the 2015 North Dakota legislative session, House Bill (HB) 1421 proposed raising the cigarette excise tax by $1.00 to $1.44 and increasing other tobacco product taxes. Additionally, HB 1421 proposed that the distribution of the tax be 60% to Community Health Trust Fund, 25% to counties for local public health services, and 15% to incorporated cities for public health and safety. HB 1421 did not pass, with 34 votes in favor and 56 votes against.
In addition to the House Bill, a bill to increase the cigarette excise tax to $2.00 per pack was proposed in the state Senate. Senate Bill (SB) 2322 also contained language to change the definition of other tobacco products. SB 2322 did not pass, receiving 17 votes in favor and 30 votes against. Resistance to the bills included pushback on any tax increase, concerns about the financial impact on low-income smokers and on businesses that sell tobacco products, and skepticism that increasing the tax would result in significant smoking behavior change.
9 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium
Figure 4. North Dakota Residents’ Support for Raising State Cigarette Tax, 2014–2015
Source: Study conducted by RTI for the Center for Tobacco Prevention and Control Policy.
The Raise It for Health North Dakota coalition worked daily on HB 1421 and SB 2322 with e- mails, phone calls, and one-on-one meetings with legislators at the Capitol, communicating about the importance of raising the cigarette excise tax to decrease youth initiation and increase adult cessation while shrinking state health care costs and increasing funding for health-related programs.
Although the state cigarette excise tax was not increased during the 2013–2015 biennium, the strong efforts of the Center and its partners helped result in the introduction and advancement of two bills.
Consistency with Best Practices CDC’s (2014) Best Practices consistently identifies increasing the price of tobacco products as one of the most critical interventions that tobacco control programs can implement to prevent initiation of tobacco use and promote cessation. This state plan objective is clearly consistent with Best Practice recommendations. The wording regarding “nicotine products” could inadvertently apply to nicotine replacement products, but revisions to the language in the next iteration of the state plan have resolved this.
The program’s strategies related to this objective are aligned with CDC’s recommendations. The program focuses on educating policy makers and the public about the importance of increasing the unit price of tobacco. This is supported by CDC Best Practices, which reports
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that grassroots community support and involvement is especially important for increasing the unit price of tobacco.
4.1.2 Increase Support for Federal Tobacco Tax Increase
Objective Progress
By June 30, 2014, advocate for FY Program grantees conducted activities 2014 federal excise tax increase from to promote an increase in the federal $1.01 to $1.95. excise tax on tobacco, although no federal-level changes were implemented.
The U.S. federal government taxes cigarettes at a rate of $1.01 per pack. The federal government last raised the cigarette excise tax in 2009, from $0.39 to its current rate. Evidence shows that increasing the unit price of cigarettes—through federal, state, or local taxation—is one of the most effective ways to prevent youth smoking and promote smoking cessation (Guide to Community Preventive Services, 2012). This state plan objective aims to increase the current federal cigarette excise tax by $0.94 to $1.95.
Activities and Progress North Dakota’s comprehensive state plan indicates that the following strategies will be used to achieve the objective focused on the federal excise tax: congressional visits by partners, letter-writing campaigns by coalitions, letters to the editor, and earned media campaigns. In July 2013, SIG Tobacco-Free North Dakota discussed the benefits of raising the federal tax on tobacco products directly with Senator Heitkamp and Congressman Cramer and had a productive meeting with Senator Hoeven’s staff. Noting that tobacco lobbyists are also communicating with members of Congress, Tobacco-Free North Dakota used its newsletter to encourage supporters to send letters to U.S. Congressional delegates, showing citizen support for an increase in the tax. LPHU grantees reported sending 36 letters to North Dakota’s congressional delegation during FY 2015. Although President Obama proposed increasing tobacco taxes in his FY 2015 budget plan, and there is support among allied national organizations for this change (CFTFK, 2014c), there has been no increase in the federal cigarette excise tax during the past year.
Consistency with Best Practices Efforts to promote increases in tobacco prices at the state and local levels remain a primary recommendation from CDC Best Practices. Although tobacco control advocates should be supportive of federal tobacco tax increases, no published research suggests that state-level efforts have a measurable impact on federal tax policy. Because there is no nationwide coordinated effort regarding this objective, and because passing a state tobacco tax increase in North Dakota is an important strategy to achieve reductions in tobacco use prevalence, we believe that state-level tax efforts should be prioritized over federal tax
11 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium efforts. It is appropriate for the program to promote a federal tax when communicating with relevant stakeholders and to support increasing the federal tax. In response to feedback, the program has moved efforts supporting a federal tax increase to a strategy within another objective in the next iteration of the state plan, rather than a stand-alone objective.
4.1.3 Increase the Percentage of Tobacco-Free K–12 Schools
Objective Progress
By June 30, 2016, increase the Although more than 1 year remains percentage of ND Department of before the target date of this objective, Public Instruction defined Local 66% of LEAs had tobacco-free school Education Agencies (LEAs) with policies as of March 2015, representing August 2013 ND Center an increase of nearly 11 percentage comprehensive model tobacco-free points during the biennium. school policy to 80%.
CDC (2008) promotes school-based tobacco use prevention efforts as part of community- wide comprehensive efforts focused on tobacco use prevention, reinforcing policy as a foundation to help establish norms in schools and community settings. Federal law prohibits smoking inside school buildings (U.S. Code Title 20 Chapter 70, Section 7183), and comprehensive tobacco-free school policies further prohibit tobacco use by all students, staff, and visitors on school grounds, in school vehicles, and at school-sponsored events. CDC has called for applying existing tobacco control strategies to new and emerging products like electronic cigarettes, which have increased in youth use nationally (CDC, 2013a, 2013b, 2015). This objective seeks to expand the percentage of school districts with policies that meet program-defined model policy requirements.
Activities and Progress Center-funded LPHU grantees promote implementation of the Center’s tobacco-free school model policy as they collaborate with Local Education Agencies (LEAs) to assess the comprehensiveness of existing tobacco-related policies on a regular basis, offer assistance with implementing tobacco-free school policies, share policy successes, and help ensure ongoing enforcement. NDDoH’s tribal grantees work with schools located on American Indian reservations to implement tobacco-free policies. The Center and NDDoH each make available a comprehensive tobacco-free school policy checklist, and the Center and the North Dakota School Boards Association (NDSBA) each make available a model tobacco-free school policy; NDDoH uses the NDSBA model policy in its policy promotion efforts. Model tobacco-free school policies created by the Center and NDSBA prohibit use of tobacco products by students, staff, and visitors on school grounds. Both model policies prohibit the use of e-cigarettes, although the Center’s policy is more specific and inclusive. Additionally, while both model policies mention communicating the policy in a manner consistent with the statewide smoke-free law, the Center policy also stipulates that the district will post signs
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indicating that the property is tobacco-free. Although there has been communication among these agencies, there is not yet a single agreed-upon model policy, which the Center reports has caused some confusion for schools and LEAs.
Adults in North Dakota support tobacco-free schools. According to a 2014 survey of North Dakota adults, 95.1% of North Dakotans agree that tobacco use should be prohibited on school property. The overwhelming majority of nonsmokers (97.0%) and smokers (87.6%) support policies that prohibit tobacco use on school property.
According to the state’s Department of Public Instruction, there are 226 LEAs in North Dakota, comprising 177 public school districts, 40 nonpublic schools, 5 Bureau of Indian Affairs schools, and 4 state institutions. A total of 151 North Dakota LEAs (66.8%) have comprehensive tobacco-free school policies that the Center has confirmed meet its tobacco- free school policy criteria as of June 2015 (Figure 5) (BreatheND, 2015, unpublished). During the 2013–2015 biennium, 24 LEAs implemented a tobacco-free school policy.
Figure 5. Percentage of North Dakota Local Education Agencies Covered by Tobacco-Free School Policies, 2013–2015
Source: Center for Tobacco Prevention and Control Policy
The objective of reaching 80% of LEAs with comprehensive tobacco-free school policies has not yet been achieved. Although the objective’s target date is still 1 year out, it will take continuing efforts and coordination to achieve this objective.
Consistency with Best Practices CDC’s Best Practices describes the importance of changing social norms through policy interventions. Best Practices also specifically cites the Healthy People 2020 initiative’s
13 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium national health objectives, which includes increasing tobacco-free school environments. This state plan objective, to increase the proportion of LEAs that have a tobacco-free policy in place, is consistent with Best Practices. The current approach involves grantees working with LEAs across the state to reassess, strengthen, communicate, and enforce their policies. This approach is consistent with Best Practices. However, given Best Practices’ support of coordinated efforts across partnering agencies, North Dakota efforts would be more aligned with Best Practices if these agencies could reach consensus on policy criteria and present a unified front in support of a common tobacco-free school objective. To ensure comprehensiveness of tobacco-free school policies, we recommend that the agencies adopt a single comprehensive model policy that is inclusive and descriptive regarding e-cigarettes and that requires signage to reflect that the entire campus grounds are tobacco-free.
4.1.4 Increase the Number of Tobacco-Free Post-Secondary Institutions
Objective Progress
By June 30, 2016, increase the One year before the target date of this number of public and private post- objective, 14 of the state’s 21 post- secondary institutions with secondary institutions have tobacco-free comprehensive tobacco-free campus policies, with 2 of the policies campus policies to 17. being implemented within the 2013–2015 biennium.
Smoke-free policies on college and university campuses are implemented to prevent exposure to secondhand smoke and promote tobacco-free social norms that encourage cessation and reduce initiation (CDC, 2014). The American College Health Association (2014) recommends the adoption of comprehensive college and university campus policies that prohibit all tobacco use in campus buildings and outdoor areas. This objective aims to increase the number of public and private post-secondary institutions in North Dakota with comprehensive tobacco-free policies.
Activities and Progress LPHU grantees have worked with North Dakota colleges and universities to implement comprehensive tobacco-free campus policies. Data available from the grantee reporting system show that LPHU grantees held 45 meetings with key individuals and/or colleges and universities during the first three quarters of FY 2015. To support LPHU efforts, the Public Health Law Center, one of the Center’s SIGs, has updated a model tobacco-free campus policy.
North Dakota has 21 college and university campuses: 11 North Dakota University System (NDUS) campuses, 5 private campuses, and 5 tribal campuses. Of these colleges and universities, the Center reports that 14 have tobacco-free campus policies (10 NDUS, 3 private, and 1 tribal) and 3 have smoke-free campus policies (1 NDUS and 2 private) (Table 2). The majority (68.4%) of students in North Dakota colleges and universities are
14 Final Report covered under a tobacco-free policy, and approximately 96.8% of students are covered under either a tobacco-free or smoke-free campus policy.
Table 2. North Dakota Colleges and Universities’ Tobacco-related Policies
Neither Tobacco-Free nor Tobacco-Free Campus Smoke-Free Campus Smoke-Free Campus
Bismarck State College NDSU Nursing at Sanford Cankdeska Cikana Dakota College Health Community College Dickinson State University North Dakota State Fort Berthold Community University College Lake Region State College Rasmussen College Sitting Bull College Mayville State University (Bismarck and Fargo Turtle Mountain Community Minot State University Campuses) College North Dakota State College of Science Trinity Bible College University of Jamestown University of Mary University of North Dakota Valley City State University Williston State College United Tribes Technical College
Seven of the 14 tobacco-free campus policies and 2 of the 3 smoke-free campus policies were adopted after Measure 3 increased program funding and established the Center. During the 2013–2015 biennium, two post-secondary institutions adopted tobacco-free policies. Williston State College became tobacco-free on November 1, 2013. United Tribes Technical College became the first tribal college in North Dakota and the third tribal college in the United States to become tobacco-free. The Bismarck-Burleigh LPHU facilitated this change, using Center grant funds to provide assistance with the policy change and signage regarding the new policy. The college implemented the policy on November 21, 2013, the day of the Great American Smoke Out (Figure 6). This policy also prohibits the use of e-cigarettes, but exempts the traditional or sacred use of tobacco for American Indian spiritual and cultural ceremonies when requests are made and approved in advance.
