1. Building a Legacy of Tobacco-Free Communities
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Building a Legacy of Tobacco-Free Communities
Jeff McKenna, MS
Associate Director for Communication Science
Key messages·      
Need to tell your story throughout·      
How you can tell your story—model activity·      
Prepare for pushback
ACHIEVE Action Institute
April 25, 2012
Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion

2. The Good News: We Have Recast Social Norms

3. The Bad News: Smoking Kills 443,000 Americans Each Year
Average annual number of deaths,
Source: Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses – United States, MMWR 2008;57(45):

4. U.S. Adult Per-Capita Cigarette Consumption, 1900-2010
Source: USDA Tobacco & Situation Outlook report until 2002; Office on Smoking & Health Data

5. U.S. Adult Per-Capita Cigarette Consumption Projected through 2035
Tobacco use is a minor public health nuisance
Source: USDA Tobacco & Situation Outlook report until 2002; Office on Smoking & Health Data
Projection: Calculations from Gary Giovino, University of Buffalo

6. Trends in Current Cigarette Smoking by High School Students and Adults—U.S., 1965-2010
*High school students who smoked on 1 >/ of the 30 days preceding the survey--United States, CDC. Youth Risk Behavior Survey,
** Total population adults who were current cigarette smokers, National Health Interview Surveys,

7. Surgeon General’s Report: Preventing Tobacco Use Among Youth and Young Adults

8. Current High School Cigarette Smoking and Projected Rates if Decline Had Continued—U.S., 1991-2009
3 million fewer youth and young adults would be smokers 8%
Source: YRBS: Centers for Disease Control and Prevention, Division of Adolescent and School Health, Office on Smoking and Health (unpublished data).

9. FDA Granted Authority to Regulate Tobacco
Adult Per Capita Cigarette Consumption and Major Smoking-and-Health Events—U.S.,
1st Surgeon
General’s Report
End of WW II
Master
Settlement
Agreement
Fairness Doctrine
Messages on TV
and Radio
FDA Granted Authority to Regulate Tobacco
1st Smoking-
Cancer Concern
Federal Cigarette
Tax More Than Doubles
Great Depression
Source: USDA Tobacco & Situation Outlook report until 2002; Office on Smoking & Health Data

10. Lung Cancer Incidence, US Men, 1998
U.S. Cancer Statistics: 1998–2007 Incidence and Mortality.

11. Lung Cancer Incidence, US Men, 2007
U.S. Cancer Statistics: 1998–2007 Incidence and Mortality. 11

12. Adult Smoking Prevalence
by State
Behavioral Risk Factor Surveillance System, 2010

13. Percent of Adults Who Smoke
by Sex
National Health Interview Survey, 2010

14. Percent of Adults Who Smoke by Racial/Ethnic Group
National Health Interview Survey, 2010

15. Percent of Adults Who Smoke
by Poverty Level
National Health Interview Survey, 2010

16. Percent of Adults Who Smoke
By Education Level
National Health Interview Survey, 2010

17. We Know What Works: Evidence-Based Interventions

18. CDC’s Recommendations for Prioritizing Policies
Phase I
Comprehensive Smoke-Free Policies
Price Increases
Hard-Hitting Media Campaigns
Sustained/Increased Program Funding
Phase II
Policy-Based Cessation
Expanded Smoke-Free Environments
Reduce Retailer Density, Location, Type
Product Display Bans
Graphic Retail Health Warnings

19. Factors that Affect Health
Largest
Impact
Smallest
Examples
Eat healthy, be physically active
Counseling
& Education
Rx for high blood pressure, high cholesterol, diabetes
Clinical
Interventions
Immunizations, brief intervention, cessation treatment, colonoscopy
Long-lasting Protective Interventions
Fluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax
Changing the Context
to make individuals’ default
decisions healthy
Poverty, education, housing, inequality
Socioeconomic Factors 19

20. Changing the Cost-Benefit Calculus
Tobacco easily accessible
Smoking in public legal
Unfettered advertising, no counter-advertising
Hard to access quitting resources
Cigarettes designed to addict
Individual

21. Changing the Cost-Benefit Calculus
Tobacco more expensive, less accessible
Smoke-free policies
Counter-marketing, promotion restrictions
Easy access to help
Cigarettes made less addictive
Individual

22. Phase I Priorities Comprehensive Smoke-Free Policies Price Increases
Hard-Hitting Media Campaigns
Sustained/Increased Program Funding

