Megan Resolutions

2016- Decreasing Prescription (Opioids) Drug Misuse

August 25, 2016
The Arizona Public Health Association (AzPHA) supports the adoption of the following APHA Policy Statement 20154 – Prevention and Intervention Strategies to Decrease Misuse of Prescription Pain Medication and its action step recommendations.

Policy Statement: 20154

Abstract

The United States is undergoing an epidemic of deaths caused by prescription drug overdoses. Every 19 minutes, someone in the United States dies from an unintentional prescription drug overdose. One major contributing factor to the rise in such deaths is the increased use of opioid analgesics. This policy statement recommends legislative and educational strategies to combat misuse of prescription pain medications.

Legislation needs to address physical and mental status examination laws, doctor shopping laws, tamper-resistant prescription form requirements, regulation of pain management clinics, prescription drug monitoring laws, prescription drug overdose emergency response immunity, and access to naloxone. Education must be required for health care prescribers and for the general public. Community education efforts could focus on safe storage, use, and disposal of prescription medications. Pain medication prescription prescribers must be educated on identification and treatment of pain, alternative modalities, substance abuse screening, and mental illness assessments and treatment for vulnerable populations.

Relationship to Existing APHA Policy Statements

This policy has been identified as a policy statement gap for 2015 (a related policy is 20133, Reducing Opioid Overdose through Education and Naloxone Distribution).

Existing policies focus predominantly on naloxone distribution programs. A more comprehensive policy statement with additional actions that should be taken at the local, state, and national levels was requested. These additional actions are included in this policy.

Problem Statement

According to a report released in 2013 by the Trust for America’s Health, “prescription drug abuse has quickly become a top public health concern, as the number of drug overdose deaths—a majority of which are from prescription drugs—[has] doubled in 29 states since 1999. The rates [have] quadrupled in four of these states and tripled in 10 more of these states.”[1] Enough prescription painkillers were prescribed in 2010 to medicate every American adult around the clock for 1 month. Although most of these pills were prescribed for a medical purpose, many ended up in the hands of people who abused them.[2]

According to the Centers for Disease Control and Prevention (CDC), prescription drug abuse was the fastest growing drug problem in the United States as of 2012.[3] Many people who use heroin in the United States today used prescription opioids first.[4] Although the number of drug deaths related to prescription opioids has stabilized,mortality rates associated with heroin have increased over the last 3 years.[4] One major contributing factor to this growing drug problem in the United States is the increased use and prescribing of opioid analgesics, which, over the past decade, have caused more overdose deaths than heroin and cocaine combined.[3] One CDC report noted that, for every overdose death, there are 10 treatment admissions for abuse, 32 emergency department visits for misuse or abuse, 130 people who abuse or are dependent, and 825 people who take prescription painkillers for nonmedical use.[2] In that report, nonmedical use was defined as “use of a prescription pain reliever without a prescription belonging to the respondent or use for the experience or feeling the drug causes.”[2]

Not only are the morbidity and mortality rates associated with prescription drugs a top public health concern, but the costs imposed on the US economy are also substantial. A 2011 study estimated that, in 2006, nonmedical use of prescription painkillers imposed a cost of $53.4 billion on the US economy, including $42 billion in lost productivity, $8.2 billion in increased criminal justice costs, $2.2 billion for drug abuse treatment, and $944 million in medical complications.[2]

As a result of the growing drug problem in the United States and the associated costs incurred by the US economy, the White House Office of National Drug Control Policy, the CDC, the Substance Abuse and Mental Health Services Administration (SAMHSA), and state and local public health agencies have made reducing prescription drug abuse a top priority to address associated rates of morbidity and mortality.[1] In addition, in 2014, the Association for State and Territorial Health Officials implemented the 15 by 15 challenge, intended to reduce prescription drug misuse and deaths by 15% by 2015.[5]

The Prescription Drug Monitoring Program (PDMP) Center of Excellence describes the prescription drug abuse epidemic as a factor of increased prescribing of prescription drugs: “The rise in the misuse and abuse of prescription drugs, opiates in particular, has been attributed to their increased availability over the last decade, a result of increased prescribing. Increased prescribing in turn has been driven by more aggressive treatment of pain in response to patient advocacy groups, the development of new formulations of opiate analgesics to meet this demand, and increased marketing of opiates by pharmaceutical companies. Hydrocodone-acetaminophen, sold under the brand name Vicodin™, is among the most widely prescribed medications in the US in any drug category. Synthetic opioids such as OxyContin™, oxycodone and methadone are more frequently prescribed to treat non-cancer pain than in prior decades. Because of their psychoactive and addictive properties, these drugs, along with tranquilizers (e.g., benzodiazepines such as Xanax, Klonopin, and Valium) and stimulants (Ritalin, Adderall) have high street value. They are diverted for illicit use by means of sharing among friends and family, doctor shopping, prescription fraud, and theft.”[6]

Opioid painkillers are only one group of prescription drugs that have potential for misuse or abuse. The National Institute on Drug Abuse (NIDA) has grouped the most commonly used addictive drugs into 13 different categories, one of which is prescription and over-the-counter medications.[7] Although the prescription drug abuse epidemic may be commonly discussed in terms of opioid analgesics, there are several other groups of prescription and over-the-counter medications that may be subject to misuse and abuse. For example, stimulants such as amphetamines and methylphenidates are commonly prescribed to treat attention-deficit hyperactivity disorder and have the potential for abuse. In addition, depressants may be used to treat anxiety- or sleep- related disorders and contribute to the prescription drug abuse problem in the United States. Prescription-strength cold medicines may contain ingredients such as promethazine or codeine, both of which can illicit euphoric or sedative effects.

Furthermore, common over-the-counter drugs that contain ingredients such as dextromethorphan and pseudoephedrine may be subject to misuse and abuse.[7] Thus, it is important for initiatives aimed at curbing the prescription drug abuse epidemic to address the abuse and misuse of all groups of prescription and over-the-counter medications that have the potential for abuse.
Policy efforts aimed at reducing the impact of morbidity and mortality related to prescription drug abuse commonly focus on the supply side of the “drug abuse supply- and-demand equation.”[8] However, there is some literature that questions the effectiveness of heavy supply-side-focused initiatives.[9] The concern is that these initiatives may limit access to medications for patients who have legitimate chronic pain. Some policy initiatives, however, may have the potential to reduce the supply of prescription drugs and thus reduce the potential for drug diversion that leads to misuse and abuse. According to Twillman et al., policy initiatives that focus on the supply of prescription drugs should consider (1) abuse-deterrent opioid formulations, (2) increased medication storage security at home, (3) drug take-back opportunities, (4) improved clinician education, and (5) improved effectiveness of prescription drug monitoring programs.[8] These five solutions strive to reduce access to prescription drugs that may be used for reasons other than their originally intended purpose. For example, improved clinician education aims to teach clinicians “to prescribe only the number of doses they expect patients to need in acute pain settings and the importance of avoiding excess prescribing.”[9] Similarly, PDMP electronic databases provide supplemental information on controlled substance prescriptions and allow for detection of and intervention among individuals attempting to fraudulently obtain such prescriptions. Although supply-side initiatives are a major focus in prescription drug abuse efforts, the demand side of the equation is equally important.

Policymakers and public health officials must also aim to reduce the demand for prescription drugs to prevent individuals from developing the disease of addiction. Primary drug abuse prevention efforts that aim to educate patients and their families form the foundation for reducing prescription drug demand. Research efforts must focus on understanding how to improve the effectiveness of primary drug abuse prevention programs.[9] Furthermore, these programs must become more prominent throughout the country to prevent the development of addiction. Although the goal is to completely prevent abuse of prescription drugs, treatment services must be available to those who have abused or are currently abusing these drugs. Therefore, demand reduction strategies must ensure that there is an adequate supply of substance abuse treatment programs and mental health professionals to provide these services.

Prescription drug misuse and abuse disproportionately affect men as compared with women. According to SAMHSA, the rate of nonmedical use of prescription psychotherapeutic drugs is 2.6% among men and 2.3% among women.[10,11] SAMHSA also identifies young adults, veterans, and military service members, as well as older adults, as being disproportionately affected by prescription drug misuse and abuse.[11] In fact, many young people believe prescription drugs to be safer than illegal drugs. In 2014, youths 12 to 17 years of age and young adults 18 to 25 years of age were more likely to have misused prescription drugs in the past year than adults 26 years or older.[11]

On the other end of the spectrum, NIDA notes that prescription drug misuse and abuse are increasing among people in their 50s.[11] This population is at higher risk for medication misuse than the general population, largely as a result of increased rates of pain, sleep disorders/insomnia, and anxiety.[11] In addition, elderly individuals are typically more sensitive to medications because of their slower metabolism.[11] Furthermore, the elderly population may be more likely to take multiple medications concurrently for the treatment or management of several comorbidities, a practice referred to as polypharmacy. According to a systematic literature review conducted in 2005, polypharmacy is correlated with adverse health outcomes among elderly individuals.[12] These adverse outcomes are likely due to the increased risk of drug interactions between multiple medications and the complexity of the treatment and management of multiple comorbidities. Therefore, improved health outcomes in this population may depend on successful care coordination and reductions in cases of polypharmacy.

Intervention strategies that aim to curb the prescription drug abuse epidemic must (1) improve legislation and enforcement of existing laws, (2) improve medical practice with respect to prescribing opioids, (3) educate prescribers regarding the underappreciated risks and benefits of high-dose opioid therapy, and (4) include secondary and tertiary prevention measures to improve access to substance abuse services and overdose harm reduction programs.[3] In addition, policy initiatives must not focus solely on the supply side of the prescription drug abuse equation, which could reduce access to treatment among patients who have a legitimate need for medications to control chronic pain. As such, policy initiatives focused on demand must also be considered, with particular attention to populations disproportionately affected by prescription drug misuse and abuse.

Evidence-Based Strategies to Address the Problem

The prescription drug abuse injury policy report published by the Trust for America’s Health in 2013 described several strategic interventions considered to be the most promising to fight prescription drug abuse.[1] Unfortunately, many of these intervention

strategies are relatively new, and therefore strong research and evidence are limited.[1] However, the Trust for America’s Health convened a group of medical, law enforcement, and public health experts to identify the most promising policies and approaches to reducing prescription drug abuse on the basis of available research and data.[1] As a result, these strategies may be considered as informed by evidence.

The strategies can be broken into two categories. The first category includes strategies aimed at prevention of drug misuse and abuse, such as implementation and mandatory use of PDMP initiatives, adoption of doctor shopping laws and medical provider education laws, and implementation of physical exam requirements. The second category of interventions aims to increase access to and support for substance abuse services. These strategies include adoption of good Samaritan laws, laws that support access to rescue drugs, and other overdose harm reduction programs. This category also recommends that resources be allocated for development and continued support of substance abuse services. Specifically, SAMHSA has reported a growing workforce crisis in the addictions field due to high turnover rates, worker shortages, an inadequately qualified and aging workforce, and stigma.[13]
In combination with counseling, medication-assisted treatment for opioid addiction in opioid treatment programs can reduce prescription overdose deaths. Best practice guidelines, available through SAMHSA, include individually designed programs with detoxification and medically supervised withdrawal and maintenance medications. Also recommended are psychosocial counseling and treatment for any co-occurring disorders, vocational and rehabilitation services, and case management services.[14] Other recommendations are listed below.

• Legislation requiring a practitioner to examine or evaluate the physical and mental status of a patient before prescribing or dispensing controlled substances. “Practitioner” broadly refers to physicians, dentists, pharmacists, physician assistants, nurse practitioners, or any other individuals permitted to prescribe, dispense, and distribute a controlled substance.[15]

• Legislation addressing doctor shopping to prevent patients from obtaining controlled substances from multiple providers. Although all states follow the Narcotic Drug Act of 1932 or the Uniform Controlled Substances Act of 1970, according to which no person “shall obtain or attempt to obtain a narcotic drug, or procure or attempt to procure the administration of a narcotic drug…by fraud, deceit, misrepresentation, or subterfuge,” only 20 states have additional regulations to specifically prevent doctor shopping.[16] PDMPs are useful in allowing access to information across state lines, and prescribers should be required to check this information before the initial prescription is given and at least every 3 months thereafter.[17] Also, if patients are receiving multiple prescriptions, providers need to be knowledgeable regarding how to refer them for treatment.

