Q: Break Free Alliance is a national network funded by CDC/OSH to reduce the burden of tobacco use in low socioeconomic status (SES) populations. We are directing more efforts into assisting state and territorial tobacco control programs with addressing Goal Area Four of CDC’s comprehensive tobacco control program strategy and the social determinants of health. We are trying to assess the need for services and technical assistance so that we may better assist individual states but also develop a more comprehensive, national strategy to reduce prevalence rates in the specific populations identified.
 
Please share a copy of your state’s action plan, if available. Does the plan include outreach to the following populations?

1. Incarcerated,
2. Homeless,
3. And/or those with behavioral health issues (mentally ill, substance abusing populations)?

If so, what policies/strategies is your state implementing to reach these populations?

A:

1. Mississippi: Even though individuals with disabilities are not specifically listed in this request, the Tobacco Control Strategies for Mississippians with Disabilities project may be of interest to some network members who are working in the social determinants of health area.
    
   This project is sponsored by the Mississippi State Department of Health, Office of Tobacco Control. We conducted outreach to smokers with disabilities across Mississippi to get baseline information (Phase I) on some major interest and critical issue areas, and based on the findings we will set “evidence-based” strategies specifically targeting this population (Phase II) on tobacco cessation. Currently, we have completed the Phase I study, and are implementing Phase II of the project. For an overview of the project, see the attached poster presentation.
    
   More detailed information, including findings and data, is available in our project report posted here.
    
2. Oklahoma: Our state’s action plan is available here. The State Plan is currently being updated.
    
   Outreach efforts:
    
   1. Incarcerated:
       
      1. OSDH staff have been in communication with Department of Correction staff at various levels to discuss ways to meet immediate cessation needs of the incarcerated population. These discussions have involved ways to access NRT, access to the Oklahoma Tobacco Helpline and technical assistance to discover evidence based cessation programs. All of these issues are currently in the discussion and research stage. One issue is the question of whether NRT will be allowed shipment within the facility and what access the population will have to the individual counseling and support.
      2. OSDH staff have participated on the Break Free Alliance webinars, discussing working with correctional facilities and will be utilizing resources from that group.
          
   2. Homeless:
       
      1. This population has been discussed within the hospital system implementation process and what is the best option available to work with them. No specific plan is in place.
      2. OSDH staff has utilized the BFA guide “Addressing Tobacco Use in Homeless Populations”
          
   3. Those with behavioral health issues (mentally ill, substance abusing populations):
       
      1. Oklahoma Department of Mental Health and Substance Abuse:
      2. Substance Abuse & Mental Health divisions are working together to implement policy change within ODMHSAS system.
         1. Working to assist contract providers in enforcing tobacco free policies.
         2. Working to implement tobacco cessation counseling within provider’s standard treatment plans.
             
   4. Policies/strategies to reach those with behavioral health issues (mentally ill, substance abusing populations):
       
      1. Providing education on “nicotine dependence” as a recognized addiction.
      2. CMHC electronic medical record (EMR) systems are being evaluated for use in tracking cessation related services. Wherever possible, procedures for tracking services through the EMR will be standardized across CMHC’s.
      3. OHCA has agreed to allow physicians to utilize the 5-As codes for non-Medicaid clients, for which ODMHSAS will reimburse providers. ODMHSAS is working with the Oklahoma Health Care Authority to add tobacco-specific wellness and rehabilitation codes for providers to utilize when performing wellness related services specific to tobacco use.
      4. Revised contract language for all ODMHSAS treatment providers to reiterate that facilities are required to have tobacco-free campuses and to include tobacco cessation as a treatment issue.
      5. ODMHSAS was notified by SAMHSA (in partnership with the Smoking Cessation Leadership Center) that Oklahoma has been chosen as one of five states to host a Leadership Academy for Wellness and Smoking Cessation. The goal of the Academies is to reduce smoking and nicotine addiction among behavioral health consumers and staff and to create an environment of cooperation and collaboration among the fields of public health, (including tobacco cessation), mental health and substance use prevention and treatment that will serve to improve wellness among behavioral health consumers.
          
3. Oregon: Oregon was awarded a 2-year ARRA grant to address tobacco disparities. The Tobacco Control Integration Project (TCIP) was created with this funding.
    
   In Oregon, people with lower incomes and lower education levels smoke at more than three times the rate of those with greater resources. TCIP is taking a comprehensive and collaborative approach to reducing this tobacco-use disparity by advancing policies and systems changes at the service-delivery level. TCIP brings what the state's Tobacco Prevention and Education Program (TPEP) knows about tobacco control to the Oregonians who need it most.
    
