Problems & possibilities: smoking prevalence & cessation efforts in Virginia.

McKinney, Beth ; Maxey, Heather

Introduction

According to the Centers for Disease Control & Prevention (CDC), cigarette smoking contributes to the top leading causes of death: heart disease, cancer, chronic obstructive pulmonary disease, and stroke (2013b), making tobacco use the leading cause of preventable disease and death in the U.S. (2011a). Despite such serious health consequences, 19.0% of adults in the U.S. currently smoke (CDC, 2013a). While cigarette smoking is prevalent throughout the U.S., there are specific factors that affect smoking prevalence within each state. For example, Virginia ranks 12th among states because 16.4% of adults in Virginia currently smoke (CDC, 2011d). Some of the specific factors that are related to smoking prevalence in Virginia include failing grades on the American Lung Association's State of Tobacco Control Report (2013 a) as well as a large rural population that experiences poorer health status than those living in other regions of the state. In order to reduce the prevalence of smoking in Virginia it is important to determine what can be done to lessen the impact of these factors. The purpose of this paper is to describe the seriousness of as well as discuss current and future means of modifying each factor to reduce the prevalence of smoking in Virginia.

State of Tobacco Control Report for Virginia

The American Lung Association released its 11th annual State of Tobacco Control Report in 2013. This report monitored laws and policies in place since the beginning of January 2013 in order to determine how well tobacco use is being controlled at the state and federal level (American Lung Association, 2013d). According to this report, Virginia earned failing grades in all of the categories that were assessed: Tobacco Prevention Control & Spending, Smoke Free Air, Cigarette Excise Tax, and Cessation (American Lung Association, 2013b).

Tobacco Prevention Control & Spending

The Tobacco Prevention Control & Spending category indicates whether or not states are allocating adequate funds for aiding in tobacco prevention and reduction (American Lung Association, 2013c). A failing grade in this category is earned if states allocate funds for tobacco control programs in amounts less than 50% of the $103,200,000 that the CDC recommends (American Lung Association, 2013e). During the 2013 fiscal year, Virginia provided $11,279,257 for such programs, which is significantly less than the amount recommended by the CDC (American Lung Association, 2013b). Virginia's minimal allocation of funds is due in part to the fact that a portion of the money set aside for such programs has been used to cover non-tobacco-related budget deficits as well as to assist in efforts addressing other health issues, such as childhood obesity (Richmond Times-Dispatch, 2012).

Smoke Free Air

The Smoke Free Air category indicates the extent to which states keep their residents from being exposed to potentially lethal secondhand smoke (American Lung Association, 2013c). Virginia earned a failing grade in this category due to inadequate policies for the restriction of smoking. Virginia currently restricts smoking in a limited number of locations (i.e., health care facilities, restaurants, retail stores, and grocery stores), which means that smoking must be confined to certain designated areas within these locations. In addition, there are only two locations in Virginia where smoking is completely prohibited (i.e., public schools (K-12) and licensed childcare facilities), which means that smoking is not allowed within these locations at all (American Lung Association, 2012; American Lung Association, 2013b).

Cigarette Excise Tax

The Cigarette Excise Tax category compares such taxes among states. Virginia earned a failing grade in this category for having a cigarette excise tax less than $0.73 (American Lung Association, 2013c). More specifically, Virginia ranks 49th in the U.S. for having a cigarette excise tax of only $0.30 (American Lung Association, 2013b).

Cessation

The Cessation category measures the effectiveness of cessation efforts offered by each state (American Lung Association, 2013c). Virginia earned a failing grade in this category due to inadequate coverage in the following areas: Medicaid, State Employee Health Plans, Quit Lines (American Lung Association, 2013a). Quit lines are one of the three areas considered when grading states in this category because they are an economical and centralized way for states to offer referrals as well as actual services to all of their residents. Such centralized services are important given the fact that the availability of smoking cessation resources across the state is often inadequate (Riordan, 2012). Currently, Virginia's Medicaid Program only covers individual counseling and a couple of medications (e.g., Zyban and the Nicotine Replacement Therapy Patch) while State Employee Health Plans only cover phone counseling and certain medications (e.g., Zyban, Chantix, and Nicotine Replacement Therapy Patches, Gums, and Inhalers). In addition, Virginia only invests $0.42 per smoker in the state quit line, which is significantly less than the $10.53 recommended by the CDC (American Lung Association, 2013b).

