Program,Policy, and Price Interventions for Tobacco Control: Quantifying the Return on Investment of a State Tobacco Control Program

Objectives. We examined health effects associated with 3 tobacco control interventions in Washington State: a comprehensive state program, a state policy banning smoking in public places, and price increases.Methods. We used linear regression models to predict changes in smoking prevalence and specific tobacco-related health conditions associated with the interventions. We estimated dollars saved over 10 years (2000–2009) by the value of hospitalizations prevented, discounting for national trends.Results. Smoking declines in the state exceeded declines in the nation. Of the interventions, the state program had the most consistent and largest effect on trends for heart disease, cerebrovascular disease, respiratory disease, and cancer. Over 10 years, implementation of the program was associated with prevention of nearly 36 000 hospitalizations, at a value of about $1.5 billion. The return on investment for the state program was more than $5 to $1.Conclusions. The combined program, policy, and price interventions resulted in reductions in smoking and related health effects, while saving money. Public health and other leaders should continue to invest in tobacco control, including comprehensive programs.Price increases, policies establishing smoke-free public places, and comprehensive tobacco control programs are all proven strategies for reducing smoking prevalence.1,2 Furthermore, implementation of comprehensive programs that reduce smoking have been shown to reduce tobacco-related health conditions, such as heart disease3 and cancer.4,5 Laws mandating smoke-free air have also been associated with a reduction in health conditions caused by smoking or environmental tobacco smoke exposure.6–13 A recent review of specific tobacco control interventions found that most are cost effective.14In the face of current economic conditions and limited budgets, policymakers may wonder whether implementing a tax on tobacco can produce revenue and decrease smoking without the cost of a program. Similarly, they may wonder whether a smoke-free policy may improve public health at little cost, while generating revenue.15 They may also question the return on investment from tobacco control programs. State programs have declined in priority in recent years, and state funding remains substantially lower than levels recommended by the Centers for Disease Control and Prevention.16Washington State has effectively used all 3 cornerstone tobacco control interventions: program, policy, and price. The state has had a well-funded comprehensive tobacco prevention and control program since late 2000, a statewide smoke-free public places law since December 2005,17 and multiple cigarette tax increases. A previous study reported that significant declines in smoking were achieved by the state''s total tobacco control effort.18We examined the relative magnitude of effect on smoking and health from the 3 cornerstone tobacco control interventions and assessed the return on investment (ROI) for the state''s tobacco control program after 10 years. Our study was the first that we are aware of to comprehensively examine the association between multiple specific health conditions and multiple proven tobacco control interventions.     

青少年吸烟现状及控烟知识调查

为了解山西省青少年吸烟现状 ,了解青少年对吸烟危害的认识以及对控烟法律法规有关内容的态度 ,便于今后更好地开展青少年控烟工作 ,山西阳城县卫生防疫站、阳城白桑乡卫生院、山西省烟草与健康协会于 2 0 0 3年在全省城乡组织开展了青少年吸烟现状抽样调查 ,结果报告如下。对象与方法1 对象　在校高年级小学生 ,初、高中学生 (含中专生 ) ,职业高中生 ,大专及以上学生和 2 5岁以下的社会青少年。调查总人数2 1 53人 ,其中男性 1 0 87人 ,女性 1 0 66人。2 方法　采取分层整群随机抽样法 ,在全省范围内抽取了 6个市县区 ,1 0个乡镇 ,2个街…     

Strong Tobacco Control Program Requirements and Secure Funding Are Not Enough: Lessons From Florida

