Monitoring & Evaluation:Tools for the civil society to

advance effective tobacco control policies

Ernesto M Sebrié, MD MPH

Transdisciplinary Tobacco Use Research Center

Department of Health BehaviorRoswell Park Cancer Institute

Buffalo, New York

Healthy Caribbean 2008

Caribbean Chronic Disease ConferenceBridgetown, Barbados, October 16, 2008

Overview of the presentation 1. Tools for advancing & enforcing specific tobacco control policies

– Smokefree policies• Public opinion polls

• Air monitoring study

• Monitoring of compliance (direct observation)

– Labeling & packaging policies• Pre-testing: mall intercept survey

• Monitoring of compliance (e.g., retail stores, sale in the street, etc.)

– Tobacco advertising & sponsorship ban • Monitoring of compliance (e.g., street, retail stores, magazines, youth venues, etc.)

Example: Public opinion polls on public support and air contamination with tobacco smoke particles; warning labels tool kit

2. Evaluation of mass media behaviorExample: content analysis of newspapers articles published on tobacco control

3. Evaluation of policymakers behavior– Mapping of public officials (legislators, health authorities, etc.)– Bills and other regulations introduced

Example: analysis of tobacco control legislation

4. Tobacco industry behavior– Arguments & strategies – Volunteer programs– Front groups allies

Example: analysis of internal tobacco industry documents to expose/reveal deceptive strategies to the public; analysis of tobacco industry websites/ social reports

5. Monitoring government behavior– Tobacco control policy implementation

Example: edition of a civil society report on the implementation of the FCTC (e.g., Mexico & Canada)

Overview of the presentation (cont.)

Tools for advancing & enforcing smokefree

policies

Public Opinion Surveys Knowledge on SHS & Support for smokefree policies

• DemographicsAge, Gender, Level of formal education, Income

• Smoking status

Have you ever smoked at least 100 cigarettes in your life?/ Do you currently smoke?

• Health effects of smoking I am going to read you a list of health effects and diseases that may or may not be caused by smoking cigarettes. Based on what you know or believe, does smoking cause…Lung cancer, Heart disease, Lung disease (e.g., bronchitis, asthma, or emphysema), Stroke, Impotence in male smokers, Complications during the pregnancy (e.g., abortion, low birth weight, or premature delivery), Blindness, Mouth & throat cancer, Peripheral vascular disease and gangrene, Breast cancer in young women, Addiction, Yellow teeth/ skin wrinkles,

• Health effects of SHS exposureNow, I am going to read you a list of health effects and diseases that may or may not be caused by SHS exposure in nonsmokers. Based on what you know or believe, does exposure to SHS cause…Lung cancer in adults nonsmokers/ Heart disease in adults nonsmokers Lung disease in adults nonsmokers/ Stroke in adults nonsmokers Mouth cancer in adults nonsmokers/ Breast cancer in young women nonsmokersAsthma in children

• Sources of information/ educational campaigns In the last 6 months, have you noticed information that talks about the dangers of smoking and SHS, or that encourages quitting in any of the following places? On television/ On radio/ At the cinema/ On posters or billboards/ In newspapers or magazines/ On shop/store windows or inside shops/stores where you buy tobaccoIn warning labels on cigarette packages/ On leaflets/ On the internet/ Anywhere else?

• Knowledge, attitudes & support for smokefree policiesDo you know if there is any smokefree policy in your country?Do you know if there is any smokefree policy in your city?Do you know if there is any specific policy in ….(e.g., hospital, university, etc.?)Do you support 100% smokefree environments in …

enclosed public places, public transportation, enclosed workplaces, bars and restaurants, casinos, etc.?

Do you agree with the following statement…“SHS is dangerous for nonsmokers’ health”?“All workers have the right to work in a smokefree environment”?

Public Opinion Surveys Knowledge on SHS & Support for smokefree policies

Public Opinion Surveys in Latin AmericaCountry(year)

Location Agree with: “SHS is

dangerous for

nonsmokers health”

Agree with:“Every

worker has the right to work in a

SFE”

Support SFE

government, private offices, banks &

shopping malls

Support SFE in bars &

restaurants

Support SFE in health

care and educatio

nal facilities

ARGENTINA (2006)

National population

92.9% 96.8% 93.4% 76.5% 96.7%

BRAZIL (2006)

City of Sao Paulo

(not asked) (not asked) 85%(covered public places in general)

Restaurants 83%Bingos 67%Bars/discos 62%

-

URUGUAY(2006)

Urban areas 92% 95% General agreement with the 100% smokefree country (including every type of facilities)Agree 80%; Indifferent 8%; Disagree 11%

MEXICO( 2007)

7 cities 84% (smokers) (not asked) 81% of smokers preferred SME More than 75% of smokers supported smokefree

hospitals, public transportation, museums, cinemas, and theatres

• Cigarettes, cigars and pipes produce a great amount of breathable particles smaller than 2.5 microns (PM 2.5) which are easily inhaled to the lungs.

