1. Tobacco 101 Reducing the Problem of Tobacco Use

2. Our Learning Environment

3. Training Topics Credible Tobacco Control Resources Public Health Approach Comprehensive Programs Strategies for Success

4. Learning Objectives  Find resources and data to help with planning and communication.  Understand the benefits of using credible resources. Credible Tobacco Control Resources

5. Public Health Approach Learning Objectives  Understand the public health approach to tobacco prevention and control.  Know of effective policy interventions to reduce tobacco use.

6. Learning Objectives  Define the components of a comprehensive tobacco prevention and control program.  Understand the elements of science- based tobacco control programs. Comprehensive Programs

7. Strategies for Success Learning Objectives  Understand how to implement strategies to reduce tobacco use in your community.  Understand how to sustain your tobacco control programs long term.

8. Credible Tobacco Control Resources

10. Credible Resources 1998 Master Settlement Agreement (MSA) Tobacco Control and Prevention  Attorneys general of 46 states and the four largest U.S. tobacco companies settled lawsuits against the tobacco industry for recovery of their tobacco- related healthcare costs.  Tobacco companies agreed to cease certain marketing practices.

11. Credible Resources  Provides information on the history of tobacco control.  Discusses prevention and treatment interventions.  Contains a set of tobacco control policies for federal and state governments. Tobacco Control and Prevention

12. Credible Resources Explains —  Which laws are effective in reducing tobacco use.  Which interventions work or do not work.  Cost of interventions.  How to find funds, set priorities, build community support, influence legislators, and more. Source: The Task Force on Community Preventive Services

13. Credible Resources  Evidence-based guide developed to help states plan and establish effective tobacco control programs.  October, 2007 CDC, Office on Smoking and Health Tobacco Control and Prevention

14. State Tobacco Activities Tracking and Evaluation (STATE) System Tobacco Control and Prevention Credible Resources CDC, Office on Smoking and Health

15. Credible Resources: Activity

16. Partners in Tobacco Control

17.  Organizations representing populations with higher than average rates of tobacco use  Not-for-profit organizations  State and local governments  Federal agencies Tobacco Control and Prevention

18. National Networks  National African American Tobacco Prevention Network  The National Latino Tobacco Control Network  Asian Pacific Partners for Empowerment, Advocacy and Leadership  The National LGBT Tobacco Control Network  Break Free Alliance Ending the cycle of tobacco and poverty  National Native Commercial Tobacco Abuse Prevention Network Partners in Tobacco Control Tobacco Control and Prevention Source: National Networks for Tobacco Control and Prevention

19. Selecting Partners: Activity Selecting Partners: Activity

20. Taking a Public Health Approach to Tobacco Control

21. The Public Health Approach  Global tobacco control models: what works in the U.S. and around the world  CDC recommendations for comprehensive programs  Policy interventions  Strategies for success

22. Comprehensive Programs  Public health approach to tobacco control uses environmental approaches to increase the wellbeing of individuals within a community and decrease the rate of mortality and morbidity related to tobacco use.

23. Global Tobacco Control Model

24. MPOWER Six effective policies that reduce tobacco use and foster social change WHO Framework Convention

25. MPOWER M Monitor tobacco use and prevention policies. P Protect people from tobacco smoke. O Offer help to quit tobacco use. W Warn about the dangers of tobacco. E Enforce bans on tobacco advertising, promotion, and sponsorship. R Raise taxes on tobacco.

