The California Tobacco Control Program

1
The California Tobacco Control Program

• Tonia Hagaman, MPH, Chief
• Local Programs and Advocacy Campaigns
• California Department of Public Health
• Tobacco Control Section

2
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.

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A Bit About California

• 36 million people
• Most of CAs geography is rural
• Population is extremely diverse, which creates
  many challenges

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DHS/TCS Budget 1989-1990 to 2006-2007
Millions
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Tobacco Program Budget2006/2007
Evaluation/Surveillance
Non-profit Agency Grants
DHS Administration
School Programs
Local Health Departments
Media Campaign
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Goal Change Social Norm
Outcome prevention cessation
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Social Norm Change Cycle
For continued progress, the cycle must continue
to press forward.
Apathy
?
Awareness
Contentment
?
?
?
Concern
Expectation
?
?
Attitudinal Shift
?
Social Norm
?
?
Social Concern
Action/ Legislation
Stagnation in outcome results from not moving
through the cycle and not pressing for new public
health protections.
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Denormalization Strategy
Lasting change in youth behavior regarding
tobacco can only be secured by first changing the
adult world in which youth grow up.
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How California Defines the Problem
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Problem Sex Sells
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Problem Target Marketing
Find Your Voice
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February 2007
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Problem Tobacco Industry Bar Night Sponsorship
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Problem Tobacco Company Sponsorship
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Problem Free Tobacco Sampling
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Problem 2006 Rite Aid Heart Disease
CampaignWhats wrong with this picture?
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Problem Unprotected Workers
American Indian Casinos
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Problem Drifting Smoke in Multi-Unit Housing
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Problem Tobacco Litter Pollutes
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Problem Fighting for the Beaches
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Problem Reduced Harm Products
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Problem Tobacco Sales to Kids

• Adults make decisions to.
• Enforce tobacco control laws

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Problem Retail Advertising

• Adults Make Decisions to.
• Promote tobacco use through ads

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Adults Make Decisions to.

• Raise taxes on tobacco products

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Problem Tobacco use in the movies

• Adults Make Decisions to..
• Glamorize model tobacco use in movies

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Adults Make Decisions to..

• Dedicate funding for tobacco control

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Adults Make Decisions to...

• Protect workers from secondhand smoke

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Four Effective Strategies
Outcomes
Strategies
Reduce Exposure to SHS and Tolerance to Exposure
Decrease Tobacco Consumption
Decrease Tobacco Use Prevalence
Counter Pro-Tobacco Influences
Decrease Youth Uptake of Tobacco
Reduce Availability to Tobacco from Retail
Social Sources
Provide Cessation Services
Decrease Exposure to SHS
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Social Norm Change Strategy

• Doesnt rule out educating individuals, but
  emphasizes making changes in the larger physical
  social environment
• It creates lasting population changes
• As new people or businesses move into your
  community, they inherit, adopt and conform to the
  established norms about tobacco use

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A Powerful Equation
Media

Community Involvement

Social Norm Change
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California Tobacco Control Program Media Campaign
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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

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Three Main Media Strategies

• Secondhand Smoke (SHS) Provides smokers a reason
  to quit and facilitates SHS laws (protect loved
  ones)
• Counter the Tobacco Industry Motivates smokers
  to quit as they understand TI manipulation and
  nicotine addiction
• Cessation Provides resources to quit

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Secondhand Smoke Strategy
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Rationale for Secondhand Smoke Strategy

• Secondhand Smoke
• Educate people about the hazards, and they will
  take action to protect themselves
• Cessation is an outcome - people smoke less
  quit to protect their families
• Gives non-smokers a voice
• Turns public apathy into action mobilizing
  communities to enact policies to protect
  non-smokers

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Cumulative Number of Cities with Smoke-Free
Provisions in Local Laws
286
133
82
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18
1
5
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Economic Impact of Smoke-free Restaurants and Bars
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Bar Patron Approval of the Smoke-Free Bar Law,
1998 and 2002
Source California Bar Patrons Field Polls Mar
1998 and September 2002 Prepared by California
Department of Health Services, Tobacco Control
Section, Nov 2002
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Bar Establishment Ease of Compliance with the
Smoke-Free Bar Law
Fairly Easy
Easy
Very Easy
48.5
28.3
76.8
10.5
22.5
12.0
Fairly Difficult
Very Difficult
Difficult
Source California Bar Establishments Field
Polls, October 2002 Prepared by California
Department of Health Services, Tobacco Control
Section, Nov 2002
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Bar Owners/Employees Prefer Smoke-Free Environment
Source California Bar Establishments Field Polls
Mar 1998 and October 2002 Prepared by California
Department of Health Services, Tobacco Control
Section, Nov 2002
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Bar Revenues in California 1990-2002
Millions of Dollars
Smoke-free bar law
Smoke-free restaurant law
Source California Board of Equalization. Data
is from the Eating and drinking establishments -
all types of liquor category. Prepared by
California Department of Health Services, Tobacco
Control Section.
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Anti-Industry Strategy
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Rationale for Anti-Industry Strategy