23. State Smoke-Free Indoor Air Laws for Private Worksites, Restaurants, and Bars
Laws in effect as of Dec 31, 2004 WA VT MT ND ME OR MN NH ID WI SD NY MA WY MI RI IA PA NV NE CT NJ IL UT IN OH DE CA CO WV VA KS MO KY MD NC
D.C. TN AZ OK
Comprehensive smoke-free policies are not new…
Over the past decade, we’ve seen great progress in policies from coast to coast.
Here’s a look at 2004 – when we had 3 states with comprehensive laws:
Massachusetts
Delaware
New York SC NM AR
Ban in worksites,
restaurants, and bars (n=3) MS AL GA LA
Ban in two of three
locations (n=1) TX AK FL
No Ban in all these
locations (n=47) HI
N=51
Source: Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) System. Available at:

24. State Smoke-Free Indoor Air Laws for Private Worksites, Restaurants, and Bars
Laws in effect as of April* 2012 WA VT MT ND ME OR MN NH ID WI SD NY MA WY MI RI IA PA NV NE CT NJ IL UT IN OH DE CA CO WV VA KS MO KY MD NC
D.C. TN AZ OK SC NM AR
Ban in worksites,
restaurants, and bars (n=26) MS AL GA LA
Ban in two of three
Locations (n=5) TX AK FL
No Ban in all these
locations (n=20) HI
N=51
Source: Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) System. Available at:
*Note Indiana is effective in July 2012

25. Almost 50% of U.S. population is covered by comprehensive state or local smoke-free laws
Population figures are as of December 31 of each given year; July for All population figures are from the United States Census. Source: American Nonsmokers’ Rights Foundation,

26. Benefits of Smoke-free Policies
Reductions in exposure among
nonsmoking hospitality workers
general population of nonsmokers
Health improvements among nonsmoking hospitality workers
Reductions in sensory and respiratory symptoms
Improved lung function
Reductions in hospital heart attack admissions among the general public
Increased cessation, reduced smoking rates among workers
Smoke-free policies reduce secondhand smoke exposure among smokers and nonsmokers and lead to improvements in lung function. They also lead to substantial reductions in heart attack admissions immediately following implementation of a smoke-free policy.

27. There is Also a Good Business Case for Going Smoke-Free

28. Groups Disproportionately Exposed to Secondhand Smoke
Children and adolescents
African Americans
Blue-collar, service, and hospitality workers
Low-income Americans
Examples of exposed populations include:
Children, who are primarily exposed in homes or cars; or
blue collar and service industry workers, since voluntary smoke-free policies tend to trend to favor white-collar office jobs.
Employees who report working in a smoke-free workplace are:
83% of white collar workers
72% of food- service workers
63% of blue collar workers
(Based on 2008 State Law MMWR)

29. Phase I Priorities Price Increases Comprehensive Smoke-Free Policies
Hard-Hitting Media Campaigns
Sustained/Increased Program Funding

30. State Cigarette Excise Tax Rates
Laws in effect as of Jan 1, 2011 WA
Chicago $3.66
(state + local) VT MT ND ME OR MN NH ID WI SD NY MA WY MI RI IA PA NV NE CT NJ IL IN OH
NYC $5.85 (state + local) UT DE CA CO WV VA KS MO KY MD NC
D.C. TN AZ OK SC NM AR
≥ $3.00 per pack MS AL GA LA
$2.00-$2.99 per pack TX AK
$1.50-$1.99 per pack FL
$1.00-$1.49 per pack
Anchorage $3.45
(state + local) HI
50-99 cents per pack
<50 cents per pack
CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System. 30 30 30

31. Phase I Priorities Hard-Hitting Media Campaigns
Comprehensive Smoke-Free Policies
Price Increases
Hard-Hitting Media Campaigns
Sustained/Increased Program Funding

32. Florida Truth Campaign: Dramatic Impact on Youth Smoking
Over 2 years, cigarette use plunged 40% among middle-school students and 18% among high-school students

33. National truth® Campaign
Research finding: more truth® ad exposure, less risk of beginning to smoke among teens
Annual media buy down from $100 million in 2000 to $30 million today
Farrelly et al. The Influence of the National truth Campaign on Smoking Initiation. AJPM 2009.

