Tobacco Prevention and Control Coalition



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The Coalition, Inc. FY2014


Tobacco Prevention and Control Coalition

Narrative-Form Needs Assessment Outline



FY2014

Coalition Name: The Coalition, Inc.
Submission Date: 7/15/14

Part I – Geographic / Target Population and Coalition Overview
Angelina and Nacogdoches Counties are located deep within the piney woods of East Texas. They are unusual for many reasons. They are rural, poor, and undereducated with a number of small communities and no large cities. They are spread over a large timber forest thus making the delivery of services a nightmare. Both are serviced by the Brazos Transit District, a public transportation system, within the Lufkin and Nacogdoches city limits only.

Angelina County is 120 miles north of Houston and 220 miles southeast of Dallas. Angelina County has a population of 87,597 estimated by the Census Bureau for 2012. Angelina County has 864 square miles of land area and a population density of 100 people per square mile. Primary industries are manufacturing, healthcare, education, agriculture and tourism. The largest employers are Brookshire Brothers, Lufkin Industries, Lufkin ISD, Lufkin State Supported Living Center, Memorial Health System of East Texas, and Pilgrim’s Pride. The healthcare industry is one of the fastest growing industries in the county and has become a regional medical center for the East Texas area.


Table 1.1

Angelina County’s racial demographics are (represented in Table 1.1, above): 62.6% white, 14.5% African American, 20.5% Hispanic/Latino, and 2.4% other. Those with less than a high school education in Angelina County are 23.9%; 30.94% have graduated from high school and .09% have a bachelor’s degree or higher. The median household income in Angelina County is $39,325 with 18.4% living below the poverty level. The average family size is three. Sixty-nine percent own their own homes and 11.2% rent their homes. According to the Texas Department of State Health Services Health Facts Profile 2009, the total population in Angelina County without health insurance is 21,396 (31.5%).

Nacogdoches County has a population totaling 66,034 estimated by the Census Bureau for 2012. Nacogdoches has the distinction of being the Oldest Town in Texas. Nacogdoches is located 150 miles northeast of Houston, 220 miles southeast of Dallas, and 80 miles southwest of Shreveport, Louisiana. Nacogdoches County has a diversified industrial base: manufacturing, health care, education, retail trades, tourism and agriculture being the primary industries. The manufacturing industry includes such operations as feed and fertilizer, valves, business forms, electrical parts, transformers, motor homes, poultry processing and sealing components. The two largest employers in the county are Pilgrim’s Pride (poultry processing) with 1,725 employees and Stephen F. Austin State University (higher education) with 1,609 employees.
Table 1.2


Nacogdoches County’s racial demographics are (represented in Table 1.2, above): 61.1% white, 18.2% African American, 18.2% Hispanic/Latino, and 2.5% other. Those with less than a high school education in Nacogdoches County are 19.5%; 80.5% have graduated from high school and 24.1% have a bachelor’s degree or higher. Nacogdoches County has a median household income of $35,378 with 24.1% living below the poverty level. The average family size is three. Fifty-nine percent own their own homes and 21.3% rent their homes. According to the 2009 Health Facts Profile from the Texas Department of State Health Services, the total population in Nacogdoches County without health insurance is15,593 (28.5%). The poverty population of Nacogdoches County has been designated as a Medically Underserved Population (MUP) with a whole county poverty population as approved by the Governor as of February 2010.
Lufkin is the county seat of Angelina County and the largest town, with a population of 35,067. It has been named a micropolitan area by the Bureau of Census. Lufkin ISD is a Class 5-A district with eleven elementary schools, one middle school, one high school and one alternative school. The district has 535 classroom teachers. Lufkin is experiencing white flight to the smaller communities who do not have the racial mix. The Hispanic population is the fastest growing group in the Lufkin schools.

The Lufkin ISD records indicate the racial demographics to be: 47.3% white, 30.2% African American, 21.1% Hispanic and 1.4% other. Of the Lufkin ISD students 73.3% are considered economically disadvantaged. Lufkin is home to Angelina College with a student enrollment of approximately 6,000 students.



Central, located in the northern part of Angelina County, does not have an incorporated city. It is a small rural community focused on the school district and the only major employer, the Lufkin State School, which employs over 1,100 people. The majority of the residents are employed outside of Central. The Diboll community, located on Highway 59 South also has a large employer, Georgia Pacific, who employs 500, many of which are Hispanic. The population of Diboll is 4,776.