• Legislation regulating “pill mills,” pain management clinics where large numbers of prescriptions are provided. Actions can include requiring clinics to register with the state or obtain a license or certificate. Also, owners can be required to be licensed prescribers and in good standing in the state, and unannounced inspections can be conducted as a means of verifying documentation and responding to complaints. Florida has experienced a decrease in overdose- related mortality as a result of its actions in this area.[18]

• Education for prescribers on appropriate diagnosis and treatment of chronic pain. One study of physicians revealed a knowledge gap related to abuse-deterrent formulations and the amount of recreational abuse stemming from diversions of legitimate prescriptions.[19]

• Education for providers on alternative modalities such as physical therapy, acupuncture, and nonnarcotic therapy. Providers who prescribe extended- release/long-acting opioid analgesics to treat chronic pain need to consider other drugs that can interact and cause respiratory depression.[20] A systematic review of randomized controlled trials of complementary and alternative medicines for cancer pain indicated some success with hypnosis, imagery, acupuncture, and healing touch.[21]

• Use of naloxone by first responders as well as family and friends of individuals addicted to opioids or other narcotics. Family and friends of those at risk of opioid overdose must be educated on the signs of overdose emergency and must be told to call 911 and administer naloxone. They and the naloxone prescriber need to be protected by immunity from prosecution.[22]

• Increased preparation of substance abuse treatment specialists and increased availability of treatment facilities. The National Association of Community Health Centers[23] found that 43% of physicians working in federally qualified health centers were interested in being trained to provide medication-assisted treatments for people with addictive disorders. SAMHSA workforce initiatives should be encouraged, including partnerships with community-based providers and organizations, efforts to increase the diversity of the behavioral health workforce, and initiatives to expand the numbers of on-site and distance education programs. Prescribers need to practice compassionate weaning if access to prescription drugs is restricted.[14]
The World Health Organization (WHO) has outlined several recommendations on treatment options and prevention of opioid overdose, including increasing the number of opioid dependency treatment programs. WHO also recommends reducing inappropriate opioid prescribing, making naloxone available to those who might witness an opioid overdose, and offering more psychosocial support to maintain treatment options.

WHO’s suggested treatment options include methadone, buprenorphine, and detoxification. Initial treatment would involve non-opioid medications, to be followed by weak opioids and, subsequently, stronger opioids.[24]
The Scottish government has funded a national take-home naloxone program since 2011 to educate families, friends, and caregivers on causes of overdose and administration of naloxone. All individuals released from prison who were on an opioid drug are given naloxone as they leave. This policy has led to a 20% to 30% reduction in opiate-related deaths among the prison release population.[25]

The International Narcotics Control Board has reported actions to overcome prescription drug abuse that include preventing forging of prescriptions and decreasing thefts from pharmacies, hospitals, and doctors’ offices. The board also discourages doctor shopping and illegal Internet pharmacy operations.[26]

Opposing Arguments/Evidence

A 2011 Institute of Medicine report addressed relieving pain. Tens of millions of Americans are affected by pain, contributing to morbidity, mortality, disability, demands on the health care system, and economic costs. Disparities in the treatment of pain exist, and serious undertreatment of pain has been reported among children, the elderly, and racial and ethnic minority groups.[27] Restricting access to pain medications through legislative or criminal justice actions to prevent doctor shopping or close “pill mills” can further decrease legitimate pain medication access.[28]

Failure to adequately medicate a patient can place a physician at risk for malpractice. In addition to being charged with negligence, physicians have been sued as a result of complaints regarding both overtreatment and undertreatment of pain.[29]

Objections to distributing naloxone to nonmedical personnel also persist despite a lack of scientific evidence to support such objections. In fact, naloxone is safe, effective, and easy to administer via nasal spray or intramuscular injection. It has been argued that naloxone can encourage opiate users to increase their drug consumption, but the evidence contradicts this claim.[30–32] Legislators, police, and prosecutors still need to be convinced that naloxone programs are effective. Naloxone distribution has been an important step in harm reduction to help reach the goal of stopping dependence on and misuse of opiate substances. Syringe exchange programs and opiate substitution therapy are other examples of harm reduction strategies. Studies of naloxone distribution and overdose prevention programs report reductions in self-reported drug use. As noted in one report, “[i]t is unethical to allow a narrow focus on the harms of drug use to overshadow an opportunity to save human lives.”[22]

Action Steps

Therefore, APHA:
• Urges public health and public policy education programs to prioritize and implement evidence-based community and provider training programs on mental health, nonpharmacological pain treatment alternatives, substance abuse, and overdose prevention. Among those with prescriptive authority, gaps in education can be assessed and continuing education provided at the time of licensing renewal. States can use resources from the National Conference of State Legislatures to assess legislation addressing these actions and gaps.[33]
• Urges public education on nonsharing of prescription medications as well as safe storage, use, and disposal of medications. Messaging must come from multiple public health partners and resources, including public radio and television, billboards, and social media. Some states are using pledges to not share and website messaging (e.g., on state and local health department and public safety department sites).
• Urges pain prescription providers to become more knowledgeable on identifying and treating pain with alternative modalities and to coordinate pain management with complementary and integrative care providers.
• Urges providers to be educated on and require the use of PDMPs before prescribing pain medications and to increase integration of patients’ information into their electronic health records. Prescribers need to be educated on referral and treatment options if concerns are identified on the PDMP assessment.
• Urges federal and state legislators to prioritize resources for development and continued support of evidence-based substance abuse treatment programs that include medication-assisted treatment and supportive counseling.
• Urges state legislation to require individuals to have physical and mental examinations before they are prescribed pain medications. Also, there is a need for legislation addressing doctor shopping, “pill mills,” and use of tamper-resistant prescriptions. Plans to accommodate patients who need new providers must be coordinated with these actions.
• Urges state legislators to enact laws increasing distribution of and access to naloxone among first responders, family members, and friends of individuals who may be misusing opioids.
References

1. Trust for America’s Health. Prescription drug abuse: strategies to stop the epidemic. Available at:http://healthyamericans.org/reports/drugabuse2013/. Accessed December 5, 2015.
2. Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011;60:1487.
3. Centers for Disease Control and Prevention. CDC grand rounds: prescription drug overdoses—a U.S. epidemic. JAMA. 2012;61:10–13.
4. Centers for Disease Control and Prevention. 2013 drug overdose mortality data announced. Available at:http://www.cdc.gov/media/releases/2015/p0114-drug- overdose.html. Accessed December 5, 2015.
5. Association of State and Territorial Health Officers. ASTHO 2014 president’s challenge: highlights from state/territory pledges. Available

at: http://www.astho.org/annual-meeting-2014/presentations/state-pledges-prescription- drug-misuse-session/. Accessed December 5, 2015.
6. Prescription Drug Monitoring Program Center of Excellence at Brandeis. Prescription drug abuse epidemic. Available at: http://www.pdmpexcellence.org/drug-abuse- epidemic. Accessed December 5, 2015.
7. National Institute on Drug Abuse. Most commonly used addictive drugs. Available at:http://www.drugabuse.gov/publications/media-guide/most-commonly-used-addictive- drugs. Accessed December 5, 2015.
8. Twillman RK, Kirch R, Gilson A. Efforts to control prescription drug abuse: why clinicians should be concerned and take action as essential advocates for rational policy. CA Cancer J Clin. 2014;64:369–376.
9. Brownhill JF. An analytic assessment of US drug policy. J Soc Polit Econ Stud. 2005;30:398.
10. Center for Behavioral Health Statistics and Quality. Results from the 2013 National Survey on Drug Abuse and Health: Summary of National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.
11. Substance Abuse and Mental Health Services Administration. Specific populations and prescription drug misuse and abuse. Available
at: http://www.samhsa.gov/prescription-drug-misuse-abuse/specific-populations. Accessed December 5, 2015.
12. Frazier SC. Health outcomes and polypharmacy in elderly individuals: an integrated literature review. J Gerontol Nurs. 2005;31:4–11.
13. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Report to Congress on the nation’s substance abuse and mental health workforce issues. Available at:http://store.samhsa.gov/shin/content/PEP13-RTC-BHWORK/PEP13-RTC- BHWORK.pdf. Accessed December 5, 2015.
14. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Quick guide for clinicians based on TIP 45: detoxification and substance abuse treatment. Available at: https://store.samhsa.gov/shin/content/SMA06-4225/SMA06-4225.pdf . Accessed December 5, 2015.
15. Centers for Disease Control and Prevention. Prescription drug physical examination requirements. Available at: http://www.cdc.gov/phlp/docs/pdpe-requirements.pdf. Accessed December 5, 2015.
16. Centers for Disease Control and Prevention. Prescription drugs: doctor shopping laws. Available at: http://www.cdc.gov/phlp/docs/menu-shoppinglaws.pdf. Accessed December 5, 2015.
17. Centers for Disease Control and Prevention. Addressing prescription drug abuse in the United States: current activities and future opportunities. Available at: http://www.cdc.gov/drugoverdose/pdf/hhs_prescription_drug_abuse_report_09.2013.pdf
. Accessed December 5, 2015.
18. Pain Medicine News. Study finds decreasing number of pill mills and drug overdose deaths in Florida. Available
at: http://www.painmedicinenews.com/ViewArticle.aspx?d=Policy+%26+Management&d
_id=83&i=January+2015&i_id=1139&a_id=29251. Accessed December 5, 2015.

19. Lowry F. Doctors have knowledge gaps about opioid abuse. Available at:http://www.medscape.com/viewarticle/824702. Accessed December 5, 2015.
20. Rosenberg EI, Genao I, Chen I, et al. Complementary and alternative medicine use by primary care patients with chronic pain. Pain Med. 2008;9:1065–1073.
21. Bardia A, Barton DL, Prokop LJ, Bauer BA, Moynihan TJ. Medicine therapies in relieving cancer pain: a systematic review. Available
at: http://jco.ascopubs.org/content/24/34/5457.full. Accessed December 5, 2015.
22. Bazazi AR, Zaller ND, Fu JJ, Rich JD. Preventing opiate overdose deaths: examining objections to take-home naloxone. J Healthcare Poor Underserved. 2010;21:1108–1113.
23. National Association of Community Health Centers. NACHC 2010 assessment of behavioral health services in federally qualified health centers. Available at: https://www.nachc.com/client/NACHC%202010%20Assessment%20of%20Behavioral% 20Health%20Services%20in%20FQHCs_1_14_11_FINAL.pdf. Accessed December 5, 2015.
24. World Health Organization. Information sheet on opioid overdose. Available at:http://www.who.int/substance_abuse/information-sheet/en/. Accessed December 5, 2015.
25. Bird SM, Parma MKB, Strong J. Take-home naloxone to prevent fatalities from opiate overdose: protocol for Scotland’s public health policy evaluation, and a new measure to assess impact. Informa Healthcare. 2015;22:66–76.
26. International Narcotics Control Board. Annual report 2009. Available at: https://www.incb.org/documents/Publications/AnnualReports/AR2009/AR_09_English.p df. Accessed December 5, 2015.
27. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academy Press; 2011.
28. Worley J. Prescription drug monitoring programs, a response to doctor shopping: purpose, effectiveness, and directions for future research. Issues Ment Health
Nurs. 2012;33:319–328.
29. Kirschner N, Ginsburg J, Sulmasy LS. Prescription drug abuse: executive summary of a policy position paper for the American College of Physicians. Ann Intern Med. 2014;160:198–200.
30. Maxwell S, Bigg D, Stanczyiewicz K, et al. Prescribing naloxone to actively injecting heroin users: a program to reduce heroin overdose deaths. J Addict Dis. 2006;25:89– 96.
31. Seal KH, Thawley R, Gee L, et al. Naloxone distribution and administration program in New York City. Subst Use Misuse. 2008;43:858–870.
32. Wagner KD, Valente TW, Casanov M, et al. Evaluation of an overdose prevention and response training programme for injection drug users in the Skid Row area of Los Angeles, CA. Int J Drug Policy. 2010;21:186–193.
33. National Conference of State Legislatures. Prevention of prescription drug overdose and abuse. Available at:http://www.ncsl.org/research/health/prevention-of-prescription- drug-overdose-and-abuse.aspx#1

169~2018_(1) AzPHA Title X Resolution(reproduceive health, education)

162~2016_(1)APHA Decreasing RX Drug Misuse (medication, healthcare)

Megan Resolutions

2016- – Support for Community Health Worker Leadership in Determining Workforce Standards for Training and Credentialing and its action step requirements.

August 25, 2016
The Arizona Public Health Association (AzPHA) supports the adoption of the following APHA Policy Statement 201414 – Support for Community Health Worker Leadership in Determining Workforce Standards for Training and Credentialing and its action step requirements.

Policy Statement: 201414

Abstract

Community health workers (CHWs) are frontline public health professionals who are known by many job titles, but they share the characteristics of being trusted and culturally responsive within the communities they serve. CHWs are included in the Patient Protection and Affordable Care Act as health professionals who serve as members of health care teams, and a recent change to Medicaid rules allows for the possibility of reimbursement for preventive services offered by CHWs. These developments may prompt further movement toward developing training and credentialing standards for the CHW workforce. Numerous stakeholders may be interested in addressing these issues, but there is significant evidence that CHWs are both capable of and best suited for leading collaborative efforts to determine their scope of practice, developing standards for training, and advocating for policies regarding credentialing. As individual states make decisions about whether and how to regulate the CHW workforce, policies are needed to support CHW leadership in determining, in collaboration with other public health colleagues, whether standards for training and credentialing are appropriate and what these standards should be.
Relationship to Existing APHA Policy Statements
In 2009, APHA adopted Policy Statement 20091, Support for Community Health Workers to Increase Health Access and to Reduce Health Inequities. The policy addressed numerous issues related to the community health worker (CHW) workforce. Importantly, the statement included a definition of CHWs developed within the APHA Community Health Workers Section, with national representation of CHWs and their advocates. The definition is as follows:

“Community Health Workers (CHWs) are frontline public health workers who are trusted members of and /or have an unusually close understanding of the community served.
This trusting relationship enables CHWs to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. CHWs also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.”

Policy Statement 20091 encouraged employers and academic institutions to support initial and continuing education for CHWs. However, the policy did not specifically address the issue of CHWs’ participation in determining standards for CHW training and credentialing. This statement complements and supplements Policy Statement 20091 by providing recommendations regarding CHW involvement in the development and oversight of training and credentialing standards. This resolution does not replace any existing policies.

Problem Statement

“Community health worker” is an umbrella term for dozens of paid and volunteer job titles that constitute a vital part of the public health workforce.[1] Some examples of commonly used job titles are community health representatives, health outreach workers, lay health workers, community health advisors, peer health educators, and promotores.[1] CHWs’ defining feature is their trusted relationships with the communities they serve.[2] Their roles include, but are not limited to, health coaching, connecting underserved communities to health and human service systems, advocating for individual and community needs, providing social support, increasing the cultural competence of service delivery, service coordination,[1] and participating in research.[3]
Since the advent of CHW programs in the United States in the 1950s,[4] the field has evolved in a piecemeal fashion, with CHW initiatives waxing and waning depending on community needs and on funding streams from local, state, federal, and private sources.[5] CHWs have worked on a variety of programs in numerous settings, and they have filled a wide range of roles.[1] Nonetheless, there is evidence that the workforce is becoming more professionalized. Recent research demonstrates that activities of CHWs in the United States have become more standardized over time, and experts have argued for conceptualizing CHWs as a workforce.[6] CHWs have organized themselves into professional groups in at least 20 states and the District of Columbia.[7] In 2009, the United States Department of Labor (DOL) recognized CHWs as a distinct occupation by creating a standard occupational classification for the field,[8] and in 2010 DOL added CHWs to its list of apprenticeable occupations.[9] The Patient Protection and Affordable Care Act specifically lists CHWs as health professionals who function as members of health care teams.[10] Another key development for the workforce is a 2013 change to federal Medicaid rules that opened the door for potential reimbursement for preventive services offered by CHWs.[11] This rule change may spur the hiring of new CHWs, and DOL estimates that there will be a 25% increase in demand for these workers by 2022.[12]

Increased demand for CHW services raises the issue of how to ensure that members of the paid workforce are adequately prepared. The Centers for Medicare and Medicaid Services and other federal agencies, along with state and local governments, academic institutions, CHWs, or other stakeholders, may seek to standardize training for CHW practices or advocate for the requirement of CHW credentialing. Such decisions require

careful consideration for several reasons. For example, the CHW role requires a fundamentally different skill set than other health professions. Training for other health professions focuses primarily on development of advanced clinical skills and knowledge. Preparing CHWs, in contrast, requires first carefully selecting people with essential qualities that employers seek (e.g., community trust and shared life experiences) and then offering them training in various nonclinical skills through widely recommended popular education techniques.[13,14] In addition, CHWs work in a variety of settings. Training must be appropriate for those who function as members of health care teams as well as those who work in a myriad of other community-based settings.

Practices regarding CHW training and credentialing vary widely throughout the United States.[15] As with the licensing of clinical professions, governmental recognition of standards for the CHW workforce has been established on a state-by-state basis. In some areas, CHWs may receive informal, on-the-job training, while in other places CHW courses are offered by community colleges, area health education centers, proprietary training institutions, or community-based agencies.[15] Only a few states require CHWs to attend a state-certified training program, and CHWs receive an associated credential upon successful program completion.[16–19] As of July 2014, only Texas and Ohio had adopted statewide certification for CHWs, but CHW policy initiatives were under way in other states. State legislation calling for the development of state standards for CHWs has been passed in Illinois,[20] Maryland,[21] Massachusetts,[22] New Mexico,[23] and Oregon.[24]

The establishment of education and credentialing programs for CHWs also requires responsiveness to the circumstances of individuals who are best suited for this work. While the commonality in background between CHWs and the communities they serve is essential to their effectiveness, this also means that education and credentialing programs must avoid creating barriers to entry related to financial resources, educational attainment, language preference/proficiency, race/ethnicity, culture, or immigration status.

Therefore, it is vital that the estimated 120,000 CHWs in the United States[1] lead discussions about how and whether CHW workforce standards should be developed, as they and future CHWs will be affected by these decisions. CHWs have special insight into the training and professional development needs of the workforce. Furthermore, as the CHW field becomes increasingly recognized as a profession, self-determination of training standards is a logical next step, consistent with theory on emergence of professions[25] and current practices in other health professions.[26] Given that many stakeholders may be interested in setting CHW workforce standards, policies are necessary to ensure that CHWs lead the development of such standards when and if they are created.

Evidence-Based Strategies to Address the Problem

There is strong evidence that CHWs are well suited to lead conversations about workforce definitions and standards. CHWs have contributed to developing culturally appropriate training protocols at the community level.[27–33] A CHW-led national initiative funded by the US Department of Education made recommendations for establishing CHW capacity-building programs at community colleges. However, this initiative stopped short of recommending any specific curriculum, advocating instead that such issues be resolved at the state and local levels with the leadership and participation of CHWs.[34] While other occupational groups such as medical interpreters[35] and health educators[36] have chosen to create professional standards and credentialing at a national level, the breadth of CHWs’ scope of practice and the many local variations in titles and job duties suggest that a state-level CHW workforce may be more appropriate.

CHWs have also organized themselves to make recommendations (and, in some cases, pass laws) regarding workforce standards in their respective states according to local needs. In New York, for example, CHWs conducted research that established a professional scope of practice and provided guidance for CHW training content and methodology.[37] Ultimately, as a result of considerations related to potential effects on the local CHW workforce, they opted not to require or offer a credential.[13,37] In Minnesota, CHWs participated in developing a CHW certificate curriculum that is offered for credit in community colleges.[38] CHWs in Massachusetts drafted a bill and were successful in advocacy efforts to pass legislation on voluntary CHW certification.[22,39] This legislation created a CHW board of certification that is required to include, among its 11 members, “no fewer than four community health workers selected from recommendations offered by the Massachusetts Association of Community Health Workers.”[22] A recently enacted law in New Mexico requires that three of the nine members of the state’s newly created Board of Certification of Community Health Workers be CHWs.[23] Similarly, legislation in Oregon established a commission to recommend CHW education and training requirements and mandated that at least 50% of members be traditional health workers, including CHWs.[24] In addition, CHWs in Michigan are developing an optional credentialing process,[40] as are CHWs in several other states. Texas requires CHW representation on the statewide advisory committee related to CHW training and certification.[41] CHWs in other states have recommended that CHWs participate in any board that develops policies regarding certification.[16,17,34]

It is common practice for workforce standards for a given occupation to be overseen by boards composed primarily of members of that profession. Among 60 boards of nursing in the United States, more than 90% report that at least half of their members are from the nursing profession.[42] Similarly, in more than 90% of the 70 medical boards in the United States and its territories, physicians account for more than half of the members.[43] Social workers make up the majority of the membership of the Association of Social Work Boards, which oversees upwards of 60 US and Canadian regulatory bodies for the profession.[44]

Opposing Arguments

Some may argue that policies regarding CHW participation in the development of workforce standards are not necessary. However, in at least one state, Ohio, CHW standards are already determined by the state board of nursing rather than CHWs themselves.[19] This situation could be replicated in other states, particularly those in which CHWs are not yet organized into professional groups. In addition, CHWs are generally members of underserved and underrepresented groups.[1] Without codification of their participation, members of this workforce could face cultural, linguistic, and other barriers that would limit their ability to participate in conversations about their own workforce standards.

In addition, CHWs’ participation in workforce decisions could address some of the larger issues that have caused opposition to formalized training and credentialing. For example, some experts have noted concern that participation in required courses or credentialing could create barriers to workforce entry or cause CHWs to lose their trusted status among the communities they serve.[45] People who do not identify themselves as CHWs, even if they fill similar roles, may resist being considered part of the workforce and potentially being subject to training and credentialing requirements.[46] These challenges can be overcome if CHWs of various backgrounds participate in discussions about whether formalized training and credentialing are appropriate and for whom. When such programs are deemed to be fitting, CHW input could help develop guidelines to ensure that incumbent workers receive recognition for prior learning and practice-based experience. CHWs can also advise on training and credentialing costs, continuing education, cultural appropriateness, and linguistic accessibility among CHWs with limited English proficiency.

Finally, it is important to note that CHW leadership in addressing issues related to training and credentialing does not preclude equitable collaboration with outside entities or experts who may contribute a wealth of knowledge on relevant topics such as health service delivery models, public health competencies, training curriculum development, and public health policy. Previous collaborations among CHWs, researchers, government agencies, and other stakeholders demonstrate that such groups can create effective CHW capacity-building programs[28–33] and generate policy change regarding credentialing.[37]

Action Steps

Therefore, APHA:
• Encourages local and state CHW professional associations to organize CHWs in developing a consensus about the desirability of training standards and credentialing, including decisions about the most appropriate organizational location for the administration of a credentialing program, if established.

• Calls on local and state CHW professional groups to consider creating policies regarding CHW training standards and credentialing, if appropriate for local conditions, in collaboration with CHW advocates and other stakeholders.
• Urges state governments and other entities considering creating policies regarding CHW training standards and credentialing to engage in collaborative CHW-led efforts with local CHWs and/or CHW professional groups. If CHWs and other entities partner in pursuing policy development on these topics, a working group composed of at least 50% self-identified CHWs should be established.
• Encourages state governments and any other entities drafting new policies regarding CHW training standards and credentialing to include in the policies the creation of a governing board in which at least half of the members are CHWs. This board should, to the extent possible, minimize barriers to participation and ensure a representation of CHWs that is diverse in terms of language preference, disability status, volunteer versus paid status, source of training, and CHW roles.

References
1. US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions. Community Health Worker National Workforce Study. Available at: http://bhpr.hrsa.gov/healthworkforce/reports/chwstudy2007.pdf. Accessed January 17, 2015.
2. American Public Health Association. Policy Statement 20091. Available at: http://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy- database/2014/07/09/14/19/support-for-community-health-workers-to-increase-health- access-and-to-reduce-health-inequities. Accessed January 17, 2015.
3. Otiniano AD, Carroll-Scott A, Toy P, Wallace SP. Supporting Latino communities’ natural helpers: a case study of promotoras in a research capacity building course. J Immigr Minor Health. 2012;14:657–663.
4. Hoff W. Role of the community health aide in public health programs. Public Health Rep. 1969;84:998–1002.
5. Dower C, Knox M, Lindler V, O’Neil E. Advancing community health worker practice and utilization: the focus on financing. Available at: http://futurehealth.ucsf.edu/Content/29/2006- 12_Advancing_Community_Health_Worker_Practice_and_Utilization_The_Focus_on_F inancing.pdf. Accessed January 17, 2015.
6. Ingram M, Reinschmidt KM, Schachter KA, et al. Establishing a professional profile of community health workers: results from a national study of roles, activities and training. J Community Health. 2012;37:529–537.
7. American Public Health Association. Community Health Workers Section. Available at: http://www.apha.org/apha-communities/member-sections/community-health-workers. Accessed January 17, 2015.
8. US Department of Labor, Bureau of Labor Statistics. Standard Occupational Classification: community health workers. Available at:

