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The California The California Tobacco Control Tobacco Control Program: A Model for Program: A Model for ChangeChange
TOBACCO CONTROL SECTION
California Department of Health Services
March 2001
c
Comprehensive FundingComprehensive Funding
7%
3%
30%
30%
30%
Evaluation
State Administration
StatewideAdvertising
and Publications
Community Grants
61 Local Health Departments
Goal = change social norm
Outcome = prevention & cessation
Denormalization StrategyDenormalization Strategy
Lasting change in youth behavior
regarding tobacco can only be secured
by first changing the adult world in
which youth grow up.
Strategy to Reduce Tobacco Use in California
Reduce Exposure to ETSand Tolerance to Exposure
Reduce Access to Tobaccofrom Retail & Social Sources
Provide Cessation Services
Decreased TobaccoConsumption
Decreased Tobacco Use Prevalence
Decrease Youth Decrease Youth Uptake of TobaccoUptake of Tobacco
Decreased Exposureto ETS
Counter Pro-Tobacco Influences
Training/
TAClearing-
houseQuitline
11 Regions
4Ethnic
Networks
83 Competitive Grantees
61 Health DepartmentCoalitions
Statewide Evaluation
CDC Legacy
DHS Tobacco Control Program
STAKE
Statewide Media Campaign
Local ProgramsLocal Programs
Statewide Projects
Direct Service Providers• Quitline
• Clearinghouse
• Tobacco Industry Sleuthing Project
Training/TA Providers• Technical Assistance Legal Center
• Media/PR Technical Assistance
• BREATH (Smoke-free Bar Project)
Impact Leaders and Institutions
• Youth Advocacy Network
• Entertainment Industry Campaign
• Key Opinion Leader Project
• Divestment Project
• Labor Project
• Ethnic Networks
• Provides intensive telephone cessation counseling to adults and teens
• Provides self-help kits and referral services
• Serves approximately 3500 new clients per month and 1200 new clients counseled monthly
• 26.7% success rate at one year f/u
• Educational materials distribution
• Educational materials development
• Library services
• Maintain web sites
• Technical assistance
• Serve 170 Contractors &1000 School Districts
TTechnical echnical AAssistance ssistance LLegal egal CCenterenter
• Provides California communities with free technical assistance on legal issues related to drafting and passing tobacco control policies
• Provides high quality legal analyses to city attorneys, county counsels, elected officials and project directors
TCS WorkgroupsTCS Workgroups
Gardening experts….Secondhand SmokePoint-of-Sale PracticesProject SMART MoneyChew/Dip, Cigars & Alternative Tobacco
Statewide Statewide CampaignsCampaigns
• Operation Storefront
• Project SMART Money
• Communities of Excellence
The Media CampaignThe Media Campaign
Mature CampaignMature Campaign
ApathyApathyAwarenessAwareness
ConcernConcern
Attitudinal Attitudinal ShiftShift
Social Social ExpectationExpectation
Action/ Action/ LegislationLegislation
Social NormSocial Norm
ExpectationExpectation
ContentmentContentment
The Cycle Of AThe Cycle Of A Social Issue Social Issue
Strategies That WorkStrategies That Work
• Secondhand Smoke– Educate people about the hazards, and they
will take action to protect themselves
– Turns public apathy into action
– Gives non-smokers a voice
– Cessation is an outcome--people quit to protect their families
Strategies That WorkStrategies That Work
• Countering Pro-Tobacco Influences– Causes people to question industry
motives and rallies smokers & non-smokers alike
– Youth & adults rebel against industry manipulation
– Supports local policy activities
Youth Strategic Learning Youth Strategic Learning Strategies that DID MotivateStrategies that DID Motivate
• “Tobacco Industry Manipulation”
• Nicotine Addiction
• “Secondhand smoke is more dangerous than you think”
• Impactful personal stories
Youth Strategic Learning Youth Strategic Learning Strategies that DIDN’T MotivateStrategies that DIDN’T Motivate
• Long-term health effects
• Short-term health effects
• Short-term cosmetics effects
• Romantic rejection
• Smoking isn’t cool
“If health education and prevention can’t show it’s effective, it doesn’t deserve the money.”
Evaluation and Surveillance
The Law We Live or Die By
Source: California State Board of Equalization (packs sold) and California Department of Finance (population). U.S. Department of Agriculture. Note that CA data is by fiscal year (July 1-June 30) and U.S. data is by calendar year.Prepared by: California Department of Health Services, Tobacco Control Section, June 2000.
0
50
100
150
200
CA 162.3 158.8 152.5 141.4 136.4 131.1 126.6 112.6 94.7 91.1 84 79.3 77.5 74.8 69.2 61.3
US 192 187.7 175.1 168.5 163.7 159.9 154.8 146.3 136 132.1 127.2 126.2 125.3 124.1 116 106.8
80/81 81/82 82/83 84/85 85/86 86/87 87/88 88/89 90/91 91/92 92/93 93/94 94/95 95/96 97/98 98/99
Packs/Person
California and US cigarette consumption, California and US cigarette consumption, packs per fiscal year, 80/81 - 98/99packs per fiscal year, 80/81 - 98/99
US
CA
California vs. U.S. California vs. U.S. Adult Smoking PrevalenceAdult Smoking Prevalence
Sources: United States--NHIS, US Centers for Disease Control and PreventionCalifornia--CTS, 1990, 1992-3, 1996, weighted to 1990 CA population; CATS/BRFS, 1994-1998, weighted to 1990 CA population.
