NEEDS ASSESSMENT – NARRATIVE FORM

Coalition Name: UNIDAD Tobacco Prevention & Control Coalition

Contractor Name: Behavioral Health Solutions of South Texas

Contract Number: 2014-045454

Submission Date: July 10, 2014

Epi Work Group Members: Gilda Bowen, TPCC CoordinatorMartin Castaneda, TPCC ChairBerta Cavazos, DSHS Regional TPCC CoordinatorLisa Garza, School NurseStephanie Segura, Juvenile Probation (Intern)

Contract Evaluators: Terry TutchingsSandra EamesPaul Golliher

Part I-Geographic/Target Population

The targeted geographic area (Hidalgo County) is found in the Lower Rio Grande Valley; the area borders the Mexico/Texas international border and in land miles is approximately 1,570 square miles. The area is often referred to as the McAllen, Edinburg, and Mission, Texas metro area and includes zip codes 78563, 78572 and 8 more. Given the close proximity to Mexico where tobacco products are considerably less expensive and there are no age restrictions on the purchasing of tobacco products, youths in this target area are considered high risk due to the great availability of tobacco products from across the Texas-Mexico border.

During the 2013 needs assessment process, Behavioral Health Solutions of South Texas (BHSST) determined a need for prevention efforts related to tobacco use, secondhand smoke, and related fatalities in the Hidalgo and surrounding county area. The city of Edinburg located in Hidalgo County has been designated as the target area for these prevention activities. Rapid population growth, relatively low levels of educational attainment, a high rate of poverty, limited higher education opportunity, accessibility of tobacco products, low perception of harm, and a population whose norms condone the use of tobacco products are some of the intervening variables that make the city of Edinburg the focal point for transformation to healthier communities

The United States (U.S.) Census Bureau in 2013, estimated the ethnic percentages for Hidalgo County at having a higher than Texas average of Hispanic or Latino and foreign born persons. The target area also has a lower than state average of median household income and high school graduates. Research has found that differences in health status among ethnic and racial groups, if left unattended, will potentially show a magnified impact as the ethnic and racial diversity of the population as a whole continues to increase. Immunization rates, infant mortality, coronary heart disease, cancer, obesity, diabetes, HIV infections/AIDS, mental health, and substance abuse are important health indicators that illustrate health status disparities, and they suggest potential areas of investment in the future health and productivity of Texas.

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Hidalgo County – 2013 U.S. Census Bureau data: Population: 815,996 Hispanic or Latino: 90.9% (Texas is 38.2%) White: 7.5% (Texas is 44.5%) Foreign-born persons: 29.5% (Texas is 16.3%) Language other than English: 85% (Texas is 34.6%) High School Graduate or Higher: 61.2% (Texas is 80.8%) Median Household income for 2012: $33,218 (Texas is 51,563) Persons below poverty level for 2012: 35% (Texas is 17.4%)

A. Adult Smoking (Percent of adults that reports smoking >=100 cigarettes and currently smoking) Source - http://www.countyhealthrankings.org/texasAransas 15% ; Bee 10% ; Brooks Information Pending (IP) ; Cameron 13% ; Duval IP ; Hidalgo 13% ; Jim Hogg IP ; Jim Wells IP ; Kenedy IP ; Kleberg IP ; Live Oka IP ; MC Mullen IP ; Nueces 24% ; Refugio IP ; San Patricio 18% ; Starr 15% ; Webb 21% ; Willacy IP ; Zapata IP

B. Adult Obesity (Percent of adults that report BMI >=30) Source - http://www.countyhealthrankings.org/texasAransas 27%; Bee 29%; Brooks 27%; Cameron 27%; Duval 27%; Hidalgo 29% ; Jim Hogg 28%; Jim Wells 28%; Kenedy 28% ; Kleberg 27%; Live Oak 28%; McMullen 28%; Nueces 28% ; Refugio 28%; San Patricio 27%; Starr 27%; Webb 28%; Willacy 28%; Zapata 28%

C. Excessive Drinking (Percent of binge plus heavy drinking) Source - http://www.countyhealthrankings.org/texasAransas 12%; Bee IP; Brooks IP; Cameron 17%; Duval IP; Hidalgo 15% ; Jim Hogg IP; Jim Wells IP; Kenedy Ip; Kleberg IP; Live Oak IP; McMullen IP; Nueces 23% ; Refugio IP; San Patricio 13%; Starr 16%; Webb 24%; Willacy IP; Zapata 5%

D. Motor vehicle crash death rate (Motor vehicle crash deaths per 100,000 population)Source - http://www.countyhealthrankings.org/texas Aransas 18; Bee IP; Brooks 47; Cameron 12; Duval IP; Hidalgo 16; Jim Hogg IP; Jim Wells 29; Kenedy IP; Kleberg IP; Live Oak 32; McMullen IP; Nueces 15; Refugio IP; San Patricio 17; Starr 25; Webb 11; Willacy 19; Zapata 30

