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© 2001 American Society for Clinical Oncology
California as a ModelByFrom the Cancer Control Branch, California Department of Health Services, Sacramento, CA. Address reprint requests to Dileep G. Bal, MD, Cancer Control Branch, California Department of Health Services, PO Box 942732, MS-662, Sacramento, CA 94234-7320; email: dbal{at}dhs.ca.gov
ABSTRACT: One of every three persons who starts smoking falls ill and dies prematurely because he or she smoked. Smoking has been causally linked to heart disease, cancer, and respiratory diseases and continues to be the number one preventable cause of death in this country. To prevent these deaths and the incidence of these diseases, California’s Tobacco Control Program was established in 1989 specifically to reduce tobacco use in the state. The strategy of the program is to "denormalize" tobacco. This strategy emphasizes three areas of programmatic activity: to counter pro-tobacco influences, to reduce exposure to environmental tobacco smoke, and to reduce access to tobacco products, with a focus on both social and commercial sources. A fourth priority area, cessation, is considered more of an outcome. California’s Tobacco Control Program has touched the life of every Californian. Adult smoking prevalence in the state has gone from approximately 11% lower than the rest of the nation in 1988 to 20% lower in 1996. There are now approximately one million fewer smokers in California than would have been expected. Overall, per capita cigarette consumption has fallen by more than 50%. Seventy percent of adult smokers reported that they tried to quit in the last year. Exposure to secondhand smoke has plummeted. California’s lung and bronchus cancer incidence is already declining at a significantly higher rate than that seen elsewhere in the nation. Youth smoking rates have also declined significantly. However, contrary to the message of its massive public relations campaign, the tobacco industry has not changed its stripes after the national tobacco settlement. They are still aggressively marketing their products to teenagers, ethnic minority groups, and young adults. They need to be combated with renewed vigor by a vigilant health community.
THE STATEWIDE ANTI-tobacco use campaign implemented by the California Department of Health Services (CDHS) represents one of the largest public health interventions of its kind nationally or internationally.1 The underpinnings of the state’s campaign were based on the Standards for Comprehensive Smoking Prevention and Control of the National Cancer Institute, issued in draft form in 1989, which embodied knowledge accumulated over the years. This was extensively modified and retooled over the years as an increasingly knowledgeable staff in CDHS contributed to the evolution of the state of the science and state of the practice of tobacco use prevention and control. California’s Tobacco Control Program (TCP) was established to reduce tobacco use in the state and thus prevent the terrible toll in heart disease, cancer, and respiratory diseases caused by tobacco use.2 This includes the diseases people get as a result of smoking and also the diseases nonsmokers get because they were exposed to the secondhand tobacco smoke produced by smokers. One of every three persons who starts smoking falls ill and dies prematurely because he or she smoked.2 Smoking continues to be the number one preventable cause of death in this country. Tobacco products kill over 450,000 Americans each year—more than all of the deaths from AIDS, alcohol, cocaine, heroin, homicide, suicide, automobile crashes, and fires combined. Another 50,000 or more Americans who never smoked also die each year because of exposure to secondhand tobacco smoke. Tobacco use is a public health problem of epidemic proportions. In response to a successful citizen-led ballot initiative, Proposition 99—which was passed by the California voters in the 1988 general election, despite a $21 million media counterattack by the tobacco industry—the State of California increased taxes levied on cigarettes from 10 cents (one of the lowest in the country) to 35 cents per pack; this represented what was at the time (January 1989) the second-highest state tobacco excise tax in the nation.1 For noncigarette tobacco products, a new tax of 42 cents on the dollar wholesale was levied, with the rate to be set annually by the State Board of Equalization. California’s initiative earmarked the new revenues for tobacco use control, medical care, and research activities. Twenty percent of the new revenues were set aside for programs to reduce tobacco use in California.2 The original statutorily mandated goal of the program was to reduce tobacco use in California by 75% (from the preprogram 1988 level) before the year 2000 and to prevent the exposure of Californians to environmental tobacco smoke (ETS). Since the spring of 1990, when the program was launched, nearly one billion dollars have been expended in support of activities aimed at reducing tobacco use, primarily by changing the way tobacco and its use are understood in the communities of California.2 These activities are carried out by tobacco control programs based in the state’s 61 local health departments and by some 100 competitive grant projects in communities across the state, including four ethnic networks and 11 regional community linkage