Tomorrow will not be like

yesterday….

What’s next in tobacco control ?

April Roeseler Minnesota Tobacco Control Conference

December 6, 2010

Tomorrow will not be like yesterday Global economic meltdown

Tomorrow will not be like yesterday

Overconsumption

Tomorrow will not be like yesterday

Highly effective interventions

• Tobacco tax

increases

•Secondhand

smoke policies

•Media

interventions

Tomorrow will not be like yesterday

Health Inequities

Yesterday

California Tobacco Control Program Begins

1988 –California voters

pass Proposition 99.

Tobacco tax increases

from 10¢ to 35¢ per

cigarette pack and

earmarks 5¢ (20%) of

the revenues for a

tobacco control

program.

CTCP Prop 99 Budget 1989-90 to 2010-11

95.3

62.1

52.6 50.9

43.1 41.0 36.6

89.5

105.3

72.5

60.3

87.4

107.3

61.2 62.8

55.9 57.8

64.2

55.7 54.6 54.7 53.8

0

20

40

60

80

100

120

89-

90

90-

91

91-

92

92-

93

93-

94

94-

95

95-

96

96-

97

97-

98

98-

99

99-

00

00-

01

01-

02

02-

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03-

04

04-

05

05-

06

06-

07

07-

08

08-

09

09-

10

10-

11

Mill

ions

Fiscal Year

Strategy

Goal = change social norm

Outcome = prevention & cessation

Social Norm Change Strategy

Creates a social milieu and legal climate, where tobacco becomes:

Less Desirable

Less Acceptable

Less Accessible

Denormalization Strategy

Lasting change in youth behavior regarding

tobacco can only be secured by first changing

the adult world in which youth grow up.

High Level Logic Model

Reduce Exposure to

Secondhand Smoke

(SHS)

Support

Cessation

Decrease Tobacco

Consumption

Decrease

Tobacco

Use Prevalence

Decrease Youth

Uptake of

Tobacco

Decrease

Exposure to

SHS

Counter Pro-

Tobacco Influences

Outcomes Goals

Program Implementation

Technical

Assistance

Legal

Center

37 Community Non-profit Agency Projects

61 Health Department Projects

& Community Coalitions

Statewide Evaluation/Surveillance

California Tobacco Control Program

Statewide Media Campaign

Center

for Policy & Community

Organizing

Clearinghouse

Tobacco

Control

Evaluation

Center

Cessation Quitline

& Training

Center

California Youth

Advocacy

Network

Statewide Infrastructure & Training & Technical Assistance Projects Capacity

Building Center

for

Diverse

Populations

STAKE Youth

Recruitment Team Lab

Materials

Development

Media

Community Involvement

+

=

Social Norm Change

A Powerful Equation

Role of Media

• To be ahead of

the of the wave

(public opinion)

• To use the

energy at the

front of the wave

to pull public

opinion forward

Attitudes Influence Behavior

Secondhand Smoke Strategy

• Increases support

for local policies

• Provides smokers

a reason to quit

Secondhand Smoke (SHS)

• Positive SHS attitudes predict quitting

– Smokers are 70% more likely to have made a recent quit attempt

– Smokers are over 2 times more likely to have intentions to quit smoking in the next 6 months

California Tobacco Control Program, California Department of Public Health, A Confirmatory Factor Analysis of

a Social Norm Change Paradigm for the California Tobacco Control Program, May 2006.

Anti-Industry Strategy

• Motivates smokers to quit; inoculates them against advertising and marketing

• Undermines tobacco industry’s point of view

• Holds the industry accountable for their marketing practices

• Increases non-smoker’s empathy towards smokers

Countering Pro-

tobacco Influences

• Californians with highly negative attitudes

about the tobacco industry are:

– Among smokers, 67% were more likely to

have made a recent quit attempt

– Among smokers, 62% are more likely to have

intentions to quit in the next six months

California Tobacco Control Program, California Department of Public Health, Evaluation of California’s Anti-tobacco Media Campaign,

Waves 6, 7 and 8. February 2008.

Cessation Strategy

Call 1-800-NO BUTTS

• Demonstrates

empathy for

smokers

• Provides

resources and

encouragement to

quit

Smoking Cessation Ads

• Are effective at

generating motivated

smokers to call the

Quitline, they do not

make an impact on

smokers who are

unmotivated to quit.