E. Teen birth rate (Teen birth rate per 1,000 female population, ages 15-19) Source - http://www.countyhealthrankings.org/texasAransas 72; Bee 16; Brooks 122; Cameron 90; Duval 37; Hidalgo 96; Jim Hogg 85; Jim Wells 86; Kenedy IP; Kleberg 66; Live Oak 54; McMullen IP; Nueces 68; Refugio 65; San Patricio 78; Starr 110; Webb 107; Willacy 86; Zapata 127

F. Unemployment (Percent of population age 16+ unemployed by seeking work) Source - http://www.countyhealthrankings.org/texasAransas 6.9%; Bee 9.3%; Brooks 9.5%; Cameron 9.9%; Duval 11.1%; Hidalgo 10.6% ; Jim Hogg 7.8%; Jim Wells 8.9%; Kenedy 6%; Kleberg 6.8%; Live Oak 7.3%; McMullen 7.2%; Nueces 6.9% ; Refugio 6.5%; San Patricio 8.7%; Starr 16.7%; Webb 8.7%; Willacy 12.3%; Zapata 10.8%

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G. Children in poverty (Percent of children under age 18 in poverty) Source - http://www.countyhealthrankings.org/texasAransas 33%; Bee 32%; Brooks 45%; Cameron 44%; Duval 34%; Hidalgo 45% ; Jim Hogg 32%; Jim Wells 32%; Kenedy 25% ; Kleberg 30%; Live Oak 24%; McMullen 18%; Nueces 25% ; Refugio 24%; San Patricio 24%; Starr 16.7%; Webb 35%; Willacy 42%; Zapata 38%

H. Inadequate social support (Percent of children without social/emotional support) Source - http://www.countyhealthrankings.org/texasAransas IP; Bee IP; Brooks IP; Cameron 30%; Duval IP; Hidalgo 29%; Jim Hogg IP; Jim Wells IP; Kenedy IP; Kleberg IP; Live Oak IP; McMullen IP; Nueces 20% ; Refugio IP; San Patricio 18%; Starr IP; Webb 22%; Willacy IP; Zapata IP

I. Single-parent households (Percent of children that live in a household headed by a single parent)

Source - http://www.countyhealthrankings.org/texasAransas 39%; Bee 43%; Brooks 43%; Cameron 34%; Duval 29%; Hidalgo 32% ; Jim Hogg 32%; Jim Wells 40%; Kenedy 66% ; Kleberg 32%; Live Oak 23%; McMullen 3%; Nueces 40% ; Refugio 27%; San Patricio 31%; Starr 32%; Webb 36%; Willacy 38%; Zapata 31%

J. Violent crime rate (Violent Crime Rate per 100,000 population) Source - http://www.countyhealthrankings.org/texasAransas 224; Bee 236; Brooks 429; Cameron 429; Duval 394; Hidalgo 364; Jim Hogg 214; Jim Wells 760; Kenedy 591; Kleberg 839; Live Oak 65; McMullen 156; Nueces 753; Refugio276; San Patricio 249; Starr 238; Webb 580; Willacy 1177 ; Zapata 266

Part II-Prevention Resources, Capacities, and Gaps

1. What prevention resources currently exist in your target community? Please discuss the following specifically, and how you can engage them in assisting the coalition:

a. Other Coalitions (Drug Free Community Coalition, SPF coalition) Collaborative working agreements will be established and/or renewed

with coalitions throughout the region and assistance with coalition projects and/or increasing awareness of coalition efforts will be provided through PRC 11.

Uniting Neighbors in Drug Abuse Defense (UNIDAD) Communities Against Substance Abuse (CASA) Texans Standing Tall BACODA

b. School Program (communities in schools, etc.) The TPCC staff have facilitated 40 prevention presentations, 4

cessation presentations and 4 law enforcement presentations Red Ribbon Festival Texas Tobacco-Free Kids Day events Tar Wars activities American Smoke Out

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All Stars And More

c. Community Services BHSST – provides Youth and Adult assessment, screening and

intervention for ATOD Tropical Texas Behavioral Health YMCA

d. Parent Programs (PTS, etc.) Strengthening Families Creating Lasting Family Connections Al’s Pals: Kids Making Health Choices

e. Direct Prevention Service Providers- Behavioral Health Solutions of South Texas Communities for Drug Free Schools

f. Treatment Providers- Behavioral Health Solutions of South Texas Origins

2. What prevention gaps exist in your target community?

Increases in border crossings and violence have led to gaps related to resources available to cope with ensuing violent acts. Geographical settings throughout the region create gaps in prevention efforts due to the close proximity to the Mexico-Texas border and vast rural areas. The close proximity to the border and high volume of undocumented individuals increases the amount of work to be completed with limited resources. Also, the vast rural areas and close proximity to Mexico increases socioeconomic factors impacting families creating additional stressors and life altering events.