programs. Social change at the community level is supported by a statewide media campaign that uses paid advertising, a state clearinghouse of educational materials, an 800-number quit-line for tobacco users, and a statewide surveillance and evaluation program. The state’s primary role is to provide the people of California with the information, tools, and support they need to break the deadly, addictive grip tobacco has on their communities. The strategy of the program is to "denormalize" tobacco use (ie, render it abnormal, less acceptable, less desirable, and less common as a public or social behavior) in California communities.2 This strategy emphasizes three areas of programmatic activity: 1. To counter pro-tobacco influences by exposing the tobacco industry as the vector or source of tobacco-related disease. This includes exposing the industry’s deceptive business and marketing practices, its manipulation of nicotine to more quickly addict the young, and its targeting of youth, including teenagers. Also included in this area of emphasis are activities to promote policies that restrict the advertising and promotion of tobacco products and that hold the tobacco industry accountable for the commonly accepted standards of business practice in this country. 2. To reduce exposure to ETS by educating the public about the serious health risks associated with exposure to secondhand tobacco smoke and by promoting policies that protect people from such exposure. 3. To reduce access to tobacco products, with a focus on both social and commercial sources. This involves various activities, including public and merchant education, checks of retailer compliance with laws prohibiting sale of tobacco products to minors, and the promotion of policies that restrict or tighten up retail sales practices, marketing, and promotions. A fourth priority area, cessation, which is considered more an outcome supported by the program’s comprehensive efforts than a program intervention, is supported primarily by the 800-number quit-line, which provides both referrals to local cessation and telephone counseling services.2 The denormalization strategy strives to prevent young people from using tobacco products by first changing the world defined by adult behavior, which children only inhabit as relatively powerless subjects seeking adult status and power.2 Teens are initially attracted to tobacco use because, to them, it suggests adult power and independence. As community norms change and smoking becomes increasingly inconvenient, less acceptable, and less common among adults, fewer children will seek to add smoking as a component of their personality armor. Also, by exposing the tobacco industry’s practice of callously exploiting teenagers for profit, the program encourages youth to boycott tobacco products as an assertion of their independence. California’s TCP has touched the life of every Californian. In addition to hundreds of trained and experienced public health workers, behind the statewide media campaign, local programs, community coalitions, community-based organizations, and regional and statewide agency networks,3 thousands of adult and youth volunteers have contributed to this effort. After a decade, public support for tobacco control in California remains strong. In fiscal year 1998 and 1999, California smokers spent approximately $3.8 billion on cigarettes, only a fraction of the true costs of tobacco addiction in the state.3 Each year, approximately 42,000 Californians die prematurely because they smoked. Additionally, the cost of treating and caring for Californians suffering from illnesses caused by smoking reached $8.7 billion in 1993, the highest amount among all states in the nation. Premature death attributable to smoking shortened the average life of a California smoker by more than 15 years. During the early years of the program (1989 through 1993), the tobacco industry annually spent more than five times the amount on tobacco advertising and promotions in California than the program spent each year on interventions to reduce tobacco use.3 This disparity in spending grew to a ratio of nearly 10 to 1 in the period of 1993 through 1996. Although present (1999 to 2000) per capita expenditures have increased to $2.52, throughout the past decade our per capita budget has remained considerably below the range of $5.12 to $13.71 per capita recommended by the Centers for Disease Control and Prevention for funding an effective statewide tobacco control program in California. Yet, despite being considerably outspent by the tobacco industry and underfunded according to federal best-practices standards, our efforts have reduced tobacco use and exposure to ETS and helped to produce substantial short- and long-term improvements in the health and well being of all Californians. From the 1988 passage of Proposition 99-1993, adult smoking prevalence in California declined at nearly twice the rate of the remaining United States.3 Since the passage of Proposition 99, adult smoking prevalence in California went from approximately 11% lower than the rest of the nation to 20% lower in 1996. There are now approximately 1 million fewer smokers in California than would have been expected before Proposition 99 (Fig 1).3