Role of Community

• Amplifies the message

• Ties the program to the

community

• Diversifies expertise,

influence, & connections

• Results in policy change

Local Data Collection Drives

Policy

Chico & San Francisco ban free

tobacco & coupons

Tobacco Retail Licensing 1.0

TRL 2.0: San Francisco bans tobacco

sales in pharmacies

San Francisco drugstore before midnight

October 1, 2008

San Francisco drugstore after midnight

October 1, 2008

Tobacco Litter: 1.0 Policies

Cigarette Litter: 2.0 Policies

A funny thing happened on the way

to the forum (aka State Capitol)

Sacramento News and Review

May 27, 1993

Sacramento Bee

February 21, 2008

“We didn’t get to

where we are on

tobacco cessation

by working

cooperatively with

the industry.”

Senator Alex Padilla

Outcomes

30-day smoking prevalence for California and United States high school (9th-12th grade) students,

2000-2010

28.1

22.5 21.7 19.7

17.2

21.6

16.0

13.2 15.4 14.6 13.8

0

5

10

15

20

25

30

2000 2002 2004 2006 2008 2009 2010

Perc

ent

High School U.S. (9-12th graders)

High School CA (9-12th graders)

Source: The 2000 California data is from the National Youth Tobacco Survey (NYTS) collected by the American Legacy Foundation, which used passive parental consent. The 2002, 2004, 2006, 2008, and 2010 data are from the California Student Tobacco Survey. The 2002 and 2004 data collection used active parental consent while the 2006, 2008, and 2010 used a mixed parental consent procedure. The United States data are from the NYTS collected by the American Legacy Foundation and the Centers for Disease Control and Prevention. Note that the NYTS was conducted in 2009 thus 2008 and 2010 United States data are unavailable. Prepared by: California Department of Public Health, California Tobacco Control Program, April 2011.

0

20

40

60

80

100

120

140

160

180

200

Pa

ck

s/p

er

ca

pit

a

CaliforniaUS-CaliorniaPoly. (California)Poly. (US-Caliornia)

California 160 156 149 142 139 133 128 123 110 102 95 92 86 81 79 76 74 71 62 55 51 48 46 45 45 44 41 41 38 35

US-Caliornia 183 180 173 167 165 161 157 153 147 139 134 130 126 123 123 120 120 117 112 108 104 101 95 92 89 85 82 77 73

80/

81

81/

82

82/

83

83/

84

84/

85

85/

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86/

87

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89/

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90/

91

91/

92

92/

93

93/

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94/

95

95/

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96/

97

97/

98

98/

99

99/

00

00/

01

01/

02

02/

03

03/

04

04/

05

05/

06

06/

07

07/

08

08/

09

09/

10

Source: Behavioral Risk Factor Surveillance System (BRFSS) 1984-1992, BRFSS and California Adult Tobacco Survey data is combined for

1993-2008. The smoking prevalence is adjusted from 1984 to 1995 to account for the change in smoking prevalence that includes more

occasional smokers. The data is weighted to the 2000 California population. California State Board of Equalization (packs sold) and US

Census (population).

Prepared by: California Department of Public Health, California Tobacco Control Program, July 2010.

California Adult per Capita Cigarette Pack Consumption

1984 to 2009

Proposition 99

20%

48%

0

5

10

15

20

25

30

Perc

en

t

CA 25.9 27.7 26.6 22.4 23.7 22.1 20.4 20.2 21.0 19.2 17.6 16.9 17.8 17.4 17.5 17.1 16.3 16.4 15.8 15.4 14.6 14.0 13.3 13.8 13.3 13.1

US-CA 24.0 23.6 23.4 23.1 23.0 23.6 23.5 23.0 21.6 21.3 20.3 20.2 19.1

84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09

Adult Smoking Prevalence among California

and US (- CA)

1984-2009

Source: Behavioral Risk Factor Surveillance System (BRFSS) 1984-1992, BRFSS and California Adult Tobacco Survey data is combined for 1993-2008. The data is weighted to the 2000 California population. State BRFSS data is weighted to 2000 national population based on each states population.

Note an adjustment was made to address the change of smoking definition in 1996 that included more occasional smokers. Prepared by: California Department of Public Health, California Tobacco Control Program, March 2010.

