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Tobacco Control Strategies I
Frances Stillman, EdD
Institute for Global Tobacco Control
Johns Hopkins Bloomberg School of Public Health
Section A
Background
Conceptual Framework
4
Tobacco Wars
Tobacco control
Consumers
Tobacco industry
5
Early Tobacco Control
Individual approach
using
health promotion
Smokers and potential
smokers
6
Maturing Tobacco Control
Environmental
Influences
Individual
Influences
Interaction
Change in social and political
structures, community norms
and individual behavior
7
Why Tobacco Control?
„
To reduce morbidity and mortality from tobaccorelated diseases—
− Cancer (lung and other)
− Cardiovascular disease
− Chronic obstructive pulmonary disease
8
Goal of Tobacco Control Programs
„
„
„
„
Encourage smokers to quit
Encourage smokers to reduce their exposure to
harmful tobacco products
Discourage smoking initiation
Protect nonsmokers from secondhand smoke
9
Dissemination of Health Consequences of Smoking
Population Level of Knowledge in the U.S., 1950–1990
100
90
Smoking causes lung cancer
80
% of Population
70
60
50
40
Smoking is hazardous
to nonsmokers health
30
20
10
0
1950
1955
1960
1965
1970
1975
1980
1985
1990
Year
Source: Reducing the Health Consequences of Smoking. A Report of the Surgeon General. (1989).
10
Tobacco Control Approaches
„
Lecture 1
− Individual Approach
− Population/Social Environment Approach
− Policy Approach
„
Lecture 2
− Comprehensive Approach
− Product Regulation
− Litigation
11
Section B
Individual Approach
Individual Approach
„
Public information campaigns on health effects of
smoking to motivate cessation
− Successful in increasing awareness of the
disease risks associated with smoking
− Do not create substantial change in the
behavior of regular smokers when used as an
isolated smoking control strategy
13
Individual Approach
„
Delivery of school-based health education curricula
designed to prevent initiation by youth
− Information model
X Presumes that teaching adolescents that
smoking is harmful will alter their smoking
behavior
− Affective model
X Assumes that tobacco use is influenced largely
by attitudes. Programs using this model
attempt to enhance self-esteem and selfimage, teach stress management, and improve
decision making
14
Individual Approach
−
−
−
Information model
X Presumes that teaching adolescents that
smoking is harmful will alter their smoking
behavior
Affective model
X Assumes that tobacco use is influenced largely
by attitudes. Programs using this model
attempt to enhance self-esteem and selfimage, teach stress management, and improve
decision making
Social influence model
X Gives students skills to resist smoking
15
Individual Approach
„
Development of programs and clinics that smokers
can use individually or in groups to improve the
likelihood of long-term success with cessation
attempts
16
Hospital-Based Individual Approach
„
Self-help materials
Image source: http://www.surgeongeneral.gov/tobacco/hospital.pdf accessed 2/23/06
17
More Self-Help Materials
Image source:
http://www.surgeongeneral.gov/tobacco/consorder.pdf
accessed 2/23/06
Image source: http://www.smokefree.gov/index.asp accessed 2/23/06
18
Section C
Population/Social Environment Approach
Population/Social Environment Approach
„
„
„
„
Public opinion/community norms
Community mobilization
Preventing tobacco sales to minors
Economic incentives
20
Importance of Community Norms
„
People in a community tend to behave in ways that
are sanctioned by the community
„
Perceived community norms inform individuals about
non-sanctioned and sanctioned behavior
„
A community’s “structural” rules are a strong
manifestation of the community’s norms
„
The media are an important source of communicating
community/societal norms
21
Community Mobilization
„
Community interventions are highly effective
„
To achieve change in a community, the target
population must be involved in identifying the
problem and planning and undertaking steps to
correct it
22
Community Intervention Trial for Smoking Cessation
„
Community intervention trial for smoking cessation
(COMMIT)
− Community-level, multi-channel, four-year
intervention
− Increased quit rates for light-to-moderate smokers
− Did not increase quit rates of heavy smokers;
reaching them may require new clinical programs
and policy changes
Source: Fisher, E. B. Jr. (1995, February). The results of the COMMIT trial. Community Interventon
Trial for Smoking Cessation. Am J Public Health, 85(2), 159–160.