North Dakota adults support tobacco-free college campuses. As part of a telephone survey that RTI conducted in 2014, more than half of North Dakota adults (51.7%) reported that they are strongly in favor of policies that prohibit the use of all kinds of tobacco, including e-cigarettes, on college or university property, with an additional 12.8% reporting that they are somewhat in favor. A separate online survey of 930 North Dakota college students in 2015 found that students reported even higher levels of support for tobacco-free campus policies than adults in the general population. Specifically, North Dakota college student
15 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium survey respondents supported prohibiting on-campus cigarette smoking (83.4%), other tobacco product use (70.4%), and e-cigarette use (66.3%).
Figure 6. Web Page of United Tribes Technical College Discussing the Tobacco- Free Campus Policy
North Dakota’s state plan cites a target of 17 tobacco-free campuses by June 2016. North Dakota has made good progress in this area, with a large percentage of college students covered by an existing tobacco- or smoke-free policy. The Center is also coordinating with the NDUS Director of Student Affairs to integrate tobacco-free policies on their member campuses. If 3 additional campuses adopt a tobacco-free policy in the next year, the program will achieve this objective.
Consistency with Best Practices Colleges and universities are specifically named in CDC’s Best Practices as community settings important for tobacco control intervention. CDC notes that “adolescents and young adults are very sensitive to perceived social norms” (CDC, 2007, p. 32), making smoke-free environments at colleges and universities critical for preventing initiation among young adults. The tobacco-free college and university campus objective and the program’s approach to achieve this objective are consistent with Best Practices.
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4.1.5 Uphold Statewide Smoke-Free Law
Objective Progress
By June 30, 2015, uphold the North The statewide smoke-free law remains Dakota Smoke-Free Law as passed in intact. November 2012.
Smoke-free laws are effective at reducing secondhand smoke exposure, improving air quality, and reducing smoking. They have also consistently been shown to impact health; after smoke-free laws are implemented, health events including acute respiratory problems such as wheezing, shortness of breath, and coughing decrease, and the number of heart attacks is reduced (Goodman et al., 2007; Institute of Medicine, 2009; Palmersheim et al., 2010). New research also shows immediate drops in pre-term births and childhood emergency department visits (Been et al., 2014). Additional benefits include preventing youth from starting to smoke (Siegel et al., 2005) and encouraging smokers to quit (Fichtenberg & Glantz, 2002). North Dakota’s 2012 smoke-free air law covers worksites; enclosed public places; and places of employment, including bars and restaurants. It also prohibits the use of e-cigarettes in locations where smoking is not allowed. This objective focuses on upholding the current statewide law.
Activities and Progress This smoke-free law went into effect in December 2012. During the 2013–2015 biennium, the program conducted a range of activities to communicate with businesses and organizations about the law. The Center has been a resource for questions regarding the smoke-free law and facilitated distribution of smoke-free signs and information about the law with NDDoH food and lodging license renewals. The Center spent approximately $315,000 on signage and education efforts, including print, digital, radio, and television ads about the law; provision of metal signs, adhesive window signs, and other signs to businesses as required by the law; and other indoor and outdoor public signage communicating about the law’s implementation. Grantees engaged the public, partners, and policy makers through communication efforts across the state in support of the law and followed up on compliance issues. Additionally, LPHU grantees held 14 meetings with local state’s attorneys, 43 meetings with legislators, and 15 presentations to the general public about the smoke-free air law.
North Dakotans continue to show a high level of support for the 2012 smoke-free air law. A 2015 telephone survey found that more than 80% of North Dakota residents support the smoke-free law, with nearly 73% reporting strong support (Figure 7). More than 84% of nonsmokers support the smoke-free law.
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Figure 7. North Dakota Residents’ Support for Statewide Smoke-Free Law, Overall and by Smoking Status, 2015
Source: Study conducted by RTI for the Center for Tobacco Prevention and Control Policy.
Public support for the law is reinforced with observed compliance in hospitality venues. According to a 2014 study of compliance with the statewide law, including air quality measures within a stratified random sample of hospitality venues in North Dakota, more than 90% of bars and restaurants in the sample had good or moderate air quality scores and data collectors observed indoor smoking in only three venues out of 107 (2.8%) (Buettner-Schmitt, Boursaw & Lobo, 2014). Comparing air quality before and after the law was expanded in 2012, tobacco smoke pollution decreased 84% on average at the sampled venues (Buettner-Schmitt, Boursaw & Lobo, 2014).
RTI explored compliance with the smoke-free air law by obtaining data on violations from those with enforcement responsibility across the state and by reviewing data collected about where North Dakota adults saw tobacco use, as reported in response to a 2014 telephone survey. City- and county-level contacts responsible for enforcing the smoke-free law reported that people and businesses generally comply with the law. Less than one-quarter of enforcement contacts reported any violations of the statewide smoke-free air law in the 2 years since it was implemented. The majority of the reported violations were for smoking within 20 feet of entrances, exits, operable windows, air intakes, and ventilation systems of enclosed areas in which smoking is prohibited. These reports from enforcement officials are consistent with reports from the general public. In June 2014, few North Dakotans reported seeing anyone violate the statewide smoke-free air law during the past 12 months. Fewer than 20% of North Dakota adults reported seeing smoking indoors in places where it is prohibited during the past year. Approximately 23% of adults reported having seen
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e-cigarettes used indoors during the past 12 months. Although outdoor tobacco use near doors and windows was more common than indoor use, most adults did not report having seen this type of violation. Sixty-eight percent of adults reported that they did not see or did not remember seeing smoking outdoors where it is prohibited.
RTI also conducted an economic analysis of restaurant and bar employment data to examine whether the expanded statewide law or coverage by pre-existing local laws was associated with significant changes in employment in restaurants and bars in North Dakota. Using quarterly employment data at the county level from 1990 to 2014, we estimated separate models for restaurant and bar employment using two methods of controlling for smoke-free law coverage. We found no evidence of a significant association between employment in restaurants and bars in North Dakota and the expanded statewide law or pre-existing local laws. Prior employment levels in restaurants and bars and prevailing economic conditions were the main factors determining restaurant and bar employment, not smoke-free air laws.
Consistency with Best Practices Creating smoke-free environments is a cornerstone of CDC’s (2014) Best Practices for comprehensive tobacco control programs. In addition to reducing secondhand smoke exposure, smoke-free environments help establish and reinforce smoke-free norms (Callinan et al., 2010). North Dakota’s comprehensive smoke-free air law is consistent with Best Practices recommendations. Ongoing efforts to expand the law are captured in subsequent objectives, and future inclusion of this objective in the state plan may not be necessary.
4.1.6 Increase Indoor Smoke-Free Air Exempted from ND Smoke-Free Law
Objective Progress
By June 30, 2016, advocate for During this biennium, the program’s policies/ordinances/laws that grantees have advocated for tobacco-free restrict exposure to secondhand and smoke-free policies in indoor areas smoke and tobacco use in indoor not covered by the state law, and they areas not covered by ND Smoke- have succeeded in implementing some Free Law, e.g., multi-unit housing, multi-unit housing policies in public casinos. housing and privately owned properties.
North Dakota’s 2012 comprehensive smoke-free air law included exemptions for the following areas: (1) private residences except those used as child care, adult day care, or health care and mental health facilities licensed by state agencies; (2) outdoor areas of places of employment except those outdoor areas specifically included in the law; and (3) areas in owner-operated businesses that have no employees and are not generally accessible to the public. Smoking as part of a traditional American Indian ceremony is also
19 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium allowed (N.D.C.C. §§ 23-12-9 to 23-12-11) (2012). This objective focuses on advocating for increasing the coverage of policies that will reduce secondhand smoke exposure in areas not currently covered under the statewide smoke-free air law.
Activities and Progress The North Dakota smoke-free law covers workplaces, including bars and restaurants, as well as nursing homes, hotel and motel rooms, airports, and state-regulated gambling facilities. North Dakota has seen continued progress toward increasing smoke-free air through the passage of local ordinances. Eight local ordinances are in place that are stronger than the 2012 law (Figure 8).
Figure 8. North Dakota Cities with Local Smoke-Free Ordinances
Source: North Dakota Center for Tobacco Prevention and Control Policy
A significant proportion of program efforts to decrease exposure to secondhand smoke focused on expanding smoke-free policies in multi-unit housing. LPHU grantees educated landlords, apartment building owners, and property management services about smoke-free multi-unit housing policies. Outreach included in-person visits, telephone calls, and
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participation in relevant conferences. The Center’s Web site also provides resources for tenants and landlords, from background information on the issue to model leases and a link to a database of smoke-free apartments in the state. In addition, the Center’s health communications efforts promoted smoke-free housing policies (as discussed in Section 4.2).
In the 2013–2015 biennium, 42 smoke-free multi-unit housing policies were added or updated. These smoke-free multi-unit housing policies covered over 200 buildings and more than 1,500 units throughout the state. Notably, two new smoke-free policies were implemented in public housing facilities, including 8 buildings in Burleigh County and more than 200 units in Minot.
North Dakota adults are supportive of smoke-free policies in multi-unit housing. In 2015, 63.5% of North Dakota adults reported that they support prohibiting smoking in apartments and multi-unit housing, with 51.2% reporting that they strongly favor this type of policy. College students, who often live in apartments or dorms, report even stronger support than the general public for smoke-free multi-unit housing. In a 2015 study of college students in North Dakota, 66.6% of respondents were strongly in favor of tobacco-free policies in multi- unit housing (Figure 9).
Figure 9. North Dakota College Students’ Support for Smoke-Free Policies in Multi-Unit Housing
Source: Study conducted by RTI for the Center for Tobacco Prevention and Control Policy, 2015.
North Dakota has worked collaboratively to address tobacco use in Tribal casinos. In August 2013, NDDoH and the Northern Plains Tribal Tobacco Technical Assistance Center organized the Traditional Tobacco (Cansasa Coalition) Conference, focusing on traditional tobacco use,
21 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium tobacco dependence, and comprehensive tobacco control policies. According to NDDoH CDC progress report, an interest in establishing smoke-free policies in tribal casinos grew out of the conference. In January 2014, Tobacco Prevention Coordinators from the Spirit Lake Sioux Tribe, Standing Rock Sioux Tribe, Three Affiliated Tribes, and the Turtle Mountain Band of Chippewa met as members of the Intertribal Tobacco Abuse Coalition and committed to getting involved with the ND Smoke-Free Casino Project, with the goal of getting all North Dakota tribal casinos to become smoke-free together. An informal RTI study of tribal casinos’ policies in 2014 found that of the seven tribal casinos in North Dakota, one “mini-casino” does not allow smoking at all, five casinos allow smoking in designated areas, and one has no restrictions on smoking.
In 2015, an RTI survey found that two-thirds (66.6%) of North Dakota adults support prohibiting smoking in tribal casinos. Statewide, support was higher among nonsmokers (72.2%) than among smokers (39.3%). Analysis also considered regional differences, bisecting the state into Eastern and Western regions. Support was slightly lower in the Western region of the state (62.5%) than in the Eastern region (70.0%).
This objective does not set a specific and measurable target. However, the program has advocated for smoke-free policies and achieved successes.
Consistency with Best Practices This objective is consistent with Best Practices, which emphasizes the importance of policies to create smoke-free public and private environments. CDC (2014) specifically mentions multi-unit housing as a target for smoke-free policies where comprehensive smoke-free policies have already been implemented. Work with tribes to promote smoke-free casino policies on American Indian reservations addresses the expansion of smoke-free environments and works to protect a population facing significant tobacco-related disparities: American Indians working in and visiting tribal casinos. The program’s implementation of this objective, advocating for smoke-free multi-unit housing policies with landlords and for smoke-free casinos with tribes, is consistent with Best Practices.