Change in Smoking Prevalence Among California Adults

by Race/Ethnicity and Gender, 1990-2005

1990

2005

Percent Decline

Male African American

28.9 21.0 27.3%

Non-Hispanic White

21.4 16.0 25.2%

Hispanic 23.3 16.7 28.3%

Asian/Pacific Islander

21.8 16.1 26.1%

Female African American

24.2 17.1 29.3%

Non-Hispanic White

18.5 13.1 29.2%

Hispanic 11.7 6.8 41.9%

Asian/Pacific Islander

7.3 6.5 11.0%

Lung and Bronchus Cancer Mortality Rates per 100,000 for

California and the US minus California, age 35 years and

older, 1970 to 2007

0

20

40

60

80

100

120

140

1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006

Year

Ag

e-A

dju

ste

d R

ate

s p

er

10

0,0

00

US-CA Age-Adjusted Rates

CA Age-Adjusted Rates

Poly. (US-CA Age-AdjustedRates)Poly. (CA Age-AdjustedRates)

Rates are per 100,000 and age adjusted to the 2000 US std population (19 age groups-Census-P25-1130) standard.

Source: California Cancer Registry, California Department of Public Health.

Prepared by the Cancer Surveillance Section, California Cancer Registry.

On the edge of a new beginning

Tomorrow’s

Manifesto

Do work that matters Price

• Earmarked tax increases

• Minimum price laws

• Tobacco mitigation fees

• Tighten definition of tobacco products

• Ensure equivalent tax on OTP

• Advocate for an encrypted federal tax

stamp

Do work that matters Secondhand Smoke

• Eliminate exemptions & loopholes in

smoke-free local/state/tribal policies

• Expand smoke-free MUH policies

• Expand outdoor smoke-free policies

• Eliminate tobacco use from all acute and

long term health care facility campuses

Do work that matters Tobacco marketing

• Increase tobacco retail density and zoning policies

• Eliminate tobacco sales where health care services are provided (e.g., drug stores, grocery stores, big box stores)

• Use tobacco waste issue to leverage tobacco marketing policies & healthier community campaigns

• Maximize use of FDA marketing restrictions

• Aggressively monitor & enforce FDA legislation

Do work that matters Cessation

• Expand partners in motivating & promoting

cessation

• Aggressively promote & encourage use of

cessation benefits

• Systematize use of EMR to promote

cessation & SHS protection

Performance Matters

Technical assistance powers

social change

• Public health, efforts are more likely to be successful if scientific evidence is incorporated into decisions, policies, and programs.

• While there is evidence about what works, agencies may not uniformly embrace or effectively implement control interventions in a way that produces uniform results.

• TA facilitates rapid dissemination and the uptake of a single policy to statewide scale.

Report Cards Matter

“We’ve got a lot of threats to public health in Richmond said City Councilman Tom Butt who said both his parents died of smoking-related illnesses. We’ve got air pollution problems. We’ve got high asthma rates. We’ve got high diabetes rates. We need to start getting rid of the ones we have control over, and this is one place where we have full control where we can make a significant difference in the health of Richmond residents.”

February 9, 2009

Richmond bans smoking in

MUH, July 2009

Create heath equity

Two criteria to measure every policy

1. “Goodness”: The best attainable goal

that moves public health interests

forward

2. “Fairness” : Achieve the smallest feasible

differences among individuals and

groups

Capitalize on the

“responsibility revolution”

• Tobacco control creates value • 1 million lives saved

• $86 billion in health care costs saved

• Tobacco use is not beneficial to us as a

society, it does not pay the costs

– Tobacco industry causes disease, death, and

it pollutes the environment

Efficiency Matters Adapt Technology

Identify positive

deviance….amplify

Innovate, but have a path to

scale

• Scale is simply something that is so

pervasive or large enough that it makes a

dent in the problem you are trying to solve

• Success will depend on the ability to

amplify the efforts of individuals so that

small successes can be catalyzed for

broad impact

Build sustainable ventures

Sustainability is something that endures

Keys to Sustainability

1. Simple

2. Systematic

3. Adaptable to a broad range of settings

4. Not too many “moving” parts

Grasp that marketing has changed

“Today’s marketers lead tribes”

Create a culture of collaboration

• Develop the “power of pull”…the ability to

draw out people & resources as needed to

address opportunities & challenges

• Learn from others, adapt & adopt

• Stay close with others working in your field

• Be the first to give when building new

relationships

Ideas that Spread Win

“Trapped”: Commercial Image

Award of the Year

California ads on DVDs of 6 movie studios

Tomorrow will not be

like yesterday….