PART III-Consequences and Consumption Patterns of the Community

Please identify the patterns in each of the following data sources, when available. If the data source is unavailable in the community, provide an explanation. Please feel free to also utilize alternative data sources.

The Behavioral Risk Factor Surveillance Survey (BRFSS), Adult Tobacco Survey and the Texas Youth Tobacco Survey results are not current for this target area however, they have been found for Region 11 and Hidalgo County is in that Region. Although the state of Texas has a wealth of data, there are still data gaps regarding tobacco use prevalence among specific populations such as lesbian, gay bi-sexual, transgender (LGBT); individuals with disabilities; low income individuals; military personnel; those who are institutionalized; and ethnicities within African Americans, Hispanics and Asian Americans for the city of Edinburg and Hidalgo County.

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Recent surveys administered to Coalition members in the TPCC target area identified a number of needs, assets, and thing-to-do moving forward with the TPCC agenda. Some of the responses are found under “survey data” below:

a. Survey Datai. Perceptions of harmfulness of use (tobacco)

See Appendix B of this document for data results for the State of Texas from the “Texas, High School Youth Risk Behavior Survey, 2013.”

Survey results of 19 TPCC Coalition members indicated that tobacco use was a significant problem in their community.

Behavioral Risk Factor Surveillance Survey (BRFSS), Adult Tobacco Survey and the Texas Youth Tobacco Survey results are pending here.

Future intentions to use None of the 19 TPCC Coalition members indicated an intent to

use tobacco products. The Texas School survey for our target population is pending

here. Family/social bonding indicators Data collection pending here.

b. Substance-Use Related Crime and Delinquency Datai. Violent crimes for 2012

Murder: 22 up 15% since 2011 Violent crimes: 527 in 2012, up 0.5% Property crime: 6,179, down 7% Much of the increase came from the robbery rate which spiked

24% in 2012, with 138 incidents1

ii. Possession of illicit drugs (arrests) Data pending

iii. Public intoxications (arrests- Data pending

iv. Minors in Possession (MIP) data Data pending

c. Public Health Datai. Hospital discharge for tobacco related health disparities

The “Health Facts Profile 2009 for Hidalgo County” published by Texas DSHS does not reflect a hospital discharge for tobacco related disparities section however; it does list mortality by cause. The mortality by cause are as follows:

o Heart Disease 935o Stroke 186o All Cancer deaths 675o Respiratory/Lung cancer 129o Breast cancer 44o Colon, rectum, and anus 56

1 Rural Hidalgo County’s overall crime rate down: violent crime up. Found online: http://www.themonitor.com/news/local/article_ff5663a2-78b0-11e2-a6e2-001a4bcf6878.html

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o Male prostate cancer 29o Chronic lower respirator 112o Chronic liver disease & cirrhosis 90

d. Education Data i. Truancy data/drop-out rates

Data is pending hereii. Academic Achievement

Data is pending hereiii. Graduation rates-

High School Graduate or Higher: 61.2% (Texas is 80.8%)2

iv. Suspensions and expulsions

The Table Below Lists Suspensions and Expulsions for McAllen ISD - 2013 

01-PERMANENT REMOVAL BY TEACHER 1102-CONDUCT PUNISHABLE AS A FELONY 604-CONTROLLED SUBSTANCE/DRUGS 32805-ALCOHOL VIOLATION 1409-TITLE 5 FELONY - OFF CAMPUS 1210-NON-TITLE 5 FELONY-OFF CAMPUS -14-PROHIBITED WEAPON -18-INDECENCY WITH A CHILD -21-VIOLATED LOCAL CODE OF CONDUCT 735322-CRIMINAL MISCHIEF 727-ASSAULT-DISTRICT EMPLOYEE 728-ASSAULT-NONDISTRICT EMPLOYEE 2330-AGG ASSAULT-NONDIST EMPLOYEE -32-SEXUAL ASSAULT-NONDIST EMPLOYE -33-TOBACCO 1135-FALSE ALARM/FALSE REPORT -36-FELONY CONTROLLED SUBS VIOLAT 641-FIGHTING/MUTUAL COMBAT 21543-TRUANCY - 3 UNEXCUSED ABSENCES -44-TRUANCY - 10 UNEXCUSED ABSENCE -

