professor of community health sciencesexport the u.s. is the world’s largest exporter of...
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Virginia C. Li, PhD, MPHProfessor of Community Health Sciences
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Health Promotion (Green)
The combination of educational and environmental supports for actions and conditions conducive to health
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An Ecological View on Health Promotion
‐Intrapsychological factors‐Interpersonal processes‐Institutional factors‐community factors‐public policy
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Health Promotion in Community Health promotion actions means:‐create supportive environment‐strengthen community action‐develop personal skills‐reorient health services‐build healthy public policy
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Health Education
Any combination of learning experiences designed to facilitate voluntary actions conducive to health
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Principles of Health Education ‐principle of educational diagnosis ‐hierarchical principle ‐principle of cumulative learning ‐principle of participation ‐principle of situation specificity ‐principle of multiple methods ‐principle of individualization ‐Feedback principle ‐principle of intermediate target
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Deaths due to Tobacco Use• In the 20th century, the tobacco epidemic killed 100 million people worldwide.
• During the 21st century it could kill one billion.
• Tobacco causes 1 in 10 adult deaths worldwide
• WHO 2002
• And ……
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Smoking Prevalence Among U.S. Adults, 1955–2007(as a percent of population, 18 years of age and older)
Year Overall population
Males Females Whites Blacks
1955 — 56.9% 28.4% — —
1965 42.4% 51.9 33.9 42.1% 45.8%
1970 37.4 44.1 31.5 37.0 41.4
1980 33.2 37.6 29.3 32.9 36.9
1990 25.5 28.4 22.8 25.6 26.2
2000 23.3 25.7 21.0 24.1 23.2
2002 22.5 25.2 20.0 23.6 22.4
2003 21.6 24.1 19.2 22.7 21.5
2004 20.9 23.4 18.5 22.2 20.2
2007 20.8 23.9 18.0 21.9 23.0
Source: U.S. Centers for Disease Control and Prevention. Web: www.cdc.gov.
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Declines in U.S. Cigarette Consumption 1990‐2005
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Dimensions of the Anti‐smoking Movement1) Epidemiological research2) Mass media2) Interpersonal communications3) Advocacy /Legislation
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Dimensions of the Anti‐smoking Movement : Epidemiology
Surgeon Generals Report ‐ 1964 ‐smoking linked to lung cancer , heart disease Continuing research ‐ quitting improves health, nicotine addictive Continuing research ‐ second hand smoke kills, health of persons in smoke free zones better
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Dimensions of the Anti‐smoking Movement: Mass Media
1971 ban on TV/Radio cigarette ads Warning signs on cigarette packs Change in behavior of public figures Many visible /viable anti‐smoking efforts Publicity about epidemiological findings
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Dimensions of the Anti‐smoking Movement: InterpersonalEarly 1980’s Increase # anti‐smoking clinics
Increase expectations/social pressure not to smoke
Increase awareness of preventive health behaviors
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Dimensions of the Anti‐smoking Movement: Advocacy/Legislative
Late 1980’s : Government regulations about smoke‐free environments
Advocacy groups push policy changes at all levels: higher taxes on cigarettes
Corporate anti‐smoking policies Insurance companies‐no smokersLawsuits‐ get big tobacco
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Types of Smoking Control Programs ‐Worksite Control Programs‐Worksite Control Policies‐School Based Control Programs‐Community Based Control Programs‐Physician/Clinic Based Control Programs‐Policy‐Based Smoking Programs‐Economic‐Based Smoking Programs
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Policy and Environmental Interventions
‐clean indoor air‐restricting tobacco advertising and promotion‐restricting use access to tobacco‐comprehensive school health programs‐price/excise taxesAdditional interventions‐insurance premium differentials‐reimbursement for smoking cessation‐differential hiring of smokers‐litigation as policy
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Physician Counseling Behavior‐Charleston Navel Shipyard
Source: Journal of Medical Education, Vol 58. June 1983
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Physician Counseling Behavior‐Baltimore Family Planning Clinics
Source: Journal of Medical Education, Vol 58. June 1983
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Healthy People 2010 Objectives Increase to at least 905 the proportion of internists and family
physicians who routinely advise cessation and provide assistance, follow up, and document charts for all their tobacco‐using patients.
