Clarkston Tobacco Report Final

Tobacco Control and
Resources for Refugees

in Clarkson, GA
Community Needs Assessment
Nadine Mushimbele, Kristin Liu, Sarah Wiatrek, Paris Harper, & Sarah Henderson
BSHE 524
December 2016
EXECUTIVE SUMMARY
This community needs assessment (CNA) was done in collaboration with the
Center for Pan Asian Community Services (CPACS) and Emory Rollins School of
Public Health Behavioral Science and Health Education CNA fall class of 2016.
The mission of CPACS is to promote self-sufficiency and equity for
immigrants, refugees, and the underprivileged through comprehensive health and
social services, capacity building, and advocacy. CPACS has also played a significant
role in advocating for the implementation of Clarkstons new Clean Indoor Air Act
(Ordinance 398).
The purpose of this needs assessment was to understand how organizations,
beyond CPACS, providing services to newly arrived refugees in Clarkston are aware
of and preparing for the implementation of Ordinance 398. This CNA will describe
what tobacco education and services are already being provided and what gaps in
services exist.
The CNA team collected both primary and secondary data to assess the
communitys current assets, resources, and needs of refugee resettlement agencies
serving Clarkston. Primary data collection included six interviews with key informants
who work closely with the Clarkston refugee community; a survey of agency
employees; and a windshield survey of the Clarkston neighborhood. Secondary data
collection included a literature review of the health consequences of tobacco use,
the refugee communities specific vulnerability to those consequences, and the
known health impacts of clean air ordinances; and a profile of the community as it
relates to the rest of DeKalb County and Georgia.
After concluding the key informant interviews and survey data collection, the
team collected the notes in order to synthesize the information and data and create
a report of our findings. All the team members reviewed notes, identified themes
through inductive coding, discussed their perceptions of the needs expressed by the
community, and compiled recommendations based on the findings.
1
Recommendations were generated based on three major themes: 1) Clean

Indoor Air Act, 2) smoking prevention and cessation needs, and 3) availability of
community resources. The recommendations were then organized into short-term,
mid-range, and long-term timeframes based on feasibility and importance. Shortterm goals include creating multilingual tobacco cessation and Clean Indoor Air Act
flyers and brochures and creating a standardized smoking cessation curriculum.
Recommendations that are considered mid-range are informing the Clarkson
community about the Clean Indoor Air Act through Sagal Radio and improving
communication between refugee agencies that serve the Clarkston community.
Lastly, long-term recommendations include creating an interagency list serve for
monthly newsletters and developing an interagency organization to address
smoking cessation resource needs.
In conclusion, the community needs assessment assessed needs of the
Clarkson refugee population and resources needed by the agencies serving this
community related to the policy. The information gathered for this report was used
to recommend ways to address these needs in order to better prepare the
community and newly arrived refugees for Ordinance 398.
ACKNOWLEDGEMENTS
This community needs assessment could not have been completed without
gracious support from the Center for Pan-Asian Community Services, particularly
Karuna Ramachandran. Karuna was instrumental in introducing us to Ordinance 398
and guiding the development of our needs assessment questions, as well as helping
us to identify key informants and distribute our online survey. With her help, we were
able to incorporate a variety of perspectives to gain a clear and well-rounded
perspective of the needs and aspirations of refugee-serving agencies in Clarkston.
We would also like to thank Dr. Cam Escoffery, for guiding the progress of this
report and educating us in the core principles of community needs assessment.
Jingjing Li has also provided welcome insight and support throughout this process.
Finally, this needs assessment would not have been possible without the
cooperation and help of our many informantsincluding those who work for the
DeKalb County government, nonprofit agencies, and the Clarkston Community
Center. We would like to thank all those who participated in our interviews and our
online survey for their honesty and insight into the issue of tobacco use in Clarkston.
TABLE OF CONTENTS
EXECUTIVE SUMMARY ..........................................................................................................................1
ACKNOWLEDGEMENTS ........................................................................................................................2
INTRODUCTION.......................................................................................................................................6
LITERATURE REVIEW ........................................................................................................................... 11
CLARKSTON COMMUNITY PROFILE ............................................................................................. 16
WINDSHIELD SURVEY......................................................................................................................... 26
KEY INFORMANT INTERVIEW .......................................................................................................... 33
ONLINE CLARKSTON TOBACCO ASSESSMENT ........................................................................ 43
DATA TRIANGULATION ..................................................................................................................... 53
RECOMMENDATIONS ........................................................................................................................ 57
LIMITATIONS ......................................................................................................................................... 61
LESSONS LEARNED.............................................................................................................................. 63
CONCLUSION ........................................................................................................................................ 63
BIBLIOGRAPHY ...................................................................................................................................... 65
APPENDICES........................................................................................................................................... 68
APPENDIX A: Key Informant Interview Guide ........................................................................ 68
APPENDIX B: Online Clarkston Tobacco Assessment ......................................................... 70
List of Tables
Table Description
Page Number
1: Country of Origin for Refugees Arriving in Clarkston,

October 2004 - June 2015
12
2. Regions of Birth of Foreign Born Clarkston Residents
18
3: Employment by Industry of Residents in the City of

Clarkston
20
4: Key Informants Interviewed
35
5: Organizations of Respondents
46
6: Data Triangulation of Themes Using Sources of Evidence
54
7: Recommendations for CPACS
58
List of Figures
Figure Description
Page Number
1: CPACS Map
2: CPACS Mobility Shuttle Route
3: CPACS Service Chart
4: City of Clarkston
17
5: A-1 Hookah
27
6: World Relief Front Entrance
28
7: Green Space
29
8: Baseball Field Behind Milam Park Pool Center
30
9: The Clarkston Community Center
30
10: Clarkston Community Center Activity Field
31
11: Kabu Hookah Lounge
32
12: Tobacco Services Offered by Organizations
47
13: Tobacco Services Offered Outside Organization
48
14: Meeting Needs for Clarkston Refugees
49
15: Opinions About Health Impacts of Secondhand Smoke
50
16: Locations to Target Cessation Programs
51
17: Factors to Decrease Tobacco Product Use
51
18: Awareness of Clean Indoor Air Ordinance
52
INTRODUCTION
The following section introduces the community needs assessment (CNA),
the purpose and questions the assessment sets out to address, the background
and history of the stakeholder, the Center for Pan Asian Community Services, and
details of the Clean Indoor Air Act (Ordinance 398).
Purpose of the Community Assessment

In August 2016, the city of Clarkston, Ga. adopted the Clean Indoor Air Act
(Ordinance 398) which prohibits smoking in public spaces and indoor public
spaces (Clarkston Clean Indoor Air Ordinance, 2016).The purpose of this
assessment is to determine how organizations providing services to newly arrived
refugees in Clarkston are preparing for the implementation of the Clean Indoor Air
Act. The CNA will assess the tobacco education and services already provided by
the organizations and the opportunities for collaboration with CPACS. For the
purposes of this report, organizations include refugee resettlement agencies and
community centers.
Questions the CNA will aim to answer are:
1. What tobacco prevention and cessation resources are available
for newly arrived refugees from local organizations?
2. What are the anticipated impacts of Ordinance 398, and how are
organizations preparing for them?
3. How can CPACS partner with other agencies to fill in the
education and service gaps concerning the upcoming tobacco
use ordinance?
Center for Pan Asian Community Services:

Background and History
The Center for Pan Asian Community Services (CPACS) is a non-profit
organization located in Northwest Atlanta, Georgia in Fulton County,
approximately ten miles from the City of Clarkston (Figure 1). Founded in 1980,
CPACS started as a volunteer organization providing health and human services to
Korean Americans. Today, CPACS provides essential services for the support of
underprivileged Asian Americans, African Americans, Hispanic Americans and
White Americans with a mission to ... promote self-sufficiency and equity for
immigrants, refugees and the underprivileged through comprehensive health and
social services, capacity building and advocacy. CPACS provides a range of
services for their clients, including the Mobility Shuttle, which assists with
transportation to different community resources (Figure 2). This shuttle is funded
by the Atlanta Regional Commission to assist with connecting the Clarkston
residents to employment opportunities.
Figure 1: CPACS and Cosmo Health locations in

reference to Clarkston, GA
7
Figure 2: The CPACS Mobility Shuttle route on

data from CPACS (2016) through Atlanta, GA
(CPACS, 2016)
Clients of CPACS also receive assistance for food stamp applications and
insurance enrollment, translation and interpretation services, health education
around breast cancer, family and relationship skills workshops, senior wellness and
home services, and other services related to advocacy, health, immigration,
housing, and education. CPACS received an award through the Department of
Health and Human Services to expand their federally qualified health center,
Cosmo Health, to serve low income communities (CPACS, 2016). All services are
listed below in the service chart (Figure 3).
Figure 3: CPACS service chart, based on data from CPACS

(2016)
Clean Indoor Air Act

To protect the community from harmful effects of tobacco smoke, the City of
Clarkston passed Ordinance 398, Clean Indoor Air Act (Clarkston Clean Indoor Air
Ordinance, 2016). The ordinance was adopted on August 4th, 2016 and became
effective 30 days after adoption. This ordinance prohibits smoking in public spaces
and indoor public spaces, which includes but is not limited to bars, banks, hotel
rooms, nursing homes, and parking structures. Smoking is also prohibited within 30
feet of building openings (windows, vents or doors), playgrounds, public events,
parking lots of recreation areas, and transportation stations. Anyone who violates
these restrictions is punishable by a fine up to fifty dollars.
The law is enforced by the Clarkston Police Department, the Quality of Life
Officer, Solomon Teklu, and the City Manager, Keith Barker. Business owners may
request an individual to leave if they continue to violate the law after first being
asked to stop using the tobacco smoking product. Business owners who fail to
enforce the Clean Indoor Air Act will be fined up to one hundred dollars for the first
violation, up to two hundred dollars for the second violation, and up to five hundred
dollars for each subsequent violation. Repeated violation can also result in loss of
permit or licenses necessary for the operation of their business (Clarkston Clean
Indoor Air Ordinance, 2016).
Definition of Community
For the purposes of this needs assessment, the Community Needs Assessment
(CNA) team has defined the community as the refugee service organizations who
serve the City of Clarkston, Georgia, along with their clientele. After collaborating
with CPACS, the CNA team established this twofold definition while understanding
that the focus of the needs assessment will be on the organizations tasked with
assisting the refugees who live in Clarkston.
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LITERATURE REVIEW
This literature review first discusses patterns of tobacco use amongst foreignborn U.S. populations with a particular focus on refugees in Georgia. The overall
health needs of these populations are considered as well as barriers to accessing
health services. Additional research is presented on the known health impacts of
tobacco use, including cigarettes, chewing tobacco, hookah, and secondhand smoke.
Finally, clean indoor air ordinances are reviewed in regards to their growing
popularity and positive and negative impacts on health.
U.S. Refugee Populations

Refugees are people who have been forced to flee their countries of origin
because of persecution, war, or violence (United Nations High Commissioner for
Refugees). In Georgia, and the United States in general, refugee populations are
considered one of the most vulnerable populations in terms of physical, social, and
psychological well-being. Since 1981, Georgia has resettled over 69,000 refugees
with many settled in Clarkston City.
Many of these refugees bring with them physical and mental health problems
originating from experiences of traumatic events and lack of access to adequate
health care before their arrival in the United States. However, while refugee health
issues are often preventable or easily treated, cultural, linguistic, and systemic
barriers often prevent refugees from accessing health care in the United States
(Georgia Department of Public Health [GADPH]).
Tobacco Use among Refugees

