Arizona suffers from low compliance with youth-access laws. In 1996, 36% of retailers checked sold cigarettes to minors in Tucson, and only after a $3 million grant over 1996-2000 from the Robert Wood Johnson Foundation’s Smoke Less States project did compliance rates improve , while TEPP did little during this period to reduce tobacco sales to minors.Retailer compliance checks are carried out by the Arizona Attorney General’s Office, subcontracted by TEPP starting FY2002. Prior to FY2002, some counties performed their own compliance checks, but aside from various creative forms of shaming the retailer , there was no consequence for breaking the law. The Attorney General’s Office performs compliance checks in all 15 Arizona counties throughout the year, with more checks in areas heavier populated, such as Phoenix and Tucson . Only police officers can issue a citation. If a retailer sells tobacco products to the undercover volunteer minor, the inspector sends out letters to the retailer, local police departments, and local health departments indicating the date and time of the compliance check and whether or not the retailer passed. Local law enforcement, when present with inspectors , can fine the retailer, but they cannot retroactively cite the retailer. Arizona’s sting operations helped lower the incidence of selling tobacco to minors from 25% of retailers approached in FY2005, yet FY2006 retail sales to minors nonetheless remained high with 20% of retailers approached violating the law.In comparison, New York announced that for FY2007 compliance levels reached only 11% of retailers approached sold to minors .TEPP’s evaluation management has changed over time,indoor growing table done internally from 1995-2001, contracted out to Arizona State University and the University of Arizona from 2002 through 2007.
TEPP’s evaluation and surveillance was in disarray from its inception when it lacked a baseline prevalence measurement until 2001, providing unreliable tobacco use prevalence data, especially for youth. However, since 2002, the Evaluation, Research, and Development Unit at the University of Arizona has provided dependable evaluation statistics standardizing Arizona tobacco prevalence reporting. The initial phases of evaluation lacked sufficient data and standardized as well as compiled evaluations. TEPP Health Educator Jean-Roberts Jeoffroy explained in a 2006 interview that until 1999, “We didn’t have a centralized evaluation, each program individually was doing their own evaluation and my understanding was, there was a lot of evaluation out there, it just hadn’t been brought together, and that was the main criticism from the Auditor General, that we really needed to centralize our evaluations.”Most of the data TEPP gathered on smoking prevalence between 1995 and 2001 cannot be considered reliable.TEPP used a hodgepodge of methodologies in its evaluation, making comparisons across time difficult. TEPP’s 1997 Youth Tobacco Survey Baseline Report used telephone surveys targeting youth aged 10-17, and found 21.2% smoking prevalence for the 16-17 year-old group and 15% for 9th to 12th graders surveyed. The next youth evaluation TEPP conducted in 2000 only received valid surveys yielding a sufficient sampling size from middle school students surveyed; too many of the high school surveys were incomplete and deemed invalid by the CDC. TEPP was forced to omit the high school data, creating gaps in youth prevalence data, even though high school populations have substantially higher current smoker rates than middle school populations . Unlike TEPP’s media recall rates and the efficacy of its local projects , its smoking prevalence information was not methodologically consistent from year to year.From FY2002 through 2007, TEPP contracted the collection of surveillance data with the Northern Arizona University for the Adult Tobacco Survey .
