1. 1 Michael A. Tynan Public Health Analyst Centers for Disease Control & Prevention Office on Smoking and Health Ending the Tobacco Use Epidemic The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Strategic Alliance for Health, Action Institute Houston, TX April 27, 2010

2. 22 About 443,000 U.S. Deaths Per Year Attributable to Cigarette Smoking *Average number of deaths, 2000-2004. Source: Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses --- United States, 2000— 2004 MMWR 2008;57(45):1226-1228. Other cancers 35,500 Chronic Obstructive Pulmonary Disease 92,900 Lung cancer 128,900 Stroke 15,900 Other diagnoses 44,000 Ischemic Heart Disease 126,000 Every year: $96 billion in medical costs $97 billion in lost productivity

3. 3 Smoking and Secondhand Smoke Damages the Entire Human Body Image: ImpacTeen Chartbook: Cigarette Smoking Prevalence and Polices in the 50 States. Sources: Surgeon General’s Report, 2004, 2006. SmokingSecondhand Smoke

4. 44 Trends in Current Cigarette Smoking by High School Students and Adults—United States, 1965-2007 Youth HP 2010 - 16% Adults HP 2010 - 12% *High school students who smoked on 1 >/ of the 30 days preceding the survey--United States, CDC. Youth Risk Behavior Survey, 1991-2007. ** Total population adults who were current cigarette smokers, National Health Interview Surveys, 1965-2006. High school students* Adults**

5. 5 Age-adjusted smoking rates 9.2 - 16.4 16.5 – 17.6 17.7 – 19.4 19.5 – 21.7 22.2 – 26.6 Note: Persons who have smoked at least 100 cigarettes in lifetime and currently report smoking everyday or some days. SOURCE: Behavioral Risk Factor Surveillance Survey, NCCDPHP, CDC. Cigarette Smoking in the U.S., Adults 18 Years and Over, 2008

6. 6 Source: CDC Division of Heart Disease and Stroke Prevention Heart Disease Death Rates, U.S. 2000-2004

7. 77 Evidence-Based Interventions  Sustained funding of comprehensive programs  Excise tax increases  100% smoke-free policies  Aggressive media campaigns  Cessation access  Comprehensive ad restrictions

8. 88 Source: Project ImpacTEEN; CDC/Office on Smoking and Health; Campaign for Tobacco Free Kids; Research Triangle Institute; University of Illinois at Chicago; University at Buffalo, State University of New York *High school students who smoked on 1 >/ of the 30 days preceding the survey--United States, CDC. Youth Risk Behavior Survey, 1993-2007. Total Funding for State Programs Adjusted to FY2008 Dollars

9. 99 State Status Toward Reaching CDC-Recommended Funding Levels — FY2009 AZ WY OR ID MT UT NV WA CA TX AR OK ND LA KS IA NE SD CO NM MO MN TN AL KY OH MS MI IN GA FL PA ME NY WV VA NC SC VT CT D.C. RI NJ MD DE NH MA IL WI AK HI <20% (n=28) 40-59% (n=5) 60-79% (n=5) >80% (n=1) 20-39% (n=12) Source: CDC, Office on Smoking and Health.

10. Tobacco Industry is Outspending Prevention Efforts 20:1 -- 2007 State Tobacco Revenue (taxes and settlement funds) $22.3 billion State Tobacco Program Budgets $0.6 billion Sources: Campaign for Tobacco Free Kids, American Heart Ass’n, American Cancer Soc., American Lung Ass’n, SmokeLess States National Tobacco Policy Initiative Total CDC- Recommended Spending Level $3.7 billion Tobacco Industry Marketing & Promotion Expenditures $12.5 billion

11. 11 Cigarette Sales and Cigarette Prices United States, 1970-2007 Source: ImpacTeen Chartbook: Cigarette Smoking Prevalence and Polices in the 50 States.

12. 12 State Cigarette Excise Tax Rates - 2006 AZ WY OR ID MT UT NV WA CA TX AR OK ND LA KS IA NE SD CO NM MO MN TN AL KY OH MS MI IN GA FL PA ME NY WV VA NC SC VT CT D.C. RI NJ MD DE NH MA IL WI AK HI 50-99 cents per pack $1.00-$1.49 per pack $1.50-$1.99 per pack $2.00+ per pack Source: CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System. <50 cents per pack

13. 13 State Cigarette Excise Tax Rates - 2007 AZ WY OR ID MT UT NV WA CA TX AR OK ND LA KS IA NE SD CO NM MO MN TN AL KY OH MS MI IN GA FL PA ME NY WV VA NC SC VT CT D.C. RI NJ MD DE NH MA IL WI AK HI 50-99 cents per pack $1.00-$1.49 per pack $1.50-$1.99 per pack $2.00+ per pack Source: CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System. <50 cents per pack

