Promoting Tobacco Control and the Puerto Rico Quitline through a Community-Based Outreach Program

1. Promoting Tobacco Control and the Puerto Rico Quitline through a Community-Based Outreach Program Carlos Mazas, Ph.D., InstructorDepartment of Health Disparities ResearchFunded by the National Cancer Institute U54 CA096300-05 University of Puerto Rico and the M. D. Anderson Cancer Center Partnership for Excellence in Cancer Research

2. Background • Hispanics are the largest and fastest growing minority group in the U.S. (14% of the U.S.) • Tobacco use is a major public health problem among Hispanics including Puerto Ricans living in Puerto Rico (PR) • Smoking prevalence is lower among the population in Puerto Rico than among the general population (12.7% vs. 20.9), • Three of the four leading causes of death among Puerto Ricans are related to smoking (heart disease, cancer, stroke) • Lung cancer is the leading cause of cancer deaths among Puerto Ricans • More than 10% of all health care costs in PR are attributable to smoking • Thus, even though the prevalence rate of smoking is lower in PR than the continental USA, tobacco still places a tremendous public health burden on the people of PR

3. Tobacco-Related Disparities and Hispanics Disparities in cessation affecting Hispanics relative to non-Hispanics (National Health Interview Survey) • Less motivated to quit (71 vs. 62%) • Less likely to have made a quit attempt in the preceding year (41 vs. 38%) • Less likely to have successfully quit (former smoker/eversmoker; 51 vs. 43%) Health care delivery disparities affecting Hispanics relative to non-Hispanics • Highest rates of no health insurance of any racial/ethnic group in the U.S. (33%) • Less likely to visit a physician or to have a personal health care provider • Less likely to receive cessation advice from a physician during a quit attempt • Less likely to utilize pharmacotherapy during a quit attempt

4. Intervention Development & Delivery Among Hispanics Freeman,2004 Hispanics experience disparities in the delivery of preventive health care including tobacco cessation interventions. There are exceedingly few randomized clinical trials (gold standard) demonstrating intervention efficacy among Hispanic smokers. Because of the dearth of interventions designed to help minorities and underserved populations, the development and evaluation of such interventions has been identified as a national health priority (Fiore et al., 2000; USDHHS, 1998).

5. Specific Aims of the Outreach Program • Increase the utilization of the Puerto Rico Quitline. • Provide career development opportunities in cancer prevention to researchers and community partners. • Develop collaborations among the University of Puerto Rico (UPR), M. D. Anderson Cancer Center (MDACC), and key PR health and community-based organizations interested in tobacco control.

6. Puerto Rico Quitline (PRQ) • In 2004, the Puerto Rico Department of Health implemented a telephone-based smoking cessation program funded by the Centers for Disease Control and Prevention (CDC). • PR residents can call a toll free local number (1-877-335-2567) or the National Quitline number, 1-800-QUIT-NOW, and will be automatically transferred to the local number.

7. PRQ (continued) • Proactive service • ~ 7 counseling calls over a period of one year • Mailed Quit-Kit – Quit guide, handheld stress relievers, substitutes for smoking, etc. • Data collection

8. Outreach Program Methods • The Outreach Program began in April of 2005 • Success and sustainability of the project was measured by the following criteria: • Numbers of calls to the PRQ • Number of alliances supporting the PRQ 3. Number of presentations, trainings, manuscripts, and grant proposals produced by the outreach team with a focus on developing junior faculty and increasing cancer research capacity in PR.

9. Results of the Outreach Program

10. Conferences to Promote the PRQ • Cumbre de Tabaquismo 2005 and 2006 were organized by the outreach team • CONFERENCES OBJECTIVES: • Develop and implement an Outreach Agenda for Smoking Cessation in Puerto Rico and generate an outreach action plan for increasing the utilization of the PRQ among smokers in PR. • Build collaborations between the UPR, MDACC tobacco outreach team, and key organizations such as the PR Department of Health, PR Tobacco Control Coalition, legislators, health care systems, health care providers, and other organizations involved in tobacco control. • Establish commitments of collaboration among the participants through the education of each conference participant in tobacco cessation and control practices.

11. 2005 and 2006 Conference Results • For the first time in PR, over 60 community-based organizations representing private, religious, hospital, health centers, health insurers, education, youth, government and media sectors met and agreed to actively support smoking cessation, tobacco control, and the PRQ. • Selected 11 Steering Committee members to coordinate outreach activities and mediate community needs. • Trained 132 physicians, dentists, and health care administrators on integrating smoking cessation into their practices. • Implemented the Fax-to-Quit program among physicians and dentists throughout the island based on the principles of Ask, Advise, and Connect.

12. Development of Materials

13. Educational Activities MEDIA CAMPAIGNS • PSA ads and TV and radio interviews promoting the PRQ • Promoting and supporting Law 66 – an indoor smoking ban and the most aggressive smoking ban in the Caribbean • Smoke-Out Day ORAL PRESENTATIONS • Cumbre de Tabaquismo 2005 and 2006 • PR College of Physicians and Dentists • PR Oncology Association • PR Churches, School District, and college campuses POSTER PRESENTATIONS • Cumbre de Tabaquismo 2006 • 19 posters (11 from community partners)

14. Training TRAINING • Trained 1 postdoctoral fellow and 3 junior faculty from UPR and MDACC on cancer prevention research, research designs, brief intervention, manuscript writing, budget and grant preparation. • Trained counselors who provide smoking intervention to the PRQ callers on smoking cessation and motivational interviewing • Trained 26 community partners and Steering Committee members on best practices in smoking cessation and tobacco control

15. Academic Products Manuscripts: • Characteristics of smokers accessing the PRQ • Integrating community, government, and academic institutions to promote tobacco cessation: The Puerto Rico Quitline Grant Submission: • Oral Cancer Risk Reduction through Combined Treatment of Tobacco and Alcohol Use • Recently applied for the renewal of the Outreach Program: Puerto Rico Community Cancer Control Outreach Program – focusing on tobacco-related cancers, and breast and cervical cancers Oral Presentations • National Latino Council on Alcohol and Tobacco Prevention (LCAT) Poster Presentation • American Public Health Association (APHA) 133rd Annual Meeting, Dec 10-14, Philadelphia, Pennsylvania. • 13th World Conference on Tobacco and Health. July 12-15, 2006. Washington D.C

16. PRQ

17. Summary The Outreach Program was able to accomplish the following objectives: • Held two major conferences to promote tobacco control in PR • Developed an extensive network of over 60 PR organizations • Gained the collaboration of key PR government, health agencies, and leaders • Provided career development opportunities in cancer prevention to junior faculty and community partners

18. Summary (continued) • Secured funding from the PR government and industry to further the aims of the Outreach Program • Contributed to the passage of a strong smokefree law for closed spaces • Developed a new and innovative research project aimed at reducing the risk of tobacco- and alcohol-related cancers. • Expanded the goals of the project to include breast and cervical cancer screening

19. University of PR CC Elba C. Diaz-Toro, DMD Maria C. Santos Ortiz, Ph.D. Ana P. Ortiz, Ph.D. Virmarie Correa-Fernandez, Ph.D. William Calo, MPH UT M. D. Anderson CC David W. Wetter, Ph.D. Luz M. Mejia, MA ACKNOWLEDGEMENTSOP Research Collaborators