1. Changing Public Policy to Reduce Tobacco Use Andrew Hyland, PhD Roswell Park Cancer Institute Andrew.hyland@roswellpark.org Stanton Glantz, PhD University of California San Francisco glantz@medicine.ucsf.edu June 2, 2010

2. Key Messages from Today’s Talk Tobacco is the number one preventable health problem that faces our nation today We know what works! Broad-based policy change Programs and public education  $$$ Policy change  political will BUT…be careful…the financial viability of a massive oligopy is at stake They will undermine your efforts and be creative to continue to maximize their profits BUT…science tells us that broad-based policy change saves lives and money

3. What Drives Tobacco Use

4. Societal Change Requires Societal Action And This Will Reflect Itself With Individual- Level Change

5. The Motivation Tobacco will kill tens of millions of US residents this century We know what causes this death We have a responsibility to do something about it Speed matters

6. What We Know Works Clean air Mass media Higher prices Cessation Comprehensive programs Some policies are feasible at the local level

9. What about cessation? Quitlines and direct services are fine But most people quit unaided Goal should be to promote and support unaided quit attempts Smokefree workplaces and homes Reduce social acceptability of smoking Smokefree policies are 10 times more cost effective per new nonsmoker than direct services

10. What About Youth Smoking? The policies that impact adult smoking impact youth smoking Little evidence school-based education by itself is effective Little evidence youth access policies are effective Why spend lots of money to target a sliver of the smoking population when other policies are less expensive and work for everyone?

11. Localities can now restrict tobacco marketing Limit number of outlets Limit where ads are placed in retail setting Eliminate buy-one-get-one-free offers These actions may be challenged based on 1 st Amendment Do after clean indoor air

12. Outlet Density, Ad Ban Policies

13. Retail Environment

15. Change Social Acceptability Similar effect to price increases Estimate 15% consumption drop if US was raised to the level in California in 1999 = $1.17 per pack price increase SOURCE: Alamar and Glantz. AJPH 2006

16. Let’s Focus on Clean Air…

18. Hayman Fire – Worst in Colorado History, June 8 2002

19. Denver June 9, 2002

20. Denver’s visibility – before Hayman fire

21. Denver’s visibility – 1 day after Hayman fire Worst PM 2.5 - 43 µg/m 3 (24-hr max) or 200 µg/m 3 (hourly max)

23. Particulate Matter Levels in the US.

24. Generated Media on Air Monitoring Studies U.S.A.

25. "Common Sense" - Tobacco Institute, 1982 (ti53100003)

26. Clean air policies can be done locally to change social norms… In large part because the data are on our side

27. Introducing Stan Glantz Pioneer in the clean air and social change movement in California to share his perspective

28. US Surgeon General (1986) Involuntary smoking is a cause of disease, including lung cancer, in in healthy non- smokers. The children of parents who smoke compared with the children of nonsmoking parents have an increased frequency of respiratory infections, increased respiratory symptoms, and slightly smaller rates of lung function as the lung matures. The simple separation of smokers and nonsmokers within the same airspace may reduce, but will not eliminate, exposure to environmental tobacco smoke.

29. Secondhand Smoke Causes (Cal EPA/NCI, 1997) Fetal growth retardation SIDS Respiratory problems in kids Asthma in kids Eye and nasal irritation Middle ear infections in kids Lung cancer Nasal sinus cancer Heart disease mortality and morbidity About 53,000 deaths

30. Secondhand Smoke Causes (Cal EPA, 2006) Pre-term delivery Asthma induction in adults Breast cancer in younger (primarily premenopausal) women Acute and chronic heart disease morbidity Altered vascular properties About 50,000 deaths (not including breast cancer)

31. Annual deaths due to SHS Source: Wells,1998 37,000 13,000 3,000

32. InjuryRepair Maintenance of Vascular Endothelium lumen intima media EPCsEndothelial microparticles balance NO

33. Physical evidence for endothelial damage * p<0.05 vs baseline # p<0.05 vs respective time point on control day * CD31 + /CD41 - (PECAM/Gp IIb) CD144 + (VE-Cadherin) CD62e + (E-Selectin) “Activation” “Structural damage” Endothelial microparticles

34. Endothelial function is acutely decreased to smokers levels * p<0.05 vs baseline # p<0.05 vs respective time point on control day VEGF

35. Increased EPC number in blood * p<0.05 vs baseline # p<0.05 vs respective time point on control day

36. Sustained inhibition of EPC chemotaxis to VEGF * p<0.05 vs baseline, # p<0.05 vs respective time point on control day

37. Disturbed Maintenance of Vascular Endothelium lumen intima media EPCs Endothelial microparticles balance NO InjuryRepair

38. Gala Event

40. Helena, Montana Population of city: 28,306 Population of Helena Zip Codes: 46,943 Total Population of Study area: 65,913 Geographically isolated population Next nearest cardiologist: 60 miles

41. Significant Drop in AMI Admissions while Ordinance in Effect

42. Effect grows with time

43. Institute of Medicine … secondhand-smoke exposure increases the risk of coronary heart disease and heart attacks and that smoking bans reduce this risk. … smoking bans can have a substantial impact on public health.

44. Mammary Carcinogens in Tobacco Smoke Aromatic hydrocarbons Benzene Benzo[a]pyrene Dibenz[a,h]anthracene Dibenzo[a,e]pyrene Dibenzo[a,h]pyrene Dibenzo[a,I]pyrene Dibenzo[a,l]pyrene Nitrosamines N-nitrosodiethylamine N-Nitrosodi-n-butyl-amine Aliphatic compounds Acrylamide Acrylonitrile 1,3-Butadiene Isoprene Nitromethane Propylene oxide Urethane Vinyl chloride Arylamines and nitrarenes 4-Aminobiphenyl Nitrobenzene Ortho-Toluidine

45. Human evidence Increases in risks for smoking and passive smoking among younger women 70% increased risk in younger women Exposure between puberty and lactation probably most dangerous Susceptible women probably get the cancers young

46. Source: Piazza K, Hyland A. Unpublished analysis. % Women With Smokefree Home AND Workplace By State, 1992/1993 CPS TUS, All Ages STATES WITH MORE 100% SMOKEFREE RULES HAVE LOWER BREAST CANCER MORTALITY

49. New York Response

51. Invasion of the Tobacco People

52. Per capita cigarette consumption Prop 99 Tax increase

53. Age Adjusted Heart Disease Mortality Prop 99 Tax increase

54. Effect on Mortality 59,000 fewer deaths (9%) 1,500 unnecessary deaths

55. Effect on Industry Sales 2.9 billion packs not smoked ($4 billion) 1 billion extra packs ($1.4 billion)

56. Large Scale Tobacco Control Programs Work Over the first 15 years the California program cost $1.4 billion It saved $86 billion These savings started appearing quickly and grew with time By 2004, the program was saving $11 billion in health costs 7.3% of all health costs

57. Large Scale Tobacco Control Programs Work Prevented 3.6 billion packs of cigarettes from being smoked Worth $9.2 billion in lost sales The tobacco industry is motivated to stop you

58. How do you make change? Identify local champions Health department has to its public policy job Public education Policy maker education Creating positive environment through media Private agencies need to do their job Aggressive Close the deal

59. The industry will oppose you They have a lot to lose They are highly motivated Work through third parties Public records act requests “Illegal lobbying” Lawsuits

61. “Illegal lobbying” and litigation

62. Not that We’re Paranoid

63. Specific amendment language drafted to stop NCI grants to Glantz and Richard Daynard (Faxed to RJR from Tobacco Institute) [ydn60d00]

64. For people who think we have not made progress