Tobacco use is one area where health disparities amongst refugee groups
might be alleviated if adequate and culturally appropriate services were available.
Tobacco use outside of the United States, particularly in developing countries, is a
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growing health concern and represents a rising challenge for global public health.
Table 1 shows how the prevalence of smoking in the United States compares to the
ten countries with the largest number of refugees arriving to Georgia. The table
shows that many of the countries of origin have higher rates of smoking than the
United. Particularly for men arriving from Asia and the Middle East, it is likely that
refugees are arriving to Georgia with an established smoking habit.
While annual deaths attributable to tobacco are expected to decline in highincome countries like the United States, they are also expected to double across lowand middle-income countries from 3.4 million to 6.8 million by 2030 (Plotnikova, Hill,
Table 1: Country of Origin for Refugees Arriving in Georgia, October 2004 June 2015
Country of Origin*
United States
% using tobacco daily, 2013a
Number of arrivals
2004-2015*
Men
Women
17.2
14.2
Bhutan
5437
16.7
3.5
Burma/Myanmar
6929
30.6
6.5
Democratic Republic of Congo
978
15.3
1.3
Eritrea
901
11.3
0.6
1005
7.7
Iran
811
23.3
1.7
Iraq
2419
33.1
2.9
823
51
17
3831
19.7
2.3
699
8.3
Ethiopia
Russia
Somalia
Sudan
Other countries
4531
*Refugee arrivals by ten most common countries of origin for FY2004-2015. Source: State of
Georgia Refugee Program
a
Source: The World Lung Foundation
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& Collin, 2014). This represents the consequences of the global expansion of the
tobacco industry and global inequities in tobacco control. In addition, those who
have recently moved to the United States may not have a complete understanding of
the health impacts of tobacco use. For example, the 2007 ClearWay Minnesota
survey of West African smokers reported a general awareness of the health risks of
smoking, but less knowledge about the impacts of exposure to secondhand smoke
(Dillon & Chase, 2010).
Hookah is a particularly prevalent form of tobacco use for U.S. immigrant
populations, particularly those of Middle Eastern or North African descent. Although
hookah has been the purview of older men traditionally, it is now an activity shared
by all genders and ages. In Arab families, hookah can act a form of cultural
expression and family bonding, and is acceptable for children while cigarettes are
forbidden (Jamil et al., 2014). However, cigarette use is very common amongst
immigrants from other parts of the world. The ClearWay survey also found that a
high percentage of West African immigrants reported an increase in their smoking
behaviors after setting in the U.S. (Dillon & Chase, 2010).
Health Impacts of Tobacco Use

Although the United States has seen a decline in adult per capita cigarette
consumption of over 70%, with an estimated 8 million premature deaths due to
smoking averted, over 42 million adults in the United States still struggle with
tobacco dependence (Koh, 2014). Common forms of tobacco use include
cigarettes, smokeless/chewing tobacco, hookah, as well as secondhand smoke
exposure. An analysis of the 2012 RTI National Adult Tobacco Survey found that
32.1% of U.S. adults use at least one form of tobacco product regularly. Of these
tobacco users, 14.9% use cigarettes exclusively, 1.6% use smokeless tobacco
exclusively, and 1.3% use hookah exclusively (Lee, Hebert, Nonnemaker, & Kim,
13
2014). It should be noted that an additional 10.6% of tobacco users regularly

combine their cigarette use with other forms of tobacco.
Although less common in the U.S. general population than cigarettes or
even smokeless tobacco, hookah is considered a global public health threat.
There are global estimates of 100 million people who smoke hookah daily (Jamil
et al., 2014). With its origins in Africa and the Middle East, hookah use is
especially prevalent among U.S. immigrants from those regions. Because smoke
from hookah is filtered through water, many users, of all genders, ages, and
ethnicities, believe that this form of smoking is less harmful than cigarettes.
However, the volatile carcinogens and other particles in tobacco smoke stay in
the air bubbles as they pass through the water, so hookah is associated with
many of the same negative health outcomes as cigarettes. In addition, it bears
the additional risk of infectious diseases which can be spread through pipesharing. Moreover, hookah smoking is frequently performed in conjunction with
alcohol use, psychoactive drugs, and/or synthetic marijuana which can cause
further complications. (Jamil et al., 2014).
There are 16 million current and former smokers who live with a smokingrelated illness with an estimated 500,000 tobacco-related deaths annually. Besides
lung cancer and other respiratory disorders, evidence links tobacco use to
conditions such as colorectal cancer, liver cancer, diabetes mellitus, rheumatoid
arthritis, heart disease, low birth weight, and periodontal disease (Jamil, Geeso,
Arnetz, & Arnetz, 2014; Koh, 2014).
Health consequences of tobacco use also extend beyond those who
choose to smoke to others who are involuntarily exposed to secondhand smoke
in their environments. Approximately 3,000 lung cancer deaths and 62,000
deaths from coronary heart disease are attributed to secondhand smoke
exposure every year in the United States (CDC, 2001). Especially dangerous for
children, secondhand smoke is associated with sudden infant death syndrome,
14
low birth weight, chronic ear infections, and respiratory diseases. Thus, the
Centers for Disease Control has recommended comprehensive programs to
reduce tobacco use as well as the implementation of clean indoor air policies to
reduce involuntary exposure to secondhand smoke (CDC, 2001).
Clean Indoor Air Ordinances

Amongst strategies to improve the health of those affected by tobacco use
and secondhand smoke, clean indoor air ordinances have been gaining wide
ranging public support, even with smokers (CDC, 2001). Clean air laws and smokefree policies are components of comprehensive tobacco programs whose purpose
is to reduce the harmful effects of tobacco smoke in the environment by restricting
smoking in designated public areas (CDC, 2014). In addition to protecting
nonsmokers from involuntary exposure to secondhand smoke, a number of
studies have shown that restrictions in businesses and public places are associated
with decreasing consumption and prevalence rates of smoking (Levy, Friend, &
Polishchuk, 2001). The mechanism for this association is presumed that by limiting
smoking in key areas, clean air laws reduce opportunities for smokers to consume
tobacco (Levy & Friend, 2003). This may improve some individuals chances of
quitting smoking, and change social norms around the acceptability of smoking.
However, there is still uncertainty about the effects of clean air laws,
particularly upon specific sociodemographic groups such as refugee populations.
One possibility is that clean air laws may increase anti-smoking sentiment in an
area, creating an additional burden on smokers. For refugees in particular, clean air
laws may make it difficult for individuals who smoke to find and maintain jobs, or
lead to increased negative encounters with law enforcement when smoking
restrictions are violated (Levy, Friend, & Polishchuk, 2001). To counteract these
negative effects, the Centers for Disease Control (CDC) makes several
recommendations for activities to support tobacco control programs in
15
communities with high levels of tobacco-related disparities such as considering

health equity in all tobacco prevention strategies (CDC, 2014). Another
recommendation is mitigating barriers to tobacco use prevention by increasing
access to cessation service. A final suggestion is providing additional funding to
organizations which are able to educate and involve the populations experiencing
tobacco-related disparities, as well as providing culturally competent technical
assistance and materials to those organizations.
CLARKSTON COMMUNITY PROFILE

The community profile provides in-depth background on the physical, social
and environmental characteristics of the community of interest. In this section, the
CNA report will include information about the following topics related to Clarkston,
Ga.: history, geography, demographics, business and economics, social structures,
social services, community health status, politics, and community assets.
History
The city of Clarkston emerged from the 1840s Georgia Railroad expansion,
making it one of the first of Atlantas many suburbs. The city was officially founded
on December 12, 1882 by Governor Alexander H. Stevens, who named the city
after Georgia Railroad director, Colonel W.W. Clark, although for part of the 1900s
it was known as Angora Heights in honor of the significant number of Angora goat
farms. (History, 2012). From the time of its founding to until the 1970s, Clarkstons
population was primarily white farmers and railroad workers (St. John, 2007). The
city also has the oldest womens club in Georgia which was established in 1913.
The clubhouse was used for many years as a place for schooling and Sunday
school classes, but now is a historic landmark used for small social events. The
womens activity in the community led to the first park in DeKalb County, Milman
16
Park, in 1927. The women, predominantly Mrs. A.P. Milman and Mrs. Sadie Ray,
believed there needed a place for the citys children to play (History, 2012).
The city was made up of 90% white citizens in the 1980s, but now is less
than 14% white (History, 2012). The Klu Klux Klan used to gather in this
community, but the population shift from predominantly white to AfricanAmerican residents decreased the popularity of that organization. In the 1990s,
due to the collaborative efforts of many aid agencies and the federal government,
Clarkston transformed into an important resettlement site for international
refugees (St. John, 2007). The city was an appropriate fit for a refugee community
due to its variety of housing choices from single family to multi-family residential
options. Ultimately, this decision led to a transition which led to Clarkstons current
reputation as the Ellis Island of the south.
Geography
The City of Clarkston has a total area of 1.1 square miles (2.7 km2),
consisting of 1.0 square mile of land and 0.01 square mile of water (Figure 4) (US.
Figure 4: City of Clarkston (City of Clarkston, 2016)

17
Census). Clarkston is approximately ten miles northeast of Atlanta, five miles east
of Decatur and five miles west of Stone Mountain. It has a convenient access to
public transportation and major highways (City of Clarkston, 2016).
Demographics
Clarkston, Ga. is known as the most
diverse square mile in America, with over 60
different languages spoken (City of Clarkston,
2016). The 2014 US Census estimated the total
population of the city of Clarkston at 7,717, a
significant part of DeKalb Countys entire
population of 71,130 (U.S. Census Bureau,
2014). While the majority of Clarkstons
residents are Christian and attend Christian
services regularly, 52% of the population
reported that they did not attended religious
services regularly in 2002 (Clarkston, GA
Religion Statistics, 2016). The population is
relatively young, with a median age of 28.3,
Table 2: Regions of Birth of

Foreign Born Clarkston Residents
World region of birth
of foreign born
Estimate
Foreign-born
population
4,125
Europe
121
Asia
2,219
Africa
1,587
Oceania
Latin America
0
198
North America
*Data for Clarkston City, Georgia.

