1. Public Health Efforts to Decrease Smoking in California
August 7, 2015
While there is literally decades of research and volumes of articles that document health disparities and the importance of social determinants of health, much of the work is unfamiliar to those outside academic circles, public health and related fields. This is especially true for the private and public sector decision makers with authority to make change.
Tonya Gorham Gallow, M.S.W.
Cynthia Song Mayeda, RN, PHN, BSN
Los Angeles County Department of Public Health
Division of Chronic Disease and Injury Prevention
Tobacco Control and Prevention Program

2. Presentation Overview
Define social determinants of health and interventions to reach Healthy People 2020 goals.
Examine tobacco use and intervention to decrease smoking prevalence.
Discuss Los Angeles County efforts to decrease smoking in substance abuse and behavioral health communities.
So, today we are going to talk about the social determinants of health and health equity as it relates to our efforts in public health and our work in tobacco control and prevention program. First, let start by saying that we recognize that the causes of health inequities are complex and deep rooted. And that righting these inequities is a matter of social justice that is much bigger beyond our program, department and this county. And that changing the social determinants of health and health equity is a long-term agenda requiring sustained support and investment. But in order for the department to affect change, we need first to learn more about the issues, invest in more research, and bring together different disciplines and areas of expertise to work out how social determinants of health, and how we can action to create better health.

3. Health
“The presence of physical, psychological, social, economic and spiritual well being not merely the absence of disease or infirmity”
“The maintenance of a harmonious balance between mind body and spirit “
Read slide…
We must stop thinking of health as something we get at the doctor’s office, but instead as something that starts in our families, in our schools and workplaces, in our playgrounds and parks, in the air that we breathe and the water we drink.
But health arises not just from a doctor’s office, but also from our homes, jobs, schools, communities, and places of worship—in short, where we live, labor, learn, play, and pray. All of these conditions determine whether we can fully be healthy, defined by the World Health Organization as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” While some Americans meet this standard, far too many fall short. Disturbingly, many cannot reach their full potential because of the conditions in which we live and work have an enormous impact on our health, long before we ever see a doctor. Such situations limit opportunities for good health choices.
Addressing these health disparities requires first a better understanding of measures representing social, economic, educational, environmental, policy-oriented, cultural, and even spiritual dimensions of health.
The Troutman Group

4. Health Equity
“Health equity is the realization by ALL people of the highest attainable level of health.  Achieving health equity requires valuing all individuals and populations equally, and entails focused and ongoing societal efforts to address avoidable inequalities by assuring the conditions for optimal health for all groups, particularly for those who have experienced historical or contemporary injustices or socioeconomic disadvantage.”
The Troutman Group

5. Healthy People 2020
An overarching goal of Healthy People 2020 is to ‘create social and physical environments that promote good health for all.’
HP 2020 recognizes that social determinants influence population heath and limit the ability of many to achieve health equity.
Also, the recently unveiled goals and objectives of Healthy People 2020 for the first time have identified the social determinants as one of its 42 topic areas.
Healthy People 2020 highlights the importance of addressing the social determinants of health by including “Create social and physical environments that promote good health for all” as one of the four overarching goals for the decade. This emphasis is shared by the World Health Organization, whose Commission on Social Determinants of Health in 2008 published the report, Closing the gap in a generation: Health equity through action on the social determinants of health. The emphasis is also shared by other U.S. health initiatives such as the National Partnership for Action to End Health Disparities and the National Prevention and Health Promotion Strategy.
In joining time-honored topic areas such as tobacco use and immunization, social determinants outcomes over the next decade move us closer to assessing the foundations of health, not just disease.
The Social Determinants of Health topic area within Healthy People 2020 is designed to identify ways to create social and physical environments that promote good health for all. All Americans deserve an equal opportunity to make the choices that lead to good health. But to ensure that all Americans have that opportunity, advances are needed not only in health care but also in fields such as education, childcare, housing, business, law, media, community planning, transportation, and agriculture. Making these advances would involve working together to:
Explore how programs, practices, and policies in these areas affect the health of individuals, families, and communities.
Establish common goals, complementary roles, and ongoing constructive relationships between the health sector and these areas.
Maximize opportunities for collaboration among Federal-, state-, and local-level partners related to social determinants of health.
The other three overarching goals are:
Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
Achieve health equity, eliminate disparities, and improve the health of all groups. Promote quality of life, healthy development, and healthy behaviors across all life stages.
Koh, H., Pitrowski J., Kumanyika S., Fielding J. Healthy People: A 2020 Vision for the Social Determinants Approach. Health Education & Behavior, Dec 2011, 38(6)