4.1.7 Increase Smoke-Free and Tobacco-Free Outdoor Venues
Objective Progress
By June 30, 2016, advocate for The program has successfully policies/ordinances/laws that restrict advocated for tobacco-free and exposure to secondhand smoke and smoke-free policies at outdoor venues. tobacco use at outdoor public venues not covered by ND Smoke-free air law, for example parks.
North Dakota’s comprehensive smoke-free air law does not cover outdoor areas, such as parks, playgrounds, recreational areas, and some outdoor places of employment. This
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objective focuses on encouraging the implementation of more stringent smoke-free policies for outdoor areas not currently covered by the statewide smoke-free air law.
Activities and Progress According to the state plan, Center grantees educate organizational decision makers about the benefits of tobacco-free outdoor policies. In the current biennium, the Center and the Americans for Nonsmokers’ Rights Foundation (one of the Center’s SIGs) have worked to promote clean outdoor air policies, including training and providing technical assistance to LPHUs. During the 2013–2015 biennium, grantees reported 31 new tobacco-free and 7 new smoke-free grounds policies, as well as 3 new Board of Health resolutions supporting outdoor policies. Seventeen cities in North Dakota have tobacco-free park policies (Figure 10).
Figure 10. North Dakota Tobacco-Free Parks
Source: North Dakota Center for Tobacco Prevention and Control Policy, March 2015.
A 2015 survey conducted by RTI asked North Dakotans their opinion of policies prohibiting smoking in outdoor public places. Nearly two-thirds (64.4%) of North Dakota adults reported that they are in favor of prohibiting smoking in outdoor areas, with 48.0% of adults reporting that they are strongly in favor.
Consistency with Best Practices CDC’s Best Practices charges community programs with implementing environmental changes in a range of settings, including outdoor public spaces. The intent and implementation of this objective are consistent with Best Practices.
23 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium
4.1.8 Prevent Preemption in State Tobacco Prevention and Control Laws
Objective Progress
By June 30, 2015, prevent preemption North Dakota remains free from in all North Dakota state tobacco tobacco control preemption. prevention and control laws.
Preemption laws prohibit the implementation of local laws or regulations, keeping municipalities from adopting laws more comprehensive than state law. Preventing preemption of local tobacco prevention and control laws means that local municipalities are able to pass local smoke-free ordinances that reinforce the state law and can further clarify the rules or cover more areas than the state law. This objective in the comprehensive plan aims to maintain the absence of tobacco control preemption in North Dakota.
Activities and Progress The state plan includes the following strategies for this objective: educating the public, grantees, partners, and policy makers; monitoring legislative bills; and encouraging Board of Health resolutions opposing preemption. In this biennium, two county Boards of Health passed resolutions in support of the right of local government to adopt comprehensive smoke-free policies: Wells (2012) and Burleigh (2013). This brings the total number of counties in North Dakota with anti-preemption resolutions to 52 out of 53 counties. North Dakota remains one of the 37 states without preemption of local smoke-free air laws (ANRF, 2015).
Consistency with Best Practices CDC’s Best Practices supports the elimination of state-level laws that preempt local-level tobacco control laws. Given that North Dakota does not currently have preemption of local tobacco control laws, the program’s strategies are consistent with Best Practices but may not require a distinct objective within the state plan.
4.1.9 Promote Point-of-Sale Ordinances
Objective Progress
By June 30, 2016, develop and North Dakota implemented a state- advocate for ordinances that restrict level law prohibiting the sale of youth access to tobacco and nicotine e-cigarettes to minors, and many products at point-of-sale. cities have adopted policies to limit youth access to e-cigarettes.
The place where a customer makes a payment to a merchant for services or goods, also referred to as the point of sale, is an important area of focus for comprehensive tobacco control programs. Most tobacco sales occur in retail establishments, and the tobacco
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industry is committing the vast majority of marketing and promotional dollars to the retail environment (FTC, 2015). A number of studies have demonstrated that availability, advertising, promotion, and marketing of tobacco products at the point of sale increase youth and adult impulse buys (CDC, 2014; Henriksen et al., 2010; National Cancer Institute, 2008; Paynter & Edwards, 2009; Slater et al., 2007; Wakefield et al., 2008). The 2009 Family Smoking Prevention and Tobacco Control Act increased the options for tobacco control efforts aimed at the point of sale by allowing state and local governments to enact tobacco control legislation restricting the time, place, and manner (but not content) of cigarette advertising and promotion. This allows for a range of new tobacco control strategies with greater potential for impact than traditional efforts aimed solely at prohibiting sales to minors. In April 2014, FDA released a proposed rule to extend its regulatory authority to include e-cigarettes, cigars, pipe tobacco, nicotine gels, waterpipe (hookah), and dissolvables, which will further enable local and state governments to regulate these products once the rule is made final.
Activities and Progress North Dakota’s state plan strategies include educating policy makers about policy options to prevent youth tobacco use initiation. Program-defined strategies include education about ordinances that would
. restrict the number, type, and location of tobacco retailers by retail licensing, zoning law, or direct regulation of who can sell tobacco products;
. restrict the placement of tobacco products in retail stores;
. restrict pricing by regulating price promotions or limiting or prohibiting price discounting mechanisms like coupons, multipack discounts, and cross-promotions;
. restrict marketing tactics of payment for prime shelf space and in-store branded displays; and
. restrict sales to minors on e-cigarettes and other nicotine containing products.
E-cigarettes have been the primary focus of point-of-sale activities within North Dakota during the 2013–2015 biennium. The Public Health Law Center has provided research assistance regarding e-cigarette ordinances, and the American Lung Association−ND and Tobacco-Free North Dakota have educated decision makers about the importance of e-cigarette regulations. LPHU grantees reported making 112 visits to policy makers to discuss point-of-sale issues and garnering 52 instances of earned media to educate the public and decision makers. Program grantees, including American Lung Association−ND and Tobacco-Free North Dakota, provided testimony and education during the legislative session.
During the 2013–2015 biennium, there was significant activity at the local level related to e-cigarettes. Twenty-three cities in North Dakota have adopted ordinances addressing sale
25 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium to minors, self-service, and/or licensing related to e-cigarettes, with five of these cities adopting ordinances that include all three provisions. All 23 of these cities have prohibited e-cigarette sales to minors, 17 have restricted self-service of e-cigarettes, and 6 have required stores that sell e-cigarettes to be licensed locally (Table 3). All but two of these ordinances define e-cigarettes as a tobacco product; Bismarck and Lisbon do not include this definition. Eight of the 10 most populous cities in North Dakota have adopted e-cigarette ordinances. Nearly 70% of the state’s population resides in cities covered by these ordinances.
In 2014, three local Boards of Health issued resolutions of support for policies restricting the sale of e-cigarettes to minors. The Grand Forks Board of Health and Lake Region District Health Unit Board of Health adopted resolutions, and the jurisdictions of Grand Forks and Devils Lake passed ordinances. Additionally, the City-County Health District Board issued a resolution in November 2014 encouraging Valley City to prohibit e-cigarette sales to minors, restrict self-service displays, and require licensing, although an ordinance has not yet been adopted.
During the 2015 legislative session, three bills pertaining to e-cigarettes were introduced in the House with provisions that would restrict sales to and use by minors, prohibit self- service displays, and require child-resistant packaging. A key difference in the bills was the terminology used for e-cigarettes, with HB 1078 using “nicotine devices,” HB 1265 using “electronic smoking devices,” and HB 1186 using “electronic smoking devices and alternative nicotine products.” HB 1078 passed in the House but ultimately failed in the Senate, while HB 1265 failed to pass because the committee preferred another bill (HB 1186). HB 1186 was passed by the Senate and was signed by the Governor on April 8, 2015. The bill, effective August 1, 2015, restricts the sale of electronic smoking devices and alternative nicotine products to minors, prohibits the use of these products by minors, prohibits the sale of electronic smoking devices and alternative nicotine products through self-service displays, and mandates child-resistant packaging for liquid nicotine containers.
Table 3. City Ordinances Prohibiting E-cigarette Sales to Minors, Restricting E-cigarette Self-Service, and Requiring a License for Sale of E-cigarettes, 2013–2015 Biennium
City Prohibits Sales to Minors Restricts Self-Service Requires License
Bismarck Cando Casselton Crosby Devils Lake Fargo
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Forman Grand Forks Hankinson Harvey Harwood Hazen Kindred Langdon Lisbon Mandan Mapleton Minot Mohall Rutland Wahpeton West Fargo Williston
Source: Center for Tobacco Prevention and Control Policy, March 2015.
The definition of e-cigarettes was a point of debate as these bills were being considered. The tobacco industry lobby argued against defining e-cigarettes as a tobacco product. Meanwhile, the Center and NDDoH supported defining e-cigarettes as a tobacco product, which would allow them to be regulated uniformly under the state’s existing tobacco laws rather than having to add them separately to particular sections of the law. Additionally, doing so would maintain consistency within state and local laws and with FDA’s proposed deeming regulation. Ultimately, e-cigarettes were not considered tobacco products; instead, the legislation added “electronic smoking devices and alternative nicotine products” as their own classifications to the existing tobacco law.
RTI’s 2015 survey of adult North Dakota residents found that North Dakota adults are supportive of point-of-sale policies. Residents most commonly expressed support for policies prohibiting the sale of e-cigarettes to youth, with support very high among smokers and nonsmokers. More than 91% of North Dakota adults were somewhat or strongly in favor of a law restricting the sale of e-cigarettes to minors.
Support was more mixed for other point-of-sale policies. The survey found that 80.2% of North Dakota adults were somewhat or strongly in favor of requiring that all tobacco products be kept behind the counter (Figure 11), and 54.5% of North Dakota adults were somewhat or strongly in favor of prohibiting the sale of candy-flavored tobacco products
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(Figure 12). Support for policies prohibiting the sale of candy-flavored tobacco products and requiring that tobacco products be kept behind the counter was higher among nonsmokers than smokers and higher among residents in the Eastern region than in the Western region.
Figure 11. Percentage of North Dakota Adults Somewhat or Strongly in Favor of Policies that Require that All Tobacco Products Be Kept Behind the Counter, Overall and by Smoking Status, 2015
Source: Survey conducted by RTI for the Center for Tobacco Prevention and Control Policy, 2015.
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Figure 12. Percentage of North Dakota Adults Somewhat or Strongly in Favor of Policies that Prohibit the Sale of Flavored Tobacco Products, Overall and by Smoking Status, 2015
Source: Survey conducted by RTI for the Center for Tobacco Prevention and Control Policy, 2015.
Consistency with Best Practices Efforts to mobilize communities to restrict minors’ access to tobacco products in combination with efforts to pass stronger local laws directed at retailers, active enforcement of retailer sales laws, and retailer education remain recommended best practices within the broader scope of state and community interventions (CDC, 2014). Efforts aimed at the point of sale are also consistent with the Healthy People 2020 objective to reduce the proportion of adolescents and young adults who are exposed to tobacco marketing. The point of sale has become the primary source of tobacco industry marketing and promotion, and efforts to restrict the time, manner, and placement of tobacco advertising, along with strategies to mitigate the effects of tobacco price promotions, are consistent with CDC Best Practices. Each of the strategies listed in the state plan have been identified as having high potential impact and good legal feasibility (i.e., likelihood of surviving legal challenges), as discussed in a recently released resource on this topic (Center for Public Health Systems Science, 2014). The importance of the increased prevalence of e-cigarettes and the impact of point- of-sale marketing on youth smoking may merit two distinct objectives in the state plan.