   In partnership with TPEP, Oregon Health Authority (OHA) and Oregon's Department of Human Services (DHS), TCIP integrates comprehensive tobacco control initiatives into the health and human services provided by DHS/OHA.
    
   TCIP reaches approximately half of all tobacco users in the state through policy changes to reduce exposure to second-hand smoke; procedural changes to ensure that all DHS clients have direct access to smoking cessation resources; and messaging specifically addressing DHS/OHA clients. TCIP objectives also include a counter-advertising campaign and support of a policy proposal to raise tobacco prices in Oregon. TCIP's grant application (available from the TCN upon request) includes Implementation Objectives.
    
   As a result of the collaborative work TCIP has undertaken, several policies have been implemented and/or will be implemented in 2012. These are:
    
   • Tobacco-free grounds for all addictions and mental health residential treatment facilities that are licensed and funded by the State Division of Addictions and Mental Health. There are approximately 268 of these facilities.
      
   • A policy that requires the inclusion of tobacco cessation treatment as part of the addictions and mental health treatment plan for residents of above facilities.
      
   • A policy is in place to systemically promote tobacco cessation benefits, resources and supports to homecare workers. Homecare workers provide care to clients with disabilities in their own home. Homecare workers have a high rate of smoking.
      
   • TCIP and the agency that administers Oregon Medicaid developed Tobacco Cessation Minimum Standards of Service (TCMSS) for contracted Managed Care Organizations (MCOs) who serve the Medicaid population here in Oregon.
      
   • TCIP is working with the Public Health Division Wellness committee Initiative and has partnered with the Department of Administrative Assistance (DAS) to implement a tobacco-free grounds policy at the Portland Office State Building this coming October. This building is open to the public and houses approximately 1000 state employees.
      
   • TCIP, in partnership with the Seniors and People with Disability Division (SPD), is creating strategies to connect the clients they serve to tobacco cessation resources and support and exploring a tobacco-free grounds policy for Adult Foster Homes and Nursing, Memory Care, Assisted Living and Residential Care facilities.
      
4. Palau: Palau is one of the territories that just passed comprehensive tobacco legislation. We do not have a state plan yet, however, the Tobacco Prevention and Control Program is a sister program to the Community Guidance Center, both of which are housed under the Division of Behavioral Health. Because our population is small, all of our services are integrated. There is daily service at the only jail in Palau; this is in partnership with the faith based organizations. Rehabilitation, 12-step, and AA are part of the ongoing service. Our cessation services are still in early development. We have trained providers in the 5 A's and are currently developing protocols. We don't have NRTs on island and are looking for creative ways of procuring them as we have no funds for these and the stores don't want to sell them because no one can afford to purchase them. By U.S. standards, Palau is impoverished, and wages/salaries can't keep up with the paradise taxes.
    
5. Vermont: Please see our disparities strategic plan, “Bridging the Gap: Partnering to Address Tobacco Disparities in Vermont.”
    
6. Washington: The Washington State Tobacco Prevention and Control Program’s 5-Year Strategic Plan prioritizes disparities. The plan is online here.
    
   We have used CPPW money to train substance abuse and mental health clinics and provide on-site technical assistance so they can screen and treat/refer for tobacco addiction. We also encourage them to have tobacco free campuses to support recovery.
   We are also working with the Division of Behavioral Health and Recovery to get an administrative rule requiring the above objectives. DBHR has a webpage devoted to our Tobacco Free Treatment Initiative.
    
   Before we lost our funding from the state, we also had contracts with five agencies to address tobacco use in priority populations including:
    
   1. Low income
   2. Asian Pacific Islander
   3. Urban Indian
   4. African American
   5. Hispanic/Latino
   6. Gay/Lesbian/Bisexual/Transgender/Questioning
    
   We also contracted with almost all of the 29 federally recognized tribes in the state borders.
    
   Unfortunately we don’t have funding for any of these contracts this year except the Low income population contractor that we are focusing on creating non-smoking policies in publicly and privately owned multi-unit housing www.smokefreewashington.com. We are also contracting with the American Indian Health Commission this year to encourage tribes to develop policy interventions. Most tribes receive funding from gaming proceeds as a requirement of the most recent state gaming compact. Many tribes use this funding to do cessation and prevention work.

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Additional Resources:

• Listing of State & Territory Tobacco Control Strategic Plans (ASTHO)
   
• Listing of State & Territory Tobacco Disparities Strategic Plans and Case Studies (TCN website)

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