34. CDC’s National Tobacco Education Campaign “Tips from Former Smokers”
National Center for Chronic Disease Prevention and Health Promotion
Office on Smoking and Health

35. The Office of Smoking and Health took an evidence based approach to ad development.
First, we reviewed our experience running a pilot campaign in HHS Region 6 in the Spring of 2011 where we ran 3 hard-hitting TV ads for 12 weeks.
After the 12 weeks, a significant increase in ad awareness was seen and for every dollar we spent, we earned two and a half dollars in free placement.
We received very little negative feedback, from only a handful of individuals, and received strong, consistently positive and appreciative feedback from state and local health departments, including State Health Officers.
At the same time the pilot campaign was running, we began developing new ads for the national campaign. With message platform testing.
We found that messages that were clear, simple, believable and emotional were most well-received, and people responded very well to the “immediacy of health dangers” theme.
Next, we developed three campaign concepts and tested them via in-person focus groups. Of the three, the "Tips" concept was strongly preferred by almost all participants, and was rated the most powerful of the campaign concepts.

36. U.S. Total Quitline Calls: March 1-26
Week 1 Metrics
Week 1 Metrics
Campaign website : 230,000 page views
Terrie ad: viewed over 240,000 times
Quitline calls doubled
U.S. Total Quitline Calls: March 1-26
Campaign Launch
The metrics from the first week of the campaign are encouraging.
Our new campaign website had almost 230,000 page views during the first week.
The most often viewed ad was the Terrie ad, which was viewed more than 240,000 times.
There was about a 114% increase in QUIT-NOW call volume on 3/22 when compared to the previous week’s call volume, prior to the start of the paid campaign.
We also received some initial encouraging feedback from one of our states. Arkansas is reporting that their quitline volume increased from 442 calls (the week before the campaign launched) to 563, which was the highest number of calls they’ve ever had.

37. Phase I Priorities Sustained/Increased Program Funding
Comprehensive Smoke-Free Policies
Price Increases
Hard-Hitting Media Campaigns
Sustained/Increased Program Funding

38. Immediate Impact of a Comprehensive Approach:
Youth and Adult Smoking Rates in NYC
3-yr. average
21.6%
21.5%
21.7%
19.2%
18.3%
18.9%
17.5%
16.9%
15.8%
City and State tax increases
Smoke-free
policy
Media
campaign
17.6%
14.8%
11.2%
8.5%
State and Federal Tax increases
15.8%
14%
Percent
8.4% 7%
Source: BRFSS 1993 – 2001; NYC Community Health Survey – 2010; and NYC YRBS

39. Long-term Impact of a Comprehensive Approach: Lung Cancer Incidence Rates in CA
California: A 15 year investment of $1.8 billion in tobacco control reduced health care costs by $86 billion
Rates are per 100,000 and age-adjusted to the 2000 U.S. standard (19 age groups).
* The annual percent change is significantly different from zero (p<0.05).
Source: Cancer Surveillance Section. Prepared by: California Department of Public Health, California Tobacco Control Program,

40. Tobacco Industry is Outspending Prevention Efforts >23:1
State Tobacco
Revenue
(taxes and settlement
funds)
$25.3 billion
Federal
Cigarette
Tax Revenues
Tobacco Industry Marketing & Promotion
Spending (2008)
$15
billion
Total CDC-Recommended Spending Level
$10.5
billion
State Tobacco Program Budgets
$0.45 billion
$3.7 billion
Source: Campaign for Tobacco Free Kids, Federal Trade Commission, CDC Office on Smoking and Health

41. State Taxes vs. State Spending
The average state cigarette excise tax increased from $1.11 at the end of 2007 to $1.46 today
Total state spending on tobacco control decreased from $717 million in FY2008 to $457 million in FY2012
+ 32%
- 36%

42. Key CDC Tobacco Prevention Activities
National Tobacco Control Program
Funding and support to 50 states, D.C., U.S. territories, tribes, national organizations.
Community Transformation Grants
Community-level efforts in 61 states and communities
Funded by Affordable Care Act’s Prevention and Public Health Fund
“Next Generation” of Communities Putting Prevention to Work
National Tobacco Education Campaign
TV, radio, print, billboards, theater, bus shelters, and digital ads
Funded by the Prevention and Public Health Fund

43. Family Smoking Prevention and Tobacco Control Act of 2009
FDA given authority to regulate sales, advertising, and ingredient content of tobacco
Prohibits candy flavoring and misleading terms
introduces new youth access provisions
Requires new warnings for cigarettes, smokeless tobacco

44. Legal Challenges
Federal lawsuit challenging FDA’s regulatory authority
Federal lawsuit challenging graphic warning labels
Injunction has placed new warnings on hold for now
Continued lawsuits in states and communities against smoke-free, point of sale policies

45. A Self-Fulfilling Prophecy? Let’s Help!

46. Building a Legacy of Tobacco-Free Communities
Key messages·      
Need to tell your story throughout·      
How you can tell your story—model activity·      
Prepare for pushback
Thank You!
Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion