Tobacco Control Strategies: What Works
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1 Tobacco Control Strategies: What Works Kenneth E. Warner University of Michigan School of Public Health University of Washington April 2, 2008
2 Smoking then then
3 and now
4 Then Now
5 Adult Per Capita Cigarette Consumption U.S., Number of Cigarettes YEAR
6 Trends in cigarette smoking among adults aged >18 years, by sex - United States, % CURRENT SMOKERS Women Men YEAR
7 Percent Trends in cigarette smoking among adults aged >25 years, by education- U.S., Year <12 years 12 years years >=16 years
8 Stages of cultural change re smoking 1. Smoke everywhere; offer cigarette to others when lighting up; ashtrays pervasive (thru 1950s) 2. Smokers ask, as a courtesy, Do you mind if I smoke? Nonsmoker s s polite response: Not at all. (Ashtrays pervasive) (1960s)
9 Stages of cultural change re smoking (cont d.) 3. Beginning of nonsmokers rights movement leads to nonsmoking sections of restaurants. Smokers now ask with sense of trepidation Do you mind if I smoke? Increasingly, answer is I d d prefer that you don t. t. (1970s) 4. Smokers assume they should not light up in a friend s s home unless the friend has done so first; can ask if see ashtrays (1980s)
10 Stages of cultural change re smoking (cont d.) 5. Huge increase in homes with no-smoking policy including including smokers homes (1990s-on) 6. Smoke-free workplace laws extended to include bars and restaurants (2000s) a. 12 countries entirely smoke-free workplaces b. 30 states entirely smoke-free (some with minor exceptions)
11 What has produced this major behavioral and culture change?
12 U.S. anti-smoking campaign Phase I (1964-early 1970s): : Information & persuasion Phase II (1973-present; phase II of phase II in 2000s): : Non-smokers rights movement Phase III (late 1980s-?): : Comprehensive tobacco control
13 Adult Per Capita Cigarette Consumption, Number of Cigarettes End of WW II 0 Great Depression YEAR
14 Adult Per Capita Cigarette Consumption, Number of Cigarettes End of WW II 1 st Smoking-Cancer Concern 0 Great Depression YEAR
15
16 Adult Per Capita Cigarette Consumption, Number of Cigarettes End of WW II 1 st Smoking-Cancer Concern 0 Great Depression YEAR
17 Adult Per Capita Cigarette Consumption, Number of Cigarettes st Surgeon General s Report End of WW II 1 st Smoking-Cancer Concern 0 Great Depression YEAR
18 Adult Per Capita Cigarette Consumption, st Surgeon General s Report Broadcast Ad Ban Number of Cigarettes End of WW II 1 st Smoking-Cancer Concern Fairness Doctrine Messages on TV and Radio 0 Great Depression YEAR
19 Adult Per Capita Cigarette Consumption, st Surgeon General s Report Broadcast Ad Ban Number of Cigarettes End of WW II 1 st Smoking-Cancer Concern Fairness Doctrine Messages on TV and Radio Non-Smokers Rights Movement Begins Surgeon General s Report on ETS Federal Cigarette Tax Doubles Master Settlement Agreement 0 Great Depression YEAR
20 Health consequence Since 1964, > 5 million premature deaths averted in U.S. as a result of campaign- induced decisions to quit smoking or not to start. Greatest public health success of last 50 years Greatest remaining burden of preventable death and illness
21 Purpose Typology of interventions (end user perspective) Information/ education Producer / End user Incentive Law/ regulation Prevention School health ed; Truth campaign; ad ban Tax increase Sales-to-minors and PUP laws Cessation Protection from second- hand smoke 1990 Surgeon General s s report; warning labels; ad ban 1986 Surgeon General s s report on ETS Tax increase; insurance premium differentials Smoking ban in workplace, public places
22 Intervention effectiveness Tax Effective Clean indoor air laws, policies Counter-advertising Ad bans Comprehensive TC programs Not effective School health ed Warning labels (New ones?) Insurance differentials Minors possession, use, & purchase laws Sales to minors laws
23 Taxation Strongest research base of all tobacco control (TC) policies From public health pariah to First Principle of TC
24 Tax increases - Pros Overall price elasticity of demand -0.4 Approx. ½ quitting, ½ reducing cigs/day Kids twice as responsive as adults; very effective deterrent to youth smoking Generates (lots of) tax revenue ( Doing well while doing good ) Politically popular Sin tax, with redemptive features tied to youth smoking prevention) features (especially if Doesn t t affect majority, especially upper SES Progressive health impact
25 Real cigarette prices & per capita consumption US, Year consumption
26 Federal cigarette tax rate & cigarette tax revenue in the US, Year Cigarette tax rate
27 Tax increases - Cons Behavioral engineering Desired neutrality of tax policy (Here? Here?) Increased incentive for smuggling Regressivity (equity issues) Distinguish regressivity of overall tax from Progressivity/regressivity of tax increase Effects on continuing smokers among poor even if overall impact progressive
28 Smoke-free workplaces Strong research base Heart of TC movement 30 states nearly 100% smoke-free workplaces, rests. & bars 12 countries
29 Smoke-free: evidence base Substantial evidence on adverse health effects of second-hand smoke (<50,000 deaths/year) Strong evidence that bans on smoking in workplaces Dramatically reduce workers exposure to SHS (by 80-95%) Increase quitting (3.8%; median state tax) (3.8%; ~ 20% price increase or doubling of Decrease smoking among continuing smokers (3.1 cigs/day) Do not harm business in hospitality industry enterprises Reduce some business costs
