Smoking Prevention

1. Smoking Prevention Brian A. Primack, MD, EdM Assistant Professor of Medicine and Pediatrics University of Pittsburgh School of Medicine

3. Composite Theoretical Model

4. Outline Increase cigarette price? Education campaigns? Reduce youth access? Reduce advertising/promotion? School-based programs?

5. Increasing the Unit Price for Tobacco Products?

6. Increasing the Unit Price for Tobacco Products? Yes! (Strong Evidence)

7. Composite Theoretical Model

8. Composite Theoretical Model

9. Price Higher prices for tobacco products ? reduced consumption 10% price increase ? 4% consumption decrease Data primarily comes from 13-25 year old age group Best way: excise tax Challenge: requires passing legislation

10. Price Studies More effect among African Americans than Caucasians More effect among males than females More effect among younger than older

11. Kinds of Excise Tax Federal State Local

12. State Excise Tax Mean: 80 cents Highest rates NJ ($2.57) RI ($2.46) WA ($2.02) AZ ($2) ME ($2) MI ($2) AK, HI ($2) later this year Lowest excise taxes NC (35�) FL (34�) KY (30�) VA (30�) TN (20�) MS (18�) MO (17�) SC (7�) PA: $1.35 (#15)

13. Other Excise Taxes Local AL, 1� to 6� IL, 10� to 15� MO, 4� to 7� NYC $1.50 TN, 1� VA, 2� to 15� Federal Increased to 39� in 2002 ALA and others seek $2 increase

15. Anatomy of Cigarette Price Illinois Factory Price: $2.28 Federal Excise Tax: 39� Retailer markup: $1.12 State Excise Tax: 98� Sales Tax: 29� TOTAL: $5.23

16. Anatomy of Cigarette Price Illinois Factory Price: $2.28 Federal Excise Tax: 39� Retailer markup: $1.12 State Excise Tax: 98� Sales Tax: 29� TOTAL: $5.23

17. Anatomy of Cigarette Price Illinois Factory Price: $2.28 Federal Excise Tax: 39� Retailer markup: $1.12 State Excise Tax: 98� Sales Tax: 29� TOTAL: $5.23

18. Anatomy of Cigarette Price Illinois Factory Price: $2.28 Federal Excise Tax: 39� Retailer markup: $1.12 State Excise Tax: 98� Sales Tax: 29� TOTAL: $5.23

19. Anatomy of Cigarette Price Illinois Factory Price: $2.28 Federal Excise Tax: 39� Retailer markup: $1.12 State Excise Tax: 98� Sales Tax: 29� TOTAL: $5.23

20. Anatomy of Cigarette Price Illinois Factory Price: $2.28 Federal Excise Tax: 39� Retailer markup: $1.12 State Excise Tax: 98� Sales Tax: 29� TOTAL: $5.23

21. Anatomy of Cigarette Price Illinois Factory Price: $2.28 Federal Excise Tax: 39� Retailer markup: $1.12 State Excise Tax: 98� Sales Tax: 29� TOTAL: $5.23

22. Mass Media Education Campaigns?

23. Mass Media Education Campaigns? Yes! (Strong Evidence)

24. Composite Theoretical Model

25. Composite Theoretical Model

26. Mass Media Education Campaigns PSA�s: Print, TV, Radio 12 studies, all aimed at adolescents Compare smoking rate changes in different communities Florida, Massachusetts, Minnesota Hard to control for other factors

30. Shards O Glass Light

31. Mass Media Education Campaigns Decrease by about 2.4% (absolute) Most effective: >2 years Those that combined education campaigns with other interventions worked better Contests Community education School-based programs Effects decrease over time

32. Youth Access?

33. Youth Access? Maybe ...

34. Composite Theoretical Model

35. Composite Theoretical Model

36. Minimum Age;Photographic ID Required

40. Composite Theoretical Model

41. Clerk Intervention

42. FreeDistribution/Samples

43. Vending Machines

44. Other Access Issues Packaging Graduated Penalties Random Inspections Statewide Enforcement

45. �Recommended� �Community Mobilization When Accompanied by Additional Interventions� Absolute reductions as much as 5.8%

46. �Insufficient Evidence� Sales laws directed at retailers alone Laws directed at minor purchase alone Active enforcement of sales laws alone Retailer education alone

47. Reduce Smoking Promotions?

48. Reduce Smoking Promotions? Yes! (and no ...)

49. Composite Theoretical Model

50. Composite Theoretical Model

51. Smoking Promotions Definitely Increase Smoking Tobacco Promotion and the Initiation of Tobacco Use: Assessing the Evidence for Causality DiFranza, Wellman, Sargent et al Pediatrics 2006; 117: e1237-e1248

52. Films

53. Advertisements

54. Flexibility of the Industry TV Movies Billboards Concerts, other promotions �Kool Mixx� tour �Stir the Senses� tour Free products

56. Camel �Seven Pleasures of the Exotic�

57. School-Based Programs?

58. School-Based Programs? Unknown ...

59. Composite Theoretical Model

60. Composite Theoretical Model

61. HSPP (JNCI, 2000) Curriculum for youth, 3rd-10th grades 47.25 hours total �Social Influences� approach How to say no, effects on body, resisting peer influence, self esteem, etc. 20 school districts got the program, 20 did not 94% follow up, high implementation fidelity

62. Results of HSPP No difference in smoking at 12th grade No difference in smoking 2 years after high school No difference among boys or girls No difference among people of other subgroups (such as family risk for smoking)

63. Depends on the Kind of Program �Life Skills Training�/�Social Influences� Self esteem Refusal �Media Literacy� Analysis of tobacco advertisements/promotions Understanding of marketing and industry

64. Summary Price Increases Comprehensive Mass Media Education Campaigns Youth Access Reduction of Advertising School & Community Based Programs

65. bprimack@pitt.edu

67. Price References CDC 1998 Chaloupka 1996, 1997, 1999 Gruber 2004 Lewit 1981, 1997 Ohsfeldt 1994, 1997 Wasserman 1991

68. Media Campaign References Bauman, 1991 CDC, 1999 Flay, 1987, 1995 Flynn, 1997 Hafstad, 1997 Johnson, 1990 Kaufman, 1994 Murray, 1994

69. Economic Analysis 4 year study from MT, NY, VT 5-10th grade students followed for 2 years Mass media campaign and school-based program Smoking 20.4% vs. 25.9% Cost per smoker averted: $6069 Program cost/QALY: $333