‘‘Til Death Do Us Part: Seeking Til Death Do Us Part: Seeking an End to America’s Turbulent an End to America’s Turbulent Love Affair with the CigaretteLove Affair with the Cigarette
Kenneth E. WarnerKenneth E. WarnerUM School of Public HealthUM School of Public Health
CLOSUP, Ford School, October 7, 2013CLOSUP, Ford School, October 7, 2013
CoverageCoverage1.1. A (brief) consideration of change in A (brief) consideration of change in
smoking attitudes and behavior, smoking attitudes and behavior, past 100 yearspast 100 years
2.2. Policy interventions & their effectsPolicy interventions & their effects
3.3. Why evidence-based policiesWhy evidence-based policiesa.a. Are necessaryAre necessaryb.b. But not sufficientBut not sufficient
4.4. Where do we go from here?Where do we go from here?a.a. From more of the sameFrom more of the sameb.b. To the endgameTo the endgame
Dramatic change in Dramatic change in attitudes and norms attitudes and norms concerning smokingconcerning smoking
Cultural position of smoking has Cultural position of smoking has changed dramaticallychanged dramatically
Then…Then…
Other images from the Other images from the dustbin of historydustbin of history
Cultural position of smoking has Cultural position of smoking has changed dramaticallychanged dramatically
Now… Now…
Change in smoking behaviorChange in smoking behavior
Adult smoking prevalence ↓ by more Adult smoking prevalence ↓ by more than halfthan half
42% in 196542% in 1965 18% in 201218% in 2012
Total cigarette consumption ↓ from Total cigarette consumption ↓ from 633B in 1981 to 299B in 2011633B in 1981 to 299B in 2011
Adult per capita cigarette Adult per capita cigarette consumption, U.S., 1900-2011consumption, U.S., 1900-2011
End of WW II
1st Smoking-Cancer Concern
Fairness Doctrine Messages on TV
and Radio
Non-Smokers Rights Movement
Begins
Federal Cigarette Tax Doubles
Surgeon General’s Report on ETS
1st Surgeon General’s
Report
Broadcast Ad Ban
Master Settlement Agreement
Great Depression
Fed. Cig. Tax Increase
Actual adult per capita cigarette consumption Actual adult per capita cigarette consumption (dotted line) (dotted line) and “predicted” in absence of and “predicted” in absence of
antismoking campaignantismoking campaign (dashed line) (dashed line), U.S., 1900-2011, U.S., 1900-2011
What produced this What produced this remarkable change in remarkable change in attitudes, norms, and attitudes, norms, and
behavior?behavior?
5 decades of tobacco control5 decades of tobacco control
Phase IPhase I (1964-early 1970s)(1964-early 1970s): Information & : Information & persuasionpersuasion
Phase IIPhase II (1973-late 1980s)(1973-late 1980s): First incarnation of : First incarnation of non-smokers’ rights movementnon-smokers’ rights movement
Phase IIIPhase III (late 1980s-early 2000s)(late 1980s-early 2000s): Comprehensive : Comprehensive tobacco controltobacco control
Phase IVPhase IV (Early 2000s-present)(Early 2000s-present): Second incarnation : Second incarnation of non-smokers’ rights movementof non-smokers’ rights movement
Process of changeProcess of change
1.1. Information & public education first, Information & public education first, understood & acted upon by SES eliteunderstood & acted upon by SES elite
2.2. Elites – most politically engaged – lobby Elites – most politically engaged – lobby for policy changesfor policy changes
Public health & social motivationsPublic health & social motivations But selfish tooBut selfish too
Cigarette tax increasesCigarette tax increases Ban on smoking on airlinesBan on smoking on airlines
3.3. Middle and lower SES respond to social Middle and lower SES respond to social pressures & environmental changespressures & environmental changes
4.4. Norms change leads to more (and Norms change leads to more (and stronger) policy change – Virtuous cyclestronger) policy change – Virtuous cycle
Health consequenceHealth consequence
Since 1964, ≈Since 1964, ≈10 million 10 million premature deaths premature deaths averted in U.S. as a result of tobacco averted in U.S. as a result of tobacco control-induced decisions to quit smoking control-induced decisions to quit smoking or not to start. On average, 20 year gain!or not to start. On average, 20 year gain!