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4.2 Mass-Reach Health Communication Interventions
Objective Progress
By June 30, 2016, implement effective, The program conducted significant ongoing tobacco prevention and control tobacco prevention and control health health communication initiatives that communications initiatives during the focus on changing the broad social biennium. In FY 2015, the program norms of tobacco. The communication revised media plans to enhance initiatives will deliver strategic, reach, focus campaign themes, and culturally appropriate and high-impact increase use of high-impact earned and paid messages through advertisements to better align with sustained and adequately funded CDC’s 2014 Best Practices. campaigns integrated into the overall comprehensive North Dakota Tobacco Prevention and Control plan.
Health communication interventions are an essential component of comprehensive tobacco control programs. A strong body of evidence from numerous studies confirms the effectiveness of health communication campaigns in preventing youth initiation of smoking, promoting tobacco cessation and the use of cessation services such as quitlines, decreasing tobacco use prevalence, and shaping social norms related to tobacco use (CDC, 2014; National Cancer Institute, 2008; Wakefield, Loken, & Hornik, 2010). This objective proposes implementing effective, ongoing tobacco prevention and control health communication initiatives that focus on changing the broad social norms of tobacco, by delivering strategic, culturally appropriate, and high-impact messages. Approaches include advertising via paid television, radio, billboard, print, and digital media.
Activities and Progress The comprehensive program’s health communication efforts comprise media campaigns of the Center and NDDoH. Table 4 describes the program’s television health communication campaigns aired during the 2013–2015 biennium. Media buy data for traditional television advertising are often expressed in gross rating points (GRPs). GRPs measure the intensity of advertisements over a designated time period and provide a metric of relative dose by media channel in a specific media market.
During the 2013–2015 biennium, the Center ran health communication campaigns with three main themes in accordance with CDC recommendations. The first campaign focused on transforming social norms to prevent tobacco use. Messages in this campaign were centered on the tobacco industry’s use of deceptive marketing practices, including the marketing of tobacco products with candy-like flavors and packaging, as a means of recruiting youth to become lifelong tobacco users. This campaign included six ads—“Choose,” “Corrupt,” “Hearing,” “Table,” “Toe Tag,” and “One of Three”—and averaged 1,150 GRPs per quarter
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Table 4. North Dakota Television Health Communication Campaigns
Theme and Target Description Image
Tobacco Industry This ad series educates about the (adults aged 25 to devastating impact of tobacco use on 54) youth and describes the tobacco industry’s use of deceptive marketing practices, including the marketing of tobacco products with candy-like flavors and packaging, as a means of recruiting youth to become lifelong tobacco users. Still image from “Toe Tag” Secondhand Ads in this series educate about how Smoke (adults smoke from cigarettes can carry between aged 25 to 54) apartments where smoking is allowed, increasing the risk of smoking-related illness and death for adults and children.
Still image from “Apartment” NDQuits (adults This campaign aims to motivate tobacco aged 18 to 54) users to quit using all tobacco products and inform them about NDQuits as a cessation resource. The ad “Chains” points out that use of non-cigarette tobacco products is on the rise and is fostering nicotine addiction.
Still image from “Chains” Cessation (adults This campaign aims to motivate tobacco aged 18 to 54) users to quit by featuring personal and graphic portrayals of the negative health consequences of tobacco use. The campaign uses several ads from CDC’s Tips From Former Smokers campaign, including an ad about Buerger’s disease that featured Brandon from North Dakota.
Still image from “Buerger’s Disease”
during the biennium. A second campaign focused on the harms of secondhand smoke. Two ads, “Binky” and “Apartment,” educated about how secondhand smoke from cigarettes can travel between apartments where smoking is allowed, and a third ad, “Nathan,” featured an American Indian man describing how he suffers from asthma attacks and lung damage as a result of secondhand smoke in his workplace.
The Center’s SHS-campaigns averaged 725 GRPs per quarter during the biennium. The third campaign focused on motivating smokers to quit and aired several hard-hitting, graphic ads from CDC’s Tips From Former Smokers (Tips) campaign, including an ad that featured
31 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium someone from North Dakota. This campaign also included “Artery,” a graphic ad that illustrates how cigarette smoking can lead to fatty deposit buildup in the arteries that makes it difficult for the heart to circulate blood. The cessation campaigns began running in FY 2015 and averaged 1,125 GRPs per quarter in FY 2015. The Center’s tobacco industry, secondhand smoke, and cessation campaigns were targeted to adults aged 25 to 54, whereas the NDDoH cessation campaigns were targeted to adults aged 18 to 54. These campaigns also included radio spots that ran in conjunction with the television ads. The Center ran complementary campaign ads on the radio, in newspapers, and via digital media throughout the biennium.
NDDoH ran ad campaigns during the 2013–2015 biennium to motivate tobacco users to quit using tobacco products and inform them about NDQuits as a cessation resource. One of these ads, “Chains,” features a young adult woman explaining that while smoking prevalence among young adults is on the decline, use of other tobacco products like snus, chew, cigars, and e-cigarettes is on the rise and is fostering nicotine addiction. Another ad, “American Indian,” features American Indians describing the risks of smoking and providing encouragement to quit. The NDDoH campaign was targeted toward adults aged 18 to 54 and averaged 847 GRPs per quarter over the biennium. NDDoH ran complementary ads on the radio, in newspapers, and via digital media.
RTI’s telephone survey of adult North Dakota residents, conducted in April 2015, assessed awareness of several of the health communication campaigns that ran during the 2013– 2015 biennium. Specifically, the survey measured whether respondents reported seeing the following ads or campaigns within the past 6 weeks: (1) NDQuits, (2) antismoking ads or campaigns on television about how tobacco companies try to get children to start smoking, and (3) antismoking ads in which former smokers share “tips” for living with health problems caused by smoking.
Of the three campaigns, awareness was highest for the Tips ads, with 77.2% of North Dakota residents reporting in April 2015 that they had seen the ads within the past 6 weeks. Awareness was similar among smokers (79.6%) and nonsmokers (76.8%). More than two- thirds of North Dakota adults (67.2%) had seen ads about how tobacco companies try to get children to start smoking, which likely reflects awareness of the BreatheND industry ads described above. Again, awareness of the industry ads was fairly similar for smokers (69.6%) and nonsmokers (66.7%). While awareness of ND Quits ads was 61.6% overall, awareness was notably higher among smokers, with 72.7% of smokers reporting having seen an NDQuits ad, compared with 59.1% of nonsmokers. The 2015 survey did not measure awareness of any ads related to secondhand smoke. Differences in awareness among the three campaigns assessed likely reflect differences in the timing and relative weight of campaign flights.
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RTI conducted analyses to examine the potential impact of North Dakota’s antitobacco advertising campaigns on enrollment in NDQuits, North Dakota’s telephone and online smoking cessation service. The analysis reviewed broadcast television GRPs and NDQuits enrollment from July 2010 through March 2015 (Figure 13). During this period, ads ran at an average of 918 GRPs per month, and there were an average of 130 Web-based and 183 phone-based NDQuits enrollments each month. GRPs and total NDQuits enrollment were moderately correlated (r = 0.64).
Figure 13. NDQuits Enrollments and Broadcast Television GRPs for Center and NDDoH Campaigns, July 2010—March 2015
The analysis found a positive association between GRPs and NDQuits enrollment. This association exists for each agency’s antitobacco media campaigns independently, as well as the combined GRPs for the state, which suggests that both Center and NDDoH campaigns appear to be positively associated with NDQuits enrollment and the combination of Center and NDDoH campaigns is positively associated with NDQuits enrollment. This analysis found that for every 100 Center GRPs, we would expect approximately 5.5 NDQuits enrollments, controlling for the effects of NDDoH GRPs. For every 100 NDDoH GRPs, we would expect approximately 20.2 NDQuits enrollments, controlling for the effects of Center GRPs. For every 100 combined Center and NDDoH GRPs, we would expect 9.9 NDQuits enrollments. Therefore, for a typical 918-GRP campaign (according to average monthly GRPs), we would
33 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium expect approximately 91 NDQuits enrollments. As expected, the NDDoH campaigns specifically encouraging smokers to call the quitline appear to have the intended effect of increasing NDQuits enrollments. Center Campaigns, despite a primary focus on transforming social norms about tobacco use, appear to also have the ancillary effect of increasing NDQuits enrollment volume.
Consistency with Best Practices CDC recommends that states deliver “strategic, culturally appropriate, and high-impact messages in sustained and adequately funded campaigns that are integrated into a comprehensive state tobacco program effort” (CDC, 2014, p. 32). North Dakota’s comprehensive program specifically adopted this language into its state plan, evidencing an aim to comply with Best Practices. This state plan objective is clearly consistent with CDC Best Practices.
The program consulted with CDC in developing its FY 2014 media plans, which were developed before the release of CDC’s 2014 Best Practices update and revised for FY 2015 to better align with the updated guidelines. CDC’s 2014 Best Practices offers both minimum and recommended GRP levels and more specific guidance on the prioritization of media campaigns focused on cessation, secondhand smoke, and social norms of tobacco use. Specifically, CDC’s 2014 Best Practices recommends an average of 1,600 GRPs per quarter (and a minimum of 1,200 GRPs) for four quarters for cessation or secondhand smoke media campaigns, and 1,200 GRPs per quarter (and a minimum of 800 GRPs) for four quarters for each of the other campaigns. During the biennium, North Dakota’s combined Center and NDDoH cessation campaigns aired at levels that were consistent with current CDC recommendations (1,409 GRPs per quarter, on average) (Table 5). These average quarterly GRP levels reflect a tailored approach developed in consultation with CDC that accounts for North Dakota’s higher smoking prevalence compared with the national average. North Dakota’s tobacco industry-focused campaign aired at levels that aligned with CDC recommendations for a secondary campaign (1,150 GRPs per quarter during the biennium), while the SHS-focused campaign aired at levels slightly lower than current CDC recommendations for a secondary campaign (725 GRPs per quarter during the biennium). Of the total combined GRPs aired during the biennium, 43% were cessation- focused, 35% were industry-focused, and 22% were SHS-focused.
In terms of the content of the ads run by the Center and NDDoH, the secondhand smoke ads fit with CDC recommendations and promote quitline services. At the start of FY 2015, the Center transitioned new ads into the media plan to better reflect 2014 CDC recommendations regarding cessation-focused ads. In doing so, the program became more aligned with 2014 Best Practices by improving the extent to which high-impact messages are used to encourage smokers to quit. Evidence from state tobacco prevention
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Table 5. Average Quarterly GRPs, by Campaign Type, FY 2014–2015
Campaign
FY Quarter Cessation Industry SHS
2014 Q1 0 2,400 0 Q2 602 1,200 0 Q3 1,519 2,200 43 Q4 754 1,000 2,157 2015 Q1 386 0 1,200 Q2 2,443 124 0 Q3 2,357 2,276 0 Q4 3,214 0 2,400 Quarterly Average 1,409 1,150 725
Notes: FY 2014 Cessation GRPs provided by NDDoH Quarterly “Media Recap” reports; FY 2015 Cessation GRPs are planned GRPs from the Center’s FY 2014–2015 Media Plan. Cessation GRPs represent combined Center/NDDoH cessation-focused media campaigns. programs and from numerous studies consistently shows a strong base of support for the use of hard-hitting, emotionally evocative ads that use graphic imagery or personal testimonials illustrating the negative health consequences of smoking. Messages that elicit a strong emotional response have proven to produce stronger and more consistent effects on audience recall, knowledge, beliefs and attitudes related to tobacco use, and cessation behaviors (CDC, 2003; Durkin, Brennan, & Wakefield, 2012; Farrelly et al., 2012; McAfee et al., 2013; USDHHS, 2012; Wakefield, Loken, & Hornik, 2010). In addition to impacting adult cessation, these types of ads have also been associated with prevention of smoking initiation among youth (Wakefield, Loken, & Hornik, 2010).
Additionally, the Center’s decision to air ads from CDC’s Tips campaign is consistent with the Best Practices recommendation to use ads that have already been developed. CDC encourages programs to adapt or use existing advertisements from national organizations and other cities, states, or countries to “save time, money, and the risks associated with new advertisement development” (CDC, 2014, p.31). Rather than developing new ads, the program used existing ads that fit with its campaign objectives.
CDC’s 2014 funding recommendation formulations specifically encourage programs to focus the majority of GRPs on motivating smokers to quit and protecting people from the harms of secondhand smoke. In FY 2014, the majority of North Dakota’s media campaigns highlighted the tobacco industry’s deceptive marketing practices and the dangers of secondhand smoke exposure as a means of denormalizing tobacco and promoting social norms change. In FY 2015, the Center began to use the type of high-impact ads most strongly supported by the literature. We encourage continued use of ads with graphic imagery or personal testimonials
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(e.g., CDC’s recent Tips campaign ads) in both agencies’ media plans to ensure that the program’s health communications efforts continue to be aligned with Best Practices.
4.3 Cessation Interventions
Interventions that facilitate tobacco use cessation involve three main approaches: promoting health systems change, supporting state quitline capacity, and removing barriers to accessing proven cessation treatment. North Dakota’s cessation-focused initiatives focus on increasing the reach of NDQuits and improving tobacco use screening and treatment in health care settings and mental health and substance use treatment settings.
4.3.1 Increase Treatment Reach of NDQuits
Objective Progress
By June 30, 2015, increase annual Although data for the target date of this treatment reach of NDQuits to 2.5% objective are not yet available, as of FY of all smokers and smokeless 2014, NDQuits treatment reach was tobacco users. approximately 1.5%, enrollments increased over the prior biennium, and participants reported a 31.3% quit rate.
Although most smokers quit without using assistance (CDC, 2011; Shiffman et al., 2008), the use of assistance is associated with higher rates of success (Zhu et al., 2000b). Telephone and Web-based cessation services are a vital component of comprehensive tobacco prevention and control programs that have been shown to be effective at helping smokers quit successfully (Carroll & Rock, 2003; Owen, 2000; Zhu et al., 2000a, 2002). Quitline “reach” refers to the percentage of a state’s tobacco-using population that is served by a state’s tobacco cessation programs. NDQuits’ reach specifically focuses on the number of individuals enrolled in services, one indicator of the success of a state’s cessation efforts.
Activities and Progress NDDoH oversees NDQuits, which offers free telephone counseling as a brief intervention, single-session, or counselor-initiated multi-session service. The NDQuits telephone service is available to tobacco users Monday through Thursday from 7 am to 9 pm and Friday from 7 am to 7 pm; it does not operate on Saturday and Sunday. Adult residents who are uninsured, underinsured, or are covered by Medicaid or Medicare are eligible for a free 8- week supply of nicotine replacement therapy (NRT). Additionally, NDQuits offers online services, including online counseling, Quit Tips e-mail messages offering tips for staying quit, NRT, information about NDQuits telephone services, self-help tools, resources, and online support from other quitters. NDQuits also offers text messaging with tips for quitting and appointment reminders. NDDoH and the Center promote NDQuits services through television; radio; print advertising and flyers; and digital media, including Web and social media ads that are tagged with NDQuits and 1-800-QUIT-NOW contact information. NDDoH
36 Final Report and the Center’s grantees encourage referrals to NDQuits in their interactions with health care providers and other health, mental health, and substance use providers in their areas.
NDDoH has launched a Campus Tobacco Prevention Project, which promotes NDQuits cessation service options on college campuses. The campuses participating in this project are Dakota College, Mayville State University, Minot State University, North Dakota State College of Science, North Dakota State University, University of Jamestown, University of North Dakota, and Valley City State University.
NDDoH contracts with National Jewish Health and the University of North Dakota for NDQuits services, and with Professional Data Analysts, Inc. (PDA) for the NDQuits evaluation. Data from NDDoH show that monthly telephone and Web services during the 2013–2015 biennium averaged 341 enrollments, and this number has continued to rise each biennium (Figure 14). During the 2013–2015 biennium, telephone enrollment was slightly higher than Web enrollment, with the telephone modality enrolling 52.8% of registrants. Total monthly enrollments during this period ranged from 265 (December 2013) to 537 (January 2014). Overall enrollment was highest around January, which is typical of quitline programs and likely reflects increased commitments to quit in the new year and increased intensity of antitobacco advertising during this month. Between July 2013 and March 2015, a total of 7,158 people registered for NDQuits telephone or online programs. A total of 3,782 participants received support through the telephone program, and 3,376 used the online program.
Overall, the combined treatment reach of NDQuits in FY 2014 was 1.5%, meaning that 1.5% of adult tobacco users in North Dakota either spoke with an NDQuits counselor, logged in to the Web program at least once, or received NRT through NDQuits. Reach differed by type of tobacco use, with statewide reach being higher for smokers (1.8%) than for smokeless tobacco users (0.4%) and dual cigarette and smokeless users (0.4%). The program’s objective to reach 2.5% of all tobacco users had not yet been met as of June 2014. It is unclear whether this objective will be met by the target date of June 30, 2015.
PDA calculated the percentage of NDQuits participants who had abstained from any tobacco use for at least 30 days at 7 months after program enrollment among all participants who were current tobacco users at the time of enrollment and who had received phone counseling (with or without accessing the Web program, e-mail, or text). PDA calculated that 31.3% of all participants surveyed in FY 2014 who received phone counseling had successfully quit tobacco 7 months later. This quit rate exceeds the 30% objective set for quitlines by the North American Quitline Consortium (NAQC, 2013a). It is very close to the FY 2013 national quit rate estimate (31.6%) based on an average of 31 states for NAQC (NAQC, 2013b).
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Figure 14. Monthly NDQuits Telephone and Web Enrollments, July 2007—March 2015
Consistency with Best Practices CDC’s Best Practices states that all tobacco users should have access to quitlines as population-based cessation interventions because they are “one of the most accessible cessation resources and can efficiently reach large numbers of smokers” (CDC, 2014, p. 47). North Dakota offers NDQuits telephone and online services and promotes these services in multiple ways.
CDC’s (2014) Best Practices suggests that state tobacco quitlines should strive to reach 8% of adult tobacco users annually. However, this is a steep targeted increase from the current national reach of approximately 1%, and CDC notes that this guideline assumes that Meaningful Use, the Affordable Care Act, and the national Tips campaigns will contribute to increased reach. North Dakota’s objective specifies a treatment reach of 2.5% of North Dakota tobacco users, which is above the national average but below the current CDC recommendation. Some state quitlines have achieved 2% to 6% reach with additional tobacco control efforts, such as added hours of operation and a rise in the cigarette tax (An et al., 2006; Cummings et al., 2006; Keller et al., 2010; Woods & Haskins, 2007). North
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Dakota is likely to see higher reach with an increase in the cigarette tax and continued health communication campaigns that motivate tobacco users to quit and provide the NDQuits number or 1-800-QUIT-NOW. North Dakota’s efforts to achieve higher quitline treatment reach are consistent with Best Practices, even if the objective is not yet set as high as CDC suggests.
4.3.2 Increase Use of U.S. Public Health Service (PHS) Guideline in Health Care Settings
Objective Progress
By June 30, 2016, increase the All LPHUs report implementation of number of health care settings and PHS guideline-concordant policies, and enhance public health agencies that audits show some improvement in use the systems approach for tobacco documentation of Ask-Advise-Refer. dependence treatment as The number of health systems recommended in the US Public Health participating in Million Hearts “S” Service Treating Tobacco Use and Grants to integrate and enhance Dependence, Clinical Practice cessation interventions has increased Guideline—2008 Update. over the biennium.
The PHS guideline, Treating Tobacco Use and Dependence—2008 Update, is an evidence- based resource that outlines a clinical intervention approach to promote cessation from tobacco use (Fiore et al., 2008). The PHS guideline reviews the evidence for cessation interventions in the clinical setting and recommends that all patients be asked about tobacco use and that every tobacco user receive an intervention at every visit. The PHS guideline highlights evidence supporting the implementation of systems that require or reinforce clinical cessation intervention. Specifically, the PHS guideline asserts, “In contrast to strategies that target only the clinician or the tobacco user, systems strategies are intended to ensure that tobacco use is systematically assessed and treated at every clinical encounter” (Fiore et al., 2008, p. 67). The intervention model outlined in the PHS guideline is called the 5 A’s: Ask every patient about tobacco use, Advise every tobacco user to quit, Assess readiness to quit, Assist with a quit attempt, and Arrange for follow-up (Fiore et al., 2008). North Dakota’s Tobacco Prevention and Control Program uses a condensed version of this model: Ask-Advise-Refer (AAR). This objective focuses on grantee efforts to facilitate health care organizations’ implementation of systems consistent with the PHS guideline.
Activities and Progress All North Dakota LPHU grantees report implementing the PHS guideline in their client services programs. As defined by the program’s ad hoc 2009 cessation workgroup, guideline implementation in the local public health setting focuses on the adoption of a policy requiring that the health unit use systems to ensure that tobacco use and secondhand smoke exposure are queried and documented for every client at every visit. Additionally,
39 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium the policy should require new staff orientation, ongoing staff education and regular chart audits to promote systematic institutionalization of this intervention approach.
The Center supports LPHU grantee activities through training, technical assistance, and oversight of the audit process. Efforts to enhance the systems approach in LPHUs include support for shifts from paper charts to electronic health records, ongoing training for staff, and refinements to the AAR audit process. During the 2013–2015 biennium, grantees conducted 29 formal presentations to train 623 LPHU staff. LPHUs also conduct outreach to health care organizations in their area to promote implementation of the PHS guideline and tobacco-free buildings and grounds policies. During this biennium, LPHU grantees conducted 31 formal presentations with health care organizations, training 360 providers.
NDDoH implements the Million Hearts “S” Grant program (a program based on components of the national Million Hearts initiative created by the U.S. Department of Health and Human Services), providing funding for health care centers in North Dakota to establish cessation centers in their health care systems. This includes establishing in-house cessation counseling by certified tobacco treatment specialist staff, identifying protocols to provide these services, standardizing 5 A’s or AAR tobacco use questions in facilities’ electronic health record systems, and expanding the reach of these changes by implementing components throughout the health care system. NDDoH has provided grants to implement these cessation centers in 12 health care centers: Altru Health System (Grand Forks), Community Action Partnerships (Dickinson), Custer Family Planning (Bismarck), Essentia Health (Fargo), Family HealthCare Center (Fargo), First District Public Health (Minot), Jamestown Regional Medical Center (Jamestown), Northland Community Health Center (Turtle Lake), Sanford Health (Bismarck), Sanford Health (Fargo), St. Alexius Medical Center (Bismarck), and Valley Community Health Centers (Northwood). NDDoH also administers grants to promote cessation interventions in safety net dental clinics. These grants require that tobacco use be assessed for each visit and all tobacco users be advised to quit and referred to a cessation program. PDA is evaluating these NDDoH cessation programs beyond NDQuits, and RTI does not have data on these activities at this time.
The percentage of North Dakota smokers who report that their health care provider performed the elements of the AAR intervention is an important measure of PHS guideline clinical intervention implementation. These data reflect the efforts of the comprehensive program because smokers’ interactions with health care providers take place in multiple health care settings, including hospitals, health care practices, and LPHUs. In 2012, 89.2% of North Dakota smokers who visited a doctor in the past year reported that a health care provider asked them if they used tobacco (Figure 15). Nearly sixty-four percent of North Dakota smokers who visited a doctor reported that a health care provider advised them to quit using tobacco; and 41.2% also offered assistance, information, or additional advice. In 2012, 31.9% reported that a health care provider suggested they use a smoking cessation class, program, quitline, or counseling, a significant increase from 19.8% in 2010.
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Figure 15. North Dakota Reports of Health Care Providers Asking Them about Tobacco Use, Advising Them to Quit, Assisting Them with Quit Efforts, and Referring Them to a Smoking Cessation Class, Program, Quitline, or Counseling, among Smokers Who Visited a Health Care Provider in the Past 12 Months, North Dakota ATS 2009–2012
Note: ATS = Adult Tobacco Survey; NA = Not applicable.
