Restrictions on
Tobacco Use, Sales
& Marketing
Frank J. Chaloupka
Developing Public Health Regulations for Marijuana:
Lessons from Alcohol and Tobacco
Arlington, VA, February 11 2013
1
Smoke-Free Air Policies
2
Diseases and Adverse Health
Effects Caused by SHS
3
Image source: adapted by CTLT from U.S. Surgeon General’s Report. (2006); from JHBSPH/IGTC on-line course.
Early Evidence & Action
!
Leading up to his 1972 report, US Surgeon
General Jesse Steinfeld stated:
•  “Nonsmokers have as much right to clean air and
wholesome air as smokers have to their so-called
right to smoke, which I would define as a ‘right to
pollute.’ It is high time to ban smoking from all
confined public places such as restaurants,
theaters, airplanes, trains, and buses.”
The “Non-smokers’ Rights”
movement is born
4
Source: Eriksen and Chaloupka, 2007
Early Evidence & Action
!
Smoke-free policies emerge:
•  Existing policies intent was fire safety,
prevention of food contamination
•  1973 – Arizona first state to limit smoking in
public places
•  1974 – Connecticut first to limit smoking in
restaurants
•  1975 – Minnesota first to limit smoking in
private worksites
•  First wave of policies restricted smoking in
various venues; no complete bans
5
Source: Eriksen and Chaloupka, 2007
Policy Development
!
Over time, state/local policies get stronger:
•  1998 California bans smoking in public places,
including restaurants and bars without
separately ventilated areas
•  2002 New York city bans smoking in bars,
restaurants and virtually all other public places
and private workplaces
•  2003 Florida ballot initiative with similarly
comprehensive ban passes easily
•  By 2003 all states have at least some
restrictions on smoking in public places
!
Thousands of local policies
6
Source: Eriksen and Chaloupka, 2007
2006 Surgeon General’s Report
“Eliminating smoking in
indoor spaces fully
protects nonsmokers
from exposure to
secondhand smoke”
7
“Separating smokers
from nonsmokers,
cleaning the air, and
ventilating buildings
cannot eliminate
exposure of
nonsmokers to
secondhand smoke”
Smoke-Free Policies, 2012
Source: Americans for Nonsmokers’ Rights Foundation
Smoke-Free Policies Globally
Source: WHO 2011
Smoke-Free Air Policies - Impact
!
Attitudes & Compliance
•  Support for smoke-free policies grows after
adoption/implementation of policy
•  Compliance is moderate to high in most
countries that adopt smoke-free policies
!
Compliance better where pre-implementation
efforts to inform and build support
•  Generally self-enforcing
10
Source: IARC, 2009
Smoke-Free Air Policies - Impact
!
Anti-Smoking Norms
•  Generally majority level support for smokefree policies in HICs
•  In HICs, evidence of support among
smokers for smoke-free policies
•  Prevalence of smoke-free homes is growing
11
Source: IARC, 2009
Smoke-Free Air Policies - Impact
!
Smoking Behavior
•  ‘Smoke-free workplace policies reduce cigarette
consumption among continuing smokers and lead
to increased successful cessation among
smokers.’
•  ‘Smoke-free policies appear to reduce tobacco
use among youth’
•  ‘There is a greater decline in smoking when
smoke-free policies are part of a comprehensive
tobacco control program’
•  Impact of smoke-free home policies on behavior
greater than of public policies
Source: IARC, 2009
Smoke Free Air Policies and Young Adult Smoking
Prevalence, 2003-04
18-24 Smoking Prevalence
50
45
y = -0.1176x + 43.509
2
R = 0.1151
40
35
30
25
0.0
10.0
20.0
30.0
40.0
Smoke Free Air, State Policy Index
Source: NSDUH, Mayatech &RPCI, and author’s calculations
50.0
Smoke Free Air Policies and Adult Smoking Prevalence,
2003-04
31
Adult Smoking Prevalence
29
27
y = -0.0791x + 26.516
2
R = 0.1169
25
23
21
19
17
15
0.0
10.0
20.0
30.0
40.0
Smoke Free Air, State Policy Index
Source: NSDUH, Mayatech &RPCI, and author’s calculations
50.0
25
88
86
20
84
82
15
80
78
10
76
74
5
72
70
0
1991
1993
1995
1997
Smoke-Free Policies
1999
2001
2003
2005
Disapproval, 8th Grade
Source: ImpacTeen Project, UIC; Monitoring the Future, 2012
2007
2009
Disapproval, 10th Grade
2011
Smoke-Free Policy Index
% Disapproving of Smoking One or More Packs per Day
90
Social Norms About Smoking
Smoke-Free Air Policies
Future Directions
!