Other contracts were awarded to the Arizona Department of Education for administering the Youth Tobacco Survey , and the Arizona Criminal Justice Commission for the Arizona Youth Survey.The Coalition for a Tobacco-Free Arizona , the tobacco control organization responsible for creating TEPP in 1994 by successfully passing Proposition 200, grew out of tobacco control advocates coalescing in 1990 to sponsor tobacco control policy proposals. While CTFA originally benefitted from ADHS staffing it, ADHS stepped out in 1994 as CTFA became politically involved in passing and implementing the initiative that created TEPP. Leaving ADHS was financially tenable at the time because the Robert Wood Johnson Foundation awarded CTFA a three-year implementation grant in excess of $1 million to support the creation of TEPP.Since 2000, however, when RWJF funding expired, CTFA returned to ADHS’s umbrella, becoming completely dependent on ADHS for its funding. Because of this funding change and TEPP’s lobbying restrictions, CTFA’s previous advocacy operations halted. In order to receive TEPP funding, CTFA could not participate in tobacco control advocacy, and while its original charter included advocacy and policy change as a central tenant, CTFA was forced to amend its charter to remove this language. Without TEPP funding, CTFA could not exist. Yet, with TEPP funding, CTFA also ceased to be a focal-point for public health advocates to pursue tobacco control public policy. Reflecting TEPP’s extremely restrictive rules on public engagement, Jill Gomez explained, “we can educate, but cannot advocate or lobby.”CTFA performs quarterly trainings for the county health departments and the local projects on a wide variety of tobacco control issues, ranging from “Innovative uses of technology for cessation” to “Smoke free environments.” The Coalition also provides technical assistance for statewide projects for TEPP, such as providing speakers to educate TEPP staff members on new developments in cessation and prevention.
Following passage of Proposition 200 in 1994, HB 2275, the enabling legislation creating TEPP, authorized the 11 member Tobacco Use Prevention Advisory Committee to oversee the TEPP funds and programs. TUPAC reported biannual reviews of TEPP evaluation program outcomes and cost effectiveness115 to ADHS, to the governor, the president of the Senate, and the speaker of the House.The initial TUPAC board contained both tobacco control advocates and tobacco industry allies from the retail and distributors associations.Despite its general ineffectiveness, TUPAC and its subsequent incarnations did provide a modest institutional barrier to legislative attempts at diverting the Health Education Account funds. Notably, Don Morris, Executive Director of Arizonans Concerned About Smoking and TUPAC board member,indoor plant growing tables worked to expand TEPP’s scope to include a cessation program against the will of industry allied board members.He also was instrumental in achieving TEPP’s unrestricted ability to address issues of secondhand smoke by his challenging ADHS Director Dillenberg’s restrictions on the media campaign, citing TEPP’s founding goals which included decreasing Arizonans’ exposure to secondhand smoke.TUPAC’s commission expired December, 31, 1999.Tobacco control advocates commented that TEPP was experiencing the same problems in 2007 it dealt with 10 years prior.The turnover rate of staff from 2005-2007 left TEPP with not a single longstanding employee in 2007. While TEPP’s new staff composition appears enthusiastic to turn over a new leaf in the book of TEPP’s history –engaging in a strategic planning process, creating new positions, increasing spending, re-contracting media with Riester, even changing TEPP’s name to BTEP – it is unclear whether all these changes will solidify into lowered tobacco use prevalence and consumption. TEPP has been slow to keep up with Arizona’s public sentiment on tobacco control, which appears to be significantly more advanced in leading tobacco control policy than TEPP. Since 2002, when Proposition 303 successfully restored funding to TEPP after its FY2002 diversion, TEPP has neglected to make full and productive use of its funds. TEPP’s priorities have been misplaced, dedicating significant funding on school programs and youth access inspections that often failed to fine violators rather than on hard-hitting media prevention campaigns. Arizona’s statewide smoke free law, passed in 2006 , raised the bar for how TEPP must operate. TEPP will have to shift its focus away from projects encouraging individual workplaces to go smoke free, and move toward increasingly effective media campaigns to prevent future generations of children and young adults from becoming smokers. TEPP must also educate both adolescent and pre-adolescent populations if it is to continue school tobacco prevention programs. Additionally, TEPP’s partnering with county health departments to encourage adherence to Smoke-Free Arizona will also promote smoke free social norms in Arizona.Tobacco control policy and law in Arizona do not effect the 5.6% of Arizonans who are Native American and live on reservations, because Arizona laws do apply on tribal lands under thesovereignty of First Nations. Arizona has seven tribal nations and three urban Indian centers. Native Americans use commercial tobacco more than any other ethnic group in Arizona .Current commercial tobacco use prevalence was 52% in 2003188 and 51% in 2005 for high school-aged native Americans.
