Tobacco Control Strategies: What Worksdepts.washington.edu/tobacco/docs/Warner08.pdf · 2008-05-02 · Consumption, 1900-1973 0 1000 2000 3000 4000 5000 1900 1910 1920 1930 1940 1950

Tobacco ControlTobacco ControlStrategies: What WorksStrategies: What Works

Kenneth E. WarnerKenneth E. WarnerUniversity of Michigan School of Public HealthUniversity of Michigan School of Public Health

University of Washington University of Washington ––April 2, 2008April 2, 2008

SmokingSmoking……thenthen……

and nowand now……

ThenThen…… NowNow……

Adult Per Capita CigaretteAdult Per Capita CigaretteConsumption U.S., 1900-2001Consumption U.S., 1900-2001

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Trends in cigarette smoking among adults aged>18 years, by sex - United States, 1955-1998

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Trends in cigarette smoking amongTrends in cigarette smoking amongadults aged adults aged >>25 years, by25 years, byeducation- U.S., 1965-2002education- U.S., 1965-2002

Stages of culturalStages of culturalchange re smokingchange re smoking

1.1. Smoke everywhere; offer cigarette to othersSmoke everywhere; offer cigarette to otherswhen lighting up; ashtrays pervasive when lighting up; ashtrays pervasive (thru 1950s)(thru 1950s)

2.2. Smokers ask, as a courtesy, Smokers ask, as a courtesy, ““Do you mind ifDo you mind ifI smoke?I smoke?”” Nonsmoker Nonsmoker’’s polite response:s polite response:““Not at all.Not at all.”” (Ashtrays pervasive) (Ashtrays pervasive) (1960s)(1960s)

Stages of culturalStages of culturalchange re smoking change re smoking (cont(cont’’d.)d.)

3.3. Beginning of nonsmokersBeginning of nonsmokers’’ rights movement rights movementleads to nonsmoking sections of restaurants.leads to nonsmoking sections of restaurants.Smokers now ask Smokers now ask –– with sense of trepidation with sense of trepidation–– ““Do you mind if I smoke?Do you mind if I smoke?”” Increasingly, Increasingly,answer is answer is ““II’’d prefer that you dond prefer that you don’’t.t.”” (1970s)(1970s)

4.4. Smokers assume they should not light up inSmokers assume they should not light up ina frienda friend’’s home unless the friend has dones home unless the friend has doneso first; can ask if see ashtrays so first; can ask if see ashtrays (1980s)(1980s)

Stages of culturalStages of culturalchange re smoking change re smoking (cont(cont’’d.)d.)

5.5. Huge increase in homes with no-smokingHuge increase in homes with no-smokingpolicypolicy……including smokersincluding smokers’’ homes homes (1990s-on)(1990s-on)

6.6. Smoke-free workplace laws extended toSmoke-free workplace laws extended toinclude bars and restaurants include bars and restaurants (2000s)(2000s)

a.a. 12 countries entirely smoke-free workplaces12 countries entirely smoke-free workplacesb.b. ≈≈ 30 states entirely smoke-free 30 states entirely smoke-free (some with minor(some with minor

exceptions)exceptions)

What has producedWhat has producedthis major behavioral this major behavioral ––and culture and culture –– change? change?

U.S. anti-smoking campaignU.S. anti-smoking campaign Phase I Phase I (1964-early 1970s)(1964-early 1970s): Information &: Information &

persuasionpersuasion

Phase II Phase II (1973-present; (1973-present; ““phase II of phase IIphase II of phase II”” in in

2000s)2000s): Non-smokers: Non-smokers’’ rights movement rights movement

Phase III Phase III (late 1980s-?)(late 1980s-?): Comprehensive: Comprehensivetobacco controltobacco control

Adult Per Capita CigaretteAdult Per Capita CigaretteConsumption, 1900-1952Consumption, 1900-1952

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Begins

Federal CigaretteTax Doubles

SurgeonGeneral’sReport on ETS


BroadcastAd Ban

MasterSettlementAgreement

Great Depression

Health consequenceHealth consequence

Since 1964, > 5 million premature deathsSince 1964, > 5 million premature deathsaverted in U.S. as a result of campaign-averted in U.S. as a result of campaign-induced decisions to quit smoking or not toinduced decisions to quit smoking or not tostart.start.

