Health Promotion and Tobacco Control

1. Health Promotion and Tobacco Control Virginia C. Li, PhD, MPH Professor of Community Health Sciences

2. Health Promotion (Green) The combination of educational and environmental supports for actions and conditions conducive to health

3. An Ecological View on Health Promotion • -Intrapsychological factors • -Interpersonal processes • -Institutional factors • -community factors • -public policy

4. Health Promotion in Community Health promotion actions means: • -create supportive environment • -strengthen community action • -develop personal skills • -reorient health services • -build healthy public policy

6. Health Education Any combination of learning experiences designed to facilitate voluntary actions conducive to health

7. Principles of Health Education • -principle of educational diagnosis • -hierarchical principle • -principle of cumulative learning • -principle of participation • -principle of situation specificity • -principle of multiple methods • -principle of individualization • -Feedback principle • -principle of intermediate target

8. Deaths due to Tobacco Use • In the 20th century, the tobacco epidemic killed 100 million people worldwide. • During the 21st century it could kill one billion. • Tobacco causes 1 in 10 adult deaths worldwide • WHO 2002 • And ……

10. Smoking Prevalence Among U.S. Adults, 1955–2007(as a percent of population, 18 years of age and older) Source: U.S. Centers for Disease Control and Prevention. Web: www.cdc.gov.

12. Declines in U.S. Cigarette Consumption 1990-2005

13. Dimensions of the Anti-smoking Movement • 1) Epidemiological research • 2) Mass media • 2) Interpersonal communications • 3) Advocacy /Legislation

14. Dimensions of the Anti-smoking Movement : Epidemiology • Surgeon Generals Report - 1964 - smoking linked to lung cancer , heart disease • Continuing research - quitting improves health, nicotine addictive • Continuing research - second hand smoke kills, health of persons in smoke free zones better

15. Dimensions of the Anti-smoking Movement: Mass Media • 1971 ban on TV/Radio cigarette ads • Warning signs on cigarette packs • Change in behavior of public figures • Many visible /viable anti-smoking efforts • Publicity about epidemiological findings

16. Dimensions of the Anti-smoking Movement: Interpersonal • Early 1980’s Increase # anti-smoking clinics • Increase expectations/social pressure not to smoke • Increase awareness of preventive health behaviors

17. Dimensions of the Anti-smoking Movement: Advocacy/Legislative • Late 1980’s : Government regulations about smoke-free environments • Advocacy groups push policy changes at all levels: higher taxes on cigarettes • Corporate anti-smoking policies • Insurance companies-no smokers • Lawsuits- get big tobacco

18. Types of Smoking Control Programs • -Worksite Control Programs-Worksite Control Policies-School Based Control Programs-Community Based Control Programs-Physician/Clinic Based Control Programs-Policy-Based Smoking Programs-Economic-Based Smoking Programs

19. Policy and Environmental Interventions -clean indoor air-restricting tobacco advertising and promotion-restricting use access to tobacco-comprehensive school health programs-price/excise taxesAdditional interventions-insurance premium differentials-reimbursement for smoking cessation-differential hiring of smokers-litigation as policy

21. Physician Counseling Behavior- Charleston Navel Shipyard Source: Journal of Medical Education, Vol 58. June 1983

22. Physician Counseling Behavior- Baltimore Family Planning Clinics Source: Journal of Medical Education, Vol 58. June 1983

23. Healthy People 2010 Objectives • Increase to at least 905 the proportion of internists and family physicians who routinely advise cessation and provide assistance, follow up, and document charts for all their tobacco-using patients. • Percentage of Clinicians 1992 • Routinely providing service to 81-100% of patients • Inquiry about tobacco use • Internists 75% • Family physicians 59% • Discussion of strategies to quit • Internists 50% • Family physicians 45%

24. Anti-smoking Movement: California(1999) • Late 80’s- Prop 99 -taxes fund anti smoking efforts • Funds spent - smoking rates come down • Early 90’s : Wilson re-appropriates funds • Campaign stalls ( mid 90’s)- smoking rates go up especially among youth , minority members • Attorney General forced to join law suit against tobacco companies

25. Mass Settlement Agreement (1998) • Holds tobacco companies accountable for their actions • Pays restitution to 46 states for health care costs incurred from tobacco-caused illnesses • Also exempted the companies from private tort liabilities regarding harms caused by an use of tobacco. In exchange, companies agreed to: • Curtail certain marketing practices • Pay, in perpetuity, various amount payments to the states to compensate for some of the medical costs • Dissolve the tobacco industry groups- Tobacco Institute, Center for Indoor Air Research, • Council for Tobacco Research

26. Family Smoking Prevention and Control Act (June 11, 09) Initiated by Waxman, signed by B Obama, opposed by GW Bush • Allow FDA to lower the amount of nicotine in tobacco products • Ban candy flavorings that appeal to kids • Block misleading labels such as “low tar” and “light” • Tobacco companies will be required to cover their cartons with large graphic warnings

27. Tobacco use is the leading preventable cause of death in the world! WHO 2003

28. ….Tobacco is the only legally available consumer product which kills people when it is used entirely as intended. Oxford Medical Companion (1994)

29. Tobacco Industry at Work Today’s teenager is tomorrow’s potential regular consumer, and the overwhelming majority of smokers first begin to smoke while still in their teens. Philip Morris Internal Document (1981)

30. Teenagers – advertising target While sports is by far the best avenue to attract, sample, and influence our core target smokers, it is not the only way. International movies and videos also have tremendous appeal to our young adult consumers in Asia. Philip Morris Internal Document (1990)

31. THE Layout of the Market outside U.S. Within the total market, there are areas of strong growth, particularly in Asia and Africa.…It is an exciting prospect. British American Tobacco Internal Document (1990)

32. Cigarette Production, Exports, and Domestic Consumption—United States, 1990–2004

33. Export • The U.S. is the world’s largest exporter of cigarettes, and for many years burgeoning exports offset declines in domestic consumption. • However, export volume that peaked at 243 billion pieces in 1996 has fallen to an estimated 170 billion in 1999. • Cigarette exports are falling as U.S. manufacturers transfer production of cigarettes to overseas sites to reduce costs and as consumption declines in some of the major U.S. export markets as anti-smoking activity increases.

34. Foreign Draw

35. PUFFED UP • Philip Morris Readies Global Tobacco Blitz • Division Spin off Enables Aggressive Product Push; High Tar Smokers in Asia • New Products: • Marboro Mix 9- a high nicotine and high tar cigarette (introduced in Indonesia in July 2007) • Marboro Filter Plus- sold in South Korea, Russia, • Kazakhstan, Ukraine • Marboro Intense- a quick nicotine hit sold in Turkey • Heatbar- hand held electronic device emits less smoke than regular cigarette • Marboro Wides- extra thick cigarettes Wall Street Journal (1/29/2008)

37. Global Youth Tobacco Survey Source: WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2008

39. Missing in Tobacco Control Policies Tobacco CROP SUBSTITUTION