Monitoring & Evaluation: Tools for the civil society to advance effective tobacco control policies Ernesto M Sebrié, MD MPH Transdisciplinary Tobacco Use Research Center Department of Health Behavior Roswell Park Cancer Institute Buffalo, New York Healthy Caribbean 2008 Caribbean Chronic Disease Conference Bridgetown, Barbados, October 16, 2008

Overview of the presentation 1.Tools for advancing & enforcing specific tobacco control policies –Smokefree policies Public opinion polls Air monitoring study Monitoring of compliance (direct observation) –Labeling & packaging policies Pre-testing: mall intercept survey Monitoring of compliance (e.g., retail stores, sale in the street, etc.) –Tobacco advertising & sponsorship ban Monitoring of compliance (e.g., street, retail stores, magazines, youth venues, etc.) Example: Public opinion polls on public support and air contamination with tobacco smoke particles; warning labels tool kit 2.Evaluation of mass media behavior Example: content analysis of newspapers articles published on tobacco control 3.Evaluation of policymakers behavior –Mapping of public officials (legislators, health authorities, etc.) –Bills and other regulations introduced Example: analysis of tobacco control legislation

4.Tobacco industry behavior –Arguments & strategies –Volunteer programs –Front groups allies Example: analysis of internal tobacco industry documents to expose/reveal deceptive strategies to the public; analysis of tobacco industry websites/ social reports 5.Monitoring government behavior –Tobacco control policy implementation Example: edition of a civil society report on the implementation of the FCTC (e.g., Mexico & Canada) Overview of the presentation (cont.)

Tools for advancing & enforcing smokefree policies

Public Opinion Surveys Knowledge on SHS & Support for smokefree policies Demographics Age, Gender, Level of formal education, Income Smoking status Have you ever smoked at least 100 cigarettes in your life?/ Do you currently smoke? Health effects of smoking I am going to read you a list of health effects and diseases that may or may not be caused by smoking cigarettes. Based on what you know or believe, does smoking cause… Lung cancer, Heart disease, Lung disease (e.g., bronchitis, asthma, or emphysema), Stroke, Impotence in male smokers, Complications during the pregnancy (e.g., abortion, low birth weight, or premature delivery), Blindness, Mouth & throat cancer, Peripheral vascular disease and gangrene, Breast cancer in young women, Addiction, Yellow teeth/ skin wrinkles, Health effects of SHS exposure Now, I am going to read you a list of health effects and diseases that may or may not be caused by SHS exposure in nonsmokers. Based on what you know or believe, does exposure to SHS cause… Lung cancer in adults nonsmokers/ Heart disease in adults nonsmokers Lung disease in adults nonsmokers/ Stroke in adults nonsmokers Mouth cancer in adults nonsmokers/ Breast cancer in young women nonsmokers Asthma in children

Sources of information/ educational campaigns In the last 6 months, have you noticed information that talks about the dangers of smoking and SHS, or that encourages quitting in any of the following places? On television/ On radio/ At the cinema/ On posters or billboards/ In newspapers or magazines/ On shop/store windows or inside shops/stores where you buy tobacco In warning labels on cigarette packages/ On leaflets/ On the internet/ Anywhere else? Knowledge, attitudes & support for smokefree policies Do you know if there is any smokefree policy in your country? Do you know if there is any smokefree policy in your city? Do you know if there is any specific policy in ….(e.g., hospital, university, etc.?) Do you support 100% smokefree environments in … enclosed public places, public transportation, enclosed workplaces, bars and restaurants, casinos, etc.? Do you agree with the following statement… “SHS is dangerous for nonsmokers’ health”? “All workers have the right to work in a smokefree environment”? Public Opinion Surveys Knowledge on SHS & Support for smokefree policies

Public Opinion Surveys in Latin America Country (year) LocationAgree with: “SHS is dangerous for nonsmokers health” Agree with: “Every worker has the right to work in a SFE” Support SFE government, private offices, banks & shopping malls Support SFE in bars & restaurants Support SFE in health care and educatio nal facilities ARGENTINA (2006) National population 92.9%96.8%93.4% 76.5%96.7% BRAZIL (2006) City of Sao Paulo (not asked) 85% (covered public places in general) Restaurants 83% Bingos 67% Bars/discos 62% - URUGUAY (2006) Urban areas92%95%General agreement with the 100% smokefree country (including every type of facilities) Agree 80%; Indifferent 8%; Disagree 11% MEXICO ( 2007) 7 cities84% (smokers)(not asked)81% of smokers preferred SME More than 75% of smokers supported smokefree hospitals, public transportation, museums, cinemas, and theatres