Prepared by: California Department of Health Services, Tobacco Control Section, May 24, 2000.
0
10
20
30
40
Pe
rce
nt
US CA
US 37.9 34.9 33.6 32.3 31.9 29.9 30.2 27.4 25.0 25.5 24.7
CA 35.0 32.3 31.7 29.4 30.5 26.8 26.7 22.2 20.0 20.2 17.3 16.7 18.6 18.4 18.0
77 78 79 81 82 83 84 85 87 88 89 90 92 93 94 95 96 98 99
Tax Increase and Start of
the CA Tobacco Control Program
* Definition change in 1996 resulted in more “occasional smokers” being counted.
*
30-day smoking prevalence among California 30-day smoking prevalence among California youth using a telephone survey, 1994-1999youth using a telephone survey, 1994-1999
0
2
4
6
8
10
12
14
Overall 11 12.1 11 11.2 10.7 6.9
1994 1995 1996 1997 1998 1999
Source: CYTS 1994-1999.Prepared by: Tobacco Control Section, California Department of Health Services, June 2000.
Per
cen
t
1999 Youth Smoking Prevalence1999 Youth Smoking PrevalenceSubstance Abuse and Mental Health Services Administration (SAMHSA)Substance Abuse and Mental Health Services Administration (SAMHSA)
0
5
10
15
20
25National 30-Day Use
California 30-Day Use
Utah 30-DayUse
Florida 30-Day Use
Kentucky 30-Day Use
23.9
11.510.3
9
15.1
Cumulative Number of Cities with Cumulative Number of Cities with Smoke-Free Provisions in OrdinanceSmoke-Free Provisions in Ordinance
1 5 1835
82
133
286
0
50
100
150
200
250
300
1989 1990 1991 1992 1993 1994 1995
Number of Cities
California 1989-1995
35
90
0
20
40
60
80
100
1990 1998
Protection From Environmental Protection From Environmental Tobacco Smoke In The WorkplaceTobacco Smoke In The WorkplaceProtection From Environmental Protection From Environmental Tobacco Smoke In The WorkplaceTobacco Smoke In The Workplace
Perc
en
tag
e o
f w
ork
ers
pro
tecte
d
CTS, 1998
Smokers with Children Under 18 Who Smokers with Children Under 18 Who Prohibit Smoking in Their HouseholdProhibit Smoking in Their Household
Relation Between Policy and Relation Between Policy and Cigarette ConsumptionCigarette Consumption
13.9
11.2
8.27.3
0
2
4
6
8
10
12
14
None Work ban only Home ban only Both
Source: CTS 1999
Daily Cigarette Consumption and Smoking Bans
Cig
are
ttes/
Day
Percent of Retailers Selling Tobacco Percent of Retailers Selling Tobacco to Youthto Youth 1994-20001994-2000
52.1
37
29.3
21.7
13.1
16.9
12.8
0
10
20
30
40
50
60
1994 1995 1996 1997 1998 1999 2000
Per
cen
t
Attempted buy protocol 1994-1996; Actual buy protocol 1997-2000.Due to different methodologies 1994 survey results may not be comparable to the 1995-2000 results.Source: California Youth Purchase Survey, 1994-2000.Prepared by: California Department of Health Services, Tobacco Control Section, September 2000.
45
50
55
60
65
1988 1989 1990 1991 1992 1993 1994 1995 1996
United States (minus California)California
Lung and Bronchus Age-Adjusted Lung and Bronchus Age-Adjusted Cancer Rates, 1988-1996Cancer Rates, 1988-1996
EAPC = -2.3*
EAPC = -0.6
1 United States (Surveillance, Epidemiology, End Results [SEER]) includes the following registries Connecticut, Detroit, Hawaii, Iowa, New Mexico, Seattle, Utah, and Atlanta. San Francisco-Oakland has been excluded.2 California Cancer Registry, California Department of Health Services (11/99)* Estimated annual percent change (EAPC) is significantly different from zero (p<0.01)
Rate per 100,000
1
2
Savings in Smoking Attributable Savings in Smoking Attributable Direct & Indirect CostsDirect & Indirect Costs
0
1
2
3
4
5
6
7
8
9
1990-1998
Expended
Saved
Billions
$836 Million
$8.4 Billion
ConclusionsConclusions• A comprehensive program is most effective.
• Media and local programs must be coordinated and well funded.
• If you want kids to not smoke, you have to get the adults to change their behavior.
• Anti-industry and secondhand smoke strategies are effective.
• Empower the communities to advocate.
• Be culturally sensitive
• Accountability is the key to success.
• Provide strong leadership and allow program flexibility.