Center for Health Behavior Research
University of Pennsylvania
April 3, 2012
Unhealthy advertising in Philadelphia
 Counting ads in a 4-month period in Austin, Los Angeles, and
Philadelphia
Hillier, Health & Place, 2009
Key determinants of smoking
 Climate
 Normative behavior (up to 4 in 10 adults in some neighborhoods)
 Aggressive marketing in poor communities
 Access
 High density of tobacco retailers, particularly near schools
 High rate of illegal sales to youth
 Relatively low cigarette prices in Philadelphia
 Cessation resources
 Most smokers try to quit on their own
 Inadequate coverage for and use of quit aids
 Limited availability and use of cessation counseling
Key determinants of obesity
 Poor Diet
 Limited access to healthy foods in poor communities
 Easy availability and aggressive marketing of unhealthy foods
 Higher relative price of healthy foods
 Lack of Physical Activity Opportunities
 Auto-based planning
 Disrepair and lack of safety in neighborhoods
 Dramatic increase in indoor, screen-based activities
Overweight and Obesity in Philadelphia
Overweight and Obesity Among Philadelphia Adults (18+) and
Children (6-17), 2000 - 2010
70.0%
60.0%
62.3%
64.6%
64.3%
66.3%
60.3%
60.0%
50.0%
Adult overweight-obesity
46.9%
46.4%
Percent
40.0%
39.6%
42.0%
39.6%
40.7%
30.0%
Child overweight-obesity
(6-17 years)
20.0%
10.0%
0.0%
2000
2002
2004
PHMC Household Health Survey, 2000-2010
2006
2008
2010
Diabetes and hypertension in
Philadelphia
Diabetes among Philadelphia Adults
14.0
13.0
Hypertension among Philadelphia Adults
13.3
38.0
12.0
12.0
36.0
10.9
P
e
r
c
e
n
t
35.8
2008
2010
34.0
10.2
10.0
35.7
34.0
32.7
9.4
P
e
r
c
e
n
t
8.0
6.0
4.0
32.0
31.3
29.6
30.0
28.0
26.0
24.0
2.0
22.0
0.0
20.0
2000
2002
2004
2006
2008
2010
PHMC Household Health Survey, 2000-2010
2000
2002
2004
2006
Smoking prevalence for
10 largest U.S. cities
25%
20% 20%
18% 17%
17%
16%
15%
14%
12%
Behavioral Risk Factor Surveillance Survey and local data sources, 2007
Philadelphia
Chicago
Phoenix
San Antonio
NYC
Houston
Dallas
San Diego
LA
San Jose
Health and economic costs
in Philadelphia
Tobacco use
Poor Diet and Physical
Inactivity
2,400 deaths per year
~2,000 deaths per year
$700 million in productivity
losses annually
~$750 million in health care
costs annually
Philadelphia Vital Statistics Reports, Philadelphia Department of Public Health
Obesity health care costs estimated from Finkelstein et al, Health Affairs, 2009
How can we make it easier for Philadelphians
to engage in healthy behaviors?
Health Impact Pyramid
Examples
Smallest
Impact
Counseling
& Education
Clinical
Interventions
Long-lasting
Protective Interventions
Changing the Context
Largest
Impact
to make individuals’ default
decisions healthy
Socioeconomic Factors
Frieden T, AJPH 2009
Eat healthy, be
physically active
Rx for high blood
pressure, high
cholesterol, diabetes
Immunizations, brief
intervention, cessation
treatment, colonoscopy
Fluoridation, 0g trans
fat, iodization, smokefree laws, tobacco tax
Poverty, education,
housing, inequality
How can we make it easier for Philadelphians to
engage in healthy behaviors?
Media
Educational
institutions
Built environment
Workplaces
Community retail
environment and
restaurants
Legislation and
regulation
Insurers and health
care providers
Schools –
School Wellness Councils
School Wellness Council Interventions, (November 2011)
140
Healthy classroom rewards
120
Healthy fundraisers
100
Socialized Recess
80
60
Classroom movement breaks
128
102
40
20
Healthy school stores
83
42
3
0
Philadelphia Department of Public Health,
School District of Philadelphia
Afterschool programs –
food and fitness policies
• Food and fitness standards developed for
over 207 afterschool programs, serving
20,000 low-income children
• Structured physical activity opportunities in
94 recreation center afterschool programs
• Healthier, more complete meals in 50+
recreation center afterschool programs
Built environment – smoke-free rec
centers, playgrounds, pools
• 183 smoke-free recreation centers, playgrounds, and
pools, affecting over 2 million annual visits
• 850 new smoke-free acres!
