Tobacco Use Prevention and Denormalization

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Tobacco Use Prevention and Denormalization
Californias Model including ETS

• November 2002
• Australia
• Dileep G. Bal, M.D.

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WRITTEN DISCLAIMER

• This presentation represents the opinions of
• Dileep G. Bal, M.D.
• and not the California Department of Health
  Services, in any way whatsoever. The opinions of
  either can change without further notice.

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Etymology of the WordPOLITICS

• Poly Many
• Ticks Blood Sucking Creatures

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Big Funding Picture
Health Education Account2000-01 TCS (millions)
DHS Competitive Grants
DHS Evaluation
DHS Administration
DHS Local Lead Agencies
Dept. of Education
DHS Media
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DHS Tobacco Control Program
Statewide Evaluation
Statewide Media Campaign
4 Ethnic Networks
11 Regions
61 Health DepartmentCoalitions
83 Competitive Grantees
Training/ TA
Clearing-house
Quitline
CDC
Legacy
STAKE
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Denormalization
Goal change social norm
Outcome prevention cessation
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Were not attempting to circumcise the rules.

• --Bill Cowher
• Pittsburgh Steelers Coach

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Strategy to Reduce Tobacco Use in California
Reduce Exposure to ETS and Tolerance to Exposure
Decrease Tobacco Consumption
Decrease Tobacco Use Prevalence
Counter Pro-Tobacco Influences
Decrease Youth Uptake of Tobacco
Reduce Access to Tobacco from Retail Social
Sources
Decrease Exposure to ETS
Provide Cessation Services
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The distinction between targeted, even
aggressive health education (Kosher) and
lobbying (Verboten)
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Statewide Projects
Direct Service Providers
Impact Leaders and Institutions

• Quitline
• Clearinghouse
• Tobacco Industry Sleuthing Project

• Youth Advocacy Network
• Entertainment Industry Campaign
• Key Opinion Leader Project
• Divestment Project
• Labor Project
• Ethnic Networks

Training/TA Providers

• Technical Assistance Legal Center
• Media/PR Technical Assistance
• BREATH (Smoke-free Bar Project)

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Mature Campaign

Apathy
Awareness
Contentment
Concern
The Cycle Of A Social Issue
Expectation
Attitudinal Shift
Social Norm
Social Expectation
Action/ Legislation
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Smoking Prevalence Among California Adults,
1984-2001
Percent
Source Behavioral Risk Factor Surveillance
System 1984-1992, Behavioral Risk Factor
Surveillance System and California Adult
Tobacco Survey combined 1993-2001. Note change of
smoking definition in 1996 that included more
occasional smokers. Prepared by California
Department of Health Services, Tobacco Control
Section, May 2002.
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Age-adjusted Smoking Prevalence Among California
Adults by Racial/Ethnic Group, 1994-2001
Percent
Source Behavioral Risk Factor Surveillance
System / California Adult Tobacco Survey
1994-2001 is weighted to the the 1990
California population. Note definitional change
of smoker in 1996 to include more occasional
smokers. Prepared by California Department of
Health Services, Tobacco Control Section, May
2002.
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California and U.S. Adult Per Capita Cigarette
Consumption, Packs Per Fiscal Year,
1980/1981-2000/2001
Packs/Person
US
CA
Source California State Board of Equalization
(packs sold) and California Department of Finance
(population). U.S. Department of
Agriculture. Note that California data is by
fiscal year (July 1-June 30) and U.S. data is by
calendar year. Prepared by California
Department of Health Services, Tobacco Control
Section, April 2002.
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Percent of Smokers with Children under 18 Years
of Age, Who Prohibit Smoking in Their Household,
California vs. U.S. (1998)
Percent
Sources U.S., MMWR, Volume 48, No. 43, 11/15/99
California, CATS 1998
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1999 Youth Smoking PrevalenceSubstance Abuse and
Mental Health Services Administration (SAMHSA)
23.9
15.1
11.5
10.3
9
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Statistics are merely aggregations of numbers
with the tears wiped away.

• --Dr. Irving Selikoff

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Lung Cancer Rates, 1988-1996 (TIME-LAG ISSUE ! !
!)

• Total changes over 8 years
• -14.4 California
• -4 United States
• California lung cancer rates have been declining
  for both genders however, nationally womens
  rates are still increasing.
• Male decreases
• -20.3 California
• -12.6 United States
• Female decrease/increase
• -6.7 California
• 9.3 United States

United States Surveillance, Epidemiology, End
ResultsCalifornia California Cancer Registry
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Gains Against Lung Cancer

• These decreases in California lung and bronchus
  cancer incidence rates equate to substantial
  reductions in the toll of tobacco over the past 8
  years in California
• There were approximately 3,000 to 4,000 fewer
  lung/bronchus cancer cases per year during this
  period in California.
• There were an estimated 2,000 fewer deaths per
  year from lung or bronchus cancer in California.
  