Hudson is another small rural community in Angelina County, with 4,731 residents, located on Highway 94 West. Lockheed Martin Vought Systems is the largest employer. Most of the residents are employed in Lufkin. Huntington, located on Highway 69 South, has a population of 2,118. There is no major industry in Huntington. Most of the residents are employed elsewhere in the county, primarily in Lufkin. The poverty population of Huntington has been designated as a Medically Underserved Population (MUP).

Zavalla, located in the southernmost part of the county on Highway 69 South, is the smallest town with a population of 713. Zavalla’s major industry is recreation from Lake Sam Rayburn. Residents are employed in recreation-related business, by the school district, or in Lufkin.

Nacogdoches serves as the county seat for Nacogdoches County. It is one of the largest towns in the region with a population of 33,405 individuals. Nacogdoches Independent School District records indicate the racial demographics to be: 24% white, 43.5% Hispanic/Latino, 29.2% African American, and 3.3% other. Of the Nacogdoches ISD students 78.63% are considered economically disadvantaged. Nacogdoches is proud to be home to Stephen F. Austin State University (SFASU) founded in 1923. In addition to the Nacogdoches County residents, there are approximately 13,000 SFASU students.

Nacogdoches County has many small communities. Garrison is a small town of 907 residents and served by Garrison ISD, with 671 students; Cushing is a community of 621 people and served by Cushing ISD, a predominately white district of 496 students; Appleby, a community of 480 is served by the Nacogdoches Independent School District. Other smaller communities within the county are Central Heights, located in north central Nacogdoches County, is served by Central Heights ISD, a predominately white school district of 861 students; Chireno, a small community of 393 people, is served by Chireno ISD, a school district of 350 students; Douglass, located in south Nacogdoches County is served by Douglass ISD, a white rural school district of 362 students; Etoile, located in southeastern Nacogdoches County is served by Etoile ISD, a predominately white rural school district of 123 students; Martinsville in eastern Nacogdoches County is served by Martinsville ISD, a predominately white rural district of 322 students; and Woden located in the southeastern part of the county is served by Woden ISD, a predominately white rural district with 814 students.

The Coalition, a 501 C(3) organization, is a group of concerned citizens and parents intent on eliminating the use of harmful substances by influencing public policy, laws, attitudes, and behaviors. This organization was established in 1988 by the superintendents of the six school districts in Angelina County who saw drugs as a problem and wanted a county-wide prevention program. The Coalition has collaborated with the Texas Department of State Health Services since 1999 when it was then the Texas Commission on Alcohol and Drug Abuse. We were one of eleven grant recipients in the state who received the first community coalition grants that TCADA awarded and continue to receive this funding.



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.

    1. Prevention Resource Center (PRC)- Alcohol & Drug Abuse Council of Deep East Texas – This grant was just awarded but we have always worked with the Alcohol & Drug Abuse Council.

    2. Other Coalitions (DFC and CCP Coalitions, other tobacco coalitions) - CCP for Angelina County, of which The Coalition is the grant recipient and CCP for Nacogdoches County, of which the Alcohol & Drug Abuse Council is the grant recipient.

    3. Other state or federally funded prevention providers- The Alcohol & Drug Abuse Council and The Coalition work together for Red Ribbon Week, Recovery Oriented Systems of Care, and the Executive Director serves on The Coalition board.

    4. School Programs (Communities in Schools, etc.)- Lufkin ISD has a School Health Advisory Council, of which The Coalition is a member. We provide drug prevention information at events that they sponsor and suggest ways to integrate drug prevention in health programs. Youth Prevention International, which covers grades 1-3, is provided as part of the Alcohol and Drug Abuse Council’s prevention services.

    5. Community Programs and Services (YMCA, Goodwill, etc.) in Angelina County are Burke Center MHMR, Angelina County & Cities Health District, Lufkin Dream Center, Boys and Girls Club, Salvation Army, and Goodwill. The Coalition works with these groups through the Interagency Coalition. The Interagency Coalition includes all of the social service agencies in Angelina County which has monthly meetings and publishes an Interagency Brochure. The Interagency Brochure is bilingual and updated yearly in print form (10,000 brochures printed) and monthly on The Coalition’s website. It includes the phone numbers for the following: emergency services, education training, employment, housing, medical, family services, transportation and alcohol/drug abuse. The Coalition notifies members of meetings and acquires speakers for the meetings.

