This presentation provides a historical overview of the California Tobacco Control Program and thoughts on the future of tobacco control

1. Tomorrow will not be like
yesterday….
What’s next in tobacco control ?
April Roeseler
Minnesota Tobacco
Control Conference
December 6, 2010

2. Tomorrow will not be like yesterday
Global economic meltdown

3. Tomorrow will not be like yesterday
Overconsumption

4. Tomorrow will not be like yesterday
Highly effective interventions
• Tobacco tax
increases
• Secondhand
smoke policies
• Media
interventions

5. Tomorrow will not be like yesterday
Health Inequities

6. Yesterday

7. California Tobacco Control
Program Begins
1988 –California voters
pass Proposition 99.
Tobacco tax increases
from 10¢ to 35¢ per
cigarette pack and
earmarks 5¢ (20%) of
the revenues for a
tobacco control
program.

8. CTCP Prop 99 Budget
1989-90 to 2010-11
120
105.3 107.3
100 95.3
89.5 87.4
80
Millions
72.5
64.2
62.1 60.3 61.2 62.8
60 55.9 57.8 55.7 54.6 54.7 53.8
52.6 50.9
43.1 41.0
40 36.6
20
0
89- 90- 91- 92- 93- 94- 95- 96- 97- 98- 99- 00- 01- 02- 03- 04- 05- 06- 07- 08- 09- 10-
90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11
Fiscal Year

9. Strategy

10. Goal = change social norm
Outcome = prevention & cessation

11. Social Norm Change Strategy
Creates a social milieu and legal
climate, where tobacco becomes:
 Less Desirable
 Less Acceptable
 Less Accessible

12. Denormalization Strategy
Lasting change in youth behavior regarding
tobacco can only be secured by first changing
the adult world in which youth grow up.

13. High Level Logic Model
Goals Outcomes
Reduce Exposure to Decrease Tobacco
Secondhand Smoke Consumption
(SHS)
Decrease
Counter Pro- Tobacco
Tobacco Influences Use Prevalence
Decrease Youth
Uptake of
Tobacco
Decrease
Exposure to
Support SHS
Cessation

14. Program Implementation

15. California Tobacco Control Program
Statewide Evaluation/Surveillance
Statewide Media Campaign
61 Health Department Projects
& Community Coalitions
37 Community Non-profit Agency Projects
Statewide Infrastructure & Training & Technical Assistance Projects
Capacity
Technical Center Tobacco Building Center California Youth
Assistance for Policy & Control for Advocacy
Legal Community Evaluation Diverse Network
Center Organizing Center Populations
Team Lab Cessation Quitline STAKE Youth
Clearinghouse Materials & Training Recruitment
Development Center

16. A Powerful Equation
Media
+
Community Involvement
=
Social Norm Change

17. Role of Media
• To be ahead of
the of the wave
(public opinion)
• To use the
energy at the
front of the wave
to pull public
opinion forward

18. Attitudes Influence Behavior

19. Secondhand Smoke Strategy
• Increases support
for local policies
• Provides smokers
a reason to quit

20. Secondhand Smoke (SHS)
• Positive SHS attitudes predict quitting
– Smokers are 70% more likely to have made a
recent quit attempt
– Smokers are over 2 times more likely to have
intentions to quit smoking in the next 6 months
California Tobacco Control Program, California Department of Public Health, A Confirmatory Factor Analysis of
a Social Norm Change Paradigm for the California Tobacco Control Program, May 2006.

21. Anti-Industry Strategy
• Motivates smokers to
quit; inoculates them
against advertising and
marketing
• Undermines tobacco
industry’s point of view
• Holds the industry
accountable for their
marketing practices
• Increases non-smoker’s
empathy towards
smokers

22. Countering Pro-
tobacco Influences
• Californians with highly negative attitudes
about the tobacco industry are:
– Among smokers, 67% were more likely to
have made a recent quit attempt
– Among smokers, 62% are more likely to have
intentions to quit in the next six months
California Tobacco Control Program, California Department of Public Health, Evaluation of California’s Anti-tobacco Media Campaign,
Waves 6, 7 and 8. February 2008.

23. Cessation Strategy
• Demonstrates
empathy for
smokers
• Provides
resources and
encouragement to
quit
Call 1-800-NO BUTTS

24. Smoking Cessation Ads
• Are effective at
generating motivated
smokers to call the
Quitline, they do not
make an impact on
smokers who are
unmotivated to quit.