2 Source: U.S. Census Bureau, 2013.6

50-NON-ILLEGAL KNIFE -59-SERIOUS MISBEHAV WHILE IN DAEP

e. Other Community Indicatorsi. TABC data on citations

Data is pending hereii. Media coverage of tobacco-use issues

Television interviews with TPCC Coordinator Television commercials on 3 channels Operation Store Front Coverage Media awareness: Facebook, twitter and Instagram are being

used to deliver prevention messageiii. Tobacco advertising

No local data has been found on the cost of tobacco advertising however, in Texas, an estimated $884.7 million dollars was spent on marketing tobacco products in 2005. That equates to 37.63 dollars for every Texas resident. Political contributions from “Big Tobacco” accounted for $254,500 from 2001 to 2006. These political contributions went to 1 of the 2 U.S. Senators from Texas and 23 of the 32 U.S. Representatives from Texas.3

iv. Tobacco retail outlet density Retailer density throughout the city of Edinburg pose potential

reluctance to establishing smoke free communities due to perceived profit loss.

Operation Store Front Coverage has been implemented by the TPCC coalition. There is a need for volunteers to identify the amount of stores that sell tobacco products and determine how many outlets there are per square miles and per 100k people (spatial analysis)

f. Consequences Data Texas economic toll (costs): $1.6 billion dollars are spent in

Medicaid; $5.83 billion overall health costs; $10.3 million in fire loss; $6.44 billion in lost productivity. State and federal tax burden from smoking costs $630 per Texas household. Each pack of cigarettes sold costs the U. S. $10.28 in health care related costs and lost productivity.4

g. Calls to Quitline Quitline calls in May, 2014 = 6 individuals reached out for

services from Hidalgo County. The TPCC will consider these 6 as our baseline and moving forward, will monitor the Quitline numbers monthly.

h. Laws and Policies Edinburgh has a 1992 (outdated) smoking ordinance which

provides limited protection levels at municipal worksites,

3 Sharp, Barry (2013) Tobacco 101. Texas Department of State Health Services (DSHS).4 Sharp, Barry (2013) Tobacco 101. Texas Department of State Health Services (DSHS).

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private sector worksites and restaurants – the American Heart Association and the TPCC are working on strategies to update that smoking ordinance.

Current law restricts law enforcement from issuing citations for MIP’s for youth under 17 years of age.

Current Texas Facts (baseline data) - Center for Disease Control and Prevention: 5 18.2% of Adult Texans Smoke (Behaviors, cigarette use – Adult current smokers;

BRFSS, 2012) 14.1% Youth Current Smokers (YRBBS, 2012) Texans have less than comprehension coverage for Cessation (Medicaid coverage of

cessation treatments) For funding, appropriations/grants = Texas spends .76 whereas Alaska spends $15.73 and

Arkansas spends $4.78. New Jersey was lowest at .34; Tennessee was next lowest at .42. Texas was fourth lowest (category - Funding, Appropriations/Grants – Total per capita) Tennessee and New Jersey are the lowest at $3 and Alaska is the highest at $99.6.

Texas spends $7 and are the seventh lowest State on Funding – expenditures as a percentage of 2007 CDC recommended level

Texas cigarette tax in 2006 was .41 cents, in 2014 the cigarette tax has increased to $1.41. In comparison to other states Louisiana is the lowest at .36 cents, New York is highest at $4.35 (Legislation – Excise Tax – Excise Tax Rates on Packs of cigarettes)

Texas has no Preemption laws whereas some states have one to three. Please see link below to learn more about preemption laws.6 (Legislation – Preemption, Smoke Free Indoor Air, Youth Access, Advertising)

Texas has no designated area or separate ventilation law in place; in comparison 35 other states have one or more of the bans by location in place (Legislation – Smokefree Indoor Air – Private Worksites, Restaurants, and Bars). However, laws can be adopted at the local level.

Texas Quitline – Incoming calls per 100,000 state population (service utilization) for 2011 was 1.9; in comparison Michigan was the lowest at 1.8 and Oklahoma at 46.8 and South Dakota at 47.8 had the highest volume of calls and service utilization (no data available for Wyoming and North Dakota)

Texas Quitline – for 2011, 0.3 received services compared to the highest at 8.2 in Oklahoma (Callers who received counseling and/or medication per 1,000 tobacco users)

Current Research Regarding Marketing Industry

Adolescents are being groomed by the tobacco marketing industry. The youth today consume more than one tobacco product in multiple ways (i.e. chewing tobacco, cigarettes, hookah, vaping, etc.) and have been identified as polytobacco users. It is becoming a public health concern. A recent poster/study presented by the University of Texas, Department of Kinesiology and Health Education found that “polytobacco use is known to lead to a faster increase in tobacco consumption and a higher likelihood of nicotine dependence than using cigarettes

5 Center for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation System. Found online: http://apps.nccd.cdc.gov/statesystem/InteractiveReport/InteractiveReports.aspx?MeasureID=4#6 Americans for Nonsmokers Rights. Preemption: Tobacco Control’s #1 Enemy. Found online: file:///Users/seames/Documents/RGC%20Border/Preemption%20smoke%20free%20ordinances.pdf

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alone.”7 These findings are consistent with similar research; the majority of adolescents who use tobacco products are considered polytobacco users. These findings suggest that prevention and intervention efforts and programs should focus on the use of multiple tobacco products rather than cigarettes alone. Focus group findings indicate that Polytobacco users believe the use of one tobacco product over another is less dangerous; more research and prevention tools should be targeted on these findings.

