The Kanawha-Charleston Health Department (KCHD) and the Kanawha Coalition for Community Health Improvement (KCCHI) have developed numerous initiatives to ensure that Kanawha County has a CLEAN environment, Clean Living Environment in Appalachian Neighborhoods. The Kanawha-Charleston Health Department instituted a comprehensive clean indoor air regulation on July 1, 2008. To goal of CLEAN is to lessen the mobility and mortality due to second hand smoke in accordance with the Surgeon General and the Institute of Medicine. The objectives are to implement a comprehensive clean indoor air regulation and educate the citizens of Kanawha County through a social marketing campaign and support activities. To save lives of Kanawha County Residents a medical education and social marketing campaign must be undertaken, aggressive enforcement and prosecution with fee structure changes, advocate for tobacco cessation programs and research. While the public health impact of a reduction in second hand smoke is clear there have been significant challenges to the regulation. Many bar and gaming establishment owners were very resistant to the change and the vocal minority engaged the local media to foster activism for the limited number of smoking patrons.
The initiatives include a social marketing campaign entitled Eat Drink and Breathe Easy, community events as well as periodic inspections of establishments at nontraditional times such as evenings. The Coalition’s Tobacco Workgroup developed the social marketing campaign to celebrate the one year anniversary of a Smoke Free Kanawha County to encourage patronage to establishments among non-smokers to the new smoke free establishments. The goal of the marketing campaign was to provide an upbeat and positive message and promoting top of mind awareness of the health effects of secondhand smoke and encourage the public’s continued patronage and support of these businesses as opposed to the negative effects bar owners believed would occur.
The cost of the marketing campaign was $5,000 which was funded by the WV Division of Tobacco Prevention and the enforcement of the CIAR is approximately $100,000 annually funded completely by KCHD without any state or federal financial support of these enforcement expenditures. CLEAN encompasses the enforcement of the comprehensive clean indoor air regulation and the use of social marketing with community events to raise the awareness and support of the Kanawha-Charleston Health Department’s goal for a smoke free community. Many residents and business owners were completely against the expansion of the Clean Indoor Air Regulation to bars and gaming establishments and the social marketing campaign highlighted the positive effects of the regulation. Media outlets were highlighting disgruntled bar owners who were blatantly disregarding the CIAR and the kickoff event provided an opportunity for positive messaging. The campaign and enforcement enhanced the opportunity for the majority to silence the vocal minority. Research published in the Preventing Chronic Disease showed that the incidence of hospital admissions for heart attacks in Kanawha County, West Virginia, declined during the years 2000 through 2008, a time period following the introduction of clean indoor air regulation. The study found a pattern of consistent decline in the rates of hospital admissions for heart attacks may continue to occur over long periods of time.
The public health issue that this practice addresses. The Kanawha-Charleston Health Department’s CLEAN initiative addresses the alarming rate of smoking in Kanawha County and West Virginia as well as the need for a comprehensive clean indoor air regulation. The Kanawha-Charleston Health Department comprehensive clean indoor air regulation was implemented on July 1, 2008 to include all bars and gambling establishments. Tobacco is the leading cause of death and disease in West Virginia. Almost 4,000 residents die each year from tobacco use and if the current trend continues, over 40,000 more residents will die by the year 2020. According to the Trust for America’s Health West Virginia has the highest average of adult smokers with 26.3% and 21.8% of high school students currently use tobacco. According to the 2009 BRFSS 15.8% of respondents in Kanawha County smoke every day compared to 20.7% for WV while 5.7% smoke some days, 26.3% are former smokers and 52.1% never smoked. The economic costs of tobacco use are incredibly high in West Virginia. These costs are estimated to be $2 billion annually from direct healthcare cost and occupational productivity cost. It is estimated through the Campaign for Tobacco-Free Kids that 410 adults die annually from secondhand smoke.
The process used to determine the relevancy of the public health issue to the communityThe Kanawha Coalition for Community Health Improvement along with community agencies conducted its community health assessment in 2006. The survey covered a wide variety of health topics and was designed to determine the community’s perception of health needs and concerns, and to provide some indication of actual health-related behaviors. The survey also addressed a number of social and economic concerns. The Kanawha Coalition’s comprehensive community health assessment is comprised of four components: telephone survey among randomly selected Kanawha County households, paper/electronic surveys among Kanawha County key informants, data analysis (survey results and existing health statistics) and a community health issues forum. The report is divided into categories including; Community Life; Access to Health Care; Dental Care; Tobacco; Physical Activity; Safety; and Key Health Statistics. Under each category are the community perceptions based on the results of the telephone survey, comments from key informants, and related health statistics for Kanawha County as compared to State and National data.