Greatest public health success of last 50Greatest public health success of last 50yearsyears

Greatest remaining burden of preventableGreatest remaining burden of preventabledeath and illnessdeath and illness

Typology of interventionsTypology of interventions(end user perspective)(end user perspective)

Information/Information/educationeducation

IncentiveIncentive Law/Law/regulationregulation

PreventionPrevention School health ed;School health ed;Truth campaign;Truth campaign;ad banad ban

Tax increaseTax increase Sales-to-minorsSales-to-minorsand PUP lawsand PUP laws

CessationCessation 1990 Surgeon1990 SurgeonGeneralGeneral’’s report;s report;warning labels;warning labels;ad banad ban

Tax increase;Tax increase;insuranceinsurancepremiumpremiumdifferentialsdifferentials

ProtectionProtectionfrom second-from second-hand smokehand smoke

1986 Surgeon1986 SurgeonGeneralGeneral’’s reports reporton ETSon ETS

Smoking ban inSmoking ban inworkplace,workplace,public placespublic places

PurposePurpose Producer / End userProducer / End user

Intervention effectivenessIntervention effectiveness

EffectiveEffectiveTaxTaxClean indoor air laws,Clean indoor air laws,

policiespoliciesCounter-advertisingCounter-advertisingAd bansAd bansComprehensive TCComprehensive TC

programsprograms

Not effectiveNot effectiveSchool health edSchool health edWarning labels Warning labels (New(New

ones?)ones?)

Insurance differentialsInsurance differentialsMinors possession,Minors possession,

use, & purchase lawsuse, & purchase lawsSales to minors lawsSales to minors laws

TaxationTaxation

Strongest researchStrongest researchbase of all tobaccobase of all tobaccocontrol (TC) policiescontrol (TC) policies

From public healthFrom public healthpariah to First Principlepariah to First Principleof TCof TC

Tax increases - ProsTax increases - Pros Overall price elasticity of demand Overall price elasticity of demand ≈≈ -0.4 -0.4

Approx. ½ quitting, ½ reducing cigs/dayApprox. ½ quitting, ½ reducing cigs/dayKids twice as responsive as adults; veryKids twice as responsive as adults; veryeffective deterrent to youth smokingeffective deterrent to youth smokingGenerates (lots of) tax revenue Generates (lots of) tax revenue ((““Doing well whileDoing well whiledoing gooddoing good””))

Politically popular Politically popular““Sin tax,Sin tax,”” with with ““redemptiveredemptive”” features features (especially if(especially iftied to youth smoking prevention)tied to youth smoking prevention)

Doesn Doesn’’t affect majority, especially upper SESt affect majority, especially upper SES Progressive health impact Progressive health impact

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Real cigarette prices & per capita consumption

US, 1970-2000

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Federal cigarette tax rate & cigarette tax revenue in the US, 1960-2000

Cigarette tax rate

Tax increases - ConsTax increases - Cons

““Behavioral engineeringBehavioral engineering””

Desired neutrality of tax policy Desired neutrality of tax policy ((Here?Here?))

Increased incentive for smuggling Increased incentive for smuggling

Regressivity (equity issues) Regressivity (equity issues) Distinguish regressivity of overall tax fromDistinguish regressivity of overall tax from Progressivity/regressivity of tax Progressivity/regressivity of tax increaseincreaseEffects on continuing smokers among poorEffects on continuing smokers among pooreven if overall impact progressiveeven if overall impact progressive

Smoke-free workplacesSmoke-free workplaces

StrongStrongresearchresearchbasebase

Heart of TCHeart of TCmovementmovement

30 states30 statesnearly 100%nearly 100%smoke-freesmoke-freeworkplaces,workplaces,rests. & barsrests. & bars

12 countries12 countries

Smoke-free: evidence baseSmoke-free: evidence base

Substantial evidence on adverse healthSubstantial evidence on adverse healtheffects of second-hand smoke effects of second-hand smoke ((<<50,000 deaths/year)50,000 deaths/year)

Strong evidence that bans on smoking inStrong evidence that bans on smoking inworkplacesworkplaces…… Dramatically reduce workersDramatically reduce workers’’ exposure to SHS exposure to SHS (by 80-95%)(by 80-95%)

Increase quitting Increase quitting (3.8%; (3.8%; ~ 20% price increase or doubling of~ 20% price increase or doubling ofmedian state taxmedian state tax))

Decrease smoking among continuing smokers Decrease smoking among continuing smokers (3.1 cigs/day)(3.1 cigs/day)

Do not harm business in hospitality industry enterprisesDo not harm business in hospitality industry enterprises Reduce some business costsReduce some business costs

Counter-advertisingCounter-advertising

truth campaign, CAtruth campaign, CAand MA campaigns,and MA campaigns,& Fairness Doctrine& Fairness Doctrineads all documentedads all documentedto decrease smoking.to decrease smoking.