Florida’s Tobacco Pilot Program (TPP; 1998–2003), with its edgy Truth media campaign, achieved unprecedented youth smoking reductions and became a model for tobacco control programming. In 2006, 3 years after the TPP was defunded, public health groups restored funding for tobacco control programming by convincing Florida voters to amend their constitution. Despite the new program’s strong legal structure, Governor Charlie Crist’s Department of Health implemented a low-impact program. Although they secured the program’s strong structure and funding, Florida’s nongovernmental public health organizations did not mobilize to demand a high-impact program. Implementation of Florida’s Amendment 4 demonstrates that a strong programmatic structure and secure funding are insufficient to ensure a successful public health program, without external pressure from nongovernmental groups.Large-scale, well-executed state tobacco control programs reduce tobacco use,1–4 tobacco-induced disease,5–7 and health costs.3,4 Despite this proven effectiveness, many state governments have eliminated or restricted the scope of tobacco control programs, often under pressure from the tobacco industry,8–10 which recognizes such programs’ power.11 In response, tobacco control advocates in some states have tried to create stronger tobacco control program structures to insulate these programs from political attacks.8,12–14 However, absent consistent pressure from public health groups, strong programmatic structures are not sufficient to protect these programs from attacks or to ensure successful implementation.8,10,14,15Following the 1997 settlement of Florida’s Medicaid lawsuit against the tobacco industry, Governor Lawton Chiles (D, 1991–1998) immediately created and provided strong political support for Florida’s large youth-focused Tobacco Pilot Program (TPP).16 The TPP and its edgy Truth media campaign, focusing on tobacco industry behavior (a strategy known as industry denormalization17), achieved unprecedented success18–22: smoking prevalence among middle school students dropped by 40% and among high school students by 18% during the program’s first 2 years (Figure 1).24 Despite its success, and perhaps because of the threat the program posed to the tobacco industry,11,25,26 the TPP was subject to almost immediate funding cuts from Governor Jeb Bush (R, 1999–2007) and the Florida legislature. Even after the Florida Department of Health (DOH) released its 1999 Florida Youth Tobacco Survey, showing large drops in youth smoking associated with the TPP,16 the legislature and governor reduced TPP funding from $70.5 million to $36.8 million for fiscal year 2000. For fiscal year 2004, the program was essentially eliminated, with a budget slashed to $1 million. These cuts significantly decreased youths'' Truth campaign recall27,28 and increased cognitive precursors to smoking initiation27 (although the effect on smoking rates continued until the youth cohort exposed to the Truth campaign aged out of survey samples29).Open in a separate windowFIGURE 1—Declines in current smoking prevalence rates among Florida youths during the Tobacco Pilot Program Truth campaign (1998–2002) and the BTPP (2008–2010).Note. BTPP = Bureau of Tobacco Prevention Program. Solid line is regression fit allowing for slope changes at the end of the Truth campaign and beginning of the BTPP campaign.23Florida’s public health groups did not effectively protect TPP funds.16,30 Nevertheless, in 2006, the local affiliates of the American Cancer Society (ACS), American Lung Association (ALA), and American Heart Association, along with the Washington, DC–based Campaign for Tobacco-Free Kids, ran a successful $5.2 million campaign for a state constitutional amendment to restore tobacco control funding. Amendment 4 passed 61% to 39%, demonstrating a significant political constituency for tobacco control.Amendment 4 created a strong legal foundation for a new tobacco program. In addition to securing funding, it mandated a youth-focused, comprehensive tobacco control program comprising an advertising campaign, youth programs, community-based partnerships, youth access enforcement, and evaluation.31 Although Amendment 4 did not explicitly reconstitute the TPP, recreating it was a central theme of the political campaign.32 Public health groups sought to ensure the quality of the program by requiring that it adhere to the updated Best Practices for Comprehensive Tobacco Control Programs from the Centers for Disease Control and Prevention (CDC).31,33 Amendment 4 allocated an annual 15% of the value of Florida’s 2005 tobacco settlement dollars ($57.9 million for the tobacco control program in 2005, about two thirds of the 1999 Best Practices lower-bound funding recommendation33) and required annual inflation adjustments to protect the program’s purchasing power.31Analysis of the implementation of Amendment 4 by the DOH of Governor Charlie Crist (R, 2006–2011), suggests that, despite the strong legal structure and secure funding in Amendment 4, the DOH did not recreate Florida’s successful tobacco control program. Instead, the administration restricted effective staffing of the program, pursued low-impact tobacco control strategies, and attempted to limit program oversight. Public health groups credited with passing Amendment 4 did not use their strong voter mandate or galvanize Florida’s tobacco control leadership to demand a high-quality, aggressive tobacco control program. The Florida experience reinforces the lesson that a strong legal structure and secure funding are not enough to ensure implementation of a high-quality evidence-based tobacco control program. It is necessary for public health groups to continually maintain pressure on tobacco control programs to ensure that their efforts are not in vain and an effective program is realized.     