• Countering Pro-Tobacco Influences
• Causes people to question industry motives and
  rallies smokers non-smokers alike
• Youth adults rebel against industry
  manipulation
• Motivates quitting as people become angry about
  the manipulation
• Holds the industry accountable for their
  marketing practices which target vulnerable
  populations

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The Role of Litigation
Tobacco Control Section Records Boxed and Ready
for Tobacco Industry Imaging
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Role of Litigation Government Lawsuits

• 1998 Master Settlement Agreement (MSA)
• Generated 25 billion/25 years for California
• Limits youth tobacco marketing
• Aggressive MSA enforcement
• 11.4 million settlement against RJR for MSA
  violations (2004)
• 5 million settlement against RJR for free
  tobacco samples (2006)

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Cessation Strategy
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Rationale for Cessation Strategy

• Demonstrates empathy for smokers
• Acknowledges that quitting is hard work
• Provides assistance with quitting

Call 1-800-NO BUTTS
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Role of Cessation Services in Reducing Smoking
Prevalence

• To create a substantial public health benefit,
  the intervention must create significant change
  at the population level
• Weaker interventions that create change with
  large numbers of smokers can make a significant
  impact
• Californias program has relied on changing the
  environment coupled with support for cessation
  services

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Community-Based Efforts
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Rationale For Community Involvement

• Increases the likelihood that members of the
  target group will come into contact with your
  messages
• Promoting messages through multiple channels is
  effective at changing norms
• Ties the program to the community since members
  were involved in developing it

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Rationale For Community Involvement

• Brings together a variety of expertise, influence
  and connections
• Through involvement of the community and its
  leaders, the community is mobilized

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CDPH Tobacco Control Program Infrastructure
Statewide Evaluation/Surveillance
Statewide Media Campaign
61 Health Department Projects
CommunityCoalitions
Capacity Building Network
Statewide Youth Advocacy Network
39 Community Non-profit Agency Projects
Statewide Training Technical Assistance Projects
Legal Technical Assistance Center
Policy Community Organizing Center
Materials Clearinghouse
Local Program Evaluation Center
Cessation Quitline
Secondhand Smoke Training
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Overview Who We Fund

• 61 city and county health departments, a.k.a.
  Local Lead Agencies (LLA)
• Over 50 competitive grantees (CGs), including 39
  local grantees
• LLAs and CGs work on the four tobacco control
  priority areas

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Direct Service Providers

• California Smokers Helpline
• Toll-free quitline that provides intensive
  cessation counseling in multiple languages
• Self-help and referral services
• Over 25 quit rate
• Tobacco Education Clearinghouse
• Educational materials development and
  distribution
• Library and web site services
• Technical assistance to contracted agencies

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Integrated Approach to Addressing Disparities

• Multi-cultural and multi-lingual media
• Multi-cultural and multi-lingual quitline Asian,
  English, Spanish, Hearing impaired
• Extensive tobacco educational materials
  clearinghouse
• Surveillance English and Spanish
• Special population surveillance studies
• Priority population local project procurements
• Requirement for health depts. to assess cultural
  competency assets and include an objective to
  address cultural competency
• Requirement for health dept. coalitions to
  reflect population diversity
• Statewide training technical assistance

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Training and Technical
Assistance Providers

• Tobacco Control Evaluation Center
• TA regarding evaluating tobacco control programs
  training
• Technical Assistance Legal Center
• TA regarding drafting and passing tobacco control
  policies high quality legal analyses training
• California Clean Air Project
• TA regarding SHS issues, including
  compliance/enforcement of existing laws new
  policy issues (OTS) training

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Training and Technical
Assistance Providers

• Center for Community Organizing
• TA regarding community mobilization and policy
  passage
• Youth Advocacy Network
• TA regarding youth and college-based advocacy
  coordinate statewide youth coalition and advocacy
  activities

