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October 31st, 2007:

Best Practices for Comprehensive Tobacco Control Programs

Tobacco* use is the single most preventable cause of death and disease in the United States. People begin using tobacco in early adolescence; almost all first use occurs before age 18. An estimated 45 million American adults currently smoke cigarettes. Annually, cigarette smoking causes approximately 438,000 deaths. For every person who dies from tobacco use, another 20 suffer with at least one serious tobacco-related illness. Half of all long-term smokers die prematurely from smoking-related causes. In 2004, this addiction costs the nation more than $96 billion per year in direct medical expenses as well as more than $97 billion annually in lost productivity. Furthermore, exposure to secondhand smoke causes premature death and disease in nonsmokers. In 2005, the Society of Actuaries estimated that the effects of exposure to secondhand smoke cost the United States $10 billion per year.

Nearly 50 years have elapsed since the first Surgeon General’s Advisory Committee concluded: “Cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action.” There now is a robust evidence base about effective interventions. Yet, despite this progress, the United States has not yet achieved the goal of making tobacco use a rare behavior. A 2007 Institute of Medicine (IOM) report presented a blueprint for action to “reduce smoking so substantially that it is no longer a public health problem for our nation.” The twopronged strategy for achieving this goal includes not only strengthening and fully implementing currently proven tobacco control measures, but also changing the regulatory landscape to permit policy innovations. Foremost among the IOM recommendations is that each state should fund a comprehensive tobacco control program at the level recommended by the Centers for Disease Control and Prevention (CDC).

We know how to end the epidemic. Evidencebased, statewide tobacco control programs that are comprehensive, sustained, and accountable have been shown to reduce smoking rates, tobaccorelated deaths, and diseases caused by smoking. Recommendations that define a comprehensive statewide tobacco control intervention have been provided in the Surgeon General’s reports Reducing Tobacco Use (2000) and The Health Consequences of Involuntary Exposure to Tobacco Smoke (2006), the Task Force for Community Preventive Services’ Guide to Community Preventive Services (2005), IOM’s Ending the Tobacco Problem: A Blueprint for the Nation (2007), the Public Health Service’s Clinical Practice Guideline Treating Tobacco Use and Dependence (2000), and the National Institutes of Health’s State-of-the-Science conference Statement Tobacco Use: Prevention, Cessation, and Control (2006) and President’s Cancer Panel Annual Report Promoting Health Lifestyles: Policy, Program and Personal Recommendations for Reducing Cancer Risk (2007).

A comprehensive statewide tobacco control program is a coordinated effort to establish smoke-free policies and social norms, to promote and assist tobacco users to quit, and to prevent initiation of tobacco use. This comprehensive approach combines educational, clinical, regulatory, economic, and social strategies. Research has documented the effectiveness of laws and policies in a comprehensive tobacco control effort to protect the public from secondhand smoke exposure, promote cessation, and prevent initiation, including increasing the unit price of tobacco products and implementing smoking bans through policies, regulations, and laws; providing insurance coverage of tobacco use treatment; and limiting minors’ access to tobacco products. Additionally, research has shown greater effectiveness with multi-component intervention efforts that integrate the implementation of programmatic and policy interventions to influence social norms, systems, and networks.

This document updates Best Practices for Comprehensive Tobacco Control Programs—August 1999. This updated edition describes an integrated programmatic structure for implementing interventions proven to be effective and provides the recommended level of state investment to reach these goals and reduce tobacco use in each state. It is important to recognize that these individual components must
work together to produce the synergistic effects of a comprehensive tobacco control program. Based on the evidence of effectiveness documented in scientific literature, the most effective population-based approaches have been defined within the following overarching components:

I. State and Community Interventions
State and community interventions include supporting and implementing programs and policies to influence societal organizations, systems, and networks that encourage and support individuals to make behavior choices consistent with tobacco-free norms. The social norm change model presumes that durable change occurs through shifts in the social environment, initially or ultimately, at the grassroots level across local communities. State and community interventions unite a range of integrated programmatic activities, including local and statewide policies and programs, chronic disease and tobacco-related disparity elimination initiatives, and interventions specifically aimed at influencing youth.