• The TSI Side Pack is a devise, scientifically validated that measures the PM 2.5 in the air.

TSI Side Pack AM510 Personal Aerosol Monitor

The TSI SidePak is small (weight: 1lb) and can be used for discrete sampling

Why PM2.5?• Very sensitive marker of SHS• Can monitor and record data in “real-time”• Relatively inexpensive equipment• Marker of the more than 4,000 chemicals• Meaningful measure: there are PM2.5 standards in

place to protect public health– The EPA has set standards of 15 μg/m3 as the average

annual level of PM2.5 exposure and 35 μg/m3 24-hour exposure in order to protect the public health.

– The WHO has an annual target of 10 μg/m3

• Limitations of PM2.5 as a Marker of SHS

Not specific to tobacco smoke; other sources include cooking, vehicles, ambient/ background levels

0

200

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0 60 120 180 240 300

Elapsed Time (minutes)

Fin

e p

arti

cle

air

po

llu

tio

n (

PM

2.5

in μ

g/m

3 )New Jersey Air Monitoring Study (2005)

8/279:00pm

Start

DinerSmoking

8/297:47pm

End

BarSmoking

RestaurantSmokefree

RestaurantSmoking

BarSmoking

BarSmoking

8/2912:14pm

8/297:00pm

-98%

-80%

-98%

-84%

-86%

-89%

-98%

-98%-95%

-73%

-91%

-96%

-95%-84%

0

200

400

600

800

1000

1200

1400

Bar ABar B

Bar CBar D

Bar EBar F

Bar G

Bar/Res

taura

nt H

Bar/Res

taura

nt I

Bar/Res

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Bar/Res

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Resta

urant NR

esp

irab

le S

usp

end

ed P

arti

cles

(μ

g/m

3 of

PM

2.5)

Change in Air Quality in Western New York Bars and Restaurants After Implementation of the NY State Clean Indoor Air Law

Before Law: Average = 412 μg/m3

After Law: Average = 27 μg/m3

Why measure air quality?

• Quantify exposure, determine risk

• Educate the public and policy makers

• Evaluate smoke-free air policies

• Generate media attention

Website: training coursewww.tobaccofreeair.org

Evaluating tobacco products labeling policies

A. Pre-implementation: • Pre-testing the layout and design of

warnings• Concept and content testing

B. Implementation evaluation: • Monitoring & compliance

C. Post Implementation: • Impact evaluation

Pre-implementation: Pre-testing the layout, design, and content of warnings

• OBJECTIVE: To evaluate the most effective health warning designs, and concepts for each theme and subject.

• METHODS:•Focus groups•Mall intercept surveys•Combination

MALL INTERCEPT STUDYMALL INTERCEPT STUDY

o “Delivers less tar?”

o “Smoother taste?”

o “Lower health risks?”

• Mock ups

• 4 Caribbean countries

• Bloomberg funding

Implementation evaluation: Monitoring & compliance

• OBJECTIVE: To examine whether health warnings have been implemented on packages as planned.

• METHODS:To visit retail outlets to visually inspect packages: commonly referred to as an “environmental scan.” Number of retail outlets visited will depend greatly on the availability of resources; a range of retail outlets in different parts of the country should be visited. It requires relatively little expertise, with the potential to involve tobacco control advocates.Some regulators can visit factories of domestic tobacco manufacturers to ensure that packages are being printed in accordance with the regulations.

Post Implementation: Impact evaluation

• OBJECTIVE: To examine the potential effectiveness of health warnings after implementation.

• Increases in health knowledge and perception of risk.• Greater awareness of cessation services.• Increases in motivation to quit and cessation.

• METHODS:Population-based surveys

Tobacco Labeling Resource Centerhttp://www.tobaccolabels.org/

Monitoring tobacco industry’s

arguments & strategies

Subjects– Marketing, Advertising, & PR– R&D efforts, Scientific research– Lobbying, Legislative, and Legal Efforts

Formats– Letters, Memos, & Faxes– Meeting Minutes & Presentations– Invoices, Statements– Junk

Internal tobacco industry documents: what are they?

• + 50 million pages and growing– US Companies– BAT

• Released under US litigation

Legacy Tobacco Documents Libraryhttp://legacy.library.ucsf.edu

Why use the Documents?

• Important tool for researchers, policy makers, tobacco control advocates, lawyers

• Expose, educate, disseminate, advocate

• Understand tobacco industry strategies

BATCCA: BAT Caribbean & Central America http://www.batcentralamerica.com/

Trinidad & Tobago (2004)

Tobacco industry “Youth Smoking

Prevention” Program

Trinidad & Tobago (2004)

Accommodation

BAT Jamaica (2008)

SOCIAL REPORT

Jamaica (2008)

Tobacco industry “Youth Smoking

Prevention” Program

Jamaica (2008)Tobacco industry

Advertising

Ernesto Sebrie, MD MPH ernesto.sebrie@roswellpark.org

Roswell Park Cancer Institute