23
Preventing Tobacco Sales to Minors
„
In the United States today, more than three million
children under the age of 18 regularly smoke
cigarettes or use smokeless tobacco
„
More than half of all smokers begin before the age of
14, and 90% begin before the age of 19
„
An estimated 1 billion packs of cigarettes are sold to
minors each year
24
Economic Incentives
„
Higher excise taxes on cigarettes
„
Insurance reimbursement for cessation program
„
Insurance reimbursement for pharmacological
treatment including nicotine replacement therapy
„
Insurance premium differentials for smokers and
nonsmokers
25
Section D
Policy Approach: Part I
Policy Approach
„
„
„
„
„
„
„
Taxation
Clean indoor air policies
Youth policy initiatives
Advertising and promotion
Warning labels
Countermarketing
Reimbursement of cessation and treatment
27
Pros and Cons of Policy Approach
Pros
Cons
↑ Powerful tool to promote
↓ Can go too far…lose
behavioral change
↑ Changes can be
immediate
↑ Educate/policy makers
↑ Community mobilization
public support
↓ Enforcement
↓ Time/energy/money
↓ TI opposition
↓ Need skilled people (legal,
grassroots, media)
28
Taxation
Introduction
Philip
Morris
Threats to our business
•
Excise tax
• Advertising restrictions
• Smoking restrictions
Source: Philip Morris document site, Bates no. 2501213724.
29
Taxation: Increase the Price of Tobacco
„
„
Increase the price of tobacco products
− Raise government revenue
− Earmark revenue for tobacco control
Raising price lowers demand
− Addiction
− Price elasticity
− With each ten percent increase in price,
consumption falls 3–5 percent
− Youths are 2–3 times more responsive to price
increases than adults
30
Taxation: Arguments for and Against
„
Arguments against—
−Unfair/regressive
−Nanny state
−Smuggling
−Governments
become dependent
on revenue
„
Rationale for—
−Cheap way to
save lives
−Raises revenue
−Is very effective
31
Impact of Increasing Price through Taxation
„
Impact of increasing price through taxation—
− Reduction of consumption, with greatest impact in
low- and middle-income countries
X Increase in price of ten percent produces a
four percent reduction in demand in highincome countries and eight percent in lowand middle-income countries
− Effect is most pronounced among youths
Source: World Bank. (1999). Curbing the epidemic.
32
Price and Tax Increases Lower Consumption
Impact of Increasing Price through Taxation
Cigarette Price and Consumption go in Opposite Trends. Real price
of cigarettes and annual cigarette consumption per capita, Canada,
1989-1995
Tax reduced in an
attempt to counter
smuggling
90
80
6
70
5
60
4
50
3
40
30
2
20
1
10
0
0
1989
1990
1991
Real price
1992
1993
1994
Annual cigarette
consumption per capita (in
packs)
Real price per pack (US$)
7
1995
Consumption
Data source: World Bank. (1999). Curbing the epidemic.
33
Taxation
Impact of Increasing Price through Taxation
Real price of cigarettes and annual cigarette consumption per
adult (15 years of age and above), South Africa, 1970-1989
1.3
1.2
0.08
1.1
0.07
1
Real Price
Cigarette consumption per
adult (in packs)
0.09
0.9
0.06
0.8
0.05
0.7
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
Year
Real price
Data source: World Bank. (1999). Curbing the epidemic.
Consumption
34
Tax as Percentage of Average Retail Price
Average Cigarette Price, Tax and Percentage of Tax Share per
Pack, by World Bank Income Groups, 1996
Average tax in US$
Tax as a percentage of price
3.50
80
3.00
70
60
2.50
50
2.00
40
1.50
30
1.00
20
0.50
10
0.00
0
High income
Upper middle
income
Lower middle
income
Tax as a percentage of price
Average price or tax per pack
(US$)
Average price in US$
Low income
Countries by income
Data source: World Bank. (1999). Curbing the epidemic.
35
Japan’s Approach to Taxation
“Tobacco tax
goal: over
800,000,000 yen.”
“Buy a cigarette in
our city.”