Source: U.S. census Bureau, 2010-2014
American Community Survey 5-year
estimates
which is lower than Georgias median age of 35 (U.S. Census Bureau, 2014).
The racial and ethnic composition of Clarkstons population is 15.8% White,
52.2% Black or African American, 31.1%Asian, 0.1% American Indian and Alaska
Native, and 1.4% Hispanic or Latino. Among Asians residing in Clarkston, 0.9% are
Chinese, 0.7% Korean, 3.7% Vietnamese and 25.8% other Asian (U.S. Census
Bureau, 2014). About half of the communitys residents are of international
descent or current refugees, and over 30% of Clarkston residents were born
outside of the US (City of Clarkston, 2016). Table 2 shows which world regions
foreign born residences are from based on the 2010 Census. Clarkstons extremely
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high diversity can be attributed to the fact that the city serves as a hub for
refugees resettling in the United States. Between 1996 and 2001, almost 19,000
refugees arrived in Georgia from around the world, and most of them came to
DeKalb County and the City of Clarkston (John & Clarkston, 2007).
Business and Economics

Clarkston has a booming commercial district with many businesses owned
and patronized by refugees. Refugees own about 85% of the businesses in the
Clarkston (Hinojosa, 2012). However, there is also a high degree of economic
inequity. In 2015, 43.9% of Clarkston residents were living below the poverty level
and 31.5% had no health insurance (Smith-Lindsey, 2016). In 2014, median
household income in Clarkston was only $33,151 compared to the median
household income of $49,378 for the entire state of Georgia (U.S. Census Bureau,
2014). Over fifteen refugee service agencies operate in the city of Clarkston, many
of which are members of the Coalition of Refugee Service Agencies (Coalition of
Refugee Service Agencies [CRSA], 2013). These agencies play a critical role in
providing aid to struggling Clarkston residents.
Although the unemployment rate in Clarkston is approximately 18%
(Hinojosa, 2012), there is a high diversity in the range of employers in the city.
Manufacturing is the strongest industry in Clarkston, employing 25% of adults
over age 16. An additional 15% of Clarkston residents are employed in arts,
entertainment, recreation, accommodation, and food services. Around 14% of
Clarkston residents are employed in the education services, health care and social
assistance fields. Another 14% are employed in retail and another 10% of
Clarkston residents are employed in professional, scientific, management and
administration, and waste management services. Table 3 provides a more detailed
description of percentages of employment by industry in Clarkston compare with
the state of Georgia (U.S. Census Bureau, 2014).
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Table 3: Employment by Industry of Residents in the City of Clarkston

Type of Industry
City of Clarkston
Population
Georgia General
Population
Civilian employed population 16 years and over
2,875
4,300,074
Agriculture, forestry, fishing and hunting, and mining
0.0 %
1.2%
Construction
1.3%
6.4%
25.0%
10.6%
3.1%
2.9%
13.7%
12.0%
Transportation and warehousing, and utilities
6.7%
6.0%
Information
1.6%
2.5%
Finance and insurance, and real estate and rental and

leasing
4.4%
6.3%
9.9%
11.4%
14.3%
21.1%
15.3%
9.2%
Other services (except public administration)
3.5%
5.0%
Public administration
1.1%
5.4%
Manufacturing
Wholesale trade
Retail trade
Professional, scientific, and management, and

administrative and waste management services
Educational services, and health care and social
assistance
Arts, Entertainment, and recreation, and
accommodation and food services
Source: U.S Census Bureau. (2014). American Fact Finder
Social Structure
The City of Clarkston promotes outdoor activities through a renovated Milam
park which includes a playground with equipment, walking trail, a tennis court,
soccer and baseball area, a swimming pool complex for summer activities, a bike
paths, a dog park, Friendship Forest wildlife sanctuary and lakes with open fishing for
the residents (Clarkston city, 2016). Clarkston womens club is offered for private
rental by the city of Clarkston to resident for community and family gatherings and
event celebrations. Also, the city offers Clarkston 101, which is an educational
20
program that offers classes to teach residents about the city government (Clarkston
City, 2016).
The Clarkston Community Center offers residents a place of art, education,
recreation, and community building (Clarkston Community Center, 2016). The
Community Center can also be rented out for weddings and other events.
Additionally, Clarkston is home to different churches including First Baptist
churches, Methodist churches, Catholic churches, Pentecostal and Assembly of God
churches, and Clarkston International Bible and Lutheran church (Church finder,
2016). There is also a Masjid Al-Momineen mosque that serves the Muslim residents
in Clarkston and Stone Mountain (Masjid Al-Momineen, 2016).
Clarkston has a high school, two private elementary schools, two public
elementary schools and one middle school. The Atlanta Area School for the Deaf and
the central campus of the Georgia Perimeter College are also located in Clarkston
(Clarkston City, 2016).
Social Services
The city of Clarkston has many resources within and near the city limits that
are available to all residents and specifically for refugees. These resources include
community centers, health centers, and refugee serving organizations.
The local Clarkston Community Center offers many services such a bike
refurbishing program, summer camps, a senior refugee program for learning
English, and computer classes (Clarkston Community Center, 2016). These
programs are open to all Clarkston residents including the healthy living initiative
program which provides healthy and nutritious food choices as well as access to a
community gardens where residents have plots to grow their own food.
Specifically for children, there is a youth initiative program focusing on violence
prevention and a summer camp which helps children ages 6-14 improve their
English and academic skills.
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Health services are provided to the local community through the Clarkston
Community Health Center, Walgreens Healthcare Clinic, and Care One Health
Service. Additionally, Cosmo Health, the federally qualified health center run by
CPACS, provides services such as dental health, family planning, free mammogram
screening, and immunization. The two hospitals near Clarkston are Emory Clinic
Hospital and Oakhurst Medical Center.
For refugees, community services may be provided through organizations
such as Catholic Charities, World Relief Atlanta, and Friends of Refugees. Catholic
Charities is one of the largest charities in the United States, which provides
professional and community services to the refugees in Atlanta (Catholic Charities
Atlanta, 2016). Additionally, Catholic Charities provides services such as
immigration legal services, refugee resettlement services, outpatient mental health
counseling, English language instructions and many more. World Relief Atlanta is a
non-governmental organization that provides multiple services to refugees in
Clarkston and Georgia including refugee resettlement, employment services, and
immigration and legal services (World Relief Atlanta, 2016). Friends of Refugee is
non-profit organization founded 1995 to provide support and services to Bosnian
refugee and their families. Their mission is to empower refugees through
opportunities that provide well-being, education and employment (Friends of
Refugee, 2016). The Jolly Avenue Community Garden hosted by Friends of
Refugees has over 77 family garden plots (Friends of Refugee, 2016). Friends of
Refugees also offer services such as the Career Hub, an internet caf that helps
provide career resources (Career Hub: Clarkston, 2016).
Community Health Status

Obesity is a major health issue in DeKalb County affecting 30% of adults
and 13% of high school students (CDC, 2016). An additional 38% of adults can be
classified as overweight. Exacerbating this problem is the low degree of physical
22
activity in the county. Nineteen percent of adults living in this county do not
exercise and 11% reported having poor general health (DeKalb County Board of
Health [DCBH], 2011).
Broadly, chronic health conditions are a significant problem in DeKalb
County as the leading causes of death for the county are cardiovascular disease,
cancer, and respiratory diseases (DCBH, 2011). In addition, 10% of adults live with
diabetes. Chronic conditions such as these are often caused or exacerbated by
tobacco use, and encouraging smoking cessation in DeKalb County could reduce
the incidence of conditions like heart disease, diabetes, lung cancer, and stroke.
In addition to worsening chronic conditions, tobacco use itself is a pressing
issue for its residents because 6% of adults are current smokers with over 50% of
these users smoking daily (CDC, 2016). This is also becoming a problem that
begins younger and younger as 14% of high school students reported smoking
some form of tobacco within the last 30 days. According to a survey administered
by the DeKalb County Board of Health in 2011, 15% of residents reported being
exposed to secondhand smoke in public areas and 8% were exposed in their
homes (DCBH, 2011).
However, access to cessation services and education about the risks
associated with tobacco use are not available to many DeKalb County residents,
including those in Clarkston. While the DeKalb County Board of Health currently
provides health-screening services to newly arrived refugee to eliminate healthrelated barriers upon arrival to the USA, fewer refugees access medical care on a
regular basis (DCBH, 2015). In fact, about 18% of DeKalb County adults do not
have health insurance, and over 50% do not have a primary care physician. The
uninsured rate is approximately equal with the rest of Georgia (19%), but is much
higher than the national average of 13.8% (Sweeney, 2015).
23
Politics
Today, the refugee population in Clarkston, Georgia is well received and
celebrated by residents and officials. In a 2015 interview with the Atlanta local NPR
station, Clarkston mayor Ted Terry stated that the refugee population strengthens
Clarkston (Lin Erdman, 2015). He noted that once refugees are settled, they pay
taxes and contribute to the local economy. Mayor Terrys goals for Clarkston are to
create a safer and greener city (City of Clarkston, 2016b). In addition to strong
community perceptions, Clarkston has been chosen to receive $80,000 in funding
from the Atlantic Regional Commission through the Livable City Initiative program
(LCI). These funds are provided to update the original LCI plan to help improve the
city center and mixed-income housing (City of Clarkston, 2012a). To improve
community health, the City of Clarkston is developing new policies and initiatives
such as the Clean Indoor Air Act.
The governance structure of Clarkston is composed of a mayor, city council,
city manager, clerk, chief police and departments (City of Clarkston, 2016). The
mayor directs the administrative structures as well as appointing and removing
department heads. He oversees the Clarkstons main departments, including the
police, fire, education, housing and transportation and daily operation of the city
itself. The city council has four members who have the legislative power to pass
ordinances and budgets, make appropriations, and even set local tax rate if
needed. The city clerk has the responsibilities to coordinate and distribute the
agenda for the council meetings as well as maintain contracts, ordinances,
resolutions and agreements. Additionally, the clerk focuses on the oversight of the
adoption and publication of the city of Clarkstons code of ordinance, and also is
responsible for providing business and alcohol licenses to residents who request
them. The chief of police works alongside other departments to enforce all laws
impartially, maintain the highest degree of ethical behavior and professional
conduct, and serve the Clarkston community.
24
There are several departments within the Clarkston city government. The
Clarkston Municipal Court is headed by the clerk of court, who oversees all
violation of state laws and local ordinances within the city of Clarkston (City of
Clarkston, 2016). The Planning and Development Department supports balanced
and innovative development within Clarkston and provide for future growth and
innovation of businesses. The Quality of Life Department provides fair and
consistent enforcement of all city, environmental, building, housing and zoning
codes for residential and commercial areas. The Public Works Department
manages infrastructure in Clarkston, including street and stormwater
infrastructure, right-of-way maintenance, repair and maintenance of the citys fleet
of vehicles and special trash removal.
Community Assets
Clarkston is a community that is strong in human assets, exemplified by its
great diversity and the variety of organizations and businesses that cater to the
needs of specific groups. The commercial district is composed of restaurants,
groceries, and convenience stores and is located in downtown Clarkston along
East Ponce de Leon Avenue and Market Street. Many of these businesses have a
regional focus, making foreign-born residents feel at home and providing a
different suite of flavors and foods to all. In the city are public elementary school
and child care facilities. There are community services that provide education and
recreation to children and adults, including the Clarkston Community Center and
the DeKalb Public Library. (Clarkston City, 2016).
Lastly, there are many nonprofits which serve Clarkston, and in particular
the refugees who have settled there. These organizations have established trust
and expertise within the community by demonstrating their ability to
operationalize their resources to improve the health and well-being of refugees in
Clarkston. Many of these assets are located within a short distance from each
25
other allowing the services to be easily accessible to community members.