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Relation Between Policy and Cigarette Consumption
Daily Cigarette Consumption and Smoking Bans
Cigarettes/Day
Source CTS 1999
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Public Support for a Tobacco Tax Increase
Cumulative Percentage Favoring Additional
Cigarette Excise Tax
Percent Cumulative
Additional Excise Tax
Source CTS 1996, 1999
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Savings in Smoking-Attributable Costs
8.4 Billion
836 Million
Source DHS/TCS Data Analysis and Evaluation
Unit, 1999.
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Conclusions

• A comprehensive program is most effective.
• Media and local programs must be coordinated and
  well funded.
• If you want kids to not smoke, you have to get
  the adults to change their behavior.
• Anti-industry and secondhand smoke strategies are
  effective.
• Empower the communities to advocate.
• Be culturally sensitive and use the power of the
  communities.
• Oversight and accountability is the key to
  success.
• Provide strong leadership and allow program
  flexibility.

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Strategy-Strategy-Strategy

• Secondhand Smoke
• Rallied 75 non-smokers
• Personalized issue of smoking
• Created basis for policy
• Promoted cessation messages
• Industry Attack
• Held Tobacco Industry responsible
• Generated world attention
• Labeled Tobacco Industry bad guy - not smokers

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Youth Strategic Learning Strategies that DIDNT
Motivate

• Long-term health effects
• Short-term health effects
• Short-term cosmetics effects
• Romantic rejection
• Smoking isnt cool

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Youth Strategic Learning Strategies that DID
Motivate

• Tobacco Industry Manipulation
• Nicotine Addiction
• Secondhand smoke is more dangerous than you
  think
• Impactful personal stories

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• Now on to the story of Second Hand Smoke a.k.a.
  Environmental Tobacco Smoke a.k.a. ETS.

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AB (Assembly Bill) 13/AB 3037 Californias
Smoke-Free Workplace Law

• Effective January 1, 1995 - state law prohibited
  smoking in nearly all enclosed worksites. This
  eliminated the need for local governments to
  enact workplace smoking restrictions within their
  respective jurisdictions.
• On January 1, 1998, bars, taverns and gaming
  clubs went smoke-free.

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Enforcement (cont.)

• Who?
• Local Agency
• Non-compliance
• 100/first violation
• 200/2nd violation within 1 year
• 500/3 violations within 1 year
• Referred to Cal-OSHA-7,000

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Smoking in Bars Compliance

• 75 of California Bar Patrons DONT SMOKE IN BARS
  (1997)
• 75 of Bar Patrons who Smoke COMPLY WITH THE LAW
  (1998)
• 90 of Bars and Restaurants COMPLY WITH THE LAW
  (1999)

July 1997, March 1998 and August 1998 studies
conducted by the Field Poll Corporation for the
California Department of Health Services, Tobacco
Control Section, Informal statewide survey
conducted 1/99.
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What the Tobacco Industry Cant Lie About

• Several Field Polls have been conducted which
  found increasing support for smoke-free
  environments and laws, including bars.
• Annual taxable sales figures for eating and
  drinking establishments show continuing increases
  in sales tax revenues.
• The tourism industry has not been affected by
  smoke-free restaurants and bars.

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An internationally renowned expert on indoor air,
James Repace, testified before the NY City
Council. He made the following 4 arguments

• (1). Levels of fine particle pollution (PM2.5) in
  3 city bars were 50 times as high as in the
  Holland Tunnel (a major highway route under the
  Hudson River) during rush hour, and exceeding the
  level of the US National Ambient Air Quality
  Standard by a factor of 58.
• (2). Based on those air pollution measurements, a
  substantial fraction of the city's 200,000
  hospitality workers had an annual mortality risk
  of 300 per 100,000.

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James Repace arguments continued

• (3). The smoking prevalence in Los Angeles is
  18, in New York City, it's 19, and revenues in
  California went up considerably every year after
  the smoke-free bar law in 1998.
• (4). Control of secondhand smoke (SHS) by
  ventilation would require tornado-like levels of
  airflow. The opponents of this legislation
  (CLASH) behaved like the bunch of obnoxious boors
  hired by the tobacco industry that they were.

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Some Non-Random Reflections, Ruminations, and
Rumblings
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The meek may inherit the Earth, but they are not
going to push their agenda.
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Government is a contrivance of human wisdom to
provide for human wants. Men have a right that
these wants should be provided for by this
wisdom.-EDMUND BURKE, (FROM REFLECTIONS ON
THE REVOLUTION IN FRANCE-1790)
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When spider webs unite, you can bind a
lion.-Jomo Kenyatta
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He who accepts evil without protecting against
it, is really cooperating with it.
-Rev. Martin Luther King, Jr.
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If you want to change the world, be that
change.

• --Mahatma Gandhi

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I slept and dreamt that life was joyI awoke and
saw that life was dutyI acted and behold! duty
was joy.

• --Indians Nobel Prize Winning LaureateRabindrana
  th Tagore