Part IV-Intervening Variables

Please discuss each of the following and their affect in the target community:

A. Easy Retail Access- 18 youth participated in 30 store alert activities

B. Social Access- Data is pending here/State surveys coming

C. Perceived Risk- Data is pending here/State surveys coming

D. Social Norms- Data is pending here/State surveys coming

E. Tobacco Promotion- See comments above on tobacco advertising and tobacco

promotion.F. Pricing-

The State of Texas excise tax rate on cigarettes is slightly higher than the U.S. median price. Texas excise tax is $1.41 and the U.S. median is $1.36. The 3 lowest and 3 highest tax rates in the U.S. are listed below as an example of how taxes vary among states:Lowest Missouri = 17 cents Louisiana = 36 cents North Dakota = 44 centsHighest Rhode Island = $3.50 Connecticut = $3.40 Washington = $3.02

Part V-Community ReadinessPlease describe the readiness of your community:

The Lower Rio Grande Valley and specifically Hidalgo County has a strong community culture with strong family values and unique cultural ties. The TPCC coalition also has strong ties within the community and has emerged to address the growing problem of youth and adults using tobacco products. The TPPCC was created to address a community need and is supported

7 Loukas, A., Batanova, M., Karn, S., Robertson, T., (2012) Examining Adolescent Polytobacco Use. University of Texas, Department of Kinesiology and Health Education.

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by its parent agency Behavioral Health Solutions of South Texas (BHSST). BHSST has been working in the community and providing ATOD treatment and prevention services for over 20 years and has deep roots and is well respected in the community. Additionally, the SPF/SIG has successfully operated within this agency for 5 years and those members were anxious to join the TPCC and address the newest threat to the youth of the Valley – e-cigs and other tobacco products. Reviewing the research, the demographics, talking with community partners, school district leaders, and lastly reviewing the EPI data from the State of Texas measured the community readiness for this initiative. The ability to build capacity from the community readiness was tested in the first TPCC Coalition meeting. Fourteen community members attended the first meeting to discuss the problem, in that first meeting and the meetings to follow the evaluator’s were able to assess, observe, and document all the “dimensions/stages of community readiness”8

Awareness of Problem – Community Efforts Effective interagency collaboration (school districts identify the problem of e-

cigs and tobacco products on campus) agree on evidence-based interventions (classes facilitated by TPCC)

Strong fiscal agency that has proven ability to build community programs and create prevention funding streams

Relationship with community leaders

Denial – Community Knowledge of the Efforts

Coalition members are learning about local efforts from those experts who are in the field and bring critical information back to the Coalition leaders. Such as: TPCC has partnered with the American Heart Association on changes community smoking policy ordinances. Other local efforts include an awareness of the problems in local schools and the need for more education around the subject.

Vague Awareness - Leadership

TPCC members are championing the message to as many elected officials and leaders in the community as they can. A strategic plan is being developed to address strategies to present in front of the school board, to help educate law makers and to partner with key law enforcement. This community has quickly shifted from vague awareness to leadership.

Preplanning – Community Climate

Preplanning is an important step when addressing the prevailing attitude of the community toward this issue. The strategy here is to empower the Coalition members, give them some responsibility in working on changing how the community thinks around this problem. It is similar to what this agency faced with the SPF/SIG; underage wasn’t thought of as being that big of a problem but when you look at the alcohol related traffic fatalities, the community

8 Community Readiness: A handbook for successful change. Rand Fidelity Document Sponsored with funding from the SPF/SIG (2005)

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begins to listen. That shift is happening again with the TPCC and the efforts are focused on the details.

Preparation – Community Knowledge about the Issue

TPCC leaders have been planning events and the community is beginning to offer support around those events. Most recently, TPCC is sponsoring a tennis tournament at PAN AM at University of Texas. The TPCC staff will have a booth and resources next to the tennis courts. They are laying the groundwork to get the message out on the campus. Through the efforts of the EPI workgroup and the evaluator’s original gathering of data, the knowledge around the negative consequences to youth and adults who use tobacco products has been well discussed and is therefore one of the driving motivators to build community capacity and create change.