Restrictions on smoking in multi-unit housing
•  Some limited to common areas only
•  Some limited to public housing
•  Some complete bans
!
Outdoor Venues
•
•
•
•
!
Beaches, public parks, zoos
Outdoor dining
Sporting venues
Public transit stops
Private policies expanding
•  Hotel chains going smoke-free
•  Rental car companies going smoke-free
16
Limits on Youth Access
17
Youth Access Policies
!
Include a range of policies:
•  Minimum legal purchase age
•  Minimum age to sell
•  Penalties on vendor
!
Fines, license suspension/revocation
•  Penalties on youth
!
!
!
!
Purchase, possession, and/or use policies
Fines, smoking education/cessation classes
Parental notification
Driver’s license suspension
•  Limits on vending machine sales
•  Limits/bans on sampling
18
Youth Access Policies
!
Need for enforcement
•  Compliance checks
•  Effectiveness will depend on variety of
factors
!
!
!
!
!
!
!
Randomness
Frequency
Penalties
Characteristics of checker
Merchant education efforts
Social norms against tobacco
More……
•  Not self-enforcing
19
Youth Access Policies
!
History
•  State minimum purchase age policies in
effect for decades
!
Little enforcement, low compliance
•  Success with MLDA in reducing youth
drinking spurred interest in same for tobacco
•  Led to 1992 “Synar Amendment”
!
!
Required MLPA of 18 for tobacco products
Had to demonstrate compliance with policies
•  FDA
!
!
20
1996-2000 strong youth access program
Resumed with Family Smoking and Prevention Act
of 2009
Youth Access Policies
Youth Access to Tobacco Products Scores, 1993-2006
14.00
Youth Access Index
12.00
10.00
8.00
6.00
4.00
2.00
0.00
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Year
21
Note: Bars depict the simple average of state scores for the NCI State Cancer Legislative Database Youth
Access to Tobacco total score, including pre-emption.
Source: National Cancer Institute (2007).
Youth Access Policies
22
Source: SAMHSA, 20012
Compliance & Availability
90
% Saying Easy or Fairly Easy to Get
33
80
75
28
70
23
65
18
60
13
55
50
8
1997
1998
1999
2000
2001
2002
Perceived Availability, 8th Grade
2003
2004
2005
2006
2007
Perceived Availability, 10th Grade
23
Source: SAMHSA, 20012; Monitoring the Future, 2012
2008
2009
2010
2011
2012
Synar Non-Compliance Rate
% of Retailers Selling to Minors
38
85
Youth Access Policies
!
History
•  Initial focus on retailers led to call for
policies holding youth accountable
!
24
Led to policies that penalize youth for
purchase, possession, and/or use
Youth Access Policies
Mean Number of State Purchase, Possession and
Use Laws, per State, 1988-2005
PPU
2
1.5
1
0.5
19
8
19 8
89
19
9
19 0
91
19
92
19
9
19 3
94
19
9
19 5
96
19
9
19 7
98
19
9
20 9
00
20
0
20 1
02
20
03
20
0
20 4
05
0
Year
25
Source: Roswell Park Cancer Institute and the ImpacTeen Project, unpublished data.
Youth Access Policies
!
Impact of youth access policies
•  Little evidence that youth access-related
policies by themselves are effective in US and
other high-income countries
•  2005 Cochrane review by Stead and Lancaster
!  Policies improve compliance
!  Compliance needs to be high to impact youth
smoking
!  High compliance difficult to sustain
•  Enforcement more effective than merchant
education
26
Youth Access Policies and Youth Smoking Prevalence
2003-04
20
12-17 Smoking Prevalence
18
16
14
12
10
y = 0.0067x + 12.777
2
R = 0.0002
8
6
5
10
15
20
25
Youth Access Policy Index
27
Sources: Substance Abuse and Mental Health Services Administration (2006a), National Cancer Institute
(2007), and author’s calculations
30
Youth Access Policies
!
Impact of youth access policies
•  Little evidence that high compliance leads to
significant reductions in youth tobacco use
!
!
Underage tobacco users find stores that are willing to
sell
Youth turn to social sources for tobacco products
•  Perhaps greater impact on uptake of heavier
smoking among underage youth
!