26. M POWER Monitoring —  Measures the extent of tobacco use.  Ensures the success of the other five policies.  Helps when allocating tobacco control resources.  Shows the effectiveness of tobacco control policies. Monitor tobacco use and prevention policies WHO Framework Convention

27. M P OWER  Protect everyone from secondhand smoke.  Prompt more smokers to quit.  Increase the number of successful quit attempts.  Reduce the number of cigarettes smoked.  Discourage kids from starting to smoke. Protect people from tobacco smoke WHO Framework Convention

28. Smoke-Free Environments are Popular WHO Framework Convention

29. MP O WER  Incorporate stop-smoking programs into primary care  Set up quit lines  Provide pharmacological treatment  Look for government support for treatment of tobacco dependence Offer help to quit tobacco use WHO Framework Convention

30. MPO W ER Warn about the dangers of tobacco  Educate everyone about the risks of tobacco use.  Change the image of tobacco use (not “cool”).  Print warnings with graphic pictures of the results of tobacco use on cigarette packs. WHO Framework Convention

31. Graphic Warnings on Cigarette Packs WHO Framework Convention

32. MPOW E R  Regulate tobacco industry (no advertising, marketing, promoting, or sponsoring).  Enforce bans on marketing tobacco.  Enforce bans on tobacco companies’ sponsoring events. Enforce bans on tobacco advertising, promotion, and sponsorship WHO Framework Convention

33. MPOWE R  Taxation is the best way to cut tobacco use.  Higher taxes increase government revenue.  Higher taxes help the young and the poor.  Excise taxes are most effective at reducing tobacco use. Raise taxes on tobacco WHO Framework Convention

34. Global Tobacco Control  Tobacco prevention and control is a health priority worldwide.  MPOWER, when implemented and enforced, will  Prevent young people from smoking.  Help current smokers quit.  Protect nonsmokers from secondhand smoke WHO Framework Convention

35. CDC Recommendations for Comprehensive Programs

36. Comprehensive Programs CDC, Office on Smoking and Health

37. Comprehensive Programs CDC Best Practices CDC, Office on Smoking and Health

38. Comprehensive Programs 1.Prevent the initiation of tobacco use among young people. 2.Promote quitting among young people and adults. 3.Eliminate nonsmokers’ exposure to secondhand smoke. 4.Identify and eliminate the disparities related to tobacco use and its effects among different population groups. CDC Best Practices: Four Goals

39. Comprehensive Programs 1.State and community interventions 2.Interventions through health communications 3.Cessation programs 4.Surveillance and evaluation 5.Administration and management CDC, Office on Smoking and Health CDC Best Practices

40. Comprehensive Programs CDC Recommended Annual Investment13.9 million Deaths in Delaware Caused by Smoking Annual average smoking attributable deaths1,200 Youth ages 0-17 projected to die from smoking18,000 Annual Costs incurred in Delaware from Smoking Total medical$284 million Medicaid medical$79 million Lost productivity from premature death$304 million State revenue from Tobacco Excise Taxes and Settlement FY 2006 tobacco tax revenue$86.1 million FY 2006 tobacco settlement payment$23.1 million Total state revenue from tobacco excise taxes and Settlement$109.2 million Percent revenue to fund at CDC recommended level13% CDC Best Practices

41. Comprehensive Programs Year CDC: National Center for Chronic Disease Prevention & Health Promotion, BRFSS Massachusetts - Percentage Current Adult Smokers Percentages

42. Percentages CDC: National Center for Chronic Disease Prevention & Health Promotion, BRFSS. Missouri - Percentage Current Adult Smokers Comprehensive Programs Year

43. Funding of State Tobacco Control Programs (2008) A Decade of Broken Promises: The 1998 State Tobacco Settlement Ten Years Later

44. Tobacco is now the world’s leading killer. We have the proven means to reduce tobacco use, but policy-makers are not yet applying these interventions. Michael R. Bloomberg, Mayor of New York City

45. Effective Policy Interventions  Increase excise taxes.  Enact smoke-free laws.  Offer quit services.

46. I NCREASE E XCISE T AXES

47. Trends in sale of cigarettes and price of cigarettes (U.S. 1970-2005) Source: Robert Wood Johnson ImpactTeen Tobacco Chart Book

48. Trends in Smoking by Young People and Price of Cigarettes (U.S. 1991-2007) Source: Robert Wood Johnson ImpactTeen Tobacco Chart Book

