Volume 2: No. 1, January 2005

COMMUNITY CASE STUDY
Clean Indoor Air in El Paso, Texas: A Case Study

	TABLE OF CONTENTS
	Print this article E-mail this article: Send feedback to editors Download this article as a PDF (252K) You will need Adobe Acrobat Reader to view PDF files.
	Navigate This Article � Abstract � Background � Context � Methods � Consequences � Interpretation � Acknowledgments � Author Information � References

Jennifer H. Reynolds, MPH, Robin L. Hobart, MPH, MPP, Patricia Ayala, Monica H. Eischen

Suggested citation for this article: Reynolds JH, Hobart RL, Ayala P, Eischen MH. Clean indoor air in El Paso, Texas: a case study. Prev Chronic Dis [serial online] 2005 Jan [date cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2005/
jan/04_0065.htm.

PEER REVIEWED

Abstract

Background
Exposure to secondhand smoke is an important preventable cause of illness and death. A Smoke-Free Paso del Norte Coalition in El Paso, Texas, led a drive to introduce an ordinance to protect nonsmoking persons from the health effects of secondhand smoke in public places. The ordinance was introduced in April 2001 and was passed on June 26, 2001.

Context
El Paso is the fifth largest city in Texas and the largest border city in the United States. It is the 10th poorest city in the United States; 37% of its residents do not have health insurance. Seventy-eight percent of El Paso’s residents are Hispanic/Latino. A large percentage of El Paso’s restaurant and bar workers are recent immigrants from Mexico.

Methods
Campaign activities included a letter-writing campaign to the El Paso Times, petition gathering, community outreach education, meetings with city council members, print and television advertising, a proactive media advocacy campaign, and a youth rally.

Consequences
One month after the ordinance went into effect, an opinion poll found solid support for the new ordinance. Another survey conducted in December 2002 also found a 22% decline in adult smoking, from 22.1% in 1996 to 17.3% at the time of the survey.

Interpretation
The El Paso campaign is an example of a successful grassroots campaign. El Paso’s campaign relied on direct organizing to identify, recruit, and mobilize supporters, and involved relatively little paid media or paid advocacy efforts. These lessons are transferable to other communities, and the El Paso coalition serves as a model for developing a diverse, representative coalition in a predominantly Mexican American community.

Back to top

Background

The health effects of secondhand smoke are well documented; exposure to secondhand smoke is an important preventable cause of illness and death (1-3). Smoking bans have been developed as a legal tool to limit smoking in workplaces and other public areas (4), and they are recommended by the Task Force on Community Preventive Services as an effective intervention for creating smoke-free environments (5).

In April 2000, A Smoke-Free Paso del Norte Coalition was founded with funding for a four-year comprehensive tobacco control project from the Paso del Norte Health Foundation. Its primary objective was to win approval for an ordinance to protect nonsmoking employees and patrons from the health effects of secondhand smoke in all workplaces and public places, including restaurants, bars, bingo facilities, and bowling alleys.

In El Paso, the process for passing a new ordinance begins with introduction of the ordinance to the city council, followed by a city council vote. An ordinance such as a smoking ban is proposed by the El Paso City-County Health and Environmental District. Health and Environmental District policies must be approved by vote of the city council. There are eight members of the El Paso City Council. The mayor votes if votes are tied.

In April 2001, the Health and Environmental District introduced the ordinance, and the El Paso City Council approved it by a vote of seven to one on June 26, 2001.

The introduction of the ordinance in 2001 represented the second attempt to pass a clean indoor air ordinance in El Paso. The first attempt began in November 1994, when the El Paso Tabaco/Smoke-Free Coalition presented a proposal to the El Paso City-County Health and Environmental District to strengthen the city smoking ordinance. Although the Health and Environmental District approved the proposal, this initial ordinance campaign failed in the city council. In March 1996, the city council tabled the proposed ordinance indefinitely.

Back to top

Context

With a population of more than 550,000, El Paso is the fifth largest city in Texas and the largest border city in the United States. It is the 10th poorest city in the United States; 37% of its residents do not have health insurance, the highest percentage of uninsured in the nation (6). Seventy-eight percent of El Paso’s residents are Hispanic/Latino (7). The Fort Bliss Army base and the University of Texas at El Paso are two important institutions that play a large role in the life of the community. On the other side of the Rio Grande River is El Paso’s sister city, Ciudad Juarez, the fifth largest city in Mexico.