Additionally, the close proximity of the resources listed provide opportunities and
easy for collaboration between community organizations, agencies, and business.
Many of these community assets were observed directly during the CAN teams
windshield survey.
WINDSHIELD SURVEY
Purpose
A windshield survey is a useful methodology for understanding the physical
community because driving or walking through the community allows it to be
observed (Escoffery, 2016). When researchers allow time to conduct a windshield
survey, they are able to observe specific attributes about the community such as the
people, structures related to the health of the community, open spaces and
boundaries, and media and signage. The windshield survey provided the CNA team
with a context for understanding Ordinance 398, the community it will impact, as
well as the accessibility between organizations and the rest of the community.
Methods
On Thursday, October 6, 2016, the five members of the CNA team conducted
a windshield survey through Clarkston from 6:30-8:00pm, by motor vehicle and on
foot. During the survey, team members noted types of residential areas, popular
stores and service centers, demographics of people outside, transportation
accessibility, open spaces, and the presence of smokers. Observations were
documented using handwritten notes and photographs taken on the road and at
specific locations. Notes were compiled and photographs were uploaded in the
shared Google Drive in the days following the survey.
26
Windshield Survey Results

The team first drove from Emory Rollins School of Public Health to World
Relief using GA-10 E. World Relief was actually located 3 miles away from
Clarkston in Stone Mountain, approximately eight minutes away by car or a fortyminute bus ride. Along Memorial Drive, which was the nearest major road to
World Relief, the team observed that many people were walking outsidesome
were families with strollers and some were alone with backpacks. The strip malls
nearby had several car-related stores (car washes, auto tune-ups, auto sales),
packing stores, hookah shops, bars, fast-food restaurants, and convenience stores.
The team did not notice many grocery stores but instead noted that there were
variety stores that sold cheap household products such as Dollar Tree and the
Family Dollar. It was also observed that the A-1 Hookah was located right next to
Family Dollar (Figure 5). There were few health centers with the exception of
Walgreens with a clinic, Oakhurst Medical Center, a healers house, and a medical
center with dialysis. The CNA team also observed Korean churches, a Taiwanese
church, and an elementary school.
On the corner of Village Square Drive and Memorial Drive, there was a
vacated strip mall with its main store out of business. The complex was almost
deserted with a wide open parking lot. The team observed that the Georgia
Figure 5: A-1 Hookah was in the same shopping complex as the

Family Dollar (Sarah K. Henderson)
27
Medical Association and childcare were located in close proximity to World Relief
on Village Square Drive. However, the closest bus stop to World Relief was on
Memorial Drive, so the 0.3-mile walk could be very difficult for older and/or
disabled people. Additionally, World Relief had two tall staircases at their front
entrance and no apparent disability access. In the same area as World Relief was
MedSide Healthcare which advertised adult daycare (Figure 6). Across the street
from World Relief and Medside were apartments with a large open grass field
(Figure 7). There were children of diverse ethnicities playing soccer on the field.
One team member noted that World Relief often provides housing for refugees for
up to six months, and that could be the purpose of the apartment units.
Next, the team then drove from World Relief to Clarkston Community
Center along Rays Road and Norman Road. This was a residential area with older
homes from the 1960s and 70s. Many large families were outside walking and
playing, including children with a soccer ball and a young woman riding a scooter.
Milam Park Pool Center and a playground with open green space were on Norman
Figure 6: The front entrance of World Relief front

(Sarah K. Henderson)
28
Figure 7: The green space across the street from World

Relief (Sarah K. Henderson)
Road (Figure 8). Georgia Power, the train tracks, and entrances to the regional
PATH trail were tucked between the houses in the neighborhood. As it became
less residential, several churches emerged, including the Clarkston First Baptist
Church and Family Life Center, which hosts health classes.
At the Clarkston Community Center (CCC), the CNA team saw a lot of open
green space and a library. CCCs mission is to be a gathering place for art,
education, recreation and community building for long-time Americans and newlyarrived refugees in Clarkston and greater DeKalb County (Figure 9). A tour of the
facility included computer labs, meeting rooms, warming kitchen, and a green
space with a community garden and soccer field (Figure 10). The guide said he had
not seen kids smoking in the five years that he worked there. Upon leaving, the
team noticed few cigarette butts on the ground.
29
Figure 8: Baseball field behind Milam Park Pool Center (Sarah K.

Henderson)
Figures 9: The front entrance to the Clarkston Community Center

30
Figures 10: The activity field behind the Clarkston Community Center
The team then sought to find the Clarkston Community Health Center
which should have been next to City Hall, a dentist, and FIRMA, but were unable to
locate it. In the immediate surrounding area, a Methodist church was located right
next to a police station. Apart from the green space in the CCC, there were no
open spaces in the surrounding area other than parking lots. Not many people
were seen outside, possibly due to the late time of day the windshield survey was
conducted. The team started driving around to find more tobacco and hookah
related shops and spotted the J&B Liquor Store and the Kabu Hookah Lounge
(Figure 11) which had one smoker outside.
A team member began speaking with the smoker outside Kabu Hookah
Lounge, who proved to be a friend of the business owner. The owner spoke to the
team for about 10 minutes, including playing a news clip on his phone showing his
31
Figure 11: Kabu Hookah Lounge (Sarah K. Henderson)

interview with local news regarding the enforcement of Ordinance 398. The owner
recounted fifteen days ago, when officials came into his bar and lounge and told
him to stop selling hookah, a major component of his business. He also
complained that other businesses, such as Strokers, a Clarkston strip club, were
given a two-year grace period to continue selling hookah, while smaller businesses
like Kabu were ordered to cease sales immediately. The owner felt the ordinance
to be culturally insensitive because many of the hookah lounge owners in
Clarkston were refugees. The team was particularly interested in the business
owners account because it challenged the understanding that Ordinance 398 was
not going to be enforced until 2018.
To conclude the survey and get a better feel for the people and culture
of Clarkston, the team visited Kathmandu Bar and Grill for dinner. When the
team finished eating and was leaving the complex, they saw a few men
32
standing outside the Fatma Halal Meat and Groceries, but they did not spot
any smokers. They also noticed a Clarkston police car driving across the
parking lot which may have explained the lack of smoking. The insight gained
from the windshiled survey was later supplemented with additional data
provided by members of our commutiy of interest. These data were collected
through Key Informant interviews, and an online mixed-methods survey.
KEY INFORMANT INTERVIEW

Purpose
The purpose of the key informant interviews was to gain insight on
Ordinance 398 (Clean Indoor Air Act) and how it will impact the Clarkston refugee
community. The interviews were designed to provide insight in the areas of
refugee health, tobacco use behaviors, and currently available tobacco products
and cessation resources in Clarkston, GA. Subject matter experts were interviewed
to yield information on the needs, health outcomes, and impacts of tobacco use
policy changes among newly arrived refugees in Georgia. Refugee agency
employees provided information on their awareness of the impacts of Ordinance
398 and what programming, workshops, and/or informational sessions their
organizations are planning to implement for their clients, if any. Additionally,
community leaders provided insight into how members of the refugee community
feel about Ordinance 398 as well as what tobacco cessation resources would be
helpful and welcomed to meet the community's needs.
Instrument
The interview guide was created to gain various experts knowledge and
unique perspectives on tobacco education and cessation resources for refugees in
33
the city of Clarkston. The complete interview guide, consisting of 19 items, is

located in Appendix A. Key questions included:
What is the current state of refugee health and refugee tobacco use
behaviors?
What services do refugee resettlement agencies in Clarkston offer to

their clients who use tobacco products?
How are refugee resettlement agencies preparing for Ordinance 398,

if anything?
How does the Clarkston refugee community feel about tobacco use?
How does the refugee population in Clarkston feel about Ordinance

398?
What services would the Clarkston refugees like resettlement

agencies to provide in regard to Ordinance 398?
Understanding the culture surrounding tobacco use within Clarkston is

crucial to creating and implementing effective interventions, so the team asked
questions to better understand the current tobacco attitudes of residents and
newly arrived refugees. A community leader provided additional insight into how
people in Clarkston will react to Ordinance 398 and what their needs might be.
Interviewing key informants from local resettlement agencies clarified how these
organizations are preparing for the upcoming Ordinance 398, if at all. Questions
pertaining to organizational resources helped to identify potential assets which are
already available to Clarkstons refugee community for tobacco use and cessation.
By asking organizational resource questions, the team also gained a better
understanding of the current and future collaborations between CPACS and other
agencies in the effort to facilitate the implementation of the Ordinance 398 in the
city of Clarkston. Interviewing public health experts in the Georgia state
government helped us understand the positive potential outcomes of the
implementation of Ordinance 398 regarding potential collaborations and tobacco
34
cessation programs. Having this knowledge may help the stakeholder coordinate
efforts with other agencies and better prepare for the changing needs of the
Clarkston refugee community.
Methods
Sample
The sample included six individuals who have knowledge related to the
tobacco use and cessation, tobacco policy, the refugee community, and the city of
Clarkston. To diversify perspectives, the CNA team sought to gather information
from the multiple levels of need which include three primary stakeholders, one
secondary stakeholder, and two subject matter experts (Table 4).
Table 4: Key informants Interviewed

Category of
Informant
Title
Affiliation
Senior Support Specialist, LMSW

Refugee Resettlement Services
Refugee
Service Agency
Primary
Stakeholder
Health Programs Director, CPACS
Refugee
Service Agency
Primary
Stakeholder
Programs Coordinator, Clarkston

Community Center
Clarkston
Resident
Primary
Stakeholder
Mayor of Clarkston
State
Government
Secondary
Stakeholder
Deputy Director, GA Dept. of

Public Health
State
Government
Subject Matter
Expert
Research Associate, GA Health

Policy Center
State University
Subject Matter
Expert
Procedures
The key informants were recruited at the recommendation of our primary
stakeholder and through purposively reaching out directly to refugee
resettlement agencies, the Georgia Department of Public Health, and officials in
State Government. As the key stakeholder for the Community Needs Assessment
35
(CNA) team, Karuna Ramachandran identified potential key informants from

refugee-serving agencies and also served as a key informant because she is also
an employee of the Center for Pan Asian Community Services (CPACS),
Additionally, the CNA team members used their own connections to find experts
on tobacco use and cessation to interview.
Each selected informant was emailed separately and invited to participate in
an interview in person or by phone. Five informants preferred to be interviewed by
phone, and one informant selected a convenient location for an in-person
interview. Twenty-four hours prior to each interview, the team sent an email
reminder to the participant to confirm the appointment. At the beginning of each
interview, the interviewer explained the purpose of the assessment, summarized
the interview objectives, and asked for permission to record the interview.
Participants were informed that they may stop the interview at any time and may
refuse to answer any question.
Most interviews were conducted with two team members present, one to
conduct the interview using the 19-item interview guide (Appendix A) and the
other to listen and take notes. In two of the interviews, only one team member was
present. After the conclusion of all the interviews, the CNA team engaged in
qualitative data analysis to identify recurring themes and provide more context
into understanding the needs and expectations of the agencies and stakeholders
concerning tobacco use and cessation issues that may arise with the new
ordinance. This allowed for obtaining a more nuanced picture of the needs within
the community.
Analysis
The CNA team engaged in qualitative data analysis by reviewing the
interview notes and listening to the recorded interviews. A thematic analysis was
conducted to gain a better understanding of the data emerging from the
recordings (Salazar, Crosby, & DiClemente, 2015).
36
Those who participated in the interview typed up any handwritten notes

and took additional electronic notes after listening to the interview recording.
Once all the interviews were completed and annotated, every team member read
through the notes and made a list of prominent or recurring themes (Creswell &
Clark, 2011). Prominent quotations that matched each theme were transcribed and
coded. Descriptive codes were used to organize the key informant responses by
themes and categories. For example, smoking cessation resources and opposition
from the business community were both themes that were expressed in multiple
interviews. Cross-interview comments were organized into similar categories to
identify pattern associations and relationships in the themes. Upon completion of
the thematic analyses, audio recordings were destroyed.
Key Informant Results

The CNA team identified three major themes from the key informant
interviews: 1) The Clean Indoor Air Acts health impacts on the health and businesses
of the community of Clarkston, 2) Smoking prevention and cessation needs
throughout the community, both in programs and medical health resources for
smoking cessation, and 3) Availability of community resources, particularly with time
availability, interagency communication, and programs that help people with
smoking cessation.
Theme 1: The Clean Indoor Air Act

