Running head: TOBACCO PREVENTION POLICY 1

Health Policy Plan to Combat Tobacco Use in Pinellas County, FL

Catherine Whitford

University of South Florida

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Health Policy Plan to Combat Tobacco Use in Pinellas County, FL

The purpose of this paper is to identify a priority health issue within a selected county,

assess the contributing factors, and develop a health care policy that could potentially improve

the overall health outcome of the community. This was carried out by assessing the selected

county’s health data, identifying a priority health issue, and exploring evidence based

interventions. This paper will examine Pinellas County, Florida and it’s increased tobacco use

among the adult population. A health care policy will be proposed to create a primary level

intervention such as creating a school-based peer led tobacco prevention program to aid in

preventing increased rates of tobacco use in adults.

Overview of Pinellas County

Pinellas County is a peninsula positioned on the west central coast of Florida, surrounded

by the Gulf of Mexico and Tampa Bay. The two main cities are St. Petersburg and Clearwater.

According to the Office of Economic and Demographic Research (2019), Pinellas is Florida’s

second smallest county in land mass, the 6th most populace, and the most densely populated.

Pinellas County is mainly urban with some rural areas. The average age in Pinellas is 47.6 and

inhabits 81.9% White, 10.2% Black, and 7.9% Hispanic or other individuals (U.S. Census

Bureau, 2017).

Pinellas’s top business sectors are health services, tourism services, manufacturing and

financial services (Office of Economic and Demographic Research, 2019). The top major

employers include Raymond James, HSN, and Tech Data employing over 2,000 employees

alone (Pinellas County Economic Development, n.d.). Three major healthcare systems in

Pinellas County are Baycare, Advent Health, and Hospital Corporation of America (HCA). To
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evaluate the progress of such an established and fast growing county it is beneficial to see how it

compares to the state’s socioeconomic factors.

Comparison of Local and State Populations

The U.S. Census Bureau (2017) concluded, that compared to the state average

percentages of families below poverty level in Pinellas County was 8.6% vs. 10.6%, the

population ≥ age 25 with a high school diploma was 91.1% vs. 88%, and the population ≥ age 5

that does not speak English was 5.1% vs. 11.9%. Pinellas’s ratio of population to primary care

provider is 1120:1 vs. the Florida average of 1390:1 (County Health Rankings and Roadmaps

[CHK&R], 2019). This data concludes lower rates of poverty and higher rates of educated

citizens, although access to primary care seems to be an issue for both the county and state.

Analysis and Interpretation of Data

In developing solutions for improving public health outcomes healthcare professionals

should evaluate both the strengths and weaknesses of the community in question. By reviewing

the strengths and weakness of a community, health care professionals can develop or improve

upon current procedures and policies. The Florida Department of Health’s county health profile,

Pinellas County health rankings, and Healthy People 2020 collected the following data.

Identified Strengths

Pinellas County has provided significant access to exercise opportunities. The population

has a 96% chance of obtaining physical activity resources compared to the state average of 88%

(CHK&R, 2019). Increased physical activity has been proven to reduce the risk of obesity, which

in turn reduces chronic diseases such as hypertension, high cholesterol, diabetes, heart disease

and stroke, and osteoarthritis (United States Department of Health and Human Services [HHS],

Healthy People 2020, 2016).

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Children subjected to poverty can be both an indicator and predictor of poor health

outcomes. Pinellas County identifies 17% of children live in poverty compared to the Florida

average of 21% (CHK&R, 2019). Research on adult health points to pre-disease pathways that

have their initial impact in early and middle childhood (HHS, Healthy People 2020, 2016).

Health People 2020 also concluded that behaviors developed by adolescents due to financial

burdens have long-term costs of preventable chronic diseases.

Environmental conditions, such as air quality, can have a huge impact on an individual’s

health status. Pinellas County’s air pollution measured 6.8 micrograms per cubic meter vs.

Florida’s average of 8.2 (CHK&R, 2019). According to Healthy People 2020 (2016), poor air

quality is identified as a major risk factor in premature deaths, cancer, and long-term damage to

respiratory and cardiovascular systems.

Identified Weaknesses

Adult smoking is demonstrated by 17% of Pinellas’s population compared to the Florida

average of 15% (CHK&R, 2019). Tobacco use is the single most preventable cause of disease,

disability, and death in the United States (HHS, Healthy People 2020, 2016). Cigarette smoking

is identified as a cause of various cancers, cardiovascular disease, and respiratory conditions, as

well as low birth weight and other adverse health outcomes (CHK&R, 2019).