El Paso has a large number of blue collar and hospitality workplaces — the types of workplaces least likely to voluntarily protect workers from secondhand smoke (8). A large percentage of El Paso’s restaurant and bar workers are recent immigrants from Mexico who are unlikely to know about the dangers of secondhand smoke, and because of a perception that their options are limited, they are not likely to seek jobs elsewhere (9). These factors played an important role in deciding which kinds of provisions to include in the ordinance.

Although tobacco industry opposition to clean indoor ordinances is commonplace (10) — and El Paso was no exception to this opposition — coalition members shared a belief that El Paso’s efforts may have been somewhat protected by the opposition’s underestimation of the community’s ability to organize effectively. This underestimation may have been made because of the area’s primarily low-income Hispanic population and historically low voter turnout. Opposition was strongest from the restaurant and bar associations, although they turned down an offer of assistance from the tobacco industry in their efforts to fight the ordinance.

One factor that also may have positively influenced the community was the smoke-free workplace restaurant ordinance in Las Cruces, New Mexico, which is located 35 miles from El Paso. Passed in 1995, the Las Cruces ordinance created a supportive environment for smoke-free policies and was further solidified when Las Cruces strengthened its ordinance again in 1997. The Tobacco-Free Las Cruces Coalition provided invaluable assistance to the El Paso Coalition as it began its own campaign, offering advice on what to look out for, how to undertake a grassroots organizing effort, who to include as coalition members, and other key stakeholders with whom it should meet.

Back to top

Methods

When the coalition was first formed in April 2000, its original plan was to conduct a four-year campaign in two parts, with an anticipated introduction of an ordinance in 2003. The first part was to be a comprehensive community education campaign preceding introduction of the ordinance. The second part was to be a year-long grassroots mobilization and media advocacy campaign leading up to ordinance approval. This plan changed dramatically, however, when the Health and Environmental District decided to introduce the ordinance well in advance of the coalition’s readiness to run a campaign.

The ordinance was introduced earlier than the coalition expected because in fall 2000, a health district board member questioned an effort that had begun in the mid-90s to create an ordinance but had never progressed to a vote. By law, when a city entity like the health district requests that an issue be considered, the issue must be presented to the city council within two weeks. When the coalition learned that the issue was under question and that introduction of the ordinance could be imminent, it appealed to the health district to slow the process so that both the health district and the coalition could work together most effectively toward their common goal of creating an ordinance. The health district agreed to delay the introduction, but it was not willing to wait until 2003. Instead, the ordinance's introduction was scheduled for spring 2001. Thus, the coalition learned in November 2000 that it had only six to eight months to implement what it had previously planned to implement over four years.

In November 2000, the coalition quickly formed a Clean Indoor Air Ordinance Task Force of 15 members to serve as the core team responsible for developing a campaign plan and directing day-to-day campaign operations. The coalition recruited key community leaders to join the task force. In addition to the voluntary health agencies, key supporters included Community Voices Tobacco Control Program (a project funded by the W.K. Kellogg Foundation and the American Legacy Foundation), state and local health departments, local law enforcement, local hospitals and community clinics, Planned Parenthood, the Independent School District and the Region 19 Education Center, a coalition of 18 churches, faculty from the University Health Sciences Center, a waiter/bartender, and a supportive (behind-the-scenes) local restaurant.

Task force members made community presentations to educate the public and recruit new supporters, and members identified a strong champion on the city council. The task force also developed a youth smoke-free coalition, whose efforts were deemed vital to the success of the ordinance. Task force members recruited youth volunteers through independent school districts.

The El Paso coalition relied on models developed and published by Americans for Nonsmokers’ Rights (ANR) in Clearing the Air: Citizen Action Guide (11) and by the Centers for Disease Control and Prevention (CDC) in Best Practices for Comprehensive Tobacco Control (12) to develop a clean indoor air campaign. In 2000, members of the coalition attended the CDC’s Summer Institute course on clean indoor air. This week-long course provided detailed information and skill-building sessions focused on grassroots organizing, coalition building, and other important elements of developing a clean indoor air campaign.

The coalition also sought information and technical assistance from ANR, the CDC, the Texas State Department of Health, the Tobacco-Free Las Cruces Coalition, voluntary health agencies, and other local coalitions across the country with experience passing local smoke-free ordinances. In March 2001, ordinance task force members attended an ANR “Back to Basics” ordinance training, and in April 2001, a member of the New Mexico Department of Health conducted training on mobilizing communities.