All of the interviews confronted the subject of Clarkstons implementation
of the Clean Indoor Act. The most common subjects that arose around this theme
were awareness of the ordinance, the potential health impacts, law enforcement,
and opposition from businesses.
The informants all expressed concern that awareness of the new Clean
Indoor Air Act was low amongst the Clarkston refugee community. In addition,
most informants agreed that awareness was also low to medium amongst refugee
37
resettlement agencies that serve Clarkston. High awareness was only understood
to be the case amongst state government employees, public health workers, and
amongst the business community. Two informants posited that the communitys
low awareness was compounded by a lack of civic engagement. A number of town
hall meetings have been held regarding the ordinance, but community
participation in these events was low. All six informants also admitted that there
was a need for more diversified communication about the ordinance. Most
informants had some ideas about how this could be achieved, including creating
more signage, employing cultural ambassadors to reach out to the community,
and developing more culturally competent educational materials.
The anticipated impacts of the ordinance were unanimously positive by all
of the informants, even as team members probed to discover if anyone could
imagine a negative outcome. The informants all stated that the ordinance will
contribute to reducing the prevalence of smoking in Clarkston and DeKalb County
overall, and will also protect children from the harmful impacts of secondhand
smoke. One informant also expressed the expectation that the ordinance could
help monitor alternative forms of tobacco, specifically gutka, a flavored tobacco of
Indian origin similar to chewing tobacco, but not well-regulated in the United
States and easily obtainable by children and adults. The same informant also
hoped that limiting smoking in public places might inspire people in the
community to change their smoking habits at home and in public spaces to reduce
secondhand smoke exposure to children and pregnant women.
Enforcement was also an important topic in many of the interviews. Most

informants agreed that without consistent enforcement, the ordinance would not
have much of an impact. Some informants were skeptical that the Clarkston Police
Department would prioritize enforcing the anti-smoking ordinance because their
attention is better spent addressing more serious criminal issues. While some
informants imagined that enforcement would largely take place on the streets,
38
others felt that local businesses should be the main sites of enforcement, because
lounges, clubs, and even convenience stores were key locations for selling and
smoking tobacco products. If people cannot access or use tobacco when and
where they want, they will be forced to change their behaviors. As one informant
stated, I don't believe that our refugee clients who smoke will stop unless they
can't get cigarettes [at stores] or they get in trouble [with the police] for smoking."
Many informants also made a point of noting that the opposition to the
ordinance has largely come from the businesses of Clarkston. Businesses that sell
tobacco stand to lose a lot of money through reduced sales and, in the case of
clubs and lounges that cater to smokers, loss of business. One informant
suggested that the notifications to businesses had been very specific on what the
new legal requirements for selling tobacco, but did not go in depth to explain
what purpose the ordinance serves or how it might benefit the community overall.
The Mayor of Clarkston pointed out that a second wave of business opposition
had been recently provoked after the implementation and enforcement of the
ordinance began. While clubs and hookah bars had been made aware of the
ordinance two years ago, many were given time to transition their business
models. Originally registered as restaurants but have made a majority of profits
from selling tobacco products, some businesses have been blindsided by the
apparently sudden change in city policy, such as the Kabu Hookah Lounge which
was visited during the CNA teams windshield survey. However, despite their
awareness of the opposition from local businesses, none of our informants
believed that it was enough to stymie the implementation of the ordinance. One
informant stated adamantly, I am of the mind that whatever we have to do to get
people to stop smoking we have to do, because it is a public health hazard."
Theme 2: Smoking Prevention and Cessation Needs

All six informants discussed smoking prevention needs in some way. Both
informants representing refugee resettlement agencies admitted that their
39
organizations did not provide tobacco cessation-related programming in any way.

The informants all believed that there was a need for better education about
smokings health impacts, and that classes about health and resources for quitting
were both needed in Clarkston. One informant observed, Theres really not much
resources for the refugees to help to stop smokingJust signs, you know, No
Smoking, those are some of the things that you see around, but I have not seen a
really strong campaign like, Stop Smoking: These are the effects, these are the
side effects.
Creating culturally competent materials was a frequent topic. As one
informant stated, "we need to tap into those community champions by educating
them about what [smoking] is and what the benefits are and then once they are
able to buy into it, you can help them communicate that to their group." One
informant also suggested that there was a responsibility to teach recently arrived
refugees about local ordinances such as the Clean Indoor Air Act, because these
kinds of laws are easy to violate by accident and lead to increased negative
encounters with the police. This type of training should be incorporated into other
health information provided to new Americans.
The informants all commented on their perceptions of refugee smoking
behaviors and attitudes. Many informants suggested that refugees feel a low
motivation to quit smoking because it is perceived as a sign of affluence, and
some people do not take the health risks seriously. One informant from the
Clarkston Community Center commented on the ubiquity of smoking in the city,
You drive around and see people smoking. Not even just refugees, but people
who have been there [a long time] and they are smoking. [For some refugees] it's a
habit for them and they came doing it already. Its not something they just
adopted here." On the other hand, another informant pointed out that it would be
a fallacy to assume that all refugees are smokers and that all smokers oppose the
40
ordinance. It was speculated that many Clarkston refugees do not smoke and even
more are in favor of stricter smoking regulations in public places.
In addition to tobacco dependence issues, our informants also commented
on the other challenges facing newly resettled refugees in Clarkston. Language
barriers, finding and keeping a job, and adapting to the urban American lifestyle
were also frequent themes. One informant also mentioned that gang and
interpersonal violence was a problem in Clarkston and went on to say,
"America is a fast country. Its a very fast country. Things are moving so fast
that a lot of the community members are just trying to keep up. Jobs are
not really available for them, and most times they find themselves in jobs
they wouldnt be doing, necessarily, because of the skills that they have. But
simply because they cant speak English they have to work at the chicken
factory or hard labor."
To the same end, the Mayor of Clarkston pointed out that dealing with
these issues can exacerbate a smoking habit, or make smoking seem like less of a
pressing issue in someones life.
Theme 3: Availability of Community Resources

The third theme encompasses the topics covered by the key informants
concerning the opportunities for interagency collaboration and the resources and
assets that already exist in Clarkston. When asked the informants about Clarkstons
assets, the first thing that every informant mentioned was the great diversity in
Clarkston and how that diversity contributes to creating a vibrant community.
According to the Clarkston Community Center informant, Diversity is one thing
the community is really proud of. You come to Clarkston and you meet all sorts of
people, all walks of life. You don't find this everywhere, so it's a small city but
really, really diverse."
41
In addition to diversity, Clarkston also has a number of community

resources that help to improve the quality of life of residents. DeKalb County
Quitline and handout materials from the DeKalb County Board of Health are
specific smoking resources. There are also cessation resources available at local
hospitals, and many resettlement agencies are able to refer clients who are
interested in smoking cessation to the Refugee Health Clinic in Decatur or the
Clarkston Community Center Healthy Living Initiative.
To further promote the health of Clarkston residents, the Community
Center also provides a bike repair and resale program, ESL classes, and a food
pantry. Emphasizing the importance of ongoing support for healthy living, the
Clarkston Community Center informant stated, Clarkston Community
Centerhelps bridge the gap between resettlement agencies and real settlement
and being comfortable. With the refugees moving to country, resettlement
agencies might work with them and help them settle, but after that they still feel
stranded, so we fill the gap. They can come in for programs that we have that help
them navigate the system."
However, it may be the case that important knowledge is not being shared
between refugee resettlement agencies. One of the agency informants stressed
the point that smoking cessation is not a high priority in his organization
compared to other issues. He said, Cessation is not a high priority because of
other needs such as housing, etc. It depends on health of individual. [The agency's]
priorities are higher on Maslow's hierarchy like housing and food. However,
tobacco cessation was a very important issue for the other agency informant, but
she admitted, ...other stakeholders, we don't really know what is being shared
about tobacco, alcohol, other drugs...let alone any other health issue...
While the government informants believed the implementation of
Ordinance 398 was an example of successful collaboration, they may not have
considered resettlement agencies specifically. The informant from the Board of
42
Health stated, Its one of the best examples we have of the national, the state, the
health district, and the local community-based organizations collaborating on
something that is going to improve the health of citizens.
ONLINE CLARKSTON TOBACCO ASSESSMENT

The following section outlines the purpose and procedures used to collect
and analyze primary data from the Clarkston Tobacco Assessment, a survey
evaluating tobacco prevention and cessation services available to newly arrived
refugees. Findings from this data collection method supplemented the findings from
the key informant interviews, community profile, windshield survey, and literature
review to inform the thematic analysis and recommendations to the Center for Pan
Asian Community Services (CPACS).
Purpose
The survey was created to gain a diverse perspective on the needs of newlyarrived refugees who use tobacco products and available services to address the
upcoming implementation of the Clean Indoor Air Act (Ordinance 398) in Clarkston,
GA. The main focus of this survey was to glean what tobacco-related prevention
programs are currently available and the perceived gaps in available programs in
preparation for the Clean Indoor Air Act. The key questions used to guide the survey
are as follows:
1. What tobacco use services are being offered for newly arrived refugees by
Clarkston organizations?
2. To what extent are current tobacco use programs offered to newly arrived
refugees adequately addressing their tobacco prevention and cessation
needs?
3. How can available resources for newly arrived refugees who use tobacco
products be improved or expanded?
43
Methods
Sample & Recruitment
The populations sampled for this survey are those who assist the Clarkston
refugee community with tobacco prevention or community leaders who have
knowledge about tobacco use in Clarkston. All survey participants were required to
work directly or indirectly with the Clarkston refugee population and have
knowledge about tobacco product use in Clarkston and/or the needs of newly
arrived refugees. The CNA team used convenience and snowball sampling. This was
accomplished by emailing the survey to key informants after their interviews. For
ease, key informants were given a brief description of the purpose and a link to the
online survey to be share with their colleagues. Contacts of Karuna Ramachandran of
CPACS and internal contacts of the CNA team were also forwarded the survey link.
Snowball sampling was accomplished by providing those who completed the survey
an opportunity to suggest others for the survey. The contact information of survey
participants and suggested survey participants were kept in a protected Google
spreadsheet. This allows team members to contact potential participants and to
thank completed participants.
Procedure
There are a total of 24 items with a variation of open-ended, multiple choice,
rating, and Likert scale questions. The survey was designed to last approximately 1015 minutes. Participants were not given an incentive for completing the survey. To
protect participant anonymity, all survey responses were de-identified. Name, job
title, and organization name were separated from responses during final data
analysis and reporting of results. Anonymity encouraged honest responses regarding
evaluation of tobacco cessation programs and resources. As a major purpose of the
community needs assessment was to assess organization resources, participants
could agree to have their information compiled into a list for future partnership. The
list of contacts was not linked to participant responses.
44
Instrument
The 24 survey items were separated into four sections: demographics,
evaluation of programs, gaps, and contact information (Appendix B). Demographic
questions collected information regarding the survey participants associated
organization, education level, area of residence, race/ethnicity, and country of origin.
The section of evaluation of programs consists of two subsections: 1) current
state of programs and 2) the assessment of current programs and community needs.
These questions were designed to collect information about respondents
organizations including what tobacco services their organization provide and who
they work with in the community around health and tobacco use. This section also
allowed responders to provide their opinion regarding clean air legislation and how
they think the community views such legislation. Additionally, this part of the survey
provided an opportunity for survey participants to give feedback on which locations
are important to target for tobacco cessation materials and what resources are, or
are not, meeting the needs of the refugee population regarding tobacco cessation.
The section addressing gaps in resources was designed to gain perspective
about resources needed for tobacco prevention and cessation and gaps in
community knowledge about the Clean Air Ordinance. In the last section, contact
information was gathered and referrals for additional participants were requested.
Data Analysis and Management

All surveys were numbered in a serial order (1, 2, 3, etc.). Using the Google
response summary application, the CNA team analyzed rating, multiple choice, Likert
scale, and open-ended questions to determine the number and frequencies of
responses. Percentages and response counts were reported in the results section.
Additionally, a thematic analysis was used on open-ended questions. Two team
members read the open-ended responses thoroughly, and made a list of prominent
or repeating keywords. This sorting was done to identify pattern associations and
relationships between keywords. A comprehensive list of Clarkston community
45
resources was compiled into a table for stakeholder use. Data findings were used
alongside results from the key informant interviews during triangulation and to
ultimately inform the final recommendations given to CPACS.
Survey Results
Demographics
Data were collected between the dates of October 15th, 2016 to November
18th, 2016. A total of 16 respondents completed the survey. One survey participant
was removed from the data as they did not meet the criteria of working directly or
indirectly with the Clarkston refugee population. Among the eligible respondents,
86.7% (n=13) were associated with a refugee-service agency. All other survey
respondents were associated with public health agencies (n=2). The table below lists
the organizations survey participants were associated with (Table 5). Regarding
education attainment, 46.7% (n=7) of the sample was a college graduate, 46.7%
(n=7) had a post-graduate/professional degree, and 6.7% (n=1) had some college.
Among the sample, 20% (n=3) lived in
the City of Clarkston. All other
respondents lived in the Atlanta
metropolitan area. One respondent
reported their country of origin as
Somalia, while the remainder 14
respondents reported being born in the
Table 5: Organizations of Respondents