49. Effect of Federal Tobacco Tax Increase Source: Free and Clear, Inc. Tax increased from 62 cents to $1.01 per pack on April 1, 2009 National Jewish Health quit lineCalls tripled Arkansas (number of calls per week) Jan 2009: 550 Mar 2009: >2000 calls Free and Clear (operator of quit lines in 17 states) 3250 calls on April 1, 2009 (date of tax increase) 369% increase in calls on Apr 1, 2009 over April 1, 2008

50. Source: Robert Wood Johnson ImpactTeen Tobacco Chart Book

51. E NACT S MOKE -F REE L AWS

52. Effects of Smoke-free Laws Smoke-free laws do NOT hurt business. They —  Protect everyone from secondhand smoke.  Prompt many smokers to quit.  Increase the number of successful quit attempts.  Reduce the number of cigarettes smoked.  Discourage kids from starting to smoke.

53. O FFER Q UIT S ERVICES

54. Comprehensive Programs Help Adult Smokers Quit Massachusetts: Cut adult smoking by 21% from 1993 to 2000 California: Cut adult smoking by 35% from 1988 to 2007 Maine: Cut adult smoking by 12.5% from 2001 to 2004 Washington: Cut adult smoking by 30% from 1999 to 2008 New York: Cut adult smoking by 22.6% from 2000 to 2008 Source: Campaign for Tobacco-Free Kids

55. Comprehensive Programs Reduce Youth Smoking Ohio: Cut high school smoking by 45% from 1999 to 2003 Washington: Cut youth smoking by 50% from 2000 to 2006 Maine: Cut high school smoking by 64% from 1997 to 2007 Mississippi: Cut smoking among public middle school students by 48% in 5 years Indiana: Cut high school smoking by 42% from 2000 to 2008 Source: Campaign for Tobacco-Free Kids

56. We Know What Works  New York’s combined comprehensive approach  Excise tax increases: State: 55¢ in March 2000 and 39¢ in April 2002 State: 55¢ in March 2000 and 39¢ in April 2002 City: $1.42 in July 2002 City: $1.42 in July 2002  Smoke-free workplace laws enacted: City on March 20, 2003 City on March 20, 2003 State on July 24, 2003 State on July 24, 2003 With the help of quit services, smoking in NYC declined substantially.

57. City and State Combined Comprehensive Approach Adult smokers in NYC declined by 15% in just 2 years. That’s 188,000 fewer smokers.

58. Increase to $1.11 per pack on 3/1/00 State smoke-free law went into effect on 7/24/03 City cigarette tax increase to $1.50 per pack on 7/2/02 State cigarette tax increase to $1.50 per pack on 4/3/02 City smoke-free law went into effect on 3/30/03 NY Youth Smoking Rates City and State Combined Comprehensive Approach

59. We must become the change we want to see. Mahatma Gandhi

60. Strategies for Success

61.  Implementing tobacco control programs locally is a process that requires community members’ time and effort. 1.Engage stakeholders. 2.Develop a strategic plan. 3.Implement the program. 4.Evaluate the program. 5.Sustain programs.

62. Strategies for Success Engaging Stakeholders

63. Strategies for Success  Community mobilization “is the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the wellbeing of those people.” Engaging Stakeholders Fawcett et al., 1995

64. Strategies for Success Parent Organizations Parent Organizations Business Community Business Community Tribal Councils Tribal Councils Faith-Based Organizations Faith-Based Organizations Neighborhood Associations Neighborhood Associations Teachers and Other Education Professionals Teachers and Other Education Professionals Community Mobilization (State and Local) Concerned Citizens Concerned Citizens Community Leaders Community Leaders Youth Groups Youth Groups Local Boards of Health Local Boards of Health Local Health Departments Local Health Departments Professional Associations Professional Associations Medical Community Medical Community Engaging Stakeholders

65. Strategies for Success Engaging Stakeholders

66. Strategies for Success

67.  Strategic plans are roadmaps to your organization’s destination.  Strategic plans include (among other items)—  Set of goals and objectives.  Strategies for achieving the goals.  Funding sources.  Evaluation methods. Developing a Strategic Plan