One of the key issues debated by coalition members early in the campaign was which provisions to include in the ordinance. After much discussion, the coalition decided to draft a comprehensive ordinance creating full protection from secondhand smoke in all workplaces, including free-standing bars. Although including free-standing bars was a radical idea for its time, the coalition considered it vital to promote a comprehensive workplace ordinance. The coalition countered criticism of the free-standing bar provisions by emphasizing the message that secondhand smoke is a health hazard that affects all workers, and all workers deserve protection. The coalition also pointed out that a comprehensive ordinance creates a level playing field; exempting some workplaces but not others might offer an unfair competitive advantage to the free-standing bars over restaurants and bars attached to restaurants.

Public awareness campaign

Highlights of Activities for Passing Clean Indoor Air Ordinance in El Paso, Texas, 2000–2004

1996 First attempt at clean indoor air ordinance fails in El Paso City Council. April 2000 A Smoke-Free Paso del Norte Coalition is founded with mission to win approval for an ordinance to protect nonsmoking persons from the health effects of secondhand smoke in public places. Coalition plans to introduce ordinance in 2003. June 2000 Coalition members attend the Centers for Disease Control and Prevention’s (CDC’s) Summer Institute course on clean indoor air. November 2000 Coalition learns that ordinance will be introduced by the Health and Environmental District in spring 2001. Fifteen-member task force is recruited and organized with diverse city-wide representation. News media advocacy campaign launches with visit to El Paso Times editorial board. December 2000 Research on clean indoor air ordinances, opposition to clean indoor air laws, and the harmful effects of secondhand smoke is gathered and synthesized into education materials for the news media, city council, and general public. March 2001 Petition-gathering effort with a focus on the faith community takes place, and 7000 signatures are hand-delivered to each of eight city council members, plus the mayor. Letter-writing campaign to El Paso Times editors and city council members begins. Ordinance task force members attend an Americans for Nonsmokers’ Rights “Back to Basics” ordinance training. April 2001 District introduces an ordinance to protect nonsmoking persons from the health effects of secondhand smoke in public places. A 30-second educational message airs on television to raise public awareness of secondhand smoke. Coalition members participate in educational session on mobilizing communities, conducted by New Mexico Department of Health. June 2001 The ordinance is passed by a city council vote of seven to one. December 2001 Coalition distributes 18,000 educational packets, including required decals, to all businesses, public places, and worksites in El Paso. Members of law enforcement responsible for enforcing the provision are trained. January 2002 The clean indoor air ordinance goes into effect. February 2002 El Paso Times and ABC affiliate (KVIA) sponsor an opinion poll, which finds solid public support for the new ordinance (13). February 2004 The CDC and Texas Department of Health analysis shows that no statistically significant changes in restaurant and bar revenues occurred after the smoking ban took effect (15).