25. Role of Community
• Amplifies the message
• Ties the program to the
community
• Diversifies expertise,
influence, & connections
• Results in policy change

26. Local Data Collection Drives
Policy

27. Chico & San Francisco ban free
tobacco & coupons

28. Tobacco Retail Licensing 1.0

29. TRL 2.0: San Francisco bans tobacco
sales in pharmacies

30. San Francisco drugstore before midnight
October 1, 2008

31. San Francisco drugstore after midnight
October 1, 2008

32. Tobacco Litter: 1.0 Policies

33. Cigarette Litter: 2.0 Policies

34. A funny thing happened on the way
to the forum (aka State Capitol)

35. Sacramento News and Review
May 27, 1993

36. Sacramento Bee
February 21, 2008
“We didn’t get to
where we are on
tobacco cessation
by working
cooperatively with
the industry.”
Senator Alex Padilla

37. Outcomes

38. 30-day smoking prevalence for California and
United States high school (9th-12th grade) students,
2000-2010
30 28.1
High School U.S. (9-12th graders)
25 22.5 High School CA (9-12th graders)
21.6 21.7
19.7
20
17.2
16.0
Percent
15.4 14.6
15 13.2 13.8
10
5
0
2000 2002 2004 2006 2008 2009 2010
Source: The 2000 California data is from the National Youth Tobacco Survey (NYTS) collected by the American Legacy Foundation, which
used passive parental consent. The 2002, 2004, 2006, 2008, and 2010 data are from the California Student Tobacco Survey. The 2002
and 2004 data collection used active parental consent while the 2006, 2008, and 2010 used a mixed parental consent procedure. The
United States data are from the NYTS collected by the American Legacy Foundation and the Centers for Disease Control and Prevention.
Note that the NYTS was conducted in 2009 thus 2008 and 2010
United States data are unavailable.
Prepared by: California Department of Public Health, California Tobacco Control Program, April 2011.

39. California Adult per Capita Cigarette Pack Consumption
1984 to 2009
200
Proposition 99
180
160
140
Packs/per capita
20%
120
100
80 California
US-Caliornia
Poly. (California)
60 Poly. (US-Caliornia)
48%
40
20
0
80/ 81/ 82/ 83/ 84/ 85/ 86/ 87/ 88/ 89/ 90/ 91/ 92/ 93/ 94/ 95/ 96/ 97/ 98/ 99/ 00/ 01/ 02/ 03/ 04/ 05/ 06/ 07/ 08/ 09/
81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10
California 160 156 149 142 139 133 128 123 110 102 95 92 86 81 79 76 74 71 62 55 51 48 46 45 45 44 41 41 38 35
US-Caliornia 183 180 173 167 165 161 157 153 147 139 134 130 126 123 123 120 120 117 112 108 104 101 95 92 89 85 82 77 73
Source: Behavioral Risk Factor Surveillance System (BRFSS) 1984-1992, BRFSS and California Adult Tobacco Survey data is combined for
1993-2008. The smoking prevalence is adjusted from 1984 to 1995 to account for the change in smoking prevalence that includes m ore
occasional smokers. The data is weighted to the 2000 California population. California State Board of Equalization (packs sold) and US
Census (population).
Prepared by: California Department of Public Health, California Tobacco Control Program, July 2010.

40. Adult Smoking Prevalence among California
and US (- CA)
1984-2009
30
25
20
Percent
15
10
5
0 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09
CA 25.9 27.7 26.6 22.4 23.7 22.1 20.4 20.2 21.0 19.2 17.6 16.9 17.8 17.4 17.5 17.1 16.3 16.4 15.8 15.4 14.6 14.0 13.3 13.8 13.3 13.1
US-CA 24.0 23.6 23.4 23.1 23.0 23.6 23.5 23.0 21.6 21.3 20.3 20.2 19.1
Source: Behavioral Risk Factor Surveillance System (BRFSS) 1984-1992, BRFSS and California Adult Tobacco Survey data is combined for
1993-2008. The data is weighted to the 2000 California population. State BRFSS data is weighted to 2000 national population based on each states
population.
Note an adjustment was made to address the change of smoking definition in 1996 that included more occasional smokers.
Prepared by: California Department of Public Health, California Tobacco Control Program, March 2010.