In 1988, the year Proposition 99 was approved, approximately 23% of adults in California smoked.3 Smoking prevalence subsequently declined to approximately 17% in 1994 to 1995 and then rose to approximately 18% in 1996 (primarily because of a change in the definition of "current smoker") and continued substantially unchanged through 1999. That year there were approximately 4.3 million smokers in the state. Since 1996, there have been no significant changes in adult smoking prevalence overall or in the major race or ethnicity groups other than a small decline among the African-American population (Fig 2).3
Overall, per capita cigarette consumption in California has fallen by more than 50% since the passage of Proposition 99.3 Because of Proposition 99, California’s historical rate of decline in cigarette consumption has tripled, reaching a low of 61.3 packs per capita consumed in 1998 and 1999. In contrast, the packs per capita consumption in the United States was 106.8 in 1999. From 1989 to 1996, an estimated two billion fewer packs of cigarettes have been sold in California, which has cost the tobacco industry approximately $3 billion in lost sales. Smokers are trying to quit.3 Seventy percent of adult smokers reported that they have tried to quit. In 1996, 50% of California adult smokers reported that they had succeeded in quitting for at least 7 days. This represents a 20% increase in the 7-day quit success rate over the 1990 rate of 41.4%. Among smokers who have seen their doctor in the previous year, nearly half (48.7%) report that they were advised to quit smoking, 12% received a suggested quit date, and 7.5% were given a prescription to assist them in quitting.3 The California Smokers’ Helpline has served more than 100,000 smokers since its inception in 1992. Smoking-related diseases are on the decline.3 Although it typically takes 10 to 15 years for the effect of population-side changes in smoking to impact the incidence of smoking-related cancers, reductions in the incidence of heart attack, stroke, and low-weight births have already resulted from the accelerated decline in smoking among Californians. Moreover, California’s lung and bronchus cancer incidence is already declining at a significantly higher rate than that seen elsewhere in the nation. This suggests that far greater declines in smoking-related cancers will be seen in a few years when the full impact of reductions in smoking in the 1990s takes effect (Fig 3).3
Savings from California’s TCP between 1990 and 1998 amounted to an estimated $8.4 billion in smoking-attributable direct and indirect costs.3 In avoided direct medical costs alone, the program saved an estimated $3.02 billion dollars, or $3.62 for every dollar spent on the program. Short-term savings are nearly equal to the cost of operating the program (Fig 4).3
Youth smoking rates are on the decline.3 Since 1995, youth smoking in California (ages 12 to 17 years) has declined by 43%—down from 12.1% in 1995 to 6.9% in 1999 (Fig 5). From 1998 to 1999 alone, prevalence decreased by 35.5%. It is likely that this 1-year drop was influenced by the 40% increase in the price of cigarettes that occurred in California in 1999 and removal of all tobacco billboards as a result of the tobacco settlement agreement between the tobacco companies and state Attorney General. In general, there has been little difference between male and female smoking rates over the years in California (Fig 5).3
Smokeless tobacco use by California youth also trails that seen in most other states.3 In California, 6.9% of boys and 3.4% of girls aged 12 to 17 reported in 1998 that they had ever used smokeless tobacco. Fewer stores are selling tobacco to kids.4 In 1994, 52.1% of stores surveyed illegally sold cigarettes to minors. In 1999, that number plummeted to 12.8% of stores surveyed. Additionally, the perceived case of obtaining tobacco by minors has declined from 64.6% in 1994 to 54.8% in 1999.5 More Californians are protected from ETS.3 Hundreds of local ordinances and a statewide smoke-free indoor workplace law in 1995 have made California indoor public places and work sites safer places to be. Virtually all indoor workplaces in California are now smoke-free, including restaurants, bars, and gaming clubs. More than 86% of California adults—including 71.4% of smokers—feel that all indoor workplaces should be smoke-free.3 California’s 890,000 food service employees are now protected from secondhand smoke at their workplaces, and most Californians prefer to eat in smoke-free restaurants (87.7%). Two thirds of bar patrons are concerned about the effect of secondhand smoke on their health. And despite tobacco industry arguments to the contrary, tax data clearly demonstrate that smoking bans in restaurants and bars have had no adverse impact on revenues. Fewer California youth are exposed to secondhand smoke at home and at school.3 In 1994, approximately one half of all California residents did not allow smoking in the household (56.5%). By 1999, nearly two thirds did not allow smoking in the household. Moreover, in 1999, more than half of all California smokers with children under 18 years of age had established a voluntary policy against smoking in their household. As of 1999, 97% of California school districts have adopted policies prohibiting tobacco use on district grounds and in district vehicles. Tobacco companies invest heavily in marketing campaigns targeting youth.3 Joe Camel is gone, but teenagers continue to be a primary target of tobacco industry marketing. By increasing its magazine and print advertising, the tobacco industry