Using a Collaborative Approach to Tobacco Control Efforts in Marginalized Communities
Authors: Robertson Crystal , Mamudu Hadii M. , Littleton Mary Ann , Boghozian Rafie , Owusu Daniel , Collins Candice , Wang Liang , Sreenivas Veeranki P. 
Published: May 2017

ObjectiveTo examine community engagement as a means to strengthentobacco-related policies and programs use in marginalizedpopulations.IntroductionAlthough significant progress has been made in tobacco control inthe United States (US) over the past 50 years, more than 15% of thepopulation currently use tobacco products.1Tobacco use continuesto be the leading cause of preventable death, contributing to over480,000 deaths and about $300 billion in economic costs each year.To achieve theHealthy People 2020(HP2020) objective of 12%national adult smoking rate by 2020, it is important to focus ourtobacco control efforts on surveillance and addressing disparitiesin tobacco use prevalence and tobacco-induced diseases acrossdifferent subpopulations and geographic areas.2Utah reportedthe lowest prevalence rate (9.7% in 2014), while rates as high as28% were identified in central Appalachia. Modern epidemiologyis limited in its ability to explain patterns of tobacco use andtobacco-related interventions and policies in these highly prevalent,marginalized environments. Therefore, a combination of quantitativeand community-based participatory research (CBPR), as proposedin Public Health 3.0, will expand the scope and reach to addressall factors of tobacco use, including cross-sector collaboration andmulti-level actions.3This study aimed to comprehensively investigatecounties in the Northeast Tennessee region where tobacco useprevalence is disproportionately highest, and to identify regionaland culturally specific evidence-based practices for tobacco control.Additionally, the study examined how these practices can be scaledup to address similar high tobacco use and disadvantaged populationselsewhere in the US and worldwide.MethodsGrounded by the CBPR framework, a mixed-methods approachtriangulated multiple sources of data using a three-prong assemblageofProtection,Prevention, andCessation, to develop tobaccocontrol recommendations and goals as part of a Population HealthImprovement Plan for Tennessee. Information gained from healthcouncil discussions, focus groups, interviews, and stakeholdermeetings were combined with quantitative analyses of secondarydata from Tennessee Department of Health, school-based surveys,and qualitative analyses conducted for descriptive and inferentialstatistics. All discussions and interviews involving 222 individualsfrom 91 organizations were recorded and organized using NVivo10, thematically coded using grounded theory, and analyzed usingdescriptive statistics. The results utilized aggregated themes generatedfrom the data.ResultsTobacco use in the Northeast Tennessee region comprises cigarettesmoking and smokeless tobacco, with increasing uptake of electroniccigarettes across all age groups. Among others, culture of tobaccouse and cultivation was identified as the most salient factor fortobacco use. Reducing tobacco use requires a foundation built oninformatics, community engagement, and a model for sustainablefunding to support infrastructure and program interventions. Whilestate and national policies and programs have received less attentionin this region, several effective community-based policies andprograms to prevent tobacco use were identified, including incentiveprograms such as Baby and Me, voluntary smoke-free campuspolicies by businesses and colleges, 100% screening programs byhospitals, and nicotine-free employee population. Overall, a total of25 recommendations were identified, with 14 aimed at protection,four at prevention, and seven at cessation. These recommendationsculminated into five overarching goals:Protectthe population fromtobacco and secondhand smoke exposure through policy enforcementand implementation and counter-marketing;Preventinitiation oftobacco use with comprehensive youth-focused programs that increaseknowledge and awareness;Expandaccess to cessation resources andtreatment, especially in high risk populations;Fostercollaborationand partnership; andMonitordata for evaluation and validity.ConclusionsThis is one of the few comprehensive attempts to address the socialdynamics of tobacco use and identify population and geographicpolicies and programs in highly prevalent communities. Amongthe myriad issues identified, the expansion of surveillance data toinform tobacco policy and culturally-tailored tobacco policies andprograms are essential to reduce tobacco use in population subgroups.Combining CBPR with actionable data can spur innovations inlocal efforts, highlight social determinants of health, and contributeto evidence-based policy. While the results of this study primarilyprovide in-depth descriptions of central Appalachia’s tobacco-relatedrisks and their perceptions of and reactions to tobacco preventionintervention, the policies and programs identified through the processmay be more readily adopted and scaled-up to address the disparitiesin tobacco use and tobacco-induced diseases, particularly pertainingto low-income, disadvantaged, and hard-to-reach populations.