II. Health Communication Interventions
An effective state health communication intervention should deliver strategic, culturally appropriate, and high-impact messages in sustained and adequately funded campaigns integrated into the overall state tobacco program effort. Traditional health communication interventions
and counter-marketing strategies employ a wide range of efforts, including paid television, radio, billboard, print, and web-based advertising at the state and local levels; media advocacy through public relations efforts, such as press releases, local events, media literacy, and health
promotion activities; and efforts to reduce or replace tobacco industry sponsorship and promotions. Innovations in health communication interventions include more focused targeting of specific audiences as well as fostering message development and distribution by the target audience through appropriate channels.

III. Cessation Interventions
Interventions to increase cessation encompass a broad array of policy, system, and populationbased measures. System-based initiatives should ensure that all patients seen in the health care system are screened for tobacco use, receive brief interventions to help them quit, and are offered more intensive counseling services and FDA-approved cessation medications. Cessation quitlines are effective and have the potential to reach large numbers of tobacco users. Quitlines also serve as a resource for busy health care providers, who provide the brief intervention and discuss medication options and then link tobacco users to quitline cessation services for more intensive counseling. Optimally, quitline counseling should be made available to all tobacco users willing to access the service.

IV. Surveillance and Evaluation
State surveillance is the process of monitoring tobacco-related attitudes, behaviors, and health outcomes at regular intervals. Statewide surveillance should monitor the achievement of overall program goals. Program evaluation is used to assess the implementation and outcomes of a program, increase efficiency and impact over time, and demonstrate accountability. A comprehensive state tobacco control plan—with well-defined goals; objectives; and short-term, intermediate, and long-term indicators—requires appropriate surveillance and evaluation data systems. Collecting baseline data related to each objective and performance indicator is critical to ensuring that program-related effects can be clearly measured. For this reason, surveillance and evaluation systems must have first priority in the planning process.

V. Administration and Management
Effective tobacco prevention and control programs require substantial funding to implement, thus making critical the need for sound fiscal management. Internal capacity within a state health department is essential for program sustainability, efficacy, and efficiency. Sufficient capacity enables programs to plan their strategic efforts, provide strong leadership, and foster collaboration between the state and local tobacco control communities. An adequate number of skilled staff is also necessary to provide or facilitate program oversight, technical assistance, and training.

The primary objective of the recommended statewide comprehensive tobacco control program is to reduce the personal and societal burden of tobacco-related deaths and illnesses. Research shows that the more states spend on comprehensive tobacco control programs, the greater the reductions in smoking—and the longer states invest in such programs, the greater and faster the impact. States that invest more fully in comprehensive tobacco control programs have seen cigarette sales drop more than twice as much as in the United States as a whole, and smoking prevalence among adults and youth has declined faster as spending for tobacco control programs has increased.

In California, home of the longest-running comprehensive tobacco control program, adult smoking rates declined from 22.7% in 1988 to 13.3% in 2006. As a result, compared with the rest of the country, heart disease deaths and lung cancer incidence in California have declined at accelerated rates. Due to the program-related reductions in smoking, lung cancer incidence has been declining four times faster in that state than in the rest of the nation. Among women in California, the rate of lung cancer deaths decreased while it increased in other parts of the country. Because of this accelerated decline, California has the potential to be the first state in which lung cancer is no longer the leading
cancer cause of death.

Implementing a comprehensive tobacco control program structure at the CDC-recommended levels of investment would have a substantial impact. For example, if each state sustained its recommended level of funding for 5 years, an estimated 5 million fewer people in this country would smoke. As a result, hundreds of thousands of premature tobaccorelated deaths would be prevented. Longer-term investments would have even greater effects.

The tobacco use epidemic can be stopped. We know what works, and if we were to fully implement the proven strategies, we could prevent the staggering toll that tobacco takes on our families and in our communities. We could accelerate the declines in cardiovascular mortality, reduce chronic obstructive pulmonary disease, and once again make lung cancer a rare disease. If we as a nation fully protected our children from secondhand smoke, more than one million asthma attacks and lung and ear infections in children could be prevented. With sustained implementation of state tobacco control programs and policies (e.g., increases in the unit price of tobacco products), IOM’s best-case scenario of reducing adult tobacco prevalence to 10% by 2025 would be attainable.

View the entire document on the Best Practices for Comprehensive Tobacco Control Programs here.