Respondents Associated Organizations
1.
2.
3.
4.
5.
6.
Catholic Charities
Friends of Refugees
Lutheran Services of Georgia
New American Pathways
Somalia ACC
World Relief
United States. Furthermore, a majority of respondents parents were born in the

United States (n=11). Two respondents parents were born in the Philippines, one
individual had parents who were born in Germany, and another had parents born in
Somalia.
46
Evaluation of Programs
Current State of Programs
A majority of organizations provide referral services for tobacco cessation to
Clarkston refugees (39%). The other top service provided is pamphlets and brochures
about tobacco cessation services; 13% of organization offer pamphlets and
brochures and 13% report offering multilingual pamphlets and brochures. There
were no reported offerings of tobacco cessation and health workshops, free tobacco
cessation aids, or purchasable tobacco cessation aids among the organization. Figure
12 displays the type and proportion of services offered by respondents associated
organizations. Survey participants reported the top services offered outside their
organization are referral services, pamphlets and brochures about tobacco cessation
services, community health fairs, and counseling. Respondents included tobacco
cessation and health workshops, free tobacco cessation aids, and purchasable
tobacco cessation as being offered outside their organization (Figure 13).
Tobacco Services Offered by Organizations

Referral Services
6%
6%
Counseling
10%
39%
Pamphlets/brochures
Multilingual
pamphlets/brochures
Community health fairs
3%
13%
13%
10%
Youth tobacco
prevention education
Adult tobacco prevention
education
Other
Figure 12. Tobacco cessation and prevention services offered by

organizations.
47
Tobacco Services Offered Outside

Origanizations
Referral Services
Counseling
Pamphlets/brochures
7%
5%
5%
Multilingual
pamphlets/brochures
23%
Community health fair
4%
2%
Youth tobacco prevention

education
4%
11%
Adult tobacco prevention

education
Other
14%
16%
9%
Tobacco cessation and

health workshops
Free tobacco cessation aids
Purchasable tobacco
cessation aids
Figure 13. Respondents knowledge of tobacco services offered

outside their organization.
Survey participants were asked about other agencies or organizations that
focus on health or tobacco in the Clarkston community. CPACS and Sagal Radio were
noted twice as agencies or organizations that focus on health or tobacco in the
Clarkston. One individual reported the Clarkston Community Center as focusing on
tobacco or health. Additionally, three respondents noted that no organizations or
agencies focus on health or tobacco and one respondent said they could not think of
the names of the organizations. Two respondents reported working with CPACS.
Others noted partnering with Women Watch Africa, community organizations, and
48
the coalition of refugee service agencies. One individual noted not partnering with
any other organizations.
Assessment of Current Programs & Needs

The survey participants listed free tobacco cessation aids, multilingual
pamphlets and brochures and purchasable tobacco aids as the top three unmet
needs of the Clarkston refugee population. Nine survey participants reported free
tobacco cessation aids and multilingual pamphlets as unmet needs. Regarding
purchasable tobacco cessation aids, seven respondents noted this type of service as
not meeting tobacco resource needs. Community health fairs were marked as the
resource meeting the most needs; three respondents reported health fairs as
somewhat meeting needs for the Clarkston community. Figure 14 provides a list of
all the resources and depicts how many individuals viewed these services as meeting,
or not meeting, Clarkston refugee tobacco prevention and cessation needs.
Meeting Needs for Clarkston Refugees

Purchasable tobacco cessation aids
Free tobacco cessation aids
Multilingual pamphlets/brochures
Pamphlets/brochures
Tobacco cessation workshops
Adult health education
Youth tobacco health education
Health education sessions/workshops
Counseling
Referral services
0
Meeting Needs
10
12
Not Meeting Needs
Figure 14. Resources are ranked based on meeting needs.

49
66.7% (n=10) reported second-hand smoke as a serious health hazard, 26.7%

(n=4) thought second-hand smoke was a moderate health hazard and 6.7% (n=1)
thought it was not a health hazard. All survey participants supported smoke-free
places such as restaurants, bars, hotels, and worksites. When asked how the
Clarkston community viewed exposure to second-hand smoke, 6.7% (n=1) thought
the community viewed it as a serious health hazard, 26.7% (n=4) thought the
community viewed it as a moderate health hazard and 26.7% (n=4) thought the
Clarkston community did not view it as a health hazard. Forty percent (n=6) thought
the community was unsure of the health impact of second-hand smoke. A majority
of respondents reported being unsure if the Clarkston community supported smokefree places (53.3%, n=8), while 33.3% (n=5) reported thinking the Clarkston
community supported smoke-free places and 13.3% (n=2) reported thinking the
community did not support smoke-free places. Figure 15 displays respondents
personal views of second-hand smoke and their perceptions of how the Clarkston
community views second-hand smoke.
Health Impact of Second-hand Smoke

12
10
8
Serious health hazard
6
Moderate health hazard

Not a health hazard
Unsure of the health impact
Respondents' view of
second-hand smoke
Clarkston community view

of second-hand smoke
Figure 15. Opinions about health impacts of second-hand smoke

50
Respondents rated how important they thought each of the provided venues
would be for targeting tobacco cessation programs. The top four locations reported
were: community centers, schools, health clinics/doctors offices, and hospitals
(Figure 16). The other top ranked venues were churches, refugee resettlement
agency offices, and bus stops. On the provided other section, two participants
wrote in apartment complexes as an additional location to target tobacco cessation
resources. Survey participants were then asked about factors would help decrease
the use of tobacco products in Clarkston. Education and knowledge were listed as
top factors (Figure 17). These were followed by services to address mental health and
methods to cope with stress and increased cigarette prices.
Figure 16. Locations to target cessation programs
Figure 17. Factors to help decrease tobacco product use

51
Gaps in Resources
There were several themes around the types of programs or resources needed
for reducing tobacco use among Clarkstons newly arrived refugees. Themes
included education, broad public outreach, multilingual tools, high cigarette tax, and
cessation resources. One person noted, refugees are too preoccupied with other
matters to focus on long-term health. Respondents were then asked what resources
would aid their organization in preparing for the Clean Indoor Air Act. Among the six
individuals who provided a response, a majority reported education materials in
different languages as resources needed to better prepare for implementation of the
ordinance. When asked how much respondents have heard or read about the Clean
Indoor Air Act in Clarkston, most respondents reported not having heard or read
anything about the Clean Indoor Air Act in Clarkston (53.3%, n=8). Twenty percent
(n=3) noted not having heard or read much, while 13.3% (n=2) and 13.3% (n=2)
reported having read or heard some or a great deal about the ordinance (Figure 18).
Awareness of Clean Indoor Air Act
13%
Nothing at
all
Not much
13%
Some
54%
20%
Figure 18. Proportion of respondents who have or have not heard or

read about the Clean Indoor Air Act in Clarkston
52
DATA TRIANGULATION
Once the observational (windshield), qualitative (interviews), and quantitative
(surveys) data were collected and analyzed, the team completed the data
triangulation. Because both qualitative and quantitative data had small sample sizes
of n=15 or less, aggregation of all five sources of evidence, including the literature
review and community profile, was crucial in order to properly triangulate the data
for recommendations and priorities.
The windshield survey allowed for an immersive, broad look into Clarkston as
a city and a social structure. An in-person survey of the community and city gave
tangible insight into the business opposition against the ordinance and smoking
norms for different cultures. Multiple themes were found to be recurrent within the
qualitative key informant interviews that were also common across the four other
evidence sources. The quantitative surveys confirmed several themes found in the
interviews such as the need for additional tobacco health education and the need for
agency collaboration.
Both the literature review and community profile supported many of the
themes that emerged from primary data collection, providing wide perspectives into
indoor air ordinances, refugee health with tobacco use, and Clarkston social services
and demographics.
After all the data was analyzed, all possible themes from the five evidence
sources were compiled. An iterative process was performed to narrow, revise and,
validate the final three themes with three additional sub-themes (Table 6). From the
final list of themes and sub-themes, priorities and recommendations were developed
and measured in importance and feasibility.
53
Table 6: Data triangulation of themes using sources of evidence
Sources of Evidence
Literature
Review
Community
Profile

Low Awareness
Opposition from
businesses
X
X
Positive health
impacts
Smoking Prevention and Cessation Needs
Need for additional
tobacco health
education
Insufficient cessation
resources
X
Cultural norms
Availability of Community Resources
X
Agency assets
X
Community assets
Need for
collaboration
Windshield
Key
Online
Survey
Informant Survey
Interviews
X
X
X
X
X
X
X
X

This theme encompasses lack of awareness and effects of the implementation
and enforcement of the Clean Indoor Air Act. Both interview and survey participants
reported overall low awareness of the Indoor Air Act for themselves. It was also
believed that the Clarkston community and refugee agencies also had little
awareness of the ordinance and its potential effects. Many either did not know what
the ordinance was, what it specifically addressed, or that it was passed earlier in the
year, which many attributed to lack of signage and education.
Another subtheme was the opposition of businesses. A common belief was
that certain businesses, such as clubs or hookah lounges, opposed the ordinance
54
because it could potential impact their profits. One informant said, [The ordinance]
costs the business. Some of them are completely dependent on hookah sales, so
they are going to have to come up with something new by 2018thats the bottom
line for them. Additionally, during the windshield survey, there was an encounter
with a hookah lounge business owner who thought that the ordinance was unfair
and was costing him all his business.
However, support for the ordinance also stems from the potentially positive
health impacts. Evidence from the literature review and community profile showed
that indoor air ordinances would reduce smoking prevalence and exposure to
secondhand smoke. Those interviewed specifically thought that this ordinance would
reduce secondhand smoke exposure for kids. Furthermore, 100% of surveys thought
that exposure to secondhand smoke was a moderate to serious health hazard.
Smoking Prevention and Cessation Needs

This theme focuses on what areas of smoking prevention need resources and
current cultural norms in regards to tobacco use and cessation. Those who were
interviewed and surveyed believed that there was a need for additional health
education related to tobacco use and cessation. Sixty-four percent of those surveyed
requested classes or workshops about health and smoking, such as creating
education programs for refugees coming to America. Some of the interview
participants offered suggestions for what these programs and materials might look
like and how they could be disseminated. For example, these programs could be
developed with support from community champions, who could then assist in
diffusing the knowledge to others in Clarkston.
The windshield survey, interviews, and surveys also showed a lack of cessation
resources. Those who were surveyed or interviewed displayed little or no knowledge

of current programs, clinics, hotlines, or general resources for tobacco cessation.
There were mentions of the DeKalb County Quitline, the refugee clinic in Decatur,
55
and the Clarkston Community Center as potential referrals and resources. During the
windshield survey, no signage or services related to smoking and/or tobacco use
were identified, while retail outlets for tobacco products were quite common.
The final subtheme was the cultural smoking norms of incoming and current
refugees. Interviewees believed that many refugees had low motivation to quit as
there was a perception of smoking as a sign of affluence. Other suggested that
smoking is a stress reliever, and given the other challenges faced by recently arrived
refugees, smoking cessation was a low priority. The literature stated that depending
on their country of origin, refugees might arrive as established smokers, so they may
continue smoking as a way to socialize or stay in touch with their culture. Multiple
informants said that it was culturally naive to assume all refugees smoke and, thus,
oppose the ordinance. Overall, there was agreement from the windshield survey,
interviews, and literature review that smoking could be an established cultural norm
as well as an addictive behavior that may complicate cessation and prevention.
Availability of Community Resources

