Changing Public Policy to Reduce Tobacco Use

Andrew Hyland, PhDRoswell Park Cancer Institute

Andrew.hyland@roswellpark.org

Stanton Glantz, PhDUniversity of California San Francisco

glantz@medicine.ucsf.edu

June 2, 2010

Key Messages from Today’s Talk Tobacco is the number one preventable health

problem that faces our nation today We know what works! Broad-based policy change Programs and public education $$$ Policy change political will BUT…be careful…the financial viability of a

massive oligopy is at stake They will undermine your efforts and be creative to

continue to maximize their profits BUT…science tells us that broad-based policy

change saves lives and money

What Drives Tobacco Use

Societal Change Requires Societal Action

And This Will Reflect Itself With Individual-Level Change

The Motivation

Tobacco will kill tens of millions of US residents this century

We know what causes this death We have a responsibility to do something

about it Speed matters

What We Know Works

Clean air Mass media Higher prices Cessation Comprehensive programs

Some policies are feasible at the local level

What about cessation? Quitlines and direct services are fine But most people quit unaided

Goal should be to promote and support unaided quit attempts

Smokefree workplaces and homes Reduce social acceptability of smoking

Smokefree policies are 10 times more cost effective per new nonsmoker than direct services

What About Youth Smoking?

The policies that impact adult smoking impact youth smoking

Little evidence school-based education by itself is effective

Little evidence youth access policies are effective

Why spend lots of money to target a sliver of the smoking population when other policies are less expensive and work for everyone?

Localities can now restrict tobacco marketing

Limit number of outlets Limit where ads are placed in retail

setting Eliminate buy-one-get-one-free

offers These actions may be challenged

based on 1st Amendment Do after clean indoor air

Outlet Density, Ad Ban Policies

Retail Environment

Retail Environment

Change Social Acceptability

Similar effect to price increases Estimate 15% consumption drop if

US was raised to the level in California in 1999

= $1.17 per pack price increase

SOURCE: Alamar and Glantz. AJPH 2006

Let’s Focus on Clean Air…

Hayman Fire – Worst in Colorado History, June 8 2002

Denver June 9, 2002

Denver’s visibility – before Hayman fire

Denver’s visibility – 1 day after Hayman fire

Worst PM 2.5 - 43 µg/m3 (24-hr max) or 200 µg/m3 (hourly max)

Particulate Matter Levels in the US.

15 15 15 163

163

290

132

181

92

0

100

200

300

400

All Venues(n=609)

Bars (n=170) Restaurantswith Bars(n=314)

Restaurants(n=107)

LargeRecreation

Venues (n=17)

Ge

om

etr

ic M

ea

n P

M2.

5 C

on

ce

ntr

ati

on

(μ

g/m

3 )

No Observed Smoking

Observed Smoking

Error Bars: 95% CI’s

15 15 15 163

163

290

132

181

92

0

100

200

300

400

All Venues(n=609)

Bars (n=170) Restaurantswith Bars(n=314)

Restaurants(n=107)

LargeRecreation

Venues (n=17)

Ge

om

etr

ic M

ea

n P

M2.

5 C

on

ce

ntr

ati

on

(μ

g/m

3 )

No Observed Smoking

Observed Smoking

Error Bars: 95% CI’s

Generated Media on Air Monitoring Studies

U.S.A.

"Common Sense" - Tobacco Institute, 1982 (ti53100003)

Clean air policies can be done locally to change social norms…

In large part because the data are on our side

Introducing Stan Glantz

Pioneer in the clean air and social change movement in California to share his perspective

US Surgeon General (1986)

Involuntary smoking is a cause of disease, including lung cancer, in in healthy non-smokers.

The children of parents who smoke compared with the children of nonsmoking parents have an increased frequency of respiratory infections, increased respiratory symptoms, and slightly smaller rates of lung function as the lung matures.

The simple separation of smokers and nonsmokers within the same airspace may reduce, but will not eliminate, exposure to environmental tobacco smoke.

Secondhand Smoke Causes(Cal EPA/NCI, 1997)

Fetal growth retardation SIDS Respiratory problems in kids Asthma in kids Eye and nasal irritation Middle ear infections in kids Lung cancer Nasal sinus cancer Heart disease mortality and morbidity About 53,000 deaths

Secondhand Smoke Causes(Cal EPA, 2006)

Pre-term delivery Asthma induction in adults Breast cancer in younger (primarily

premenopausal) women Acute and chronic heart disease morbidity Altered vascular properties About 50,000 deaths (not including breast

cancer)

Annual deaths due to SHS

Other cancers

Lung cancer

Heart disease

Source: Wells,1998

37,000

13,000

3,000

Injury RepairMaintenance of Vascular Endothelium

lumen

intimamedia

EPCsEndothelial microparticles

balance

NO

NO

NO

NO

Physical evidence for endothelial

damage

* p<0.05 vs baseline# p<0.05 vs respective time point on control day

*Baseline 0 h 1 h 2.5 h 24 h

0

500

1000

1500

2000

Baseline 0 h 1 h 2.5 h 24 h

0

500

1000

Baseline 0 h 1 h 2.5 h 24 h

0

50

100

150

200

250

300

350

400

*#

*#A

*#

CD

31+ E

MP

s (e

v/m

L)

SHS clean air

*#

B

CD

144+

EM

Ps

(ev/

mL)