Requirements:Requirements:○ProfessionallyProfessionallyproducedproduced

○Well-fundedWell-funded○SustainedSustained

Advertising and promotionAdvertising and promotionbanban

Evidence strong but not conclusiveEvidence strong but not conclusive Best study: complete ban can reduce smoking Best study: complete ban can reduce smoking ≈≈ 6% 6% Partial ban ineffectivePartial ban ineffective

due to ability todue to ability tosubstitute other formssubstitute other formsof promotionof promotion

Comprehensive TC policiesComprehensive TC policies(state level)(state level)

Few studies; indicate small incrementalFew studies; indicate small incrementaleffect effect (over additive effects of individual interventions)(over additive effects of individual interventions)

Risk of bias of investigatorsRisk of bias of investigators Potential for synergistic effects of multiplePotential for synergistic effects of multiple

policiespolicies Potential for duplicative effects (sum > whole)Potential for duplicative effects (sum > whole)

School healthSchool healtheducationeducation

Some programs show Some programs show efficacyefficacy (impact with(impact withbest-practice)best-practice) but but……

None show None show effectivenesseffectiveness (impact in everyday(impact in everydayconditions)conditions)

Teachers not well trained nor interestedTeachers not well trained nor interested Competing demands on timeCompeting demands on time Relatively low school-board priorityRelatively low school-board priority Few resources devoted to programsFew resources devoted to programs ““BoosterBooster”” programs rare programs rare

Pack warning labelsPack warning labels

Old labels ineffectiveOld labels ineffective

New, Canadian-New, Canadian-style labels maystyle labels mayincrease intention toincrease intention toquit and, possibly,quit and, possibly,quittingquitting

Sales to minors & PUP lawsSales to minors & PUP laws

Sales to minors laws do not reduce youthSales to minors laws do not reduce youthsmoking unless very seriously enforcedsmoking unless very seriously enforced

≈≈ 95% compliance needed for major impact 95% compliance needed for major impact

PUP laws do not workPUP laws do not work(and generally are not even(and generally are not evenrecognized by youth or parents)recognized by youth or parents)

Objectives of tobacco controlObjectives of tobacco control

Prevent initiation Prevent initiation (children)(children)

Assist with cessation Assist with cessation (adult smokers)(adult smokers)

Protect from secondhand smoke Protect from secondhand smoke (nonsmokers) (nonsmokers)

-------------------------------------------------------------------------------------------- Harm reduction? Harm reduction? (smokers who don(smokers who don’’t quit)t quit)

Objectives as strategies: Youth-Objectives as strategies: Youth-oriented prevention campaignoriented prevention campaign

Benefits Benefits Nip problem in the budNip problem in the bud Maximize eventual health benefit Maximize eventual health benefit Political acceptability Political acceptability (paternalism appropriate for kids)(paternalism appropriate for kids)

Less industry opposition Less industry opposition

ProblemsProblems Ineffectiveness of many youth-oriented strategiesIneffectiveness of many youth-oriented strategies Long-term pay-off only; misses current smokers Long-term pay-off only; misses current smokers

Objectives as strategies: AdultObjectives as strategies: Adultcessation campaigncessation campaign

Benefits Benefits Maximize near-term health benefit Maximize near-term health benefit

ProblemsProblems Political opposition on philosophical groundsPolitical opposition on philosophical grounds More industry opposition More industry opposition Resources for individual cessation treatment Resources for individual cessation treatment Doesn Doesn’’t (necessarily) cut off flow of newt (necessarily) cut off flow of new smokers into system smokers into system

Objectives as strategies: CleanObjectives as strategies: Cleanindoor air campaignindoor air campaign

BenefitsBenefits Quick, substantial protection of nonsmokers Quick, substantial protection of nonsmokers Leads to more quitting among smokers Leads to more quitting among smokers Defines acceptable social behavior Defines acceptable social behavior

ProblemsProblems Political opposition on philosophical groundsPolitical opposition on philosophical grounds More industry opposition More industry opposition May not cut flow of new smokers into system May not cut flow of new smokers into system Doesn Doesn’’t reduce smoking t reduce smoking ““enoughenough””

Comprehensive tobacco controlComprehensive tobacco controlprogramprogram

BenefitsBenefits Addresses all issuesAddresses all issues Covers different smokers Covers different smokers’’ differing needs differing needs Maximum benefit Maximum benefit Synergies among interventions (?) Synergies among interventions (?)

ProblemsProblems Resources requiredResources required Political opposition on philosophical grounds Political opposition on philosophical grounds Industry opposition Industry opposition Uncertainty re best mix of interventions Uncertainty re best mix of interventions Duplicative effects (?) Duplicative effects (?) ((““anti-synergyanti-synergy””))

Ireland: a cautionary taleIreland: a cautionary tale

First country to haveFirst country to have100% smoke-free100% smoke-freeworkplaces, restaurants,workplaces, restaurants,& bars (2004)& bars (2004)

Pack of cigarettes costsPack of cigarettes costs>$9.00>$9.00

No cig. advertisingNo cig. advertisingpermittedpermitted

And yetAnd yet……


Smoking prevalence fell from 25.5% justSmoking prevalence fell from 25.5% justbefore smoke-free law (March 2004) tobefore smoke-free law (March 2004) to23.3% one year later.23.3% one year later.

