Advocates hope push in rural areas will help pass statewide smoking ban, at least in the state House

By Justin Richter

University of Kentucky College of Communication and Information

Kentucky has had a love affair with both growing and smoking tobacco, but supporters of a statewide smoking ban believe that smoke should not be shared with people who don’t smoke.

Rep. Susan Westrom

For the fourth straight year, Democratic State Rep. Susan Westrom of Lexington is filing a bill for a smoking ban in workplaces and enclosed public places. She and her allies are focusing increased attention in the state’s rural areas, where smoking is more prevalent.

This summer Westrom visited several towns, from Owensboro to tiny Sandy Hook, to talk with fellow legislators and their constituents about the bill. “We want to be able to access legislators in the rural areas, meet them on their own turf,” showing them their constituents care about secondhand smoke, Westrom said.

A third of the adults in Eastern Kentucky smoke, and almost a third of those in Western Kentucky do, according to the Behavioral Risk Factor Surveillance System, an ongoing telephone survey by the federal Centers for Disease Control and Prevention.

"We're going to need a lot more legislative support, and we're pretty much doing that one legislator at a time," Smoke-Free Kentucky Coordinator Betsy James said at last month's meeting of Kentucky Voices for Health, an association of health lobbying groups. "This is sort of a rural-urban issue, so we do need help out in the counties."

Advocates are hoping to build on the passage of smoking bans in 28 Kentucky cities and 10 counties.  “We’ve got 38 different locations that have smoke-free ordinances and we want to meet the standard we have in Louisville and Lexington,” Westrom said in an interview. 

Louisville and Lexington were two of the first cities to ban smoking in enclosed public places.  Each had exemptions, including bars and clubs, but by 2008 both went to comprehensive bans, unlike some other jurisdictions in the state that have large exceptions.

The Hopkins County Board of Health, for example, passed a regulation in 2009 that permits individuals from smoking in workplaces but has large exceptions that allow individuals to smoke in private clubs, privately rented restaurants, as well as hotel and motel rooms that are rented.

Westrom is working with Dr. Ellen Hahn, director of the Tobacco Policy Research Program at the University of Kentucky College of Nursing, who has led the efforts to pass local smoke-free measures.  After working for years on local bans, she is now working on both local and state fronts. 

Work towards smoke-free public enclosed places has gained ground steadily since Hahn started 10 years ago, but most of the state remains unaffected by any smoking ordinances or regulations.

According to a booklet prepared by the College of Nursing and the state Cabinet for Health and Family Services, “70 percent of Kentuckians are regularly exposed to secondhand smoke in the workplaces and public places.”

Smoking is more common in Kentucky than any other state, with 28.3 percent of adults smoking, compared to 19 percent nationwide according to the CDC. Kentucky Youth Advocates recently released a study done that revealed Kentucky has one of the highest rates of smoking during pregnancy in the nation. 

Westrom and Hahn have been working together since 2011, when Westrom first filed a state-wide smoking ban bill. The first bill did not get out of the House Health and Welfare Committee, but the next two bills did. 

Last year, her bill was then sent to the Judiciary Committee, a sign that it was being taken a bit more seriously, because that panel was more skeptical of it and raised issues that if resolved could help the bill pass.

In 2013 the bill was not given a vote on the House floor, presumably because it did not have enough votes to pass.  Westrom is anticipating getting past the House floor and into the Senate this year. “I think we’re really close in the Senate,” she said, noting that almost every Senate district has at least one smoke-free community.

The Kentucky Chamber of Commerce has supported Westrom’s bill since it was introduced three years ago.  “Over 90 percent of respondents expressed support for a smoke-free law in Kentucky in a recent Chamber survey,” said Ashli Watts, the business lobby’s public-affairs manager.

The chamber is advocating a smoke-free workplace largely because of lost worker productivity due to illnesses causes or worsened by smoking. Research by The Ohio State University's College of Public Health found that every U.S. smoker is costing his /her company an extra $6,000 per year.

Democratic Gov. Steve Beshear said he will continue to support a statewide smoking ban, and that it would be a help to business.  House Speaker Greg Stumbo, D-Prestonsburg, said he hopes the House will pass the bill.

Stumbo spoke at a panel discussion held by the Kentucky Hospital Association with Senate President Robert Stivers, R-Manchester.  Stivers said individual businesses should be able to allow smoking, but said that he would not impose his view on the rest of the Senate.

Three Kentucky health departments in first group up for national accreditation; requires local health assessment, improvement plan

By Molly Burchett
Kentucky Health News

Three Kentucky health departments are among the first in the nation to be considered for national accreditation, a process that could help improve patient care and put the agencies in closer touch with their communities' needs.

