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Tobacco 101 Barry Sharp, MSHP, CHES Texas Department of State Health Services.

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1 Tobacco 101 Barry Sharp, MSHP, CHES Texas Department of State Health Services

2 Tobacco = Problem Nationally – One person dies every 72 seconds from a tobacco related cause. Nationally – One person dies every 72 seconds from a tobacco related cause. Texas – One person dies every 22 minutes from a tobacco related cause. Texas – One person dies every 22 minutes from a tobacco related cause. 1,140 youth take up smoking every day; one third of them will die from their habit. 1,140 youth take up smoking every day; one third of them will die from their habit.

3 Tobacco = Problem In Comparison, In Comparison, –Every two and a half days, tobaccos death toll on Americans equals the number of deaths from the terrorist attacks on September 11, –In 2006, alcohol-related car wrecks claimed the lives of 1,677 Texans. Tobacco kills more Texans each month.

4 Texas Preventable Deaths, ,899 2,214 1,607 1,405 1,052 18,649 2,851 3,736 11,132 Suicide DWI Tobacco Use Homicide AIDS Overweight/Obesity Drugs Auto Accidents Alcohol Fire 218

5 Tobacco use will remain the leading cause of preventable illness and death in this Nation and a growing number of other countries until tobacco prevention and control efforts are commensurate with the harm caused by tobacco use. David Satcher, MD, PhD Former U.S. Surgeon General Reducing Tobacco Use, A Report Of the Surgeon General

6 Tobacco 101 Prevalence Prevalence Tobacco – Products & Chemistry Tobacco – Products & Chemistry The Tobacco Industry The Tobacco Industry Health Effects Health Effects Tobacco Laws Tobacco Laws Pro-Health Initiatives Pro-Health Initiatives The Awareness Class The Awareness Class Best Practices for Schools Best Practices for Schools

7 Tobaccos Human Toll 9.5% middle school students smoke. 9.5% middle school students smoke. 24.7% of high school students smoke. 24.7% of high school students smoke. 18.1% of adults smoke. 18.1% of adults smoke. Deaths in Texas from smoking: Deaths in Texas from smoking: –24,200 adults each year –503,000 youth alive today will die prematurely from smoking –2,660 to 4,720 adults, children and babies die from diseases caused by secondhand smoke and pregnancy smoking

8 Tobaccos Economic Toll Texas Economic costs: Texas Economic costs: –$1.6 billion in Medicaid –$5.83 billion overall health costs –$10.3 million in fire loss –$11.7 million in highway trash cleanup –$6.44 billion in lost productivity State and federal tax burden from smoking- caused government expenses - $630 per household State and federal tax burden from smoking- caused government expenses - $630 per household Each pack of cigarettes sold costs the United States $10.28 in health care related costs and lost productivity. Each pack of cigarettes sold costs the United States $10.28 in health care related costs and lost productivity.

9 Big Tobaccos Spending $13.36 billion – tobacco industry marketing expenditures nationwide in $13.36 billion – tobacco industry marketing expenditures nationwide in $884.7 million – estimated portion spent in Texas for marketing in $884.7 million – estimated portion spent in Texas for marketing in –$37.63 for every Texas resident –$28.05 every second $254,500 – political contributions, $254,500 – political contributions, –1 of 2 U.S. Senators from Texas –23 of 32 U.S. Representatives from Texas

10 Middle School Tobacco Use

11 High School Tobacco Use

12 Boys vs. Girls

13 Tobacco Use by Race

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15 Tobacco Use by DSHS Region

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17 Tobacco Use by Grade

18 Texas Synar Rates Federal Tobacco Sales Inspection

19 How Youth Get Tobacco Methods used by middle school students: Methods used by middle school students: –Gave someone else money to purchase –Borrowed from someone willing to share –Stole (often from parents) –Other (i.e. Internet) Methods used by high school students: Methods used by high school students: –Gave someone else money to purchase –Borrowed –Bought in store & not asked for ID –Other (i.e. Internet)

20 Youth Cessation More than half of youth smokers: More than half of youth smokers: –Tried to quit in the past 12 months –Want to completely stop smoking –Tried to quit at least twice About 8 of 10 current youth smokers: About 8 of 10 current youth smokers: –Think they would be able to quit smoking if they wanted.