This theme identifies current community and agency assets and leveraging
those for collaboration. Repeatedly, the diversity in Clarkston was mentioned as an

asset to the community. The variety of ethnicities, races, religions, ages, etc. was seen
during the windshield survey and expanded upon in the community profile.
Additionally, there are several resources within the community such as the Clarkston
Community Center. The Center has English as a Second Language (ESL) classes, after
school programs, a food pantry, computer courses, and more programs for all of the
Clarkston community including refugees.
Another sub-theme is agency assets. The community profile, interviews, and
surveys showed that smoking cessation is not a high priority for refugee agencies
compared to other issues. Survey results showed that there was a perception that
refugee agencies helped their clients in many ways, but tobacco cessation resources
56
were not a top priority. The community profile noted that the focus of these
agencies is to help the refugees settle, but not necessarily for the long-term which is
how long tobacco cessation may take. One of the agency informants said, Cessation
is not a high priority because of other needs such as housing, etc. It depends on
health of individual.
Additionally, interviews and surveys showed that there are challenges to
increasing interagency collaboration. One of the agency informants said, [For] other
stakeholders, we dont really know what is being shared about tobacco, alcohol,
other drugslet alone any other health issue [or] how it is being shared. If refugee
agencies are able to communicate more effectively and possibly collaborate, it could
provide opportunities to operationalize and share available resources for tobacco
cessation in the Clarkston community. However, 58% of survey respondents
requested to not be on a resource list for future partnerships. This finding suggests
that the challenge of increasing collaboration is both a matter of building
collaborations with other agencies, and of convincing other agencies that the
collaboration is worthwhile and needed.
RECOMMENDATIONS
After triangulating the primary and secondary data collection, the CNA team
has created recommendations for CPACS programs concerning the impacts of the
new smoking ordinance in Clarkston, GA and steps the agency can take to make the
implantation of the ordinance smooth and successful. These recommendations have
been categorized by their priority level and feasibility. In addition to priority and
feasibility, the CNA team has separated the recommendations in short-term, midrange, and long-term recommendation categories. Table 7 below provides a visual
representation of the recommendation according to their priority and feasibility. The
CNA team suggests that CPACS first addresses the high feasibility and high priority
57
recommendations and then move forward to addressing recommendations with

lower priority and feasibility levels.
Table 7: Recommendations for CPACS

High Priority
High Feasibility
Low
Feasibility
Create and distribute multilingual

brochures and flyers for tobacco
cessation.
Create and distribute multilingual
brochures and flyers for the Clean
Indoor Air Act ordinance.
Potentially with Rollins curriculum class
to create standardize smoking cessation
curriculum.
Create a webpage at CPACS to provide
information on tobacco cessation and
the ordinance
Radio Sagal announcement about
smoking cessation curriculum and
information about the ordinance.
Low Priority
Create interagency
listserv for monthly
newsletters.
Develop an
interagency website
dedicated to
smoking cessation
resources that all
agencies can work
with.
Improve communication between

refugee agencies (streamline referral
system, invite to coalitions, quarterly
town hall meetings)
Short-Term Recommendations (High Priority/High Feasibility)

1. Information about the Clean Indoor Air Act and tobacco cessation should
be distributed through multilingual brochures and flyers at diverse

community locations. After analyzing our interviews and surveys, the data
revealed that there is very limited communication to the refugees and
permanent community members about smoking cessation and the ordinance.
There were many people interviewed or surveyed who were uninformed
about the ordinance and therefore could not properly and effectively
communicate to the people they serve as well as their colleagues and
58
community leaders. In addition, there should be more communication about

the ordinance overall. According to our data, there is limited understanding as
to when the ordinance goes into effect and what are the rules and
repercussions as a result of its implementation. Agency employees and
community leaders have expressed that their knowledge about what goes
into the ordinance is quite limited and they would like to know more so they
can better inform the refugees and other people they interact. These materials
can be distributed at community center, churches, and health fairs.
2. CPACS should create or adapt a standardized smoking cessation
curriculum and use evidence based smoking cessation resources. CPACS

could partner with Rollins School of Public Healths Behavioral Science and
Health Education (BSHE) 522 Principles of Curriculum and Instruction in
Health Education class to develop a standardized, evidence based curriculum
about smoking cessation and the ordinance rules and guidelines for incoming
refugees. By creating a program, CPACS could bridge the information gap
that was found during the CNA teams triangulation of the primary and
secondary data. This program could be piloted at CPACS and then could be
used as a standardized curriculum that other refugee agencies could use.
Since Clarkston is a heavily diverse population with multiple cultures and
languages, this program would have to be all inclusive and accessible for this
range of population. The use of a single curriculum across multiple agencies
would benefit the refugees by delivering a consistent message and it would
foster much needed communication among the refugee agencies.
3. Create a web page at CPACS to provide information on tobacco cessation
and the ordinance. A major concern of found throughout the key informant
interviews and online survey was to have more access of information. Along
with the multilingual brochures, having a webpage with information on
smoking cessation resources, tips to quit, and overall detailed information on
the ordinance would help consolidate information in an easy to access
59
location. The web page could be an all-encompassing resource list available

to anyone looking for resources about tobacco cessation or the ordinance.
4. Inform the community about the ordinance through Sagal Radio
advertisements. The CNA team learned during the data analysis that
refugees in Clarkston predominantly receive information about Clarkston
through the local radio station, Senegal Radio. In order to get information
about the ordinance to the community, paying for an advertisement or a free
public service announcement through this resource would be an effective way
to increase the knowledge about the ordinance. In addition, this resource
could be used for marketing for the tobacco cessation program mentioned in
the short term recommendation section.
Mid-Range Recommendations (High Priority/Low Feasibility)

1. Improve communication between refugee agencies in Clarkston. During
the triangulation of the data, the CNA team determined that there is very little
communication among the refugee agencies that are serving Clarkston
around the issue of tobacco or secondhand smoke. It would be beneficial if
there was a monthly or bimonthly town hall meeting where the agencies
could connect and work together. This would create an overarching service
that would not duplicate efforts and make the work being done more
effective. After speaking with and surveying people about smoking cessation
and the ordinance in Clarkston, the CNA team learned that there is currently
not a consistent way of referring people who want to quit smoking to the
proper resources. If there was a streamline smoking cessation referral system
that all agencies used, there would be less confusion among the agencies and
the refugees who use their services.
60
Long-Term Recommendations (Low Priority/ High Feasibility)

1. Create an interagency list serve for monthly newsletters or other method
of communication. The data showed that there is little motivation among

agency staff to create a listserv that would email them monthly newsletters or
provide a venue for open communication because of the limited time and
overwhelming number of emails people are receiving already. Although this is
viewed as a low priority among the agencies, the CNA team has determined
that there is a significant need for this type of open and accessible
communication among the agencies. Many of the barriers of working
together stem from the lack of communication and this highly feasible
approach could create an environment where collaboration exists.
2. Develop an interagency website dedicated to smoking cessation

resources.
Many respondents claimed that there was no place they could refer refugees
to for smoking cessation resources. This website could be the resource the
refugees and residents need to permanently stop smoking by providing
comprehensive resources. These resources would include the online version
and in class version of the smoking cessation curriculum, a list of smoking
cessation resources available throughout the Clarkston community, helpline
contacts, health information, and tip and tricks to help people quick smoking.
In addition to an online curriculum, in person classes could be taught at
CPACS or the Clarkston Community. The development of this website could
also help address some of the aforementioned recommendations such as, the
streamline smoking cessation referral system and the smoking cessation
curriculum given to refugees when they first enter Clarkston.
61
LIMITATIONS
There are a number of limitations that should be considered that presented
themselves during the assessment of the implementation of the ordinance and
smoking cessation in Clarkston, GA. Most importantly, there are limitations due to
time constraints, generalizability and potential bias from interviews and surveys. The
project was conducted during the fall semester of 2016, resulting in a semester of
part time work allotted for this assessment. Broken down by sections, the team
developed the assessment, conducted a literature review, and collected and analyzed
the data in a little over two months. The assessment could have been more thorough
if the team member had more time, such as a year of full time work, to dedicate to
assessing the needs of this community. In addition, the time constraints of our key
informants should be noted. Since this field of work is strenuous and time
consuming, our key informants had tough schedules to work around and access was
significantly limited. This time constraint on the team and the key informants led to
the other limitations, generalizability and possible bias.
The CNA team conducted six key informant interviews that could potentially
limit the generalizability of the assessment, because of the limited sample size, their
informants limited time to meet, and the topic of the questions. Additionally, there
were a very limited number of survey responders that could add to the lack of
generalizability. Since these informants predominately work for refugee agencies in
Clarkston, their self-reported responses and possible social desirability could lead to
bias. Since the survey conducted for our secondary data were conducted through
snowball sampling, the people responding could also work for the agencies. Also,
the survey was emailed out by some of our key informants, including our
stakeholder, which could possibly increase the potential bias introduced by social
desirability. These people who work with or for the key informants may want to
represent their views in a way that does not make themselves or employers
perceived negatively.
62
LESSONS LEARNED
The CNA team learned how difficult it can be to access vulnerable populations
and the organizations that serve them. The assessment also taught the team about
the importance of following up and being flexible. Communication is one of the
most important skills to have when working with a community. This assessment was
beneficial in teaching the team how to effectively communicate with agencies and
community members in order to develop appropriate recommendations. The proper
communication techniques, either by phone, email, or in person, are important to
maintaining a positive rapport that will result in effective and productive work. The
windshield survey, in particular, taught the team about time management,
scheduling conflicts, and availability of community members, businesses, and the
refugee agencies. This assessment allowed them to grow as health practitioners and
improve on our public health skills out in the field.
CONCLUSION
The purpose of this needs assessment was to determine how organizations
providing services to newly arrived refugees in Clarkston, GA were preparing for the
implementation of Ordinance 398 (Clean Indoor Air Act). The CNA team assessed the
tobacco education and services provided by the organizations and the opportunities
for collaboration with CPACS.
Primary and secondary data collection methods were used to address the
community needs assessment questions, which related to tobacco prevention and
cessation resources available to newly arrived refugees from local organization, the
anticipated impacts of Ordinance 398, and partnership between CPACS with other
organizations to fill in the education and service gap concerning the upcoming
tobacco products use ordinance.
63
To identify recurring themes, the CNA conducted the data triangulation with
the survey and key informant interviews data collected. The following themes were
identified as important areas of improvement: 1) Clean Indoor Air Act, 2) smoking
prevention needs, and 3) available resources.
These themes were the basis to make recommendations for CPACS programs
regarding the impacts of the new smoking ordinance in Clarkston, GA and steps that
the agency can take to make the implementation of the ordinance smooth and
successful. The CNA team prioritized the recommendations by their priority level and
feasibility. In addition to priority and feasibility, recommendations were separated
into short-term, mid-range, and long-term recommendation categories.
It is suggested that CPACS first address the high feasibility and high priority
recommendations and then move forward to addressing recommendations with
lower priority and feasibility levels. The CNA team believes that CPACS will use these
recommendations to assist the refugees and Clarkston community during the
implementation of Ordinance 398 (Clean Indoor Air Act).
64
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10, 2016 from
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1 411.cfm
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from http://georgia.hometownlocator.com/schools/sorted-by-cities,c,clarkston.cfm
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Arabs and Chaldeans. J Immigr Minor Health, 16(3), 501-507. doi:10.1007/s10903-0139772-1
John, W.S. & Clarkston, G. (2007). The World Comes to Georgia, and an Old Church Adapts. The
New York Times. Retrieved October 11, 2016 from
http://www.nytimes.com/2007/09/22/us/22church.html
Koh, H. K. (2014). It shouldn't take another 50 years: Accelerating momentum to end the tobacco
epidemic. Clinical Cancer Research, 20, 1719-1720.
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among adults in the United States: Cigarettes, cigars, electronic cigarettes, hookah,
smokeless tobacco, and snus. Preventive Medicine, 62, 14-19.
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APPENDICES
List of Appendices
Appendix Description
Page Number
A: Key Informant Interview Guide
75
B: Online Clarkston Tobacco Assessment
77
APPENDIX A: Key Informant Interview Guide

