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Are We There Yet? Upstream to Tobacco Control in the United States

Are We There Yet? Upstream to Tobacco Control in the United States. Thomas E. Novotny, MD, MPH Department of Epidemiology and Biostatistics, UCSF. Goals of Presentation. Enumerate main upstream interventions that have reduced tobacco use in the US;

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Are We There Yet? Upstream to Tobacco Control in the United States

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  1. Are We There Yet? Upstream to Tobacco Control in the United States Thomas E. Novotny, MD, MPH Department of Epidemiology and Biostatistics, UCSF

  2. Goals of Presentation • Enumerate main upstream interventions that have reduced tobacco use in the US; • Discuss evidence for the effectiveness of these interventions; • Outline future possible upstream approaches to tobacco control in the US.

  3. Main Sources of Evidence • Reducing Tobacco Use: A Report of the Surgeon General 2000 (USDHHS) • Tobacco Control in Developing Countries (The World Bank 2000) • IMPACTeen Project (Frank Chaloupka, University of Illinois, Chicago)

  4. 1st Surgeon General’s Report Broadcast Ad Ban End of WW II Master Settlement Agreement TV/radio Messages Number of Cigarettes 1st Smoking- Cancer Concern Nonsmoker Rights Movement Marlboro Friday Federal Cigarette Tax Doubles Great Depression Source: USDA; 1986 Surgeon General's Report Adult Per Capita Cigarette Consumption and Smoking-and-Health Events, 1900-1998

  5. Current Cigarette Smoking Prevalence, Adults, US, 1965-2000 Source: NCHS, HEALTH US, 2002

  6. Tobacco is Not an Equal Opportunity Killer • Smoking affects young, the poor, depressed, uninsured, less educated, blue-collar, and minorities most in the US; • Addiction affects those with the least information about health risks, with the fewest resources to resist advertising, and the least access to cessation services; • Those below poverty line are >40% more likely to smoke than those above poverty line.

  7. 38% of persons with 9-11 yrs education 40% of cooks/truckers 1/3 of service workers covered by smoke-free policies Social norm for low SES different from high SES 13% of persons with college degree or higher 3% of lawyers ½ of white collar workers covered by smoke-free policies Less likely to be exposed to parent/peer smokers Unequal Patterns of Use and Exposure

  8. Upstream Interventions: Changing social norms • Information dissemination and education • Economic incentives/disincentives • Clean indoor air policies • Health system interventions • Comprehensive state programs • The Framework Convention on Tobacco Control • Advertising and promotion bans

  9. Directions in Development Curbing the epidemic Governments and the Economics of Tobacco Control Evidence on the economics of global tobacco control: The World Bank The World Bank

  10. Effective interventions: Demand reduction • Higher cigarette taxes • Non-price measures: consumer information, research, cigarette advertising and promotion bans, warning labels, and restrictions on public smoking • Increased access to nicotine replacement (NRT) and other cessation therapies Source: World Bank 2000

  11. Ineffective interventions:Most supply side measures • Prohibition • Youth access restrictions • Crop substitution • Trade restrictions • Control of smuggling is the only exception Source: World Bank 2000

  12. Information Dissemination • ‘Information shock’: Hammond and Horn 1954, 1964 SG Report, Fairness Doctrine TV spots = 30% relative decrease in consumption. • ‘Risk perception’: increased from 40% believe smoking causes lung ca in 1950 to 95% in 1994 • ‘Passive smoking’ and risk: awareness increased from 45% in 1974 to 88% in 1992

  13. Tobacco Taxation "With regard to taxation, it is clear that in the US, and in most countries in which we operate, tax is becoming a major threat to our existence." "Of all the concerns, there is one - taxation - that alarms us the most. While marketing restrictions and public and passive smoking (restrictions) do depress volume, in our experience taxation depresses it much more severely. Our concern for taxation is, therefore, central to our thinking...." Source: Philip Morris, “Smoking and Health Initiatives”, 1985

  14. Effect of Taxes on Tobacco Use • Higher taxes induce quitting, prevent relapse, reduce consumption and prevent starting; • Estimates from high-income countries indicate that 10% rise in price reduces overall cigarette consumption by about 4%; • About half of impact of price increases is on smoking prevalence; remainder is on average cigarette consumption among smokers; • Some evidence of substitution among tobacco products in response to relative price changes; • Young people and the poor are the mostprice responsive.

