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Applying Lessons Learned from Tobacco Control to Promote Physical Activity and Healthy Eating

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Applying Lessons Learned from Tobacco Control to Promote Physical Activity and Healthy Eating

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    1. Applying Lessons Learned from Tobacco Control to Promote Physical Activity and Healthy Eating Jamie F. Chriqui, Ph.D., M.H.S. Frank J. Chaloupka, Ph.D. Bridging the Gap Program Health Policy Center Institute for Health Research and Policy University of Illinois at Chicago Workshop for the CDC HDSP Annual Grantee Meeting September 14-15, 2010 Atlanta, GA

    2. Presentation Overview Review key policy/environmental strategies designed to reduce tobacco use Highlight policy strategies aimed at increasing physical activity and/or healthy eating outside of school environments Small group interactive exercise Large group discussion

    3. PI: Frank Chaloupka Co-Investigators and key staff include: Lisa Powell, Sandy Slater, Lindsey Turner, John Tauras, Melanie Wakefield, Lloyd Johnston, Patrick O’Malley, Dianne Barker, Leah Rimkus, Glen Szczypka, Euna Han, Jidong Huang, Sherry Emery and many others…….

    4. Policy/ENVIRONMENTAL Strategies to reduce tobacco use

    6. After a Systematic Review of the Scientific Literature, the Task Force on Community Preventive Services Recommends the Following Interventions to Reduce Tobacco Use and Protect Nonsmokers

    7. TOBACCO TAXES AND TOBACCO USE

    8. Cigarette Taxes in the US, July 2010

    9. State and Federal Cigarette Taxes Inflation adjusted, 1990-2009

    10. State and Local Cigarette Taxes and Average Price per Pack November 1, 2009

    11. Cigarette Taxes & Prices, United States, 1954-2009 (Oct. 2009 dollars)

    12. Taxes and Tobacco Product Prices Globally Tax levels and prices, vary widely across countries Price and Tax by Income Level, 2008

    13. Cigarette Marketing Expenditures by Type, 1975-2006

    14. Tobacco Industry Efforts to Offset Tax Increase On February 4th, 2009, the Federal Government enacted legislation to fund the expansion of the State Children's Health Insurance Program (SCHIP) that increases excise taxes on cigarettes by 158%. As a result, you will see the price of all cigarettes, including ours, increase in retail stores. We know times are tough, so we'd like to help. We invite you to register at Marlboro.com to become eligible for cigarette coupons and special offers using this code: MAR1558 Thank You, Philip Morris USA

    15. Impact of Federal Tax Increase Based on our estimates, the recent $0.6167 per pack increase in the Federal cigarette tax will: Reduce cigarette sales by over 900 million packs Generate almost $9 billion in new revenues Lead over 1.15 million current smokers to quit Prevent over 1.45 million youth from taking up smoking Prevent almost 720,000 premature deaths caused by smoking Generate significant reductions in spending on health care to treat diseases caused by smoking

    16. Tobacco Tax Increases and Tobacco Use Higher taxes and prices: lead current smokers to quit prevent relapse keep kids from taking up tobacco use reduce consumption among continuing users induce other changes in purchase and use behaviors Estimates from high-income countries indicate that 10% rise in price reduces overall cigarette consumption by about 4% Most elasticity estimates in range from -0.25 to -0.5, clustered around -0.4

    17. Cigarette Prices and Cigarette Sales, United States, 1970-2009

    19. Young People More Price Sensitive Proportion of disposable income youth spends on cigarettes likely to exceed that for adults Peer influences much more important for young smokers than for adult smokers about 1/3 of overall impact of price on youth accounted for by indirect impact through peers Young smokers less addicted than adult smokers Young people tend to discount the future more heavily than adults Other spillover effects for example, through parental smoking

    21. This data illustrates importance of tracking tobacco control funding; data are being used to inform states, CDC, advocacy groups on how tobacco control funding is taking a hit and how this could impact tobacco control gains made in recent decadesThis data illustrates importance of tracking tobacco control funding; data are being used to inform states, CDC, advocacy groups on how tobacco control funding is taking a hit and how this could impact tobacco control gains made in recent decades

    22. Smoke-free air and smoking cessation laws

    23. Available at: http://www.impacteen.org/chartbooks.htm Acknowledge Gary for the chartbook and all of the tobacco slidesAcknowledge Gary for the chartbook and all of the tobacco slides