Virginia's Rural Population

Approximately 65% of the counties and cities in Virginia are considered rural (Virginia Department of Health, 2011). The least healthy localities across the U.S. and in Virginia are mostly rural (Council on Virginia's Future, 2013b), with populations that categorize their health as fair to poor more often than populations from other localities (U.S. Department of Health & Human Services, 2009).

Education, Income, & Poverty

This poor health status may be due to the fact that there are more issues related to health care in rural as opposed to other areas within the U.S. (Virginia Department of Health, 2011), including lower education and income levels, which lead to higher poverty levels (National Rural Health Association, n.d.). One way that such levels can detract from health is by having a significant impact on smoking rates (Council on Virginia's Future, 2013a). With regard to education level, 25.1% of people with less than a high school education smoke; 23.8% of high school graduates smoke; and 9.9% of people with undergraduate degrees smoke (CDC, 2011a). In terms of income, there is a higher percentage of smokers among those who earn less than $15,000 annually as compared to those who earn more than $50,000 annually, 35.8% and 13.7% respectively (Council on Virginia's Future, 2013a). Concerning poverty rate, 29% of people living below the poverty level smoke and 18% of people living above the poverty level smoke (CDC, 2011a). Lower education and income levels along with higher poverty levels can impact smoking rates through associations issues related to health care (University of Missouri, 2011).

Utilization of Health Care

Lacking an accurate understanding of what it means to be healthy, rural individuals often consider good health to be the ability to do work as opposed to being free of illness. Typically, they do not place much emphasis on the negative aspects of poor health, accepting health problems as an everyday part of life (Labuhn, Lewis & Koon, 1993). As such, these individuals are less likely to utilize health care services.

Cost of Health Care

While some rural individuals may be interested in receiving health care, they make up approximately 20% of the uninsured population in the U.S. (Health Resources & Services Administration, 2009). Without the assistance of private programs such as those provided by employers as well as public programs like Medicaid to help cover the cost of health care services (Stanford School of Medicine, 2013), those who lack coverage are less likely to receive appropriate health care (Blumenthal, 2007).

Lack of Qualified Health Care

Even rural individuals who can afford health care may not have adequate access to it because only 10% of physicians throughout the U.S work in rural areas (Stanford School of Medicine, 2013). In addition, health care providers in rural areas are often less qualified to assess the smoking habits of their patients as well as to provide their patients with smoking cessation assistance (Rayens, Hahn, & Hedgecock, 2008).

Recommendations for Reducing Smoking Prevalence in Virginia

Improving Virginia's Grade on the State of Tobacco Control Report

With regard to the American Lung Association's State of Tobacco Control Report, improved grades in all of the assessed categories could potentially reduce smoking prevalence in Virginia: Tobacco Prevention Control & Spending, Smoke Free Air, Cigarette Excise Tax, Cessation (American Lung Association, 2013b).

Tobacco prevention control & spending. The CDC recommends that states spend at least $103,200,000 on tobacco control programs. To meet the CDC recommendation and to improve its grade in this category, Virginia would need to increase the amount of money allocated for such programs from $11,279,257 to at least $103,200,000 (American Lung Association, 2013b). In order to do so, Virginia should find other sources of funding to cover non-tobacco-related budget deficits as well as to assist in efforts addressing other health issues (Richmond Times-Dispatch, 2012). If this can be accomplished then all of the money that was initially designated for tobacco prevention will be available to fund such programs.

Smoke free air. To prevent another failing grade in this category, Virginia would need to improve its policies for the restriction of smoking. This could be done by expanding the prohibition of smoking beyond public schools and licensed childcare facilities, to also include government workplaces, restaurants, bars, retail stores, and recreation/cultural facilities. It would also be beneficial for Virginia to begin enforcing restrictions and/or prohibitions for smoking in the private sector as well (e.g., private schools and private childcare facilities and private workplaces) (American Lung Association, 2013b).

Cigarette excise tax. In order for Virginia to receive a passing grade in this category the cigarette excise tax would need to increase from $0.30 to at least $0.73 (American Lung Association, 2013c). However, if Virginia desired to strive for an A in this category the cigarette excise tax would need to increase from $0.30 to at least $2.92 (American Lung Association, 2013b).