The national Public Health Accreditation Board will make its first accreditation decisions next week. Among the first group being considered are the Franklin County Health Department, the Three Rivers District Health Department in Carroll, Gallatin, Owen and Pendleton counties, and the Northern Kentucky Independent District Health Department, in Boone, Grant, Kenton and Campbell counties.

The decision will be a historic one, and this is an exciting time for the board and Kentucky, said board Chair Dr. Douglas Scutchfield, professor of health services research and policy at the University of Kentucky College of Public Health.

The accreditation program was launched in September 2011 after a seven-year development process aimed at advancing quality and performance and value in the departments, and their accountability to stakeholders, Scutchfield said.

Departments are assessed by rigorous standards tested in 30 diverse health departments across the country to ensure essential public health services are provided in the community, according to the board's website. Two of the 12 "domains" of the standards deal with administration and governance. In Kentucky, state law makes county health boards responsible for the health of the county. Counties served by district health departments still have county boards.

Accreditation can help a board and department identify opportunities to improve performance and management, and to improve relationships with the community, since the process requires a community health assessment, a community improvement plan and a strategic plan to address the need of the community, said Scutchfield.

The process, often called "Mobilizing for Action through Planning and Partnerships," can help boards and departments be better prepared to proactively respond to emerging and re-emerging health challenges. For a PDF of Franklin County's MAPP document, click here.

The accrediting board has received 108 applications from health departments around the nation: 13 state health departments, 94 local health departments and one tribal agency. In addition to the three Kentucky agencies being considered in the first group, the other Kentucky departments that have applied for accreditation and are awaiting site visits are Lexington-Fayette County, Barren River District, Madison County and Christian County, Jill Midkiff, chief spokesperson for the Cabinet for Health and Family Services, said in an email.

The accreditation process encourages departments to move away from the "silo" model to collaborate with community programs. In Christian County, it has changed the way department employees view their jobs, because they have to continuously reflect on their methods and brainstorm for ways to improve, Health Department Director Mark Pyle told Nick Tabor of the Kentucky New Era.

"Accreditation will likely open new revenue streams," Tabor writes. "But in a way, the process matters more than the status designation."

Midkiff said, "In addition to benefiting from the process itself, our federal and state resources in public health are increasingly shrinking, we are being asked to do more with less. And there is a need for transparency within agencies."

Midkiff said accreditation "may make the agency more competitive for grants in the future. We are actually seeing quality improvement and performance management requirements being written in many federal grants now, so it is being expected at the national level."

Although accreditation is completely voluntary, it is being encouraged for local health departments by the state Department for Public Health, which is in the process of applying for its own accreditation in 2014. Midkiff said the department just completed its state health assessment, which is now being reviewed, and is beginning to assemble partners to write a state health improvement plan, which should take about a year.

Kentucky Health News is an independent service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Some Christian Co. health board members balk at director's idea of using $100,000 of $2.4 million reserve for recreational trail

The director of the Christian County Health Department urged its board to give $100,000 from reserves to fund a rail-to-trail project to provide residents with new opportunities for exercise.

Coverting old railroad beds to recreation trails could help improve Christian County's infrastructure to promote healthy living, which is needed because a study last year ranked Christian County 116th out of Kentucky's 120 counties in this area, said Health Department Director Mark Pyle.

The department has $2.4 million in reserve, but several board members opposed the idea, citing a budget shortfall this fiscal year, financial troubles with the school-nurse program and delays in Medicaid reimbursements, reports Nick Tabor of the Kentucky New Era.

The City of Hopkinsville hopes to raise $400,000 for the first phase of the trail project. A recreational trail would initiate a culture change and residents should have public resources equal to those of other regions, Mayor Dan Kemp told Taylor.

Pyle told Tabor the trail would help the health department accomplish its goal of advancing public health, and the reserve money isn't there for sitting on. He said he believes the board will agree to using the money for the project at its next meeting, April 22, after considering funding priorities.

The New Era endorsed the health department's contribution as a good investment in local health, which by law is the health board's responsibility. For a PDF of the editorial and the news story, click here.

Court of Appeals panel rules 2-1 that county boards of health can pass smoking bans; appeal in Bullitt County case seems likely

By Al Cross
Kentucky Health News

In Kentucky's first appellate-court ruling on the issue, the state Court of Appeals today upheld the Bullitt County Board of Health's smoking ban, which is virtually the same as others enacted by several other county health boards. However, the panel's 2-1 vote and the strength of the dissent suggests that the ruling will be appealed to the state Supreme Court.

UPDATE, Dec. 19: The county Fiscal Court voted Dec. 18 to appeal, Tom O'Neill of The Courier-Journal reports.

Health boards in Clark, Hopkins, Madison and Woodford counties have enacted smoking bans. The Hopkins County ban was upheld by the local circuit judge, whose ruling was not appealed. (Courier-Journal video story on smoking in Bullitt County bars)


In Bullitt County, the fiscal court and eight towns sued to stop the ban four days before it was to take effect last year. Bullitt Circuit Judge Rodney Burress ruled that the board lacked authority to ban smoking in public places, but the appeals court said the General Assembly had clearly given county health boards the power to impose regulations protecting public health, that secondhand smoke is a public-health issue, and that the board's regulation is reasonable, because it is virtually the same as an ordinance upheld in Lexington.

The majority cited regulations that the Jefferson County Board of Health had enacted in the 1970s to prevent lead poisoning, and cited other court decisions saying that courts should construe public-health laws liberally. The local governments argued that the Bullitt health board has usurped legislative  power held only by them, but the 2-1 majority said the state legislature had granted the board that authority in public-health matters.

Judge Jeff Taylor of Owensboro dissented, writing that the law cited by the majority and the board was passed 58 years ago. "I harbor grave doubt that the General Assembly intended to empower health departments at that time with the authority to regulate smoking as a threat to public health," he wrote. "In 1954, second-hand smoke was not a known public health issue." He said the legislature had specifically authorized the Jefferson County lead program, and the Lexington ban was passed by the local council, not the Fayette County Board of Health.

Taylor noted that the Bullitt board had relied on "national and international studies on the effects of secondhand smoke," with no local studies showing "smoking presents a threat to the health of the citizens of Bullitt County." And even if the board had such studies, he wrote, other state laws "reserve to cities and counties the authority to regulate smoking and secondhand smoke in their respective jurisdictions." The laws he cited do not appear to do that, but he argued that allowing health boards to enact smoking bans, he said, would give them "limitless" power to regulate guns, alcohol, sales of large-size soft drinks or "the number of cheeseburgers sold by fast-food restaurants."

Taylor wrote, "To the extent the cities and county, and their elected officials have failed to address a perceived serious public health issue, the citizens of Bullitt County have an easy method to remedy the problem – the ballot box," Taylor wrote. "Or, in the alternative, the Kentucky General Assembly can expressly authorize health boards to regulate smoking in each county." To read the seven-page majority opinion and the eight-page dissent, click here.

Mayfield named state's top doctor, as head of health department

Dr. Stephanie Mayfield

Dr. Stephanie Mayfield has been appointed as the commissioner for the state Department for Public Health, making her the first woman and first African American to hold the position, which has typically been held by a physician. The appointment was made by Audrey Haynes, secretary of health and family services.

The department is the largest health-care provider in the state, with an annual budget this year of almost $400 million. It includes 59 county and district health departments, many of which are "financially struggling," notes Beth Musgrave of the Lexington Herald-Leader. "The health departments have seen their budgets cut in recent years, leading to some lay offs and furloughs." (Read more)

Mayfield has been director of Kentucky’s public health laboratory since 2005. According to the Cabinet for Health and Family Services, Mayfield and the state lab team have been instrumental in speeding up tuberculosis detection and in testing the state's newborns for a wide array of problems. In addition to overseeing the state lab, Mayfield has also served as a lecturer on rotation at the University of Kentucky School of Medicine’s Preventive and Occupational Medicine Residencies and the University of Louisville School of Medicine’s Department of Pathology.

Dr. Steve Davis, who as deputy commissioner has run the department for more than a year, tells Kentucky Health News that he will remain in the agency.

County boards of health are being told to take a more active role in improving the health of their communities

Christian County's health director told the county Board of Health last week that it "needs to spend less time on the health department’s budget and more time addressing big questions of community health," Nick Tabor writes for the Kentucky New Era. "The past four years, we haven’t talked about a lot of health issues. That’s going to change,” Director Mark Pyle told the 12-member board, which is appointed by the state secretary of health and family services.

Other county health boards may be hearing likewise, as their departments seek national accreditation (required by 2020, under a recent state law) and more attention is focused on the boards' stautory responsibility for the health of their communities. (Photo from the Knox County Health Department, which had a cake to celebrate the recent opening of its new building)

Accreditation steers health departments away from a “silo” model in which they worry only about its own affairs, Assistant Christian County Health Director Laura Hammons said. Pyle said their department needs to help build a “community health system” involving all all local organizations involved in health matters, from the Red Cross to the YMCA. (Read more)

County health boards should "assume responsibility for educating their population about improving their health status," be "highly visible and proactive," and play a leading role "in developing healthy community coalitions and partnerships," the statewide Friedell Committee for Health System Transformation said in a report, "The Role of Public Health and the Health of the Community," published in May.

Partly as a result of the committee study that led to the report, "Actions have been taken to increase training for local boards of health, including presentations by the commissioner of public health at board meetings and several training sessions at the state level for board members," the report said.

The report notes that KRS 212.240 requires county health departments, under supervision of county health boards and the state, "formulate, promote, establish, and execute policies, plans, and programs to safeguard the health of the people of the county and establish, maintain, implement, promote, and conduct facilities and services for the purpose of protecting the public health." To download a PDF of the report, click here.

County health board members include three physicians, a dentist, a nurse, a sanitary engineer, an optometrist, a veterinarian, a pharmacist, a lay person "knowledgeable in consumer affairs," the county judge-executive and a person appointed by the county fiscal court. If a county lacks one of the categories, another consumer representative can be appointed. For a PDF of the law, click here. For an index of all the laws on county health programs, click here.

How to take local action to improve health at the local level is outlined at Frankfort conference

By Tara Kaprowy
Kentucky Health News

A recipe for how to improve health at the local level in Kentucky was the capstone of a day-long seminar in Frankfort Monday, with experts stressing that partnerships are key and funding will remain tight.

Communities must mobilize, prioritize, "effectivize" their actions, publicize and evaluate, measure and report performance, Trudi Matthews, director of policy and public relations at HealthBridge, summed up at the end of the Kentucky Health Quality Collaborative Conference.

The gathering was hosted by Kentucky Voices for Health in partnership with the Friedell Committee for Health System Transformation. "No single actor or set of stakeholders can solve what's wrong," Matthews said. "We really need to think across silos. We really have to collaborate."

When it comes to funding, governments "have made it very clear they will not increase the number of dollars that will be put into health care," said keynote speaker Dr. Robert Graham, national program director for Aligning Forces for Quality. "We're in a perfect storm," agreed Sue Thomas-Cox, branch manager for chronic disease prevention at the Kentucky Department for Public Health. "Federal, state and local governments don't have enough money . . . so we must work together."

Luckily, health care happens at the local level, Graham said, with hospitals and clinics unique to communities, health insurance agents locally based and consumers grounded in their communities. While there is "no particular model for how to get (change) started," Graham said, the first step is getting all stakeholders — purchasers, insurance agents, providers, consumers, faith-based organizations — around the same table. "You've got to make sure there is a balance of interests," he said. 

Also key are local boards of health and health departments, whose members and staff are charged with safeguarding the health of the people of a county, under state law, and have the advantage of being "relatively untainted by the illness-for-dollars disease," pointed out Dr. Forrest Calico, a rural health consultant and longtime worker in the field.

Health departments must ensure they don't spread themselves too thin, said Dr. Steve Davis, acting commissioner for the Department for Public Health. "One of the biggest reasons why we have not moved the health needle in Kentucky is we need to be an inch wide and a mile deep," he said. Communities need to "come up with five or six things and let's hammer, hammer, hammer it," he said. Of those priorities, Davis pointed out the importance of tackling chronic disease: "That's what's killing our brethren and eating our financial lunch." For adults, he would like to see an increase in breast, cervical, colon and lung cancer screening, as well an increase in immunization rates especially for flu and pneumonia.

For children, Davis has six priorities: reduce preterm and low-birthrate babies; improve injury-prevention programs; decrease tobacco use; reduce obesity; increase immunization rates; and improve oral health.

To get more accomplished, health departments need to team up with local organizations to avoid duplication of services, which Davis said accounts for $300 billion in unnecessary spending nationwide. He added the goal is to make "1 plus 1 equal 3," with health departments needing to adopt a "do or assure" philosophy.

But there are challenges in health departments, with some local health board members failing to "roll up their sleeves," Davis said. "You can go in with nothing in your head and leave with nothing in your head," agreed Henry Bertram, chair of the Pendleton County and Three Rivers District Board of Health.

A survey of health departments showed just 46 percent of local boards of health have a vision for the next three years to improve the health status of their community and just 44 percent say they are tracking compliance for the 10 essential services they are charged with providing. And the real numbers might be worse, because the survey was voluntary.

While about half of the state's health departments are committed to working toward achieving national accreditation, only three departments — Franklin, Northern Kentucky and Three Rivers District — have actually applied for it. 

Also crucial for communities is using data to identify priorities, take action and measure performance, whether using county-specific numbers at www.kentuckyhealthfacts.org or using national data.

"We don't want to get stuck in analysis paralysis," but communities can use the data as "a story you can use as leverage," said Jan O'Neill, community engagement specialist for County Health Rankings & Roadmaps. The County Health Rankings evaluate the morbidity and mortality rates for nearly every county in the country and rank them within a state.  The rankings can act as a motivator for counties interested in effecting health changes, but "We have to be aware of their limitations" given their margins of error, especially for small counties, pointed out Al Cross, director of the Institute for Rural Journalism and Community Issues. 

O'Neill spoke of San Bernadino County in California, which used its low ranking to spur change. The county focused on its built environment, pressing hard for Walk or Wheel to School programs, community gardens and a kids community health center. O'Neill pointed out the changes are about more than infrastructure. "It's the relationships," she said. "It's the human capital ... It's many not all doing it all, but bringing what you do best. That's what mobilizing looks like."

Jodi Mitchell, executive director for Kentucky Voices for Health, said she is "starting to see a tide of change" already in Kentucky. What's important is to keep momentum building and, equally vital, ensure people are willing to participate. "If you're not at the table," she said, "you're on the menu."

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Bullitt County health board will appeal judge's ruling against smoking ban, with financial help from Clark County

The Bullitt County Board of Health will appeal a local judge's ruling that it lacks the authority to impose a smoking ban, and it will get some help from the board in Clark County, one of four where bans have been enacted by health boards instead of county fiscal courts.

The $5,000 will come not from tax dollars, but from "money received from the University of Kentucky for consulting services provided by Health Department Director Scott Lockard," Rachel Parsons of The Winchester Sun reports. UK "contracted with the Clark County Health Department so Lockard could work with the university and other local public health directors on smoke-free issues."

If the Bullitt County ruling is upheld, the decision could invalidate regulations enacted by health departments in Clark, Madison, Woodford and Hopkins counties. At the Court of Appeals, “If they uphold the lower court’s ruling, then we will have an injunction against our ruling until it goes to the Supreme Court, so we will suspend the enforcement of it until we get a final determination,” Lockard said. “We fully anticipate that the ruling will be in favor of the boards of health, because this is just a very narrow interpretation.” (Read more)

Judge to decide if health board's smoking ban will stand in Bullitt County, as one did in Hopkins County

Whether the Bullitt County Board of Health had the authority to pass a countywide smoking ban is in the hands of Bullitt Circuit Judge Rodney Burress, who heard from the board and representatives of the Fiscal Court objecting to the move Thursday.

In March, the Board of Health passed a ban that would prohibit smoking in bars, restaurants and all public places, including some that are outside. It was supposed to go into effect in September.

But attorneys representing the Bullitt Fiscal Court said the health board has "overstepped its authority by enacting a policy that should have been handed down by a legislative body, such as a city council or Fiscal Court," The Courier-Journal's Charlie White reports.

Margaret Miller, who is helping to represent the board of health, cited the Kentucky statute, which gives boards of health the authority to adopt, implement and enforce regulations to protect people's health.

The Bullitt County Board of Health is not the first in Kentucky to enact such a ban. Health boards in Woodford, Hopkins, Madison and Clark counties did likewise. The move in Hopkins County did result in a legal battle, but the judge sided with the health department and the ruling was not appealed. (Read more)

Retiring Boyle County health director has played important roles in the community; many of his counterparts do likewise

The man behind Danville's smoke-free ordinance is stepping down from his position as Boyle County's public health director. "I've got a 100-acre farm and I plan to pursue those interests and do some extensive traveling," Roger Trent told The Advocate-Messenger's Mandy Simpson. (Advocate-Messenger photo)

Trent has been at the helm of the health department for 12 years. During his tenure, he "successfully lobbied the Danville City Commission to pass an ordinance banning smoking in all enclosed public places of employment," Simpson reports. He also started smoking cessation classes at the health department, collected food for families in need, and headed efforts during the 2009 ice storm. "He will certainly be missed, and I hope we can find somebody equivalent," said David C. Liebschutz, chairman of the Boyle County Board of Health.

Al Cross, director of the Institute for Rural Journalism and Community Issues and publisher of Kentucky Health News, commented on Trent's impact on his community: "County health directors rarely get noticed except when they create controversy or retire," he said. "They play, or should play, a more important role in the community than local news media might suggest." (Read more)