Post on 08-Apr-2018
transcript
1
Restrictions on Tobacco Use, Sales
& Marketing
Frank J. Chaloupka
Developing Public Health Regulations for Marijuana: Lessons from Alcohol and Tobacco Arlington, VA, February 11 2013
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Diseases and Adverse Health Effects Caused by SHS
Image source: adapted by CTLT from U.S. Surgeon General’s Report. (2006); from JHBSPH/IGTC on-line course.
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Early Evidence & Action ! Leading up to his 1972 report, US Surgeon
General Jesse Steinfeld stated:
• “Nonsmokers have as much right to clean air and wholesome air as smokers have to their so-called right to smoke, which I would define as a ‘right to pollute.’ It is high time to ban smoking from all confined public places such as restaurants, theaters, airplanes, trains, and buses.”
The “Non-smokers’ Rights” movement is born
Source: Eriksen and Chaloupka, 2007
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Early Evidence & Action ! Smoke-free policies emerge:
• Existing policies intent was fire safety, prevention of food contamination
• 1973 – Arizona first state to limit smoking in public places
• 1974 – Connecticut first to limit smoking in restaurants
• 1975 – Minnesota first to limit smoking in private worksites
• First wave of policies restricted smoking in various venues; no complete bans
Source: Eriksen and Chaloupka, 2007
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Policy Development ! Over time, state/local policies get stronger:
• 1998 California bans smoking in public places, including restaurants and bars without separately ventilated areas
• 2002 New York city bans smoking in bars, restaurants and virtually all other public places and private workplaces
• 2003 Florida ballot initiative with similarly comprehensive ban passes easily
• By 2003 all states have at least some restrictions on smoking in public places
! Thousands of local policies Source: Eriksen and Chaloupka, 2007
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2006 Surgeon General’s Report “Eliminating smoking in
indoor spaces fully protects nonsmokers from exposure to secondhand smoke”
“Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposure of nonsmokers to secondhand smoke”
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Smoke-Free Air Policies - Impact
! Attitudes & Compliance • Support for smoke-free policies grows after
adoption/implementation of policy
• Compliance is moderate to high in most countries that adopt smoke-free policies
! Compliance better where pre-implementation efforts to inform and build support
• Generally self-enforcing
Source: IARC, 2009
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Smoke-Free Air Policies - Impact
! Anti-Smoking Norms
• Generally majority level support for smoke-free policies in HICs
• In HICs, evidence of support among smokers for smoke-free policies
• Prevalence of smoke-free homes is growing
Source: IARC, 2009
Smoke-Free Air Policies - Impact ! Smoking Behavior
• ‘Smoke-free workplace policies reduce cigarette consumption among continuing smokers and lead to increased successful cessation among smokers.’
• ‘Smoke-free policies appear to reduce tobacco use among youth’
• ‘There is a greater decline in smoking when smoke-free policies are part of a comprehensive tobacco control program’
• Impact of smoke-free home policies on behavior greater than of public policies
Source: IARC, 2009
Source: NSDUH, Mayatech &RPCI, and author’s calculations
Smoke Free Air Policies and Young Adult Smoking Prevalence, 2003-04
y = -0.1176x + 43.509R2 = 0.1151
25
30
35
40
45
50
0.0 10.0 20.0 30.0 40.0 50.0
Smoke Free Air, State Policy Index
18-2
4 S
mo
kin
g P
revale