Pinellas County identifies 21% of its population partakes in excessive drinking compared

to the Florida average of 18% (CHK&R, 2019). Large amounts of alcohol can increase the risk

of cardiomyopathy, stroke, hypertension, liver cirrhosis, pancreatitis, and several types of

cancers (National Institute of Alcohol Abuse, n.d.). Approximately 80,000 deaths annually are

associated to excessive drinking, and claims the third leading lifestyle-related cause of fatalities

in the United States (CHK&R, 2019).

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Pinellas County was evaluated to show indications that increased hospital rates are in

result of a lack of access to primary care and instead using ambulatory care as a proxy.

Preventable Hospital stays were concluded to be 5,144 vs. the Florida average of 5,066

(CHK&R, 2019). Although the average ratio of Pinellas’s population to primary care provider is

less then the Florida average, it still makes it difficult for patients to be seen in a timely manner.

Tobacco Cessation as Primary Health Initiative

Research indicates approximately 480,000 premature deaths can be attributed to smoking

tobacco products annually (Centers for Disease Control [CDC], 2018). More deaths are caused

each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal

drug use, alcohol use, motor vehicle injuries, suicides, and murders combined (HHS, Healthy

People 2020, 2016). Smoking leads to disease, disability, and harms nearly every organ of the

body (CDC, 2018). Thankfully, in 2012, the CDC established the first paid national tobacco

education campaign that resulted in 1.6 million additional smokers making a quit attempt and

over 100,000 sustained quitters (HHS, Healthy People 2020, 2016). By promoting continued

public education and providing additional cessation resources, Pinellas County can see

tremendous improvement in community health outcomes.

Discussion and Application of Community Health Models

Community health models are important in identifying health issues, assessing risk

factors, and developing interventions within the community. The Social Determinants of Health

Model (SDOH) describes how the conditions in which people live, learn, work, and play have an

affect on individual health outcomes (U.S. Department of Health and Human Services, 2018).

This model can provide healthcare providers a firm understanding as to why a certain population

is at risk for such health outcomes and what interventions should be implemented. The SDOH
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factors that impact the use of tobacco are social cohesion, poverty, food insecurity, poor

environmental conditions, education attainment, decreased health literacy, crime and violence.

Population Diagnosis

Adults in Pinellas County are at risk for higher rates of morbidity and mortality due to

increased tobacco use.

Community Interventions

Goals to reducing tobacco use will be explored through the discussion of primary,

secondary, and tertiary interventions. Primary level of prevention focuses on strategies to prevent

disease or injury before it happens. Secondary level of prevention focuses on the prevention of

the progression of the disease. Tertiary prevention focuses on reducing the consequences of an

established disease. The Intervention Wheel model will be used to define population-based

interventions and how they contribute to improving population health.

Primary Level of Prevention

Research supports a school based, peer-led tobacco prevention program as an effective

evidence based primary level of prevention to decrease tobacco use among individual recipients

(Kumar Mall & Bhagyalaxmi, 2017). In this randomized community trial, the selected influential

students were to act as peer supporters after being taught the health hazards of smoking and

smokeless tobacco consumption through the use of charts, role-plays, videos, discussions, and

participatory lectures. Tobacco consumption reduced from 48.8% to 38.9% and 36.9% after 6

months and 1 year of the intervention, respectively (Kumar Mall & Bhagyalaxmi, 2017).

Principles of the Intervention Wheel Model that apply to this intervention are health teaching,

advocacy, and collaboration. This intervention uses health promotion as a strategy for tobacco

prevention. Stakeholders include the students, community members, healthcare providers, and
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legislature. There is a concern for the source used to provide tobacco prevention education to

students due to the possibility of untrained community members providing student training. The

role of a community health nurse is to assess health status, implement interventions, and monitor

the student’s progress throughout the program.