21 Nicotine Naturally occurring addictive substance. Created by nature as an insecticide. (Commercial use banned by EPA.) Naturally occurring addictive substance. Created by nature as an insecticide. (Commercial use banned by EPA.) Enters the blood stream and travels to brain in less than 10 seconds. Enters the blood stream and travels to brain in less than 10 seconds. Affects brain cells responsible for memory and mood control. Affects brain cells responsible for memory and mood control. Stays active for minutes. Stays active for minutes.

22 Nicotine Immediate Effects: Immediate Effects: –Increased heart rate –Blood vessels constrict –Lower skin temperature –Head rush Long-term Effects: Long-term Effects: –High blood pressure –Blockage of blood vessels –Reduced effectiveness of immune system –Wrinkling of skin

23 Effects on the Brain Dopamine – pleasure, appetite suppression Dopamine – pleasure, appetite suppression Norepinephrine – arousal, appetite suppression Norepinephrine – arousal, appetite suppression Acetylcholine – arousal, cognitive enhancement Acetylcholine – arousal, cognitive enhancement Vasopressin – memory improvement Vasopressin – memory improvement Serotonin – mood modulation, appetite suppression Serotonin – mood modulation, appetite suppression Beta-endorphin – reduction of anxiety and tension Beta-endorphin – reduction of anxiety and tension

24 What do tobacco companies think of kids? Philip Morris: Todays teenager is tomorrows potential regular customer…. Philip Morris: Todays teenager is tomorrows potential regular customer…. RJ Reynolds: …the year old group is an increasing segment of the smoking population. RJR-T must soon establish a successful new brand in this market.… RJ Reynolds: …the year old group is an increasing segment of the smoking population. RJR-T must soon establish a successful new brand in this market.…

25 Brown & Williamson: Kools stake in the 16- to 25-year-old population segment is such that the value of this audience should be accurately weighted and reflected in current media programs... all magazines will be reviewed to see how efficiently they reach this group. Brown & Williamson: Kools stake in the 16- to 25-year-old population segment is such that the value of this audience should be accurately weighted and reflected in current media programs... all magazines will be reviewed to see how efficiently they reach this group. Lorillard Tobacco: The base of our business is the high school student. Lorillard Tobacco: The base of our business is the high school student. U.S. Tobacco: Cherry Skoal is for somebody who likes the taste of candy, if you know what Im saying. U.S. Tobacco: Cherry Skoal is for somebody who likes the taste of candy, if you know what Im saying. What do tobacco companies think of kids?

26 Tobacco Marketing Tobacco companies spent $13.36 billion on U.S. advertising in Tobacco companies spent $13.36 billion on U.S. advertising in –$25,419 per minute –$ per second DSHS marketing budget for 2006 DSHS marketing budget for 2006 –$1.5 million for settlement area –$730,000 for statewide media $4.24 per minute (total for both campaigns) $4.24 per minute (total for both campaigns) 7 cents per second (total for both campaigns) 7 cents per second (total for both campaigns)

27 Tobacco Marketing During the 22-minute interval between the deaths of Texans from tobacco-related causes, the tobacco industry will spend more than $37,000 in Texas to make their products appealing in order to replace their dying customers. During the 22-minute interval between the deaths of Texans from tobacco-related causes, the tobacco industry will spend more than $37,000 in Texas to make their products appealing in order to replace their dying customers. Hows that as a reward for customer loyalty? Hows that as a reward for customer loyalty?

28 Tobacco Marketing

29 U.S. Cigarette Consumption ( In billions of individual cigarettes)

30 Does Marketing Work? 81.3 percent of youth (12-17) smokers prefer Marlboro, Camel and Newport – three heavily advertised brands percent of youth (12-17) smokers prefer Marlboro, Camel and Newport – three heavily advertised brands. Marlboro, the most heavily advertised brand, constitutes almost 50 percent of the youth market but only about 40 percent of smokers over age 25. Marlboro, the most heavily advertised brand, constitutes almost 50 percent of the youth market but only about 40 percent of smokers over age 25. Youth recall seeing tobacco ads almost 3:1 over adults. Youth recall seeing tobacco ads almost 3:1 over adults.

