1. Texas Department of State Health Services
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.
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.

3. Tobacco = Problem In Comparison,
Every two and a half days, tobacco’s death toll on Americans equals the number of deaths from the terrorist attacks on September 11, 2001.
In 2006, alcohol-related car wrecks claimed the lives of 1,677 Texans. Tobacco kills more Texans each month.

4. Texas Preventable Deaths, 2001
24,899
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. Former U.S. Surgeon General
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 Tobacco – Products & Chemistry
The Tobacco Industry
Health Effects
Tobacco Laws
Pro-Health Initiatives
The Awareness Class
Best Practices for Schools

7. Tobacco’s Human Toll 9.5% middle school students smoke.
24.7% of high school students smoke.
18.1% of adults smoke.
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. Tobacco’s Economic Toll
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
Each pack of cigarettes sold costs the United States $10.28 in health care related costs and lost productivity.

9. Big Tobacco’s Spending
$13.36 billion – tobacco industry marketing expenditures nationwide in 2005.
$884.7 million – estimated portion spent in Texas for marketing in 2005.
$37.63 for every Texas resident
$28.05 every second
$254,500 – political contributions, ‘01-’06
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

14. Tobacco Use by Race

15. Tobacco Use by DSHS Region

16. Tobacco Use by DSHS Region

17. Tobacco Use by Grade

18. Texas Synar Rates Federal Tobacco Sales Inspection

19. How Youth Get Tobacco 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:
Borrowed
Bought in store & not asked for ID

20. Youth Cessation 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:
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.)
Enters the blood stream and travels to brain in less than 10 seconds.
Affects brain cells responsible for memory and mood control.
Stays active for minutes.

22. Nicotine Immediate Effects: Long-term Effects: Increased heart rate
Blood vessels constrict
Lower skin temperature
“Head rush”
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
Norepinephrine – arousal, appetite suppression
Acetylcholine – arousal, cognitive enhancement
Vasopressin – memory improvement
Serotonin – mood modulation, appetite suppression
Beta-endorphin – reduction of anxiety and tension

24. What do tobacco companies think of kids?
Philip Morris: “Today’s teenager is tomorrow’s 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 .…”

25. What do tobacco companies think of kids?
Brown & Williamson: “Kool’s 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.”
U.S. Tobacco: “Cherry Skoal is for somebody who likes the taste of candy, if you know what I’m saying.”

26. Tobacco Marketing
Tobacco companies spent $13.36 billion on U.S. advertising in 2005.
$25,419 per minute
$ per second
DSHS marketing budget for 2006
$1.5 million for settlement area
$730,000 for statewide media
$4.24 per minute (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.
How’s 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.
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.

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.
Campaign originated in early 1960s.
Images of masculinity and rugged individualism appeal to adolescents struggling to define themselves.
Originally marketed as a woman’s cigarette.

32. Joe Camel – R.J. Reynolds
Introduced in Voluntarily removed from market in 1997.
During campaign, Camel’s share of the children’s cigarette market increased from less than 1% to more than 32% by 1993.
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.
Most sellers fail to pay taxes.
Most do not enforce or ignore age requirements.
Texas and Maine regulate tobacco sales over the Internet; New York and Connecticut ban it completely.

34. Health Effects – Short Term
Shortness of breath
Smell in hair and clothes
Discolored teeth and skin
Avoided by non-smokers
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
Heart Disease
Cerebrovascular Accidents (stroke)
Chronic Bronchitis
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.
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 15 years, risk of heart disease is that of a non-smoker.

38. Withdrawal Symptoms 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
Mental Health & Substance Abuse Services
Tobacco settlement initiative
Statewide programs for prevention & control
Synar inspections
Alcohol, tobacco and other drugs prevention & treatment
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
Sherri Scott, Canyon
Region 2/3 – North Texas
Betty Boenisch, Arlington
Region 4/5 – East Texas
Lana Herriman & Dreka Strickland, Tyler
Region 6/5 – Southeast Texas
Debbie Melecio, Houston
Region 7 – Central Texas
Sylvia Barron & Lance Starzyck, Temple
Region 8 – South Texas
Rick Meza, San Antonio
Region 9/10 – West Texas
Becky Zima & Sandra Herrera, El Paso
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 38.006 (passed 1995)
The board of trustees of a school district shall:
Prohibit smoking or using tobacco products at a school-related or school-sanctioned activity on or off school property;
Prohibit students from possession of tobacco products at a school-related or school-sanctioned activity on or off school property.
Ensure that school personnel enforce the policies on school property.

43. Selling Tobacco Health & Safety Code, Section 161. 081-161
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.
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.

44. Selling Tobacco (cont’d.)
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 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 employers to train employees on tobacco laws.

45. Advertising Tobacco Health & Safety Code, Section 161
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.)
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, 1998.

46. Minor Possession Health & Safety Code, Section 161-252-161
Minor Possession Health & Safety Code, Section (Passed 1997)
Possession and consumption of tobacco products is Class C misdemeanor.
Consequences:
Fine of up to $250;
8-hour tobacco awareness class;
8-12 hours of community service;
6 month loss or delay of driver’s license.

47. Additional Efforts Texas Tobacco Settlement Initiative
Comprehensive tobacco prevention and control effort in Southeast Texas
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

48. Recent Developments
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 number of local secondhand smoke ordinances across state
Statewide smoking ban proposed (but not passed)
2006 U.S. Surgeon General’s report on involuntary exposure to secondhand smoke

49. New Direction From the 80th Legislature
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 $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.

50. New Direction
DSHS and grantees must use only best practice or evidence-based tobacco prevention, cessation, and enforcement interventions.
DSHS or its contractor must notify Comptroller’s tobacco law enforcement grantees and local sheriff’s 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.

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

52. Risk Reduction Secondary prevention
Gain knowledge and skill with each session
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

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.
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.
Some have indicated suicide fantasies and evidence of depression.

55. How does enforcement affect your community?
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
CDC’s 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
CDC’s 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.
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.
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
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.

62. Guidelines for School Health Programs
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.

64. Guidelines for School Health Programs
Evaluation: Assess the tobacco use prevention program at regular intervals. Schools can use CDC’s 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.
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.
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 www. dshs
All Tobacco Deaths Are Preventable Barry Sharp, MSHP, CHES