28
Heavier smokers rely more on commercial sources
than on social sources
Youth Smoking Prevalence and
Synar Compliance
H 27
i
g
h
S
c
h
o
o 22
l
S
t
u
d
e
n
t
S
m
o
k
i
n
g
17
P 12
r
e
v
a
l
e
n
c
e
7
4
6
8
10
12
Synar Non- Compliance Rate
29
Source: SAMHSA, 2009; YRBS, 2009
14
16
18
Youth Access Policies
!
Impact of youth access policies
•  No evidence that PPU policies significantly
reduce youth smoking
!
30
May have some impact on kids at lowest risk to
begin with
Purchase, Possession and Use Policies and
Youth Smoking Prevalence, 2003-04
20
12-17 Smoking Prevalence
18
16
14
12
10
y = 1.0263x + 10.916
2
R = 0.1896
8
6
0
0.5
1
1.5
2
2.5
PPU Policy Index
31
Sources: Substance Abuse and Mental Health Services Administration (2006a), ImpacTeen unpublished
state policy data, and author’s calculations
3
Tobacco Marketing
32
Impact of Tobacco Marketing
!
1989 Surgeon General’s report described four
ways that marketing could directly affect tobacco
use:
•
•
•
•
!
By
By
By
By
encouraging youth experimentation and uptake
increasing consumption among current users
reducing current users’ motivation to quit
encouraging former users to restart
Also suggested three indirect mechanisms
•  Media dependence on tobacco company advertising
•  Financial dependence of some organizations on tobacco
funds (e.g. professional sports, cultural organizations,
minority organizations)
•  Ubiquity of marketing creates social norm that tobacco
use is acceptable or less objectionable
33
Impact of Tobacco Marketing
!
Extensive efforts to assess impact of marketing
!
Particularly among youth
•  Non-randomized studies
!
Ad prevalence and favorite ad studies
•  Randomized experimental studies
!
Manipulate exposure; assess attitudes, perceptions, intentions
•  Aggregate demand studies
!
Sales and marketing expenditures
•  Population based surveys
!
!
Cross-sectional studies
Longitudinal studies
•  Problems
!
!
!
Self-reported exposure vs. objective measures of exposure
Endogeneity issues
Pervasiveness of marketing
Source: NCI Monograph 19
34
Impact of Tobacco Marketing
“The total weight of
evidence – from
multiple types of
studies, conducted by
investigators from
different disciplines and
using data from many
countries –
demonstrates a causal
relationship between
tobacco advertising and
promotion and
increased tobacco use.”
35
Impact of Tobacco Marketing
“Advertising and
promotional activities
by tobacco
companies have been
show to cause the
onset and
continuation of
smoking among
adolescents and
young adults.”
36
Marketing Restrictions
!
Marketing Restrictions, US
•  Public Health Cigarette Smoking Act of 1969
!
Bans broadcast cigarette advertising, effective January
2, 1971
•  Master Settlement Agreement, November 1998:
!
!
!
!
!
prohibited tobacco advertising that targets people
younger than 18
Banned use of cartoon characters in cigarette
advertising
Eliminated most outdoor, billboard and public transit
advertising of cigarettes
Prohibited use of branded merchandise
Other restrictions
37
Cigarette Company Marketing
Expenditures,
by Type, 1975-2008
$16,000.0
$14,000.0
$12,000.0
M $10,000.0
i
l
l
i
o
n
$8,000.0
D
o
l
l
a
r
s $6,000.0
$4,000.0
$2,000.0
$0.0
1975
38
1977
1979
1981
Advertising
1983
1985
1987
Pub.Entertainment
1989
1991
Placement
1993
Price
Source: author’s calculations from data reported in FTC (2011)
1995
1997
1999
Merchandise
2001
Other
2003
2005
2007
Marketing Restrictions
!
Family Smoking and Prevention Act of
2009
•  Allows FDA to restrict marketing to youth
•  Eliminates federal preemption of strong
state restrictions on marketing
!
!
Can restrict ‘time, place or manner’ of
tobacco marketing
Providence first to attempt
•
•
•
•
Bans redemption of coupons
Bans discounted multi-pack sales
Bans sale of flavored tobacco products
Challenged by tobacco companies under First
Amendment; bans upheld; on appeal
39
Marketing Restrictions
!
Global evidence
•  Spread of more comprehensive marketing
bans
!
!
!
!
!
!