Changes in Age Trajectories of Smoking Experimentation During the California Tobacco Control Program

Objectives. We aimed to investigate population-level changes in smoking initiation during California''s Tobacco Control (CTC) Program from 1990 to 2005, a period during which tobacco industry marketing practices also changed.Methods. We used a discrete time survival analysis of data from the California Tobacco Survey to model changes in age of first smoking experimentation across birth cohorts.Results. Smoking initiation patterns were stable across cohorts aged 9 years or older at the start of the CTC program. For children entering preadolescence since 1990, initiation declined with each more recent cohort. By 2005, the observed decline in experimentation was 80% for male participants and 92% for female participants at age 12 to 14 years; by age 15 to 17 years, 10% of Californian adolescents had experimented in 2005 compared with 45% in preprogram cohorts. However, rates of new experimentation after age 17 years did not change, except for a recent increase in late experimentation (after age 20 years) among young adult men.Conclusion. Our models suggest that the CTC program greatly reduced adolescent smoking initiation among younger adolescents. Late experimentation may have recently increased among young adult men in California, coincident with an increase in tobacco industry marketing aimed at young adults.Since the 1960s, adolescent smoking rates have changed in response to the competing influences of tobacco industry marketing campaigns^1–3 and public health tobacco control programs.^4,5 Reducing adolescent smoking has been a primary goal of the California Tobacco Control (CTC) Program,⁶ the longest-running large tobacco control program in the world. As an evaluation component, this program sponsors a population survey of tobacco use every 3 years. Previous survey estimates indicated that the CTC Program was associated with a lower age-specific prevalence of smoking from age 12 years, which was probably a consequence of reduced experimentation.⁵ However, it is not clear whether these age-specific changes led to an overall reduction in lifetime smoking initiation within a birth cohort, especially given the apparent effectiveness of recent tobacco advertising targeting young adults. We investigated changes in the trajectories of smoking experimentation across the age window of 10 to 24 years, in which almost all first experimentation has been documented to occur.⁷Previously, an age-period-cohort model⁸ identified that smoking experimentation for California was stable for cohorts born before 1979. Subsequent cohorts, those aged 12 years or younger when the California program started in 1990, had lower experimentation levels on average over the adolescent years. However, the model in that analysis used additive effects for age, period, and cohort, with the consequence that, for example, changes in experimentation rates at a given time were averaged across cohorts and ages. Period and cohort effects, which can identify time changes, applied equally across all ages. Thus, that analysis was unable to identify changes in smoking uptake at specific ages within the age window of 10 to 24 years. This may be of concern, because other interventions that reduced smoking in early adolescence were shown to not be associated with reduced smoking in later years.^9,10 In addition, there is specific concern that tobacco industry marketing campaigns have changed to target young adults, and this may have increased rates of smoking initiation in young adulthood.¹¹Recent contributions to the methodologic literature^12–17 have addressed shortcomings of age-period-cohort models in identifying age- and period-specific effects.^18,19 Incorporating suggestions from this literature, we modeled age-specific changes in the trajectory of smoking initiation among young Californians from 1990 to 2005. We hypothesized that age-specific changes have occurred in the pattern of smoking uptake among recent birth cohorts.     

Perceptions of Smoking Prevalence by Youth in Countries With and Without a Tobacco Advertising Ban

This study examined a proposed mechanism by which exposure to cigarette advertising may mediate the subsequent smoking of youth. We hypothesized that children's exposure to cigarette advertising leads them to overestimate the prevalence of smoking, and that these distorted perceptions, in turn, lead to increased intentions to smoke. Children in Finland, where there has been a total tobacco advertising ban since 1978, were compared with children in the United States at a time when tobacco advertising was ubiquitous. Samples of 477 8- to 14-year-old Helsinki students and 453 8- to 14-year-old Los Angeles students whose lifetime cigarette use consisted of no more than a puff of a cigarette were administered questionnaires in their classrooms. The primary hypothesis was confirmed. Los Angeles youth were significantly more likely than Helsinki youth to overestimate the prevalence of adult smoking, in spite of the fact that actual adult smoking prevalence in Helsinki was almost twice that of Los Angeles adults. A similar, significant pattern for perceived peer smoking was obtained, with Los Angeles youth being more likely than Helsinki youth to overestimate prevalence, in spite of the actual greater prevalence of youth smoking in Helsinki.     

Patterns of Change in Adolescent Smoking Behavior and Results of a One Year Follow-up of a Smoking Prevention Program*

A smoking prevention program for adolescents conducted in two public middle schools focused on resisting peer pressure to smoke and understanding the intent of commercial cigarette advertising. One class in each school participated in the program group and one served as a control group. The program consisted of eight sessions and was conducted by first-year medical students. Data on smoking behavior and related information were obtained from self-administered questionnaires at baseline, at the conclusion of the program, and one year later. One year after the program was concluded, the proportion of non-smokers was higher among those who had participated in the program than among the controls. This suggests that routine implementation of smoking prevention programs in conventional school settings may be productive in reducing the prevalence of cigarette smoking.     