    6. Parent programs (PTA, etc.)- The PTAs are active and The Coalition is involved in coalition anti-tobacco efforts via the Kid’s Expo. The PTA has been well represented there each year since 2010. We will also be approaching the organization about presentations on prevention to parent/teacher groups and gatherings and becoming involved in health fairs and other activities.

    7. Direct Prevention Service Providers are the Alcohol and Drug Abuse Council YPU, YPI, Preventing Abuse by Reaching Today’s Youth (PARTY) covers youth and adult prevention needs in a twelve county region, which includes Angelina and Nacogdoches counties. DETCOG STAR, Boys and Girls Club of Deep East Texas are two others to which we provide tobacco no use presentations.

    8. Treatment Providers- The only treatment provider is the Alcohol and Drug Abuse Council OSAR, Outpatient and the Lufkin Dream Center. His Most Excellent Way, Greyson’s Place, Celebrate Recovery, and Alcoholics Anonymous are available after treatment. The Coalition is a member of the Recovery Oriented Systems of Care (ROSC) in Angelina County, meets monthly with the ROSC, and works with these groups providing Recovery Day in the Park in September, which is National Recovery Month.

    9. Healthcare providers- Angelina County has two hospitals: Memorial Health System of East Texas and Woodland Heights Medical Center. The Coalition has representation on the board from Memorial Medical System and Woodland Heights has representation on the Drug-Free Business Partnership Committee. The hospitals provide The Coalition with drug related statistics for assessment. The Healthy Nacogdoches Coalition is a part of Nacogdoches Memorial Hospital and provides smoking prevention information. Local clinics, such as East Texas Community Health Services and the Cushing Clinic have utilized our services.

    10. Higher Education Prevention- Angelina County has a community college, Angelina College. The Coalition board has representation from Angelina College and we plan to continue our collaboration with the Great American SmokeOut and the Angelina College Fitness Fair. Stephen F. Austin State University participates on the Healthy Nacogdoches Coalition as a tobacco committee member.

    11. Law Enforcement- The Coalition board has representation from the Lufkin Police Department, the Nacogdoches Police Department, and the Angelina County Sheriff’s Department. The Coalition works with the Angelina County Sheriff’s Department and the Nacogdoches Police Department on tobacco compliance checks.




  1. Identify and explain existing smoke free ordinances and organizational/school policies.

The cities of Lufkin and Nacogdoches have comprehensive smoke free ordinances. All four of the hospitals in Angelina and Nacogdoches counties are smoke free campus. All schools have tobacco free policies.


  1. What prevention gaps exist in your target community?

A predominately rural geography of the region, country lifestyles and traditions, and the socio-economic challenges combine to create equally daunting gaps and barriers. 26% of the adult population smokes and smokeless tobacco is traditional in the region.

In order to address these issues, we need to establish a presence in the outlying communities as well as the county seats and deal with the issues of that rural population.



PART III – Community Consumption Patterns
The Texas School Survey of Nacogdoches ISD elementary students, grades 4-6, tell us the following:

  • 69% of students believe tobacco use is “very dangerous” (76% statewide)

  • 14% reported they had been offered cigarettes ( 9% statewide)

  • 7% reported some or most of their close friends use snuff or chewing tobacco (5% statewide)

  • 8% reported general tobacco use at least once during their lifetime (5% statewide)

  • 7% reported smoking cigarettes at least once during their lifetime (4% statewide)

  • 2% reported lifetime use of smokeless tobacco products (1% statewide)

  • 20% of district elementary students said some or most of their close friends smoke cigarettes (11% statewide)

The Texas School Survey of Nacogdoches ISD secondary students, grades 7-12, tell us the following (represented in Table 3.1, below):

  • 54% of Nacogdoches ISD secondary students believe that tobacco use is “very dangerous” (57% statewide)

  • 31% reported general tobacco use at least once during their lifetimes (28% statewide)

  • 13% said they had used a tobacco product during the past month (11% statewide)

  • 12% reported they had smoked cigarettes during the past month (10% statewide)

  • 2% reported smoking cigarettes on a daily basis (2% statewide)

  • 81% of students said their parents strongly or mildly disapprove of kids smoking (85% statewide)

Table 3.1



The Angelina County Environmental Strategies Survey of secondary students, grades 6, 8, 10, and 12, tell us the following (represented in Table 3.2, below):



  • 36.4% of Angelina County secondary students believe that tobacco use is “very harmful or harmful”

  • 26.3% reported general tobacco use at least once during their lifetime

  • 14.8% said they had used a tobacco product during the past month

  • 63.9% of students said their parents strongly or mildly disapprove of kids smoking

In the past 17 years in Angelina County, the youth tobacco rates have gone down substantially due to education efforts from 27.5% in 1994 to 11.2% in 2011.


Table 3.2


Of the most recent report from the Behavioral Risk Factor Surveillance Systems (BRFSS) in 2010, only data at the Regional level is available. It shows several modifiable risk factors for chronic disease are more prevalent in the DSHS Region 4/5N than statewide:


BRFSS

2010

Current

Smoker

Uses Cigarettes or Smokeless

Diabetes

No Leisure Time Physical Activity

Obesity (BMI 30 or greater)

Reg 4/5N

21.4%

26.0%

11.9%

37.0%

33.5%

Texas

15.8%

18.3%

9.7%

26.7%

31.8%

In the recent 2013 County Health Rankings report, Nacogdoches County was found to be ranked 167/232 of ranked Texas counties and Angelina County was found to be ranked 189/232. The County Health Rankings measure the health of nearly all counties in the nation and rank them within states.  The Rankings are compiled using county-level measures from a variety of national and state data sources.

The tobacco related health consequences in Angelina and Nacogdoches counties result in higher rates of lung and bronchus cancers, heart attacks, strokes, chronic pulmonary obstructive disease, emphysema, and many other cancers. Children of smokers suffer with higher incidents of respiratory infections, asthma, and Sudden Infant Death Syndrome.


Estimated New Cases of Lung and Bronchus Cancers5

Plus Rate per 100,000

2003 – 2006 Texas Cancer Registry


Texas

Public Health Region

Or


Metropolitan Statistical Area (MSA) or Public Health Region (PHR)

51,009

66.9 cases/100,000



Angelina County/Nacogdoches County

407,176


350 cases/100,000

Source: Texas Cancer Registry, Selected Cancer Facts by PHR, 2007, http://www.dshs.state.tx.us/tcr




Estimated Number of First Heart Attacks (Myocardial Infarction)Per Year

Plus Rate per 100,000

Local Hospital Discharge Data (list dates covered)


Hospital Name

Dates

# First Myocardial Infarctions

Memorial Health System of East Texas

01/01/2009-12/31/2009

314

Nacogdoches Memorial Hospital

01/01/2010-12/31/2010

69

Woodland Heights Medical Center

01/01/2014-07/01/2014

163

Source: Memorial Health System of East Texas and Nacogdoches Memorial Hospital




Estimated Number of Lung Cancer Deaths

Plus Rate per 100,000

2003-2006 Texas Cancer Registry


Texas

Public Health Region Or MSA

38,717

Angelina County/Nacogdoches County

51.2 deaths/100,000

407,176

231 deaths/100,000



Source: Texas Cancer Registry, Selected Cancer Facts by PHR, 2007, http://www.dshs.state.tx.us/tcr

*An estimated 80 – 90% of these deaths are due to smoking

U.S. DHHS, The Health Consequences of Smoking: a report of the surgeon general, Atlanta, GA. Centers for Disease Control and Prevention, Office of Smoking and Health; 2004.


PART IV – Community Consequences
Please identify the patterns in each of the following data sources, if available. You may also include data on additional consequences and/or focus on the consequence data that you find to be most relevant to your community. Highlight any identified disparities in community consequences.


    1. Citations for underage tobacco possession-

    2. Citations for selling tobacco to minors – 2 out of 60

    3. Asthma rates-8.9% at risk – 1,741 sample size

    4. Cancer rates – 4,677 new cancer cases; 1,766 deaths in HSR 4/5

    5. Heart disease rates – 5.7% at risk – 1,741 sample size

    6. Emergency room visits for heart attacks - 5.7% at risk – 1,741 sample size

    7. Emergency room visits for asthma-

    8. Healthcare costs associated with tobacco-related diseases-

    9. Number/percentage of restaurants that are smoke free- 100% in Lufkin and Nacogdoches

    10. Number/percentage of bars that are smoke free- 100% in Lufkin and Nacogdoches

    11. Number/percentage of campuses that are smoke free – All of the ISDs in Angelina and Nacogdoches are smoke free and both Angelina College and Stephen F. Austin University are smoke free. All 4 hospitals, all colleges and universities, and three businesses.