6. Key Social Determinants
Income and Poverty
Education and Employment
Housing
Communication Environment
Community/Place
The opportunity for health begins in our families, neighborhoods, schools, and jobs.

7. Assessment, Monitoring, Evaluation & Dissemination
Action Model to Achieve Healthy People 2020 Overarching Goals
Determinants of Health
Outcomes
Behavioral
outcomes
Specific risk factors,
diseases, & conditions
Injuries
Well-being & health-related Quality of Life
Health equity
Interventions
Policies
Programs
Information
Assessment, Monitoring, Evaluation & Dissemination

8. Impact of Tobacco Use in L.A. County
Just under 1 million adults still smoke.
Each year, 1 out of every 7 deaths is caused by cigarette smoking.
Smoking costs more than $4.3 billion dollars per year:
$2.3 billion direct medical costs
$2.0 billion indirect costs (lost productivity).
More than 500,000 non-smoking adults and children are exposed to secondhand smoke.
Top 5 causes of death are associated with tobacco use.
It is a risk factor for four of the five leading causes of death: cardiovascular disease, stroke, lung cancer, and emphysema/COPD. In Los Angeles County, tobacco use is directly linked to the top five causes of death: 14.6% of coronary heart disease, 9.3% of stroke, 77% of respiratory (lung/tracheal/bronchial) cancer, 14.7% of pneumonia, and 85.2% of emphysema deaths. One out of every seven deaths (8,500 deaths per year) in Los Angeles County stem from these tobacco-related diseases. In addition, smoking during pregnancy is associated with miscarriage, Sudden Infant Death Syndrome (SIDS), complications of pregnancy and delivery, premature birth, and low infant birth weight. It is estimated that tobacco-related illnesses cost the county $4.3 billion dollars per year, of which $2.3 billion is for direct healthcare expenditures.
Tobacco use is associated with the top five leading causes of death in LA County including heart disease, stroke, lung cancer, and emphysema/COPD. These diseases are responsible for nearly half of all deaths in LA County.
COPD = Chronic obstructive pulmonary disease, involving constriction of the airways and difficulty or discomfort in breathing.

9. Smoking Prevalence Among Los Angeles County Adults, 2011
Healthy People 2020 Goal
(12%)
Smoking rate per service planning area in Los Angeles County compared to the Healthy People 2020 goal of 12.0 percent
Despite impressive declines in the number of people in Los Angeles County who smoke (now at 13.2%), certain vulnerable populations have not benefitted from tobacco control efforts, continue to smoke at alarmingly high rates, and are suffering grievous consequences. We have had a 1.1% drop in prevalence rate from 14.3 since 2007.
(LA County prevalence is at 14.3%, with cities ranging from 5.3% to 21.9% (2007).)
Tobacco use remains the single most preventable cause of death, responsible for more than 440,000 deaths per year in the United States.
By the year 2030, an estimated 10 million annual deaths will occur worldwide due to tobacco.
There are 50,000 deaths every year in the United States due to second hand smoke exposure alone.