Thank you for agreeing to do this interview today. We are students from Rollins
School of Public Health conducting a community needs assessment with Center of Pan
Asian Community Services to better understand the resources provided to newly arrived
refugees in Clarkston regarding tobacco product use, cessation, and community policies.
We are also collecting information on the perception of the community and the impact of
the upcoming Clean Indoor Air law in Clarkston. This law will prohibit smoking in public
spaces, such as parks, as well as indoor public spaces such as businesses. We will be using
the information gathered from this interview today in a final report to be presented to the
Center of Pan Asian Community Services. The final report will outline tobacco product
use and cessation in order for the Center Pan Asian Community Services to prepare for the
upcoming Ordinance 398. We will be taking notes during the interview, however we
would also like to ask your permission to record the interview session.
Do you consent to an audio recording of the interview?
If you do not wish to be identified in our report, please let us know.
Opening Questions
First, we would like to begin by asking you some questions about your job position in this
organization.
1. What is your current job position?
a. How long have you held this position?
b. What does your agency do in relation to the Clarkston community?
(Services offered in general)
2. Please talk briefly about your experience and role within the Clarkston community.
68
a. What are issues facing refugees in Clarkston community?

b. What do you think the Clarkston community is proud of?
Tobacco Behaviors of Clarkston Refugees and Residents
3. How common is tobacco use in Clarkston?
a. Where are people using tobacco use in Clarkston?
b. What forms of tobacco are people using?
4. Do you think smoking a pressing issue for refugees in Georgia?
5. Do you think refugees are aware of the health risks associated with smoking?
a. If so, how did they learn?
Organizational Resources
6. What tobacco product use and cessation resources does your organization provide
for refugees?
a. What has been the community response?
b. Do you have good results with the materials?
7. Do you know of other tobacco cessation resources in the Clarkston community?
a. If yes, what and where are they?
8. What obstacles are you currently facing with reducing tobacco use in Clarkston?
a. Why are those obstacles?
Impacts of Tobacco Policy
9. To what extent do you think the community and refugee organizations are aware of
the smoking restriction ordinance?
a. What could help increase awareness of the ordinance?
10. What are some health impacts that might result from the smoking restriction
ordinance?
a. b. What are some other impacts?
11. Do you think people will follow the smoking ordinance?
a. b. What about businesses or the people who sell cigarettes or tobacco
products?
12. Do you think local law enforcement will be able to enforce the ordinance?
13. What kind of public support is there for the ordinance?
a. Who, or what groups, are supportive of it? How have they shown this
support?
69
i. Why are they supportive of it?

b. Are there people or groups who oppose the ordinance?
i. Why are they opposing it?
Wrap-up/Final questions
We are just about done with the interview questions. Do you have any last comments or
questions you would like to ask or say?
Thank you for your time and participation in this interview. The information that you
provided to us will be very helpful in this needs assessment.
APPENDIX B: Online Clarkston Tobacco Assessment

The purpose of this survey is to assess the tobacco prevention and cessation services
being provided to newly-arrived refugees in Clarkston in order to address the 2018 Clean
Indoor Air Act. This ordinance prohibits smoking inside public locations and businesses in
the City of Clarkston. Thank you for taking time to complete this questionnaire.
Taking this survey is completely voluntary and you are not required to answer any
question you do not feel comfortable addressing. This survey is designed to last 10-15
minutes. Although we ask for your contact information at the end of the survey, all responses
will be de-identified for the data analysis and final reporting. This is done in attempt to keep
your responses anonymous to encourage honest feedback. If you would like your contact
information to be compiled into a resource list for future use, please indicate so on the final
question.
Demographic
What type of organization are you associated with?
Dropdown: Refugee-service agency, clinic or hospital, food service, business
owner, school, other
For other, please specify (short answer)
What is the main focus of your organization?
Short answer: e.g. organizational goals or purpose
What is your level of education?
Dropdown: Some high school, high school graduate, some college, college
graduate, post-graduate/professional, other
70

What area of Atlanta do you live?
Short answer
What is your country of origin?
Short answer
What racial/ethnic category would you consider yourself to be in?
Dropdown: White Non-Hispanic, Latino, African American/Black, Asian,
Native American, Hawaiian/Pacific Islander, Other
Evaluation of Programs
Current State of Programs
What programs does your organization offer to newly arrived refugees who use
tobacco products?
Select all that apply: Referral services, counseling, health education sessions
and/or workshops, pamphlets/brochures, multilingual pamphlets/brochures,
free tobacco cessation aids (such as nicotine gum), purchasable tobacco
cessation aids (such as nicotine gum), community health fairs, youth tobacco
prevention education, adult tobacco prevention education, other
Can you describe anything more about these programs?
Short answer
Based on your knowledge, what types of services outside of your organization are
available to newly arrived refugees who use tobacco products in Clarkston?
Select all that apply: Referral services, counseling, health education sessions
and/or workshops, pamphlets/brochures, multilingual pamphlets/brochures,
free tobacco cessation aids (such as nicotine gum), purchasable tobacco
cessation aids (such as nicotine gum), youth tobacco prevention education,
adult tobacco prevention education, community health fairs, other
What organizations do you partner with for your activities?
Short answer
71
What other agencies do you know that focuses on health or tobacco in the Clarkston
community?
Short answer
Assessment of Current Programs & Needs
In general, do you feel exposure to second-hand smoke is:

o Dropdown: a serious health hazard, a moderate health hazard, a minor health
hazard, or not a health hazard at all, unsure
Do you support smoke-free places such as restaurants, bars, hotels, and worksites?
o Dropdown: Yes, No, Unsure
In general, do you think the Clarkston community views exposure to second-hand

smoke as:
o Dropdown: a serious health hazard, a moderate health hazard, a minor health
hazard, or not a health hazard at all, unsure
Do you think the Clarkston community supports smoke-free places such as

restaurants, bars, hotels, and worksites?
o Dropdown: Yes, No, Unsure
The following questions will be answered through a linear scale with 1 being Not
Important and 5 being Very Important. Please rate how important you think each of
these venues would be for targeting tobacco cessation programs among the Clarkston
refugee community.
Hookah lounges
Bars
Restaurants
Community centers
Parks
Churches
Community gardens
Schools
Health clinics/doctors offices
Hospitals
Grocery stores
Dollar stores
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Bus stops
Refugee resettlement agency offices
Gas stations
Please list other needs not listed above. (short answer)
In your opinion, what factors would make a difference in decreasing the use of
tobacco products in Clarkston?
Short answer
The following questions will be answered through a linear scale with 1 being Not
meeting the needs and 5 being Fully meeting the needs. Please rate how well the
following types of programs are meeting the needs of the Clarkston refugee
community:
Referral services for tobacco cessation
Tobacco cessation counseling
Tobacco health education for youth
Tobacco health education of adults
Tobacco cessation workshops
Pamphlets/brochures about tobacco cessation services
Multilingual pamphlets/brochures about tobacco cessation services
Free tobacco cessation aids (such as nicotine gum)
Purchasable tobacco cessation aids (such as nicotine gum)
Please list other needs not listed above. (short answer)
Gaps in Resources
What type of programs or resources, if any, would be useful to address the tobacco
use needs among Clarkstons newly arrived refugees?
Short answer
How much, if anything, would you say you have heard or read about the Clarkston
Clean Indoor Air ordinance that prohibits smoking in indoor public places such as
workplaces, public buildings, offices, restaurants and bars?
o Dropdown: a great deal, some, not too much, nothing at all
What resources does your organization/business need to better prepare for the
implementation of the Clean Indoor Air ordinance in Clarkston? This ordinance
prohibits smoking inside public locations and businesses in the City of Clarkston.
Short answer
73
Contact Information
If youre comfortable doing so, please provide your contact information. This
information will not be linked to your responses during final analysis and reporting.
Name:
Organization Name:
Job Title:
Email:
Phone Number:
Would you like your information to be compiled into a resource list for future
partnership among local organizations?
Categorical: Yes/No
Can you recommend anyone else to participate in this survey who might have insight
on the topic?
Short answer: Please provide name and e-mail address
74

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Tobacco Control and

Resources for Refugees

Recommendations were generated based on three major themes: 1) Clean

1: Country of Origin for Refugees Arriving in Clarkston,

2. Regions of Birth of Foreign Born Clarkston Residents

3: Employment by Industry of Residents in the City of

4: Key Informants Interviewed

6: Data Triangulation of Themes Using Sources of Evidence

7: Recommendations for CPACS

2: CPACS Mobility Shuttle Route

3: CPACS Service Chart

6: World Relief Front Entrance

8: Baseball Field Behind Milam Park Pool Center

9: The Clarkston Community Center

10: Clarkston Community Center Activity Field

11: Kabu Hookah Lounge

12: Tobacco Services Offered by Organizations

13: Tobacco Services Offered Outside Organization

14: Meeting Needs for Clarkston Refugees

15: Opinions About Health Impacts of Secondhand Smoke

16: Locations to Target Cessation Programs

17: Factors to Decrease Tobacco Product Use

18: Awareness of Clean Indoor Air Ordinance

Purpose of the Community Assessment

Center for Pan Asian Community Services:

Figure 1: CPACS and Cosmo Health locations in

Figure 2: The CPACS Mobility Shuttle route on

Figure 3: CPACS service chart, based on data from CPACS

Clean Indoor Air Act

U.S. Refugee Populations

Tobacco Use among Refugees

% using tobacco daily, 2013a

Democratic Republic of Congo

Source: The World Lung Foundation

Health Impacts of Tobacco Use

2014). It should be noted that an additional 10.6% of tobacco users regularly

Clean Indoor Air Ordinances

communities with high levels of tobacco-related disparities such as considering

CLARKSTON COMMUNITY PROFILE

Figure 4: City of Clarkston (City of Clarkston, 2016)

Table 2: Regions of Birth of

*Data for Clarkston City, Georgia.

Business and Economics

Table 3: Employment by Industry of Residents in the City of Clarkston

Civilian employed population 16 years and over

Agriculture, forestry, fishing and hunting, and mining

Transportation and warehousing, and utilities

Finance and insurance, and real estate and rental and

Other services (except public administration)

Professional, scientific, and management, and

Source: U.S Census Bureau. (2014). American Fact Finder

Community Health Status

other allowing the services to be easily accessible to community members.

Windshield Survey Results

Figure 5: A-1 Hookah was in the same shopping complex as the

Figure 6: The front entrance of World Relief front

Figure 7: The green space across the street from World

Figure 8: Baseball field behind Milam Park Pool Center (Sarah K.

Figures 9: The front entrance to the Clarkston Community Center

Figure 11: Kabu Hookah Lounge (Sarah K. Henderson)

KEY INFORMANT INTERVIEW

the city of Clarkston. The complete interview guide, consisting of 19 items, is

What services do refugee resettlement agencies in Clarkston offer to