Tobacco Control: Celebrating Extraordinary Progress While Preparing For Challenges Ahead

Tobacco Control:
Celebrating Extraordinary Progress While

Preparing for Challenges Ahead
Matthew L. Myers
Campaign for Tobacco-Free Kids
July 17, 2017
1
Campaign for Tobacco-Free Kids www.tobaccofreekids.org
The Problem
Tobacco use is leading cause of preventable death in the U.S.
Smoking kills 480,000 Americans annually (1 out of 5 deaths)
Smoking causes nearly 90% of lung cancer deaths, 1/3 of total
cancer deaths, and nearly 1/3 of heart disease deaths
Each day, about 2,500 kids in the United States try their first
cigarette
8.0% of high school students are current smokers; 15.1% of adults
are current smokers, but over 26% of adults living below the
poverty level are current smokers
Tobacco use costs ~ $170 billion in annual health care costs
Twenty Years of Progress
U.S. Adult Smoking Trends
Source: National Health Information Survey, 1994-2015 3

U.S. Adult Smoking Trends,
2011-2015
20.0 19.0%
18.1% 17.8%
18.0 16.8%
16.0 15.1%
Adult Smoking Prevalence (%)
14.0
12.0
10.0
8.0
6.0
4.0 20% decline

2.0
0.0
2011 2012 2013 2014 2015
Source: National Health Information Survey, 2011-2015 4

Huge Declines in U.S. High School Smoking
30% 28.0
25%
22.5 21.7
19.8
20%
17.2
15.8
15% 14.0
12.7
10% 9.2 9.3

8.0
5%
71% Decrease
0%
Source: CDC, National Youth Tobacco Survey (NYTS)

5
U.S. High School Smoking Trends,
2011 - 2016
18%
15.8%
16%
14.0%
14% 12.7%
12%
10% 9.2% 9.3%
8.0%
8%
6%
4%
2% 49% Decrease
0%
Source: CDC, National Youth Tobacco Survey (NYTS)

6
High School Tobacco Use Proof of What is Possible
- In Each the Greatest Decline Was Since 2008/2009
Cigarette Use
2000 2001 2014 2016
Percent Decline
High School Rate High School Rate
New York 27.1% 4.3% 84%
Rhode Island 24.8% 4.8% 81%
Florida 22.6% 5.2% 77%
Wisconsin 32.9% 8.1% 75%
Massachusetts 26% 7.7% 70%
Nevada 25.2% 7.5% 70%
Minnesota 32.4% 10.6% 67%
California 21.6% 4.3%* 80%
US 28.5% 10.8% 62%
NY, FL, WI from Youth Tobacco Survey. MA, NV, RI, US from Youth Risk Behavior Survey (YRBS)
*CA data from different surveys: 2000 data from CA Student Tobacco Survey, 2015 data from YRBS 7
This progress was no
accident.
We know what works.
8
1997-2009: Major Changes Driven by Change at
State and Local Levels
Program
Funding

Federal Cigarette Excise Tax + Average
State Cigarette Tax, 1995-2017
$3.00 2017 federal rate ($1.01) +
Federal Cigarette Tax current state average
State Average Cigarette Tax
($1.70*):
$2.50 $2.71 per pack
$2.00 2001 federal rate (34) +

state average (43):
1996 federal rate (24) + 77 per pack
$1.50
state average (33):
57 per pack
$1.00
$0.50
$0.00
2017
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
2016
* Includes state cigarette tax rates in effect as of July 3, 2017.
Percent of Population Covered by Smoke-Free Laws
(Workplaces, Restaurants & Bars)
100
Through July 3, 2017: 58%*
11/27/2002: 3%
25 states and hundreds of
DE becomes 1st smoke-free state
80 in all workplaces,
communities are smoke-free
restaurants and bars
60
1996: < 1%
Comprehensive smoke-free laws 2011: 48%
in 7 communities nationwide
40
20
Source: American Nonsmokers Rights Foundation, as of January 1 of each year except most recent year, which is most
recent quarterly report; Census population figures updated in 2017.
Total Annual State Tobacco Prevention
Spending, FY1999 - FY2017
$800.0
$749.7
$737.5
$717.2
$700.0
$680.3 $674.4 $670.9
$597.5
$600.0 $551.0 $569.3
$542.8 $538.2
$517.9
$490.4 $491.6
$500.0 $481.2 $481.7
$456.7 $459.5
Millions
$400.0
$300.1
$300.0
$200.0
$100.0
$0.0
FY99 FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16* FY17
Only 3 states AZ, CA and MA - spent any money on tobacco prevention prior to 1999. Settlement payments to states began in 1999. All states were
receiving payments by 2001. Funding amounts only include state funds.
* State spending for FY16 includes $13.7 million for Pennsylvania that was not available for the 2015 Broken Promises Report.
2009: Acceleration of Action at the
National Level
2009 Tobacco Control Act limited marketing, banned flavored
cigarettes, increased youth access enforcement, etc.
2009 - 61.5 increase in the federal excise tax
2009 PACT Act limited mail order and internet sales
Unprecedented mass media each of which produced measurable
and meaningful results
CDC multi-year Tips From Former Smokers campaign
FDA The Real Cost youth tobacco prevention campaigns
Truth Initiative re-invigoration of Truth mass media campaigns
13
14
BUT Substantial Challenges Remain
Three Broad Categories