14. 14 State Cigarette Excise Tax Rates - 2008 AZ WY OR ID MT UT NV WA CA TX AR OK ND LA KS IA NE SD CO NM MO MN TN AL KY OH MS MI IN GA FL PA ME NY WV VA NC SC VT CT D.C. RI NJ MD DE NH MA IL WI AK HI 50-99 cents per pack $1.00-$1.49 per pack $1.50-$1.99 per pack $2.00+ per pack Source: CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System. <50 cents per pack

15. 15 State Cigarette Excise Tax Rates - 2009 AZ WY OR ID MT UT NV WA CA TX AR OK ND LA KS IA NE SD CO NM MO MN TN AL KY OH MS MI IN GA FL PA ME NY WV VA NC SC VT D.C. NJ MD DE NH MA IL WI AK HI 50-99 cents per pack $1.00-$1.49 per pack $1.50-$1.99 per pack $2.00+ per pack Source: CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System. <50 cents per pack CT RI

16. 16 State Cigarette Excise Tax Rates - 2009 AZ WY OR ID MT UT NV WA CA TX AR OK ND LA KS IA NE SD CO NM MO MN TN AL KY OH MS MI IN GA FL PA ME NY WV VA NC SC VT D.C. NJ MD DE NH MA IL WI AK HI 50-99 cents per pack $1.00-$1.49 per pack $1.50-$1.99 per pack $2.00+ per pack Source: CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System. <50 cents per pack CT RI $3.46

17. 17 State Cigarette Excise Tax Rates - 2009 AZ WY OR ID MT UT NV WA CA TX AR OK ND LA KS IA NE SD CO NM MO MN TN AL KY OH MS MI IN GA FL PA ME NY WV VA NC SC VT D.C. NJ MD DE NH MA IL WI AK HI 50-99 cents per pack $1.00-$1.49 per pack $1.50-$1.99 per pack $2.00+ per pack Source: CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System. <50 cents per pack Chicago $3.66 NYC $4.25 CT RI $3.46

18. 18 Indoor Air Quality Before and After Implementing a Smoke-Free Law Source: Institute of Medicine. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press; 2009. The outdoor ambient air quality standard for small particulate matter (PM 2.5) is 35 µg/m3. There is no indoor standard. PM 2.5 µg/m3 35 µg/m3

19. 19 Workplaces and/or Restaurants and/or Bars Workplaces and Restaurants and Bars Proportion of U.S. Population Covered by Local and State Smoke-Free Laws, 2000-2009 Population figures are as of December 31 of each given year, and October for 2009. All population figures are from the United States Census. Source: American Nonsmokers’ Rights Foundation. Percent 100 million Americans continue to be exposed

20. State Smoke-Free Indoor Air Laws for Private Worksites, Restaurants, and Bars AZ WY OR ID MT UT NV WA CA TX AR OK ND LA KS IA NE SD CO NM MO MN TN AL KY OH MS MI IN GA FL PA ME NY WV VA NC SC VT CT D.C. RI NJ MD DE NH MA IL WI AK HI N=51 Source: Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) System. Available at: http://www.cdc.gov/tobacco/statesystem. Ban in worksites, restaurants, and bars (n=22) Ban in two of three locations (n=5) No Ban in all these locations (n=24) Laws in effect as of December 31, 2006

21. State Smoke-Free Indoor Air Laws for Private Worksites, Restaurants, and Bars AZ WY OR ID MT UT NV WA CA TX AR OK ND LA KS IA NE SD CO NM MO MN TN AL KY OH MS MI IN GA FL PA ME NY WV VA NC SC VT CT D.C. RI NJ MD DE NH MA IL WI AK HI N=51 Source: Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) System. Available at: http://www.cdc.gov/tobacco/statesystem. Ban in worksites, restaurants, and bars (n=22) Ban in two of three locations (n=5) No Ban in all these locations (n=24) Laws in effect as of December 31, 2007

22. State Smoke-Free Indoor Air Laws for Private Worksites, Restaurants, and Bars AZ WY OR ID MT UT NV WA CA TX AR OK ND LA KS IA NE SD CO NM MO MN TN AL KY OH MS MI IN GA FL PA ME NY WV VA NC SC VT CT D.C. RI NJ MD DE NH MA IL WI AK HI N=51 Source: Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) System. Available at: http://www.cdc.gov/tobacco/statesystem. Ban in worksites, restaurants, and bars (n=22) Ban in two of three locations (n=5) No Ban in all these locations (n=24) Laws in effect as of December 31, 2008