Secondary Level of Prevention

Research supports a text-messaging-based smoking cessation intervention as effective

evidence based secondary level of prevention to increase tobacco cessation among individual

recipients (Lloa & Wu & Kelly & Zhang & Tang & Wang & Ren & Hao & Yang & Cohen &

Tang, 2018). In this randomized community trial, cognitive behavioral therapy was conducted

through high and low frequency texting messages. Biochemically verified continuous smoking

abstinence at 24 weeks was significantly higher in both the HFM (6.5% versus 1.9%, p < 0.001)

and LFM (6.0% versus 1.9%, p = 0.002) groups compared with the control group (Lloa & Wu &

Kelly & Zhang & Tang & Wang & Ren & Hao & Yang & Cohen & Tang, 2018). Principles of

the Intervention Wheel Model that apply to this intervention are counseling and advocacy. This

intervention uses risk factor modification as a strategy for tobacco cessation. Stakeholders

include the students, community members, healthcare providers, and legislature. Cellphone text

messaging rates can be expensive if not able to afford unlimited talk and text plans so funding is

a concern. The role of a community health nurse is to follow up on progress and provide

guidance throughout the program.

Tertiary Level of Prevention

Research supports a home-based pulmonary rehabilitation program for subjects with

COPD to be effective evidence based tertiary level of prevention among individual recipients. In

this randomized community trial, patients were to adhere to a 4-step home based pulmonary
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rehabilitation program that included warm up exercises, aerobic exercises, stretching, and post

workout relaxation. The home-based rehabilitation group walked a significantly longer distance,

with a mean increase of 65.7 to 83.1 m (p=.039), whereas the control group walked only an

additional 5.5 to 92.9 m (p=.34) (Pradella & Belmonte & Maia & Delgado & Luise &

Nascimento & Gazzotti & Jardim, 2015). Principles of the Intervention Wheel Model that apply

to this intervention are advocacy, counseling, and health teaching. This intervention uses risk

factor modification as a strategy for tobacco cessation. Stakeholders include the patients,

community members, public officials, legislature, and health care providers. The role of a

community health nurse is to provide the referral for home care, facilitate health teaching,

reinforce adherence, and monitor progress within the program.

Development of Health Policy

The purpose of developing this health care policy is to reduce the rate of initiating

tobacco use and/or promote cessation amongst school age children and adolescents in Pinellas,

County. Younger populations who use tobacco products are at a higher risk for developing

nicotine dependence and could lead to continuing the use of tobacco in adulthood (U.S.

Department of Health and Human Service, 2000). As a primary intervention, Pinellas County

schools can update school-based tobacco cessation programs by establishing a peer-led tobacco

prevention program as well as providing direct health counseling to decrease rates of tobacco use

in this population. Developing this community policy will address this population directly. By

doing so, can lead to an overall increase in community health outcomes.

The desired goal of the health policy is to develop a new school-based tobacco prevention

program that will educate and counsel students in the scholastic setting. These interventions

tackle the developmental stages that influence initiation of tobacco use and provide
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adolescents the ability to connect with peers and create the tools to self regulate. Current

evidence based adolescent tobacco interventions that support the best level of outcomes are

motivational enhancement, individual counseling, and cognitive behavioral therapy (CBT) (Pbert

& Farber & Horn & Lando & Muramoto & O'Loughlin & Tanski & Wellman & Winickoff &

Klein, 2015).

In initiating this health care policy proposal a nurse should first develop a supportive

network and establish his/herself as an active community member. A nurse can do this by joining

nursing organizations such as the American Nursing Association (ANA), Association of

Community Health Nursing Educators (ACHNE), or the Association of State and Territorial

Directors of Nursing (ASTDN). Seeking a mentor is important in guiding the policy process.

Next nurses should propose policy information to the Center for Disease Control and Prevention

(CDC) and The World Health Assembly (WHA). These establishments work to create and

promote community health policies and can be of great help. Inquiring the Agency for

Healthcare Research and Quality (AHRQ) to evaluate and back supportive research can be used

to inform members of congress. Next information needed to draft bill should be provided to

members of congress, in both the House and the Senate. Following the introduction of the policy

proposal, nurses will provide testimony during House and Senate committee meetings. A face-to-

face encounter can be strategically used with a legislator or a staffer to push the policy agenda

forward, allowing members to see the reality of how the policy affects real persons (Stanhope &

Lancaster, 2016). Testimonies and policy information will also be given to corresponding

subcommittee members. Once the full committee reports the drafted bill, policy, then nurses can

lobby members in local district and Washington, D.C.. Nurses should also learn how to properly

conduct email and phone calls to promote the implementation of the policy. This should be done
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at a local, state, and federal level during the federal policy discussions. Sending a letter to the

President can also help inform and aid solidifying implementation of proposed policies. If

passed, a nurse can then offer expertise to assist in modifying regulations.