nce
Source: NSDUH, Mayatech &RPCI, and author’s calculations
Smoke Free Air Policies and Adult Smoking Prevalence, 2003-04
y = -0.0791x + 26.516R2 = 0.1169
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17
19
21
23
25
27
29
31
0.0 10.0 20.0 30.0 40.0 50.0
Smoke Free Air, State Policy Index
Ad
ult
Sm
okin
g P
revale
nce
Source: ImpacTeen Project, UIC; Monitoring the Future, 2012
Social Norms About Smoking
0
5
10
15
20
25
70
72
74
76
78
80
82
84
86
88
90
1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011
Sm
oke-
Free
Pol
icy
Ind
ex
% D
isap
pro
vin
g o
f S
mok
ing
On
e or
Mor
e P
acks
per
Day
Smoke-Free Policies Disapproval, 8th Grade Disapproval, 10th Grade
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Smoke-Free Air Policies Future Directions
! Restrictions on smoking in multi-unit housing • Some limited to common areas only • Some limited to public housing • Some complete bans
! Outdoor Venues • Beaches, public parks, zoos • Outdoor dining • Sporting venues • Public transit stops
! Private policies expanding • Hotel chains going smoke-free • Rental car companies going smoke-free
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Youth Access Policies
! Include a range of policies: • Minimum legal purchase age • Minimum age to sell • Penalties on vendor
! Fines, license suspension/revocation
• Penalties on youth ! Purchase, possession, and/or use policies ! Fines, smoking education/cessation classes ! Parental notification ! Driver’s license suspension
• Limits on vending machine sales • Limits/bans on sampling
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Youth Access Policies
! Need for enforcement • Compliance checks
• Effectiveness will depend on variety of factors
! Randomness ! Frequency ! Penalties ! Characteristics of checker ! Merchant education efforts ! Social norms against tobacco ! More……
• Not self-enforcing
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Youth Access Policies
! History • State minimum purchase age policies in
effect for decades ! Little enforcement, low compliance
• Success with MLDA in reducing youth drinking spurred interest in same for tobacco
• Led to 1992 “Synar Amendment” ! Required MLPA of 18 for tobacco products ! Had to demonstrate compliance with policies
• FDA ! 1996-2000 strong youth access program ! Resumed with Family Smoking and Prevention Act
of 2009
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Youth Access Policies Youth Access to Tobacco Products Scores, 1993-2006
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
You
th A
cces
s In
dex
Note: Bars depict the simple average of state scores for the NCI State Cancer Legislative Database Youth Access to Tobacco total score, including pre-emption.
Source: National Cancer Institute (2007).
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Compliance & Availability
Source: SAMHSA, 20012; Monitoring the Future, 2012
8
13
18
23
28
33
38
50
55
60
65
70
75
80
85
90
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
% o
f R
etai
lers
Sel
ling
to
Min
ors
% S
ayin
g E
asy
or F
airl
y Ea
sy t
o G
et
Perceived Availability, 8th Grade Perceived Availability, 10th Grade Synar Non-Compliance Rate
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Youth Access Policies
! History • Initial focus on retailers led to call for
policies holding youth accountable ! Led to policies that penalize youth for
purchase, possession, and/or use
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Youth Access Policies Mean Number of State Purchase, Possession and
Use Laws, per State, 1988-2005
0
0.5
1
1.5
2
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Year
PPU
Source: Roswell Park Cancer Institute and the ImpacTeen Project, unpublished data.
