1

Restrictions on Tobacco Use, Sales

& Marketing

Frank J. Chaloupka

Developing Public Health Regulations for Marijuana: Lessons from Alcohol and Tobacco Arlington, VA, February 11 2013

2

Smoke-Free Air Policies

3

Diseases and Adverse Health Effects Caused by SHS

Image source: adapted by CTLT from U.S. Surgeon General’s Report. (2006); from JHBSPH/IGTC on-line course.

4

Early Evidence & Action !  Leading up to his 1972 report, US Surgeon

General Jesse Steinfeld stated:

•  “Nonsmokers have as much right to clean air and wholesome air as smokers have to their so-called right to smoke, which I would define as a ‘right to pollute.’ It is high time to ban smoking from all confined public places such as restaurants, theaters, airplanes, trains, and buses.”

The “Non-smokers’ Rights” movement is born

Source: Eriksen and Chaloupka, 2007

5

Early Evidence & Action !  Smoke-free policies emerge:

•  Existing policies intent was fire safety, prevention of food contamination

•  1973 – Arizona first state to limit smoking in public places

•  1974 – Connecticut first to limit smoking in restaurants

•  1975 – Minnesota first to limit smoking in private worksites

•  First wave of policies restricted smoking in various venues; no complete bans

Source: Eriksen and Chaloupka, 2007

6

Policy Development !  Over time, state/local policies get stronger:

•  1998 California bans smoking in public places, including restaurants and bars without separately ventilated areas

•  2002 New York city bans smoking in bars, restaurants and virtually all other public places and private workplaces

•  2003 Florida ballot initiative with similarly comprehensive ban passes easily

•  By 2003 all states have at least some restrictions on smoking in public places

!  Thousands of local policies Source: Eriksen and Chaloupka, 2007

7

2006 Surgeon General’s Report “Eliminating smoking in

indoor spaces fully protects nonsmokers from exposure to secondhand smoke”

“Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposure of nonsmokers to secondhand smoke”

Smoke-Free Policies, 2012

Source: Americans for Nonsmokers’ Rights Foundation

Smoke-Free Policies Globally

Source: WHO 2011

10

Smoke-Free Air Policies - Impact

!  Attitudes & Compliance •  Support for smoke-free policies grows after

adoption/implementation of policy

•  Compliance is moderate to high in most countries that adopt smoke-free policies

!  Compliance better where pre-implementation efforts to inform and build support

•  Generally self-enforcing

Source: IARC, 2009

11

Smoke-Free Air Policies - Impact

!  Anti-Smoking Norms

•  Generally majority level support for smoke-free policies in HICs

•  In HICs, evidence of support among smokers for smoke-free policies

•  Prevalence of smoke-free homes is growing

Source: IARC, 2009

Smoke-Free Air Policies - Impact !  Smoking Behavior

•  ‘Smoke-free workplace policies reduce cigarette consumption among continuing smokers and lead to increased successful cessation among smokers.’

•  ‘Smoke-free policies appear to reduce tobacco use among youth’

•  ‘There is a greater decline in smoking when smoke-free policies are part of a comprehensive tobacco control program’

•  Impact of smoke-free home policies on behavior greater than of public policies

Source: IARC, 2009

Source: NSDUH, Mayatech &RPCI, and author’s calculations

Smoke Free Air Policies and Young Adult Smoking Prevalence, 2003-04

y = -0.1176x + 43.509R2 = 0.1151

25

30

35

40

45

50

0.0 10.0 20.0 30.0 40.0 50.0

Smoke Free Air, State Policy Index

18-2

4 S

mo

kin

g P

revale

nce

Source: NSDUH, Mayatech &RPCI, and author’s calculations

Smoke Free Air Policies and Adult Smoking Prevalence, 2003-04

y = -0.0791x + 26.516R2 = 0.1169

15

17

19

21

23

25

27

29

31

0.0 10.0 20.0 30.0 40.0 50.0

Smoke Free Air, State Policy Index

Ad

ult

Sm

okin

g P

revale

nce

Source: ImpacTeen Project, UIC; Monitoring the Future, 2012

Social Norms About Smoking

0

5

10

15

20

25

70

72

74

76

78

80

82

84

86

88

90

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011

Sm

oke-

Free

Pol

icy

Ind

ex

% D

isap

pro

vin

g o

f S

mok

ing

On

e or

Mor

e P

acks

per

Day

Smoke-Free Policies Disapproval, 8th Grade Disapproval, 10th Grade

16

Smoke-Free Air Policies Future Directions

!  Restrictions on smoking in multi-unit housing •  Some limited to common areas only •  Some limited to public housing •  Some complete bans