http://www.bls.gov/soc/2010/soc211094.htm. Accessed January 17, 2015.
9. US Department of Labor, Employment and Training Administration. Bulletin 2010-21. Available at: http://www.doleta.gov/oa/bul10/Bulletin-2010- 21OccCommunityHealthWorker.pdf. Accessed January 17, 2015.
10. Patient Protection and Affordable Care Act, 42 USC § 18001 et seq.
11. Centers for Medicare and Medicaid Services. Medicaid and children’s health insurance programs: essential health benefits in alternative benefit plans, eligibility notices, fair hearing and appeal processes, and premiums and cost sharing; exchanges: eligibility and enrollment. Available at: https://www.federalregister.gov/articles/2013/07/15/2013-16271/medicaid-and-
childrens-health-insurance-programs-essential-health-benefits-in-alternative-benefit. Accessed January 17, 2015.
12. US Department of Labor, Bureau of Labor Statistics. Health educators and community health workers. Available at: http://www.bls.gov/ooh/community-and-social- service/health-educators.htm#tab-6. Accessed January 17, 2015.
13. Matos S, Findley S, Hicks A, Legendre Y, Do Canto L. Paving a path to advance the community health worker workforce in New York State: a new summary report and recommendations. Available at: http://nyshealthfoundation.org/uploads/resources/paving-path-advance-community- health-worker-october-2011.pdf. Accessed January 17, 2015.
14. Wiggins N. Popular education for health promotion and community empowerment: a review of the literature. Health Promot Int. 2012;27:356–371.
15. Kash BA, May ML, Tai-Seale M. Community health worker training and certification programs in the United States: findings from a national survey. Health Policy. 2007;80:32–34.
16. Martin MA. CHW certification and credentialing: states’ perspectives on successful practices and lessons learned. Available at: https://apha.confex.com/apha/140am/webprogram/Session35081.html. Accessed January 17, 2015.
17. Mayfield-Johnson S. CHW certification and credentialing: what have we learned and how will we proceed? Available at: https://apha.confex.com/apha/140am/webprogram/Session36221.html. Accessed January 17, 2015.
18. Texas Department of State Health Services. Promotor(a) or Community Health Worker Training and Certification Program. Available at: http://www.dshs.state.tx.us/mch/chw.shtm. Accessed January 17, 2015.
19. Ohio Board of Nursing. Community health workers. Available at: http://codes.ohio.gov/oac/4723-26. Accessed January 17, 2015.
20. Illinois General Assembly. Public Act 098-0796. Available at: http://www.ilga.gov/legislation/publicacts/fulltext.asp?Name=098-0796. Accessed January 17, 2015.
21. General Assembly of Maryland. Workgroup on Workforce Development for Community Health Workers. Available at:

http://mgaleg.maryland.gov/2014rs/chapters_noln/ch_181_sb0592e.pdf. Accessed January 17, 2015.
22. Commonwealth of Massachusetts. An act establishing a board of certification of community health workers. Available at: https://malegislature.gov/Laws/SessionLaws/Acts/2010/Chapter322. Accessed January 17, 2015.
23. New Mexico State Legislature. Community Health Workers Act. Available at: http://www.nmlegis.gov/Sessions/14%20Regular/final/SB0058.pdf. Accessed January 17, 2015.
24. Oregon State Legislature. 2013 regular session. Available at: https://olis.leg.state.or.us/liz/2013R1/Measures/Text/HB3407/Enrolled. Accessed January 17, 2015.
25. Evetts K. The sociological analysis of professionalism: occupational change in the modern world. Int Sociol. 2003;18:395–415.
26. World Medical Association. WMA declaration of Madrid on professionally led regulation. Available at: http://www.wma.net/en/30publications/10policies/r4/. Accessed January 17, 2015.
27. Wennerstrom A, Johnson L, Gibson K, Batta SE, Springgate BF. Community health workers leading the charge on workforce development: lessons from New Orleans. J Community Health. 2014;39:1140–1149.
28. Ruiz Y, Matos S, Kapadia S, et al. Lessons learned from a community-academic initiative: the development of a core competency-based training for community- academic initiative community health workers. Am J Public Health. 2012;102:2372– 2379.
29. Cristopher S, Burhansstipanov L, Know His Gun-McCormick A. Using a CBPR approach to an interviewer training manual with members of the Apsáalooke Nation. In: Israel BA, Eng E, Schultz AJ, Parker EA, eds. Methods in Community-Based Participatory Research for Health. San Francisco, CA: Jossey-Bass; 2005:128–145.
30. Two Feathers J, Kieffer EC, Palmisano G, et al. The development, implementation, and process evaluation of the REACH Detroit Partnership’s diabetes lifestyle intervention. Diabetes Educator. 2007;33:509–520.
31. Harvey I, Schulz A, Israel B, et al. The Healthy Connections Project: a community- based participatory research project involving women at risk for diabetes and hypertension. Prog Community Health Partnersh. 2009;3:287–300.
32. Parker EA, Israel BA, Robins TG, et al. Evaluation of Community Action Against Asthma: a community health worker intervention to improve children’s asthma-related health by reducing household environmental triggers for asthma. Health Educ Behav. 2008;35:376–395.
33. Schulz AJ, Parker EA, Israel BA, Allen A, Decarlo M, Lockett M. Addressing social determinants of health through community-based participatory research: the East Side Village Health Worker Partnership. Health Educ Behav. 2002;29:326–341.
34. Community Health Worker National Education Collaborative. Key considerations for opening doors: developing community health worker education programs. Available at:

http://www.chw-nec.org/pdf/Guidebook.pdf. Accessed January 17, 2015.
35. National Board of Certification for Medical Interpreters. History. Available at: http://www.certifiedmedicalinterpreters.org/history. Accessed January 17, 2015.
36. Cottrell RR, Auld ME, Birch DA, Taub A, King LR, Allegrante JP. Progress and directions in professional credentialing for health education in the United States. Health Educ Behav. 2012;39: 681–694.
37. Findley SE, Matos A, Hicks AL, Campbell A, Moore A, Diaz D. Building a consensus on community health workers’ scope of practice: lessons from New York. Am J Public Health. 2012;102:1981–1987.
38. Rosenthal EL, Brownstein JN, Rush CH, et al. Community health workers: part of the solution. Health Aff (Millwood). 2010;29:1338–1342.
39. Mason T, Wilkinson GW, Nannini A, Martin CM, Fox DJ, Hirsch G. Winning policy change to promote community health workers: lessons from Massachusetts in the health reform era. Am J Public Health. 2011;101:2211–2216.
40. Michigan Community Health Worker Alliance. Governance. Available at: http://www.michwa.org/about/governance/. Accessed January 17, 2015.
41. Texas Administrative Code § 146.1–146.12. Available at: http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p
_tloc=&p_ploc=&pg=1&p_tac=&ti=25&pt=1&ch=146&rl=2. Accessed January 17, 2015.

42. National Council of State Boards of Nursing. Member board profiles. Available at: https://www.ncsbn.org/Board_Structure.pdf. Accessed January 17, 2015.
43. Federation of State Medical Boards. Membership composition. Available at: https://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/GRPOL_Board_Composition
_Table_2013.pdf. Accessed January 17, 2015.
44. Association of Social Work Boards. Governance. Available at: http://www.aswb.org/about/governance/. Accessed January 17, 2015.
45. Rush CH. Basics of community health worker credentialing. Available at: http://www.chw- nec.org/pdf/Basics%20of%20Community%20Health%20Worker%20Credentialing.pdf. Accessed January 17, 2015.
46. Keane D, Neilsen C, Dower C. Community health workers and promotores in California. Available at: http://calhealthworkforce.org/wp-content/uploads/2011/01/2004- 09_Community_Health_Workers_and_Promotores_in_California.pdf. Accessed January 17, 2015.

163~2016_(1)APHA CHWs (education, PH infrastucture

Megan Resolutions

2016- Regulating Marijuana

August 25, 2016
The Arizona Public Health Association (AzPHA) supports the adoption of the following APHA Policy Statement 201410 – Regulating Commercially Legalized Marijuana as a Public Health Priority and its action step recommendations.

Policy Statement: 201410

Abstract

As of 2014 four states, Colorado, Washington, Alaska, and Oregon, and the District of Columbia have legalized the sale and use of marijuana through a commercial market, and many other states are considering the option. So far the federal government has not challenged state laws legalizing commercial marijuana as long as states maintain strict rules involving sales and distribution. This policy statement calls for a public health approach to regulating and controlling commercially legalized marijuana and urges that regulation of legalized marijuana be viewed as a public health priority. Regulation will provide oversight of a market that is currently uncontrolled and can help address the unforeseen effects of marijuana legalization. If marijuana is legalized, federal, state, and local governments should develop, adopt, monitor, and evaluate strict regulatory mechanisms to control marijuana production, sales, and use while advancing the public health goals of preventing access by minors, protecting and informing consumers of legalized marijuana, and protecting third parties from unwanted consequences of legalized marijuana use. These mechanisms may include taxes, age limits, product labeling requirements, product quality testing, potency limits, labeling requirements, motor vehicle operation restrictions, and advertising restrictions.

Relationship to Existing APHA Policy Statements
• APHA Policy Statement 8817(PP): A Public Health Response to the War on Drugs: Reducing Alcohol, Tobacco and Other Drug Problems among the Nation’s Youth
• APHA Policy Statement 7121: Substance Abuse as a Public Health Problem
• APHA Policy Statement 7014: Marijuana and the Law
• APHA Policy Statement 201312: Defining and Implementing a Public Health Response to Drug Use and Misuse

Problem Statement

Marijuana is the most widely used illegal drug in the United States. In 2012, more than 111 million Americans 12 years or older (nearly 43% of this population) admitted to having tried marijuana in their lifetime, and almost 19 million had used it in the preceding month.[1,2] More than half of US states and the District of Columbia currently provide legal protections for patients whose doctors recommend the medical use of marijuana. After voters in Colorado and Washington elected to legalize marijuana, these states began to establish regulatory schemes for its cultivation, distribution, and retail sale to those 21 years of age and older. Under these and other regulatory proposals,

marijuana would be regulated in a manner similar to alcohol, with age limits, licensing controls, and other regulatory and public health mechanisms. The federal government decided to not challenge state laws legalizing commercial marijuana as long as states maintain strict rules involving sales and distribution. The areas of regulatory emphasis for the federal government include preventing distribution to minors, preventing revenue from being directed to illegal enterprises, stopping drugged driving, ensuring that marijuana does not cross to states where it is illegal, preventing marijuana activity from being used as a cover for other illegal drug activity, and stopping marijuana from being grown on public land.[3] While the decision to not challenge state adoption of commercial marijuana was an executive branch decision, the recent change in the political control of Congress is unlikely to alter the federal government’s stance. Since Washington and Colorado became the first states to legalize marijuana, other states have considered commercial legalization of the drug, with legislative proposals in Oklahoma, Maryland, Massachusetts, New York, New Jersey, Hawaii, New Hampshire, New Mexico, Pennsylvania, and Vermont and voter initiative efforts in Alaska, California, Missouri, Rhode Island, and Oregon.[4]

With the onset of commercial legalization of marijuana, several questions arise: How will access and availability to adolescents be prevented? How will the impact on vulnerable populations be addressed? What types of quality and informational controls will protect consumers? How will unwanted exposures and driving impairment be handled?

Increased availability: The national Monitoring the Future study has consistently shown that roughly 80% of 12th graders, 70% of 10th graders, and 40% of 8th graders in the United States report that marijuana is either “fairly easy” or “very easy” to obtain.[5–7] Concern exists that commercial legalization will increase the availability of marijuana to adolescents. The density of marijuana retailers is also an issue that needs to be addressed by regulation. If retailers congregate in a few locations, the populations in those areas will be more exposed to use, misuse, and abuse of marijuana. Advertising by retailers will also need to be examined, especially in light of studies revealing that alcohol and tobacco advertising is more prevalent in communities of color and areas of lower income.[8]

Passive exposures: As with the smoking of tobacco, passive exposure to marijuana smoke among children, tenants of multiunit housing developments, and nonsmokers is a concern. Protection for workers who cultivate commercial marijuana is also a concern since they may be exposed to pesticides, fertilizers, and other unhealthy adulterants.
For example, a group of workers at a medical marijuana cultivator in Maine filed a complaint with the National Labor Relations Board because of the cultivator’s use of pesticides and the workers’ exposure to mold.[9]

Quality control and consumer protection: Because marijuana remains illicit, there are no mechanisms for its production to be monitored, its potency and quality to be

standardized and tested, or its labeling for potential health effects before being sold. Research has shown that potency can vary widely depending on the strain of marijuana and that the drug can be contaminated by fungi and bacteria, heavy metals, pesticides, growth enhancers, and substances (e.g., glass beads) that are intended to increase its weight or give the appearance of a higher potency.[10] A failure to provide accurate and credible information about marijuana’s potency and quality can lead to consumer harm.