  15. Cigarette Smoking Among Youth by the Average Price of a Pack of Cigarettes, 50 States and DC, 1999 Data: 1999 NHSDA (12-17 year olds); 1999 Tax Burden On Tobacco Source: Giovino, et al., 2001

  16. Effect of Smoke-free Workplaces on Smoking Behavior • Totally smoke-free workplaces associated with 3.8% reductions in prevalence and 3.1 fewer cigarettes smoked per day; to achieve similar results, taxes would increase to $1.11 per pack (Ficthenberg and Glantz 2002);

  17. Optimal mix of policy and practice in US tobacco control • Tax-funded programs (Cal., Mass.) • Legislative agenda (driven by civil society) • Behavioral surveillance • Clinical interventions (AHRQ Guidelines) • Master Settlement Agreement--$246 billion • Comprehensive State Tobacco Control Programs (CDC Guidelines)

  18. State Tobacco Control Funding as Percentage of CDC Minimum, 2002 Source: CDC

  19. Comprehensive Programs and State Cigarette Sales • Higher spending on tobacco control efforts reduces overall cigarette consumption: • Elasticity estimates for current year spending center on 0.006; • Elasticity estimate for cumulative spending: –0.025 • Marginal impact of tobacco control spending greater in states with higher levels of cigarette sales per capita; average impact significantly higher in states with larger programs; • Disaggregated program spending suggests that impact of spending on programs focusing on policy change is greater than spending on other programs.

  20. Program Implementation CA Projected Trend Tax Increase Per Capita Cigarette Consumption,California vs Projected, 1984-1997 Source: CDC

  21. Program Implementation MA Projected Trend Tax Increases Per Capita Cigarette Consumption,Massachusetts vs Projected, 1984-1997 Source: CDC

  22. Comprehensive Programs • State tobacco control programs, funded by excise taxes on tobacco products and settlements with the tobacco industry, have produced early, encouraging evidence of the efficacy of the comprehensive approach to reducing tobacco use (SGR 2000); • State budget now divert most funds for tobacco control to resolving deficits.

  23. Unequal Pattern of Health Services • Women, minorities, low SES with delayed diagnosis, treatment for CVD and other smoking-related diseases; • In 2001, 15 states offered no coverage for tobacco-dependence treatment under Medicaid; only Oregon provided coverage for all treatment options recommended by the PHS Clinical Practice Guideline; • Only 12 (33%) state Medicaid programs providing coverage informed recipients that benefits were available; • According to PHS Guideline (Treating Tobacco Use and Dependence), treatment with either counseling or medication doubles quit rates.

  24. Mortality from Smoking, 1965-1999 • 4.7 million cancer deaths • 8.4 million CVD deaths, • 2.6 million respiratory disease deaths, • 135,000 infant deaths, • 15.8 million total deaths, • Uncounted pain, suffering, and economic burdens.

  25. Disease control and health promotion objectives for the Nation http://www.health.gov/healthypeople/

  26. Example: Tobacco Adolescents, grades 9-12 36% 36% 24% 24% Adults aged >18 years old 16% (2010 Target) 12% (2010 Target) Adolescents who smoke Adults who smoke Source: CDC, YRBS 1991-1997. CDC, NHIS 1990-1997.

  27. Policy/Env. Change Behavioral Change Risk Factor Control Acute care/management Rehab/long-term care End-of-life care Social/Env. Conditions Adverse Behavior Major Risk Factors First event Disability/recurrence Fatal Complications Public Health Action Plan to Prevent Heart Disease and Stroke Approaches Reality N.B.: NO MENTION OF SMOKING! Source: US DHHS 2003

  28. Framework Convention on Tobacco Control • First health treaty to be negotiated under auspices of World Health Organization; • Agreement by consensus at 2003 World Heath Assembly (190 countries); • So far, 101 have signed, 9 ratified; NOT US • Depends on ratification and developing national policies in accordance with obligations; • Advertising ban, warning labels, misleading information on labels, taxation, clean-indoor air policy, liability, smuggling controls, etc.

  29. Advertising and Promotion Bans • Consent decree banned tobacco ads from radio and TV since 1970s in US; NZ and Canada much more restrictive; • Case law supports the contention that advertising does not receive same protection of free speech under First Amendment as noncommercial speech (SGR 2000); • Regulation of advertising and promotion, particularly that directed at young people, is very likely to reduce both prevalence and uptake of tobacco use.

  30. Smoke-free Movies: a Type of Ad Ban • Certify No Pay-Off at the end of the movie credits; • Require Strong Anti-Smoking Ads to run before any film with any tobacco presence, regardless of its MPAA rating; • Stop Identifying Tobacco Brands in the background of any movie scene; • Rate New Smoking Movies "R“ except when the presentation of tobacco clearly and unambiguously reflects the dangers and consequences of tobacco use.

  31. Future Upstream Interventions • Evaluating Comprehensive Tobacco Control Programs; • Immunizing children against uptake of tobacco use; • Evaluating ‘harm reduction’ approach; • Evaluating proposed new FDA regulations; • Understanding role of US in Global Tobacco Control.

  32. Workforce Needs in Tobacco Control • Economics—arguments need to be made to policy makers, health plans, and budgeteers; • Bioethics—a major driving force towards social justice and the moral argument for tobacco control; • Pharmaceutics—need tools for cessation; • Politics—know how to make the “sausage” of sensible health policy.

  33. Conclusions • Significant progress has been made since 1965 in preventing premature mortality and morbidity due to smoking in the US; • Still more than 50 million smokers; • Average smoking-attributable deaths/year >450,000 (20% of total US mortality) • “Life is filled with golden opportunities, carefully disguised as irresolvable problems” (J. Gardner, former Secretary of HEW)

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