Tobacco Control Strategies: What Works Kenneth E. Warner University of Michigan School of Public Health University of Washington –April 2, 2008

Smoking…then…

and now…

Then…

Now…

Adult Per Capita Cigarette Consumption U.S., 1900-2001 Number of Cigarettes

5000

4000

3000

2000

1000

0 1900

1910

1920

1930

1940

1950

YEAR

1960

1970

1980

1990

2000

Trends in cigarette smoking among adults aged >18 years, by sex - United States, 1955-1998 % CURRENT SMOKERS

60 50

Men

40 30 Women

20 10 0 1955

1960

1965

1970

1975 YEAR

1980

1985

1990

1995

Year =16 years

2001

1999

1997

1995

1993

1991

1989

1987

1985

1983

1981

1979

1977

1975

1973

1971

1969

1967

50 45 40 35 30 25 20 15 10 5 0 1965

Percent

Trends in cigarette smoking among adults aged >25 years, by education- U.S., 1965-2002

Stages of cultural change re smoking 1.

2.

Smoke everywhere; offer cigarette to others when lighting up; ashtrays pervasive (thru 1950s) Smokers ask, as a courtesy, “Do you mind if I smoke?” Nonsmoker’s polite response: “Not at all.” (Ashtrays pervasive) (1960s)

Stages of cultural change re smoking (cont’d.) 3.

4.

Beginning of nonsmokers’ rights movement leads to nonsmoking sections of restaurants. Smokers now ask – with sense of trepidation – “Do you mind if I smoke?” Increasingly, answer is “I’d prefer that you don’t.” (1970s) Smokers assume they should not light up in a friend’s home unless the friend has done so first; can ask if see ashtrays (1980s)

Stages of cultural change re smoking (cont’d.) Huge increase in homes with no-smoking policy…including smokers’ homes (1990s-on)

5.

Smoke-free workplace laws extended to include bars and restaurants (2000s)

6.

a. b.

12 countries entirely smoke-free workplaces ≈ 30 states entirely smoke-free (some with minor exceptions)

What has produced this major behavioral – and culture – change?

U.S. anti-smoking campaign 





Phase I (1964-early 1970s): Information & persuasion Phase II (1973-present; “phase II of phase II” in 2000s): Non-smokers’ rights movement Phase III (late 1980s-?): Comprehensive tobacco control

Adult Per Capita Cigarette Consumption, 1900-1952 5000

Number of Cigarettes

End of WW II

4000

3000

2000

1000

0 1900

Great Depression

1910

1920

1930

1940

1950

YEAR

Adult Per Capita Cigarette Consumption, 1900-1954 5000

Number of Cigarettes

End of WW II

4000

3000 1st Smoking-Cancer Concern

2000

1000

0 1900

Great Depression

1910

1920

1930

1940

1950

YEAR

Adult Per Capita Cigarette Consumption, 1900-1963 5000

Number of Cigarettes

End of WW II

4000

3000 1st Smoking-Cancer Concern

2000

1000

0 1900

Great Depression

1910

1920

1930

1940

1950

YEAR

1960

Adult Per Capita Cigarette Consumption, 1900-1964 5000

1st Surgeon General’s Report

Number of Cigarettes

End of WW II

4000

3000 1st Smoking-Cancer Concern

2000

1000

0 1900

Great Depression

1910

1920

1930

1940

1950

YEAR

1960

Adult Per Capita Cigarette Consumption, 1900-1973 5000

1st Surgeon General’s Report

Broadcast Ad Ban

Number of Cigarettes

End of WW II

4000 Fairness Doctrine Messages on TV and Radio

3000

1st Smoking-Cancer Concern

2000

1000

0 1900

Great Depression

1910

1920

1930

1940

1950

YEAR

1960

1970

Adult Per Capita Cigarette Consumption, 1900-2001 5000

1st Surgeon General’s Report

Broadcast Ad Ban

Number of Cigarettes

End of WW II

4000 Fairness Doctrine Messages on TV and Radio

3000

1st Smoking-Cancer Concern

2000

Non-Smokers Rights Movement Begins

1000

0 1900

Master Settlement Agreement

Surgeon General’s Report on ETS

Federal Cigarette Tax Doubles Great Depression

1910

1920

1930

1940

1950

YEAR

1960

1970

1980

1990

2000

Health consequence Since 1964, > 5 million premature deaths averted in U.S. as a result of campaigninduced decisions to quit smoking or not to start. 



Greatest public health success of last 50 years Greatest remaining burden of preventable death and illness

Typology of interventions (end user perspective)

Purpose

Producer / End user Information/ education

Incentive

Prevention

School health ed; Tax increase Truth campaign; ad ban

Cessation

1990 Surgeon General’s report; warning labels; ad ban

Protection from secondhand smoke

1986 Surgeon General’s report on ETS

Law/ regulation Sales-to-minors and PUP laws

Tax increase; insurance premium differentials Smoking ban in workplace, public places

Intervention effectiveness Effective Tax Clean indoor air laws, policies Counter-advertising Ad bans Comprehensive TC programs  

Not effective School health ed Warning labels (New  

ones?)

Insurance differentials Minors possession, use, & purchase laws Sales to minors laws 

Taxation 



Strongest research base of all tobacco control (TC) policies From public health pariah to First Principle of TC

Tax increases - Pros 

Overall price elasticity of demand ≈ -0.4 

Approx. ½ quitting, ½ reducing cigs/day

Kids twice as responsive as adults; very effective deterrent to youth smoking Generates (lots of) tax revenue (“Doing well while 

doing good”) 

Politically popular “Sin tax,” with “redemptive” features (especially if



tied to youth smoking prevention) 



Doesn’t affect majority, especially upper SES

Progressive health impact

Real cigarette prices & per capita consumption US, 1970-2000 3100 180 2900 160 2700 140 2500 2300 120 2100 100 1900 80 1700 1500 60 1970 1975 1980 1985 1990 1995 2000 Year consumption

Federal cigarette tax rate & cigarette tax revenue in the US, 1960-2000 0.30

7 6.5

0.25

6 5.5

0.20

5 0.15

4.5 4

0.10

3.5 3

0.05

2.5 0.00

2

Year Cigarette tax rate

Tax increases - Cons 

“Behavioral engineering”



Desired neutrality of tax policy (Here?)



Increased incentive for smuggling



Regressivity (equity issues) Distinguish regressivity of overall tax from  Progressivity/regressivity of tax increase Effects on continuing smokers among poor even if overall impact progressive 

Smoke-free workplaces 



Strong research base



Heart of TC movement 

30 states nearly 100% smoke-free workplaces, rests. & bars 12 countries

Smoke-free: evidence base Substantial evidence on adverse health effects of second-hand smoke ( whole) 

School health education 



Some programs show efficacy (impact with best-practice) but… None show effectiveness (impact in everyday conditions)

Teachers not well trained nor interested  Competing demands on time  Relatively low school-board priority  Few resources devoted to programs  “Booster” programs rare 

Pack warning labels 



Old labels ineffective

New, Canadianstyle labels may increase intention to quit and, possibly, quitting

Sales to minors & PUP laws 

Sales to minors laws do not reduce youth smoking unless very seriously enforced 

≈ 95% compliance needed for major impact 

PUP laws do not work (and generally are not even recognized by youth or parents)

Objectives of tobacco control 

Prevent initiation (children)



Assist with cessation (adult smokers)



Protect from secondhand smoke (nonsmokers)

--------------------------------------------- Harm reduction? (smokers who don’t quit)

Objectives as strategies: Youthoriented prevention campaign Benefits Nip problem in the bud  Maximize eventual health benefit  Political acceptability (paternalism appropriate for kids)  Less industry opposition 

Problems Ineffectiveness of many youth-oriented strategies  Long-term pay-off only; misses current smokers 

Objectives as strategies: Adult cessation campaign Benefits 

Maximize near-term health benefit

Problems Political opposition on philosophical grounds  More industry opposition  Resources for individual cessation treatment  Doesn’t (necessarily) cut off flow of new smokers into system 

Objectives as strategies: Clean indoor air campaign Benefits Quick, substantial protection of nonsmokers  Leads to more quitting among smokers  Defines acceptable social behavior 

Problems Political opposition on philosophical grounds  More industry opposition  May not cut flow of new smokers into system  Doesn’t reduce smoking “enough” 

Comprehensive tobacco control program Benefits Addresses all issues  Covers different smokers’ differing needs  Maximum benefit  Synergies among interventions (?) 

Problems Resources required  Political opposition on philosophical grounds  Industry opposition  Uncertainty re best mix of interventions  Duplicative effects (?) (“anti-synergy”) 

Ireland: a cautionary tale 





First country to have 100% smoke-free workplaces, restaurants, & bars (2004) Pack of cigarettes costs >$9.00 No cig. advertising permitted And yet…

Ireland: a cautionary tale 

Smoking prevalence fell from 25.5% just before smoke-free law (March 2004) to 23.3% one year later.

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A year later, ↑ to 24.5%!

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Dec. 2007, 24%

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16% of 12-17 year-olds smoke

Ireland: a cautionary tale 

What explains difference between U.S. (with its relatively modest policies) and Ireland?

Norms 

What can Ireland do? Media campaign  Role modeling (athletes, music and movie stars – Think Bono!) 

Aggregate impacts of TC in US 

Dramatic…but over time 





Smoking prevalence ↓ by > ½ Per capita cigarette consumption ≈ 1/3 of what it would have been in absence of antismoking campaign > 5 million smoking-produced premature deaths averted as a result of campaign, with average beneficiary gaining 15-20 years of life expectancy

How did this happen? 

Resulted from combination of public education/information campaign  push for smoke-free air policies and laws  use of extrinsic + intrinsic motivations  focus on youth smoking prevention, adult quitting (aided, slightly, by cessation treatments), and protection of rights of nonsmokers 



Relied upon norm change

Where do we go from here? Likely near-future directions 

More states go smoke-free 





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Within 5 years or so, nearly all states will be smoke-free

Federal cigarette excise tax ↑ to $1-2 per pack (from $0.39 now); state taxes ↑ U.S. smoking prevalence ↓ to 14.5-17% by 2020 (now 20.8%) More emphasis on harm reduction??

Generalizable lessons 

Most powerful drivers of health behavior change are those that change norms Smoke-free policies/laws  Anti-smoking media campaigns  Exception: tax 



Process of social (and norm) change, as illustrated by tobacco control story, involves Info/ed first, understood and acted upon by SES elite  Elites – most politically enfranchised – lobby for policy changes  Middle and lower SES respond to social pressures and environmental changes (smoke-free laws, higher prices, antismoking media campaigns) 

Generalizable lessons (cont’d.) 

Utilize multiple intervention types 





Info/education; incentives; law/regulation

Viewed from short-term perspective, creating cultural and behavioral change is arduous and frustrating; “system”, and individuals, often seem non-responsive Viewed over long haul, potential for change is enormous (even mind-boggling)

What will it take to continue making substantial progress? 

Creativity



Energy

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Politically sophisticated advocacy

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Resources

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Leadership