    24. State Smoke-free Air Laws Really Started with Government Worksites State Smokefree laws really started in Government Worksites. As you can see by this chart, as of the end of 1995, 41 states had Some form of government worksite smoking restriction (predominately DSAs). Over time, as the science became more clear, States increasingly shifted from DSAs to complete smoking bans in government worksites. By the end of 2009, 48 states had some Type of government worksite law but only 9 were DSAs, 34 were complete bans. Only TX, KY and WY don’t have laws currentlyState Smokefree laws really started in Government Worksites. As you can see by this chart, as of the end of 1995, 41 states had Some form of government worksite smoking restriction (predominately DSAs). Over time, as the science became more clear, States increasingly shifted from DSAs to complete smoking bans in government worksites. By the end of 2009, 48 states had some Type of government worksite law but only 9 were DSAs, 34 were complete bans. Only TX, KY and WY don’t have laws currently

    25. Major Smoke-free Air Legislation in the 50 States and the District of Columbia – 1991-2008 As you can see here, most of the uptake in SFA laws governing private worksites, restaurants and bars didn’t occur until Mid-late 2000s. As of 2008, 32 states banned smoking in at least one of these areasAs you can see here, most of the uptake in SFA laws governing private worksites, restaurants and bars didn’t occur until Mid-late 2000s. As of 2008, 32 states banned smoking in at least one of these areas

    26. States that Preempt Local Jurisdictions from Passing Stronger Smoke-free Air Laws – as of September 30, 2008

    27. States Providing Strong Protection from Tobacco Smoke Pollution in Private Worksites, Restaurants and/or Bars – as of April 30, 2009

    28. Smokers’ Receipt of Advice to Quit from a Physician — 2006/2007

    29. Provision of Tobacco Dependence Treatment Services to Medicaid Recipients – 2006

    30. Medicaid Coverage of Cessation Aids in the 50 States and DC: 1990-2006

    31. Establishment of Quitline Services in the 50 States and DC: 1991-2006

    32. States Offering Free/Discounted Cessation Medication to Eligible Smokers – as of September 30, 2008

    33. Implications of Tobacco Control Policymaking for Obesity Prevention Policy and environmental strategies across all levels of government have been effective at lowering tobacco consumption In the smoke-free air policy arena, much of the policy action started with policies focused on government worksites Policy action affecting private worksites, restaurants and bars lagged markedly behind government worksite restrictions Core policy strategies to date focus on increasing price and reducing ability to smoke in public places combined with treatment options New FDA regulation will add new frontier regarding advertising/marketing/labeling Primary challenge: Single industry—tobacco

    34. STRETCH BREAK

    35. Obesity Trends and Policy Strategies

    36. Obesity-related Policies Address both sides of the Energy Balance Equation

    37. Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2009 (*BMI ?30, or about 30 lbs. overweight for 5’4” person)

    38. 1988–2008 No Leisure-Time Physical Activity Trend Chart

    40. FOOD prices, Obesity Trends and Policy options

    41. Selected Food Price Trends, 1961-2009 Inflation Adjusted

    42. Selected Food Price Trends, 1978-2009 Inflation Adjusted

    43. Food Prices and Obesity Prevalence 1995-2009, Inflation Adjusted

    44. Food Prices and Obesity Prevalence 1995-2009, Inflation Adjusted

    45. Food Prices and Consumption Extensive economic research on the impact of food and beverage prices on consumption of various products; estimates suggest 10% own-price increase would reduce: Cereal consumption by 5.2% Fruit consumption by 7.0% Vegetable consumption by 5.9% Soft drink consumption by 7.8% Sweets consumption by 3.5% Food away from home consumption by 8.1%

    46. Food Prices and Weight Outcomes Relatively limited research to date on impact of food and beverage prices and weight outcomes: Higher prices for sugary foods would significantly reduce prevalence of overweight and obesity among adults (Miljkovic et al., 2008) 10% increase in fast food prices would reduce prevalence of adolescent obesity by almost 6% (Powell, et al., 2007) Weight outcomes among low-income populations and those with higher BMI more responsive to prices BMI of kids in families below poverty level about 50% more responsive to F&V prices BMI for kids at unhealthy weight levels 39% more responsive to F&V prices BMI of adolescents at unhealthy weight levels about 4 times more responsive to F&V and fast food prices.

    47. Policy Options Related to Food Prices Emerging evidence on prices suggests that significant changes in relative prices of healthy and unhealthy foods could reduce BMI and likelihood of obesity Increases in prices of less healthy foods and beverages taxes elimination of corn subsidies disallow purchases under food assistance programs Reductions in prices of more healthy foods and beverages subsidies expanded or favored treatment under food assistance programs

    48. Policy Options: Sugar Sweetened Beverage Taxes

    49. Policy Options: Sugar Sweetened Beverage Taxes

    50. Soda Consumption and Weight Outcomes California Counties, 2005

    51. State Approaches to SSB Taxation

    52. Sales Taxes on Selected Beverages, All States (as of July 1, 2010) Jamie Note: This slide was revised 7/26/10 to fix Sweetened Tea rate for MaineJamie Note: This slide was revised 7/26/10 to fix Sweetened Tea rate for Maine