One of the first steps taken by coalition members was to meet with members of the El Paso Times editorial board to counter some negative publicity that had arisen earlier in the year. The El Paso Times is a regional newspaper with a daily readership of approximately 250,000 that serves residents of far West Texas and southern New Mexico. During December 2000, the coalition focused on gathering research on various kinds of clean indoor air ordinances, opposition to such ordinances, and the harmful effects of secondhand smoke to prepare educational materials for the news media, city council, and El Paso citizens. During March 2000, a task force member active in the faith community led a petition-gathering effort among 18 churches and collected 7000 signatures that were hand-delivered to each of eight city representatives, plus the mayor. The coalition worked with an advertising agency to produce an educational television message on secondhand smoke for $2000; it cost $8000 to air the ad during April. TRUST for a Smoke-Free Texas provided a grant of $2500 to support placement of a print advertisement, which was developed on a pro bono basis by the ad agency and placed in the El Paso Times shortly before the city council vote. The Texas Division of the American Cancer Society provided $5000 to support printing (e.g., fact sheets, buttons) and postage costs. On the day of the vote, a large youth rally took place at city hall, and three young people — a nine-year-old boy and two girls from a local high school — delivered testimony to city council members on the health effects of secondhand smoke. The coalition gave out buttons with the words "I support Clean Indoor Air" and flashing lights to all those in attendance. The event was packed with citizens and members of the news media. After the ordinance passed, the coalition worked with the Health and Environmental District to develop an educational packet for 18,000 El Paso businesses. The packet included a detailed explanation of the ordinance and its provisions, sample employee policies, and decals, which were required to be placed on business entrances. In addition, the coalition held training sessions for members of law enforcement who were responsible for enforcing the ordinance. Back to top Consequences The ordinance went into effect in January 2002. In February 2002, the El Paso Times and the ABC affiliate (KVIA) sponsored an opinion poll. The poll found solid support for the new ordinance; 93% indicated they would go out to restaurants and bars as often (49%) or more often (44%) as a result of the ordinance (13). In December 2002, 11 months after the ordinance went into effect, the Paso del Norte Health Foundation sponsored a household telephone survey, which also found strong support for the ordinance; after a full year of implementation, 78.5% indicated they supported the ordinance, and only 10.9% opposed it (the rest reported no opinion). Although general knowledge about the existence of the ordinance was high, familiarity with the ordinance's specifics was not. The Paso del Norte Health Foundation survey also found a 22% decline in adult smoking, from 22.1% in 1996 to 17.3% at the time of the survey in 2002 (14). An economic impact analysis by the mayor found that total sales subject to state sales tax in eating and drinking establishments continued to grow at a steady pace after the ordinance went into effect (14). Total sales for the first two quarters of 2002 increased by 4.4%, up slightly from the prior year’s increase of 2.5% (14). The number of employed waiters and waitresses also increased by 300 from 2001 to 2002 (14). The Texas Department of Health and the CDC subsequently analyzed sales tax and mixed-beverage tax data during the 12 years preceding and one year after the smoking ban to further assess whether the El Paso smoking ban affected restaurant and bar revenues; it was determined that no statistically significant changes in restaurant and bar revenues occurred after the smoking ban took effect (15). Following enactment of the ordinance, the local restaurant association seemed resigned to complying with the new ordinance, but local bars continued to oppose it, attempting to collect enough signatures to force the ordinance to a referendum. The coalition closely tracked this effort, which failed to collect enough valid signatures to qualify (in part because the petitions did not use uniform language). Opponents also attempted to place the ordinance back on the city agenda for discussion. Coalition members monitored the council agenda and sent representatives when the ordinance was listed as an agenda item. After opponents twice failed to attend, the city council stopped putting the issue on the agenda. Back to top Interpretation This campaign was a collaborative, unified effort, based in and owned by the community. Several components led to its success. One, the coalition consistently and uncompromisingly focused on the issue of worker’s health and protection. Although some coalition members opposed including bars in the ordinance, the coalition stayed consistent with the message that bar workers deserved protection as much as workers in other workplaces. Two, the coalition members sought training on policy and media advocacy. The coalition received technical assistance and support from ANR, the CDC, the voluntary health agencies, and from other local coalitions with experience working on smoke-free ordinances (in particular, the Tobacco-Free Las Cruces Coalition). Three, the coalition was diverse, drawing from many sections of the community (e.g., health groups, law enforcement, educational groups, church groups, public agencies). Four, the coalition recruited and developed youth leaders and empowered the youth coalition to set its own goals for the ordinance campaign. The youth were vital to the letter-writing campaign and held a rally the day of the council vote; their testimony at the public hearing was extremely persuasive to city council members. Five, the coalition found and cultivated a strong champion on the city council. This champion was passionate and enthusiastic in his support for the ordinance, stayed in close communication with the coalition about developments and strategy, and