The California The California Tobacco Control Tobacco Control Program: A Model for Program: A Model for ChangeChange

TOBACCO CONTROL SECTION

California Department of Health Services

March 2001

c

Comprehensive FundingComprehensive Funding

7%

3%

30%

30%

30%

Evaluation

State Administration

StatewideAdvertising

and Publications

Community Grants

61 Local Health Departments

Goal = change social norm

Outcome = prevention & cessation

Denormalization StrategyDenormalization Strategy

Lasting change in youth behavior

regarding tobacco can only be secured

by first changing the adult world in

which youth grow up.

Strategy to Reduce Tobacco Use in California

Reduce Exposure to ETSand Tolerance to Exposure

Reduce Access to Tobaccofrom Retail & Social Sources

Provide Cessation Services

Decreased TobaccoConsumption

Decreased Tobacco Use Prevalence

Decrease Youth Decrease Youth Uptake of TobaccoUptake of Tobacco

Decreased Exposureto ETS

Counter Pro-Tobacco Influences

Training/

TAClearing-

houseQuitline

11 Regions

4Ethnic

Networks

83 Competitive Grantees

61 Health DepartmentCoalitions

Statewide Evaluation

CDC Legacy

DHS Tobacco Control Program

STAKE

Statewide Media Campaign

Local ProgramsLocal Programs

Statewide Projects

Direct Service Providers• Quitline

• Clearinghouse

• Tobacco Industry Sleuthing Project

Training/TA Providers• Technical Assistance Legal Center

• Media/PR Technical Assistance

• BREATH (Smoke-free Bar Project)

Impact Leaders and Institutions

• Youth Advocacy Network

• Entertainment Industry Campaign

• Key Opinion Leader Project

• Divestment Project

• Labor Project

• Ethnic Networks

• Provides intensive telephone cessation counseling to adults and teens

• Provides self-help kits and referral services

• Serves approximately 3500 new clients per month and 1200 new clients counseled monthly

• 26.7% success rate at one year f/u

• Educational materials distribution

• Educational materials development

• Library services

• Maintain web sites

• Technical assistance

• Serve 170 Contractors &1000 School Districts

TTechnical echnical AAssistance ssistance LLegal egal CCenterenter

• Provides California communities with free technical assistance on legal issues related to drafting and passing tobacco control policies

• Provides high quality legal analyses to city attorneys, county counsels, elected officials and project directors

TCS WorkgroupsTCS Workgroups

Gardening experts….Secondhand SmokePoint-of-Sale PracticesProject SMART MoneyChew/Dip, Cigars & Alternative Tobacco

Statewide Statewide CampaignsCampaigns

• Operation Storefront

• Project SMART Money

• Communities of Excellence

The Media CampaignThe Media Campaign

Mature CampaignMature Campaign

ApathyApathyAwarenessAwareness

ConcernConcern

Attitudinal Attitudinal ShiftShift

Social Social ExpectationExpectation

Action/ Action/ LegislationLegislation

Social NormSocial Norm

ExpectationExpectation

ContentmentContentment

The Cycle Of AThe Cycle Of A Social Issue Social Issue

Strategies That WorkStrategies That Work

• Secondhand Smoke– Educate people about the hazards, and they

will take action to protect themselves

– Turns public apathy into action

– Gives non-smokers a voice

– Cessation is an outcome--people quit to protect their families

Strategies That WorkStrategies That Work

• Countering Pro-Tobacco Influences– Causes people to question industry

motives and rallies smokers & non-smokers alike

– Youth & adults rebel against industry manipulation

– Supports local policy activities

Youth Strategic Learning Youth Strategic Learning Strategies that DID MotivateStrategies that DID Motivate

• “Tobacco Industry Manipulation”

• Nicotine Addiction

• “Secondhand smoke is more dangerous than you think”

• Impactful personal stories

Youth Strategic Learning Youth Strategic Learning Strategies that DIDN’T MotivateStrategies that DIDN’T Motivate

• Long-term health effects

• Short-term health effects

• Short-term cosmetics effects

• Romantic rejection

• Smoking isn’t cool

“If health education and prevention can’t show it’s effective, it doesn’t deserve the money.”

Evaluation and Surveillance

The Law We Live or Die By

Source: California State Board of Equalization (packs sold) and California Department of Finance (population). U.S. Department of Agriculture. Note that CA data is by fiscal year (July 1-June 30) and U.S. data is by calendar year.Prepared by: California Department of Health Services, Tobacco Control Section, June 2000.