    53. Sales Taxes on Selected Beverages, Taxing States (as of July 1, 2010)

    54. Sales taxes applied to vending machines sales, selected beverages (as of July 1, 2010)

    55. States with Non-Sales* Taxes on Selected Beverages (as of 7/1/10) or SSB-related Legislative Proposals in 2010 DC and Philadelphia proposals also died in CommitteeDC and Philadelphia proposals also died in Committee

    56. State SSB-related Legislative Activity, 2010 Legislative Session (includes carryover)—as of 8/27/10 8 states have introduced SSB-specific excise/ privilege tax bills during the current legislative session: California and Kansas (tax upon sweetened beverage manufacturers at a rate of $0.01/teaspoon sugar in SSB/concentrate) Hawaii (1% gross proceeds on sale of SSBs) Mississippi ($0.02/ounce or $2.56/gallon produced from syrup)—Died in Committee New Mexico ($0.005/ounce imposed on distributors) New York ($1.28/gallon bottled soft drinks; $1.28/gallon soft drink produced from powder/mix; $7.68/gallon of syrup) Rhode Island ($0.05/20 ounces or $0.10/>20 ounces) – in addition to existing non-sales taxes South Carolina ($0.01/13.5 grams of concentrate of sugar placed into SSB concentrate imposed on manufacturers) City-level tax proposals Philadelphia - $0.02/ounce – Died in City Council Washington DC - $0.01/ounce – Died in DC Council (but did extend sales tax base to include SSBs effective 10/1/10)

    57. Policy Options: SSB Taxes Recent and ongoing research suggests Household soda purchases lower in states where higher sales tax applies to sodas

    58. Policy Options: SSB Taxes Recent and ongoing research suggests Some children’s soda consumption lower where sales taxes are higher; specifically those who are: already overweight, African American, and/or in low income families Likelihood of obesity not associated with presence or level of tax Weight gain not affected by presence/level of tax, except for: already overweight, African American, and/or in low income families Current taxes too low to significantly impact obesity

    59. Policy Options: SSB Taxes Revenue generating potential of tax is considerable SSB Tax calculator at: http://www.yaleruddcenter.org/sodatax.aspx Tax of one cent per ounce could generate: $14.9 billion nationally if on SSBs only $24.0 billion if diet included Tax of two cents per ounce: $21.0 billion nationally, SSBs only $39.0 billion if diet included Earmarking tax revenues for obesity prevention efforts would add to impact of tax

    60. Policy Options: SSB Taxes From a public health perspective, specific excise tax preferable to sales tax for several reasons: More apparent to consumer Easier administratively Reduces incentives for switching to cheaper brands, larger quantities Revenues more stable, not subject to industry price manipulation Greater impact on consumption; more likely impact on weight outcomes Disadvantage: need to be adjusted for inflation

    61. Policy Options: SSB Taxes

    62. Policy Options: SSB Taxes Many of the same arguments used to oppose tobacco taxes Won’t generate expected revenues Substitute to untaxed products Cross-border shopping to avoid tax Regressive Will put many out of work Won’t affect obesity rates

    63. Summary: Taxes/Price as Policy Strategy Increased tobacco taxes have been highly effective in reducing tobacco use and the death and disease it causes Promote cessation, prevent initiation Food/beverage prices significantly affect consumption; emerging evidence that relative prices of healthy/less healthy products affects weight outcomes Greater impact on young people, those on lower incomes, and those already at higher weight Existing, small taxes have little impact on weight outcomes Potential for larger taxes to significantly influence obesity rates

    64. Non-Price policy options to encourage healthy eating and physical activity outside of school environments

    65. Institute of Medicine Report on Local Government Actions to Prevent Childhood Obesity—selected healthy eating recommendations Goal 1: Improve access to and consumption of healthy, safe and affordable foods through: Retail outlets (incentive programs, tax credits, etc.) Restaurants (improve availability/identification of healthful foods through menu labeling and other strategies) A variety of settings such as farmers’ markets, farm stands, mobile markets, community gardens Public programs and worksites such that they implement policies and practices to promote healthy foods and beverages and reduce or eliminate the availability of calorie-dense, nutrient-poor foods Increase participation in federal, state and local government nutrition assistance programs Title focused on Childhood Obesity but reality is that it can be broadly appliedTitle focused on Childhood Obesity but reality is that it can be broadly applied

    66. Institute of Medicine Report on Local Government Actions to Prevent Childhood Obesity—selected physical activity recommendations Goal 1:Encourage physical activity through: Built environment improvements that support active transport and active recreation Promotion of programs for walking/biking for transportation and recreation Promotion of policies that build physical activity into daily routines Worksite policies/practices building PA into daily routines (exercise breaks; walking meetings; stair use)