Built environment –
safer walking and biking
• 2 new north-south bike lanes and an education & enforcement
campaign for an area with a day-time population of 250,000
• Over 28,000 2nd and 5th graders provided pedestrian and
bicycle safety lessons
Built environment –
planning and zoning
• Encouraging the incorporation of fresh food markets into
commercial and mixed-use developments by offering density
bonuses that don’t count the square footage of those markets
against the maximum buildable area (14-603(7))
• Requiring the provision of secure bicycle parking in
developments above a certain size, and allowing the removal of 1
automobile space in exchange for the provision of 5 bicycle parking
spaces (14-804)
Retail – preventing youth
tobacco sales & use
• Penalties raised for merchants that sell tobacco to minors
• Over 2,000 tobacco merchants educated about youth sales prevention
• New tobacco retailer permitting requirement
• The public can report retailers by calling 1-888-99-SMOKE or
online
Retail – Philly Food Bucks &
Healthy corner stores
• 10 new farmers’ markets in low-income
neighborhoods
• $2 of free fruits and vegetables for every $5 of
SNAP benefits
• 435% increase in SNAP redemption at farmers’
markets
• Over 600 corner stores selling healthier
products, impacting 750,0000
Philadelphians
• 83 mini conversions completed
• On average, each store introduced 20+
new products as a result of a conversion
Healthy corner stores
•
•
•
635 enrolled
423 with at least 4 new
products
83 with mini-conversions
Workplaces – promoting and
supporting quit attempts
• City of Philadelphia
• Expanded insurance coverage to include 6 of 7 FDA
approved smoking cessation medications, affecting 7,000
employees and dependents
Workplaces – healthy vending
• City of Philadelphia
• Over 260 vending machines
undergoing changes—healthier mix,
smaller sizes, calorie labeling, and
healthy marketing—affecting 25,000
employees
Workplaces – healthy vending
Employers that have developed or implemented healthy beverage
vending standards, June 2011
HUP
31,000
City of Philadelphia
25,000
Einstein
Total
Employees
Impacted:
69,114
7,200
PA Hospital
2,700
Horizon House
1,115
KPMG
857
Fox Rothschild
497
SRSY
445
Congreso
300
0
5,000
10,000
15,000
20,000
Number of Employees Impacted
25,000
30,000
35,000
Insurers and health care providers –
promoting and supporting quit attempts
•
4 of the 5 Medicaid Managed Care Organizations in Philadelphia agreed
to provide coverage for 5 (or more) of the 7 FDA-approved smoking
cessation medications, expanding access for approximately 80,000 lowincome Philadelphia smokers
•
More than tripling of Quitline use and NRT for 10,000 Philadelphians
Callers to 1-800-QUIT-NOW for Philadelphia County
Counseling only
Counseling + NRT
4000
3500
3000
2500
2000
NRT
Giveaway
1500
NRT
Giveaway
1000
500
0
Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2010
2011
2012
Media campaigns
 Do you know what your kids are drinking?
 Raising awareness about the negative health effects of
sugary drinks and encouraging people to cut back
 ~24 million impressions
 Quit with help. Quit for good.
 Motivating smokers to quit with assistance, like
counseling or medications.
 ~50 million impressions
“Time for a Change” (TV)
“Last Pack” (TV)
Buses and subway
Buses and subway
Media
Recall of Get Healthy Philly Media Campaigns, 2010 - 2012
80%
70%
60%
Percent
50%
Tobacco
40%
Sugary Drinks
30%
20%
10%
0%
1
2
3
4
5
6
7
Month
8
9
10
11
12
13
14
15
The Annenberg Public Policy Center and School of
Communications, University of Pennsylvania
Media – Do you know what your
kids are drinking?
Amount of sugar
High
Low
Jordan et al, Annenberg Public Policy Center
Media – Do you know what your
kids are drinking?
Intention
High
Low
Jordan et al, Annenberg Public Policy Center
Media – Quit with help. Quit for
good.
No recall
< 4x wk recall
≥ 4x wk recall
100%
Percent
80%
60%
40%
20%
0%
Talked about the ad
Sought info on quitting
Hornik et al, Annenberg School of Communications
Media – Quit with help. Quit for
good.
No Recall
< 4x Wk Recall
>=4x Wk Recall
100%
T2 Quit
Percent intending to quit
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
No T1 Quit
Yes T1 Quit
Hornik et al, Annenberg School of Communications
Legislation and regulation
• On 12/23/10, Mayor Nutter signed Bill No. 100634 into law,
increasing penalties from $100 to $250 for illegal sales of
tobacco products to youth
• Passed 15 – 0 by City Council
• On May 23, 2011, Mayor Nutter signed an executive order
making all recreation centers, playgrounds, and pools 100%
smoke-free
• In June 2011, City Council passed an ordinance that will
require all tobacco retailers to obtain a permit from the
Department of Public Health
Menu labeling and exemption
from federal preemption
 Philadelphia adopted its menu labeling ordinance (080167-A) on
November 19, 2008.
 The menu labeling requirements became effective January 1,
2010.
Menu boards
Menus
Calories must be displayed
directly on the menu board next
to each food or beverage item.
Calories, sodium, saturated fat,
trans fat, and carbohydrates
must be displayed directly on
the menu next to each food or
beverage item.
Additional nutrition information
must be available upon request.
What’s the Problem with Sodium?
What’s the Problem with Sodium?
Average sodium in items served at Philadelphia sit-down
restaurants, 2011
912
Kid's meals
1114
Senior meals
1759
Other entrees
1930
Appetizers
2213
Burgers and sandwiches
0
500
1000
1500
Milligrams of sodium
2000
2500
Drexel University School of Public Health,
Philadelphia Department of Public Health
New initiatives
 Point of purchase warnings
 Smoke-free spaces
 Housing, parks
 Salt reduction
 Take-out Chinese restaurants
 Media campaign
 Healthy food procurement
 Schools, afterschools
 City agencies
 Healthy supermarkets
 Value-based insurance design
Questions?