Our greatest public health success story of Our greatest public health success story of last 50 yearslast 50 years
Greatest remaining burden of preventable Greatest remaining burden of preventable death and illnessdeath and illness
Types of policy interventionsTypes of policy interventions Information & educationInformation & education
Reports of the Surgeon General; Reports of the Surgeon General; warning labels; school health warning labels; school health education; media anti-smoking education; media anti-smoking campaignscampaigns
IncentivesIncentives Tax increaseTax increase
Laws & regulationsLaws & regulations Ad ban; smoke-free workplace laws; Ad ban; smoke-free workplace laws;
sales to minors & PUP lawssales to minors & PUP laws
Intervention effectivenessIntervention effectiveness
EffectiveEffective1.1. Info & educationInfo & education
2.2. TaxTax
3.3. Clean indoor air laws, Clean indoor air laws, policiespolicies
4.4. Counter-advertisingCounter-advertising
5.5. Ad bansAd bans
6.6. Comprehensive TC Comprehensive TC programsprograms
Not effectiveNot effective1.1. School health edSchool health ed
2.2. Old warning labelsOld warning labels
3.3. Minors possession, use, Minors possession, use, & purchase laws& purchase laws
4.4. Sales to minors lawsSales to minors laws
UncertainUncertain1.1. Insurance differentialsInsurance differentials
2.2. New warning labelsNew warning labels
Early years of anti-Early years of anti-smoking campaignsmoking campaign
Information & public educationInformation & public education 1964 Surgeon General’s report & 1964 Surgeon General’s report &
media coveragemedia coverage 15% decline in cig sales first 3 months15% decline in cig sales first 3 months
Fairness Doctrine adsFairness Doctrine ads ↓ ↓ 4 consecutive years4 consecutive years
Tax increases, 1964-71Tax increases, 1964-71
Effects of tax/price increaseEffects of tax/price increase
Price elasticity of demand = -0.3 to -0.5 Price elasticity of demand = -0.3 to -0.5 (10% price increase → 3-5% demand (10% price increase → 3-5% demand decrease)decrease) Half prevalence, half cigs/dayHalf prevalence, half cigs/day
Low-income smokers more price Low-income smokers more price responsive than high-income smokers responsive than high-income smokers (implications for health disparities)(implications for health disparities)
Children 2-3 times more price Children 2-3 times more price responsive than adultsresponsive than adults
First incarnation of First incarnation of nonsmokers’ rights lawsnonsmokers’ rights laws
Nonsmoking areas/sections, Nonsmoking areas/sections, 1973-20001973-2000
RestaurantsRestaurants AirportsAirports Arizona 1973, Minnesota 1975 Arizona 1973, Minnesota 1975
(Michigan 1986)(Michigan 1986)
Second incarnation of Second incarnation of nonsmokers’ rights lawsnonsmokers’ rights laws
Completely nonsmoking workplaces, Completely nonsmoking workplaces, including restaurants & bars, 2000-including restaurants & bars, 2000-presentpresent
Several municipalities first (Davis, CA, 1993)Several municipalities first (Davis, CA, 1993) First state: Delaware 2002First state: Delaware 2002
Today ≈ 30 U.S. states (MI 2010)Today ≈ 30 U.S. states (MI 2010) First country: Ireland 2004First country: Ireland 2004
Today > 30 countriesToday > 30 countries
Effects of smoke-free air lawsEffects of smoke-free air laws
Reduce worker exposure Reduce worker exposure (80-95%)(80-95%)
Increase quitting (3%)Increase quitting (3%) Decrease daily consumption Decrease daily consumption Decrease employer costsDecrease employer costs Decrease AMIsDecrease AMIs
Advertising & counter-adsAdvertising & counter-ads
Restrictions on advertising & Restrictions on advertising & promotionpromotion
Counter-advertisingCounter-advertising
What doesn’t work What doesn’t work (well…and now)(well…and now)??
School health ed School health ed (as administered)(as administered)
Sales-to-minors and PUP lawsSales-to-minors and PUP laws
What may or may not work?What may or may not work?