31 Marlboro Man - Altria Most successful and longest running campaign in tobacco advertising history. Honored by AdWeek as one of the top campaigns of the past century. Most successful and longest running campaign in tobacco advertising history. Honored by AdWeek as one of the top campaigns of the past century. Campaign originated in early 1960s. Campaign originated in early 1960s. Images of masculinity and rugged individualism appeal to adolescents struggling to define themselves. Images of masculinity and rugged individualism appeal to adolescents struggling to define themselves. Originally marketed as a womans cigarette. Originally marketed as a womans cigarette.

32 Joe Camel – R.J. Reynolds Introduced in Voluntarily removed from market in Introduced in Voluntarily removed from market in During campaign, Camels share of the childrens cigarette market increased from less than 1% to more than 32% by During campaign, Camels share of the childrens cigarette market increased from less than 1% to more than 32% by Joe Camel was as familiar to 6- year-olds as Mickey Mouse. Joe Camel was as familiar to 6- year-olds as Mickey Mouse.

33 Internet Marketing In 2000, there were 40 web sites selling tobacco. By 2002, the number ballooned to 200 U.S. and 200 foreign web sites. In 2000, there were 40 web sites selling tobacco. By 2002, the number ballooned to 200 U.S. and 200 foreign web sites. Most sellers fail to pay taxes. Most sellers fail to pay taxes. Most do not enforce or ignore age requirements. Most do not enforce or ignore age requirements. Texas and Maine regulate tobacco sales over the Internet; New York and Connecticut ban it completely. Texas and Maine regulate tobacco sales over the Internet; New York and Connecticut ban it completely.

34 Health Effects – Short Term Shortness of breath Shortness of breath Smell in hair and clothes Smell in hair and clothes Discolored teeth and skin Discolored teeth and skin Avoided by non-smokers Avoided by non-smokers Financial costs (Pack/day = $1,700+) Financial costs (Pack/day = $1,700+)

35 Health Effects – Long Term Cancers of the lung, larynx, oral cavity, pharynx, esophagus, bladder, pancreas, uterine, cervix and kidney Cancers of the lung, larynx, oral cavity, pharynx, esophagus, bladder, pancreas, uterine, cervix and kidney Heart Disease Heart Disease Cerebrovascular Accidents (stroke) Cerebrovascular Accidents (stroke) Chronic Bronchitis Chronic Bronchitis Emphysema Emphysema

36 Cessation Smoking cessation is more cost effective than other commonly provided clinical preventive services, including mammography, colon cancer screening, PAP tests, treatment of mild to moderate hypertension and treatment of high cholesterol.

37 Benefits of Quitting Begin within 20 minutes of quitting. Begin within 20 minutes of quitting. Within 1 year, risk of heart disease is half that of a smoker. Within 1 year, risk of heart disease is half that of a smoker. Within 5 years, risk of cancers of lung, mouth and esophagus are half that of a smoker. Within 5 years, risk of cancers of lung, mouth and esophagus are half that of a smoker. Within 15 years, risk of heart disease is that of a non-smoker. Within 15 years, risk of heart disease is that of a non-smoker.

38 Withdrawal Symptoms Withdrawal Symptoms can include: Withdrawal Symptoms can include: –Nervousness –Irritability, anger and frustration –Lack of concentration –Depression –Increased appetite and weight gain –Insomnia, restlessness

39 The Texas Tobacco Players Texas Department of State Health Services Texas Department of State Health Services –Mental Health & Substance Abuse Services Tobacco settlement initiative Tobacco settlement initiative Statewide programs for prevention & control Statewide programs for prevention & control Synar inspections Synar inspections Alcohol, tobacco and other drugs prevention & treatment Alcohol, tobacco and other drugs prevention & treatment Comptroller of Public Accounts Comptroller of Public Accounts –Cigarette & tobacco retailer permits/taxes –Enforcement & criminal investigation –Grants to law enforcement agencies

