Best Practices in Tobacco Control Programs: Update

1. Best Practices in Tobacco Control Programs: Update Stanton Glantz, PhD Center for Tobacco Studies University of California, San Francisco

2. CDC’s Best Practices for Tobacco Control Programs • Tobacco control programs should be comprehensive, sustainable, and accountable • CDC recommends that states establish and sustain tobacco control programs that contain the following overarching components: • State and community interventions • Health communication interventions • Cessation interventions • Surveillance and evaluation • Administration and management

3. Comprehensive Tobacco Control Programs • Prevent smoking initiation • Help smokers quit • Educate the public, the media, and policymakers about policies that reduce tobacco use • Serve as a counter to the ever-present tobacco industry

4. Recent Evidence • 2007 landmark reports conclude“there is overwhelming evidence that state tobacco control programs substantially reduce tobacco use” • Dose response relationship between levels of spending and program effect • Best funded and most sustained tobacco prevention programs during the 1990s—Arizona, California, Massachusetts, and Oregon—reduced cigarette sales more than twice as much as the country as a whole (43 percent compared to 20 percent) Text source: National Cancer Institute. (2007). Institute of Medicine. (2007). Farrelly, M.C. et al. (2003).

5. The California Tobacco Control Program • Began in the 1970s with Minnesota Clean Air Act • Nonsmokers rights activism • Unsuccessful efforts in state legislature • Two failed ballot initiatives (1978, 1980) • Created foundation for later successes

6. The California Tobacco Control Program • Shifted to local organizing • Takes advantage of strong public support • Local politicians more sensitive to people than state or national politicians • Fewer resources required to mount a successful campaign • Tobacco industry weaker than at higher levels in the political system • “Educate then legislate”

7. Need for Proactive Implementation • Education of public and business • Focus on nonsmokers and benefits of law • Fixed grace period when focus is on education not enforcement • Strong visible enforcement after grace period Image source: World Health Organization. (2007).

8. Anticipate Industry Pushback after the Law Passes • Often through “third parties” • Restaurant, bar, casino “organizations” • Libertarian think tanks and politicians • Claims of economic chaos and widespread defiance • Litigation • Efforts to repeal • Legislative and referendum • Lasts six to nine months

9. Defend the Law • Positive testimonials • More valuable than statistical evidence • Visible public support • Defend the law in court and politically • Serious enforcement • Many successes: California, New York City, Victoria, British Columbia, Ireland, Mexico City • Some failures: Holland bars

10. A Year Later • Law grows in popularity • With everyone, nonsmokers and smokers • Everyone will wonder what the big deal was • Model for success elsewhere

11. Proposition 99 (1988) • Idea came from environmental movement • 25 cent tax increase • 5 cents to tobacco control • 1 cent to research • 1 cent to environment • Rest to medical services • Led to the largest tobacco control program in history Image source: Glantz, A. and Balbach, E. (2000).

12. Politics of Implementation • Advocates underestimated resistance • Tobacco industry • California Medical Association (right) • Western Center on Law and Poverty (left) • Agreed to small diversions to get the appropriation through

13. Program Implementation • Stars lined up • Governor let Health Department do its job • Visionary leadership • Innovative focus • Identified the tobacco industry as the problem • Social norm change • Focused on nonsmoker • Policy intervention

14. Key Elements • Focused on social norm change and nonsmokers • Policy orientation • Not youth- or school-focused • Directly confronted the tobacco industry

15. Political Attacks • Governor Wilson suspended media campaign • American Lung Association (ALA) sued • Pitched battle over campaign content • Diversions continued • Big fight in 1994: American Heart Association (AHA), Americans for Nonsmokers’ Rights (ANR) • Funding restored • But ongoing battles over quality of campaign

16. It Worked: Per Capita Cigarette Consumption Data source: Fichtenberg and Glantz. (2000).

17. Heart Disease Deaths Dropped 59,000 fewer deaths (9%) 1,500 unnecessary deaths Datasource: Fichtenberg and Glantz. (2000).

18. So Did Industry Sales Datasource: Fichtenberg and Glantz. (2000).

19. … And Lung Cancer Incidence Datasource: Barnoya and Glantz. (2004).

20. The Health Cost Savings Grow with Time Datasource: Lightwood, Dinno, and Glantz. (2009).

21. Over First 15 Years • Over the first 15 years, the California program cost $1.4 billion • It saved $86 billion • These savings started appearing quickly and grew with time • By 2004, the program was saving $11 billion in health costs • 7.3% of all health costs • Cost tobacco industry over $9 billion

22. California Adult Smoking Prevalence, 1984-2009 Datasource: California Department of Public Health, California Tobacco Control Program, March 2010.

23. The Bottom Line • Large scale tobacco programs work • Focus on nonsmokers, social norms, and policy change • Do not focus on kids or cessation • The stakes are very high • Expect and deal with opposition • Large and immediate health and cost benefits