Warning labelsWarning labels Current ones don’t workCurrent ones don’t work New ones?New ones?
Current challengeCurrent challenge
Aggregate impacts Aggregate impacts of TC in USof TC in US
Dramatic…but over timeDramatic…but over time
But the problem isn’t solvedBut the problem isn’t solved
Persistence of smokingPersistence of smoking
≈ ≈ 20% remain smokers20% remain smokers
70% want to quit70% want to quit
50% try each year50% try each year
2.5%2.5% (or fewer)(or fewer) succeed succeed
The big problem re smoking: The big problem re smoking: Remaining smokers differentRemaining smokers different
Heavily addicted Heavily addicted (Hard core?)(Hard core?)
Low SESLow SES < 10% college grads smoke< 10% college grads smoke Some blue collar pops. > 30%Some blue collar pops. > 30%
≈ ≈ ½ have mental illness or substance ½ have mental illness or substance abuse co-morbidityabuse co-morbidity Self medicating?Self medicating?
Some may not want to quitSome may not want to quit
Mendez-Warner smoking Mendez-Warner smoking demographics model demographics model
Calibrated to NHIS data through 1995, Calibrated to NHIS data through 1995, projected 2005 U.S. prevalence projected 2005 U.S. prevalence precisely (20.9%)precisely (20.9%)
Projected 2010 prevalence 0.6 too high Projected 2010 prevalence 0.6 too high (19.9% vs. actual 19.3%)(19.9% vs. actual 19.3%)
Calibrated to data through 2000, Calibrated to data through 2000, projected 2010 prevalence 0.2 too low projected 2010 prevalence 0.2 too low (19.1% vs. actual 19.3%)(19.1% vs. actual 19.3%)
Source: Mendez and Warner, Source: Mendez and Warner, AJPHAJPH 2012 2012
Where do we go from here?Where do we go from here?Likely near-future directionsLikely near-future directions
More states go smoke-freeMore states go smoke-free Within ≈ 5 years, nearly all states will be Within ≈ 5 years, nearly all states will be
smoke-freesmoke-free
Cigarette excise tax increases – states Cigarette excise tax increases – states (and perhaps federal…several years (and perhaps federal…several years hence)hence)
More media campaigns?More media campaigns?
Problems with more-Problems with more-of-the-same (alone)of-the-same (alone)
Once every state smoke-free…doneOnce every state smoke-free…done Once new warning labels phased in …doneOnce new warning labels phased in …done Equity issues re higher taxesEquity issues re higher taxes Media campaigns expensive and difficultMedia campaigns expensive and difficult U.S. smoking prevalence ↓ to 14.5-17% by U.S. smoking prevalence ↓ to 14.5-17% by
2020 2020 (18% in 2012)(18% in 2012)
Hundreds of thousands of deaths/year Hundreds of thousands of deaths/year continue for decades to comecontinue for decades to come
Likely policy innovationsLikely policy innovationsState, local, & institutional levelState, local, & institutional level
Novel Novel outdooroutdoor smoking restrictions smoking restrictions Public parks and beaches (NYC)Public parks and beaches (NYC)
Entire university campuses (Univ.Entire university campuses (Univ.
of Michigan)of Michigan)
Cars with kids insideCars with kids inside
Also in the environmentAlso in the environment Flood of new products: snus, Flood of new products: snus,
dissolvables (orbs, sticks, dissolvables (orbs, sticks, strips), e-cigarettes…strips), e-cigarettes…
““Tobacco harm reduction”Tobacco harm reduction”
Boon or bane?Boon or bane?
Potential, but risks tooPotential, but risks too
How about true pulmonary How about true pulmonary nicotine inhaler?nicotine inhaler?
Potential policy innovationsPotential policy innovationsFederal levelFederal level
Product regulation Product regulation (with new FDA authority)(with new FDA authority)
Ban menthol?Ban menthol?
Graphic warning labels? Plain packaging?Graphic warning labels? Plain packaging?
Restrictions on marketing of some new Restrictions on marketing of some new products; approval of novel treatments?products; approval of novel treatments?
How handle E-cigs? Novel smokeless products?How handle E-cigs? Novel smokeless products?
Performance standards?Performance standards?