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Youth Access Policies
! Impact of youth access policies • Little evidence that youth access-related
policies by themselves are effective in US and other high-income countries
• 2005 Cochrane review by Stead and Lancaster ! Policies improve compliance ! Compliance needs to be high to impact youth
smoking ! High compliance difficult to sustain
• Enforcement more effective than merchant education
27 Sources: Substance Abuse and Mental Health Services Administration (2006a), National Cancer Institute (2007), and author’s calculations
Youth Access Policies and Youth Smoking Prevalence2003-04
y = 0.0067x + 12.777R2 = 0.0002
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8
10
12
14
16
18
20
5 10 15 20 25 30
Youth Access Policy Index
12-1
7 S
mo
kin
g P
revale
nce
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Youth Access Policies
! Impact of youth access policies • Little evidence that high compliance leads to
significant reductions in youth tobacco use
! Underage tobacco users find stores that are willing to sell
! Youth turn to social sources for tobacco products
• Perhaps greater impact on uptake of heavier smoking among underage youth
! Heavier smokers rely more on commercial sources than on social sources
29 Source: SAMHSA, 2009; YRBS, 2009
7
12
17
22
27
4 6 8 10 12 14 16 18
High School Student Smoking Prevalence
Synar Non- Compliance Rate
Youth Smoking Prevalence and Synar Compliance
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Youth Access Policies
! Impact of youth access policies • No evidence that PPU policies significantly
reduce youth smoking
! May have some impact on kids at lowest risk to begin with
31 Sources: Substance Abuse and Mental Health Services Administration (2006a), ImpacTeen unpublished state policy data, and author’s calculations
Purchase, Possession and Use Policies and Youth Smoking Prevalence, 2003-04
y = 1.0263x + 10.916R2 = 0.1896
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8
10
12
14
16
18
20
0 0.5 1 1.5 2 2.5 3
PPU Policy Index
12-1
7 S
mo
kin
g P
revale
nce
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Impact of Tobacco Marketing ! 1989 Surgeon General’s report described four
ways that marketing could directly affect tobacco use: • By encouraging youth experimentation and uptake • By increasing consumption among current users • By reducing current users’ motivation to quit • By encouraging former users to restart
! Also suggested three indirect mechanisms • Media dependence on tobacco company advertising • Financial dependence of some organizations on tobacco
funds (e.g. professional sports, cultural organizations, minority organizations)
• Ubiquity of marketing creates social norm that tobacco use is acceptable or less objectionable
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Impact of Tobacco Marketing ! Extensive efforts to assess impact of marketing
! Particularly among youth
• Non-randomized studies ! Ad prevalence and favorite ad studies
• Randomized experimental studies ! Manipulate exposure; assess attitudes, perceptions, intentions
• Aggregate demand studies ! Sales and marketing expenditures
• Population based surveys ! Cross-sectional studies ! Longitudinal studies
• Problems ! Self-reported exposure vs. objective measures of exposure ! Endogeneity issues ! Pervasiveness of marketing
Source: NCI Monograph 19
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Impact of Tobacco Marketing “The total weight of evidence – from multiple types of studies, conducted by investigators from different disciplines and using data from many countries – demonstrates a causal relationship between tobacco advertising and promotion and increased tobacco use.”
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Impact of Tobacco Marketing
“Advertising and promotional activities by tobacco companies have been show to cause the onset and continuation of smoking among adolescents and young adults.”
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Marketing Restrictions ! Marketing Restrictions, US
• Public Health Cigarette Smoking Act of 1969 ! Bans broadcast cigarette advertising, effective January
2, 1971 • Master Settlement Agreement, November 1998:
! prohibited tobacco advertising that targets people younger than 18
! Banned use of cartoon characters in cigarette advertising
! Eliminated most outdoor, billboard and public transit advertising of cigarettes
! Prohibited use of branded merchandise ! Other restrictions
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Source: author’s calculations from data reported in FTC (2011)
$0.0
$2,000.0
$4,000.0
$6,000.0
$8,000.0
$10,000.0
$12,000.0
$14,000.0
$16,000.0
1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007