Cigarettes, cigars and pipes produce a great amount of breathable particles smaller than 2.5 microns (PM 2.5) which are easily inhaled to the lungs. The TSI Side Pack is a devise, scientifically validated that measures the PM 2.5 in the air. TSI Side Pack AM510 Personal Aerosol Monitor

The TSI SidePak is small (weight: 1lb) and can be used for discrete sampling

Why PM 2.5 ? Very sensitive marker of SHS Can monitor and record data in “real-time” Relatively inexpensive equipment Marker of the more than 4,000 chemicals Meaningful measure: there are PM 2.5 standards in place to protect public health –The EPA has set standards of 15 μg/m 3 as the average annual level of PM 2.5 exposure and 35 μg/m 3 24-hour exposure in order to protect the public health. –The WHO has an annual target of 10 μg/m 3 Limitations of PM 2.5 as a Marker of SHS Not specific to tobacco smoke; other sources include cooking, vehicles, ambient/ background levels

New Jersey Air Monitoring Study (2005) 8/27 9:00pm Start Diner Smoking 8/29 7:47pm End Bar Smoking Restaurant Smokefree Restaurant Smoking Bar Smoking Bar Smoking 8/29 12:14pm 8/29 7:00pm

Change in Air Quality in Western New York Bars and Restaurants After Implementation of the NY State Clean Indoor Air Law Before Law: Average = 412 μg/m 3 After Law: Average = 27 μg/m 3

Why measure air quality? Quantify exposure, determine risk Educate the public and policy makers Evaluate smoke-free air policies Generate media attention

Website: training course

Evaluating tobacco products labeling policies

A. Pre-implementation: Pre-testing the layout and design of warnings Concept and content testing B. Implementation evaluation: Monitoring & compliance C. Post Implementation: Impact evaluation

Pre-implementation: Pre-testing the layout, design, and content of warnings OBJECTIVE: To evaluate the most effective health warning designs, and concepts for each theme and subject. METHODS: Focus groups Mall intercept surveys Combination

MALL INTERCEPT STUDY o“Delivers less tar?” o“Smoother taste?” o“Lower health risks?” Mock ups 4 Caribbean countries Bloomberg funding

Implementation evaluation: Monitoring & compliance OBJECTIVE: To examine whether health warnings have been implemented on packages as planned. METHODS: To visit retail outlets to visually inspect packages: commonly referred to as an “environmental scan.” Number of retail outlets visited will depend greatly on the availability of resources; a range of retail outlets in different parts of the country should be visited. It requires relatively little expertise, with the potential to involve tobacco control advocates. Some regulators can visit factories of domestic tobacco manufacturers to ensure that packages are being printed in accordance with the regulations.

Post Implementation: Impact evaluation OBJECTIVE: To examine the potential effectiveness of health warnings after implementation. Increases in health knowledge and perception of risk. Greater awareness of cessation services. Increases in motivation to quit and cessation. METHODS: Population-based surveys

Tobacco Labeling Resource Center /

Monitoring tobacco industry’s arguments & strategies

 Subjects –Marketing, Advertising, & PR –R&D efforts, Scientific research –Lobbying, Legislative, and Legal Efforts  Formats –Letters, Memos, & Faxes –Meeting Minutes & Presentations –Invoices, Statements –Junk Internal tobacco industry documents: what are they? + 50 million pages and growing –US Companies –BAT Released under US litigation

Legacy Tobacco Documents Library

Why use the Documents? Important tool for researchers, policy makers, tobacco control advocates, lawyers Expose, educate, disseminate, advocate Understand tobacco industry strategies

BATCCA: BAT Caribbean & Central America

Trinidad & Tobago (2004) Tobacco industry “Youth Smoking Prevention” Program

Trinidad & Tobago (2004) Accommodation

BAT Jamaica (2008) SOCIAL REPORT

Jamaica (2008) Tobacco industry “Youth Smoking Prevention” Program

Jamaica (2008) T obacco industry Advertising

Ernesto Sebrie, MD MPH Roswell Park Cancer Institute