Percentage of Clinicians 1992 Routinely providing service to 81‐100% of patients Inquiry about tobacco use Internists 75% Family physicians 59% Discussion of strategies to quit Internists 50% Family physicians 45%
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Anti‐smoking Movement: California(1999)
Late 80’s‐ Prop 99 ‐taxes fund anti smoking efforts
Funds spent ‐ smoking rates come down Early 90’s : Wilson re‐appropriates funds Campaign stalls ( mid 90’s)‐ smoking rates go up especially among youth , minority members
Attorney General forced to join law suit against tobacco companies
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Mass Settlement Agreement (1998)
Holds tobacco companies accountable for their actions
Pays restitution to 46 states for health care costs incurred from tobacco‐caused illnesses
Also exempted the companies from private tort liabilities regarding harms caused by an use of tobacco. In exchange, companies agreed to: Curtail certain marketing practices Pay, in perpetuity, various amount payments to the states to compensate for some of the medical costs
Dissolve the tobacco industry groups‐ Tobacco Institute, Center for Indoor Air Research,
Council for Tobacco Research
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Family Smoking Prevention and Control Act (June 11, 09) Initiated by Waxman, signed by B Obama, opposed by GW Bush
Allow FDA to lower the amount of nicotine in tobacco products
Ban candy flavorings that appeal to kids
Block misleading labels such as “low tar” and “light”
Tobacco companies will be required to cover their cartons with large graphic warnings
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Tobacco use is the leading preventable cause of death in the world!
WHO 2003
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….Tobacco is the only legally available consumer product which kills people when it is used entirely as intended.
Oxford Medical Companion (1994)
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Tobacco Industry at WorkToday’s teenager is tomorrow’s potential regular consumer, and the overwhelming majority of smokers first begin to smoke while still in their teens.
Philip Morris Internal Document (1981)
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Teenagers – advertising targetWhile sports is by far the best avenue to attract, sample, and influence our core target smokers, it is not the only way. International movies and videos also have tremendous appeal to our young adult consumers in Asia.
Philip Morris Internal Document (1990)
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THE Layout of the Market outside U.S.
Within the total market, there are areas of strong growth, particularly in Asia and Africa.…It is an exciting prospect.
British American Tobacco Internal Document (1990)
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Cigarette Production, Exports, and Domestic Consumption—United States, 1990–2004
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ExportThe U.S. is the world’s largest exporter of cigarettes, and for many years burgeoning exports offset declines in domestic consumption.
However, export volume that peaked at 243 billion pieces in 1996 has fallen to an estimated 170 billion in 1999.
Cigarette exports are falling as U.S. manufacturers transfer production of cigarettes to overseas sites to reduce costs and as consumption declines in some of the major U.S. export markets as anti‐smoking activity increases.
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Foreign Draw
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PUFFED UP Philip Morris Readies Global Tobacco Blitz Division Spin off Enables Aggressive Product Push; High Tar Smokers in Asia
New Products: Marboro Mix 9‐ a high nicotine and high tar cigarette (introduced in Indonesia in July 2007)
Marboro Filter Plus‐ sold in South Korea, Russia, Kazakhstan, Ukraine Marboro Intense‐ a quick nicotine hit sold in Turkey Heatbar‐ hand held electronic device emits less smoke than regular cigarette
Marboro Wides‐ extra thick cigarettesWall Street Journal (1/29/2008)
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Global Youth Tobacco SurveyCountry National survey or
jurisdiction where survey conducted
Surveyyear
Proportion currently using any tobaccoproduct [%]aMales (95% CI) Females (95% CI)
Brazil Rio de Janeiro 2005 17.2 (14.0 ‐ 21.0) 15.7 (12.3 ‐ 19.8)
Czech Republic
National 2002 35.5 (31.5 ‐ 39.7) 33.6 (29.8 ‐ 37.5)
Hungary National 2003 28.0 (23.8 ‐ 32.7) 26.9 (23.2 ‐ 30.9)
Bulgaria National 2002 28.6 (24.5 ‐ 33.0) 39.2 (34.3 ‐ 44.4)
Russian Federation
National 2004 30.1 (26.6 ‐ 33.8) 24.4 (21.5 ‐ 27.6)
India National 2006 17.3 (14.5 ‐ 20.4) 9.7 (7.2 ‐ 12.8)
Indonesia National 2006 24.1 (19.0 ‐ 30.1) 4.0 (3.0 ‐ 5.4)
Malaysia National 2003 40.0 (34.6 ‐ 45.7) 11.5 (9.4 ‐ 13.9)
Pakistan Islamabad 2003 12.4 (9.2 ‐ 16.5) 7.5 (5.4 ‐ 10.2)
Mexico Mexico City 2003 29.4 (25.0 ‐ 34.1) 24.8 (18.8 ‐ 32.1)
Source: WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2008
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Missing in Tobacco Control Policies
Tobacco CROP SUBSTITUTION