烟草税在控烟中的应用

吸烟是当今世界人类健康的最大威胁。烟草的使用给人们带来巨大的社会经济负担。征收烟草税是现今控烟的最有效手段之一。介绍了烟税征收的必要性、全球烟税征收的一般状况、烟税征收的健康效益等内容。与国外相比,我国的烟税征收还有巨大的上升和利用空间,实施并利用好烟税策略将会是我国一个非常有效的控烟和增进全民健康的手段。     

烟草税在控烟中的应用

吸烟是当今世界人类健康的最大威胁.烟草的使用给人们带来巨大的社会经济负担.征收烟草税是现今控烟的最有效手段之一.介绍了烟税征收的必要性、全球烟税征收的一般状况、烟税征收的健康效益等内容.与国外相比,我国的烟税征收还有巨大的上升和利用空间,实施并利用好烟税策略将会是我国一个非常有效的控烟和增进全民健康的手段.     

我国被动吸烟及烟草控制工作研究

烟草是人类健康所面临的最大且又可以预防的危险因素,主动吸烟有害健康已是众所周知,而被动吸烟同样影响非吸烟者的健康却不为大众所知.鉴于此,文章综述我国被动吸烟流行病学现状,被动吸烟对非吸烟者健康的危害,被动吸烟干预成效,以及被动吸烟难控制的成因等方面的研究,并对今后亟需开展相关领域的研究提出几点建议.     

Developing Comprehensive Smoking Control Programs in Schools

During the school years, students encounter peer influences and role models who encourage smoking initiation. To counteract these influences, schools can provide comprehensive programs that include smoking prevention and cessation education and a supportive nonsmoking environment. In the past several years, programs and information have become available to help schools establish curricula to address smoking and to create nonsmoking environments. In addition, state and local governments have acted to legally restrict smoking in schools or to require smoking content in curricula. Efforts can be categorized into three avenues of intervention: student education, school and school system policy, and governmental regulation. Resources are suggested for each category to assist in developing a comprehensive intervention to foster nonsmoking by children and adolescents in the school setting.     

Effects of a Saliva Pipeline Procedure on Adolescent Self-Reported Smoking Behavior and Youth Smoking Prevention Outcomes

Background. Two strategies to resolve the problem of under- or overreporting of tobaccouse among adolescents have been utilized: (a) objective measures for validating self-reports and (b) procedures for improving validity of self-reports, such as the pipeline procedure. The objectives of this article are to investigate the hypothesis that reporting biases may be related to intervention status and to examine what effect such biases would have on interpretation of treatment effects. Method. A two-by-two factorial design was used, with the first factor a pipeline manipulation consisting of pipeline versus control condition, and the second factor treatment status, consisting of treatment versus reference schools. Within each of the schools, half of the 9th-grade classrooms were randomly assigned to a pipeline condition and half served as controls. Analysis was conducted with school as the unit of analysis. Results. The main effect for pipeline condition and the significant interaction between treatment and pipeline conditions were not significant. However, the pipeline manipulation did have an effect on the difference detected between treatment and reference schools; 4.3% difference between treatment and reference schools in the control condition versus 9.9% difference in the pipeline condition, both in the direction of a treatment effect. Using saliva thiocyanate as an objective measure of smoking status suggested differential false negative reporting where students in the reference community falsely claimed to be nonsmokers more frequently than in the treatment community (10.04% versus 5.96%). Conclusions. The reporting bias assessed by the pipeline procedure alone appears to have masked treatment outcome effects. Adjusting the smoking-dependent variable for false negatives seems to have increased the treatment outcome effects even further. This result is contrary to the expectation that the treatment community would experience greater demand pressures to underreport their smoking behavior. Further investigation to address response biases in intervention studies is warranted.     