10. Los Angeles Tobacco Control and Prevention Program
We aim to lower tobacco related death, disease and disability in Los Angeles County with by reducing smoking prevalence and exposure to secondhand smoke, especially among vulnerable populations
Approach: Change the social norms of communities.
Create a social and legal climate where tobacco is less
desirable, less acceptable and less accessible.
The mission of the Coalition for a Tobacco Free LA County is to empower and mobilize communities to reduce tobacco-related death and disease throughout the County. The goals of the Coalition are to advocate for progressive tobacco control issues, policies, and actions within Los Angeles County; to mobilize the talents and resources of individuals, groups, and agencies to create a critical mass for promoting tobacco control efforts and strategies; to demonstrate widespread public support for tobacco control issues and actions, and address unmet needs; to collaborate with, advise and support the Tobacco Control and Prevention Program and to assist on high priority issues/projects; and to act as a spokesgroup regarding tobacco control issues within the community.
All residents and organizations within Los Angeles County and its surrounding areas that share the Coalition's mission and goals are invited to attend and contribute.
Smoking is the leading cause of preventable death in the US (443,000 death/year)
Achieve social norm change through the enactment of tobacco control policies (e.g., laws)

12. Tobacco-Free Champions Initiative
Project Director for the Tobacco Free Champions Initiative.
The focus of this project was to change organization culture through policy

13. Tobacco-Free Champions Initiative Background
Start: November 2013; Ending September 2014
Established a Partnership with Smoking Cessation Leadership Center (SCLC)
Community Transformation Grant - Choose Health LA Tobacco-Free Living objective
Establish systems, procedures, and protocols to reduce exposure to second-hand smoke among vulnerable populations
Smoking Cessation Leadership Center were and are our subject matter experts.
The objective for this project is to:
Establish systems, procedures, and protocols to reduce exposure to second-hand smoke among vulnerable populations.

14. Tobacco-Free Champions Initiative Determining Criteria
Tobacco Cessation and Behavioral Health Community
Persons with Addictions and Mental Illnesses:
Have a smoking rate of over 40%, 2x higher
Are nicotine dependent at rates of 2-3x higher
Account for 200,000 of the 435,000 annual tobacco-related deaths
Die from tobacco-related illness more than half of the time
Consume roughly 45% of ALL cigarettes smoked in the US

15. LA Pioneers Evaluation Areas for Improvement
CTG
Vulnerable Populations
Behavioral Health Community
Integrate Tobacco Cessation into the Care and Treatment Of Inpatients and Outpatients.
Routine nicotine screening assessments
(Ask, Advise, Refer)
and follow-up processes
Tobacco Free Environment Policy
Tobacco Cessation Promotion
LA Pioneers Evaluation
Areas for Improvement
More Funding
More technical assistance
More in-person training
Build support systems for agencies
Less monthly phone calls
Extend time length of program
Key Facilitators
Management buy-in
Staff buy-in
Project champion
Organizational Culture Change
Lowered Consumption
Increased Cessation
Reduced Secondhand Smoke Exposure

16. Tobacco-Free Champions
Program Overview
Tobacco-Free Champions
9-month project
$25,000 – RFP process
In-person Orientation Webinar
3 in-person Webinars
3 Skills-Building Workshops
3 Site Visits
Technical Assistance
Telephonically and in person
Subject Matter Experts, project specialists, and other resources
LA Pioneers
6-month project
$5,000 mini-grants
Orientation Webinar
3 Webinars
Monthly conference calls
2 Site Visits
Technical Assistance
Telephonically
Subject Matter Experts, project specialists, and other resources

17. Barriers and Challenges to Tobacco Cessation
Myths and Beliefs
“Clients cannot quit smoking without jeopardizing sobriety or maintaining stability of mental health.”
“Smoking is the lesser of 2 evils.”
“Patients and staff don’t want to quit.”
“We’ll lose patients and money.”
“Staff will leave if they can’t smoke.”
What were the barriers?
What had we learned from our previous work?
What were we hearing about in the community?
What were the Champions saying?
What were some of the myths and barriers?