Motor vehicle safety: The “evidence of cannabis’s culpability in on-road driving accidents and injury is far less robust, with some reviews acknowledging an association between cannabis consumption and an increased risk of motor vehicle crashes while others have not.”[11] Evidence does show that marijuana can “increase driving reaction times, impair time and distance estimation, and decrease motor coordination for up to three hours after dosage impairment.”[12] One “meta-analysis of studies examining acute cannabis consumption and motor vehicle collisions [revealed] a near doubling of risk of a driver being involved in a motor vehicle collision resulting in serious injury or death.”[13] An examination of data from the National Highway Traffic Safety Administration’s Fatality Analysis Reporting System showed that “detection of cannabis in drugged drivers [involved in fatal motor vehicle crashes] increased from 28.8% in 1993 to 36.9% in 2010.”[12] During the same period, detection of cocaine fell from 20.6% to 9.8%, while detection of prescription drugs increased from 42.2% to 46.5%.[12] However, the researchers were unable to show causality between marijuana or other drug use and involvement in fatal vehicle crashes.[12] As with other substances and products that impair the operation of motor vehicles, the issue of commercial marijuana use and motor vehicle safety will need to be addressed through federal, state, and local regulatory schemes.

Health effects: The health effects of smoking marijuana are not fully understood. A recent study published in the Journal of the American Medical Association investigated the association between marijuana use and lung function in a cohort of more than 5,000 US adults over a period of 20 years; the study’s results suggested that “occasional use of marijuana…may not be associated with adverse consequences on pulmonary function.”[14] However, marijuana, like tobacco, contains toxic gases and other substances that can cause harm to the pulmonary system.[15] A recent review published in the New England Journal of Medicine documented the effects of long-term or heavy marijuana use, including addiction for about 9% of all regular users, altered brain development and cognitive impairment among adolescent users, chronic bronchitis symptoms, and an increased risk of chronic psychosis disorders among those who are predisposed to such orders. Short-term effects include short-term memory impairment, impaired motor control, altered judgment, and, for some, paranoia and psychosis with high doses.[16]

Strategies to Address the Problem
Jurisdictions that legalize or consider the legalization of commercial marijuana should

develop, adopt, monitor, and evaluate regulatory schemes for marijuana production, sale, and use that protect and promote public health. Regulation of commercial marijuana can have positive effects on public health. For example, evidence from the Netherlands—which has adopted a de facto legalization policy regarding retail sales and regulatory guidelines that include limits on the amount a person can buy in a day, a ban on advertisements, and a prohibition on sales to individuals under 18 years of age—indicates that the Dutch use marijuana at lower rates than some other European countries, do not escalate early use relative to other countries in Europe and the United States, and do not use marijuana as a gateway drug.[17]

A strict, rigorous regulatory response to commercial sales of marijuana should focus on access to and availability of the drug among adolescents, informing and protecting consumers, and protecting third parties and vulnerable populations from the potential consequences of marijuana use (e.g., passive exposure and impaired driving).
Regulatory interventions might include but should not be limited to age restrictions; taxation; time and date limitations for sales; potency and quality standardization, testing, and monitoring; advertising and packaging restrictions; place of use restrictions; extension of liability for injury to retailers; labor protections; and continued monitoring and evaluation of regulatory interventions. Many of these interventions are used to control alcohol and tobacco use and could also be used to control the use, misuse, and abuse of commercial marijuana.

Age restrictions: Age restrictions and enhanced enforcement of age restrictions can be used to limit the use of marijuana by adolescents, just as they are used to control tobacco use and alcohol use among adolescents, which have declined significantly over the past several years. According to the Monitoring the Future study, daily use of cigarettes by 12th graders decreased from 26.9% in 1975 to 8.5% in 2013, while the 30- day prevalence of use of alcohol by 12th graders decreased from 54% in 1991 to 39.2% in 2013.[18,19] Studies and estimates show the impact of minimum legal drinking ages (MLDAs) for alcohol and minimum legal purchase ages (MLPAs) for tobacco on alcohol- related motor vehicle crashes and the prevalence of adolescent smoking. According to estimates from a 2001 systematic review of interventions designed to reduce alcohol- impaired driving, fatal and nonfatal vehicle crashes increase by 10% with lower MLDAs and decrease by 16% with higher MLDAs (i.e., age 21).[20] In another study, the researchers concluded that raising the MLPA in the United States from 18 to 21 years would reduce the prevalence of smoking among 15- to 17-year-olds to 7.5% after 75 years as a result of delayed smoking initiation, removal of social sources of cigarettes (i.e., friends who are 18 to 20 years old), and better recognition by retailers of adolescent purchasers (i.e., it would be easier for retailers to distinguish between a 16- year-old and a 21-year-old than a 16-year-old and an 18-year-old).[21] Maintaining retailer compliance with MLDA laws through enhanced enforcement of these laws against retailers and underage purchasers also reduces access to alcohol among minors.[22]

Taxation: Taxing commercial marijuana to price adolescents out of the market may also prevent many adolescents from using marijuana. Increasing the price of cigarettes through taxes can cause adolescents to stop smoking.[23] One study of state tobacco taxes showed that every $1.00 in increased state tax could potentially result in a 5.9% decrease in past-month smoking and a 4.1% decrease in frequent smoking among US high school youth.[24] Also, according to a meta-analysis of 112 studies on alcohol, higher taxes tend to reduce alcohol consumption among adult and teenage social drinkers as well as problem drinkers.[25]

Time and date restrictions: Marijuana use, misuse, and abuse can also be addressed by instituting time and place restrictions on commercial sales and imposing liability risks on commercial marijuana retailers. For example, alcohol control measures that limit the number of days and hours that alcohol can be sold as well as restricting the location and density of alcohol outlets can help decrease alcohol consumption and consumption- related harms.[26–29]

Retailer liability: Dram shop liability laws are effective in reducing and preventing harms associated with alcohol consumption by deterring overservice of alcohol to customers.[30] These laws allow licensed establishments such as restaurants, bars, and liquor stores that sell or serve alcohol to individuals to be held liable for any injuries or deaths that result from a customer’s intoxication. Although litigation involving dram shops can be expensive and inefficient,[31] extending dram shop liability to marijuana retailers may serve as a way to reduce marijuana use, misuse, and abuse.

Standardizing, testing, and monitoring potency and quality: Regulatory frameworks can also be developed to standardize and determine the quality of commercial marijuana to protect consumers from adulterants (e.g., pesticides, mold, mildew, toxins) and inform them of the product’s potency. Similar requirements are in already in place for alcohol sales. For example, federal law and agency rules require alcohol beverage labels to include the brand name, the class and type of alcohol, the alcoholic content, the name and address of the bottler or packer, the country of origin, and a disclosure of additives and sulfites.[30,32,33] Also, the Family Smoking Prevention and Tobacco Control Act allows the US Food and Drug Administration to set standards for nicotine levels in tobacco products.[34]

Warning labels: Marijuana products could also be labeled to warn consumers of health risks. Tobacco products in the United States must display the surgeon general’s warning about the risk of tobacco use. Labels on alcohol must also contain a specific warning about health risks.[35,36] While research has shown little effect on drinking behavior from alcohol labels, tobacco labeling’s impact on consumer attitudes and behaviors is more apparent.[37]

Advertising restrictions: Advertising restrictions can also be used to control marijuana use and protect consumers, just as they are used for alcohol and tobacco. Restricting advertisements can have profound health effects. For example, according to one study, a complete ban on alcohol advertising would result in 7,609 fewer deaths and a 16.4% drop in alcohol-related life-years lost.[38] Current First Amendment protections for corporate speech would likely prevent advertising regulations aimed at adult consumers but would allow restrictions on advertising aimed at adolescents and children.[39] Consideration should also be given to the impact advertising may have on communities of color and/or groups of low socioeconomic status.

Impaired driving: Concerns about driving while impaired by marijuana can be addressed with current laws against driving under the influence or by amending those laws to include marijuana impairment. One option may be to increase “penalties for drugged driving in localities with greater accessibility to [marijuana].”[12] Some states have adopted per se drugged driving laws, meaning that any trace of illicit drugs in a driver is considered a drugged driving violation. While such a standard may be useful when prosecuting a drugged driving case, a recent study questions the effectiveness of per se drugged driving laws in lowering traffic fatality rates.[40] Research should be conducted on reliable and valid methods of determining marijuana impairment. Also, similar to the case with alcohol, education on marijuana use and driving should be available.

Passive exposure: Regulatory policies should be developed to limit passive exposures to marijuana. Passive exposures can also be addressed through prohibiting use of the drug in public locations and in the presence of minor children, as well as through restricting its use in multi-unit housing to avoid smoke drifting to neighboring units. In addition, states and localities can amend existing smoke-free laws to include marijuana smoke. Also, federal and state laws regulating the use of pesticides and fertilizers and the passive exposure of workers to such chemicals and other unsafe working conditions need to be extended to individuals working for marijuana cultivators.

Monitoring and evaluating regulatory schemes: Since the regulatory scheme for commercially legal marijuana is untested and involves many unknown elements, a final strategy is to monitor and evaluate the public health impact of regulations. Regulations can then be modified according to evidence regarding their effects on public health.

Opposing Arguments/Evidence
Arguments opposing public health regulations often center on personal autonomy, the freedom to do business, and economic costs to consumers and businesses. Those who oppose regulating passive exposure to marijuana smoke and marijuana-impaired driving will focus on the lost autonomy of people who use marijuana in the presence of children, use the drug in multi-unit housing complexes, and drive after becoming impaired. Rates of alcohol-related motor vehicle fatalities have decreased since 1982, with some of the credit being given to laws aimed at deterring intoxicated driving.[41]

Laws aimed at deterring marijuana-impaired driving could lead to similar trends. Also, smoke-free laws are associated with lower risks of smoking-related cardiac, cerebrovascular, and respiratory diseases.[42]

Advertising and information restrictions along with required disclosures such as warning labels may be viewed as government interference with the protected right to free speech. However, these restrictions are designed to counter statements and messages that encourage harmful behavior, and, as noted above, a ban on alcohol advertising would result in fewer deaths and alcohol-related life-years lost.[38]

Age restrictions limit the accessibility of marijuana to adolescents, and opponents view these restrictions as an infringement upon the autonomy of youth. Restrictions that are set at 21 years of age may also be opposed because they limit access among adults (i.e., people 18 to 20 years of age). As noted, however, age restrictions could reduce health risks associated with alcohol and tobacco use among adolescents. For example, age restrictions on the use of alcohol and tobacco have been shown to decrease the prevalence of alcohol-related motor vehicle crashes and the prevalence of adolescent smoking.[21,22] These same regulatory measures could apply to marijuana.

Regulation of commercial marijuana’s quality and potency and limitations on times and dates of marijuana sales could be perceived as impairing business interests and leading to increased consumer costs. However, these actions could provide protections to consumers and limit the accessibility of marijuana among adolescents. Today, many types of commercial products are subject to content and disclosure requirements to protect consumers and allow them to make informed decisions. For example, the Family Smoking Prevention and Tobacco Control Act requires tobacco companies to disclose the contents of cigarettes and allows the Food and Drug Administration to determine nicotine levels.[34]

Regulatory opponents will argue that protecting marijuana cultivation workers from dangerous working conditions by regulating pesticide exposures interferes with business activities and interests and increases consumer costs. However, popular organophosphate pesticides are associated with “nausea, dizziness, vomiting, headaches, abdominal pain, and skin and eye problems [as well as] chronic health problems or health symptoms such as respiratory problems, memory disorders, dermatologic conditions, cancer, depression, neurologic deficits, miscarriages, and birth defects.” It is clear that limiting workers’ exposure to harmful pesticides would create safer and healthier work environments.[43]

Finally, those who oppose regulating commercial marijuana through taxation may contend that taxation adds to consumer costs and interferes with business interests. Evidence in the realm of alcohol control demonstrates that taxation reduces the use of alcohol. For example, a systematic review of 112 studies examining the association

between taxes on and prices of alcohol and alcohol sales and use revealed significant relationships between taxes or prices and overall consumption and heavy drinking.[25]

Despite any opposition to the regulation of legalized marijuana, there is strong evidence from the areas of tobacco control and alcohol control that a regulatory scheme for commercial marijuana would have an impact on marijuana accessibility and use.

Action Steps

APHA believes that, in jurisdictions that legalize the commercial sale of marijuana, the preponderance of evidence supports regulating marijuana as an important public health policy.