Potential of regulationPotential of regulation
In concept, almost unlimited In concept, almost unlimited
Can change rules for marketing quicklyCan change rules for marketing quickly
Can change product constituents quicklyCan change product constituents quickly
Can change product availability quicklyCan change product availability quickly
Perhaps greatest potential for substantial Perhaps greatest potential for substantial impacts on toll of tobacco, especially impacts on toll of tobacco, especially smokingsmoking
Barriers & opportunitiesBarriers & opportunities BarriersBarriers
Industry oppositionIndustry opposition Congressional opposition (See above)Congressional opposition (See above) Legal issuesLegal issues Black markets & other “side effects”Black markets & other “side effects” Legitimate philosophical issuesLegitimate philosophical issues Low priority in gov’t. (and society)Low priority in gov’t. (and society)
OpportunitiesOpportunities Impatience of public health community Impatience of public health community
→ political pressure→ political pressure New Director of FDA CTP, Mitch ZellerNew Director of FDA CTP, Mitch Zeller
Need for something more –Need for something more –Origins of the endgame discussionOrigins of the endgame discussion
Concern about (and frustration with) slowness of Concern about (and frustration with) slowness of progressprogress
Appreciation that business-as-usual won’t solve Appreciation that business-as-usual won’t solve the problemthe problem
W/o something more, W/o something more, hundreds of thousands of hundreds of thousands of annual deaths for decades to comeannual deaths for decades to come
Hence call for radical, out-of-the-box ideas of Hence call for radical, out-of-the-box ideas of how to reduce smoking to a minor PH problemhow to reduce smoking to a minor PH problem
End-game policy ideasEnd-game policy ideas
Govt. control of supply/salesGovt. control of supply/sales Not-for-profit regulated supply with harm reduction Not-for-profit regulated supply with harm reduction
mandate (Australia, Canada)mandate (Australia, Canada) ““Sinking lid” on availability (NZ)Sinking lid” on availability (NZ)
Prohibiting possession of tobacco for people Prohibiting possession of tobacco for people born after (e.g.) 2000 (born after (e.g.) 2000 (SingaporeSingapore))
Reducing nicotine to non-addicting levels (Reducing nicotine to non-addicting levels (USUS))
Eventual prohibition, or “prohibition lite” Eventual prohibition, or “prohibition lite” (banning combusted tobacco products) ((banning combusted tobacco products) (USUS))
Potential of endgame ideasPotential of endgame ideas
Have potential to dramatically Have potential to dramatically reduce toll of smokingreduce toll of smoking
Barriers to game-changing policy Barriers to game-changing policy innovation = enormousinnovation = enormous
Likelihood of widespread near-term Likelihood of widespread near-term implementation very lowimplementation very low But NZ, Tasmania, Uruguay, AustraliaBut NZ, Tasmania, Uruguay, Australia
Don’t ever underestimate tobacco Don’t ever underestimate tobacco controlcontrol
What will happen?What will happen?
Obvious answer: I dunnoObvious answer: I dunno..
Plausible scenario for the near-termPlausible scenario for the near-term More aggressive use of evidence-based More aggressive use of evidence-based
interventionsinterventions Expansion of smoke-free to outdoor areasExpansion of smoke-free to outdoor areas Marketing of THR products (for better or Marketing of THR products (for better or
worse?)worse?) Tentative regulatory steps forward by FDATentative regulatory steps forward by FDA
MentholMenthol Warning labelsWarning labels
An additional problem for An additional problem for tobacco control:tobacco control:
Defining ultimate successDefining ultimate success Reducing prevalence?Reducing prevalence?
Of what? Cigarette smoking? All Of what? Cigarette smoking? All tobacco use?tobacco use?
10%? 5%? 0%?10%? 5%? 0%?
Eliminating nicotine addiction? Eliminating nicotine addiction?
Minimizing harm from tobacco use?Minimizing harm from tobacco use?
When?When?
What will it take to continue What will it take to continue making substantial progress?making substantial progress?
CreativityCreativity
EnergyEnergy
Politically sophisticated advocacyPolitically sophisticated advocacy
ResourcesResources
LeadershipLeadership
Public interestPublic interest