*#*#

*#*#

C

CD

62e+

EM

Ps

(ev/

mL)

*#

*#

*#*#

CD31+/CD41-

(PECAM/Gp IIb)

CD144+ (VE-Cadherin)

CD62e+ (E-Selectin)

“Activation”

“Structural damage”

Endothelial microparticles

Endothelial function is acutely decreased to smokers levels

* p<0.05 vs baseline# p<0.05 vs respective time point on control day

VEGF

VEGF

Increased EPC number in blood

* p<0.05 vs baseline# p<0.05 vs respective time point on control day

Sustained inhibition of EPC chemotaxis to

VEGF

* p<0.05 vs baseline, # p<0.05 vs respective time point on control day

Disturbed Maintenance of Vascular Endothelium

lumen

intimamedia

EPCs

Endothelial microparticles

balance

NO

NO

NO

NO

Injury Repair

Gala Event

Helena, MontanaPopulation of city: 28,306

Population of Helena Zip Codes: 46,943Total Population of Study area: 65,913

Geographically isolated populationNext nearest cardiologist: 60 miles

Significant Drop in AMI Admissions while Ordinance in Effect

0

10

20

30

40

50

60

1998 1999 2000 2001 2002 2003

Year

AM

I A

dm

issi

on

s

Helena

Outside Helena Ordinance

Effect grows with time-.

5-.

4-.

3-.

2-.

1ln

RR

0 10 20 30 40Duration post ordinance

Institute of Medicine

… secondhand-smoke exposure increases the risk of coronary heart disease and heart attacks and that smoking bans reduce this risk. … smoking bans can have a substantial impact on public health.

Mammary Carcinogens in Tobacco Smoke

Aromatic hydrocarbonsBenzeneBenzo[a]pyreneDibenz[a,h]anthraceneDibenzo[a,e]pyreneDibenzo[a,h]pyreneDibenzo[a,I]pyreneDibenzo[a,l]pyrene  NitrosaminesN-nitrosodiethylamineN-Nitrosodi-n-butyl-amine

Aliphatic compoundsAcrylamideAcrylonitrile1,3-ButadieneIsopreneNitromethanePropylene oxideUrethaneVinyl chloride Arylamines and nitrarenes4-AminobiphenylNitrobenzeneOrtho-Toluidine

Human evidence Increases in risks for smoking and

passive smoking among younger women

70% increased risk in younger women

Exposure between puberty and lactation probably most dangerous

Susceptible women probably get the cancers young

100.0080.0060.0040.0020.00

%TOTAL PROTECTION vs SHS by RULES '92 All Ages

32.00

30.00

28.00

26.00

24.00

22.00

20.00

18.00BR

EA

ST

CA

NC

ER

MO

RT

AL

ITY

All

Ag

es 9

9-05

r = -.438 p .001 N = 51 States 1a)

r = -.438 p .001 N = 51 States 1a)

R Sq Linear = 0.192

No Smoking Home&Work '92 / BC MORTALITY 99-05

Source: Piazza K, Hyland A. Unpublished analysis.

% Women With Smokefree Home AND Workplace By State, 1992/1993 CPS TUS, All Ages

STATES WITH MORE 100% SMOKEFREE RULES HAVE LOWER

BREAST CANCER MORTALITY

New York Response

Invasion of the Tobacco People

Per capita cigarette consumption

40

60

80

100

120

140

1979 1984 1989 1994

Year

Per C

apita C

igare

tte C

onsum

ption (Packs/Y

ear)

United States - California

California

Prop 99

Tax increase

Age Adjusted Heart Disease Mortality

100

120

140

160

180

200

1979 1984 1989 1994Year

Age-

Adju

sted

Hea

rt D

isea

se M

ort

ality

(dea

ths/

100,

000)

United States - CaliforniaCalifornia

Prop 99

Tax increase

Effect on Mortality

95

115

135

155

175

1979 1984 1989 1994Year

Age-A

dju

ste

d H

eart D

isease M

ortalit

y

(death

s/1

00,0

00 R

esid

ent Popula

tion)

59,000 fewer deaths (9%)

1,500 unnecessary deaths

Effect on Industry Sales

35

55

75

95

115

1979 1984 1989 1994

Year

Per C

apita C

igare

tte C

onsum

ption (Packs/Y

ear)

2.9 billion packs not smoked ($4 billion)

1 billion extra packs ($1.4 billion)

Large Scale Tobacco Control Programs Work Over the first 15 years the California

program cost $1.4 billion It saved $86 billion These savings started appearing

quickly and grew with time By 2004, the program was saving

$11 billion in health costs 7.3% of all health costs

Large Scale Tobacco Control Programs Work Prevented 3.6 billion packs of

cigarettes from being smoked Worth $9.2 billion in lost sales

The tobacco industry is motivated to stop you

How do you make change? Identify local champions Health department has to its public policy

job Public education Policy maker education Creating positive environment through media

Private agencies need to do their job Aggressive Close the deal

The industry will oppose you They have a lot to lose They are highly motivated Work through third parties

Public records act requests “Illegal lobbying” Lawsuits

“Illegal lobbying” and litigation

Not that We’re Paranoid

Specific amendment language drafted to stop NCI grants to Glantz and Richard Daynard (Faxed to RJR from Tobacco Institute) [ydn60d00]

For people who think we have not made progress

For people who think we have not made progress