North Carolina’s Strategic Plan on Tobacco Related Health Disparities - Identifying the Data

1. North Carolina’s Strategic Plan on Tobacco Related Health Disparities - Identifying the Data Scott K. Proescholdbell, MPH; Felicia Snipes-Dixon, MPH; Laurie Mettam-Rude, MEd; Sheri Scott, MPH N.C. Dept. of Health and Human Services Division of Public Health Tobacco Prevention and Control Branch

2. Problem North Carolina (NC) is composed of a number of diverse groups many of which are affected by tobacco use. In order to better address tobacco-related problems, identification of populations with the highest tobacco burden is critical. The North Carolina Tobacco Prevention and Control Branch (TPCB) was funded by the CDC to conduct a one year pilot planning project focusing tobacco-related disparities. In conjunction with the state health department, an array of health professionals and community members formed the NC Tobacco Diversity Workgroup (Workgroup) to develop a plan for NC to address tobacco-related health disparities based on valid and reliable data.

3. Total Population: 8 million Gender: Male (49%) Female (51%) Age: Under 5 yrs (6.7%) 65+ (12.0%) Education: College degree or higher (22.5) Less than High School education (21.9%) Poverty: Individuals below poverty level (12.3%) North Carolina Demographics Source: Census 2000

4. North Carolina Demographics, Cont. • Race/ethnicity • White 72.1% 5.8 mill • African American 21.6% 1.7 mill • American Indian 01.2% 99,551 • Asian 01.4% 113,689 • Other 03.7% 293,872 • Hispanic 04.7% 378,963 Source: Census 2000 and adults (ages 18+) reporting one race

5. El Pueblo NC Commission on Indian Affairs American Cancer Society NC Office on Minority Health Old North State Medical Society African-American Action Team Dispute Settlement Center NC State Center for Health Statistics NC Office on Rural Health Development NC Council for Women HBCU Health Alliance Cancer Information Service UNC Health Promotions NC Asian American and Pacific Islander Association Faith Action International House Diversity Workgroup Established in Jan. 2001

6. Lower tobacco use prevalence rates among highest groups Eliminate gaps in data Raise awareness of tobacco-related health issues Change tobacco-related social norms Develop capacity among community leaders Secure sustainable funding to move plans forward Six CDC Sub-Goals to be Addressed

7. Methods The Workgroup identified and assessed all existing NC specific data sources available to gain insight on specific population groups. Populations that did not have valid data but were considered at risk were noted and methods identified for the future to collect valid and reliable data. A standard process was then applied to all data sources to identify and prioritize groups.

8. NC BRFSS NC YTS NC YRBSS NC PRAMS NC Asthma Survey NC Six County CVH Survey Birth & Death Certificate data Current Population Survey (CPS) SAMMEC UNC Recreational Facility Policy Study Local data Key Informant Interviews SWOT Analysis Data Sources

9. Description of Selection Process • Data Forums held whereby everyone in the Workgroup reviewed and discussed all potential data sources • Oral and visual presentations were prepared to accommodate multiple learning styles • “Critical Issues and Questions” were identified and discussed at length • Validity and reliability of data source measured

10. Attention Is the issue already being addressed? Impact What impact will addressing the issue have? Feasibility Is it possible to implement? Integration Does it link with other critical issues? Time Frame Can it be accomplished in 1-5 years? Innovation Does the issue consider the unique culture of NC? Critical Issues and Questions

11. Results The priority populations that emerged from this assessment included people identified as American Indian, Hispanic, low SES, and blue-collar workers. Furthermore, gaps in surveillance were recognized for American Indians specific tribes, Lesbian, Gay, Bisexual and Transgender (LGBT), Asian sub-groups and farm worker populations. Critically important was that the Workgroup reached consensus on each group and understood the rationale for them becoming a priority population.

12. Priority Populations • Low SES • education • income • American Indians • Service and Blue Collar Workers • Hispanic/Latinos

13. NC Adult Current Smoking by Race/ethnicity, NC BRFSS 1997-2001

14. NC Adult Current Smoking by Educational Attainment, NC BRFSS 2001

15. NC Adult Current Smoking by Household Income, NC BRFSS 2001

16. NC Adult Current Smoking by Occupation, Current Population Study 1998-1999

17. Lesbian, Gay, Bisexual & Transgender (LGBT) American Indian by specific tribe Low SES by sub-populations Rural/urban sub-populations Cigar use among African Americans Hispanic/Latino Substance Abuse Clinics Farm workers Refugees and Immigrants Asian subgroups Potential Data Needs/Gaps

18. Actions Needed to Fill Gaps • Modify NC BRFSS to over-sample counties with high proportion of American Indians • Consideration of innovative special study focusing on LGBT sampling • Adding questions to BRFSS related to Spanish Speaking and recent arriving immigrants. Interviews in Spanish. • Developing regional criteria for urban/rural

19. The Diversity Workgroup spent one year in an inclusive and open strategic planning process. The resulting plan, “Achieving Parity” describes the process and outlines a framework for eliminating tobacco related disparities. www.communityhealth.dhhs.state.nc.us/tobacco.htm

20. Conclusions Although the Workgroup was composed of a number of organizations representing specific populations, they agreed to assess the valid data and give priority to those populations that had the greatest tobacco burden. As a result, NC’s strategic plan provides a more comprehensive approach to reducing tobacco disparities. Programs seeking to identify and eliminate disparities should consider the lessons learned from NC in identifying key groups.

21. Recommendations • Include "Data 101" educational session that helps participants understand key data issues, e.g., surveillance, sampling concepts, confidence intervals, etc. • Non- statistical members need continual, but gentle, reminders of "what the data really said" as the process continues. Statisticians on the working group can bring the group back to "grounding in the data" as discussion becomes personalized and "anecdotal".

22. Recommendations • At the same time, statisticians need to remember that quantitative data are only one source of knowledge. Community members have other "ways of knowing", including personal stories that contribute critical information to the strategic planning process and should be included later in the process. • Workgroup members with specific ethnic advocacy backgrounds rose to the challenge and set aside their personal affiliations during the data review process to prioritize disparities among "crosscutting" populations, specifically youth aged 18-24, low income individuals, new immigrants and lesbian/gays.