Image source: Institute for Global Tobacco Control
36
Arguments for and against Smoke-free Workplaces
Arguments for and against smoke-free
workplaces/public places
Arguments against
„ Excessive regulation
„ Will hurt business
„ Indoor air quality dependent
on ventilation rather than on
the elimination of smoking
„ Data on secondhand smoke
(SHS) is not conclusive
Arguments for
„ Health hazards of SHS
„ Promotes smoke-free norm
„ Assists quitting
„ Sustains abstinence
„ Reduces maintenance costs
„ Reduces liability
„ Reduces fires
Image source: http://www.leominster-ma.gov/health_department_whats_new.htm accessed 2/24/06
37
Clean Indoor Air Policies
„
Some countries with smoke-free laws
− Bhutan (100%)
− India (comprehensive bans)
− Ireland (100%)
− Norway (100%)
− New Zealand (100%)
− South Africa (comprehensive bans)
− Sweden (100%)
− Uganda (100%)
38
Clean Indoor Air Policies
Remaining Challenges for Smoke-free Legislation
Country
National Smoking Regulations in
Public Places
Argentina
Not regulated at the national level
El Salvador
Not regulated; prohibited only in Ministry of
Health buildings
Germany
Voluntary restrictions in institutions,
government agencies, and transport
companies
Philippines
Banned in schools and public transportation;
Voluntary restrictions in hospitals and health
care facilities
Romania
Banned in hospitals, schools and on public
transport; restricted in others
39
Japan’s Approach to Smoke-free
• Smoking is prohibited on the street in Japan.
• A mobile smoking van, Smocar, provides a place
for smokers in Japan to smoke.
• Children are also allowed into the van and given
soft drinks.
40
Bhutan’s Approach to Smoke-free
„
Illegal to buy tobacco, sell it, or smoke anywhere in
public
„
May bring tobacco into the country for personal
consumption, but only after paying 100 percent tax on
the cost price. Can smoke tobacco only at home
„
Only about one percent of the population is thought
to smoke
41
Italy’s Approach to Smoke-free
“On January 10, 2005, Italy implemented
smoke-free workplace legislation for all
workers, including restaurant and bar
workers.”
- http://www.smokefree.net/italy/
42
Section E
Policy Approach: Part II
Youth Policy Initiatives
„
Nearly ninety percent
of adult smokers
started before age 18
Image source: http://www.ehponline.org/docs/2003/111-14/forum.html retrieved 2/24/06
44
Youth Policy Initiatives
„
Types of youth approaches
− School-based health education
− Media literacy
− Youth access restrictions
X Purchasing
X Possession
X Free sampling
X Vending machines
− FCTC Article 16
Continued
45
Pros and Cons for Youth Policy Initiatives
¬
¬
¬
Pros
Youth are new smokers
Broad political support
1990s tobacco framed
as a “pediatric disease”
Cons
− To impact youths must
impact adults
− Need change in social
norms
− Takes decades to impact
mortality and morbidity
46
What We’ve Learned about Youth Policy Initiatives
„
„
„
„
„
It’s unclear whether youth approach has
decreased youth prevalence
May take 100 percent compliance
Social sources are important
Youth access can galvanize community
Youth possession laws are controversial
47
Comparing Campaign Effectivenss
“. . . exposure to the “truth”
campaign positively changed
youths’ attitudes toward tobacco,
the Philip Morris campaign had
a counterproductive influence.”
- Farrelly et. al. 2002.
Source: Farrelly, M.C., C.G. Healton, K.C. Davis, P. Messeri, J.C. Hersey, M.L. Haviland. 2002. Getting to
the truth: Evaluating national tobacco countermarketing campaigns. Am J Public Health 92: 901-907.
48
School-Based Programs Are Ineffective
“. . . no evidence that a school-based social
influences approach is effective in the longterm deterrence of smoking among youth.”
—Peterson et al. (2000)
Source: Peterson, A.V., K.A. Kealey, S.L. Mann, P.M. Marek, I.G. Sarason. 2000. Hutchinson Smoking Prevention
Project: Long-Term Randomized Trial in School-Based Tobacco Use Prevention—Results on Smoking Journal of the
National Cancer Institute, Vol. 92, No. 24, 1979-1991.
49
Restrictions on Advertising and Promotion
Selling athleticism
Selling show biz
Selling sex
Selling fashion
Selling beauty
“The media like the money they make
from our advertisements, and they are
an ally that we can and should exploit.”
– Philip Morris
Selling freedom
Selling prosperity
Selling
death
Each year, the tobacco industry spends billions of dollars on advertising,
marketing and promotion. In the United States alone, where less than 5% of
the world’s smokers live, tobacco companies spent over $8.2 billion on
advertising and promotion in 1999.