    12. Number of tobacco retailers and geographic location – 41 retailers in Nacogdoches county

    13. Cost of cigarettes - $6.89

    14. Total number of cigarette sales -

    15. Quitline use rates -

    16. Youth truancy rates – 13% for Angelina County

    17. Tobacco use and consequence disparity data

    18. Other data sources identified


Part V – Intervening Variables
Please discuss each of the following intervening variables. Include the effect on your community as well as the evidence of each variable (i.e. the contributing factors) in your community.


  1. Retail Access- On the latest Angelina County Environmental Drug Survey students stated that it was not easy to obtain tobacco from retail establishments

  2. Enforcement – Students from the Angelina County Environmental Drug Survey felt that parents and the police would catch them using tobacco, but were neutral about teachers, counselors and school officials catching them.

  3. Social Access – Youth stated that they had access of tobacco through friends, at parties, at a friend’s home and lastly when someone else bought it, such as an older friend or sibling as stated in the Angelina County Survey.

  4. Social Norms (Includes Perceived Risk) – 54% of Nacogdoches ISD secondary students and 36.4% of Angelina County secondary students believe that tobacco use is “very harmful or harmful.”

  5. Promotion – Through observation it is determined that promotion is most heavily geared toward consumers at the gas pump and at convenience stores. There is also a discernible lack of “We card” signs. This indicates that the audience of choice for merchants is younger and wants convenience. They want to be able to offer cigarettes at cut rates (sales are always posted) that are obtainable at a counter or window when you pay for gas, and they do not want anyone who purchases illegally to fear retribution. In addition, electronic cigarettes are more and more heavily promoted in our counties as well.

  6. Pricing – Pricing maintains the state level in order to help merchants avoid losing customers. Sales are unavoidable, and local discount stores have installed vending machines to allow for quick and easy access as well. Cigarettes can be purchased at discount rates at “dollar stores” and a myriad of other discount outlets, as well as the convenience stores.


Part V – Community Readiness
Please describe the readiness of each of the following sectors in your community to implement your strategies. These answers can be based on coalition feedback and community member interviews. This information may help you identify potential allies or community perceptions and knowledge, which you can describe here.
The latest coalition member survey tells us the following:

    1. Youth – somewhat knowledgeable

    2. Parents - knowledgeable

    3. Business community - knowledgeable

    4. Media - knowledgeable

    5. Schools - knowledgeable

    6. Youth-serving organizations – somewhat knowledgeable

    7. Law enforcement agencies- knowledgeable

    8. Religious or fraternal groups- somewhat knowledgeable

    9. Civic or volunteer groups – somewhat knowledgeable

    10. Healthcare professionals- knowledgeable

    11. State, local, tribal governments - knowledgeable

    12. Other organizations interested in substance abuse prevention - knowledgeable


Part VI – Putting it all Together
Please develop a summary of the findings from your community needs assessment. Briefly discuss alignment with evidence-based strategies and the goals outlined in your Statement of Work. Also indicate opportunities for community change, such as setting a smoke-free ordinance goal or increasing specific data collection where your needs assessment indicates there is a gap.
Angelina and Nacogdoches counties are rural, poor, and undereducated which are risk factors for using tobacco. Nacogdoches ISD secondary schools reported 12% had smoked cigarettes in the past month and 14.8% of Angelina County secondary students reported using a tobacco product in the past month. In the recent 2013 County Health Rankings report, Nacogdoches County ranked 167/232 of ranked Texas counties and Angelina County was found to be ranked 189/232.
These statistics show that we must meet the following goals:

  • Prevent tobacco use among young people

  • Promote compliance and support adequate enforcement of federal, state and local tobacco laws

  • Increase cessation among young people and adults

  • Eliminate exposure to secondhand smoke

  • Reduce tobacco use among populations with the highest burden of tobacco-related health disparities

  • Develop and maintain statewide capacity for comprehensive tobacco prevention and control

Our most pressing goal is to provide cessation counseling and classes, encourage businesses to establish tobacco free campuses, and advertise the Quitline to the community.


Part VII – Logic Model
Please attach a copy of your logic model to this document, using the following format or a similar format.




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