23. AZ WY OR ID MT UT NV WA CA TX AR OK ND LA KS IA NE SD CO NM MO MN TN AL KY OH MS MI IN GA FL PA ME NY WV VA NC SC VT CT D.C. RI NJ MD DE NH MA IL WI AK HI Ban in worksites, restaurants, and bars (n=22) Ban in two of three locations (n=4) Laws in effect as of December 31, 2009 N=51 Source: Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) System. Available at: http://www.cdc.gov/tobacco/statesystem. *Enacted legislation is not yet effective in Kansas, Wisconsin. No Ban in all these locations (n=25) State Smoke-Free Indoor Air Laws for Private Worksites, Restaurants, and Bars

24. AZ WY OR ID MT UT NV WA CA TX AR OK ND LA KS IA NE SD CO NM MO MN TN AL KY OH MS MI IN GA FL PA ME NY WV VA NC SC VT CT D.C. RI NJ MD DE NH MA IL WI AK HI Ban in worksites, restaurants, and bars (n=23) Ban in two of three locations (n=5) Laws in effect as of May 1, 2010* N=51 Source: Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) System. Available at: http://www.cdc.gov/tobacco/statesystem. *Enacted legislation is not yet effective in Kansas, Wisconsin. No Ban in all these locations (n=23) State Smoke-Free Indoor Air Laws for Private Worksites, Restaurants, and Bars

25. State Smoke-Free Laws for Private Worksites, Restaurants, and Bars AZ WY OR ID MT UT NV WA CA TX AR OK ND LA KS IA NE SD CO NM MO MN TN AL KY OH MS MI IN GA FL PA ME NY WV VA NC SC VT CT D.C. RI NJ MD DE NH MA IL WI AK HI Ban in worksites, restaurants, and bars (n=23) Ban in two of three locations (n=5) Laws in effect as of May 1, 2010* N=51 Source: Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) System. Available at: http://www.cdc.gov/tobacco/statesystem. *Enacted legislation is not yet effective in Kansas, Wisconsin. No Ban in all these locations (n=23)

26. 26 Aggressive Media Campaigns  Media campaigns  Reduce youth initiation  Encourage cessation  Increase negative attitudes toward tobacco use

27. 27 The Impact of Cessation  Presently: 46 million U.S. smokers  70% of smokers want to quit  40% try to quit each year  Only 2% call state or national quitlines  Tobacco cessation works best when combined with  Significant tax and price increases  Comprehensive smoke-free policies  Advertising, promotion and sponsorship bans  Aggressive counter-advertising

28. 28 Quitline Counseling Alone or with Medication Significantly Increases 6-Month Abstinence Rates Percent Quit Source: Clinical Practice Guideline Meta-Analysis Results. Treating tobacco use and dependence: 2008 update. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service; 2008 May.

29. 29 Impact of Combined Interventions: Adult and Youth Smoking Prevalence in New York City Sources: CDC. Decline in Smoking Prevalence -- New York City, 2002—2006. MMWR. 2007. 56(24);604-608; and New York City Department of Health and Mental Hygiene. Percent of adults who smoke 3-yr. average 21.6%21.5% 21.7% 21.6% 19.2% 18.4%18.9% 17.5% 16.9% 15.8% City and State tax increases Smoke-free workplace TV ad campaign 17.6% 14.8% 11.2% 8.5% AdultYouth

30. Lung and Bronchus Age-Adjusted Cancer Incidence rates, 1988-2003 15 year investment of $1.8 billion in tobacco control reduced health care costs by $86 billion

31. 31 Opportunities Moving Forward

32. Family Smoking Prevention and Tobacco Control Act of 2009  On June 22, 2009, President Obama signed legislation granting the FDA the authority to regulate:  CONTENT of tobacco products  MARKETING of tobacco products  SALES of tobacco products

33. FDA: Major Accomplishments To Date August 2009September 2009January 2010March 2010 Established Center for Tobacco Products Ban on Flavored Cigarettes Industry Ingredient Submission Begins Reissued 1996 Rule First meeting of Tobacco Products Scientific Advisory Committee (TPSAC)

34. FDA’s Next Steps: Future Deadlines June 2010 March 2011June 2011 Ban on misleading terms (light, low, mild) New Smokeless Warning Labels 1996 Rule takes effect TPSAC Findings on Menthol New Rules for Cigarette Warning Labels

35. Graphic Cigarette Warnings  FDA legislation mandates new graphic warnings must comprise the top 50% of the front and back of cigarette packs.  Rules must be issued no later than June 2011.  New warnings will take effect 15 months later. Image Source: Health Canada

36. Roles for CDC in Tobacco Product Regulation  Technical assistance and guidance  Laboratory (NCEH)  General tobacco control (OSH)  Maintain comprehensive tobacco control programs  Coordinate national and state efforts  FDA will contract with states to aid in enforcement  Conduct post-marketing surveillance of effects of the tobacco product regulation

37. 37 Michael A. Tynan Public Health Analyst Centers for Disease Control & Prevention Office on Smoking and Health mtynan@cdc.gov Ending the Tobacco Use Epidemic The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.