18. Barriers and Challenges to Tobacco Cessation
Infrastructure Challenges
Limited or No Management/Staff Support
Limited or No Existing Policies and Procedures
Limited or No Enforcement
Knowledge Gaps
Sadly, we didn’t have to overcome ONLY myths and beliefs.
We had significant infrastructure challenges that slowed down and even temporarily stopped tobacco cessation work.
One thing that we knew was that there were many common infrastructure challenges that were being encountered in organizations in this community.
These infrastructure challenges are:
Knowledge gaps were the driving force in perpetuating common myths and beliefts

19. Needs Assessment Explore what is current state.
Assess commitment of management, staff, clients.
Identify key decision makers and determine which decision makers would follow up on findings.
Identify data resources to provide best information.
Since we already knew about the commonly held myths, beliefs and infrastructure challenges, we were able to perform a needs assessment to validate or to invalidate known challenges and to identify other challenges that were unique to that particular organization.
Because each organization was unique, we knew that there would be:
Different needs/performance gaps,
Different causes for those needs or performance gaps AND
Different priorities of those needs.
The first step of the needs assessment was to explore and to identify current state.
We did this by:
Assessing the commitment of management, staff, clients to our tobacco cessation efforts. We did this using pre-surveys, staff interviews, and site visits
Identifying who the key decision makers were and which key decision maker would be responsible for our tobacco cessation effort; and
Identifying data resources to provide best information. Critical data resources were staff. Staff became our angels of information and champions for our work.

20. Jobs grouped by function And geography Line and Staff Relationships
Organization 1
Organization 2
Size
Large
Small
Work Specialization
Single Task
Multi Tasks
Departmentalization
Jobs grouped by function
And geography
Line and Staff Relationships
Line function (Core)
Staff Function (Support)
Line Function (Core)
Staff function (Support)
Shared
Authority Hierarchy
Chain of Command
Formal Line of authority
Formal and Informal lines of authority
Decision Making Responsibilities
Centralized
Organization maintains control and decision making responsibilities near the top of the company.
Decentralized
Decision-making shared with lower level manager and non-managerial employees.
The next step in this process was to understand the organization structure. We had to learn the organization structure so that we could put together a strategy that would work with that particular organization.
Like people, each organization has a unique personality.
The organizition that we worked with in the Champions Initiative are identified as
Organization 1 and
Organization 2 .
Organization Characteristics Defined
Size:
Large versus small
Several Locations
Employee Numbers
Work Specialization
Labor division-Tasks are broken down into individual jobs.
Departmentalization
Functional Jobs, Grouped by function (Marketing, Sales)
Divisional –Jobs grouped by geography
Line and Staff Relationships - Describe how people are involved in the organization
“Line Function”–Directly advances an organization iin its core work.
“Staff function’-Supports the organization with specialized advisory and support functions.
Authority Hierarchy/Chain of Command
Formal-Line of Authority
Informal-Line of Authority
Decision Making
Decentralized –Decision making responsiblities is spread to lower –level managers and non-managerial employee.
Centralized-Organization maintains control and decision –making responsibilities near the top of the company.
This organizational picture helped us to strategize how we would within the organizational structure more effectively.

21. Staff Characteristics
Gender
Race
Age
Education
Smoking Cessation Knowledge Base
Percentage of Smokers/”On the Job” Smoking Habits
Licensed/Unlicensed Staff
Total Number of Employees at Site
Staff Turnover Rate
So now we need to knnow about the people in the organization. Who were the staff and clients that we were going to work with.
We looked at staff characteristics.