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Successes of the California Tobacco Control
Program
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California adult smoking prevalence by region,
1990 to 2005
1990
1996
1999
2002
2005
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Smoking Prevalence Among California Adults
1984-2006
Change in definition of smoking
decrease of 41.4
Source Behavioral Risk Factor Surveillance
System (BRFSS) 1984-1992. BRFSS and California
Adult Tobacco Survey data is combined for
1993-2006. The data is weighted to the 2000
California population. Note change of smoking
definition in 1996 that included more occasional
smokers. Prepared by California Department of
Health Services, Tobacco Control Section, March
2007.
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US minus CA
California
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30-day Smoking Prevalence for California and U.S.
High School Students (9th-12th Grade), 2000-2006
Prevalence
Source The 2000 data is from the National Youth
Tobacco Survey collected by the American Legacy
Foundation, which used passive parental consent.
The 2002 and 2004 data is from the California
Student Tobacco Survey, which used active
parental consent. Prepared by California
Department of Health Services, Tobacco Control
Section, 2006.
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Lung and bronchus age-adjusted cancer incidence
rates, 1988-2003
EAPC -0.4
EAPC -1.4
Rates are per 100,000 and age-adjusted to the
2000 U.S. standard (19 age groups). The EAPC
is significantly different from zero
(plt0.05). Source Cancer Surveillance Section.
Prepared by California Department of Health
Services, Tobacco Control Section, 2006.
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Secondhand Smoke Strategy Works
Relation Between Policy and Cigarette Consumption
Cigarettes/Day
Source California Tobacco Survey 1999.
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Former Smokers/Smokers Who Agreed Smoke-Free
Workplace Law Made it Easier to Quit or Smoke Less
Source The 2004 Survey of California Adults on
Secondhand Smoke conducted by Field Research
Corporation. Prepared by California Department
of Health Services, Tobacco Control Section,
January 2005.
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Most Effective Interventions

• Increase the price of tobacco products
• Secondhand smoke policies
• Counter the tobacco industry

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Increase the Price of Tobacco

• A 2.60 per pack cigarette tax in California
  would
• Reduce the number of cigarettes consumed by 312
  million packs
• 502,108 smokers would quit because of the tax
  increase
• Adult smoking would decline by 13.2 from 14 to
  12.2
• 150,000 youth would either quit or not start
• High school smoking would decline by 42.8 from
  13.2 to 7.6
• Middle school smoking would decline by 42.8 from
  3.9 to 2.2.

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Increase the Price of Tobacco

• A 2.60 per pack cigarette tax in California
  would
• Prevent 120,000 deaths due to smoking among adult
  smokers who quit
• Prevent 180,000 deaths among youth under age 17
• Save 16.5 billion in health care costs
• A simulation model estimates about 60 of the
  decline in smoking in California is attributable
  to price increases

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Secondhand Smoke (SHS)

• Negative attitudes about SHS are a strong
  predictor of quitting
• over 6 times less likely to smoke
• more than 2 times more likely to have made a
  recent quit attempt
• over 2 times more likely to have intentions to
  quit smoking in the next 6 months
• A simulation model estimates about 10 of decline
  in smoking in California due to the state clean
  indoor air law, but the impact may be
  underestimated because so many local laws were in
  effect prior to the state law

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Countering Pro-tobacco Influences

• Californians with highly negative attitudes about
  the tobacco industry are
• 22 less likely to smoke
• Among smokers, 65 are more likely to have
  intentions to quit in the next six months in
  comparison to those with moderate or low negative
  attitudes about the tobacco industry
• A simulation model estimates that 25 of
  reduction in smoking was due to the media
  campaign

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Conclusions

• A comprehensive program is most effective
• Media and local programs must be coordinated and
  well funded
• If you want kids to not smoke, you have to get
  the adults to change their behavior
• Anti-industry and secondhand smoke strategies are
  effective with adults and youth

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Conclusions

• Provide strong leadership, but allow for Program
  flexibility
• Empower the communities to advocate for local
  change
• Be culturally sensitive and use the power of the
  communities
• Oversight and accountability are the key to
  sustainability of the Program

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Continuing Challenges of the California Tobacco
Control Program
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Not everyone has benefited equally

• Smoking prevalence is high among
• Low SES
• African-Americans
• Korean men
• American Indians
• LGBT
• Active duty military
• Rural areas
• Men overall
• 18-29 year olds

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Low SES Prevalence in CA, 1990-2005
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18-24 Year Old Prevalence, 2001-2005
Percent
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New Program Priorities
Secondhand Smoke in American Indian Casinos
Smoke-free Multi-Unit Housing
Smoke-Free Outdoor Areas
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Smoke-free Cars

• Infraction to smoke a pipe, cigar or cigarette in
  a motor vehicle while a minor (lt 18) is present
• Law enforcement may not stop a vehicle for the
  sole purpose of determining a smoking violation
• Each infraction to result in a minimum fine of
  100
• To take effect January 1, 2008

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Other State Laws

• Access to Tobacco
• Retail Licensing and Enforcement
• Self Service Display Law
• Vending Machines
• Prisons

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Innovative Ideas

• Smoke-free
• Tot Lots and playgrounds
• Cars
• Outdoor dining
• Multi-unit housing

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Think BIG

• Big Hairy Audacious Goals
• Have an impossible vision of the future
• Decide what the practical steps are that start
  you in the direction of your vision
• KEEP GOING!!!

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California Tobacco Control Program Contacts

• Community Programs Tonia Hagaman
• Tonia.Hagaman_at_cdph.ca.gov
• Media Campaign Colleen Stevens
• Colleen.Stevens_at_cdph.ca.gov
• Policy Greg Oliva
• Greg.Oliva_at_cdph.ca.gov
• Evaluation Surveillance David Cowling
• David.Cowling_at_cdph.ca.gov