Cessation. To meet the CDC recommendation and to improve its grade in this category, Virginia would need to enhance its efforts to assist with smoking cessation by increasing the amount of medications and counseling covered by all Medicaid and State Employee plans. In addition, Virginia would need to increase the amount of funds it invests per smoker in the state quit line from $0.42 to at least $10.53 (American Lung Association, 2013b).

Improving Cessation-Related Health Care for Virginia's Rural Population

With regard to Virginia's rural population improvements can be made in the areas of utilization, cost, and availability of qualified health care in order to potentially reduce smoking prevalence in Virginia

Utilization of health care. In order for rural individuals to recognize the need to quit smoking and utilize health care resources to do so, health care providers can help them understand what a healthy lifestyle entails and why such a lifestyle is important (CDC, 2011b).

Cost of health care. Those who lack health care coverage, however, are less likely to receive appropriate health care services (Blumenthal, 2007). Therefore, it is important to provide more coverage by public or private resources so that rural individuals can better afford to access the health care services they need. Through the Affordable Care Act, the federal government plans to address this lack of coverage by changing eligibility requirements so that families of no more than four individuals living off of annual incomes of less than $29,000 can now receive Medicaid coverage (White House, n.d.a). In addition, the Affordable Care Act makes it more feasible for small businesses to offer health care coverage to their employees at an affordable rate by providing these businesses with tax credits for doing so (White House, n.d.b).

Lack of qualified health care. Due to the fact that only a small percentage of qualified health care providers choose to practice in rural areas (Rayens, Hahn, & Hedgecock, 2008; Stanford School of Medicine, 2013) it is important to provide adequate incentives, reimbursement, and funding to encourage them to work in these areas. It is also important to offer further training to better prepare these health care providers to meet the unique needs of those living in rural areas. Through the Affordable Care Act, the federal government plans to provide financial incentives to health care providers so that they are more inclined to work in rural areas. To further meet the needs of underserved populations, the Affordable Care Act has also provided additional funding for health care facilities to be established and staffed by trained health care providers in areas that currently have limited access to health care (White House, n.d.a). Since the prevalence of smoking is higher in such areas, it is even more important for health care providers to receive training specifically related to smoking. According to the Partnership for Prevention (2008), such training should teach health care providers how to utilize long-term and short-term treatment options that are proven to be effective when it comes to smoking, such as drug therapy and counseling.

Conclusion

As of 2010, 68.8% of smokers desired to quit, with 52.4% actually attempting to do so, and only 6.2% being successful (CDC, 2011c). Since a majority of smokers want to quit, the small percentage of smokers who were successful in their attempts indicates that the amount of resources available for effective smoking cessation is inadequate. While the Affordable Care Act has made some progress toward improving smoking cessation efforts, in order to reduce the prevalence of smoking additional support must be provided by state and federal governments as well as qualified health care providers. Implementing the recommendations outlined above gives Virginia the opportunity to improve its grade on the State of Tobacco Control Report as well as increase the availability of qualified health care resources to all Virginians, which will likely reduce the prevalence of smoking throughout the state. Doing so has the potential to improve health within the state of Virginia for smokers and non-smokers alike.

References

American Lung Association. (2013a) Cessation. Retrieved from www.stateoftobaccocontrol.org/state-grades/methodology/ cessation.html

American Lung Association. (2013b). Grade summary: Virginia. Retrieved from www.stateoftobaccocontrol.org/state-grades/ virginia/grade-summary.html

American Lung Association. (2012). SLATI state information: Virginia. Retrieved from www.lungusa2.org/slati/statedetail. php?stateId=51

American Lung Association. (2013c). State rankings. Retrieved from www.stateoftobaccocontrol.org/state-grades/staterankings/

American Lung Association. (2013d). State of tobacco control 2013. Retrieved from www.stateoftobaccocontrol.org/at-aglance/

American Lung Association. (2013e). Tobacco prevention control and spending. Retrieved from www.stateoftobaccocontrol. org/state-grades/state-rankings/tobacco-prevention-controlspending.html

Blumenthal, D. (2007). Barriers to the provision of smoking cessation services reported by clinicians in underserved communities. Journal of the American Board of Family Medicine, 20(3), 272-279.