22. Client Characteristics
Gender
Race
Age
Education
Smoking Cessation Knowledge Base
6. Number of Smokers/ Smoking Habits
7. Insurance Coverage (Type, Pending)
We also needed to know who the clients were who were being provided service.
The client characteristics are:
Insurance coverage is important to us as it helps us to identify resources that are available to them

23. Infrastructure Characteristics
Tobacco Cessation Policies and Protocols
2. Enforcement Policies
Site Environment
Client Care Access
Periodic Policy Review and Revision Process
We also had to look at infrastructure characteristics within the organization.
We had to find out where we needed to start.
So, we looked at the following infrastructure components: 1. 2.
Site Environment-Second hand Smoke Exposure, Smoking and Non-Smoking Areas, No Smoking signage, external and internal physical lay our etc)
Client care access
Now that we had collected all this data, we now had
The organization big picture,
Staff and Clients characterstics, and
Infrastructure supports and weaknesses.

24. Needs Assessment
Gather and analyze information to define current state and to compare to desired state.
Identify needs/gaps and their causes.
Identify any potential and actual barriers and challenges to attaining desired outcomes.
So now that we had our data from our surveys, site visits and interviews, we came back together to
Identify gaps and their root causes
Identify any potential and actual barriers and challenge to attaining desired outcomes.
We had clearly defined performance gaps and processes that need to be in place.
Now, we were able to move forward with strategies that were tailored to meet the needs of the organization.

25. Organizational Change
1. Get Buy-in
Educate, educate, educate
“Bust the myths”
“Tackle the challenges”
Network and participate within the community, professional organizations and local/national forums
Precontemplation
So what were the first steps.
We had to get “Buy In”.
In order to get buy in, we had to know our organizational structure to that we knew WHO and how we needed to get our message across.
Remember, we need Management and staff buy in to move forward and to maintain our momentum.
Organizations were encouraged to network and participate within their community, professional organizations and local/ national forums.
We wanted organizations to be exposed to current professional practice standards from a variety of resources.

26. Organizational Change
2. Getting the Organization Ready……
Organization plans to implement a tobacco-
free plan over the next 6-12 months.
Create a tobacco-free committee within agency.
Gather information from staff and clients.
Contemplation/ Planning
Now we needed to move forward to plan.
First Step was:
Create a tobacco free committee within the agency
Gather information from staff and clients through informal town hall meetings or through formal focus groups.

27. Organizational Change
3. Implement plan
Develop and implement written policy.
Develop method to enforce written policy.
Identify services that will help staff and clients beat the nicotine cravings to get through each day and to change behavior.
Educate, Educate, Educate.
Preparation
Tobacco Free Environment Policy
Tobacco Cessation Program

28. Organizational Change
4. Tobacco-free plan has been deployed
less than 6 months
Announce a tobacco-free date
Publicize the final tobacco-free date to staff and clients
Action
Next steps are to:
Announce a specific tobacco-free date.
Publicize widely the final tobacco-free date to staff and clients.
We had our first tobacco free kick off event at organization,
We had buy in from staff and management at a facility where there was no buy in.
Staff had integrated the message of a tobacco free facility into the organizational culture. Attitudes changed.
What worked, Lots of education. Networking with colleagues who believed in what we were trying to accomplish.

29. Organizational Change
5. Evaluating our progress…..
Tobacco-free plan has been deployed
more than 6 months
Evaluate policy and procedure efficacy
Revise policy and procedure based upon evaluation findings
Educate, Educate, Educate
In order to maintain our momentum and to sustain organizational change we had to continue to
EVALUATE OUR PROGRESS.
Educate and mentor management, staff and clients.
Maintaining our momentum is the last but most important step in our work.

30. Tobacco-Free Champions Initiative
Next Steps……….
Continue to evaluate progress and revise policy and strategies to integrate and to entrench smoking cessation programs and tobacco free policies into the organizational culture.

31. Additional Resources
Behavioral Health and Wellness Program, Mental Health Provider Toolkit
The Smoking Cessation Leadership Center
Centers for Disease Control and Prevention
U.S. Surgeon General
Partnership to Help Pregnant Smokers Quit
Tobacco Cessation Leadership Network

32. Thank you!
Contact Information:
Tonya Gorham Gallow, MSW
(213)
Cindy Song Mayeda, RN, PHN, BSN
(213)