1. The Face of Who Smokes has Changed
2. Emerging Threat of Other Tobacco Products
3. New Political Realities

Who Smokes? The Poor
35%
30% 28.7%
Adult Smoking Prevalence
25% 21.7%
20%
15% 14.1%
10% 8.0%
5%
0%
<$20K $20K - $49K $50K - $99K $100k +
Annual Household Income
Source: 2013-2014 Adult Tobacco Survey 16
Education and Employment are Critical
45
Any Tobacco Cigarettes Cigars
40
35
Past Month Use (%)
30
25
20
15
10
5
0
<HS HS Grad Some CollegeCollege Grad FT Employ PT Employ Unemployed Other
SOURCE: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2015 17
U.S. Adult Smoking by Health
Insurance Type, 2015
2015 National Rate: 15.1%
30% 27.8% 27.4%
25%
19.0%
20%
15%
11.1%
8.9%
10%
5%
0%
Medicaid Medicare Private insurance Other public Uninsured
insurance
Source: National Health Information Survey, 2015 18
Growing Life Expectancy Gap Between the Rich and
the Poor Coincides with Growing Gap in Who Smokes
Researchers at Brookings: there is a growing disparity in life expectancy

between high-income and low-income individuals. A study in JAMA also
concluded that inequality in life expectancy based on wealth has increased
over time.
These changes occur at the same time as the growing disparity in tobacco
use between the rich and the poor.
Researchers at Duke and CDC calculated that disparities in smoking
rates account for as much as a quarter to a third of the gap in life
expectancy by educational level. 19
Disparities in Policy Progress
Translate into Disparities in Use
There are dramatic differences between states.
While the national adult smoking rate has dropped to 15.1%
(2015 NHIS) and the youth smoking rate to 8.0% (2016 NYTS)
8 states have adult smoking rates below 15% BUT
13 states have adult smoking rates over 20%
19 states have youth smoking rates under 10%, and

8 states are already under 8%; 4 are at or under 5.2%
BUT
7 states have youth smoking rates over 15%

State Adult Smoking Prevalence, 2015
The Power of Taxes and Smoke-Free Air
Lowest Prevalence Highest Prevalence
1. Utah (9.1%) 1. Kentucky (25.9%)
2. California (11.7%) 2. West Virginia (25.7%)
3. New Jersey (13.5%) 3. Arkansas (24.9%)
3. Connecticut (13.5%) 4. Mississippi (22.5%)
5. Idaho (13.8%) 5. Missouri (22.3%)
6. Massachusetts (14.0%) 6. Oklahoma (22.2%)
6. Arizona (14.0%) 7. Louisiana (21.9%)
8. Hawaii (14.1%) 8. Tennessee (21.9%)
9. Washington (15.0%) 9. Ohio (21.6%)
10. Maryland (15.1%) 10. Alabama (21.4%)
10. Illinois (15.1%)
Average cigarette tax: $0.88*
Average cigarette tax: $2.50* States with smokefree restaurants and
States with smokefree restaurants and bars: 1 out of 10
bars: 10 out of 11
Source: CDC, 2015 BRFSS *Taxes in effect as of 4/1/17
Least Healthy States & Adult Smoking
Rates
8 least healthy states are in 10 highest smoking prevalence states
Least Healthy* Highest Smoking