Therefore, APHA
• Urges federal, state, and local governments to:
o Regulate commercially legalized marijuana as a public health priority and develop, adopt, monitor, and evaluate regulatory controls for commercially legalized marijuana that reduce and prevent the drug’s use, misuse, and abuse.
o Support and fund research into the health effects of marijuana use, misuse, and abuse.
o Coordinate their efforts to effectively regulate commercial marijuana in an effort to reduce and prevent its use, misuse, and abuse.
o Regulate commercially legalized marijuana in partnership with state and local health departments, including the provision of resources to local and state public health agencies for the purpose of reducing and preventing marijuana’s use, misuse, and abuse.
o Tax commercial marijuana and dedicate the revenue to funding prevention, treatment, research, and regulatory frameworks to offset the costs and effects incurred through the increased availability of marijuana and other products containing tetrahydrocannabinol (THC).
o Develop and fund standards for the quality and potency of commercial marijuana and ensure safe working conditions for those cultivate marijuana.
o Exercise their authority to limit and restrict the advertising of commercial marijuana and develop required written disclosures to protect commercial marijuana consumers.
o Develop standards for determining impaired operation of motor vehicles.
o Ensure the development and availability of linguistically competent educational and informational materials for individuals with limited English proficiency.
• Calls on the federal and state governments and all federal and state agencies involved in research, policies, and programs related to marijuana to develop an evidence base regarding the public health benefits of regulating commercial marijuana.
• Calls for states that may consider legalizing commercial marijuana to refer to evidence-based regulatory controls for legalized marijuana and review and assess the regulatory frameworks of those states that have already legalized the drug.

References
1. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Table 1.24A: Marijuana use in lifetime, past year, and past month among persons aged 12 or older, by demographic characteristics: numbers in thousands, 2011 and 2012. Available at: http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/DetTabs/NSDUH- DetTabsSect1peTabs1to46-2012.htm#Tab1.24A. Accessed January 16, 2015.
2. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Table 1.24B: Marijuana use in lifetime, past year, and past month among persons aged 12 or older, by demographic characteristics: percentages, 2011 and 2012. Available at: http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/DetTabs/NSDUH- DetTabsSect1peTabs1to46-2012.htm#Tab1.24B. Accessed January 16, 2015.
3. US Department of Justice. Guidance regarding marijuana enforcement. Available at: http://www.justice.gov/iso/opa/resources/3052013829132756857467.pdf. Accessed January 16, 2015.
4. Mother Jones. Will your state be next to legalize pot? Available at: http://www.motherjones.com/politics/2014/02/pot-marijuana-legalization-map-states. Accessed January 16, 2015.
5. Monitoring the Future. Trends in availability of drugs as perceived by 12th graders. Available at: http://www.monitoringthefuture.org/data/13data/13drtbl14.pdf. Accessed January 16, 2015.
6. Monitoring the Future. Trends in availability of drugs as perceived by 10th graders. Available at: http://www.monitoringthefuture.org/data/13data/13drtbl13.pdf. Accessed January 16, 2015.
7. Monitoring the Future. Trends in availability of drugs as perceived by 8th graders. Available at: http://www.monitoringthefuture.org/data/13data/13drtbl12.pdf. Accessed January 16, 2015.
8. Barbeau EM, Wolin KY, Naumova EN, Balbach E. Tobacco advertising in communities: associations with race and class. Prev Med. 2005;40:16–22.
9. Quimby B. Pot dispensary workers rally in Portland. Available at: http://www.pressherald.com/2013/04/06/medical-pot-workers-protest-in-portland/. Accessed January 16, 2015.
10. McLaren J, Swift W, Dillon P, Allsop S. Cannabis potency and contamination: a review of the literature. Addiction. 2008;103:1100–1109.
11. Armentano P. Cannabis and psychomotor performance: a rational review of the evidence and implications for public policy. Drug Test Anal. 2013;5:52–56.
12. Wilson FA, Stimpson JP, Pagan JA. Fatal crashes from drivers testing positive for drugs in the U.S., 1993–2010. Public Health Rep. 2014;129:342–350.
13. Asbridge M, Hayden JA, Cartwright JL. Acute cannabis consumption and motor vehicle collision risk: systematic review of observational studies and meta-analysis. BMJ. 2012;344:e536.
14. Pletcher MJ, Vittinghoff E, Kalhan R, Richman J, Safford M, Sidney S, Lin F,

Kertesz S. Association between marijuana exposure and pulmonary function over 20 years. JAMA. 2012;307:173–181.
15. Tashkin DP. Airway effects of marijuana, cocaine, and other inhaled illicit agents. Curr Opin Pulm Med. 2001;7:43–61.
16. Volkow ND, Baler RD, Compton WM, Weiss SR. Adverse health effects of marijuana use. New Engl J Med. 2014;370:2219–2227.
17. MacCoun RJ. What can we learn from the Dutch cannabis coffeeshop system? Addiction. 2011;106:1899–1910.
18. Monitoring the Future. Trends in prevalence of use of cigarettes in grades 8, 10, and
12. Available at: http://www.monitoringthefuture.org/data/13data/13tobtbl1.pdf. Accessed January 16, 2015.
19. Monitoring the Future. Trends in 30-day prevalence of use of various drugs in grades 8, 10, and 12. Available at: http://www.monitoringthefuture.org/data/13data/13drtbl3.pdf. Accessed January 16, 2015.
20. Shults RA, Elder RW, Sleet DA, et al. Reviews of evidence regarding interventions to reduce alcohol-impaired driving. Am J Prev Med. 2001;21:66–88.
21. Ahmad S, Billimek J. Limiting youth access to tobacco: comparing the long-term health impacts of increasing cigarette excise taxes and raising the legal smoking age to 21 in the United States. Health Policy. 2007;80:378–391.
22. Elder RW, Lawrence B, Janes G, et al. Enhanced enforcement of laws prohibiting sale of alcohol to minors: systematic review of effectiveness for reducing sales and underage drinking. Transp Res E-Circular. 2007;E-C123:181–188.
23. Ding A. Youth are more sensitive to price changes in cigarettes than adults. Yale J Biol Med. 2003;76:115–124.
24. Carpenter C, Cook P. Cigarette taxes and youth smoking: new evidence from national, state, and local youth risk behavior surveys. J Health Econ. 2008;27:287–299.
25. Wagenaar AC, Salois MJ, Komro KA. Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies. Addiction. 2009;104:179–190.
26. Middleton JC, Hahn RA, Kuzara JL, et al. Effectiveness of policies maintaining or restricting days of alcohol sales on excessive alcohol consumption and related harms. Am J Prev Med. 2010;39:575–589.
27. Hahn RA, Kuzara JL, Elder R, et al. Effectiveness of policies restricting hours of alcohol sales in preventing excessive alcohol consumption and related harms. Am J Prev Med. 2010;39:590–604.
28. Ashe M, Jernigan D, Kline R, Galaz R. Land use planning and the control of alcohol, tobacco, firearms, and fast food restaurants. Am J Public Health. 2003;93:1404–1408.
29. Campbell CA, Hahn RA, Elder R, et al. The effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms. Am J Prev Med. 2009;37:556–569.
30. Federal Alcohol Administration Act, 27 USC §§ 201 et seq.
31. Rammohan V, Hahn RA, Elder R, et al. Effects of dram shop liability and enhanced

overservice law enforcement initiatives on excessive alcohol consumption and related harms: two Community Guide systematic reviews. Am J Prev Med. 2011;41:334–343.
32. Labeling and Advertising of Malt Beverages, 27 CFR Part 7.
33. Labeling and Advertising of Distilled Spirits, 27 CFR Part 5.
34. US Food and Drug Administration. Overview of the Family Smoking Prevention and Tobacco Control Act. Available at: http://www.fda.gov/downloads/TobaccoProducts/GuidanceComplianceRegulatoryInform ation/UCM336940.pdf. Accessed January 16, 2015.
35. Alcoholic Beverage Labeling Act of 1988, 27 USC §§ 213 et seq.
36. Alcoholic Beverage Health Warning Statement, 27 CFR Part 16.
37. Wilkinson C, Room R. Warnings on alcohol containers and advertisements: international experience and evidence on effects. Drug Alcohol Rev. 2009;28:426–435.
38. Hollingworth W, Ebel BE, McCarty CA, et al. Prevention of deaths from harmful drinking in the United States: the potential effects of tax increases and advertising bans on young drinkers. J Stud Alcohol. 2006;67:300–308.
39. Lorillard v. Reilly, 533 US 525 (2001).
40. Anderson DM, Rees DI. Per se drugged driving laws and traffic fatalities. Available at: http://ssrn.com/abstract=2189786. Accessed January 16, 2015.
41. US Department of Transportation, National Highway Traffic Safety Administration. Statistical analysis of alcohol-related driving trends, 1982–2005. Available at: http://www-nrd.nhtsa.dot.gov/Pubs/810942.pdf. Accessed January 16, 2015.
42. Tan CE, Glantz SA. Association between smokefree legislation and hospitalizations for cardiac, cerebrovascular and respiratory diseases: a meta-analysis. Circulation. 2012;126:2177–2183.
43. McCauley LA, Anger WK, Keifer M, Langley R, Robson MG, Rohlman D. Studying health outcomes in farmworker populations exposed to pesticides. Environ Health Perspect. 2006;116:953–960.

164~2016_(1)APHA Regulating Marijuana(public safety, marijuana)

Megan Resolutions

2017- Restrict Tobacco Sales to Persons 21 and Over in Arizona

Resolution to Restrict Tobacco Sales to Persons 21 and Over in Arizona

Background and Summary

Tobacco use poses serious public health problems. Over the past 50 years, tobacco control in the United States has led to an estimated 8 million fewer premature deaths. However, tobacco use continues to significantly affect public health, and more than 40 million Americans still smoke.
Nearly all adults who have ever smoked daily first tried a cigarette before 21 years of age. The parts of the brain most responsible for cognitive and psychosocial maturity continue to develop and change through young adulthood, and adolescent brains are uniquely vulnerable to the effects of nicotine, including nicotine from electronic nicotine delivery devices (electronic cigarettes).

In 2009, the Family Smoking Prevention and Tobacco Control Act granted the U.S. Food and Drug Administration broad authorities over tobacco products but prohibited the FDA from establishing a nationwide minimum age to buy tobacco above 18. The law directed the FDA to convene a panel of experts to conduct a study on the public health implications of raising the minimum age to purchase tobacco products and electronic nicotine delivery devices.
At FDA’s request, the Institute of Medicine published a report entitled Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. The report literature on tobacco use initiation, developmental biology and psychology, and tobacco policy and predicted the likely public health outcomes of raising the minimum legal age for tobacco products.
The report concluded that: “… Increasing the minimum age of legal access to tobacco products will prevent or delay initiation of tobacco use by adolescents and young adults, particularly those ages 15 to 17, and improve the health of Americans across the lifespan”. The report also quantifies the immediate and long term accompanying public health outcome improvements. The report concludes that there would be a 12% decrease in the prevalence of smoking among the cohort if the minimum age of purchase were moved to 21 years old from the current 18.

The analysis concluded that raising the minimum age to 21 will “… likely immediately improve the health of adolescents and young adults by reducing the number of those with adverse physiological effects such as increased inflammation and impaired immune functioning caused by smoking, as these could potentially lead to negative health consequences, including increased hospitalizations and lessened capacity to heal wounds. Adverse maternal, fetal, and infant outcomes—including preterm births, low birth weight, and sudden infant death—will also probably decrease due to reduced tobacco exposure in mothers and infants. Raising the minimum legal age will also lessen the population’s exposure to secondhand smoke and its associated health effects, both now and in the future.”

Over time, the report concludes that raising the minimum legal age for buying tobacco will likely lead to substantial reductions in smoking-­‐related mortality observed for 30 years. If the minimum legal age to purchase tobacco were raised to 21 nationally, there would be approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost for those born between 2000 and 2019.

Several jurisdictions have already raised the minimum legal age to buy tobacco. New York City raised the age to 21, in 2013. Hawaii did it in 2015, becoming the first state to go to the 21 (the Hawaii Public Health Association was instrumental in that effort). California followed suit in 2016, and New Jersey and Oregon did so in 2017. In Arizona, Douglas and Cottonwood have passed local ordinances restricting the sale of tobacco to people 21 and older.

AzPHA Resolution September 2017

Whereas, the Arizona Public Health Association recognizes that tobacco use poses serious public health problems; and
Whereas, nearly all adults who have ever smoked daily first tried a cigarette before 21 years of age; and

Whereas, the parts of the brain most responsible for cognitive and psychosocial maturity continue to develop and change through young adulthood, and adolescent brains are uniquely vulnerable to the effects of nicotine, including nicotine from electronic nicotine delivery devices; and

Whereas, increasing the minimum age of legal access to tobacco products and electronic nicotine delivery devices will prevent or delay initiation of tobacco use by adolescents and young adults and improve the health of Americans across the lifespan; and

Whereas, if the minimum legal age were raised to 21 in Arizona, there would be approximately 4,460 fewer premature deaths, 1,000 fewer deaths from lung cancer, and 840,000 fewer years of life lost for those born between 2000 and 2019;

Therefore, be it resolved that the Arizona Public Health Association supports raising the minimum legal age to purchase tobacco and electronic nicotine delivery devices in Arizona to 21 years old.