Million Dollars
Cigarette Company Marketing Expenditures,
by Type, 1975-2008
Advertising Pub.Entertainment Placement Price Merchandise Other
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Marketing Restrictions ! Family Smoking and Prevention Act of
2009 • Allows FDA to restrict marketing to youth • Eliminates federal preemption of strong
state restrictions on marketing ! Can restrict ‘time, place or manner’ of
tobacco marketing ! Providence first to attempt
• Bans redemption of coupons • Bans discounted multi-pack sales • Bans sale of flavored tobacco products • Challenged by tobacco companies under First
Amendment; bans upheld; on appeal
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Marketing Restrictions ! Global evidence
• Spread of more comprehensive marketing bans ! Bans on advertising in various channels ! Bans on price reducing promotions ! Bans on brand stretching ! Bans on point-of-sale advertising ! Bans on retail displays of tobacco products ! Plain packaging
• Research shows importance of comprehensive bans ! Increased importance of remaining options as bans
get more comprehensive
Comprehensive advertising bans reduce cigarette consumption
Consumption trends in countries with such bans vs. those with no bans
(n=102 countries)
No Ban
Ban
1450
1500
1550
1600
1650
1700
1750
1981 1991
Year
Cig
aret
te c
onsu
mpt
ion
per
capi
ta
Source: Saffer, 2000
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Counter-Marketing ! Late 1960s, Fairness Doctrine
• Significant reductions in sales, prevalence ! 1988 California Proposition 99
• Earmarked excise tax to fund comprehensive tobacco control program
• Followed by several states ! 1998 Master Settlement Agreement
• Many states commit some funds to comprehensive programs
• American Legacy Foundation created
Source: 2000 SGR
47 $0.0
$200.0
$400.0
$600.0
$800.0
$1,000.0
1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
Millions of Aug 2011 Dollars
State Tobacco Control Funding 1992-2010
Source: Bridging the Gap, ImpacTeen project
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Source: Bridging the Gap, ImpacTeen project
$0.0
$2,000.0
$4,000.0
$6,000.0
$8,000.0
$10,000.0
$12,000.0
$14,000.0
$16,000.0
$18,000.0
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Millions of Aug 2011 Dollars
Tobacco Company Marketing vs. State Tobacco Control Funding
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Counter-Marketing ! Extensive research on state programs
finds ads • Are seen and recalled • Increase risk perceptions • Promote cessation among adults • Prevent youth initiation • Strengthen anti-smoking norms • More effective when part of comprehensive
interventions to reduce smoking
Source: NCI Monograph 19
50
Source: ImpacTeen Project, UIC; Monitoring the Future
0
5
10
15
20
25
30
35
40
45
45
50
55
60
65
70
1991 1993 1995 1997 1999 2001 2003 2005 2007 2009
% P
erce
ivin
g G
reat
Ris
k of
Sm
okin
g O
ne
or M
ore
Pac
ks p
er
Day
State Program Funding 8th Grade 10th Grade
Program Funding & Perceived Risk
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Source: ImpacTeen Project, UIC; YRBS
19
21
23
25
27
29
31
33
35
37
$0
$200
$400
$600
$800
$1,000
1991 1994 1997 2000 2003 2006 2009
Per
cen
t C
urr
ent
Sm
okin
g
Tota
l Fu
nd
ing
$
Mill
ion
s (F
Y1
0 d
olla
rs)
Year
total state program funding high school prevalence
Program Funding & Youth Smoking
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Source: Monitoring the Future, 2012
Social Norms – Cigarettes & Marijuana
65
70
75
80
85
1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011
% D
isap
pro
vin
g
Cigarette Disapproval, 10th Grade Marijuana Disapproval, 10th Grade
54
Source: Monitoring the Future, 2012
Perceived Risk – Cigarettes & Marijuana
50
55
60
65
70
75
80
85
1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011
% P
erce
ivin
g G
reat
Ris
k
Cigarettes, Perceived Risk, 10th Grade Marijuana, Perceived Risk, 10th Grade
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Lessons Learned ! Restrictions on Use
! Comprehensive bans on public use • Including outdoor venues, multi-unit housing,
and other emerging foci of SFA policies • Reduce opportunities for use • Maintain/strengthen social norms against use
! Restrictions on Sales ! Unlikely to be sufficient by themselves ! Need continued strong enforcement
• Funded by taxes, license fees ! Most useful as part of comprehensive
strategy
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Lessons Learned
! Marketing Restrictions ! Comprehensive bans on all advertising,
promotion and sponsorship • Including bans on retail displays, plain
packaging • To maintain/strengthen social norms against
use
! Counter-Marketing ! Strengthen risk perceptions and social
norms against use • Funded by taxes, license fees