This report was prepared for release during the 2007 Community Health Issues Forum at which community members are to decide the top health issues around which the Kanawha Coalition will focus its efforts for the next three years. 38% of those responding to the telephone survey said they smoked every day or some days, among those who had smoked during the last twelve months, 25% said they had tried to quit smoking during the past year. When respondents were asked to identify the biggest health problems in Kanawha County the following were ranked highest: obesity (87%), heart disease (84%), high blood pressure (84%), cancer (81%), ATV accidents (78%), diabetes (75%) and lung disease (70%). During the community forum the attendees ranked the top three concerns to work on during the last three years and the issues in which the coalition would focus on were obesity, physical activity and tobacco.
How the practice address the issue CLEAN encompasses the enforcement of the comprehensive clean indoor air regulation and the use of social marketing with community events to raise the awareness and support of the Kanawha-Charleston Health Department’s goal for a smoke free community. Many residents and business owners were completely against the expansion of the Clean Indoor Air Regulation to bars and gaming establishments and the social marketing campaign highlighted the positive effects of the regulation. Media outlets were highlighting disgruntled bar owners who were blatantly disregarding the CIAR and the kickoff event provided an opportunity for positive messaging. According to a bar owner, this campaign was needed to show the public how smoke free regulations helps businesses and believes that it is good for smokers and non-smokers alike in hopes of encouraging people to stop or slow down their smoking. The campaign and enforcement enhanced the opportunity for the majority to silence the vocal minority.
This practice is a creative use of an existing tool or practice.
Process used to determine that the practice is a creative use of an existing tool or practiceSocial Marketing campaigns are common practice in public health but the combination of elements makes this a unique approach. The website, radio, newspaper, billboard, window decal and direct communication with local business owners provided a multi-faceted approach. The billboard showed women sitting enjoying an evening out within a smoke free environment. The placement of the billboard was essential and one was placed by the casino as you enter Kanawha County from a county where there is very weak regulation. The social marketing campaign, community events to support the clean indoor air regulation and the extensive enforcement of the regulation makes it a unique practice that encompasses a variety of support mechanisms. As a follow-up in 2011 KCHD partnered with the American Cancer Society, American Lung Association, American Heart Association, Kanawha Coalition for Community Health Improvement and the Tobacco Free West Virginia Coalition to place a billboard along a major interstate to promote the Clean Indoor Air in Kanawha County.
Primary stakeholdersKanawha Coalition for Community Health Improvement and the Kanawha-Charleston Health Department
LHD's roleThe Kanawha-Charleston Health Department is actively involved in the Kanawha Coalition for Community Health Improvement since its inception in 1994 and has been working hand in hand for a number of years to address the tobacco control issues in Kanawha County. The Kanawha-Charleston Health Department is responsible for inspections and enforcement of the Kanawha County Clean Indoor Air Regulation of 2008.
Stakeholders/partnersThe Coalition provides a neutral setting for objective dialogue where individual organizational agendas are laid aside and joint strategies are developed for the betterment of the community. The coalition provides an opportunity for resource and information sharing to develop comprehensive approaches instead of multiple single focused activities throughout the county. The Coalition and Health Department received input from the American Cancer Society, American Lung Association, American Heart Association, Kanawha County Schools, RAZE Representatives, and other community organizations.
Describe the relationship(s) and how it furthers the practice's goals.The Kanawha-Charleston Health Department encourages open communication with the public daily and have enhanced communication channels through the use of Twitter and Facebook. The goal of KCHD is to expand our services to include tobacco cessation and prevention programs as a follow-up to the project and CIAR.
Lessons learnedThe Kanawha Coalition for Community Health Improvement is a model community coalition since 1994 with the leadership composed of CEOs and Executive Directors for all major hospitals including mental health, health department, county school and worksite wellness organizations. The Coalition is charged with identifying and evaluating health risks and coordinate resources to measurably improve the health of the people of Kanawha County. The agendas are left at the door and the focus is solely on the health of our residents.