Initiation – Resources Related to the Issue

There is enough information about the community to justify strategies and efforts’ moving forward however, there is a need to conduct local surveys regarding the use of tobacco products. Local resources are available, the volunteers, space, leaders and money are in place to support the efforts.

Stabilization – Community-Related Data

TPCC staff and Coalition members have been trained on the EBP curriculum, on the needs assessment and strategic planning. TPCC staff are trained and licensed social workers and are familiar with the community. TPCC members are administrators and community decision makers. Regarding the community-related data, currently we have EPI data from DSHS but it needs to be updated, we have research regarding our target group and the challenges that come with the proximity of the US Mexico border and access to tobacco products. However, we need data from the following: Behavioral Risk Factor Surveillance Survey (BRFSS), Adult Tobacco Survey and the Texas Youth Tobacco Survey. These surveys have not yet been administered to the target population South Texas.

We are collecting some of our own baseline data based on the media campaign and coverage data as well as administering a local community survey that was developed.

High Level of Community Ownership

One example of a high level of community ownership can be noted in the recently forged partnership between the American Heart Association (changing ordinances at community level) and some of the Independent School Districts (buy-in on EBI educational prevention tools). It was an effective evaluation of “needs” that directed the leaders and stakeholders into forming these relationships. Lastly, these two relationships are some of the best examples of creating a sustainable project in place; long after the funding has stopped.

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Part VI – Collection Methods

In an attempt to identify and resolve some difficult systemic community problems around the smoking/use of tobacco products, the Coalition decided to take a holistic approach to determining the impact of the issue that kills more Americans than any other disease. The methods employed in compiling the data specific to our target area included multiple steps and is often referred to in social sciences as “grounded theory” and includes many of the participatory evaluation steps. These steps are as follows: 1) surveys, 2) observations made by evaluators, 3) conversations with key informants, and 4) presentations to students/parents/public. The process also included keyword/context analyses from committee meeting minutes, a number of one-on-one interviews with TPCC leaders and TPCC committee members. In this process the TPCC leaders identified where the “largest” need existed and how we together as a Coalition could push our goals forward. Below is an abbreviated list of things learned from stakeholders in this process:

Enforcement:

In the May Coalition meeting during a conversation around gathering data for MIP of tobacco products, we learned from local law enforcement about the new rules around citations given to those under 17 and how new legislative laws has prevented their ability to cite for MIP of tobacco (as well as other illegal substances). Through further research the EPI group and the evaluator’s read a brief by the Texas Appleseed agency that discussed the removal of an officer’s ability to give a student a ticket/citation for smoking or possession of tobacco.9

This will remain an ongoing topic of discussion. Local enforcement also disclosed that no tobacco stings have been conducted this year or

last and expressed the “need” for teens that are willing to do stings for tobacco. The Coalition supported those efforts and TPCC staff are providing the teens needed for this initiative.

Implementing Culturally Competent Methods:

After the survey was circulated, committee members in the May Coalition meeting expressed their frustration over the language in the survey. Some comments made regarding the survey was: “it’s not written with our population in mind” “words like “social norms” don’t make sense” “you need to describe what a “coalition” is and what a TPCC is”, “everyday people don’t understand those words” and “why isn’t the survey in Spanish.” Here is another “need” that wasn’t considered and the TPCC leaders and Epi group members immediately stepped up and took the initiative to first “use language that solicited the same response but in a language laymen could understand” and second to translate the survey into Spanish. (Within the target area 90% of the population is Hispanic/Spanish speakers). To date, the survey has gone through four revisions.

The TPCC Coalition has many subcommittees in an attempt to split up into specialty groups to address the issue and better meet the Coalition’s goals. In May’s Coalition meeting the Advertising/Media committee reported out. (There has been a discussion in

9 Texas Appleseed, Texas’ School to Prison Pipeline: Ticketing, arrest, and use of force in Schools. Found online: http://csgjusticecenter.org/wp-content/uploads/2012/08/Breaking_Schools_Rules_Report_Final.pdf

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past committee meetings as well regarding how to proceed with media dollars). The Media group informed the members of what to expect in regard to advertising and how they arrived out those decisions. First no billboards will be used this year, all the money will go into television (a discussion did arise about local literacy rates, this comment was made by a teacher in one of the local school districts: “A billboard doesn’t work, if you can’t read it”. Further discussion will be around the wording and the use of radio ads). Second, all the advertising dollars will go into television. A decision was made on the use of cable or regular television. A consensus was formed based on this reasoning, “cable is expensive, and television is free with rabbit ears.” “We choose television and not cable ads even though cable is cheaper.” The message used will be a general message already being used on the State-wide campaign and will be in English and Spanish on three television channels one of which (Entravision) is a Spanish speaking only channel. Television reaches close to 2 million people from the Rio Grande Valley to Corpus and extends to both sides of the border. The hours of the commercial will be focused on our target audience/age/gender and income group.