Density and Proximity of Tobacco Outlets to Homes and Schools: Relations with Youth Cigarette Smoking

This study investigated the associations of youth cigarette smoking with tobacco outlet densities and proximity of tobacco outlets to youth homes and schools across different buffers in 45 midsized California communities. The sample comprised 832 youths who were surveyed about their smoking behaviors. Inclusion criteria included both home and school addresses within city boundaries. Observations in the 45 cities were conducted to document addresses of tobacco outlets. City- and buffer-level demographics were obtained and negative binomial regression analyses with cluster robust standard errors were conducted. All models were adjusted for youth gender, age, and race. Greater densities of tobacco outlets within both a 0.75 and 1-mile buffer of youth homes were associated with higher smoking frequency. Neither tobacco outlet densities around schools nor distance to the nearest tobacco outlet from home or school were associated with youths past-30-day smoking frequency. Lower population density and percent of African Americans in areas around homes and lower percent of unemployed in areas around schools were associated with greater smoking frequency. Results of this study suggest that restricting outlet density within at least 1-mile surrounding residential areas will help to reduce youth smoking.     

石河子市成人吸烟与被动吸烟及控烟知识态度调查

目的了解居民吸烟与被动吸烟现状,调查居民对烟草危害的知识及控烟态度,为今后控烟提供依据。方法采用中国疾病预防控制中心控烟办公室设计制订的问卷,通过随机拦截的方法,选取医院、商场、车站候车室及政府对外办公场所共200名居民进行调查。结果居民吸烟率及现在吸烟率均为40.0%,男性吸烟率为69.5%,显著高于女性吸烟率7.4%;被动吸烟率为61.1%,男性被动吸烟率（59.4%）与女性被动吸烟率（64.8%）无差异（P〉0.05）。结论石河子市居民吸烟及被动吸烟状况都比较严重,对烟草的危害性认知及禁烟态度有待提高,要加大控烟、禁烟的综合干预及健康教育,构建全民参与的社会机制,制定切实可行的法律法规。     

The Association between Point-of-Sale Advertising Bans and Youth Experimental Smoking: Findings from the Global Youth Tobacco Survey (GYTS)

Background and Objectives: while existing research has demonstrated a positive association between exposure to point-of-sale (POS) tobacco advertising and youth smoking, there is limited evidence on the relationship between POS advertising restrictions and experimental smoking among youth. This study aims to fill this research gap by analyzing the association between POS advertising bans and youths'' experimental smoking. Methods: Global Youth Tobacco Surveys from 130 countries during 2007–2011 were linked to the WHO “MPOWER” tobacco control policy measures to analyze the association between POS advertising bans (a dichotomous measure of the existence of such bans) and experimental smoking using weighted logistic regressions. All analyses were clustered at the country level and controlled for age, parents'' smoking status, GDP per capita, and country-level tobacco control scores in monitoring tobacco use, protecting people from smoke, offering help to quit, warning about the dangers of tobacco, enforcing promotion/advertising bans, and raising taxes on tobacco. Results: The results suggest that a POS advertising ban is significantly associated with reduced experimental smoking among youth (OR = 0.63, p < 0.01), and that this association is seen for both genders (boys OR = 0.74, p < 0.1; girls OR = 0.52, p < 0.001). Conclusions: POS advertising bans are significantly associated with reduced experimental smoking among youth. Adopting POS advertising bans has the potential to reduce tobacco use among their youth in countries currently without such bans.     

Changes in Smoking Prevalence and Number of Cigarettes Smoked Per Day Following the Implementation of a Comprehensive Tobacco Control Plan in New York City

The New York City (NYC) Health Department has implemented a comprehensive tobacco control plan since 2002, and there was a 27% decline in adult smoking prevalence in NYC from 2002 to 2008. There are conflicting reports in the literature on whether residual smoker populations have a larger or smaller share of “hardcore” smokers. Changes in daily consumption and daily and nondaily smoking prevalence, common components used to define hardcore smokers, were evaluated in the context of the smoking prevalence decline. Using the NYC Community Health Survey, an annual random digit dial, cross-sectional survey that samples approximately 10,000 adults, the prevalence of current heavy daily, light daily, and nondaily smokers among NYC adults was compared between 2002 and 2008. A five-level categorical cigarettes per day (CPD) variable was also used to compare the population of smokers between the 2 years. From 2002 to 2008, significant declines were seen in the prevalence of daily smoking, heavy daily smoking, and nondaily smoking. Among daily smokers, there is also evidence of population declines in all but the lowest smoking category (one to five CPD). The mean CPD among daily smokers declined significantly, from 14.6 to 12.5. After an overall decline in smoking since 2002, the remaining smokers may be less nicotine dependent, based on changes in daily consumption and daily and nondaily smoking prevalence. These findings suggest the need to increase media and cessation efforts targeted towards lighter smokers.