has been more successful at reaching teenagers after the national tobacco settlement was signed than it was before the settlement. The companies continue to sponsor community events.3 In 1998, one in 10 large public events in California had some sort of tobacco industry sponsorship or promotional activity, including 86% of rodeos and 31% of sporting and car events. The modeling of smoking in movies is another powerful contributor to youth smoking.3 A detailed review of the 50 highest-earning movies released each year in 1991 to 1995 revealed that more than half of the movies included pro-tobacco messages. In fact, movies rated PG (parental guidance) averaged 11 incidents of tobacco use per movie, and movies rated PG-13 (parental guidance suggested for children under 13) averaged 21 incidents of tobacco use. The tobacco industry also invests heavily in product placement and marketing at small retail outlets in California, places likely to be visited by youth.3 More than half of stores surveyed (58%) reported that they had received various incentives—such as cash or free or discounted products—from tobacco companies. In comparison, only 36% and 14.5% reported receiving the same types of incentives from soda or candy companies, respectively. In addition, in California, tobacco-sponsored bar and club nights have proliferated.3 These events serve to link smoking with the young adult nightlife envied by many youth. Despite restrictions on smoking in bars and clubs, these events are heavily advertised in weekly entertainment newspapers in large cities. Teens are especially susceptible to tobacco marketing.3 Repeated exposure to this variety and intensity of tobacco marketing has an impact on youth. Each year, approximately 200,000 California youth experiment with cigarette smoking. Children who say they have a favorite tobacco advertisement and who own a tobacco brand promotional item are more likely to try smoking cigarettes than other children. Hundreds of youth and adult volunteers participated in our 1995 to 1997 Operation Storefront campaign.3 This project was designed to diminish the impact of tobacco advertisements and promotional items at California tobacco retail outlets. In three years, the campaign reduced the number of stores with tobacco advertisements near candy by 13% and the number of stores with tobacco advertisements located less than four feet off the floor (at the eye level of children) by 11%. Support for additional regulation of tobacco advertising and promotion has increased significantly since 1990.3 Most adults support bans on advertising (68%), free distribution of tobacco product samples or coupons by mail (76%), tobacco industry sponsorship of sporting or athletic events (71%), and gifts in exchange for coupons on cigarette packs (58%). Even among California youth there is substantial support for additional regulation of tobacco marketing. The majority of adults in California continue to support an additional increase in the cigarette excise tax. Contrary to the message of its massive public-relations campaign, the tobacco industry has not changed its stripes.3 It continues to spend hundreds of millions of dollars a year on creative marketing of tobacco products to youth and other vulnerable population groups in California. It is profiting now more than ever from the sale of its addictive and deadly products. This has not been changed by the national tobacco settlement. The tobacco industry’s answer to the problem of manufacturing a product that continues to kill over 400,000 Americans each year is to mount another public relations campaign and to redouble its marketing efforts in magazines and entertainment weeklies, by direct mail and the Internet, at points of sale, and with sponsored events in night clubs and bars. It is not by chance that 18- to 24-year-olds now have the highest smoking prevalence of any age group in California. Clearly, this is not the time for public health to relax its efforts. In conclusion, California’s program illustrates how a small group of dedicated individuals can with adequate funds and tenacity achieve these kinds of results with such a complex statewide intervention. It remains to be seen whether the rest of the United States and the world will allocate the resources and political will and social capital to accomplish what California, Massachusetts, and a few other states have done. Moreover, even in California, the story is not over, and we need to see whether these gains can be additionally built on in the coming years to accomplish the end goal of a smoke-free society.
1. Bal D, Kizer K, Felten P, et al: Reducing tobacco consumption in California. JAMA 264: 1570-1574, 1990[Abstract] 2. Lloyd J: The California tobacco control program: Preventing tobacco-related disease and death. Tobacco Control Section, California Department of Health Services, 1998, pp 1-12 3. California Tobacco Control Update. Tobacco Control Section, California Department of Health Services, August, 2000 4. California Youth Purchase Survey, 1994-2000. Tobacco Control Section, California Department of Health Services. 5. California Youth Tobacco Survey 1994-2000. Tobacco Control Section, California Department of Health Services.
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Copyright © 2001 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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TOP
ABSTRACT
INTRODUCTION