Centers for Disease Control & Prevention (2013 a). Adult smoking in the United States: Current estimate. Retrieved from www. cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_ smoking/index.htm

Centers for Disease Control & Prevention. (2011a). Adult smoking in the U.S. Retrieved from www.cdc.gov/vitalsigns/ adultsmoking/

Centers for Disease Control & Prevention (2011b). Four specific health behaviors contribute to a longer life. Retrieved from www.CDC.gov/features/livelinger/

Centers for Disease Control & Prevention. (2011c). Quitting smoking among adults - United States, 2001-2010. Morbidity and Mortality Weekly Report, 60(44), 1513-1519.

Centers for Disease Control & Prevention. (2013b). Smoking & tobacco use: Fast facts. Retrieved from www.cdc.gov/tobacco/ data_statistics/fact_sheets/fast_facts/index.htm

Centers for Disease Control & Prevention. (2011d). Smoking & tobacco use: State highlights - Virginia. Retrieved from www.cdc.gov/tobacco/data_statistics/state_data/state_ highlights/2010/states/virginia/index.htm

Council on Virginia's Future. (2013a). Key objectives for health and family: Smoking. Virginia Performs. Retrieved from www.vaperforms.virginia.gov/ indicators/healthfamily/smoking.php

Council on Virginia's Future. (2013b). Key objectives for health and family: Summary. Virginia Performs. Retrieved from http://vaperforms.virginia.gov/indicators/healthfamily/ summary.php

Health Resources & Services Administration. (2009). HSRA care action: New strategies for rural care. Retrieved from www.hab. hrsa.gov/newspublications/careactionnewsletter/april2009.pdf

Labuhn, K., Lewis, C., Koon, K., & Mullolly, J. (1993). Smoking cessation experiences of chronic lung disease patients living in rural and urban areas of Virginia. The Journal of Rural Health, 9, 305-313.

National Rural Health Association. (n.d.). What's different about rural health care?. Retrieved from http://www.ruralhealthweb. org/go/left/about-rural-health/what-s-different-about-ruralhealth-care

Partnership for Prevention. (2008). Healthcare provider reminder systems, provider education, and patient education: Working with healthcare delivery systems to improve the delivery of tobacco-use treatment to patients - An action guide.

Retrieved from healthcare_provider_reminder_systems_provider_ education_and_patient_education-tobacco_treatment.pdf Rayens, M., Hahn, E., & Hedgecock, S. (2008). Readiness to quit smoking in rural communities. Issues in Mental Health Nursing, 29, 1115-1133.

Richmond Times-Dispatch. (2012, December 8). Va. spending only 2.5% of settlement on tobacco prevention. Richmond Times-Dispatch. Retrieved from www.timesdispatch.com/ business/economy/va-spending-only-of-settlement-on-tobacco prevention/article_00ae79cb-534b-58ed-bf16-528f9db491dc. html

Riordan, M. (2012). Quitlines help smokers quit. Retrieved from www.tobaccofreekids.org/research/factsheets/pdf/0326.pdf

Stanford School of Medicine. (2013). Healthcare disparities & barriers to healthcare: Rural health fact sheet. Retrieved from http://ruralhealth.stanford.edu/health-pros/factsheets/ disparities-barriers.html

United States Department of Health & Human Services. (2009). Hard times in the heartland: Health care in rural America. Retrieved from www.hhs.gov/news/press/2009pres/05/20090504a.html University of Missouri School of Medicine Center for Health Ethics (2011). Healthcare access. Retrieved from http://ethics. missouri.edu/Healthcare-Access.aspx

Virginia Department of Health. (2011). Virginia HIV epidemiology profile 2011. Retrieved from www. vdh.virginia.epidemiology/diseaseprevention/ Profile2011/rural_2011.pdf

White House. (n.d.a). The Affordable Care Act helps rural America. Retrieved from http://search.whitehouse.gov/search?affiliate= wh&m=false&query=rural+healthcare

White House. (n.d.b). Health care reform for rural Americans: The Affordable Care Act gives rural Americans greater control over their own health care. Retrieved from http://search.whitehouse. gov/search?affiliate=wh&m=false&query=rural+healthcare

Beth McKinney, PhD, MPH, CHES, Associate Professor of Health Promotion

Heather Maxey, MA, CHES, Instructor of Health Promotion School of Health Sciences & Human Performance, Lynchburg College