68. Strategies for Success Implementing the Program

69. Strategies for Success Evaluating the Program

70. Comprehensive Programs Sustaining State Programs for Tobacco Control: Sustaining the Program

71. Comprehensive Programs COLORADO Sustaining the Program: A Success Story

72. Sustaining the Program Examples of Hindrances to Adequate Funding:  Lobbying by tobacco companies.  Political climate of “hands-off” approach to government.  State budget deficits. Comprehensive Programs

73. Overcoming Funding Difficulties  Have a well-written strategic plan that partners and politicians can easily buy into.  Always look out for new sources of funding.  Follow procedures in Best Practices.  Have diverse, skilled, and active leaders.  Evaluate your program, so you have evidence of success. Sustaining the Program Comprehensive Programs

74. Strategies for Success CDC’s Best Practices for Comprehensive Tobacco Control Programs Centers for Disease Control and Prevention, Office on Smoking and Health

75. Strategies for Success Preventing Initiation among Youth and Young Adults

76. Strategies for Success Preventing Initiation among Youth and Young Adults

77. www.thetruth.com Preventing Initiation among Youth and Young Adults Strategies for Success

79. Promoting Quitting Among Adults and Youth

80. Strategies for Success Each Year:  70% of U.S. smokers report a desire to quit.  Almost 50% of people who have ever smoked have quit. Quitting often requires several attempts over a span of a few years. Promoting Quitting Among Adults and Youth CDC, Office on Smoking and Health

81.  Smoke-free policies motivate smokers to quit. Strategies for Success Promoting Quitting Among Adults and Youth

82. The Health Consequences of Smoking, Surgeon General’s Report, 2006 Strategies for Success   Quitting smoking has immediate and long-term benefits, reducing risks for diseases caused by smoking and improving health in general. Promoting Quitting Among Adults and Youth

83. Comprehensive approaches use a combination of these options and are systems-based: ♦ Brief clinical interventions ♦ Counseling ♦ Nicotine replacement therapy (NRT) ♦ Prescription NRT and medication Science-Based Treatment Options Strategies for Success Promoting Quitting Among Adults and Youth

84. Effective cessation outreach should include —  Payment by a third party (Managed care organization or health insurance).  Communication through multiple means.  Training for health care providers.  Worksite and health center programs. Strategies for Success Promoting Quitting Among Adults and Youth

85. Strategies for Success Successful strategies:  Increasing the unit price for tobacco products.  Organizing mass media campaigns in combination with other interventions.  Reducing smokers’ out-of-pocket costs for cessation therapies.  Multi-component interventions that include telephone support. Promoting Quitting Among Adults and Youth

86. Strategies for Success Clinical Practice Guideline “Treating Tobacco Use and Dependence” Provides recommendations for brief and intensive clinical interventions and implementing effective treatment programs. Promoting Quitting Among Adults and Youth

87. Strategies for Success Eliminating Exposure to Secondhand Smoke

88. What are the benefits of a smoke-free environment? Strategies for Success: Smoke-free Air

89. Strategies for Success Regulatory Efforts  Mandated by ordinance  Legal consequences for noncompliance  Consistent and permanent for locality  Precedent set by other localities  Campaign target: city councils and mayors Voluntary Efforts  Not mandated  No consequences for noncompliance  Useful as educational campaign  Can be used against passing regulations  Campaign target: restaurants and businesses Americans for Nonsmokers’ Rights Eliminating Exposure to Secondhand Smoke

90. Strategies for Success: Smoke-free Air What has been successful or unsuccessful in your community?

91. Strategies for Success Start on the local level. Work on a traditional council-based campaign. Develop a written campaign plan. Agree on a bottom line. Reach out. No law is better than a weak or ineffective one. American for Nonsmokers Rights and Tobacco Control Partners Eliminating Exposure to Secondhand Smoke

