‘‘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

Thank you!Thank you!

kwarner@umich.edukwarner@umich.edukwarner@umich.edu