A year later, A year later, ↑ ↑ to 24.5%!to 24.5%!

Dec. 2007, 24%Dec. 2007, 24%

16% of 12-17 year-olds smoke16% of 12-17 year-olds smoke


What explains difference between U.S. What explains difference between U.S. (with(withits relatively modest policies)its relatively modest policies) and Ireland? and Ireland?

Norms Norms

What can Ireland do?What can Ireland do? Media campaignMedia campaign Role modeling (athletes, music and movie stars Role modeling (athletes, music and movie stars ––

Think Bono!)Think Bono!)

Aggregate impacts of TC in USAggregate impacts of TC in US DramaticDramatic……but over timebut over time

Smoking prevalence Smoking prevalence ↓ ↓ by > ½by > ½

Per capita cigarette consumption Per capita cigarette consumption ≈≈ 1/3 of what it 1/3 of what itwould have been in absence of antismokingwould have been in absence of antismokingcampaigncampaign

> 5 million smoking-produced premature deaths> 5 million smoking-produced premature deathsaverted as a result of campaign, with averageaverted as a result of campaign, with averagebeneficiary gaining 15-20 years of life expectancybeneficiary gaining 15-20 years of life expectancy

How did this happen?How did this happen?

Resulted from combination ofResulted from combination of public education/information campaignpublic education/information campaign push for smoke-free air policies and lawspush for smoke-free air policies and laws use of extrinsic + intrinsic motivationsuse of extrinsic + intrinsic motivations focus on youth smoking prevention, adultfocus on youth smoking prevention, adult

quitting quitting (aided, slightly, by cessation treatments)(aided, slightly, by cessation treatments),,and protection of rights of nonsmokersand protection of rights of nonsmokers

Relied upon norm changeRelied upon norm change

Where do we go from here?Where do we go from here?Likely near-future directionsLikely near-future directions More states go smoke-freeMore states go smoke-free

Within 5 years or so, nearly all states willWithin 5 years or so, nearly all states willbe smoke-freebe smoke-free

Federal cigarette excise tax Federal cigarette excise tax ↑ ↑ to $1-2to $1-2per packper pack (from $0.39 now); (from $0.39 now); state taxes state taxes ↑↑

U.S. smoking prevalence U.S. smoking prevalence ↓ ↓ to 14.5-17%to 14.5-17%by 2020 by 2020 (now 20.8%)(now 20.8%)

More emphasis on harm reduction??More emphasis on harm reduction??

Generalizable Generalizable lessonslessons Most powerful drivers of health behaviorMost powerful drivers of health behavior

change are those that change normschange are those that change norms Smoke-free policies/lawsSmoke-free policies/laws Anti-smoking media campaignsAnti-smoking media campaigns Exception: taxException: tax

Process of social (and norm) change, asProcess of social (and norm) change, asillustrated by tobacco control story, involvesillustrated by tobacco control story, involves

Info/ed first, understood and acted upon by SES eliteInfo/ed first, understood and acted upon by SES elite Elites Elites –– most politically enfranchised most politically enfranchised –– lobby for policy lobby for policy

changeschanges Middle and lower SES respond to social pressuresMiddle and lower SES respond to social pressures

and environmental changes (smoke-free laws, higherand environmental changes (smoke-free laws, higherprices, antismoking media campaigns)prices, antismoking media campaigns)

Generalizable lessons Generalizable lessons (cont(cont’’d.)d.)

Utilize multiple intervention typesUtilize multiple intervention types Info/education; incentives; law/regulationInfo/education; incentives; law/regulation

Viewed from short-term perspective,Viewed from short-term perspective,creating cultural and behavioral change iscreating cultural and behavioral change isarduous and frustrating; arduous and frustrating; ““systemsystem””, and, andindividuals, often seem non-responsiveindividuals, often seem non-responsive

Viewed over long haul, potential for changeViewed over long haul, potential for changeis enormousis enormous (even mind-boggling)(even mind-boggling)

What will it take to continueWhat will it take to continuemaking substantial progress?making substantial progress?

CreativityCreativity

EnergyEnergy

Politically sophisticatedPolitically sophisticatedadvocacyadvocacy

ResourcesResources

LeadershipLeadership

Documents

Tobacco Control Strategies: What Worksdepts.washington.edu/tobacco/docs/Warner08.pdf · 2008-05-02 · Consumption, 1900-1973 0 1000 2000 3000 4000 5000 1900 1910 1920 1930 1940 1950