41. Change in Smoking Prevalence Among California Adults
by Race/Ethnicity and Gender, 1990-2005
Percent
1990 2005 Decline
Male
African 28.9 21.0 27.3%
American
Non-Hispanic 21.4 16.0 25.2%
White
Hispanic 23.3 16.7 28.3%
Asian/Pacific 21.8 16.1 26.1%
Islander
Female
African 24.2 17.1 29.3%
American
Non-Hispanic 18.5 13.1 29.2%
White
Hispanic 11.7 6.8 41.9%
Asian/Pacific 7.3 6.5 11.0%
Islander

42. Lung and Bronchus Cancer Mortality Rates per 100,000 for
California and the US minus California, age 35 years and
older, 1970 to 2007
140
120
Age-Adjusted Rates per 100,000
100
80
US-CA Age-Adjusted Rates
60
CA Age-Adjusted Rates
40 Poly. (US-CA Age-Adjusted
Rates)
Poly. (CA Age-Adjusted
20 Rates)
0
1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006
Year
Rates are per 100,000 and age adjusted to the 2000 US std population (19 age groups-Census-P25-1130) standard.
Source: California Cancer Registry, California Department of Public Health.
Prepared by the Cancer Surveillance Section, California Cancer Registry.

43. On the edge of a new beginning

44. Tomorrow’s
Manifesto

45. Do work that matters
Price
• Earmarked tax increases
• Minimum price laws
• Tobacco mitigation fees
• Tighten definition of tobacco products
• Ensure equivalent tax on OTP
• Advocate for an encrypted federal tax
stamp

46. Do work that matters
Secondhand Smoke
• Eliminate exemptions & loopholes in
smoke-free local/state/tribal policies
• Expand smoke-free MUH policies
• Expand outdoor smoke-free policies
• Eliminate tobacco use from all acute and
long term health care facility campuses

47. Do work that matters
Tobacco marketing
• Increase tobacco retail density and zoning
policies
• Eliminate tobacco sales where health care
services are provided (e.g., drug stores, grocery
stores, big box stores)
• Use tobacco waste issue to leverage tobacco
marketing policies & healthier community
campaigns
• Maximize use of FDA marketing restrictions
• Aggressively monitor & enforce FDA legislation

48. Do work that matters
Cessation
• Expand partners in motivating & promoting
cessation
• Aggressively promote & encourage use of
cessation benefits
• Systematize use of EMR to promote
cessation & SHS protection

49. Performance Matters

50. Technical assistance powers
social change
• Public health, efforts are more likely to be
successful if scientific evidence is
incorporated into decisions, policies, and
programs.
• While there is evidence about what works,
agencies may not uniformly embrace or
effectively implement control interventions
in a way that produces uniform results.
• TA facilitates rapid dissemination and the
uptake of a single policy to statewide
scale.

51. Report Cards Matter
“We’ve got a lot of threats to
public health in Richmond said
City Councilman Tom Butt who
said both his parents died of
smoking-related illnesses.
We’ve got air pollution
problems. We’ve got high
asthma rates. We’ve got high
diabetes rates. We need to
start getting rid of the ones we
have control over, and this is
one place where we have full
control where we can make a
significant difference in the
health of Richmond residents.”
February 9, 2009

52. Richmond bans smoking in
MUH, July 2009

53. Create heath equity
Two criteria to measure every policy
1. “Goodness”: The best attainable goal
that moves public health interests
forward
2. “Fairness” : Achieve the smallest feasible
differences among individuals and
groups

54. Capitalize on the
“responsibility revolution”
• Tobacco control creates value
• 1 million lives saved
• $86 billion in health care costs saved
• Tobacco use is not beneficial to us as a
society, it does not pay the costs
– Tobacco industry causes disease, death, and
it pollutes the environment

55. Efficiency Matters
Adapt Technology

56. Identify positive
deviance….amplify

57. Innovate, but have a path to
scale
• Scale is simply something that is so
pervasive or large enough that it makes a
dent in the problem you are trying to solve
• Success will depend on the ability to
amplify the efforts of individuals so that
small successes can be catalyzed for
broad impact

58. Build sustainable ventures
Sustainability is something that endures
Keys to Sustainability
1. Simple
2. Systematic
3. Adaptable to a broad range of settings
4. Not too many “moving” parts

59. Grasp that marketing has changed
“Today’s marketers lead tribes”

60. Create a culture of collaboration
• Develop the “power of pull”…the ability to
draw out people & resources as needed to
address opportunities & challenges
• Learn from others, adapt & adopt
• Stay close with others working in your field
• Be the first to give when building new
relationships

61. Ideas that Spread Win
“Trapped”: Commercial Image
Award of the Year
California ads on DVDs of 6 movie studios

62. Tomorrow will not be
like yesterday….