INFLUENCE OF TOBACCO AND PHARMACEUTICAL INDUSTRIES ON TOBACCO CONTROL PROGRAMS John P. Pierce, Wael Al-Delaimy Karen Messer, Dennis Trinidad & UCSD Tobacco Research Team

Tobacco Industry Tobacco Control Pharma Industry Societal Messages on Tobacco/Nicotine Use Come From Multiple Sources

Typical Tobacco Control Program Activities 1.Promote Local Community Action  To increase community social norms against smoking  To support enforcement of legislation/regulation 2.Use Mass Media Campaigns  Reduce Demand Driving Smoking Initiation  Promote Quitting  Promote protection from secondhand smoke 3.Provide Assistance in Quitting 4.Coordinate Comprehensive School Programs

Pharmaceutical Industry Marketing Goals are also to increase product sales: Promote quitting using pharmaceutical products – Build expectation that quitting is easier when pharmaceutical products are used. Promote pharmaceutical products as a means to reducing harmful consequences

Tobacco Industry Marketing Goals are to increase product sales: Promote Experimentation with Tobacco Products Promote Progression to Dependent Use Promote Delay in quitting Promote use of alternative products when smoking is not allowed.

Both The Tobacco Industry and the Pharmaceutical Industry are Very Interested in Less Harmful Forms of Nicotine What is the current level of interest in these approaches among California Smokers?

“Would You Replace Your Cigarettes With Smokeless Tobacco if you thought It Had Few Health Consequences?” California Smokers in 2005 %

“Would You Switch From Cigarettes To A New Tobacco Product If you Could Get the Dose of Nicotine that you Need from the New Product Without Smoking?” California Smokers in 2005 %

What Are the Trends in Harm Reduction Among the Smokers in the Population? Have Clean Indoor Air Laws and the Increase in Smoke-free Homes Resulted in Less Harmful Behavior? Will the marketing of less harmful products Reduce Risk in Older Smokers or Promote Use Among in Younger People?

Smoking Intensity by Smoking Restrictions: CPS Non Daily Smokers Smoking Intensity Daily Smokers

Birth Cohort differences in the proportion of smokers smoking 25+ c/d in and

Social Norm Change in Different States: Smokers Who Have Smokefree Homes %

Change In The Proportion Of Daily Smokers Among NHW By State -6.5% +3% -3% -1%

Change in Number of cigarettes consumed by daily smokers aged % -10% -8.5% -4%

Change in Number of Cigarettes Consumed by daily smokers aged % -11% -10% -7%

Conclusion: Harm Reduction is occuring rapidly across the United States without the use of Alternative Nicotine Products

$/Person Tobacco Expenditure Tobacco Industry Advertising and Promotions Expenditure and Changes in the Uptake of Smoking Among Teenagers: Pierce et al Health Economics 2005

28X Dollars per person Tobacco Industry (2003 $) TCS (2003 $) Trends in Per Capita Expenditures by Tobacco Industry and Tobacco Control in California 28 times

Changes in reported distribution of Tobacco Industry marketing dollars The Tobacco Industry reports that they spent $9.7 billion on price discounts in 2005 and that this has been the vast majority of their marketing expenditures since 2002 (66%-75%) and that all advertising is only 1.3% of expenditures Does this mean that they have given up on trying to influence people through advertising and promotions?

Receptivity Index and Adult Smoking Status 6 years later for year old Teens Gilpin et al, AJPH 2007

Trends in Favorite Cigarette Ad in Californians aged yrs %

Trends in Favorite Cigarette Ad in Californians aged yrs %

Trends in Favorite Cigarette Ad in Californians aged yrs %

Most Popular Tobacco Industry Commercials Named as Favorite Anti-smoking Commercials 1.Talk to your kids, they will listen 2.General Philip Morris Antismoking ad 3.Never too soon to talk – mother and baby 4.We card campaign Overall % reporting these as their Favorite antismoking advertisement 5%