165~2017_(1) Tobacco 21 (tobacco)

Megan Resolutions

2017- Texting and Driving

Resolution to Restrict Texting While Driving in Arizona

Background and Summary

Texting has become a social norm in recent years because of the popularity of smart phones. The scientific literature on the dangers of driving while sending a text message from a mobile phone, or driving while texting is growing. A study at the Accident Research Center1 provided strong evidence that retrieving and sending text messages has a detrimental effect on a number of safety-­‐critical driving measures including detecting and responding correctly to road signs, detecting hazards, time spent with eyes off the road.
Several studies have linked texting while driving to be the cause of life-­‐threatening accidents due to driver distraction. A recent National Traffic Highway Safety Administration NHTSA report found that teens have the highest prevalence of cell phone use while driving and rank at the top of the list for being distracted at the time of a fatal crash.

For many years, Arizona has been one of only 3 states that did not restrict the use of smart phones while driving. During the 2017 Arizona Legislative Session SB 1080 was passed and signed which restricts texting and driving among new drivers for the first 6 months of their license (if they’re under 18). Using the phone in an emergency is still allowed and citations can only be issued if the driver committed another violation. Prior to this, the only other limitation in AZ to this kind of distraction applied to school bus drivers.

A study of US crash data called Driver distraction and crashes: An assessment of crash databases and review of the literature found that driver distraction (among all ages) is a contributing factor in 8% to 13% of crashes including cell phone distractions of between 1.5 to 5%.

Arizona’s new law only restricts texting and driving among new drivers for the first 6 months of their license (if they’re under 18), yet evidence suggests that texting while driving creates unnecessary and dangerous driver distractions that cause motor vehicle accidents that result in injuries and deaths.

1. Hosking, S.G., Young, K.L., & Regan, M.A. (2006). “The effects of text messaging on young novice driver performance” (PDF). Retrieved 16 August 2014.

AzPHA Resolution September 2017

Whereas, the Arizona Public Health Association recognizes that texting has become a social norm in recent years because of the popularity of smart phones and studies have linked texting while driving to be the cause of life-­‐threatening accidents due to driver distraction; and

Whereas, a recent National Traffic Highway Safety Administration NHTSA report found that smart phone use while driving is linked with distracted at the time of a fatal crash; and

Whereas, a study of US crash data found that driver distraction is a contributing factor in 8% to 13% of crashes including cell phone distractions of between 1.5 to 5%;

Therefore, be it resolved that the Arizona Public Health Association supports a law in Arizona that would prohibit texting and other smart phone use among all drivers.

166~2017_(1) Texting and Driving(public safety)

Megan Resolutions

2017- Physical Activity in Schools

Resolution to Require 50 Minutes of Unstructured Recess in Arizona Elementary Schools (K-­‐5)

Background and Summary

The percentage of children with obesity in the United States has more than tripled since the 1970s. Today, about one in five school-­‐aged children is obese. Childhood obesity has immediate and long-­‐term impacts on physical, social, and emotional health. For example:
• Children with obesity are at higher risk for having other chronic health conditions and diseases that impact physical health, such as asthma, sleep apnea, bone and joint problems, type 2 diabetes, and risk factors for heart disease.
• Children with obesity are bullied and teased more than their normal weight peers, and are more likely to suffer from social isolation, depression, and lower self-­‐esteem.
• Childhood obesity also is associated with having obesity as an adult, which is linked to serious conditions and diseases such as heart disease, type 2 diabetes, metabolic syndrome, and several types of cancer.

Children and adolescents that participate in at least 1 hour of physical activity per day benefit from multiple health benefits, including lower risk for becoming obese. Schools provide a unique venue for youth to meet the activity recommendations. However, schools have been facing increasing challenges in allocating time for physical education and physical activity.
There is a growing body of research focused on the association between school-­‐based physical activity, and academic performance among school-­‐aged youth. A recent report from the CDC’s entitled The Association Between School-­‐based Physical Activity, Including Physical Education, and Academic Performance examined the association between school-­‐based physical activity, including physical education, and academic performance, including indicators of cognitive skills and attitudes, academic behaviors.
The CDC found that “… across all 50 studies that they examined there were a total of 251 associations between physical activity and academic performance, representing measures of academic achievement, academic behavior, and cognitive skills and attitudes. Measures of cognitive skills and attitudes were used most frequently.”

During the 2017 Arizona Legislative Session, House Bill 2082 was introduced which would have required all schools to have 50 minutes of recess per day from K through 5th grade. The Bill was passed by the House of Representatives but stalled in the State Senate.

Data from the CDC report provides evidence that such a bill, should it become law, would have a positive impact on academic achievement as well as physical activity. The report found that time spent in recess appears to have a positive relationship with children’s attention, concentration, and/or on-­‐task classroom behavior. All eight studies found one or more positive associations between recess and indicators of cognitive skills, attitudes, and academic behavior; none of the studies found negative associations between recess time and academic achievement.

AzPHA Resolution September 2017

Whereas, the Arizona Public Health Association recognizes that childhood obesity continues to pose an increasing public health threat; and

Whereas, children that are obese are at higher risk for having other chronic health conditions and diseases that impact physical health, such as asthma, sleep apnea, bone and joint problems, type 2 diabetes, and risk factors for heart disease; and

Whereas, children and adolescents that participate in at least 1 hour of physical activity per day benefit from multiple health benefits, including lower risk for becoming obese; and

Whereas, schools provide a unique venue for youth to meet the activity recommendations; and

Whereas, there is a growing body of research focused on the association between school-­‐based physical activity, and academic performance among school-­‐aged youth; and

Whereas, recess has a positive relationship with children’s attention, concentration, and on-­‐task classroom behavior;

Therefore, be it resolved that the Arizona Public Health Association supports a law in Arizona that would require all schools to have 50 minutes of recess per day from K through 5th grade and prohibit the withholding of recess for academic or behavioral reasons.

167~2017_(1) Conference Resolution Physical Activity in School(preventative health, education)

Megan Resolutions, Uncategorized

2018- Prevent Firearm Violence in Schools

Arizona Public Health Association (AzPHA) Resolution: Preventing Firearm Violence in Schools

Effective Date: October 3, 2018

Background and Summary
Since the 1999 massacre at Columbine High School, some 208,000 children at 212 schools have experienced gun violence on school campuses. School-based rampage shootings took 13 lives at Columbine High School, 26 lives at Sandy Hook Elementary School, 17 lives at Marjory Stoneman Douglas High School, and most recently 10 lives at the Santa Fe High School.
Aside from the loss of life and the pain these events inflict on survivors and the community, there are monetary costs to the community and to schools. Those costs include funerals, trauma counseling, reconstructing or refurbishing buildings, and investing in new security measures. To the broader
community, there’s a growing concern about the safety of children and what steps can be taken to reduce the risk and prevent violence. The toxic stress of exposure to gun violence affects the developing brain, causing damaging effects for these children across the lifespan.
While these events captured the attention of the media, public, and politicians, they occur in a larger context of gun violence. Gun violence is a leading cause of premature death in the United States. Guns kill more than 38,000 people and cause nearly 85,000 injuries every year. In 2016, 36 children under the age of 18 in Arizona died from firearms. Twenty-nine of the 36 were between the ages of 15-17.

The causes of gun violence are complex and deeply rooted in our culture, which is why we must take a public health approach to keeping our schools and communities safe. This effort should begin with supporting the social and emotional development of children from early childhood. We must place a renewed emphasis on improving research into firearm injuries and violence. Ongoing work must increase to ensure that firearms do not fall into the wrong hands, including preventing access by children. Mental health services must be available to help those who need it most. We need a change in mindset and policy from reaction to prevention.
AzPHA Resolution October 2018
Whereas, the Arizona Public Health Association recognizes growing public concern over issues around gun violence and public safety, especially at schools; and
Whereas, some of the deadliest incidents have happened in the past six years resulting in loss of life and trauma for the surviving victims;
Therefore, be it resolved that the Arizona Public Health Association supports:
Efforts to improve the safety of students in the school environment:
● The creation and evaluation of community- and school-based programs (including coalitions) targeting the prevention of firearm injuries including homicides and suicides.

● A national requirement for all schools to assess school climate and maintain physically and emotionally safe conditions that protect all students and adults from bullying, discrimination, harassment, and assault.
● Ongoing training and support for school-based, multi-disciplinary threat management teams that utilize behavior and facts to determine the credibility of threats of violence and evidence- based strategies to manage situations of potential violence.
● Reform of school discipline to reduce exclusionary practices and foster positive social, behavioral, emotional, and academic success for students.
● Funding for Mental Health First Aid and Youth Mental Health First Aid training in Arizona schools and communities. The funding for this program needs to be ongoing to reach new teachers and administrators every year.
● Adequate staffing for school-based counseling services for the early identification of student behavioral health concerns with referral for treatment as necessary .
● Provision of Suicide Prevention Training in schools because, as the American Foundation for Suicide Prevention reports, suicide is the leading cause of death for children ages 10-14 and the second leading cause of death for those aged 15-34.

Efforts to improve the safety of students in the community environment:
● Funding to upgrade the Criminal Background Check Database to ensure that information is
current and require its use for sales including those at “gun shows”.
● Implement a process such as a Domestic Violence Order of Protection (including judicial review) in Arizona wherein a gun would be removed from individuals identified as dangerous and a potential threat to individuals or the community. As with the Order of Protection, these determinations should be based on the behavior of the individual, not on a diagnosis of mental health or substance use disorder.
● Raising the age for purchasing a firearm to 21.
● Banning the purchase of semi-automatic firearms with large magazines of ammunition designed and configured for rapid fire and use in combat.

Efforts to improve the body of evidence to improve overall student safety:
● The creation and evaluation of comprehensive national, state, and local data collection systems to facilitate research on the prevention of firearm fatalities and injuries and the movement of firearms within the population, particularly youth.
● Urging schools of public health to offer curricula in violence prevention that includes the epidemiology of firearm-related violence, intervention design and evaluation.
● Urging schools of medicine and nursing and other health care professions to educate future health care providers about interpersonal violence, the role of firearms in violence, and how to intervene with patients to recognize risk factors and prevent the effects of v

168~2018_(1)Prevent Firearm Violence in Schools(education, violence)

Megan Resolutions

2018- Continuing Support of Title X – the Nation’s Family Planning Program

Arizona Public Health Association (AzPHA) Resolution: Continuing Support of Title X – the Nation’s Family Planning Program

Effective Date: October 3, 2018

Background and Summary
The Title X program is the nation’s only federal grant program dedicated solely to providing low-income, uninsured or underinsured individuals with comprehensive, medically accurate, reproductive healthcare and related preventive healthcare services. Title X healthcare services include contraception, cancer screening, and STD testing and treatment, annual health exams, counseling, education and more. Often times it is the only regular health care many women receive.

In Arizona a 40-year old private not for profit, the Arizona Family Health Partnership (AFHP), has been awarded the Title X grant since 1983 and continues to provide high quality, medically accurate, and non- judgmental care through a network of delegate agencies.

● In 2017, AFHP served more than 36,000 women, men and teens who received high quality family planning care and information including healthcare services, including contraception, STI testing, cancer screenings, and education, among other services;
● Additionally, Title X-funded family planning healthcare services prevented an estimated 6,070 unintended pregnancies;
● Saving the state $50 million in related healthcare expenses;
● Those 6,070 unintended pregnancies would have resulted in an estimated 2,860 unplanned births, 2,050 abortions, and 1,160 miscarriages, according to the Guttmacher Institute’s Health Benefits and Cost Savings Tool; and
● STD services prevented an estimated 570 cases of chlamydia and gonorrhea, which could have resulted in 60 cases of pelvic inflammatory disease, which can cause infertility.

