Merging tobacco prevention and enforcement programs – 7/15/10

Q: A tobacco prevention and control colleague is looking at the pros and cons of combining the state tobacco education and prevention program and the enforcement of underage sales to minors program to fall under one. Do other states have separate or combined programs? Why or why not? Please share any thoughts and ideas surrounding this topic.

A:

1. Alabama: Alabama is undertaking a grand experiment now! We plan to use our Area Tobacco Control Coordinators to conduct all inspections NOT requiring the use of a minor. (That part we are subcontracting to our ABC Board.) We haven't done this before, and we are just now starting the program.
    
2. Arizona: Here in Arizona, we contract with the Attorney General’s Office for surveillance and enforcement of sales to minors, and collaborate with SmokeFree Arizona (a division of the Arizona Dept of Health Services), to enforce smokefree laws, follow through on complaints, etc. With regards to the FDA regulatory duties, the Arizona Dept of Health Services has applied for a grant under our SmokeFree Arizona division.
    
   The rationale for such separation is both practical and philosophical. Simply put, enforcement duties would be a distraction to our education and prevention duties, as they require dramatically different strategic directions, staffing, etc. It’s important to note that in addition to tobacco prevention/cessation, we also oversee the prevention and management of chronic disease (i.e. heart, lung, cancer, stroke, diabetes, asthma), and men’s health issues, all of which are integrated into a coherent whole. Thus, while we collaborate with the enforcement folks, the nature and degree of that work is too far afield, and deserves its own focus.
    
   On a similar, albeit more philosophical note, we lean toward a compassionate view of tobacco use and other entrenched behaviors that render people at risk for chronic disease and economic disadvantage, whereas the enforcement side must necessarily remain vigilant and, when necessary, litigious.
    
3. Hawaii: It has been the experience in Hawaii that having the Synar and monthly tobacco retailer inspections, which are under the Alcohol and Drug Abuse Division (ADAD), whose funding is directly linked to Synar, has been a useful partnership between the two different parts of the Hawaii State Department of Health. The Tobacco Prevention & Education Program (TPEP) is part of the Chronic Disease Management & Control Branch which is separate and distinct from ADAD. There was some discussion many years ago when Synar was new of the benefits and liabilities of having all tobacco functions under a single unit, but it was decided to keep it separate. This has worked well for us and for the tobacco issue in DOH, especially when times are tough and having multiple, well-functioning partners brings more support to the table.
    
4. Massachusetts: In Massachusetts, the state level tobacco education and prevention program includes the enforcement of underage sales to minors. The benefit of having the education and prevention program and the enforcement programs under one umbrella provides continuity to the work that is done at the community level. Currently, our enforcement is contracted primarily through local boards of health. The local staff are able to act as community educators for retailers, local officials and other community members as well as enforcement agents.
    
   Having the two functions housed together at the state level facilitates things such as policy work and data collection. This avoids the duplication of efforts. In addition, with the funding primarily out of one agency, it is easier to combine these efforts.
    
5. New Hampshire: New Hampshire is in the process of attempting to coordinate those functions mentioned under a unified plan known as PYATT (Preventing Youth Access To Tobacco, but each function is still the prime domain of different agencies - The Substance Abuse SSA for Synar, the Bureau of Liquor Enforcement for enforcement, and the NH Tobacco Prevention and Control Program for tobacco education and prevention. This is by statute, and by funding source. The PYATT doesn't attempt to over-ride that; rather, it seeks to take advantage of the expertise in each area through a theory of action that goes roughly like this:
   • Decreased access to tobacco will lead to decreased incidence
   • Decreased incidence will lead to decreased use
   • Decreased use will lead to decreased dependency.
      
6. Washington: Our state has a merged tobacco enforcement and prevention program. The Washington State Department of Health Tobacco Prevention and Control Program originally was funded to do youth access activities including compliance checks and retailer education as a fund from tobacco retailer licenses was set up in the early 1990’s prior to the Synar amendment. After the Master Settlement, the program received additional funding from the state to implement a comprehensive program that is outlined in our strategic plan. That plan has the four major components:
    
   1. Identify and eliminate tobacco related disparities
   2. Prevent youth from beginning to use tobacco
   3. Increase quitting among tobacco users
   4. Eliminate exposure to secondhand smoke
       
   The prevention goal has four associated strategies:
    
   1. Increase health knowledge, beliefs, and skills among youth, families, and communities
   2. Promote development of tobacco-free environments for youth and young adults
   3. Decrease youth access to all tobacco products
   4. Raise awareness of the relationship between youth tobacco use and other unhealthy behaviors
       
   The second prevention strategy in our strategic plan is where the compliance checks and retailer education fits currently.
    
   Under Washington state statute, we contract with local health jurisdictions and the Liquor Control Board to do this work. Our program creates the randomized Synar list and aggregates the data into the format required for submission to the Center for Substance Abuse Prevention (CSAP). It is then sent to the state’s Single State Authority, which is the Division of Behavioral Health and Recovery (the drug and alcohol/mental health agency) who submits the Synar report to CSAP.
    
   This model has worked well in our state for more than a decade despite the logistical challenges of coordinating across three state agencies and 35 local health jurisdictions. We view enforcement of both the youth access and secondhand smoke laws to be an integral part of our efforts to reduce the public health impacts from tobacco.
    
7. Wisconsin: The Wisconsin Tobacco Prevention and Control Program (TPCP) has been responsible for management of the Synar program since 2003. Prior to 2003, the responsibilities were with Wisconsin’s Bureau of Mental Health and Substance Abuse. The decision to integrate Synar efforts into the TPCP was made because decreasing youth access to tobacco is part of, and enhances, a comprehensive tobacco control program. The relationships established during compliance checks and education of tobacco retailers has been helpful for other Wisconsin TPCP initiatives. For example with the new FDA legislation, the TPCP had easy access to the list of Wisconsin retailers and was able to notify the retailers, provide training and technical assistance and respond to questions regarding the upcoming changes. In addition, during implementation efforts for Wisconsin’s smoke-free air law, local contractors and coalition were able to utilize relationships they’d built with retailers to educate them on the law, identify media and community spokespeople and garner support.
    
8. West Virginia: The West Virginia Division of Tobacco Prevention does NOT have combined retailer enforcement and tobacco prevention programs.

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