Named Favorite Anti-Smoking Advertisement by Age in 2005

Most Popular Secondhand Smoke Advertisements 1.Pregnant Mother and Baby Smoking 2.Blowing Bubbles commercial 3.Testimonial from smoker whose wife had died 4.Man smoking with pregnant wife or child in room Overall % reporting these as their Favorite antismoking commercial – 13%

Most Popular Quitting Assistance Advertisements NO BUTTS advertisements 2.NRT Patch pharmaceutical industry commercials 3.Training to Quit commercials 4.Quitting Takes Practice Overall % reporting these as their Favorite antismoking advertisement – 5%

Named Favorite Anti-Smoking Advertisement by Age in 2005

Most Popular Anti-Industry Advertisements 1.Truth commercials (named general category) 2.Boardroom series 3.Protests in front of tobacco company headquarters 4.Body Bags Overall % reporting these as their Favorite antismoking advertisement – 23%

Named Favorite Anti-Smoking Advertisement by Age in 2005

Most Popular Health Consequences Advertisements 1.Debbie – Addiction -Tracheotomy and Smoking 2.Images of Lung Cancer and other physical effects 3.Limp Cigarette-Impotence 4.# Deaths due to Smoking Billboard. Overall % reporting these as their Favorite antismoking advertisement – 37%

Named Favorite Anti-Smoking Advertisement by Age in 2005

Conclusion The Tobacco Industry has not given up on advertising and promotion. It is still very effectively targeting teens and young adults. The Tobacco Industry has successfully repositioned themselves so that some see them as on the side of Tobacco Control Advertising that focuses on the tactics of the Industry appears very effective with young people Health Consequences advertising remains important

Teen Perceptions that If They Started Smoking, They Could Quit At Any Time Can Only Promote Smoking Initiation A Concern with Pharmaceutical Advertising to Associate Their Products with Successful Quitting…

Perception of Ability to Quit at Anytime if Started Smoking: California Teen Committed Never Smokers

Perception of Ability to Quit at Anytime if Started Smoking: California Susceptible Never Smokers

Perception of Ability to Quit at Anytime if Started Smoking: California Teen Ever Smokers

Change in Belief that NRT is a Sure Way To Quit Among California Never Smokers who think that They Could Quit At Any Time ↑ 28%

No Change in Belief Among California Teen Ever Smokers Who Think That They Can Quit Anytime and That NRT is a Sure Way To Quit

Conclusion Pharmaceutical advertising that it is easy to quit with their products could lead to more teens starting to smoke

Should Tobacco Control Programs Buy Pharmaceutical Aids to Help Smokers Quit? Giving out free or heavily discounted pharmaceutical aids will dramatically increase calls to your quitline Many of these callers have little tolerance for behavioral counseling – “Is it over yet, can I get my patch now?” For those who see the pharma aid as a “magic bullet”, self-efficacy in ability to quit is unlikely to improve during the quit attempt

What is the Impact of Free Pharmaceutical Aids? Do they just increase calls to your quitline? OR Do they really increase successful quitting in your population? Clinical Trial Evidence Does NOT always Convert Into Good Public Health Practice

Percent reporting Pharmaceutical Aid on Last Quit Attempt: TUS-CPS 2003

Use of Pharma Aid on Most Recent Quit Attempt of Past Year: California Tobacco Survey

Success in Quitting for 6+ months Among Those who Tried by use of Pharmaceutical Aid: 2003 TUS-CPS. Messer et al AJPH in press

Population relapse curve by use of Nicotine Replacement Therapy (all 15+/day smokers with a quit attempt)

Source: 1999 and 2002 CTS Cessation relapse curve by use of Pharma Aid 15+/day smokers with a Smoke-Free home and another smoker in household

Smoking Status among Ever Smoking Men: CTS % 36%19%12%

Incidence of Successful Quitting (1+yr) in US by Age: TUS-CPS, yrs yrs yrs

The quickest way to increase successful quitting is to focus on young adults. Pharmaceutical Aids appear to most beneficial to smokers over the age of 35 years If you are going to subsidize pharmaceutical aids for quitting with public health dollars, then you need to evaluate that their use is associated with increased successful quitting –not just more calls to the Helpline Conclusion