1. Mississippi Prevalence
2. Louisiana 1. Kentucky (25.9%)
3. Arkansas 2. West Virginia (25.7%)
4. Alabama 3. Arkansas (24.9%)
5. Oklahoma 4. Mississippi (22.5%)
6. Kentucky 5. Missouri (22.3%)
7. Tennessee 6. Oklahoma (22.2%)
8. West Virginia 7. Louisiana (21.9%)
9. South Carolina 8. Tennessee (21.9%)
10. Georgia 9. Ohio (21.6%)
*Americas Health Rankings 2016 Annual Report 10. Alabama (21.4%)
Behavioral Risk Factor Surveillance System, 2015
22
The Least Heart Healthy States Have
the Highest Adult Smoking Rates
8 of Least Heart Healthy States are in 10 Highest Smoking Prevalence States
Least Heart Highest Smoking
Healthy* Prevalence
1. Mississippi 1. Kentucky (25.9%)
2. West Virginia 2. West Virginia (25.7%)
3. Kentucky 3. Arkansas (24.9%)
4. Louisiana 4. Mississippi (22.5%)
5. Alabama 5. Missouri (22.3%)
6. Tennessee 6. Oklahoma (22.2%)
7. Arkansas 7. Louisiana (21.9%)
8. South Carolina 8. Tennessee (21.9%)
9. Oklahoma 9. Ohio (21.6%)
10. Indiana 10. Alabama (21.4%)
*Based on CDC data excess heart age, smoking rates & obesity prevalence data
(http://conditions.healthgrove.com/stories/6140/states-healthiest-hearts)
Behavioral Risk Factor Surveillance System, 2015 23
States with Highest Proportion of Cancer Deaths
Attributable to Smoking and Adult Smoking Prevalence
8 States with Greatest Smoking-Attributable Cancer Deaths
are in 10 Highest Smoking Prevalence States
Proportion of Cancer Deaths Highest Smoking
Attributable to Smoking* Prevalence
1. Kentucky (34.0%) 1. Kentucky (25.9%)
2. Arkansas (33.5%) 2. West Virginia (25.7%)
3. Tennessee (32.9%) 3. Arkansas (24.9%)
4. West Virginia (32.6%) 4. Mississippi (22.5%)
5. Louisiana (32.6%) 5. Missouri (22.3%)
6. Alaska (31.4%) 6. Oklahoma (22.2%)
7. Missouri (31.3%) 7. Louisiana (21.9%)
8. Alabama (31.3%) 8. Tennessee (21.9%)
9. Oklahoma (31.1%) 9. Ohio (21.6%)
10. Nevada (30.9%) 10. Alabama (21.4%)
J, et al., State-Level Cancer Mortality Attributable to Cigarette Smoking in the United States, JAMA Internal Medicine, published online
* Lortet-Tieulent,
October 24, 2016.

Behavioral Risk Factor Surveillance System, 2015 24
If You are Poor, Where You Live Impacts
How Long You Will Live
Where you live matters for the poor: Life expectancy among low-income
individuals varies by where you live but there is little or no difference
where you live if you are wealthy
If you are poor, your smoking rate also varies based on where you live.
The smoking rates of the wealthy are similar wherever they live.
Poor people have lower smoking rates when they live in an environment
where the government invests in a safety net
Disparities in life expectancy are not inevitable. There are communities
throughout the US, where differences in life expectancy are relatively
small.
Source: Chetty, R, et al., The Association Between Income and Life Expectancy in the United
States, 2001-2014, JAMA, published online April 10, 2016. 25
Urgent Threats to Tobacco Progress
Proposals to weaken FDA authority over tobacco products
Proposed cuts to funding for the Office on Smoking and Health at CDC--
threatens the Tips From Former Smokers media campaign, state
quitlines and state tobacco prevention programs
ACA repeal: ACA mandated coverage of tobacco cessation treatment for

individuals in private plans and many on Medicaid
HUD regulations to make public housing smoke-free just went into effect
will they be challenged with other regulatory rollbacks?
26
Three Threats are Immediate
Congress curtailment of FDA Authority: Efforts to undercut the

legislative authority of the FDA related to cigars, e-cigarettes
and other tobacco products during the Appropriations process
Already in bill approved by House Approps Committee
Administration's budget attack on CDC-OSH: Proposed FY2018
budget eliminates CDCs Office on Smoking and Health
Congressional/industry attacks to NNN proposed standard
Would prevent FDA from moving forward on its first product
standard
27
The Emergence of
Other Tobacco ProductsMany
of them Targeting Kids
28
30
High School Boys Smoke Cigars and Cigarettes at
About the Same Rate
10% 9.1% 9.0%
8%
6%
4%
2%
0%
Cigarettes Cigars
2016 National Youth Tobacco Survey
E-Cigarettes Marketing Mimics the Worst
of Cigarette Marketing
TV Ads
Kid-Friendly
Flavors
Music
Sponsorships
NASCAR Car
Sponsorships
Celebrity
Endorsements
Magazine
Branded Items Ads
Cartoons
Cigarette Girls
Building on the Momentum Already
Created: Whats Next?
Continue to expand the number of people protected by
proven measures AND
Adopt new innovative state & local policies
Raising the tobacco sale age to 21
Restrictions on flavored tobacco products other than cigarettes
Innovative approaches to curtailing menthol products
Coupon and discounting bans
Minimum price laws
Tobacco-free retailers
35

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Tobacco Control:

Celebrating Extraordinary Progress While

Source: National Health Information Survey, 1994-2015 3

4.0 20% decline

Source: National Health Information Survey, 2011-2015 4

10% 9.2 9.3

Source: CDC, National Youth Tobacco Survey (NYTS)

Source: CDC, National Youth Tobacco Survey (NYTS)

Campaign for Tobacco-Free Kids www.tobaccofreekids.org

$2.00 2001 federal rate (34) +

Three Broad Categories

2. Emerging Threat of Other Tobacco Products

3. New Political Realities

Campaign for Tobacco-Free Kids www.tobaccofreekids.org

Researchers at Brookings: there is a growing disparity in life expectancy

19 states have youth smoking rates under 10%, and

Campaign for Tobacco-Free Kids www.tobaccofreekids.org

Least Healthy* Highest Smoking

October 24, 2016.

ACA repeal: ACA mandated coverage of tobacco cessation treatment for

Congress curtailment of FDA Authority: Efforts to undercut the

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