Specific tasks taken that achieve each goal and objectiveAugust 28, 2008: Met with Charleston Area Alliance. January 23, 2009: Campaign Planning Meeting February 19, 2009: Campaign Planning Conference Call March 9, 2009: First contact with restaurant owner to serve as a spokesperson for the campaign April 13, 2009: Meeting with bar owner. Shared campaign concept and materials. He approved and agreed to host Campaign window sticker kick-off. Scheduled event for April 23. April 20, 2009: Did mailing labels for all Kanawha County bars. January 23, 2009: Campaign planning team selected language for billboard Feb. 5, 2009: Recruited developer for billboard and window sticker. Feb. 15, 2009: Received billboard/window sticker concept ideas. Feb. 17, 2009: Approved contract with billboard production / site Feb. 17, 2009: Registered website and began site development Feb. 20, 2009: Approved concept/artwork for billboard Feb. 23, 2009: Artwork to billboard company and vendor for window stickers Feb. 27, 2009: Recruited college students for radio spot testimonials March 3, 2009: Radio Script finalized March 5, 2009: Radio Spots taped March 6 – April 3, 2009: Billboard placement March 6, 2009: Website operational / ongoing March 16-22, 2009: Radio spots air April 23, 2009: Business Window Sticker kick-off at local bar April 24, 2009: newspaper article 47 - :30 sec. commercial aired Frequency of times heard by each, averaged 4.6 Billboard had a daily effective circulation of 50,072 Extending campaign beyond original grant cycle through additional funding May 14 – June 14: Billboard June 7-13:Radio spots June 1-5: Mailing of window labels to bars and gaming establishments.
ImplementingJuly 2008: Implemented a comprehensive clean indoor air regulation throughout Kanawha County. April 2009: Eat, Drink and Breathe Easy campaign begins. July 2010: Pack the Park for Public Health Event held. July 2011: Clean Indoor Air Regulation and Incidence of Hospital Admissions for Acute Coronary Syndrome in Kanawha County, West Virginia article published in the Preventing Chronic Disease journal.
Ongoing: share initiative with other counties and universities looking at comprehensive clean indoor air regulation.
Lessons learnedEngagement of the community is essential. Opportunity to partner with non-traditional partners are very worthwhile such as bar owners. A continuous campaign is essential with events at least once a year to spotlight work for clean indoor air.
Cost of implementationMarketing materials, production and dissemination including media buys $3,700.
Website maintenance and enhancements $1,000.
Coalition organizational support $300.
In-Kind included personnel from the Coalition and KCHD.
When the comprehensive clean indoor air regulation was implemented the number of violations through inspections was 7.28% which means of the 769 inspections completed there were 56 violations noted. The percentage continued to decrease throughout 2009 and 2010 with the lowest violation rate of 0.41% in September 2010 where only 4 violations were found in 980 inspections while 6 court cases were filed. The rate for June 2012 was 1.66%. The data was derived from the inspection reports from 2008 to 2012 completed by sanitarians performing clean indoor air inspections.
Objective 1:Protect the health of those who patronize Kanawha County establishments by promoting continuation of the stronger Clean Indoor Air Regulation enacted by the Kanawha-Charleston Board Health on July 1, 2008.
Performance Measures: The number of inspections completed, the number of violations found and the number of court cases filed.
Data: In September 2008, two months after implementation there were 769 inspections completed with fifty-six violations in which two court cases were filed. The percentage of violations vs. inspections was 7.28% in September 2008. The percentage continued to decline through the next two years with September 2010 violations were 0.41% of total inspections yet six court cases were filed.
Objective 2:Decrease the morbidity and mortality from acute coronary syndrome through clean indoor air regulation.
Performance Measures: For each Kanawha County resident, basic information for each patient included the date of hospital admission/discharge, diagnostic code, age, sex, race, associated medical history such as diabetes and smoking status.
Data: Data was obtained from the three major acute care hospitals that serve Kanawha County, including the largest in the state. The ICD-9-CM diagnostic codes for myocardial infarction, non=ST segment elevation myocardial infarction, or unstable angina were examined. Evaluation Results: The study included 14,245 hospital patients who were admitted for ACS between January 1, 200 and September 30, 2008. Of them, 8,075 (57%) patients were men; 3,633 (26%) were smokers, and 5,048 (35%) had diabetes. The number of hospital admissions of ACS per year declined over the entire period, from 1,949 patients in 2000 to 1,208 in 2008. This decline was most pronounced among nonsmokers, women, and adults without diabetes. The cumulative decrease in the age-adjusted ACS hospitalization rates between 2000 and 2008 was 37% overall, 36% for men and 39% for women. The patterns of decline over time were similar for men and women. However, when we stratified the age-adjusted rates of hospital admissions for ACS by smoking status, the observed decline of age-adjusted hospital admission rates for ACS was significant only among nonsmokers (both men and women). Declines in the age-adjusted rates for hospital admission of ACS were also noted by diabetes status.