Leaders of Community Involvement:

When looking at the “need” to get into school districts to spread the word and educate students and student body, members learned in the May meeting that TPCC has not gotten into all of the school districts. Specifically, McAllen school district. A strategy plan was brainstormed and someone knows someone who is on the school board. A great example of networking the “need” to get on the school board agenda.

Getting on college campuses is often challenging but there is a great need for tobacco prevention on these campuses. Another strategic move by the members proved to be effective in addressing that need with the decision of doing a fund raising tennis match on the Texas Pan Am campus. TPCC staff will have a booth beside the tennis courts; they will be educating, presenting, and distributing resources on cessation (Texas Quitline) as well as other prevention pamphlets/resource guides.

One of the Coalition partner groups, the American Heart Association has identified a “need” to update and create additional smoke free ordinances in the target area. The focus is on Edinburgh for that change in policy and a petition is being circulated and Town Hall meetings are being scheduled (Edinburgh’s last smoking ordinance was passed in 1992).

Cultural Norms:

Member of the community and the TPCC coalition recently attended a Texas Standing Tall (TST) training, at the training many “needs” were identified and are discussed here. The Rio Grande Valley’s “need” is much different from other areas in Texas. The close proximity to the U.S. Mexico border adds many more components. As mentioned in the beginning of this assessment, the close proximity, the cultural norms, the lack of perceived risk, the lack of purchasing laws around tobacco in Mexico, and the easy access to these products at a lower cost (in Mexico) are all challenges. Other challenges include the isolated geographical area, high poverty rate, legal status, parents who only speak Spanish and unsafe areas.

Additional needs found in the TST training are as follows:

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o Reading level of materials and language = need to use pictures to get message across

o Legal status = reluctance to share informationo Fear of authority = it will help to partner with trusted community groupso Use trusted key informants to spread message = Promotoraso Interviewers need to ask questions without offendingo Perceived low risk = tobacco “small” problem (compared to human trafficking,

drug trade and violence)o Laws in Mexico differ from U.S.

Contributing Factors:

Other factors that came up in the TST training were around ongoing contributing factors, they are as follows:

o Bootleggerso Cheaper products from Mexicoo Lack of Court accountabilityo Family norms - allowed to smoke at homeo Low SES equals high smoking rates (disparity focus)o Parents provide cigarettes to reduce hunger painso Availability o The least of Border problems (“tobacco is laughable”)o Vending machines sell cigarettes o Parents buy cigarettes for youtho MIP not being usedo Low enforcement in schoolo Schools worried about negative impactso Perceived risk lowo Low knowledge of harm and risko Youth can busy single cigarette

Target Populations - Patterns of Use:

Patterns of use were identified in the TST training and a need was found to strategize how to break through these cultural norms, the patterns are as follows:

o Chewing while huntingo Smoking on weekendso Using E-cigs to quito Youth go to Dairy Queen and smoke together (socialize around smoking)o Smoke to lose weighto To reduce anxietyo E-cigs to test boundaries – movies, workplace, church, sports eventso Family smokeso Youth light cigarettes for parents

Consequences for the Community:

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Cigarette smoking can cause dire quality of life and economic consequences in the community. The following consequences were identified in the TST training:

o High medical costs, health careo Economic impact at work: lost time, productivity, frequent breakso Coughingo Upper respiratory diseaseo Brittle nailso Negative impact on athleteso Cancer rateso Ear infections, hearing losso Behavioral problemso Oral cancer

Resources Needed:

o Interventions need strong consistent messages with a steady stream of funding. Also, members from the following sectors must be involved (some categories identified are already members of TPCC): business, law enforcement, non-profit, mental health, education, health care professionals, court professionals, and law enforcement in schools.

Next Steps:

o Create a TPCC newsletter for communityo Recruit and expand Coalition membershipo Educate court systemo Find donations – create sustainability of efforts

Part VII-Putting it all Together

1. Now that you have conducted your needs assessments, what have you identified as your primary target population? Why?

Youth ages 14-24. Why = Smoking and smokeless tobacco use are initiated and established primarily during adolescence. Nearly 9 out of 10 smokers started smoking by age 18, and 99% started by age 26.10

2. What have you identified as target intervening variables? Why? Low enforcement in schools. Why = new laws in place regarding citations by

law enforcement in schools Schools worry about negative impacts. Why = tobacco isn’t seen as real

problem, other problems are much bigger.

10 U.S. Department of Health and Human Services. Preventing Tobacco Use Among Young People: A report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Office on Smoking and Health, 1994. Found online: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/

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Lack of court accountability. Why = tobacco isn’t seen as real problem, other problems are much bigger.