AzPHA Resolution July 2018

Whereas, Family Planning is one of the 10 greatest public health achievements of the 20th century1; and
Whereas, medically accurate information and comprehensive care is imperative for a strong, trusted provider patient relationship; and

1 CDC: Ten Great Public Health Achievements — United States, 1900-1999

Whereas, Title X has contributed to a 30-year low in unintended pregnancies, a historic low in teen pregnancies and an absolute reduction in abortions by providing access to reproductive health care; and

Whereas, a full range of FDA approved birth control methods should be available to all women and men; and

Whereas, non-directive pregnancy options counseling and referral is essential for informed consent and is the standard of care endorsed by American Congress of Obstetricians and Gynecologists, American Academy of Pediatrics and American Academy of Physician Assistants2; and

Whereas, comprehensive, confidential and medically accurate information is the national standard of care; and

Whereas, high-quality medical care relies on honest, unfiltered conversations between patients and their physicians3; and

Whereas, Policy decisions about women’s health must be firmly rooted in science, and increase access to safe, effective and timely care4; and

Whereas abstinence-only-until-marriage message – especially (but not only) directed at adolescents is a marked shift from evidenced-informed and patient-centered approach5; and

Whereas STD cases of chlamydia, gonorrhea and syphilis are on the rise in Arizona; and Whereas, federal law specifically prohibits Title X dollars from being used for abortions; and
Whereas, eight in 10 (80%) of the public say federal funding for family planning and other reproductive health services to low-income women is “very important” or “somewhat important” to them6; and

Therefore, be it resolved that the Arizona Public Health Association supports the Title X program and rules as they are currently enacted, will advocate for the continuation of the Title X program as it is currently enacted and will educate its members and the public regarding the importance and comprehensive nature of the Title X services provided for the health of Arizonans.

2 Guttmacher: Unbiased Information on and Referral for All Pregnancy Options Are Essential to Informed Consent in Reproductive Health Care
3 AMA Objects to attack on family planning services
4 ACOG: America’s Women’s Health Providers Oppose Efforts to Exclude Qualified Providers from Federally-Funded Programs
5 Guttmacher: The Trump Administration’s Irresponsible Use of Research in Pushing Its Abstinence-Only Agenda into Title X

6 Kaiser Family Foundation Poll: Two-thirds of Americans Don’t Want the Supreme Court to Overturn Roe

169~2018_(1) AzPHA Title X Resolution(reproduceive health, education)

Megan Resolutions, Uncategorized

2018- Universal Access to Contraceptive

Arizona Public Health Association (AzPHA)
Resolution: Universal Access to Contraception

Effective Date: October 3, 2018
Based on APHA Approved Policy Number: 20153 on November 3, 2015

Abstract
This resolution supports the universal right to contraception access in Arizona (AZ) and the United States. Contraceptive use confers significant health benefits through reductions in unwanted and high- risk pregnancies, maternal and infant morbidity and mortality, unsafe abortions, and medical therapy. These benefits are so significant that universal access to contraception is accepted internationally as an essential human right.

Frequent barriers to access include financial, geographical, and sociocultural factors. Considering these barriers, as well as contraceptive failure rates, this policy supports the universal human right to voluntary, informed, affordable access to the full range of modern contraceptive methods, including emergency contraception. In addition, it urges health providers and health funding systems to ensure the right to contraception through services including comprehensive evidence-based counseling, language translation, and referrals as needed. Finally, it urges governments and donor agencies to support contraceptive technology research as well as strategies to facilitate use and acceptability.

Relationship to Existing AzPHA Resolutions
Through its resolutions, policies and advocacy, AzPHA has long supported the right to contraception access. However, AzPHA has no up-to-date comprehensive resolution addressing the necessity and public health benefits of universal, informed, and voluntary access to the full range of contraceptive methods. Previous resolutions provide basic foundations for this proposed contraception resolution and many are outdated.

The intent of this resolution is to update AzPHA’s long standing position on access to contraception and
when adopted, will replace previously approved topic-related resolutions and serve as the basis for
AzPHA’s education and advocacy efforts on this topic. The following resolutions are being recommended for updating and replacement by this new universal access to contraception resolution.

Resolution Title Date
Support for Local Birth Control Clinics 1938
Proper Medical Supervision in Birth Control Clinics 1938
Proposed Resolution by APHA on Male Involvement in Family
Planning 1981
Adolescent Access to Comprehensive, Confidential Reproductive
Health Care 2005

At the center of this proposed AzPHA resolution is the fundamental belief in an individual’s right to informed and voluntary choice of contraceptive methods during her or his life cycle for pregnancy prevention, delay of a pregnancy, disease prevention, or medical treatment. This right to contraception includes the right to information on the effectiveness of all methods, as well as their side effects,

reversibility, and other related issues, to enable voluntary and informed contraception choice.[1–4]
Ideally, a person’s literacy or income level or place of residence would not limit informed contraceptive choice.[1,4,5] This comprehensive resolution on universal access to contraception contributes to
AzPHA’s mission to improve public health and achieve equity in health status; it is an essential
component of AzPHA’s priority to ensure rights to health and health care.

Problem Statement
The development of safe, effective contraception is widely considered to be one of the greatest public health achievements of the 20th century.[6] Contraception allows individuals to safely space and limit their pregnancies and reduces unintended pregnancies, unsafe abortions,[7] and maternal morbidity and mortality.[8] Contraception also improves birth outcomes, slows population growth, and improves socioeconomic status.[9–12] Contraception plays a pivotal role in the well-being and health of women and gives individuals control over their sexuality, fertility, and reproduction.

Many contraceptive methods reduce the risk of endometrial and ovarian cancers, are therapeutic agents for menstrual-related disorders, and have other proven health benefits.[12] Evidence has shown definitively that the relative risk associated with use of any tested method of contraception is significantly lower than the risks from pregnancy, childbirth, and unsafe abortion.[13]

Evidence-Based Strategies to Address the Problem
With universal access to contraception, individuals make choices resulting in positive public health outcomes. There is extensive historical and evolving evidence over the past 60 years, both domestically and internationally, supporting many strategies to improve contraception access and use. Studies [14– 17] have shown the success of the following strategies:

● Comprehensive, evidence-based sexuality and contraception education and counseling without bias, discrimination, or coercion;
● A focus on antenatal, childbirth, and postpartum visits as key opportunities to reach clients for family planning services;
● Advocacy and community outreach projects engaging multiple disciplines and including social media, social and community gathering locations, peer-to-peer engagement, behavioral modification programs, condom negotiation training, and group engagement;
● Voluntary and client-centered choices of contraceptive methods;
● Availability of community-based reproductive health services;
● Low- or no-cost provision of contraception and reproductive health services;
● Adequate and accessible referral systems in the case of conscientious objection; and
● Safe and affordable access to emergency contraception and legal abortion.

These strategies have demonstrated higher rates of effective contraception use, lower unintended pregnancy rates, and improved birth spacing. Use of these findings to drive health policies has demonstrated the same results on a larger scale.

Whereas AzPHA Supports Universal Rights to Contraception Access;

The AzPHA urges protection and fulfillment of rights to safe, voluntary, confidential access to the full range of contraceptive methods without barriers, regardless of age, marital status, gender identity, ethnicity, sexual orientation, religious background, socioeconomic status, geography, health status (including chronic disease, especially HIV/AIDS), nationality, immigration status or other demographic characteristics.

Whereas AzPHA Strives to Ensure Universal Access to Evidence-Based Contraceptive Information and Services;

The AzPHA supports comprehensive and evidence-based reproductive health education curricula for doctors, nurses, clinicians, and non-clinicians providing primary health care so that relevant content on all currently available contraceptive methods is routinely integrated into the education of all individuals involved in the delivery of contraceptive services.

The AzPHA urges health systems to address the main barriers to access to contraception in their local/national context, such as legal, financial, and geographical factors; gender-based violence; and sociocultural factors. Also, measures should be taken to ensure implementation of referral systems for contraceptive or abortion services in cases of conscientious objection.

The AzPHA supports the right of all individuals to evidence-based, comprehensive contraceptive counseling and education free from personal bias, including information on risks, benefits, effectiveness, proper usage, alternatives, and adverse effects, accompanied by a comprehensible, culturally/linguistically appropriate informed consent process.

The AzPHA urges that health policies and regulations guarantee universal access to emergency contraception in cases of sexual violence, rape, contraception failure, and other instances of unprotected sexual intercourse.

The AzPHA supports the principle of voluntary and informed choice under all circumstances and opposes practices that coerce or exert undue pressure to use contraception or to use methods unacceptable to the user.

The AzPHA urges governments and organizations to respect, protect, and fulfill sexual and reproductive health and rights, including actions to make modern contraception and safe legal abortion available, accessible, and affordable for all Arizonans.

Whereas AzPHA Advocates to Ensure Adequate Funding of Universal Contraception;

The AzPHA urges that health funders and payers, public and private, cover the cost of all contraceptives that have been shown to be effective in preventing pregnancy or are medically indicated.

The AzPHA advocates adequate government and private funded programs and services aimed at prevention and management of unintended pregnancies (for all women and men, regardless of citizenship status) that include contraceptive methods, access to emergency contraception and legal and safe abortion.

Whereas AzPHA Supports Contraceptive Access through Research and Development;

The AzPHA urges the continued development of contraceptive technology to improve the safety, effectiveness, and acceptability of methods for both men and women. AzPHA further urges new, ongoing, and increased funding (from both public and private sources) to support research designed to address factors enhancing or limiting voluntary and informed contraceptive use in diverse cultural and social settings.

Therefore, be it resolved that the AzPHA supports and advocates for the rights to universal access and delivery of contraception services throughout Arizona, including ongoing comprehensive education, funding, use of evidenced-based information and services, and research efforts for such services.

References

1. United Nations Population Fund and Center for Reproductive Rights. Briefing paper: the right to contraceptive information and services for women and adolescents. Available at: http://www.unfpa.org/resources/rights- contraceptive-information-and-services-women-and-adolescents. Accessed December 15, 2015.

2. Cook RJ, Dickens BM, Fatahalla MF. Reproductive Health and Human Rights: Integrating Medicine, Ethics and Law. Oxford, England: Oxford University Press; 2003.

3. Population Reference Bureau. Contraceptive evidence: questions and answers. Available at: http://www.prb.org/pdf13/contraceptive-evidence-2013.pdf. Accessed December 15, 2015.

4. Hardee K, Kumar J, Newman K, et al. Voluntary, human rights–based family planning: a conceptual framework. Stud Fam Plann. 2014; 45:1–18.

5. Singh S, Darroch JE. Adding it up: the costs and benefits of investing in sexual and reproductive health. Available at: http://www.unfpa.org/adding-it-up. Accessed December 15, 2015.

6. Centers for Disease Control and Prevention. Achievements in public health, 1900–1999: family planning. MMWR Morb Mortal Wkly Rep. 1999;48:1073–1080.

7. Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol. 2012;120:1291–1297.

8. Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception and health. Lancet. 2012;380:149–156.

9. Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta A. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA. 2006;295:1809–1823.

10. Zhu B. Effect of inter-pregnancy interval on birth outcomes: findings from three recent US studies. Int J Gynaecol Obstet. 2005;89(suppl 1):S25–S33.

11. Wendt A, Gibbs CM, Peters S, Hogue CJ. Impact of increasing inter-pregnancy interval on maternal and infant health. Paediatr Perinat Epidemiol. 2012;26(suppl 1):239–258.

12. Maguire K, Westhoff C. The state of hormonal contraception today: established and emerging non-contraceptive health benefits. Am J Obstet Gynecol. 2011;205(suppl 4):S4–S8.

13. Hatcher RA, Cates W, Trussel J, Nelson A, Kowal D, Policar M. Contraceptive Technology. 20th ed. New York, NY: Ardent Media; 2011.

14. Secura GM, Madden T, McNicholas C, et al. Provision of no-cost, long-acting contraception and teenage pregnancy. N Engl J Med. 2014;371:1316–1323.

15. Harper CC, Rocca C, Thompson K, et al. Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomized trial. Lancet. 2015;386:562–568.

16. Canning D, Schultz PT. The economic consequences of reproductive health and family planning. Lancet. 2012;380:165–171.

17. Tavernise S. Colorado’s effort against teenage pregnancies is a startling success. Available at: http://www.nytimes.com/2015/07/06/science/colorados-push-against-teenage-pregnancies-is-a-startling- success.html. Accessed December 15, 2015.

170~2018_(1) AzPHA Resolution Universal Access to Contraception (medication, reproductive health)

Megan Resolutions, Uncategorized

1971- Arizona Laws Regarding Abortion

ARIZONA PUBLIC HEALTH ASSOCIATION
41st Annual Meeting – Tucson, Arizona – October 6,7,8, 1971

RESOLUTION CONCERNING ARIZONA LAWS REGARDING ABORTION

WHEREAS, the Arizona Public HeaJ.th Association recog­nizes the right of the individual to secure quality medical care, and

WHEREAS, the existing legislation is prejudicial to the rights of women in a free society; and

WHEREAS, the decision of having an abortion be the judgment of the woman and a qualified doctor

THEREFORE, BE IT RESOLVED THAT as a professional organiza­tion we will actively promote liberalization or abolishment of the current Arizona Laws concerned with abortion.

1971-arizona laws regarding abortion

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