30 Counter-advertising truth campaign, CA and MA campaigns, & Fairness Doctrine ads all documented to decrease smoking. Requirements: Professionally produced Well-funded Sustained
31 Advertising and promotion ban Evidence strong but not conclusive Best study: complete ban can reduce smoking 6% Partial ban ineffective due to ability to substitute other forms of promotion
32 Comprehensive TC policies (state level) Few studies; indicate small incremental effect (over additive effects of individual interventions) Risk of bias of investigators Potential for synergistic effects of multiple policies Potential for duplicative effects (sum > whole)
33 School health education Some programs show efficacy best-practice) but efficacy (impact with best-practice) but None show effectiveness (impact in everyday conditions) None show Teachers not well trained nor interested Competing demands on time Relatively low school-board priority Few resources devoted to programs Booster programs rare
34 Pack warning labels Old labels ineffective New, Canadian- style labels may increase intention to quit and, possibly, quitting
35 Sales to minors & PUP laws Sales to minors laws do not reduce youth smoking unless very seriously enforced 95% compliance needed for major impact PUP laws do not work (and generally are not even recognized by youth or parents)
36 Objectives of tobacco control Prevent initiation (children) Assist with cessation (adult smokers) Protect from secondhand smoke (nonsmokers) Harm reduction? (smokers who don t t quit)
37 Objectives as strategies: Youth- oriented prevention campaign Benefits Nip problem in the bud Maximize eventual health benefit Political acceptability (paternalism appropriate for kids) Less industry opposition Problems Ineffectiveness of many youth-oriented strategies Long-term pay-off only; misses current smokers
38 Objectives as strategies: Adult Benefits cessation campaign Maximize near-term health benefit Problems Political opposition on philosophical grounds More industry opposition Resources for individual cessation treatment Doesn t t (necessarily) cut off flow of new smokers into system
39
40 Objectives as strategies: Clean Benefits indoor air campaign Quick, substantial protection of nonsmokers Leads to more quitting among smokers Defines acceptable social behavior Problems Political opposition on philosophical grounds More industry opposition May not cut flow of new smokers into system Doesn t t reduce smoking enough
41 Comprehensive tobacco control Benefits program Addresses all issues Covers different smokers differing needs Maximum benefit Synergies among interventions (?) Problems Resources required Political opposition on philosophical grounds Industry opposition Uncertainty re best mix of interventions Duplicative effects (?) ( anti-synergy )
42 Ireland: a cautionary tale First country to have 100% smoke-free workplaces, restaurants, & bars (2004) Pack of cigarettes costs >$9.00 No cig. advertising permitted And yet
43 Ireland: a cautionary tale Smoking prevalence fell from 25.5% just before smoke-free law (March 2004) to 23.3% one year later. A year later, to 24.5%! Dec. 2007, 24% 16% of year-olds smoke
44 Ireland: a cautionary tale What explains difference between U.S. (with its relatively modest policies) and Ireland? Norms What can Ireland do? Media campaign Role modeling (athletes, music and movie stars Think Bono!)
45 Aggregate impacts of TC in US Dramatic but over time Smoking prevalence by > ½ Per capita cigarette consumption 1/3 of what it would have been in absence of antismoking campaign > 5 million smoking-produced premature deaths averted as a result of campaign, with average beneficiary gaining years of life expectancy
46 How did this happen? Resulted from combination of public education/information campaign push for smoke-free air policies and laws use of extrinsic + intrinsic motivations focus on youth smoking prevention, adult quitting (aided, slightly, by cessation treatments), and protection of rights of nonsmokers Relied upon norm change
47 Where do we go from here? Likely near-future directions More states go smoke-free Within 5 years or so, nearly all states will be smoke-free Federal cigarette excise tax to $1-2 per pack (from $0.39 now); state taxes U.S. smoking prevalence to % by 2020 (now 20.8%) More emphasis on harm reduction??
48 Generalizable lessons Most powerful drivers of health behavior change are those that change norms Smoke-free policies/laws Anti-smoking media campaigns Exception: tax Process of social (and norm) change, as illustrated by tobacco control story, involves Info/ed first, understood and acted upon by SES elite Elites most politically enfranchised lobby for policy changes Middle and lower SES respond to social pressures and environmental changes (smoke-free laws, higher prices, antismoking media campaigns)
49 Generalizable lessons (cont d.) Utilize multiple intervention types Info/education; incentives; law/regulation Viewed from short-term perspective, creating cultural and behavioral change is arduous and frustrating; system,, and individuals, often seem non-responsive Viewed over long haul, potential for change is enormous (even mind-boggling)
50 What will it take to continue making substantial progress? Creativity Energy Politically sophisticated advocacy Resources Leadership
51
SLIDE 1: Good morning; I would like to thank the organizers for the opportunity to speak today on a significant issue the relationship between tobacco taxation and public health. Much of the background
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