Audits and chart reviews of AAR implementation are also a measure of PHS guideline clinical intervention. Chart review findings can be compared for active clients at LPHUs in 2014 and 2015. In LPHUs in 2015, 93.8% of charts reviewed documented tobacco use, 82.2% documented whether patients were advised to quit, and 83.0% documented whether referrals were made (Table 6). These results indicate that tobacco use documentation is very high, and documentation regarding advice and referral is high and increasing.
Table 6. Documentation of Ask-Advise-Refer among Active Client Records at North Dakota LPHUs, 2014–2015
Measure 2014 2015a
Documented tobacco use, among active clients 95% 93.8% Documented advising, among tobacco users 79% 82.2% Documented referral, among tobacco users 75% 83.0% a Preliminary estimates.
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Consistency with Best Practices CDC’s Best Practices explicitly says that state cessation interventions should include strategic health systems change efforts to “institutionalize tobacco use screening and intervention within medical care” (CDC, 2014, p. 40). This objective’s focus on integration of the PHS Guideline into health care organizations is consistent with Best Practices.
Best Practices describes the aim of health systems change efforts as follows:
“The goal is to ensure that every patient is screened for tobacco use, their tobacco use status is documented, and patients who use tobacco are advised to quit. This is followed by offering the patient cessation medication (unless contraindicated), counseling, and assistance, as well as arranging follow-up contact either on-site or through referrals to the state quitline or other community resources” (CDC, 2014, p. 42)
Although Best Practices emphasizes the importance of health care provider referrals to state quitlines and acknowledges that having the option of referring patients increases the likelihood that providers will conduct interventions, it also emphasizes the role of health care providers in assisting tobacco users. Abbreviating the 5 A’s to AAR may risk oversimplifying the intervention such that providers may focus on referring patients to other resources without necessarily assisting them during the visit. Motivating patients, describing medication options, and offering immediate counseling can increase the chances that patients will consider quitting and call NDQuits. Some of the grantee activities do cover the full 5 A’s or also include the Assist component, and expanding the grantee activities to more fully address the 5 A’s could strengthen the intervention approach. Reinforcing emphasis on health care providers motivating tobacco users to quit, offering cessation medication, and counseling will help ensure that the program’s implementation of this objective is consistent with Best Practices. RTI is currently conducting a survey among North Dakota primary care providers to assess their practices regarding patient tobacco use assessment, referral, and follow-up. The Center will use the results of the study to determine and develop appropriate educational and program improvement strategies.
4.3.3 Increase Nicotine Dependence Interventions in Mental Health Treatment
Objective Progress
By June 30, 2015, ensure that The program has educated behavioral providers in private addiction and health administrators and providers mental health treatment programs about the importance of nicotine provide clients with evidence-based dependence treatment integration, nicotine dependence interventions. although administrator reports in 2014 showed additional room for improvement in their programs.
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Some populations experience a disproportionate health and economic burden from tobacco use. People with mental health or substance use disorders are significantly more likely to smoke than the general population, to suffer from tobacco-related illness, and to die prematurely as a result (SAMHSA, 2013). These individuals often receive treatment in mental health and/or substance abuse treatment programs. This state plan objective encourages integration of nicotine dependence treatment within these programs.
Activities and Progress The program has used an educational approach during the past biennium to reach out to addiction and mental health treatment programs. The Center sponsored Dr. Jill Williams, an expert on tobacco dependence treatment among people with mental illness and substance use disorders, to present at the May 2014 North Dakota Behavioral Health Conference. Dr. Williams led the opening plenary session, focusing on the need to address tobacco in behavioral health, and she led two additional sessions: one a continuation of the plenary and the other sharing updates in treating tobacco in behavioral health settings. In October 2014, the Center convened the North Dakota Behavioral Health and Tobacco Meeting with behavioral, mental health, and substance abuse stakeholders to review RTI research and to discuss challenges, concerns, and next steps.
To document baseline levels and facilitate future intervention planning, RTI conducted a survey of mental health and substance use treatment facility directors in North Dakota. The survey assessed policies, protocols, and attitudes regarding the integration of tobacco dependence screening and treatment in these settings. One-quarter of facilities reported that they prohibit smoking on their entire campus (25.0%), meaning that the majority of facilities allow smoking outdoors (29.6%) or in designated areas (45.5%) (Figure 16). Many facilities have policies that address other tobacco products, with 24.4% of facilities prohibiting other tobacco use on their campuses. Half of facilities do not yet have a policy addressing use of e-cigarettes.
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Figure 16. Percentage of North Dakota Mental Health and Substance Use Treatment Facilities Reporting Prohibition of Smoking, Other Tobacco Products, and E-cigarettes, 2014
Nearly 82% of facilities have a written policy or protocol regarding screening for tobacco use, but only half of facilities (50.0%) have written policies or protocols about interventions to address tobacco use (Figure 17). Written policies or protocols are in place at only 7.0% of facilities addressing assessment of secondhand smoke exposure and at 15.0% of facilities regarding screening for e-cigarette use.
More than 90% of facilities offer some services to help clients quit using tobacco. The most common tobacco dependence treatment service offered at mental health and substance use treatment facilities is referral to NDQuits (75.6% of facilities), followed by self-help/ education materials (60.0%), referral to medical provider (46.7%), and referral to community services (37.8%). Most facilities (83.3%) formally assess tobacco use status during intake for substance use, but a smaller proportion of facilities (65.2%) formally assess tobacco use status during mental health intake (Table 7). Fewer than half of facilities integrate tobacco dependence treatment into their treatment planning.
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Figure 17. Percentage of North Dakota Mental Health and Substance Use Facilities That Have a Written Policy or Protocol on Tobacco-Related Screening and Treatment, 2014
Table 7. Services and Staffing Related to Tobacco Dependence Screening and Treatment in North Dakota Mental Health and Substance Use Treatment Facilities, 2014
Service Percentage Formally assess tobacco use status during substance use intake 83.3% Formally assess tobacco use status during mental health intake 65.2% Integrate tobacco dependence treatment into treatment planning 46.5% Offer services to help clients quit using tobacco 91.1% Offer services to help staff quit using tobacco 28.3% Conduct tobacco-related chart audits 65.9% Designate staff person for coordinating tobacco dependence treatment 15.9%
Consistency with Best Practices Clinical interventions in the patient or client care setting are especially important among populations disproportionately affected by tobacco use, including people with mental health and substance use disorders. Best Practices describes a state’s role in implementing tobacco-free campuses at behavioral health care organizations and ensuring that they integrate treatment of tobacco dependence into their routine care. This objective is
45 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium consistent with Best Practices. The intervention is not yet well defined, but future activities can build on the gaps discovered with the baseline documentation of policies and practices.
4.4 Surveillance and Evaluation
Objective Progress
By June 30, 2015, review and update The program works with independent a comprehensive statewide evaluators and maintains evaluation surveillance and evaluation plan. plans to structure evaluation priorities and approach.
Ensuring the effectiveness of comprehensive tobacco prevention and control programs requires appropriate surveillance and evaluation systems that can link program activities to short-, intermediate-, and long-term outcomes. CDC states,
“Data obtained from surveillance and evaluation systems can be used to inform program and policy direction, demonstrate program effectiveness, ensure accountability to those with fiscal oversight, and engage stakeholders” (CDC, 2014, p. 56).
This comprehensive plan objective seeks to ensure that surveillance and evaluation are incorporated into the comprehensive program.
Activities and Progress The comprehensive program has developed a Surveillance and Evaluation Plan. The Center and the Tobacco Prevention and Control Program’s Advisory Committee and Executive Committee are responsible for making and approving updates to the Surveillance and Evaluation Plan with input from key stakeholders.
The Center contracted with RTI in 2012 to evaluate the comprehensive statewide Tobacco Prevention and Control Program. RTI’s evaluation compiles data relevant to the comprehensive program; documents the program’s process, impact, and alignment with CDC Best Practices; and makes practical recommendations for improvement. RTI developed an evaluation plan that describes the program’s theory of change and provides an evaluation planning matrix that shows existing and potential measures related to each objective. RTI identifies gaps in available data and recommends changes to existing systems and new studies to help fill those gaps. RTI delivered several reports during the 2013–2015 biennium based on specific evaluation studies focusing on key issues for the program. During this biennium, RTI launched a public opinion survey focusing primarily on policy issues, a survey of mental health and substance use treatment facilities’ policies and practices regarding tobacco use screening and treatment, and a survey of college and university students regarding policy awareness and support and tobacco-related behaviors.
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RTI updates the evaluation plan annually based on what is learned during the ongoing evaluation efforts.
NDDoH is responsible for conducting statewide surveillance to monitor tobacco-related indicators through several surveillance systems, including the Youth Tobacco Survey (YTS) and Adult Tobacco Survey (ATS). The YTS is conducted every other year, most recently in 2015. ATS was also conducted in the spring of 2015; the prior administration was in 2012. Results from the 2015 ND YTS and ATS are not yet available. Other surveys that contain some tobacco-related questions include the Behavioral Risk Factor Surveillance System (conducted by NDDoH) and the Youth Risk Behavior Survey (conducted by the ND Department of Public Instruction). NDDoH contracts with PDA for an external evaluation of cessation programs, which reports findings on a regular basis.
Consistency with Best Practices Best Practices identifies surveillance and evaluation as a high priority for comprehensive tobacco control programs (CDC, 2014), and North Dakota’s state plan includes an objective consistent with this priority. The state’s Surveillance and Evaluation Plan is in place and is being implemented through complementary data collection, analysis, and reporting activities by multiple organizations.
Overall, the program’s approach to this objective is consistent with Best Practices, in that there are prioritized, funded efforts to understand the program’s activities and outcomes. However, more collaboration between the program’s two core agencies to update a single overarching evaluation plan would be beneficial. To fully understand the impact of program activities on key outcomes, the program could improve the standardized tracking systems used to measure program activities and outcomes. Such improvements would facilitate aggregation and analysis of activities and outcomes in more detail and bring the program more in line with Best Practices.
4.5 Infrastructure, Administration, and Management
CDC recommends that programs maintain adequate infrastructure, administration, and management to manage a comprehensive tobacco control program successfully. North Dakota’s state plan contains three objectives focused on these areas. Described in the following sections, these objectives focus on program administration and management, local infrastructure and capacity, and maintaining the program in conformance with CDC Best Practice recommendations.
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4.5.1 Administration and Management
Objective Progress
By June 30, 2015, maintain and The program maintains ongoing enhance the administrative structure communication between the two lead to manage the comprehensive North agencies and with funded grantees. Dakota Tobacco Prevention and The program conducts regular Control Program adjusted annually by strategic planning and maintains most current CDC Best Practice for administrative systems to facilitate Tobacco Prevention and Control fiscal and activity tracking. Programs.
A comprehensive tobacco control program’s administrative structure encompasses the various systems and activities that work together to manage all of the program components. Administrative and management activities include strategic planning, increasing capacity at the local level by providing training and technical assistance, developing effective communication systems internally and with local coalitions and partners, and creating fiscal management and tracking systems (CDC, 2014). Administration and management are important for a comprehensive tobacco control program because an established infrastructure is critical to implementing effective interventions and is “essential for program sustainability, efficacy, and efficiency” (CDC, 2014, p. 64). Effective administrative systems, communication plans, and protocols are especially important for North Dakota because two distinct agencies (the Center and NDDoH) serve in complementary roles. This objective addresses program administration, highlighting the strategic priority of administration, management, communication, and record-keeping in effectively carrying out the comprehensive program’s activities.
