changing public policy to reduce tobacco use andrew hyland, phd roswell park cancer institute...
TRANSCRIPT
Changing Public Policy to Reduce Tobacco Use
Andrew Hyland, PhDRoswell Park Cancer Institute
Stanton Glantz, PhDUniversity of California San Francisco
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
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
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
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
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
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
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
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
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
Specific amendment language drafted to stop NCI grants to Glantz and Richard Daynard (Faxed to RJR from Tobacco Institute) [ydn60d00]