    67. After a Systematic Review of the Scientific Literature, the Task Force on Community Preventive Services Recommends the Following Interventions related to Obesity Prevention and Control Key here is on worksites – recall from tobacco, it all started with government worksitesKey here is on worksites – recall from tobacco, it all started with government worksites

    68. Examples of State and Local Policies to Improve Access to Healthy Foods and Beverages State Examples Massachusetts (EO 509, Jan. ‘09) –Establishes nutrition standards for food purchased and served by state agencies based on Dietary Guidelines Local Examples Berkeley, CA (Food and Nutrition Policy, 2001): Access to healthy, affordable food by promoting sustainable agriculture and local economy; supports farmers markets; improve public transit to increase access to affordable healthy foods Palm Beach County, FL; San Francisco, Los Angeles County, Santa Ana, Chula Vista, Santa Clara, CA: nutritional standards for foods sold in vending machines on government property Woodbury County, IA: purchase locally grown organic produce for County Departments regularly serving food Clark County, WA: Healthy food and beverage purchase guidelines

    69. Examples of Governmental Policies to Improve Physical Activity New York City, NY: Bicycle Access to Office Buildings (Policy 52, 8/31/09) Complete streets and/or Street design/ connectivity ordinances/regulations/plans to facilitate walking/biking for active transport and recreation (e.g., Cornelius, NC; Ava, MO) Many local governments: Joint use agreements that provide community access to school/park/ recreation facilities for physical activity purposes Community trails legislation/funding Worksite wellness policies Messaging/promotion related to use of stairs in lieu of elevator Worksite wellness—all starts with government agenciesWorksite wellness—all starts with government agencies

    70. Institute of Medicine Recommendations for Strategies to Reduce Sodium Intake in the United States—Selected Strategies Recommendation 2 (Interim Strategy):…The food industry, government [sic], professional organizations, and public health partners should work together to promote voluntary collaborations to reduce sodium in foods Recommendation 3 (Supporting Strategy): Government agencies, public health and consumer organizations, and the food industry should carry out activities to support the reduction of sodium levels in the food supply Food retailers, governments, businesses…that purchase or distribute food should establish sodium specifications for the foods they purchase and the food operations they oversee

    71. Institute of Medicine Recommendations for Strategies to Reduce Sodium Intake in the United States—Selected Strategies Recommendation 4 (Supporting Strategy): … Government agencies, public health and consumer organizations, health professionals, the health insurance industry, the food industry…should conduct augmenting activities to support consumers in reducing sodium intake …[They] should continue or expand efforts to support consumers in making behavior changes to reduce sodium intake in a manner consistent with the Dietary Guidelines for Americans Sodium Intake Consume less than 2,300 mg approximately 1 tsp of salt) of sodium per day. Choose and prepare foods with little salt. At the same time, consume potassium rich foods, such as fruits and vegetables. Key Recommendations for Specific Population Groups Individuals with hypertension, blacks, and middle aged and older adults. Aim to consume no more than 1,500 mg of sodium per day, and meet the potassium recommendation (4,700 mg/day) with food. Sodium Intake Consume less than 2,300 mg approximately 1 tsp of salt) of sodium per day. Choose and prepare foods with little salt. At the same time, consume potassium rich foods, such as fruits and vegetables. Key Recommendations for Specific Population Groups Individuals with hypertension, blacks, and middle aged and older adults. Aim to consume no more than 1,500 mg of sodium per day, and meet the potassium recommendation (4,700 mg/day) with food.

    72. Examples of Policies Aimed at Reducing Sodium Intake New York City Health Bulletin #72: Cut the Salt! And lower your blood pressure and risk of heart attack and stroke. Provides specific recommendations for residents to reduce sodium intake at restaurants, at home, while shopping New York City Agency Food Standards (2008): Food purchased and served in city agencies must follow sodium guidelines.

    73. Obesity Policymaking: Status and Opportunities Policy and environmental strategies seen as principal interventions early on Policy change rapidly diffusing across all levels of government Primary challenges Multiple industries (food, beverage, restaurant, agriculture) Food/beverages needed to live (unlike tobacco) Do not face the illegalities like with tobacco and youth Need time to understand true impact of policy strategies on system, community and individual behavior/attitudinal changes

    74. Small Group Didactic Exercise What are some examples of policy strategies that your state has taken to encourage healthy eating and/or physical activity? Community-level Worksite Government agencies What are some of the challenges/barriers that your state has faced (or may face) in trying to develop/implement policy strategies designed to encourage healthy eating and/or physical activity?

    75. For more information: www.bridgingthegapresearch.org www.impacteen.org jchriqui@uic.edu

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