Feedback: The study was released through the national media in partnership with the American Lung Association. A press conference was held at the Kanawha-Charleston Health Department to announce the findings. The study was published in the CDC's Preventing Chronic Disease journal in July 2011.
Objective 3:Placement and outreach of the Eat, Drink and Breathe Easy Campaign to include website development, fact sheet distribution, billboards, radio public service announcements including testimonials, newspaper advertisement and window decals for the doors of establishments. Number of radio ads, number of newspaper ads, number of billboards, number of hits to website and public comments to the KCHD. March 6, 2009 to June 5, 2009 was the time the marketing campaign ran. Over a thousand people attended the Pack the Park for Public Health Event on July 10, 2010. A billboard was placed in the spring of 2011 to highlight the partnerships with ACS, AHA and ALA as well as local coalitions to promote the clean indoor air in Kanawha County.
Stakeholder CommitmentThe “tide is turning” in Kanawha County from controversy to acceptance and support for our 100% Clean Indoor Air regulations. The Eat, Drink and Breathe Easy campaign April 23, 2009 kick-off event received news coverage which highlighted the owner placing one of the campaign stickers on his front door. This “very positive” Charleston Gazette article was a welcome change from previous stories covering only the few disgruntled bar owners that were blatantly non-compliant with the new CIA regulation. Three members of our local Board of Health attended and reported that they found it a very positive, fun evening and were pleased by the response of the “regulars” at the bar. Board members have expressed that they will not consider making changes to the existing regulation and are currently addressing any noncompliance issues with the assistance of local police authorities. Another component of our campaign was our radio commercials. We paid for forty-seven 30 second commercials which played during the week of March 16th between the hours of 6:00 a.m. and 7:00 p.m. on WCHS 58 (Talk Radio).
The commercials included recorded “testimonials” from a couple of young adults praising smoke free restaurants and bars. Additional funding to run the commercials an additional week and keep the billboard up another month was requested and received from the Smoke Free Initiative of WV and was contacted by Tri-State CW Television to see if we could possibly expand our Eat, Drink and Breathe Easy Campaign message by advertising on television. In 2010 a “Pack the Park for Public Health” was held to thank the Kanawha-Charleston Health Department Board of Health Members, sanitarians and other staff for the passage, enforcement and regulation of the clean indoor air regulation. In 2011, a partnership was form with AHA, ACA and ALA to place billboards to promote Kanawha County’s Clean Indoor Air Environment. Through these measures we intend to continue our efforts to promote Kanawha County’s smoke-free status and encourage patronage of our smoke-free businesses.
SustainabilityAs the leader in CIAR regulation in the state of WV, the Kanawha Charleston Health Department serves as the model for many counties in West Virginia, especially those surrounding counties who have had difficulty passing any regulation. KCHD will continue to strongly enforce the CIAR while expanding services to include tobacco cessation and prevention programs as funding becomes available. The ultimate goal would be for the entire state of West Virginia to pass CIAR in the future but a bill was introduced this legislative session and it is feared it will be full of preemptions and exceptions like the bingo exemption in the current legislation. State laws set a minimum standard and allow for local officials to enact more protective ordinances. Local ordinances and regulations usually are more stringent and can tailor laws to address local circumstances. State laws also tend to eliminate the public debate and news media coverage of local ordinances, such as we have seen in Kanawha County, which serves as an important educational opportunity and contributes to changes in social norms about smoking.
As stated in the report, most comprehensive smoking restrictions often originate at the local level and many states have enacted comprehensive statewide smoke-free laws only after numerous communities have adopted such laws. In West Virginia, the grassroots effort to ensure smoke free environments is essential in engaging the public and garner support. KCHD has also received support from NACCHO and CDC for strategic planning in the area of tobacco prevention and control to set a five year strategic plan to ensure a Smoke Free Kanawha County. The Kanawha-Charleston Health Department and the Kanawha Coalition for Community Health Improvement's partnership continues to enhance the smoke free environment in Kanawha County and demonstrates the sustainability of community based initiatives. Through using the media outlets in Kanawha County the reach is extensive throughout West Virginia since these outlets reach a majority of the population.