Low knowledge regarding laws. Why = tobacco isn’t seen as real problem, other problems are much bigger.

Bootlegger sell to minors. Why = close proximity to U.S. Mexico border, prices are better for tobacco products in Mexico.

E-cigs widely available. Why = lack of policies surrounding e-cigarettes. E-cigs promoted to youth nonsmokers. Why = lack of policies surrounding e-

cigarettes. MIP not being used. Why = new laws in place regarding citations by law

enforcement in schools. Cheaper products from Mexico. Why = tobacco products are cheaper and the

restrictions around purchasing them are more lenient in Mexico. Parents buying for youth. Why = low perceived risk. Vending machines sell cigarettes. Why = low perceived risk. Marketing

strategies.

3. What have you identified as secondary target populations? Why? The secondary target population that the TPCC has identified is older adults

who live in or around the colonias in the Lower Rio Grande Valley. Why = This population is out of touch and often out of reach of many services and resources. The health disparities within this population are higher than the national average and they can often only be reached by Promotoras. A cessation campaign, education campaign and partnering with the health care providers would be some of the strategies needed to make this project successful.

4. What have you identified as secondary variables you would like to address but may not be able to address this fiscal year? Why?

Lack of understanding around the severity of the issue. Easy access to cheaper tobacco products in Mexico. Low education – low socio economics Hunger – used to prevent hunger pains Cultural norm Create smoke-free policy in house and outdoors In response to “Why” use the above variables is simply because Parents have

an enormous amount of influence over their children. Parents/older adults are role models for the youth. The American Lung Association concluded from recent research that children of parents who smoke are more likely to have children who smoke. 11

5. What is the process implemented when creating a strategic plan for the selection of evidence-based environmental strategies, policy and procedure recommendations? The strategic plan outline is completed and some of the performance measures to

address environmental strategies are already identified and in place. They are as follows:

11 American Lung Association, “Tips for Parents”. Found online: http://www.lung.org/stop-smoking/about-smoking/preventing-smoking/for-parents.html

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o Change community norms around laws and policies. The groundwork is being laid to create the following: a) ordinance changes, b) law enforcement supported in their sting efforts, c) promoting public events (such as the Pan Am UT tennis tournament) and d) getting on the agenda for the School Board meeting, and more.

Strategies to limit accessibility and availability are also moving into place. Four presentations have been made to local law enforcement and to school administrators (some parents). Plans are being brainstormed on how to train retailers on the importance of carding all youth who attempt to purchase tobacco products.

A strategy has been developed and is being carried out around media messages. Media messages impact the whole community and thus play a key role in establishing community norms. See” Implement Culturally Competent Methods” in the section above for more information on media messages.

Additional evidence-based environmental strategies include: o Reduce the gaps in resources and trainings in the region. o Increase collaborations and maximize community resources.

Part VII – Logic Model

Consequences - youth continue

to initiate smoking

Use Patterns - begin at home

for many

Intervening Variables - youth, peer

and parental norms

Contributing Factors -

availability, especially cheap cigarettes from

Mexico; underage

drinking and smoking in

Mexico

Strategies - universal education through

media; defined education targeted over-the-air ("OTA")

toward Spanish-speaking

subpopulation; indicated education

and intervention messages for

QuitLine -target smoking parents

Consequences - youth continue

to initiate use of snuff, chew, smokeless

tobacco products

Use Patterns - at school and in social settings

Intervening Variables -

youth and peer norms

Contributing Factors -

availability, lack of MIP

enforcement, lack of policy,

court and school

Strategies - universal

education through media; defined

education targeted over-the-air ("OTA") toward Spanish-speaking subpopulation; indicated policy

enforcement and change where

needed

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Appendix A

Checklist of Policy Indicators for Tobacco

Yes NoTOBACCO—Public PoliciesExcise taxes (local) xTobacco sales licensing system xProhibition of smoking in public places xPrevention of preemption of local control of tobacco sales xRestrictions on advertising and promotion xBan on Vending machines xCompulsory checks form minimum purchase age and administrative penalties for violations

x

Minimum age of sales of 18 x Warning labels xMandatory seller training xBan on self-service sales (all tobacco behind the counter) xMinimum age for sellersPenalties for underage use xTOBACCO—Organizational policiesEstablishment of smoke-free-settings (restaurants, workplaces, hospitals, stadiums, malls, day care facilities)

x

Counter advertising (media) xRestrictions on sponsorship of special events (communities, colleges, stadiums)

x

Prohibition of tobacco use on school grounds, in buses and at school events

x

Enforcement of school policies (schools) xMandatory checks for age identification (businesses) xSeller training (businesses) xIncentive for checking or monitoring program (businesses) x

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