50
Direct Effects of Tobacco Advertising and Promotion
„
„
„
„
Attracts new users to the market
− (increased initiation)
Reduces current users’ willingness to leave market
− (reduced cessation)
Stimulates use among current users
− (increased consumption by smokers)
Induces former users to resume use
− (increased re-initiation)
Source: Warner. (1986). Selling smoking: Cigarette advertising and public health.
51
Indirect Effects of Tobacco Advertising and Promotion
„
„
„
„
Discourages full discussion of the health
consequences of tobacco in media dependent on
tobacco advertising
Contributes to an environment where tobacco use is
perceived to be more socially acceptable and less
hazardous
Creates political opposition to strong tobacco control
policies among institutions receiving tobacco industry
marketing dollars
Increases market segmentation/brand proliferation
Sources:
Warner. (1986).
U.S. Department of Health and Human Services. (1989). Reducing the health consequences of smoking: 25 years
of progress. A report of the Surgeon General.
52
Saffer. (2000). Tobacco advertising and promotion.
Advertising and Tobacco Use
„
„
“Logical arguments” imply that increased advertising
increases tobacco use
Substantial evidence from survey research and
experiments concludes that—
− Cigarette advertising captures attention and is
recalled
− Strength of interest is correlated with current or
anticipated smoking behavior and initiation
Sources:
Warner. (1986).
U.S. Department of Health and Human Services. (1989).
U.S. Department of Health and Human Services. (1994). Preventing tobacco use among young people. A report
of the Surgeon General.
Chaloupka and Warner. (2000). The economics of smoking.
53
U.S. Department of Health and Human Services. (2000). Reducing tobacco use.
Advertising and Tobacco Use: Other Empirical Research
„
Other empirical research—
− Youth who own tobacco company promotional
items are more likely to become smokers1
− Youth smoking is much more responsive to
advertising than adult smoking2
− Econometric studies generally find small or
negligible impact of advertising on overall
cigarette sales3
X Econometric methods are poorly suited for
detecting impact of advertising on demand
Sources:
1. Pierce et al. (1998); Biener and Siegel. (2000); Sargent et al. (2000).
2. Pollay et al. (1996).
3. Chaloupka and Warner. (2000); Saffer. (2000).
54
Comprehensive Ad Bans Reduce Consumption
Trends in weighted cigarette consumption per capita in countries
with a comprehensive ban compared with countries with no ban
Annual cigarette consumption per
capita
Comprehensive advertising bans reduce cigarette
consumption
1750
Ban
1700
1650
1600
No ban
1550
1500
1450
1981
1991
Year
Source: Saffer, H. The control of tobacco advertising and promotion. Background paper.
55
Restrictions on Advertising and Promotion
„
„
Relatively comprehensive restrictions on advertising
and promotion significantly reduce cigarette
consumption
− Estimate more than a 6 percent reduction in
consumption in response to comprehensive ban
Limited/partial restrictions on advertising and
promotion have little or no impact on cigarette
consumption
− Induce substitution to other media and new
promotional efforts
Sources:
Saffer. (2000).
Chaloupka and Warner. (2000).
Saffer and Chaloupka. (2000). Tobacco advertising: Economic theory and international evidence.
Wakefield et al. (2000). Changes at the point-of-sale for tobacco following the 1999 tobacco
billboard ban.
56
Warning Labels
Image source: Health Canada http://www.hc-sc.gc.ca/hl-vs/tobac-tabac/legislation/label-etiquette/graph/index_e.html
accessed 3/20/06
57
Warning Labels
„
FCTC Article 12—warning labels should cover no less
than 30 percent of the cigarette pack
Side of pack: a box of at
least 10% indicating
yields of tar, nicotine and
carbon monoxide.
Front: a health warning of
at least 30%
Back: a health warning of
at least 40%
Image source: http://europa.eu.int/comm/mediatheque/photo/select/tabac_en.htm accessed 3/20/06
58
Countermarketing
Image source: http://www.cdc.gov/tobacco/MCRC/countermarketing/ accessed 3/20/06
59
Reimbursement of Cessation and Treatment
Number of state Medicaid programs covering
tobacco dependence treatments (2002)
Tobacco dependence
treatment
1998
2002
Zyban
24
40
Nasal spray & inhaler
17
28
Patch
15
27
Gum
16
26
Individual counseling
5
17
Group counseling
5
10
Telephone counseling
4
5
33% of Medicaid
population are
smokers
“An ounce of prevention is worth a pound of cure”
60