Stakeholders that are affected by this health policy include the students, community

members, healthcare providers, and legislatures. Students are stakeholders because the program

will affect them. Community members and healthcare providers are stakeholders because they

will be implementing the tobacco prevention training for the students, counseling, and the

surveillance of the program. The Florida Department of health is a stakeholder because this

government establishment could provide funding for this program. Supporters of this

intervention would be local public health committee/community members who see how this

research can implement change among this community. Current youth groups that have recently

quit tobacco use / non-smokers who have had family history of lung cancer would support this

type of program. Those whom might oppose to this kind of program would be parents that do not

wish to provide tobacco education due to the fear that introduction of material could potentially

increase influence of tobacco use. Current policy health education representatives might oppose

the new policy in opposition of current programs already established due to the amount of time

and money needed to establish new interventions.

Conclusion

Facilitating a thorough community assessment, identifying a priority health issue, and

researching evidence based practice interventions can aid in the development of a health care

policy. These policies can be used to improve community health outcomes. It is one of many

nursing responsibilities to become active within his/her community to promote the constant

improvement of local and national community health care programs.

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References

Centers for Disease Control. (2018). Smoking & tobacco use fast facts. Retrieved from

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm

County Health Rankings & Roadmaps. (2019). Pinellas county demographics. Retrieved from

http://www.countyhealthrankings.org/app/florida/2019/rankings/pinellas/county/factorso

verall/snapshot

Kumar Mall, A. S., & Bhagyalaxmi, A. (2017). An informal school--based, peer-led intervention

for prevention of tobacco consumption in adolescence: A cluster randomized trial in

rural Gandhinagar. Indian Journal of Community Medicine, 42(3), 143.

Liao, Y., Wu, Q., Kelly, B. C., Zhang, F., Tang, Y.-Y., Wang, Q., Ren, H., Hao, Y., Yang, M.,

Cohen, J., & Tang, J. (2018). Effectiveness of a text-messaging-based smoking cessation

intervention (“Happy Quit”) for smoking cessation in China: A randomized controlled

trial. PLoS Medicine, 15(12), 1–18.

https://doiorg.ezproxy.lib.usf.edu/10.1371/journal.pmed.1002713

Pbert, L., Farber, H., Horn, K., Lando, H. A., Muramoto, M., O'Loughlin, J., Tanski, S.,

Wellman, R., Winickoff, J., Klein, J. (2015). State-of-the-art office-based interventions

to eliminate youth tobacco use: the past decade. Retrieved from

https://www.ncbi.nlm.nih.gov/pubmed/25780075

Pinellas County Economic Development. (n.d.). Largest target industry employers. Retrieved

from https://www.pced.org/page/Pinellas_Employers

Pradella, C. O., Belmonte, G. M., Maia, M. N., Delgado, C. S., Luise, A. P. T., Nascimento, O.

A., … Jardim, J. R. (2015). Home-based pulmonary rehabilitation for subjects with

COPD: A randomized study. Respiratory care, 60(4), 526–532.

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doi: 10.4187/respcare.02994

Stanhope, M., & Lancaster, J. (2016). Public health nursing: population-centered health care in

the community (9th ed.). St. Louis, MO: Elsevier.

United States Department of Health and Human Services, Healthy People2020. (2016).

Tobacco. Retrieved from https://www.healthypeople.gov/2020/leading-health-

indicators/2020-lhi-topics/Tobacco

U.S. Census Bureau. (2017). Poverty status in the past 12 months of families, 2013-2017

American community survey 5-year estimates. Retrieved from

http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?

pid=ACS_17_5YR_S1702

U.S. Department of Health and Human Services. (2000). Reducing tobacco use: A report of the

Surgeon General. Retrieved from

https://www.cdc.gov/tobacco/data_statistics/sgr/2000/complete_report/pdfs/full

report.pdf

U.S. Department of Health and Human Services, Office of Disease Prevention and Health

Promotion. (2018). Social Determinants of Health. In Healthy People 2020. Retrieved

from https://www.healthypeople.gov/2020/topicsobjectives/topic/social-determinants-of-

health