0

50

100

150

200

CA 162.3 158.8 152.5 141.4 136.4 131.1 126.6 112.6 94.7 91.1 84 79.3 77.5 74.8 69.2 61.3

US 192 187.7 175.1 168.5 163.7 159.9 154.8 146.3 136 132.1 127.2 126.2 125.3 124.1 116 106.8

80/81 81/82 82/83 84/85 85/86 86/87 87/88 88/89 90/91 91/92 92/93 93/94 94/95 95/96 97/98 98/99

Packs/Person

California and US cigarette consumption, California and US cigarette consumption, packs per fiscal year, 80/81 - 98/99packs per fiscal year, 80/81 - 98/99

US

CA

California vs. U.S. California vs. U.S. Adult Smoking PrevalenceAdult Smoking Prevalence

Sources: United States--NHIS, US Centers for Disease Control and PreventionCalifornia--CTS, 1990, 1992-3, 1996, weighted to 1990 CA population; CATS/BRFS, 1994-1998, weighted to 1990 CA population.

Prepared by: California Department of Health Services, Tobacco Control Section, May 24, 2000.

0

10

20

30

40

Pe

rce

nt

US CA

US 37.9 34.9 33.6 32.3 31.9 29.9 30.2 27.4 25.0 25.5 24.7

CA 35.0 32.3 31.7 29.4 30.5 26.8 26.7 22.2 20.0 20.2 17.3 16.7 18.6 18.4 18.0

77 78 79 81 82 83 84 85 87 88 89 90 92 93 94 95 96 98 99

Tax Increase and Start of

the CA Tobacco Control Program

* Definition change in 1996 resulted in more “occasional smokers” being counted.

*

30-day smoking prevalence among California 30-day smoking prevalence among California youth using a telephone survey, 1994-1999youth using a telephone survey, 1994-1999

0

2

4

6

8

10

12

14

Overall 11 12.1 11 11.2 10.7 6.9

1994 1995 1996 1997 1998 1999

Source: CYTS 1994-1999.Prepared by: Tobacco Control Section, California Department of Health Services, June 2000.

Per

cen

t

1999 Youth Smoking Prevalence1999 Youth Smoking PrevalenceSubstance Abuse and Mental Health Services Administration (SAMHSA)Substance Abuse and Mental Health Services Administration (SAMHSA)

0

5

10

15

20

25National 30-Day Use

California 30-Day Use

Utah 30-DayUse

Florida 30-Day Use

Kentucky 30-Day Use

23.9

11.510.3

9

15.1

Cumulative Number of Cities with Cumulative Number of Cities with Smoke-Free Provisions in OrdinanceSmoke-Free Provisions in Ordinance

1 5 1835

82

133

286

0

50

100

150

200

250

300

1989 1990 1991 1992 1993 1994 1995

Number of Cities

California 1989-1995

35

90

0

20

40

60

80

100

1990 1998

Protection From Environmental Protection From Environmental Tobacco Smoke In The WorkplaceTobacco Smoke In The WorkplaceProtection From Environmental Protection From Environmental Tobacco Smoke In The WorkplaceTobacco Smoke In The Workplace

Perc

en

tag

e o

f w

ork

ers

pro

tecte

d

CTS, 1998

Smokers with Children Under 18 Who Smokers with Children Under 18 Who Prohibit Smoking in Their HouseholdProhibit Smoking in Their Household

Relation Between Policy and Relation Between Policy and Cigarette ConsumptionCigarette Consumption

13.9

11.2

8.27.3

0

2

4

6

8

10

12

14

None Work ban only Home ban only Both

Source: CTS 1999

Daily Cigarette Consumption and Smoking Bans

Cig

are

ttes/

Day

Percent of Retailers Selling Tobacco Percent of Retailers Selling Tobacco to Youthto Youth 1994-20001994-2000

52.1

37

29.3

21.7

13.1

16.9

12.8

0

10

20

30

40

50

60

1994 1995 1996 1997 1998 1999 2000

Per

cen

t

Attempted buy protocol 1994-1996; Actual buy protocol 1997-2000.Due to different methodologies 1994 survey results may not be comparable to the 1995-2000 results.Source: California Youth Purchase Survey, 1994-2000.Prepared by: California Department of Health Services, Tobacco Control Section, September 2000.

45

50

55

60

65

1988 1989 1990 1991 1992 1993 1994 1995 1996

United States (minus California)California

Lung and Bronchus Age-Adjusted Lung and Bronchus Age-Adjusted Cancer Rates, 1988-1996Cancer Rates, 1988-1996

EAPC = -2.3*

EAPC = -0.6

1 United States (Surveillance, Epidemiology, End Results [SEER]) includes the following registries Connecticut, Detroit, Hawaii, Iowa, New Mexico, Seattle, Utah, and Atlanta. San Francisco-Oakland has been excluded.2 California Cancer Registry, California Department of Health Services (11/99)* Estimated annual percent change (EAPC) is significantly different from zero (p<0.01)

Rate per 100,000

1

2

Savings in Smoking Attributable Savings in Smoking Attributable Direct & Indirect CostsDirect & Indirect Costs

0

1

2

3

4

5

6

7

8

9

1990-1998

Expended

Saved

Billions

$836 Million

$8.4 Billion

ConclusionsConclusions• 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.

• Empower the communities to advocate.

• Be culturally sensitive

• Accountability is the key to success.

• Provide strong leadership and allow program flexibility.