40 Texas Department of State Health Services Tobacco Staff Region 1 – Panhandle Region 1 – Panhandle –Sherri Scott, Canyon Region 2/3 – North Texas Region 2/3 – North Texas –Betty Boenisch, Arlington Region 4/5 – East Texas Region 4/5 – East Texas –Lana Herriman & Dreka Strickland, Tyler Region 6/5 – Southeast Texas Region 6/5 – Southeast Texas –Debbie Melecio, Houston Region 7 – Central Texas Region 7 – Central Texas –Sylvia Barron & Lance Starzyck, Temple Region 8 – South Texas Region 8 – South Texas –Rick Meza, San Antonio Region 9/10 – West Texas Region 9/10 – West Texas –Becky Zima & Sandra Herrera, El Paso Region 11 – Rio Grande Valley Region 11 – Rio Grande Valley –Martha Gonzalez, Harlingen

41 Legislative Interventions While prevention is always the best method, and is a key focus of the Texas Department of State Health Services and other anti-tobacco advocates, kids are still using tobacco products. The Texas Legislature in the 1990s passed two major bills aimed at curbing tobacco abuse by minors.

42 Tobacco at Schools Education Code, Section (passed 1995) The board of trustees of a school district shall: 1)Prohibit smoking or using tobacco products at a school-related or school-sanctioned activity on or off school property; 2)Prohibit students from possession of tobacco products at a school-related or school- sanctioned activity on or off school property. 3)Ensure that school personnel enforce the policies on school property.

43 Selling Tobacco Health & Safety Code, Section Tax Code, Sections , , , , – ( Passed 1899, Modified 1989, 1997) Maintains existing penalty for store clerks who sell tobacco to a minor. Maintains existing penalty for store clerks who sell tobacco to a minor. Photo identification to verify anyone under the age of 27. Photo identification to verify anyone under the age of 27. Specified signage to include language that it is both illegal to sell to a minor and for minors to purchase tobacco. Specified signage to include language that it is both illegal to sell to a minor and for minors to purchase tobacco.

44 Restricts vending machines and self service sales to places not open to those under the age of 18. Restricts vending machines and self service sales to places not open to those under the age of 18. Prohibits the giveaway of free samples and coupons to anyone under 18. Prohibits the giveaway of free samples and coupons to anyone under 18. Prohibits the sales of cigarettes of less than 20 per package. Prohibits the sales of cigarettes of less than 20 per package. Requires a fee for a retail permit to sell tobacco. Penalty for violations is $500 to $1,000, suspension or revocation of permit. Requires a fee for a retail permit to sell tobacco. Penalty for violations is $500 to $1,000, suspension or revocation of permit. Requires employers to train employees on tobacco laws. Requires employers to train employees on tobacco laws. Selling Tobacco (contd.)

45 Advertising Tobacco Health & Safety Code, Section (Passed 1997) Outdoor advertising is prohibited within 1,000 feet of a church or school. (Measured along roadways/property lines from sign.) Outdoor advertising is prohibited within 1,000 feet of a church or school. (Measured along roadways/property lines from sign.) Cigarette advertising is in limbo due to Supreme Court ruling in Lorrilard Tobacco Co. et al v. Reilly, Attorney General of Massachusetts, et al. Cigarette advertising is in limbo due to Supreme Court ruling in Lorrilard Tobacco Co. et al v. Reilly, Attorney General of Massachusetts, et al. Texas Tobacco Settlement prohibits tobacco billboards since June 24, Texas Tobacco Settlement prohibits tobacco billboards since June 24, 1998.

46 Minor Possession Health & Safety Code, Section (Passed 1997) Possession and consumption of tobacco products is Class C misdemeanor. Possession and consumption of tobacco products is Class C misdemeanor. Consequences: Consequences: –Fine of up to $250; –8-hour tobacco awareness class; –8-12 hours of community service; –6 month loss or delay of drivers license.