Bans on advertising in various channels
Bans on price reducing promotions
Bans on brand stretching
Bans on point-of-sale advertising
Bans on retail displays of tobacco products
Plain packaging
•  Research shows importance of comprehensive
bans
!
Increased importance of remaining options as bans
get more comprehensive
40
Comprehensive advertising bans reduce cigarette
consumption
Cigarette consumption per capita
Consumption trends in countries with such bans vs. those with no
bans
(n=102 countries)
1750
1700
Ban
1650
1600
No Ban
1550
1500
1450
1981
1991
Year
Source: Saffer, 2000
Counter-Marketing
!
Late 1960s, Fairness Doctrine
•  Significant reductions in sales, prevalence
!
1988 California Proposition 99
•  Earmarked excise tax to fund comprehensive
tobacco control program
•  Followed by several states
!
1998 Master Settlement Agreement
•  Many states commit some funds to
comprehensive programs
•  American Legacy Foundation created
42
Source: 2000 SGR
State Tobacco Control Funding
1992-2010
$1,000.0
M
i
l
l
i
o
n
s
o
f
A
u
g
2
0
1
1
D
o
l
l
a
r
s
$800.0
$600.0
$400.0
$200.0
$0.0
1992
1994
1996
Source: Bridging the Gap, ImpacTeen project
1998
2000
2002
2004
2006
2008
47 2010
Tobacco Company Marketing vs. State
Tobacco Control Funding
$18,000.0
$16,000.0
M
i $14,000.0
l
l
i
o
n
s $12,000.0
o
f
A $10,000.0
u
g
2
0
1
1
D
o
l
l
a
r
s
$8,000.0
$6,000.0
$4,000.0
$2,000.0
$0.0
48
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Source: Bridging the Gap, ImpacTeen project
Counter-Marketing
!
Extensive research on state programs
finds ads
•
•
•
•
•
•
Are seen and recalled
Increase risk perceptions
Promote cessation among adults
Prevent youth initiation
Strengthen anti-smoking norms
More effective when part of comprehensive
interventions to reduce smoking
49
Source: NCI Monograph 19
Program Funding & Perceived Risk
% Perceiving Great Risk of Smoking One or More Packs per
Day
45
70
40
35
65
30
60
25
20
55
15
10
50
5
45
0
1991
1993
1995
1997
1999
State Program Funding
Source: ImpacTeen Project, UIC; Monitoring the Future
2001
8th Grade
2003
2005
10th Grade
2007
2009
50
Program Funding & Youth Smoking
37
$1,000
35
33
31
29
$600
27
$400
25
Percent Current Smoking
Total Funding
$Millions (FY10 dollars)
$800
23
$200
21
$0
19
1991
1994
1997
2000
2003
2006
2009
Year
total state program funding
Source: ImpacTeen Project, UIC; YRBS
high school prevalence
51
Lessons Learned
52
Social Norms – Cigarettes & Marijuana
85
% Disapproving
80
75
70
65
1991
1993
1995
1997
1999
Cigarette Disapproval, 10th Grade
Source: Monitoring the Future, 2012
2001
2003
2005
2007
Marijuana Disapproval, 10th Grade
2009
2011
53
Perceived Risk – Cigarettes & Marijuana
85
80
% Perceiving Great Risk
75
70
65
60
55
50
1991
1993
1995
1997
1999
Cigarettes, Perceived Risk, 10th Grade
Source: Monitoring the Future, 2012
2001
2003
2005
2007
2009
Marijuana, Perceived Risk, 10th Grade
2011
54
Lessons Learned
!
Restrictions on Use
!
Comprehensive bans on public use
•  Including outdoor venues, multi-unit housing,
and other emerging foci of SFA policies
•  Reduce opportunities for use
•  Maintain/strengthen social norms against use
!
Restrictions on Sales
!
!
Unlikely to be sufficient by themselves
Need continued strong enforcement
•  Funded by taxes, license fees
!
Most useful as part of comprehensive
strategy
55
Lessons Learned
!
Marketing Restrictions
!
Comprehensive bans on all advertising,
promotion and sponsorship
•  Including bans on retail displays, plain
packaging
•  To maintain/strengthen social norms against
use
!
Counter-Marketing
!
Strengthen risk perceptions and social
norms against use
•  Funded by taxes, license fees
56
For more information:
fjc@uic.edu
www.bridgingthegapresearch.org
www.tobacconomics.org (coming soon)