In contrast to having almost double the youth prevalence of any other ethnic group in Arizona, there are no reliable Native American adult prevalence statistics, but prevalence is estimated to be very high.TEPP’s Arizona 2005 Adult Tobacco Survey reported 23% of Native American adults smoke, up from a reported 12% prevalence for the same population in 1996.The report includes the caveat that the “American Indian samples are considered unstable due to the smaller numbers in the sample , and thus may not be representative” of actual smoking prevalence.TEPP’s report on Native American tobacco usage only includes smoked tobacco, omitting smokeless prevalence. According to the Southwest Navajo Tobacco Education and Prevention Project , a Navajo-initiated organization funded by 5 year grants from the Robert Wood Johnson Foundation and the CDC in November 2006, 56% of Navajo 9th and 10th graders chew smokeless tobacco, 37% of Navajo men chew tobacco, and 31% of Navajo women chew tobacco.Reliable tobacco use prevalence numbers are difficult to achieve for First Nations populations, because commercial versus traditional tobacco use can sometimes be conflated by respondents, and many Native Arizonans living on reservations do not have telephones and so are not included in telephone surveys.135 It could be the case that high commercial tobacco use contributes to the fact that the mean Native American life expectancy in Arizona in 2005 was nearly two decades lower than the rest of the population, 53.4 for Native Americans versus 71.5 years for Arizona’s general population.Nationwide, all Indian Health Services hospitals are tobacco-free campuses . Additionally, since 2005 Arizona’s Hopi reservation’s comprehensive clean indoor air law, all workplaces and restaurants are smoke free, disallowing smoking within 50-feet of all buildings . Navajo tobacco control advocates working with the tribal government to enact health policy benefitting tribal members appears a more successful route at ensuring Navajo public health than Arizona state government interventions. Marty Eckrem, TEPP employee in Coconino County commented that because of unresolved contract disagreements, “Unfortunately, the Navajo Nation is not really covered” by Arizona’s state tobacco control services.While TEPP has made some effort to provide outreach to Native American communities, these efforts have not been effective. In 2007, the Tohana Oldum and Walapai Nation were the only two nations receiving TEPP mini-grants to provide support for commercial tobacco prevention and cessation services.TEPP’s “Breathe Life” campaign in FY2006 marketed a tobacco prevention message to Native Americans through AlterNatives, a media agency specializing in social marketing to Native Americans. Yet TEPP only began tailoring media to the Native American community in 2001, and through 2007 had not developed a successful method of supporting a Promotoras styled tobacco education program for tribes. Between 2004 and mid-2007 TEPP did employ a Native American Outreach Coordinator, Beau Cordova, to facilitate attempts at tribal/TEPP collaboration. In a 2007 interview, Cordova reported, “Before I came onboard [TEPP in 2004], there were many issues the tribes had with working with the state.”His position “originally started as a liaison position between the tribes and TEPP.”In 2005 Cordova was moved to TEPP’s central office when Patricia Tarango became Office Chief, removing him from the frequent face-to-face interactions with the communities he was hired to help. Cordova felt he was more effective in “the Liaison role… [because that role] really acknowledged the sovereignty of the tribes/nations.”Moving the Native American Outreach Coordinator position into TEPP’s Phoenix office weakened the ties between TEPP and Arizona’s tribes as it reduced direct contact with the tribes. Cordova left TEPP in June 2007, and as of December 2007, no one had filled the Native American Outreach Coordinator position. TEPP’s media component has not been successful in reaching the Native American demographic.Instead, TEPP contractors direct the media campaigns and receive all of the media prevention and cessation funding.