47 Additional Efforts Texas Tobacco Settlement Initiative Texas Tobacco Settlement Initiative –Comprehensive tobacco prevention and control effort in Southeast Texas Community coalition building and technical assistance Community coalition building and technical assistance –TDH regional staff throughout the state State level partnerships with other stakeholders agencies seeking synergistic outcomes through collaborative efforts State level partnerships with other stakeholders agencies seeking synergistic outcomes through collaborative efforts

48 Recent Developments Increase in the state cigarette tax to $1.41 per pack Increase in the state cigarette tax to $1.41 per pack Increased compliance with youth tobacco laws (7.2% Synar buy rate for 2006) Increased compliance with youth tobacco laws (7.2% Synar buy rate for 2006) Increased number of local secondhand smoke ordinances across state Increased number of local secondhand smoke ordinances across state Statewide smoking ban proposed (but not passed) Statewide smoking ban proposed (but not passed) 2006 U.S. Surgeon Generals report on involuntary exposure to secondhand smoke 2006 U.S. Surgeon Generals report on involuntary exposure to secondhand smoke

49 New Direction From the 80 th Legislature Create competitive statewide grant program allowing health departments and school districts in communities statewide to apply for funds. Create competitive statewide grant program allowing health departments and school districts in communities statewide to apply for funds. Dedicate $3 million in tobacco settlement funds to the Texas Education Agency for tobacco education in schools statewide. Dedicate $3 million in tobacco settlement funds to the Texas Education Agency for tobacco education in schools statewide. Dedicate $1 million for smokeless tobacco prevention in rural communities. Dedicate $1 million for smokeless tobacco prevention in rural communities. Produce resource list identifying best practice and evidence-based interventions for use by organizations receiving state appropriated funds. Produce resource list identifying best practice and evidence-based interventions for use by organizations receiving state appropriated funds.

50 New Direction DSHS and grantees must use only best practice or evidence-based tobacco prevention, cessation, and enforcement interventions. DSHS and grantees must use only best practice or evidence-based tobacco prevention, cessation, and enforcement interventions. DSHS or its contractor must notify Comptrollers tobacco law enforcement grantees and local sheriffs departments in writing when Synar violations occur during the annual survey. DSHS or its contractor must notify Comptrollers tobacco law enforcement grantees and local sheriffs departments in writing when Synar violations occur during the annual survey. DSHS must prepare a report on the progress of the program to the legislature. DSHS must prepare a report on the progress of the program to the legislature.

51 Texas Youth Tobacco Awareness Program Goal is behavior modification, not punishment Goal is behavior modification, not punishment Intended for year olds Intended for year olds Program delivered in 8 hours in four two-hour sessions over two weeks Program delivered in 8 hours in four two-hour sessions over two weeks Small Class size, 20 participants maximum (10-12 ideal) Small Class size, 20 participants maximum (10-12 ideal) Sessions are activity oriented Sessions are activity oriented

52 Risk Reduction Secondary prevention Secondary prevention –Gain knowledge and skill with each session Awareness and behavioral disruption Awareness and behavioral disruption –Challenges participants to make changes in tobacco use behaviors –Meets mandate of Senate Bill 55 Focus is on long-term cessation Focus is on long-term cessation

53 TYTAP Students About 20% of the youth say their primary supplier of tobacco is their parents. They also state that parents can be a big help in quitting. About 20% of the youth say their primary supplier of tobacco is their parents. They also state that parents can be a big help in quitting. Social support is essential for youth desiring to quit. They need encouragement and understanding from a variety of social sources. Social support is essential for youth desiring to quit. They need encouragement and understanding from a variety of social sources.

54 TYTAP Students Many youth are engaging in a variety of risky behaviors, not just tobacco use. Drawings and writings in the workbooks indicate a substantial number are involved in poly-drug use, including alcohol & illegal drugs. Many youth are engaging in a variety of risky behaviors, not just tobacco use. Drawings and writings in the workbooks indicate a substantial number are involved in poly-drug use, including alcohol & illegal drugs. Some have indicated suicide fantasies and evidence of depression. Some have indicated suicide fantasies and evidence of depression.

55 How does enforcement affect your community? A study of tobacco enforcement in Illinois showed: A study of tobacco enforcement in Illinois showed: –Enforcing tobacco laws led to a decrease in youth tobacco abuse and retail sales. –Enforcing tobacco laws led to a decrease in other drug offenses. –Enforcing tobacco laws led to a decrease in overall juvenile crime.

