"Lose the cancer stick."
"When you get a real job, you're going to be one of those people who has to stand out by the street to smoke."
"That smoke's killing the people who have to be around you."
"The guy three counties over doesn't want to pay for your cancer or for everybody else you make sick."
Lauren, a University of Texas at Austin junior, has heard every warning and insult in the book when it comes to her smoking. She can't help but note, as she takes a sustaining suck on a cigarette stump, that if saying "Hey, just stop" made a smoker's addiction magically disappear she'd happily comply. And would be at least $36,000 richer, if nothing else.
When you look at the financial burden of smoking alone, Lauren's $36,000 pales in comparison to the billions of dollars spent every year by Texas taxpayers and businesses on smoking-related healthcare costs. In 1998 and 1999, the tab for Texans was $4.55 billion and, if you include lost productivity, it jumps to more than $10 billion. Then there's the emotional toll on families, friends and colleagues of smokers who have a massive stroke or discover they have emphysema, cancer or heart disease.
In all respects, the cost of tobacco use is high.
"Tobacco is incredibly seductive and addictive, as any user can tell you," says Dr. Alexandra Loukas, associate professor in The University of Texas at Austin's Department of Kinesiology and Health Education. "In Texas, it's the leading cause of preventable death and disease and has been for some time now. In the U.S., smoking-related illnesses cause more deaths annually than alcohol, car accidents, illegal drugs, suicide, homicide, driving while intoxicated and fire ... combined."
Loukas is head of The University of Texas at Austin's Tobacco Research and Evaluation Team in the College of Education's Department of Kinesiology and Health Education. The team is responsible for project leadership and evaluation in 12 federally and Texas Department of State Health Services-funded Texas communities that have a serious commitment to preventing and controlling tobacco use.
The Department of Kinesiology and Health Education's public health research and evaluation team includes Loukas, Gail Sneden, Dr. Shelley Summers-Karn, Trina Robertson, and graduate students Milena Batanova and Whitney Lang.
By teaming up with the Texas Tobacco Prevention Coalition (TPCC), of which the group is a part, funded communities have a much better chance of reducing tobacco use in their areas.
According to Loukas, a single organization can create comprehensive programs that reduce tobacco use in a city or county, but research shows efforts are much more successful if several different groups with the requisite expertise work together toward the common goal of prevention and control.
Each TPCC partner is responsible for implementing a comprehensive program in its community. In the Department of Kinesiology and Health Education, Loukas's team takes care of evaluating the efficacy of the coalition's interventions.
They collect data from each participating community and analyze and interpret it to see if the evidence-based, comprehensive prevention and cessation program developed for that community is achieving the desired ends and that money, time and human resources are being used efficiently.
"Healthy, tobacco-free communities don't just happen," says Loukas. "It takes a coordinated effort, evidence-based strategies and meaningful policy changes. Research shows that most smokers want to quit. The goal is to create the social climate, community resources and policy infrastructure to help them succeed."
It takes a multi-faceted approach to help a community that bridles at being told where people can smoke and where they can't become one that enacts ordinances to make public venues smoke-free. Fortunately, guidance from the Centers for Disease Control and a very successful pilot program in southeast Texas a decade ago have given coalition members a blueprint to follow that can be customized as needed.
"'Comprehensive' is the magic word when you're talking about reducing tobacco use and preventing it in a community," says Dr. Philip Huang, medical director for the City of Austin and a coalition member who has worked with University of Texas at Austin health educators since 1999. "You make headway when three major things happen in a community. When you have systems changes, policy changes and a change in the social and physical environment, you then begin to see an impressive drop in tobacco use. You really need that one-two-three punch.
"When we implemented the tobacco cessation pilot program in southeast Texas back in 1999, the Beaumont and Port Arthur communities had particularly high levels of tobacco use. Traditionally, southeast Texas has had a high concentration of tobacco users and has a high number of low-income African Americans, a demographic in which tobacco use still is prevalent. We had significant funding to launch comprehensive programs in these communities and in Beaumont and Port Arthur we saw a 36 percent reduction in tobacco use among youth in grades six through 12 and a 27 percent reduction in adults. These were phenomenal results. Our feeling was, if we can see success in these communities, we can do it anywhere."
The strategies Huang and his team used in the pilot program became a template for the coalition to use statewide. When the coalition partners with a community, it begins with an assessment of the city or county, gathering data on where the area stands in terms of tobacco use, determining the resources they can devote to the effort and identifying which populations need help and what the prevailing attitude is regarding the sale and use of tobacco. Many different things figure into a community's profile -- everything from the ethnic breakdown of the population to religion, income level and level of education.
The answers and data will be different for El Paso, for example, than they are for Texarkana.
Next, coalition members meet with community groups and organizations that will be helping them and share information and data, listening carefully to the community-based organizations' feedback and insights. The populations most affected by tobacco use are involved in the planning and assessment whenever possible.
"Overall, you see more tobacco use in blue-collar, uneducated populations," says Loukas, "and there are disparities in use between whites and ethnic minorities. In general, we've seen dramatic smoking decreases in white, educated, financially secure groups, but use is still high among minorities and the poor.
"Tobacco companies are all too aware of these trends and vigorously target vulnerable groups, like African American and blue-collar males, in their marketing. The coalition goes into an area that has maybe a 20 percent tobacco use rate and while we're working to reduce that, the tobacco companies are working just as hard to grab 30 percent of the market. We've seen remarkable improvements in Texas, though. In San Antonio, for example, the community rallied together, worked extremely hard with the coalition and their rates dropped from 25 to 15 percent. That's absolutely great. The state rate is around 18 percent, so San Antonio is well below the average."