Activities and Progress The Center and NDDoH have complementary roles and responsibilities within the overall comprehensive Tobacco Prevention and Control Program. Responsible for 74% of the overall program budget, the Center employs 8 FTEs and 1.5 temporary positions. NDDoH is responsible for 26% of the program budget and has 4.5 FTEs to conduct their efforts. These state-level program staff participate in Webinars, conferences, in-person trainings, teleconferences, and other opportunities to build and maintain relevant skills and competencies. Both agencies oversee a range of grantees to conduct interventions and provide services. Additionally, the Center and NDDoH each post selected fact sheets, statistics, reports, and resources on their Web sites (Figure 18).
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Figure 18. Web Sites of the Center for Tobacco Prevention and Control Policy and the North Dakota Department of Health Tobacco Prevention and Control Program
The Center’s responsibilities include managing multiple grant programs to support local and statewide tobacco prevention and control efforts. The bulk of the Center’s expenditures are directed toward funding for all North Dakota LPHUs through local tobacco control policy grants. During the 2013–2015 biennium, the Center awarded approximately $7.5 million in grants to LPHUs. The Center has a separate grant mechanism that funds LPHU Tobacco Settlement State Aid grants, which require PHS guideline implementation and audits at LPHUs (approximately $1.1 million during the biennium). The Center also funds various local and statewide organizations through the SIG program (approximately $1.8 million during the biennium) to work on evidence-based policy change effective in eliminating exposure to secondhand smoke and reducing tobacco use among youth and adults. SIG grantees include Americans for Nonsmokers’ Rights Foundation, American Lung Association–ND, Tobacco- Free North Dakota, and Kelly Buettner-Schmidt, PhD, at North Dakota State University. In a related role, the Center entered into a service agreement with the Public Health Law Center at William Mitchell College of Law in Minnesota for research and technical assistance regarding tobacco policy. Center expenditures for health communication campaigns during the 2013–2015 biennium were budgeted at $3.2 million. The Center funds the comprehensive program evaluation, allocating approximately $553,000 per biennium.
NDDoH is responsible for managing and promoting the NDQuits telephone and online cessation services and other direct cessation programs. NDDoH budgeted cessation expenditures during the 2013–2015 biennium totaled approximately $4.7 million. This includes 12 grants totaling $579,743 for the Million Hearts “S” Grant program to
49 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium institutionalize cessation intervention in health care systems and four Tribal Tobacco Prevention and Control Programs on American Indian reservations in North Dakota through a CDC grant, spending $524,000 during the biennium. NDDoH conducts statewide surveillance to monitor tobacco-related indicators through the YTS, ATS, and a statewide secondhand smoke study. NDDoH surveillance and evaluation efforts during the biennium totaled $294,501.
Because the comprehensive program comprises the efforts of the Center and NDDoH, the collaboration of these two agencies is important to the program’s success. The program has created strategic documents, including a statewide comprehensive plan, a health communications plan, and a Surveillance and Evaluation Plan. These provide a foundation to ensure that all stakeholders understand the key program goals, objectives, approach, and measurement standards. This, in turn, guides program activities and resources and assists in communication.
The Center has established infrastructure to organize and track LPHU grantee fiscal and activity data in the Program Reporting System (PRS). Other grantees use PRS for financial data but use separate systems for their activity reporting. PRS has been updated to improve its LPHU grantee activity reporting functionality and is supported by the Center and NDDoH. However, PRS output reports are not available in a format that can be aggregated regularly, which would be useful for users, program staff, and the evaluation. Additionally, RTI has not been provided progress reports or aggregated data from NDDoH for tribal or Million Hearts grantees. More in-depth evaluation of grantee progress would benefit from greater access to information regarding all grantees.
Consistency with Best Practices CDC recommends that this component be funded at the CDC-recommended level, even if the overall program is not. This North Dakota objective is consistent with Best Practices. The implementation of the objective involves program strategic planning, communications, and management systems, particularly those to oversee the multiple grants within each agency. North Dakota’s management structure requires a strong commitment to collaboration and communication. This ongoing collaboration, across the two agencies and with partnering organizations, is consistent with Best Practices and will contribute to continued improvements in the program.
Management also encompasses the tracking of grantee activities and outcomes to assess grantee program performance on an ongoing basis (CDC, 2014). Maintaining tracking systems that better allow grantee data to be aggregated and shared across agencies would be more in line with Best Practices.
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4.5.2 Local Infrastructure and Capacity
Objective Progress
By June 30, 2016, build local infrastructure The program provides grantees and capacity to collaboratively deliver with funding, guidance, evidence-based tobacco prevention and training, and technical control interventions from the most current assistance to support their CDC Best Practices for Comprehensive efforts, and these efforts are Tobacco Control Programs and The Guide to grounded on evidence-based Community Preventive Services: Tobacco Use best practices. Prevention and Control with ongoing recommendations to reach all citizens in local public health units and tribal reservations including one American Indian service area.
Local-level infrastructure and capacity provide the backbone for community-level tobacco control efforts. Infrastructure focuses on the leadership, partnerships, resources, and strategic planning to carry out program activities effectively. Capacity relates to the ability to effectively implement the program’s efforts, with an emphasis on staff that are skilled and well-trained. This objective focuses on reinforcing local infrastructure and capacity to ensure that all North Dakotans are reached with evidence-based tobacco prevention and control interventions.
Activities and Progress Program efforts to build local infrastructure and capacity include providing financial support, assistance with the development of strategic work plans, training, technical assistance, and connections to resources to facilitate grantee tobacco prevention and control activities. The program encourages partnerships with local coalitions and local and state-level organization partners to strengthen the tobacco control infrastructure and identify opportunities for collaboration. The program communicates to grantees the importance of conducting program activities consistent with the evidence base, both because using proven strategies will help the program achieve its goals most efficiently and because the Measure 3 legislation requires this approach. The program provides services to benefit all North Dakotans and ensures that local grantees represent all areas of the state. The Center awards all North Dakota LPHUs grants to implement evidence-based tobacco prevention and control interventions. NDDoH awards grants to each of the four state tribes for their local Tribal Tobacco Prevention and Control Programs. Each agency, through its historical relationships, active outreach, and the Center’s SIG program, is connected to a network of partnerships. The program has the highest per capita tobacco prevention and control resources in the United States and has implemented iterative strategic planning documents to guide the program’s approach.
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The program’s infrastructure and capacity-building includes providing grantees with funding, guidance, training, and technical assistance to support their efforts. The Center provides quarterly training sessions for its grantees and ongoing technical assistance, both directly by Center staff and via contracts with other organizations. The Center also hosts monthly technical assistance conference calls with grantees. Materials from the Center’s grantee trainings illustrate that grantees were provided detailed resources and guidance on point of sale, tobacco tax, FDA regulation, evaluation, historical and pending legislation, and smoke- free multi-unit housing policy. NDDoH conducts regular in-person meetings and conference calls with grantees, as well as other communications on an as-needed basis.
Consistency with Best Practices This objective emphasizes effective infrastructure and capacity to implement evidence- based interventions for all North Dakotans, which is consistent with Best Practices. The program’s approach to this objective, as evidenced by state plan strategies and support for local grantees and partners, is also consistent with Best Practices. Given the challenges of policy advocacy work, it is especially important to continue to provide opportunities for grantees to build, practice, and strengthen their skills in mobilizing partners and effectively communicating with decision makers about policy change.
4.5.3 Sustain Program in Conformance with CDC Recommendations
Objective Progress
By June 30, 2016, sustain ND The North Dakota program is aligned comprehensive tobacco prevention and with the updated recommendations for control program in conformance with funding levels by component, even current CDC recommendations. though CDC released new recommendations during the 2013– 2015 biennium.
CDC Best Practices is nationally recognized as the principal resource for tobacco control programs. Best Practices offers guidance regarding evidence-based approaches and funding levels for state programs. This state plan objective, consistent with the program’s legislative mandate, states that the program will conform to CDC’s recommendations. As each objective’s consistency with Best Practices has been addressed in the preceding sections, this section specifically addresses the program’s funding level.
Activities and Progress This section describes how the program’s funding relates to current CDC recommendations. Notably, the most recent CDC recommendation was released after the current biennium’s budget was established. The program’s annual funding within the 2013–2015 biennium is $10,680,040. The program’s 2013-estimated CDC recommended funding (based on the 2007 CDC Best Practices, with adjustments for population changes and inflation) is
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$12,490,499. The 2014 CDC Best Practices recommendation is $10,113,034, based on per capita estimates multiplied by Census estimates of the state population. Although the new recommendation was released after North Dakota’s budget was established, we believe that it is most helpful to review the state’s funding in the context of the most updated recommendations to best inform future planning. Therefore, we present the updated CDC estimates below.
The 2014 CDC Best Practices document recommends that the North Dakota comprehensive tobacco control program spend $10.1 million annually on implementing an evidence-based approach. The funding is distributed across the five comprehensive program components in Best Practices: state and community interventions; mass-reach health communication interventions; cessation interventions; surveillance and evaluation; and infrastructure, administration, and management. The budget for the comprehensive program (combined Center and NDDoH budgets) is $21,360,079 for the biennium, representing 106% of the CDC-recommended amount (Table 8).
Table 8. CDC Tobacco Control Program Funding Recommendations and North Dakota Comprehensive Tobacco Prevention and Control Program Funding by Component, 2013–2015 Biennium
CDC Recommended NDDoH Center Component Allocation Funding Funding Total Administration $882,539 $415,461 $695,896 $1,111,357 State and community $7,653,498 $540,000 $5,978,379 $6,518,379 Health communication $2,691,022 $0 $2,103,504 $2,103,504 Cessation $7,233,930 $4,339,566 $5,662,073 $10,001,639 Surveillance and evaluation $1,765,079 $249,223 $1,375,976 $1,625,199 Total $20,226,068 $5,544,251 $15,815,828 $21,360,079
Sources: CDC, 2014; Center for Tobacco Prevention and Control Policy, 2015. Notes: CDC = Centers for Disease Control and Prevention; NDDoH = North Dakota Department of Health. Funding is allocated on a per-biennium basis.
Funding levels for the biennium vary by program component, based on the distribution of roles and responsibilities across the two agencies and the CDC recommendations per component (Figure 19). Overall, 31% of funding ($6.5 million) was allocated to state and community interventions, with the majority of these funds being expended by the Center on LPHU grants. The program spends 47% of its funding ($10 million) on cessation interventions, with the majority of these funds being expended by NDDoH on NDQuits services and promotion efforts, cessation programs, and NRT distribution. Health communication expenditures are comprised solely of Center antitobacco media campaigns and represent 10% of the total budget ($2.1 million). The program spends 8% ($1.6 million) on surveillance and evaluation and 5% ($1.1 million) on administration.
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Figure 19. CDC Tobacco Control Program Funding Recommendations and North Dakota Comprehensive Tobacco Prevention and Control Program Funding by Component, 2013–2015 Biennium
Note: CDC recommended allocations shown reference the updated recommendations published in 2014; the North Dakota allocation was determined in 2013 and adjusted in 2014 in response to the 2014 Best Practices.
Consistency with Best Practices The comprehensive program funding is slightly above the CDC-recommended level, making North Dakota one of only two U.S. states to achieve funding levels recommended by Best Practices. North Dakota spending on state and community interventions (31%) is less than the CDC-recommended level (38%), and North Dakota’s cessation allocation (47%) is greater than the CDC level (36%); other components are very similar. This is a result of basing allocations on the CDC 2007 Best Practice recommendations in FY 2014 and on the 2014 Best Practice recommendation in FY 2015.
5. TRENDS IN KEY TOBACCO USE OUTCOMES
Monitoring trends in key tobacco-related outcome measures in North Dakota helps inform the long-term impact of the program. These outcomes include adult smoking and tobacco use prevalence and quit attempts. Among youth, relevant outcomes include smoking prevalence and age of initiation.