56 Guidelines for School Health Programs CDCs Guidelines for School Health Programs to Prevent Tobacco Use and Addiction. CDCs Guidelines for School Health Programs to Prevent Tobacco Use and Addiction. –Prohibit tobacco use at all school facilities and events. –Encourage and help students and staff to quit using tobacco. –Provide developmentally appropriate instruction in grade K-12 that address social and psychological causes of tobacco use.

57 Guidelines for School Health Programs CDCs Guidelines continued: CDCs Guidelines continued: –Provide developmentally appropriate instruction in grade K-12 that address social and psychological causes of tobacco use. –Part of a coordinated school health program. –Reinforced by community efforts.

58 Guidelines for School Health Programs Policy: Develop and enforce school policy developed in collaboration with all stakeholders. Policy: Develop and enforce school policy developed in collaboration with all stakeholders. –Prohibit tobacco use –Prohibit tobacco advertising –Students receive instruction –Access to cessation programs –Help violators quit rather than punish

59 Guidelines for School Health Programs Instruction: Short & long term negative physiologic and social consequences, social influences, peer norms and refusal skills. Instruction: Short & long term negative physiologic and social consequences, social influences, peer norms and refusal skills. –Decrease social acceptability –Understand why people start and identify more positive activities –Developed skills in assertiveness, goal setting, problem solving and resisting pressure from media and peers.

60 Guidelines for School Health Programs Curriculum: Provide prevention education in grade K-12 Curriculum: Provide prevention education in grade K-12 –Instruction should begin in elementary and intensify in middle/junior high when exposure to older students increases initiation rates. –Reinforce throughout high school years.

61 Guidelines for School Health Programs Training: Provide program-specific training on tobacco use prevention for teachers. The training should include reviewing curriculum, modeling instructional activities, and providing opportunities to practice implementing lessons. Well trained peer leaders can be an important adjunct to teacher-led instruction. Training: Provide program-specific training on tobacco use prevention for teachers. The training should include reviewing curriculum, modeling instructional activities, and providing opportunities to practice implementing lessons. Well trained peer leaders can be an important adjunct to teacher-led instruction.

62 Guidelines for School Health Programs Family Involvement: Involve parents or families in supporting school-based programs to prevent tobacco use. Family Involvement: Involve parents or families in supporting school-based programs to prevent tobacco use. –Promote discussions at home about tobacco use by assigning homework and projects that involve families. –Encourage parents to participate in community efforts to prevent tobacco use and addiction.

63 Guidelines for School Health Programs Tobacco-Use Cessation Efforts: Support cessation efforts among students and school staff who use tobacco. Schools should provide access to cessation programs that help students and staff stop using tobacco rather than punishing them for violating tobacco use policies. Tobacco-Use Cessation Efforts: Support cessation efforts among students and school staff who use tobacco. Schools should provide access to cessation programs that help students and staff stop using tobacco rather than punishing them for violating tobacco use policies.

64 Guidelines for School Health Programs Evaluation: Assess the tobacco use prevention program at regular intervals. Schools can use CDCs Guidelines for School Health Programs to Prevent Tobacco Use and Addiction to assess whether they are providing effective policies, curricula, training, family involvement and cessation. Evaluation: Assess the tobacco use prevention program at regular intervals. Schools can use CDCs Guidelines for School Health Programs to Prevent Tobacco Use and Addiction to assess whether they are providing effective policies, curricula, training, family involvement and cessation.

65 Summary Tobacco by itself is a dangerous, addictive and deadly substance. Tobacco by itself is a dangerous, addictive and deadly substance. Youth tobacco use is tied to a number of major short and long term health hazards, including substance abuse. Youth tobacco use is tied to a number of major short and long term health hazards, including substance abuse. Enforcement can lead to getting youth help with tobacco abuse and other health threats. Enforcement can lead to getting youth help with tobacco abuse and other health threats. Solutions involve all community partners and institutions coming together in a collaborative and comprehensive approach. Solutions involve all community partners and institutions coming together in a collaborative and comprehensive approach.

66 Questions? Discussion?

67 All Tobacco Deaths Are Preventable Barry Sharp, MSHP, CHES


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