Blind Eyes Towards Ban

By ADRIAN WAN CHUN-HO – Hong Kong Baptist University

Though the smoking ban has been in effect for about a year in Hong Kong, smokers are still to be found lighting up in public places.

The Tobacco Control Office (TCO) of Department of Health began working round the clock after citizens’ unlawful smoking sprees were found to run rampant when Tobacco Control Inspectors (TCI) and telephone receivers all went off duty.

Although implementation has been stepped up, smokers are still found lighting up in many entertainment premises such as game centres, high-rise cafes, internet cafes, karaoke lounges and private clubs in districts such as Mongkok, Tsim Sha Tsui and Causeway Bay.

Paul Wong Tai-long, a smoker said he smokes only if he sees other people do it in the same place.

“People smoke and never get caught. Why should I obey the law?” he questioned, pointing at other smokers in a game station in Hung Hom.

Being one of the regulars at the station, he visits three times a week, two hours each time. He said he has seen TCIs check up on smokers only three times since the ban was in place, thus seems rather safe to smoke.

A non-smoker named Joey commented in an internet cafe in Mongkok, “[The smokers] are utterly selfish. They disregard the law and disrespect themselves. I don’t like people smoking next to me when I’m having fun here.”

As only half of all the internet cafes in Hong Kong are lawabiding, and they charge higher prices. The rest, which offer lower prices, indulge their customers in a smoky and obscure milieu, left Joey with no choice.

When filing a complaint to the TCO was suggested, she replied, “I don’t think it is going to be useful. My friends tried. They always say they will investigate.”

James Middleton, a member of Clear The Air, a volunteer group committed to combate against air pollution in Hong Kong, commented on the situation, “[The TCO] are massively understaffed. By the time a complaint is made and TCIs get there, the offenders are long gone.”

“The government should make use of other employees such as those from the Leisure and Cultural Services Department (LCSD) to enforce the law,” he said.

An official from the TCO explained, “Once we receive a complaint, we will investigate the case by obtaining relevant information from the complainant. This is then followed by conducting a field inspection of the alleged premises.”

Where smoking is not allowed, ash trays are not supposed to be seen. However, smoke and ash trays are all over the place in a snooker club in Wong Tai Sin.

The club manager, who requested anonymity, said it is necessary because if ash trays are not provided, the cigarette ash and butts that customers leave over will catch his club on fire.

Mr Li Bo-lung, a client, lighting up in the club, claimed he was only “making use of the facilities provided”. He said, “Don’t ask me why I smoke. Ash trays are provided here. Ask the manager.”

When the suggestion was made to remove the ash trays, so that customers can be more aware of the law, the manager said he does not want the carpet damaged by cigarette ends, while puffing away at a cigarette himself.

Ash trays are not only seen in that particular club, they are everywhere, sometimes appear in different forms.

Some restaurants have adopted a way to get around the law : supplying smaller bowls instead of those obvious ash trays. It begs the question whether venue managers should be liable to a penalty when customers are caught lighting up.

Middleton said, “In licensed premises there should be a fine for the licensee if he does not enforce the ban, with loss of his license for subsequent offences.”

The TCO official said, “TCIs will liaise with the venue manager to identify any deficiency in anti-smoking measures such as the lack of no-smoking signs, inadequate legal knowledge and insufficient law enforcement skills”.

The ban, introduced on January 1, applies to all indoor public places, such as restaurants, workplaces, schools and karaoke lounges. Smoking outdoors, at public beaches, swimming pools, and sports grounds, is also forbidden.

In spite of this, about 750 facilities have been given deferment of the ban, thus are allowed to permit smoking on their premises until July 1, 2009.

The requirements for being able to defer the ban are minimal at best, with the stated criteria simply calling for no one under the age of 18 being allowed to enter the premise, having an exclusive entrance for clients to enter in by, and an age limit sign prominently displayed in Chinese and English at each entrance.

“It’s a laughing stock that any bar or restaurant which applies is granted a smoking exemption, while the law is intended to save lives of the bar and restaurant workers,” Middleton said.

According to their website, the TCO has issued altogether 1,975 summonses from 1 January 2007, the day when the ban became effective, to 30 September 2007. Violators are subject to a maximum penalty of $5,000. Venues are not liable to any penalty.