!  Outdoor Venues •  Beaches, public parks, zoos •  Outdoor dining •  Sporting venues •  Public transit stops

!  Private policies expanding •  Hotel chains going smoke-free •  Rental car companies going smoke-free

17

Limits on Youth Access

18

Youth Access Policies

!  Include a range of policies: •  Minimum legal purchase age •  Minimum age to sell •  Penalties on vendor

!  Fines, license suspension/revocation

•  Penalties on youth !  Purchase, possession, and/or use policies !  Fines, smoking education/cessation classes !  Parental notification !  Driver’s license suspension

•  Limits on vending machine sales •  Limits/bans on sampling

19

Youth Access Policies

!  Need for enforcement •  Compliance checks

•  Effectiveness will depend on variety of factors

!  Randomness !  Frequency !  Penalties !  Characteristics of checker !  Merchant education efforts !  Social norms against tobacco !  More……

•  Not self-enforcing

20

Youth Access Policies

!  History •  State minimum purchase age policies in

effect for decades !  Little enforcement, low compliance

•  Success with MLDA in reducing youth drinking spurred interest in same for tobacco

•  Led to 1992 “Synar Amendment” !  Required MLPA of 18 for tobacco products !  Had to demonstrate compliance with policies

•  FDA !  1996-2000 strong youth access program !  Resumed with Family Smoking and Prevention Act

of 2009

21

Youth Access Policies Youth Access to Tobacco Products Scores, 1993-2006

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

You

th A

cces

s In

dex

Note: Bars depict the simple average of state scores for the NCI State Cancer Legislative Database Youth Access to Tobacco total score, including pre-emption.

Source: National Cancer Institute (2007).

22

Youth Access Policies

Source: SAMHSA, 20012

23

Compliance & Availability

Source: SAMHSA, 20012; Monitoring the Future, 2012

8

13

18

23

28

33

38

50

55

60

65

70

75

80

85

90

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

% o

f R

etai

lers

Sel

ling

to

Min

ors

% S

ayin

g E

asy

or F

airl

y Ea

sy t

o G

et

Perceived Availability, 8th Grade Perceived Availability, 10th Grade Synar Non-Compliance Rate

24

Youth Access Policies

!  History • Initial focus on retailers led to call for

policies holding youth accountable !  Led to policies that penalize youth for

purchase, possession, and/or use

25

Youth Access Policies Mean Number of State Purchase, Possession and

Use Laws, per State, 1988-2005

0

0.5

1

1.5

2

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

Year

PPU

Source: Roswell Park Cancer Institute and the ImpacTeen Project, unpublished data.

26

Youth Access Policies

!  Impact of youth access policies •  Little evidence that youth access-related

policies by themselves are effective in US and other high-income countries

•  2005 Cochrane review by Stead and Lancaster !  Policies improve compliance !  Compliance needs to be high to impact youth

smoking !  High compliance difficult to sustain

•  Enforcement more effective than merchant education

27 Sources: Substance Abuse and Mental Health Services Administration (2006a), National Cancer Institute (2007), and author’s calculations

Youth Access Policies and Youth Smoking Prevalence2003-04

y = 0.0067x + 12.777R2 = 0.0002

6

8

10

12

14

16

18

20

5 10 15 20 25 30

Youth Access Policy Index

12-1

7 S

mo

kin

g P

revale

nce

28

Youth Access Policies

!  Impact of youth access policies •  Little evidence that high compliance leads to

significant reductions in youth tobacco use

!  Underage tobacco users find stores that are willing to sell

!  Youth turn to social sources for tobacco products

•  Perhaps greater impact on uptake of heavier smoking among underage youth

!  Heavier smokers rely more on commercial sources than on social sources

29 Source: SAMHSA, 2009; YRBS, 2009

7

12

17

22

27

4 6 8 10 12 14 16 18

High School Student Smoking Prevalence

Synar Non- Compliance Rate

Youth Smoking Prevalence and Synar Compliance

30

Youth Access Policies

!  Impact of youth access policies •  No evidence that PPU policies significantly

reduce youth smoking

!  May have some impact on kids at lowest risk to begin with

31 Sources: Substance Abuse and Mental Health Services Administration (2006a), ImpacTeen unpublished state policy data, and author’s calculations

Purchase, Possession and Use Policies and Youth Smoking Prevalence, 2003-04

y = 1.0263x + 10.916R2 = 0.1896

6

8

10

12

14

16

18

20

0 0.5 1 1.5 2 2.5 3

PPU Policy Index

12-1

7 S

mo

kin

g P

revale

nce

32

Tobacco Marketing

33

Impact of Tobacco Marketing !  1989 Surgeon General’s report described four

ways that marketing could directly affect tobacco use: •  By encouraging youth experimentation and uptake •  By increasing consumption among current users •  By reducing current users’ motivation to quit •  By encouraging former users to restart

!  Also suggested three indirect mechanisms •  Media dependence on tobacco company advertising •  Financial dependence of some organizations on tobacco

funds (e.g. professional sports, cultural organizations, minority organizations)

•  Ubiquity of marketing creates social norm that tobacco use is acceptable or less objectionable

34

Impact of Tobacco Marketing !  Extensive efforts to assess impact of marketing

!  Particularly among youth

•  Non-randomized studies !  Ad prevalence and favorite ad studies

•  Randomized experimental studies !  Manipulate exposure; assess attitudes, perceptions, intentions

•  Aggregate demand studies !  Sales and marketing expenditures

•  Population based surveys !  Cross-sectional studies !  Longitudinal studies

•  Problems !  Self-reported exposure vs. objective measures of exposure !  Endogeneity issues !  Pervasiveness of marketing

Source: NCI Monograph 19

35

Impact of Tobacco Marketing “The total weight of evidence – from multiple types of studies, conducted by investigators from different disciplines and using data from many countries – demonstrates a causal relationship between tobacco advertising and promotion and increased tobacco use.”

36

Impact of Tobacco Marketing

“Advertising and promotional activities by tobacco companies have been show to cause the onset and continuation of smoking among adolescents and young adults.”

37

Marketing Restrictions !  Marketing Restrictions, US

•  Public Health Cigarette Smoking Act of 1969 !  Bans broadcast cigarette advertising, effective January

2, 1971 •  Master Settlement Agreement, November 1998:

!  prohibited tobacco advertising that targets people younger than 18

!  Banned use of cartoon characters in cigarette advertising

!  Eliminated most outdoor, billboard and public transit advertising of cigarettes

!  Prohibited use of branded merchandise !  Other restrictions

38

Source: author’s calculations from data reported in FTC (2011)

$0.0

$2,000.0

$4,000.0

$6,000.0

$8,000.0

$10,000.0

$12,000.0

$14,000.0

$16,000.0

1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007

Million Dollars

Cigarette Company Marketing Expenditures,

by Type, 1975-2008

Advertising Pub.Entertainment Placement Price Merchandise Other

39

Marketing Restrictions !  Family Smoking and Prevention Act of

2009 •  Allows FDA to restrict marketing to youth •  Eliminates federal preemption of strong

state restrictions on marketing !  Can restrict ‘time, place or manner’ of

tobacco marketing !  Providence first to attempt

•  Bans redemption of coupons •  Bans discounted multi-pack sales •  Bans sale of flavored tobacco products •  Challenged by tobacco companies under First

Amendment; bans upheld; on appeal

40

Marketing Restrictions !  Global evidence

•  Spread of more comprehensive marketing bans !  Bans on advertising in various channels !  Bans on price reducing promotions !  Bans on brand stretching !  Bans on point-of-sale advertising !  Bans on retail displays of tobacco products !  Plain packaging

•  Research shows importance of comprehensive bans !  Increased importance of remaining options as bans

get more comprehensive

Comprehensive advertising bans reduce cigarette consumption

Consumption trends in countries with such bans vs. those with no bans

(n=102 countries)

No Ban

Ban

1450

1500

1550

1600

1650

1700

1750

1981 1991

Year

Cig

aret

te c

onsu

mpt

ion

per

capi

ta

Source: Saffer, 2000

42

Counter-Marketing !  Late 1960s, Fairness Doctrine

•  Significant reductions in sales, prevalence !  1988 California Proposition 99

•  Earmarked excise tax to fund comprehensive tobacco control program

•  Followed by several states !  1998 Master Settlement Agreement

•  Many states commit some funds to comprehensive programs

•  American Legacy Foundation created

Source: 2000 SGR

47 $0.0

$200.0

$400.0

$600.0

$800.0

$1,000.0

1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Millions of Aug 2011 Dollars

State Tobacco Control Funding 1992-2010

Source: Bridging the Gap, ImpacTeen project

48

Source: Bridging the Gap, ImpacTeen project

$0.0

$2,000.0

$4,000.0

$6,000.0

$8,000.0

$10,000.0

$12,000.0

$14,000.0

$16,000.0

$18,000.0

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Millions of Aug 2011 Dollars

Tobacco Company Marketing vs. State Tobacco Control Funding

49

Counter-Marketing !  Extensive research on state programs

finds ads •  Are seen and recalled •  Increase risk perceptions •  Promote cessation among adults •  Prevent youth initiation •  Strengthen anti-smoking norms •  More effective when part of comprehensive

interventions to reduce smoking

Source: NCI Monograph 19

50

Source: ImpacTeen Project, UIC; Monitoring the Future

0

5

10

15

20

25

30

35

40

45

45

50

55

60

65

70

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

% P

erce

ivin

g G

reat

Ris

k of

Sm

okin

g O

ne

or M

ore

Pac

ks p

er

Day

State Program Funding 8th Grade 10th Grade

Program Funding & Perceived Risk

51

Source: ImpacTeen Project, UIC; YRBS

19

21

23

25

27

29

31

33

35

37

$0

$200

$400

$600

$800

$1,000

1991 1994 1997 2000 2003 2006 2009

Per

cen

t C

urr

ent

Sm

okin

g

Tota

l Fu

nd

ing

$

Mill

ion

s (F

Y1

0 d

olla

rs)

Year

total state program funding high school prevalence

Program Funding & Youth Smoking

52

Lessons Learned

53

Source: Monitoring the Future, 2012

Social Norms – Cigarettes & Marijuana

65

70

75

80

85

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011

% D

isap

pro

vin

g

Cigarette Disapproval, 10th Grade Marijuana Disapproval, 10th Grade

54

Source: Monitoring the Future, 2012

Perceived Risk – Cigarettes & Marijuana

50

55

60

65

70

75

80

85

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011

% P

erce

ivin

g G

reat

Ris

k

Cigarettes, Perceived Risk, 10th Grade Marijuana, Perceived Risk, 10th Grade

55

Lessons Learned !  Restrictions on Use

!  Comprehensive bans on public use •  Including outdoor venues, multi-unit housing,

and other emerging foci of SFA policies •  Reduce opportunities for use •  Maintain/strengthen social norms against use

!  Restrictions on Sales !  Unlikely to be sufficient by themselves !  Need continued strong enforcement

•  Funded by taxes, license fees !  Most useful as part of comprehensive

strategy

56

Lessons Learned

!  Marketing Restrictions !  Comprehensive bans on all advertising,

promotion and sponsorship •  Including bans on retail displays, plain

packaging •  To maintain/strengthen social norms against

use

!  Counter-Marketing !  Strengthen risk perceptions and social

norms against use •  Funded by taxes, license fees

For more information:

fjc@uic.edu

www.bridgingthegapresearch.org

www.tobacconomics.org (coming soon)