92. Strategies for Success Eliminating Exposure to Secondhand Smoke Tobacco Technical Assistance Consortium

93. Americans for Nonsmokers’ Rights Smoke-free environments Avoid the “minors only” trap... ♦ Secondhand smoke is dangerous to everyone. ♦ Smoke-free policies are to protect the public and employees. ♦ “Minors only” is difficult to enforce. Strategies for Success Eliminating Exposure to Secondhand Smoke

94. Smoke-free environments Avoid the “ventilation” trap... ♦ No ventilation system can remove the dangers of secondhand smoke. ♦ All employees deserve smoke-free workplace. ♦ Businesses have to make large capital investment. ♦ It will be more difficult to pass stronger legislation in the future. Americans for Nonsmokers’ Rights Strategies for Success Eliminating Exposure to Secondhand Smoke

95. Smoke-Free Environments Avoid the “smoke-free hours” trap...  Employees deserve consistent protection.  Mixed messages lead to confusion and low compliance.  Enforcement becomes difficult and taxing. Strategies for Success Eliminating Exposure to Secondhand Smoke

96. Smoke-Free Environments Avoid the “hardship” trap... ♦ Don’t allow permits, licenses, and tax incentives – they imply financial losses will accompany smoke-free policy. ♦ Smoke-free laws have been shown to increase sales tax income. Strategies for Success Eliminating Exposure to Secondhand Smoke Americans for Nonsmokers’ Rights

97. Strategies for Success Preemption  When a state law conflicts with federal law, the federal law preempts — or trumps — the state law.  When a state law conflicts with a local ordinance, state law preempts the local ordinance. Americans for Nonsmokers’ Rights Eliminating Exposure to Secondhand Smoke

98. Preemption in Tobacco Control Local ordinances (laws) —  Are easier to enact.  Have better compliance and enforcement.  Contribute to societal rejection of tobacco.  Are more difficult for big tobacco to combat. Americans for Nonsmokers’ Rights and National Cancer Network Eliminating Exposure to Secondhand Smoke Strategies for Success

99. “...At the town meeting, we’re almost always killed. At the board of health level, we do better. At the city council level, we do very well. And at the state level we do great.” Eliminating Exposure to Secondhand Smoke

100. Tobacco industry tactics against preemption are REAL. “We introduce legislation of our own to scatter the resources of antis.” From memo by Tina Walls, Vice President, State Government Affairs, Philip Morris. Americans for Nonsmokers’ Rights Strategies for Success Eliminating Exposure to Secondhand Smoke

101. Strategies for Success Identifying and Eliminating Disparities

102. Strategies for Success Questions to ask yourselves:  How do we plan to reach out to populations with tobacco-related disparities?  Who from those populations can serve as spokespersons?  What activities and program strategies are effective with each of these populations? Identifying and Eliminating Disparities

103. To make a difference is not a matter of accident, a matter of casual occurrence of the tides. People choose to make a difference. Maya Angelou

104. Communities of Excellence Restrictions on tobacco ads Identifiable tobacco control funds/staff High taxes on tobacco No sales of tobacco to minors Public education campaigns Cessation services Tobacco-free public places and worksites Detailed plan of action Monitor & counter tobacco influence Tobacco-free school campuses Communities of Excellence Plus in Tobacco Control

105. Conclusion We know what works... What works are comprehensive programs that use a public health approach:  Increase excise taxes on tobacco.  Enact and enforce smoke-free air laws.  Provide systems-based cessation services. When we apply what we know works...we can realize our own potential.

106. Review

107. Public Health Approach  Locate resources and data to help with planning and communication.  Understand the benefits of using credible resources.  Understand the public health approach to reducing tobacco use.  Know of effective policy interventions. Review Credible Tobacco Control Resources

108. Comprehensive Programs Strategies for Success  Define the components of a comprehensive tobacco prevention and control program.  Understand elements of science-based tobacco control programs. Review  Understand how to implement strategies at the community level for successful outcomes.  Understand how to sustain your tobacco control programs.

109. Tobacco Technical Assistance Consortium Rollins School of Public Health Emory University Atlanta, Georgia To Contact: ttac@sph.emory.edu Phone: 404-712-8474