brokered no compromises. Six, the coalition was proactive with the news media. Members developed and distributed key speaking points to committed activists, provided the news media with background information, facts, and statistics, and monitored news media coverage (responding immediately to any negative coverage). The El Paso campaign is an example of a grassroots campaign. It relied on direct organizing to identify, recruit, and mobilize supporters and involved relatively little paid media or paid advocacy efforts. The broad lessons from this campaign are transferable to other communities, especially as the issue of clean air for a worker’s health and protection grows (16). In addition, the El Paso Coalition serves as a model for developing a diverse, representative coalition in a predominantly Mexican American community. One caution to coalitions considering the El Paso initiative is that the time frame to educate the community and organize grassroots support was considerably compressed because of factors outside the coalition’s control. Ideally, coalitions will have more time to educate the public and decision makers and recruit and mobilize grassroots supporters. However, it is also true that if too much time is allotted for the education and mobilization phase, coalition members can lose focus and energy and have a more difficult time putting aside other responsibilities. Therefore, coalitions must gauge an appropriate period that takes into account all of these issues. Back to top Acknowledgments This case study was adapted from another case study written by Robin Hobart for the CDC’s Office on Smoking and Health. The information was based on interviews with Patricia Ayala, Quata Casady, Luan Coalwell, Debbie Oaks, and Becky Zima, all members of A Smoke-Free Paso del Norte Coalition during the ordinance campaign. Karen Frost and Jennifer Reynolds adapted the original case study for this article. Back to top Author Information Corresponding author: Monica H. Eischen, Office on Smoking and Health, Centers for Disease Control and Prevention (CDC), 4770 Buford Hwy NE, Mail Stop K-50, Atlanta, GA 30306. Telephone: 770-488-1072. E-mail: meischen@cdc.gov. Author affiliations: Jennifer H. Reynolds, MPH, Office on Smoking and Health, CDC, Amherst, Mass; Robin L. Hobart, MPH, MPP, Denver, Colo; Patricia Ayala, El Paso, Tex. Back to top References U.S. Office on Smoking and Health. The health consequences of involuntary smoking: a report of the Surgeon General. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Center for Health Promotion and Education, Office on Smoking and Health; 1986 Jan 1. 359 p. California Environmental Protection Agency. Health effects of exposure to environmental tobacco smoke, final report. Sacramento (CA): California Environmental Protection Agency, Office of Environmental Health Hazard Assessment; 1997 Sep. U.S. Environmental Protection Agency. Respiratory health effects of passive smoking: lung cancer and other disorders. Washington (DC): U.S. Environmental Protection Agency, Office of Research and Development, Office of Health and Environmental Assessment; 1992 Dec. Mensah GA, Goodman RA, Zaza S, Moulton AD, Kocher PL, Dietz WH, et al. Law as a tool for preventing chronic diseases: expanding the spectrum of effective public health strategies. Prev Chronic Dis [serial online] 2004 Jan [2004 Oct]. Task Force on Community Preventive Services. Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med 2001 Feb;20(2 Suppl):10-5. High concentrations of Latinos linked to high uninsured rate [Internet]. Hispanic Vista. Available from: URL: http://www.hispanicvista.com/html/he000904.html*. City of El Paso Office of Economic Development. El Paso Profile and Economic Summary 2002. El Paso (TX): City of El Paso; 2001. Available from: URL: http://www.elpasotexas.gov/econdev/factbook_2002.asp*. Shopland DR, Anderson CM, Burns DM, Gerlach KK. Disparities in Smoke-Free Workplace Policies Among Food Service Workers. J Occup Environ Med 2004;46:347-56. Yanez E. Clean indoor air and communities of color: challenges and opportunities. Washington (DC): Policy Advocacy on Tobacco and Health, The Praxis Project. Available from: URL: www.thepraxisproject.org/tools/CIA_and_CoC.doc*. U.S. Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2000. p. 206-7. Americans for Nonsmokers’ Rights. Clearing the air: citizens action guide. Berkeley (CA): Americans for Nonsmokers' Rights; 2000. Available from: URL: http://www.no-smoke.org/100ordcomptext.html*. Department of Health and Human Services. Best practices for comprehensive tobacco control programs. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1999. Cruz L. Poll: more to visit smoke-free sites. El Paso Times; 27 Feb 2002. Available from: URL: http://www.elpasotimes.com*. Colwell B, Smith D, Condon K. Settling the smoke: Paso del Norte Health Foundation status report on adult smoking in El Paso � 2001. College Station (TX): Texas A&M University System Health Science Center, School of Rural Public Health; 2002. Centers for Disease Control and Prevention. Impact of a smoking ban on restaurant and bar revenues – El Paso, Texas, 2002. MMWR Morb Mortal Wkly Rep 2004 Feb 27;53(7):150-2. NYC.gov. Mayor Michael Bloomberg’s testimony to the council committee on health [Internet]. New York City: NYC.gov; 2002 Oct 10. Back to top *URLs for nonfederal organizations are provided solely as a service to our users. URLs do not constitute an endorsement of any organization by CDC or the federal government, and none should be inferred. CDC is not responsible for the content of Web pages found at these URLs. Watch KFOX news coverage in English (rm 3.6mb) Transcripts of this clip in English and Spanish are also available. Vea la cobertura de noticias por Canal 26 Noticias en Espa�ol (rm 4mb) Transcripci�nes de este video est� disponible en Espa�ol y en Ingl�s. You will need RealOne Player to view these videos. Learn more about RealPlayer.   The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.  Home  Privacy Policy | Accessibility CDC Home | Search | Health Topics A-Z This page last reviewed March 30, 2012 Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion United States Department of Health and Human Services