Problem: For the five-year period 2011-2015, Arkansas ranked third highest in the country for lung and bronchus cancer incidence (78 reported new cases per 100,000)1. For the same five-year period, lung and bronchus cancer deaths in the state surpassed the national average (59 per 100,000 Arkansans vs. 43.4 per 100,000 nationally)2,3.
PSE Change Solution: A collaboration between the Arkansas Cancer Coalition and officials of the Arkansas State Fair resulted in a site-wide smoking policy. The work culminated with a written policy prohibiting the use of tobacco products and electronic smoking devices in all indoor offices and entertainment facilities at the fair.
Problem
In 2013, 25.9% of adults in Arkansas smoked cigarettes, significantly exceeding the national average of 17.8% (Centers for Disease Control and Prevention [CDC], 2019a; Jamal et al., 2014)1. Cigarette smoking is a significant risk factor for chronic diseases and cancer, and it is linked to about 90% of deaths from lung cancer (CDC, 2018a; U.S. Department of Health and Human Services [HHS], 2014; HHS, 2010). Secondhand smoke can also harm the health of nonsmokers. It is estimated that between 2005 and 2009, secondhand smoke caused more than 7,300 lung cancer deaths per year among American nonsmoking adults (CDC, 2018b; HHS, 2014).
For the five-year period 2011-2015, Arkansas ranked third highest in the country for lung and bronchus cancer incidence (78 reported new cases per 100,000) (NCI and CDC, 2019a). For the same five-year period, lung and bronchus cancer deaths in the state surpassed the national average (59 per 100,000 Arkansans vs. 43.4 per 100,000 nationally) (NCI and CDC, 2019b; NCI and CDC, 2019c).
1In 2017, the rate of smoking in Arkansas dropped to 22.3%, while nationally, the rate fell to 14% (CDC 2019b; CDC, 2019c).
PSE Solution
The Arkansas State Fair attracts over 400,000 visitors each year and is one of the largest family events in the state. While the state fair prohibited tobacco use in enclosed buildings, it had no written site-wide policy. In 2014, the Arkansas Cancer Coalition (ACC) collaborated with state fair officials (Step 1: Engage) to staff an educational booth on the fairgrounds to educate fair attendees on the effects of smoking on health. The ACC’s work culminated in 2015 with a written policy prohibiting the use of tobacco products and electronic smoking devices in all indoor offices and entertainment facilities at the fair, including a 20-foot smoke-free zone outside of each facility. This initiative was consistent with officials’ interest in creating a healthy experience for fair attendees.
Actions/Results
Actions
At its booth in 2014, ACC staff sought community support by surveying patrons about their attitudes toward a tobacco-free fair (Step 3: Assess). Of the more than 1,000 visitors who completed the survey, 75% favored a tobacco-free fair. These positive results prompted fair officials to develop a comprehensive tobacco-free policy that went into effect the following year.
Results
In 2015, the number of fair patrons increased by 7% over the previous year, beating a 2010 sales record and refuting claims that the tobacco policy would diminish attendance. As a result of the ongoing collaboration between the ACC and the fair, officials amended the policy in 2016 to also prohibit tobacco and e-cigarette use in family areas and in waiting lines for carnival rides. The fairgrounds now are tobacco- and nicotine-free year-round.
Success Factors and Key Questions Addressed
Was enough awareness about the PSE change established to ensure successful and seamless implementation? If so, how did you generate awareness?
Yes, sufficient awareness was generated to ensure the successful implementation of the tobacco-free policy (Step 5: Promote). ACC staff initially educated state fair officials about the health effects of secondhand smoke. Along with surveying fair patrons, ACC staff distributed educational materials and promoted the state tobacco quit line. Before the fair opened in 2015, the ACC and fair officials issued a joint press release, generating traditional and social media coverage. Fair management also created permanent signage that is displayed throughout the fairgrounds.
Were stakeholders committed and engaged?
By contributing to joint annual press releases with the ACC, state fair officials demonstrated their commitment to developing a tobacco-free policy as part of an overall strategy of creating a healthy environment for fair patrons.
Describe how sufficient resources were secured to ensure successful implementation and sustainability of the PSE change.
Through funding from the Arkansas Department of Health, the ACC has continued to maintain its presence at the fair, distributing educational materials and, in partnership with the Department of Health’s Hometown Health Improvement, providing improved signage. Along with fair officials, ACC staff also contribute to the annual press releases reminding patrons of the tobacco-free policy.
How will you continuously engage stakeholders to keep momentum going?
The ACC meets with state fair officials each year to review the policy and its impact. Annual press releases, dissemination of education materials (including outreach to fair security personnel with respect to enforcement), and improved signage continue to keep the tobacco-free policy visible to patrons. Since implementation of the policy, state fair management has contracted with a new ride vendor, Deggeller Attractions Inc. Vendor personnel who staff rides must agree to abide by the policy.
The ACC recommends that similar efforts develop an evaluation plan prior to implementation. For example, taking baseline air quality measurements, followed by annual collection of air quality data, would help document and measure implementation processes related to the smoke-free policy.
Related Resources
For additional information, please see CDC Success Story: Collaboration Leads to a Safer, Tobacco-Free Arkansas State Fair.
REFERENCES
Centers for Disease Control and Prevention. (2018a). Smoking & Tobacco Use, Health Effects of Cigarette Smoking. Retrieved from https://bit.ly/2ra3YIR.
Centers for Disease Control and Prevention. (2018b). Smoking & Tobacco Use, Secondhand Smoke (SHS) Facts. Retrieved from https://bit.ly/2mNpl4o.
Centers for Disease Control and Prevention. (2019a). State Tobacco Activities Tracking and Evaluation System. Retrieved from https://bit.ly/2Xz8ksO.
Centers for Disease Control and Prevention. (2019b). State Tobacco Activities Tracking and Evaluation System. Retrieved from https://bit.ly/2qjX2fS.
Centers for Disease Control and Prevention. (2019c). Smoking & Tobacco Use, Current Cigarette Smoking Among Adults in the United States. Retrieved from https://bit.ly/2hQsVrr.
Jamal, A., Agaku, I. T., O’Connor, E., King, B. A., Kenemer, J. B., & Neff, L. (2014). Current cigarette smoking among adults–United States, 2005-2013. MMWR. Morbidity and mortality weekly report, 63(47), 1108–1112.
National Cancer Institute and Centers for Disease Control and Prevention. (2019a). State Cancer Profiles. Retrieved from https://bit.ly/2W9Be6u.
National Cancer Institute and Centers for Disease Control and Prevention. (2019b). State Cancer Profiles. Retrieved from https://bit.ly/2WAygXY.
National Cancer Institute and Centers for Disease Control and Prevention. (2019c). State Cancer Profiles. Retrieved from https://bit.ly/2IarwqL.
U.S. Department of Health and Human Services. (2014). The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.
U.S. Department of Health and Human Services. (2010). How Tobacco Smoke Causes Disease: What It Means to You. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.
Resources to Support Similar Evidence-Based Initiatives
What Works for Health:
Smoke-free policies for indoor areas
Smoke-free policies for outdoor areas
The Community Guide:
Smoke-free policies: https://www.thecommunityguide.org/findings/tobacco-use-smoke-free-policies.html
EBCCP:
Smoke-free policies for indoor areas in tribal communities: https://ebccp.cancercontrol.cancer.gov/programDetails.do?programId=113374