After the coalition determines what groups are still using tobacco and what changes in the community would address the problems, strategic planning begins. Coalition members build a plan, with measurable goals, that takes into account the health disparities in the community and prioritizes actions to address them.
Implementation then starts. This is the point at which coalition members work with the community to enact ordinances to make restaurants, bars, schools and school-sponsored events tobacco-free, for example. Businesses may be approached about making their facilities tobacco-free and media messages are designed for TV, radio, posters, billboards and the Web.
According to Megan Cermak, project coordinator for the Austin Tobacco Prevention and Control Coalition, Austin's Capital Metropolitan Transportation Authority has started an ambitious, comprehensive tobacco-free policy. The policy's being phased in, step by step, and includes displaying prominent anti-smoking messages on the buses, as well as banning tobacco use on Metrorail platforms, in park-and-ride areas and at transfer stations. Eventually, the Authority hopes to extend the ban to cover all bus stops.
Dell, which is headquartered in Austin, has become a tobacco-free site, as have many other Austin worksites. Huang says Dell's experience was fairly typical and that he received feedback that some of the tobacco users were "noisy" for a few months after the tobacco-free policy was announced. After a few more months, though, emails starting coming in from some of the employees who had been the most vocally opposed to the change, expressing that they had quit smoking as a result of the policy and that it had transformed their lives. They were effusive in their thanks to Dell for pushing forward the tobacco-free policy.
As part of implementation, health care providers are educated on the importance of questioning patients about tobacco use and are given an array of questions to use as well as intervention strategies, such as toll-free call-in help lines and free nicotine replacement products, they should tell their patients about.
"You can't underestimate the power of the healthcare provider's help in all of this," says Huang. "With one of my heavy-smoking patients, I had asked her a number of questions about her tobacco use and given her information on all of the free, and very effective, options available to help her stop smoking. We decided together on a quit date and then shook hands on it. I saw her again a bit later and she informed me she'd stopped smoking, Frankly, I was amazed. When I asked what made her stop, she said, 'We shook on it.' It was as simple as that."
Research and evaluation team member Karn adds, "Electronic records are an especially powerful tool right now and are helping us track smokers statewide and target them with appropriate treatments when they're ready to quit."
Whether it's coming up with media messages that support the anti-smoking efforts in schools or convincing companies to ban onsite smoking, the implementation stage is the point at which plans become action.
"There's a word being used to describe a policy that, once enacted, brings about long-lasting behavior and attitude changes," says Huang. "We refer to its 'stickiness.' These really important, meaningful changes can be tough to push through, but they last and you transform the whole setting and mindset. I remember back in 1995, being at the City Council meeting in Austin, testifying regarding the ordinance to make restaurants smoke-free and the chambers were packed with livid restaurant owners who said if we banned smoking in their establishments, they'd be driven out of business.
"The ordinance passed, of course, and extensive data collection shows that there have been no adverse economic effects. Same thing happened when it came to banning smoking in bars. There was a deafening uproar, and one of the organizers of the South By Southwest [SXSW] music, film and interactive festival was quoted as saying that the ban would drive SXSW out of Austin. The ordinance passed, the bars have done fine and SXSW has had record profits since then. These changes have 'stickiness' -- they're there to stay, and we can't imagine going back. Can you picture it ever again being okay to smoke on an airplane?"
After making policy and infrastructure changes in a community, evaluation is the last link in the chain. Members of the coalition's research and evaluation team collect data on all of the measurable strategies that were implemented, analyze it and report the outcomes to the community.
"We've seen remarkable improvements in Texas," says Sneden. "An early indicator of our success is the number of calls made by current smokers to the Texas Quitline (1-877-YES-QUIT). The Quitline offers a free two-month supply of nicotine replacement therapy to smokers who are medically qualified.
"Between 2008 and July 2010, we saw a combined 136 percent increase in new calls to the Quitline across six participating Texas communities. This increase is substantially larger than the 16 percent increase around the rest of the state. Also, over 1.3 million Texans were added to the roll of those protected from exposure to secondhand smoke in restaurants and bars as a result of coalition work in Fort Bend and Bexar Counties."
And the pressure to see tobacco usage numbers drop is intense. After all, it's not just the tobacco user who gets sick or suffers.
"Reducing tobacco use is a major public health issue," says Robertson, "if for no other reason than that there's so much solid research on how harmful secondhand smoke is. It contains more than 4,000 chemicals, and 69 of them are known to cause cancer. Children exposed to secondhand smoke early on are at greater risk for asthma, middle ear infections, bronchitis and pneumonia, and, not surprisingly, are at greater risk of cancer. Exposure to the smoke is even associated with sudden infant death syndrome. Interestingly, the documented health risks of secondhand smoke have led some courts to take parental smoking into account in custody and visitation disputes."
The hard work done by Texas communities and The University of Texas at Austin's Tobacco Research and Evaluation has contributed to permanent, community-level changes that will continue to promote healthy behaviors indefinitely. The state also is significantly benefiting from the tobacco-related research done by health educators in the Department of Kinesiology and Health Education.
Loukas has been studying and gathering data on the relationship among stress, depression and tobacco use and recently completed a National Institutes of Health/National Cancer Institute-funded project examining depression, stress and tobacco use in a racially and ethnically diverse sample of vocational school students. She's also working on getting federal funding to evaluate the effectiveness of a Web-based smoking cessation tool for vocational students.
For people like Lauren, the two-pack-a-day junior, the reasons to stop smoking are simple, even if the stopping itself isn't.
"My boyfriend is nice about my smoking, but I know he'd love for me to quit," she says. "My parents would stop worrying and people wouldn't be giving me dirty looks. My clothes and car wouldn't stink. I'd have more money. It's lame, irresponsible and just not cool anymore -- as if it ever was. Time to change."