Restrictions on Tobacco Use, Sales & Marketing
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1 Restrictions on Tobacco Use, Sales & Marketing Frank J. Chaloupka Developing Public Health Regulations for Marijuana: Lessons from Alcohol and Tobacco Arlington, VA, February
2 2 Smoke-Free Air Policies
3 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.
4 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
5 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
6 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
7 2006 Surgeon General s Report 7 Eliminating smoking in indoor spaces fully protects nonsmokers from exposure to secondhand smoke Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposure of nonsmokers to secondhand smoke
8 Smoke-Free Policies, 2012 Source: Americans for Nonsmokers Rights Foundation
9 Smoke-Free Policies Globally Source: WHO 2011
10 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
11 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
12 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
13 50 Smoke Free Air Policies and Young Adult Smoking Prevalence, Smoking Prevalenc y = x R 2 = Smoke Free Air, State Policy Index Source: NSDUH, Mayatech &RPCI, and author s calculations
14 31 Smoke Free Air Policies and Adult Smoking Prevalence, Adult Smoking Prevalenc y = x R 2 = Smoke Free Air, State Policy Index Source: NSDUH, Mayatech &RPCI, and author s calculations
15 Social Norms About Smoking % Disapproving of Smoking One or More Packs per Day Smoke-Free Policy Index Smoke-Free Policies Disapproval, 8th Grade Disapproval, 10th Grade 0 Source: ImpacTeen Project, UIC; Monitoring the Future, 2012
16 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
17 Limits on Youth Access 17
18 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
19 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 19 Not self-enforcing
20 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 FDA! Required MLPA of 18 for tobacco products! Had to demonstrate compliance with policies! strong youth access program! Resumed with Family Smoking and Prevention Act of
21 Youth Access Policies Youth Access to Tobacco Products Scores, Youth Access Index 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).
22 Youth Access Policies 22 Source: SAMHSA, 20012
23 Compliance & Availability % Saying Easy or Fairly Easy to Get % of Retailers Selling to Minors Perceived Availability, 8th Grade Perceived Availability, 10th Grade Synar Non-Compliance Rate Source: SAMHSA, 20012; Monitoring the Future,
24 Youth Access Policies! History Initial focus on retailers led to call for policies holding youth accountable! Led to policies that penalize youth for purchase, possession, and/or use 24
25 Youth Access Policies Mean Number of State Purchase, Possession and Use Laws, per State, PPU Year Source: Roswell Park Cancer Institute and the ImpacTeen Project, unpublished data
26 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
27 20 Youth Access Policies and Youth Smoking Prevalence Smoking Prevalenc y = x R 2 = Youth Access Policy Index 27 Sources: Substance Abuse and Mental Health Services Administration (2006a), National Cancer Institute (2007), and author s calculations
28 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! Heavier smokers rely more on commercial sources than on social sources 28
29 Youth Smoking Prevalence and Synar Compliance H i g h 27 S c h o l 22 S t u d e n t S m ok i n g 17 P rev 12 a l e n ce Synar Non- Compliance Rate 29 Source: SAMHSA, 2009; YRBS, 2009
30 Youth Access Policies! Impact of youth access policies No evidence that PPU policies significantly reduce youth smoking! May have some impact on kids at lowest risk to begin with 30
31 20 Purchase, Possession and Use Policies and Youth Smoking Prevalence, Smoking Prevalenc y = x R 2 = PPU Policy Index 31 Sources: Substance Abuse and Mental Health Services Administration (2006a), ImpacTeen unpublished state policy data, and author s calculations
32 Tobacco Marketing 32
33 Impact of Tobacco Marketing! 1989 Surgeon General s report described four ways that marketing could directly affect tobacco use: By encouraging youth experimentation and uptake By increasing consumption among current users By reducing current users motivation to quit By 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
34 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
35 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
36 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
37 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
38 $16,000.0 $14,000.0 Cigarette Company Marketing Expenditures, by Type, $12,000.0 M il l i o n D ol l a r s $10,000.0 $8,000.0 $6,000.0 $4,000.0 $2,000.0 $ Advertising Pub.Entertainment Placement Price Merchandise Other Source: author s calculations from data reported in FTC (2011)
39 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
40 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
41 Comprehensive advertising bans reduce cigarette consumption Consumption trends in countries with such bans vs. those with no bans Cigarette consumption per capita (n=102 countries) No Ban Ban Year Source: Saffer, 2000
42 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
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47 State Tobacco Control Funding $1,000.0 M il l i o n s $800.0 o f A u g D ol $600.0 $400.0 l a r s $200.0 $ Source: Bridging the Gap, ImpacTeen project
48 Tobacco Company Marketing vs. State Tobacco Control Funding $18,000.0 $16,000.0 M il $14,000.0 l i o n s $12,000.0 o f A u g D ol l a r s $10,000.0 $8,000.0 $6,000.0 $4,000.0 $2,000.0 $ Source: Bridging the Gap, ImpacTeen project
49 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 Source: NCI Monograph 19 49
50 Program Funding & Perceived Risk 45 % Perceiving Great Risk of Smoking One or More Packs per Day State Program Funding 8th Grade 10th Grade 50 Source: ImpacTeen Project, UIC; Monitoring the Future
51 Program Funding & Youth Smoking 37 $1, Total Funding $Millions (FY10 dollars) $800 $600 $ Percent Current Smoking $ $ Year 19 Source: ImpacTeen Project, UIC; YRBS total state program funding high school prevalence 51
52 Lessons Learned 52
53 Social Norms Cigarettes & Marijuana % Disapproving Source: Monitoring the Future, 2012 Cigarette Disapproval, 10th Grade Marijuana Disapproval, 10th Grade 53
54 Perceived Risk Cigarettes & Marijuana % Perceiving Great Risk Source: Monitoring the Future, 2012 Cigarettes, Perceived Risk, 10th Grade Marijuana, Perceived Risk, 10th Grade 54
55 ! Restrictions on Use Lessons Learned! 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
56 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
57 For more information: (coming soon)
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