Smoking prevalence among adults in North Dakota was 21.2% in 2013 (Figure 20). We estimate that the current smoking rate has remained unchanged in recent years. Official estimates from 2011 through 2013 from the Behavioral Risk Factor Surveillance System (BRFSS) cannot be compared to estimates from prior years due to changes in the sampling and weighting methodology implemented in 2011 (i.e., the inclusion of cell-phone-only respondents, which represent a growing proportion of the population, and updates to the weighting adjustment to make the dataset representative of the population). However, RTI prepared adjusted estimates for 2005 through 2010 by applying methodology similar to the 2011 BRFSS. These adjusted estimates provide what is more likely the adult smoking
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prevalence from 2005 through 2010. Among North Dakotans who smoke, 52.5% made a quit attempt in the past 12 months (data not shown).
Figure 20. Adult Smoking Prevalence in North Dakota, Official Estimates (BRFSS) and Adjusted Estimates, 2005–2013
Note: Official BRFSS estimates should not be directly compared between 2011 and earlier years, due to changes in methodology.
In 2012, North Dakota smokers reported smoking an average of 13.4 cigarettes per day. This translates to approximately two-thirds of a cigarette pack per day. Consumption rates have not changed significantly since 2009.
In 2013, 21.2% of North Dakota adults in the general population were current smokers, but prevalence rates vary by demographic characteristics. Some North Dakota population groups smoke at much higher rates than the general population. For example, based on BRFSS estimates pooled for 2011–2013, 53% of unemployed adults in North Dakota smoke, a rate more than twice that of the general population. Nearly half of American Indian adults in North Dakota smoke (48%), as well as 45% of uninsured adults and 41% of individuals with poor mental health (Figure 21). It is important to note that there is duplication across some of these demographic measures (i.e., some of the respondents who have low educational attainment and low income are likely also unemployed and/or uninsured and may be represented across these groups). Additionally, the proportion of North Dakota residents in each of these population groups varies considerably. For example, while smoking prevalence is high among the unemployed in North Dakota, the unemployed make up approximately 4% of North Dakota BRFSS respondents. However, analyzing prevalence
55 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium rates by demographic characteristics facilitates identification of groups disparately affected by tobacco use, even if they are not necessarily a large proportion of the state population, as recommended by CDC Best Practices.
Approximately 4.2% of North Dakota adults report using cigars and 6.4% report using smokeless tobacco, according to the 2012 North Dakota ATS. Although use of cigars and smokeless tobacco among North Dakota adults is lower than cigarette smoking, cigar use has remained unchanged in recent years, and smokeless tobacco use increased from 2010 to 2012.
E-cigarette use has been increasing in recent years, and CDC estimated that 2.6% of adults in the United States were current users of e-cigarettes in 2013 (King, Patel, Nguyen, & Dube, 2014). Although state-level data for adult use in North Dakota are not yet available from established surveys like the North Dakota ATS or BRFSS, RTI’s 2014 and 2015 telephone survey of North Dakota adults included questions about e-cigarette use. Current use of e-cigarettes by nonsmokers was 2.0% in 2014 and 1.7% in 2015. Among smokers, current use of e-cigarettes was 15.3% in 2014 and 24.0% in 2015. The health effects of e-cigarettes and their impact on smoking and tobacco use are not well known. As a result of their increasing use, it will be important for the program to continue to monitor their use and consider intervention approaches.
While tobacco use among North Dakota adults has remained steady, North Dakota’s Youth Risk Behavior Survey estimates that high school youth smoking prevalence has decreased significantly over the past decade and was 19.0% in 2013 (Figure 22). Following a similar pattern to national youth prevalence rates, the state experienced sharp declines from 1999 to 2005, followed by a leveling off.
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Figure 21. Adult Smoking Prevalence among Selected Groups with Prevalence Higher than the State Average in North Dakota, BRFSS 2011–2013
Note: Estimates represent pooled BRFSS data for 2011–2013, to ensure sufficient sample sizes.
Figure 22. High School Youth Smoking Prevalence, North Dakota and Nationally, YRBS 1999–2013
Source: YRBS.
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According to 2013 North Dakota YTS estimates, 24.2% of high school youth in North Dakota currently use any tobacco products, down from a peak of 33.9% in 2005 (Figure 23). Cigar and smokeless tobacco use have remained relatively flat, while cigarette use has declined. By comparison, 22.9% of high school youth nationally reported use of any tobacco in 2013.
Figure 23. Percentage of High School Students Who Currently Use Tobacco Products, ND YTS 2003–2013
Source. 2003–2011 estimates reported by Winkelman Consulting (2012). 2013 estimates provided by RTI International. a Any tobacco use includes cigarettes, spit (smokeless) tobacco, cigars, and bidis or kreteks as available for each year.
The percentage of high school youth who smoked a whole cigarette before age 13 has decreased significantly in North Dakota and the nation as a whole (Figure 24). Down from a peak of 25.4% in 2001, 7.9% of North Dakota high school youth in 2013 reported smoking a whole cigarette before age 13, similar to the national average of 9.3%.
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Figure 24. Percentage of High School Youth Who Smoked a Whole Cigarette before Age 13, North Dakota and Nationally, 1999–2013
50%
40%
30% 24.7% 25.4%
18.7% 17.3% 20% 22.0% 22.1% 13.8% 12.3% 18.3% 10.3% 16.0% 9.3% 10% 14.2% 10.7%
Smoking Smoking prevalence 8.6% 7.9% 0% 1999 2001 2003 2005 2007 2009 2011 2013
North Dakota National
Source: YRBS.
6. DISCUSSION
North Dakota’s comprehensive Tobacco Prevention and Control Program is tasked with implementing an evidence-based state plan to prevent tobacco use initiation, promote quitting, eliminate exposure to secondhand smoke, and maintain the infrastructure and multilevel capacity to support the program. Funded at CDC’s recommended level, the program has achieved significant successes in recent years, including the 2012 expansion of the statewide smoke-free air law. During the 2013–2015 biennium, the program has continued to work with grantees and partners to achieve its objectives.
Youth tobacco use prevalence has declined since 1999, and the percentage of youth who smoked a whole cigarette by age 13 has decreased. More K–12 students and staff and most college and university students, faculty, and staff in North Dakota are protected by tobacco- free or smoke-free campus policies. Grantees have increased the number of policies throughout the state focused on smoke-free multi-unit housing, tobacco-free outdoors, and restrictions related to e-cigarettes. In addition, more smokers are reporting that their health care providers referred them to cessation services.
The program’s work in North Dakota must continue in order to maintain improvements and improve outcomes further. Reaching objectives and achieving health outcomes will require additional policy and education efforts. Although the program has achieved successes, several outcome measures show room for improvement. Adult smoking prevalence has
59 Independent Review of North Dakota’s Comprehensive Plan for Tobacco Prevention and Control, 2013–2015 Biennium remained steady over the past several years, and smokeless tobacco use has increased. These measures highlight the need for continued interventions to prevent tobacco use initiation and promote cessation.
One of the cornerstone tobacco control interventions supported by evidence and recommended by CDC’s Best Practices is increasing the cost of tobacco products. Increasing the cigarette excise tax should continue to be a high priority for the North Dakota comprehensive program, given how low the tax currently is in North Dakota and the potential health and economic benefits to be realized. Two cigarette tax increase bills were proposed during the 2013–2015 biennium, and there is strong public support for increasing this tax. Additionally, in an audit report released in 2014, the Office of the State Auditor recommended that the program “request the Legislature to increase the cigarette tax to be in line with the national average” (Office of the State Auditor, 2014, p. 13). The program should continue to build partnerships and educate policy makers about the strong existing public support for a cigarette tax increase and the evidence surrounding the benefits of increasing the cost of tobacco.
Antitobacco media campaigns have proven effective at improving tobacco-related outcomes. Although the program’s media campaign continues to achieve high levels of audience reach and the program has adjusted to include ads that more strongly motivate tobacco users to quit, health communication campaigns could likely have a greater effect on outcomes if they used more hard-hitting, emotionally evocative ads focused on promoting tobacco cessation.
North Dakota’s statewide and community intervention component is large and complex and reaches into settings across the state. To track grantee activities and outcomes, the program maintains and updates data reporting systems. However, challenges with the current systems for tracking programmatic activities cloud the ability of the evaluation to document implementation of statewide and community interventions and the extent to which they are aligned with the comprehensive plan. Continued efforts to monitor and quantify grantee activity and progress meeting clearly identified targets will help the program maximize the efficiency and effectiveness of its efforts.
North Dakota’s comprehensive Tobacco Prevention and Control Program has implemented a range of evidence-based interventions and should continue its efforts. Continued implementation of the comprehensive plan, with adjustments to enhance the effectiveness and efficiency of the program, will reinforce a tobacco-free norm, reduce the economic toll of tobacco use, and improve the health and quality of life of North Dakotans.
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7. RECOMMENDATIONS
7.1 State and Community Recommendations . Continue to streamline the state plan. The program can assign clear, measurable targets for some objectives and consolidate some objectives. We suggest that future revisions eliminate objectives focused on preventing preemption and maintaining a program in conformance with CDC Best Practices. These aims are appropriate, but they may not need to be listed as discrete objectives.
. Continue to emphasize initiatives most likely to affect tobacco use behavior and ultimately prevalence rates, particularly educating about the benefits of a tax increase. CDC recommendations prioritize adequately funded programs, comprehensive smoke-free air laws, and tobacco pricing that discourages youth initiation. North Dakota has two of these three and should continue to collaborate with its grantees and partners to mobilize key stakeholders and highlight existing support. Activities during the 2013–2015 biennium that helped lead to the proposal of two separate bills can serve as a foundation for future efforts.
7.2 Mass-Reach Health Communication Recommendations . Continue to expand the incorporation of hard-hitting, emotionally evocative ads with graphic imagery or personal testimonials illustrating the negative health consequences of smoking into the health communication campaigns run by both agencies. Messages that elicit a strong emotional response have proven to produce stronger and more consistent effects on knowledge, beliefs and attitudes related to tobacco use, and cessation behaviors. In addition to impacting adult cessation, these types of ads have also been associated with prevention of smoking initiation among youth.
. Continue to adapt media plans collaboratively to meet the updated Best Practices recommendations regarding GRP levels and ad themes. Working together, the Center and NDDoH have achieved a more comprehensive media approach consistent with CDC recommendations.
7.3 Cessation Recommendations . Continue promoting health systems change via written policies and improvements in documentation and referral systems, supported by regular training of health care providers and staff.
. Advocate for tobacco-free campus policies at mental health and substance use treatment facilities, increase assessment of tobacco use, and integrate tobacco dependence treatment into treatment planning. Institutionalizing tobacco dependence treatment in these facilities will help tobacco dependence be treated in an integrated way, motivate quitting, provide treatment and supports for tobacco users, and change norms in these settings.
. Share cessation evaluation reports with the comprehensive program evaluator as they become available. Including timely data related to health systems change activities and other cessation efforts in comprehensive program evaluation reports will allow for a more holistic review of the program and its outcomes.
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7.4 Surveillance and Evaluation Recommendations . Continue to ensure that all media campaign efforts are evaluated. Especially as the program adjusts its media approach, evaluation allows for informative, actionable feedback.
. Implement evaluation-related strategies currently listed within the state plan, including updating the Surveillance and Evaluation Plan and establishing an expert evaluation committee.
. Recognize, assess, and address the impact of new and emerging products, such as e-cigarettes, on tobacco use in North Dakota.
7.5 Infrastructure, Administration, and Management Recommendations . Improve systems to track grantee activities and outcomes. Enhancing data reporting systems can ensure that data are collected in a standardized, efficient manner to minimize user burden; improve accountability; and facilitate data aggregation, grant monitoring, and evaluation efforts. We recommend implementing a more standardized way to measure funded efforts to change policies. The evaluation needs to be able to quantify efforts made, clearly identify targets reached, and track progress made over time to determine whether the program and its partners are making progress on these issues.
. Continue funding the comprehensive program at CDC Best Practices recommended levels.
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