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					Impacts of Tobacco Use and What We Can
               Do About it



          Philip Huang, MD, MPH
     Medical Director/Health Authority
     Austin/Travis County Health Dept.
              August 19,2010
Summary:

  Burden and Impacts of Tobacco Use
  What we are doing about it - ARRA
   Communities Putting Prevention to Work
   (CPPW)
        Policy Change
        Cessation resources
    How can we work together?
                     Leading Causes of Death, Travis County, 2007
                                        0         200           400       600           800             1000     1200


               Malignant Neoplasms                                                                        1001



              Diseases of the Heart                                                               917



                 Accidents (Injuries)                         332



 Cerebrovascular Diseases (Stroke)                      242



                  Organic Dementia                      239



Chronic Lower Respiratory Diseases                  212



               Alzheimer's Disease            133



      Intentional Self-Harm (Suicide)       111



                   Diabetes Mellitus        100




                     Data Source: Texas Department of State Health Services, Center for Health Statistics
                                         http://soupfin.tdh.state.tx.us/death10.htm
                              Diseases of the Heart1 Age Adjusted Mortality Rate
                   500
                                           Travis County 1999-2006
                   450



                   400



                   350


                                                                                                                                1999
                   300
                                                                                                                                2000
Rate per 100,000




                                                                                                                                2001
                                                                                                                                2002
                   250
                                                                                                                                2003
                                                                                                                                2004
                   200                                                                                                          2005
                                                                                                                                2006


                   150



                   100



                    50



                     0
                         Male                  Female          White Non-Hispanic   Black Non Hispanic       Hispanic   Total

                          1   ICD 9 Codes: I00-I09, I11, I13, I20-I51
                          Data Source: Texas Department of State Health Services, Center for Health Statistics
                          http://soupfin.tdh.state.tx.us/death10.htm
       Cancer Death Rates*, for Men, US, 1930-1999
 100    Rate Per 100,000
                                                                       Lung


  80




  60


                     Stomach                                                                      Prostate
                                                          Colon and rectum
  40




  20                                                                                       Pancreas



                           Leukemia                   Liver
   0
   1930   1935    1940   1945   1950    1955   1960     1965   1970   1975   1980   1985    1990    1995
*Age-adjusted to the 2000 US standard population.
Source: US Mortality Public Use Data Tapes 1960-1999, US Mortality Volumes 1930-1959,
       National Center for Health Statistics, Centers for Disease Control and Prevention, 2002.
                      Cancer Death Rates*, for Women, US,
                                  1930-1999
             Rate Per 100,000
100



 80



 60
                                                                                                                 Lung
                Uterus                                Breast
 40


             Stomach                                       Colon and rectum
 20                          Ovary

                                                                            Pancreas
  0
      1930   1935    1940    1945    1950    1955   1960    1965    1970    1975    1980   1985    1990   1995

      *Age-adjusted to the 2000 US standard population.
      Source: US Mortality Public Use Data Tapes 1960-1999, US Mortality Volumes 1930-1959,
              National Center for Health Statistics, Centers for Disease Control and Prevention, 2002.
                         Lung and Bronchus Cancer1 Age Adjusted Mortality Rate
                   120
                                       Travis County 1999-2006

                   100




                   80
                                                                                                                                                   1999
                                                                                                                                                   2000
Rate per 100,000




                                                                                                                                                   2001
                                                                                                                                                   2002
                   60
                                                                                                                                                   2003
                                                                                                                                                   2004
                                                                                                                                                   2005
                                                                                                                                                   2006
                   40




                   20




                    0
                              Males             Females         White Non-Hispanic Black Non-Hispanic           Hispanic*                  Total

                         1   ICD 9 Codes: C34
                         * Thenumber of deaths due to Lung and Bronchus Cancer for Hispanics is too small for rate calculation in 2001 and
                         2003.
                         Data Source: Texas Department of State Health Services, Texas Cancer Registry, http://www.cancer-rates.info/tx/
                     Leading Causes of Death, Travis County, 2007
                                        0         200           400       600           800             1000     1200


               Malignant Neoplasms                                                                        1001



              Diseases of the Heart                                                               917



                 Accidents (Injuries)                         332



 Cerebrovascular Diseases (Stroke)                      242



                  Organic Dementia                      239



Chronic Lower Respiratory Diseases                  212



               Alzheimer's Disease            133



      Intentional Self-Harm (Suicide)       111



                   Diabetes Mellitus        100




                     Data Source: Texas Department of State Health Services, Center for Health Statistics
                                         http://soupfin.tdh.state.tx.us/death10.htm
                                       Actual Causes of Death,
                                             Texas 2001

              Tobacco                                                                                    24,899
  Overweight/Obesity                                                                  18,649
               Alcohol*                                       11,132

      Auto Accidents                     3,736

                 Drugs*                2,851
                Suicide              2,214

                 DWI**               1,807

              Homicide           1,405
                  AIDS          1,052
                    Fire       218

                           0             5000         10000          15000           20000          25000         30000


Source: Vital Statistics, TDH; * Texas Commission for Alcohol and Drug Abuse; **Mother’s Against Drunk Driving
          Smoking-Attributable Deaths
             Travis County, 2007
Approximately 584 deaths caused by smoking among
 adults 35+ years in Travis County (over 11 each week)
Health Effects of Tobacco Use
    Cigarette smoking remains the leading preventable cause of death in the
     United States, causing an estimated 438,000 deaths - or about 1 out of every
     5 - each year. (In 2007 in Travis County approximately 584 smoking-related
     deaths-over 11 per week)
    Tobacco kills more than AIDS, heroin, cocaine, alcohol, car accidents, fire
     and murder – combined.
    Lung cancer is the leading cause of cancer death among both men and
     women in the United States, with 85- 90 percent of lung cancer deaths
     attributed to smoking.
    Smoking also increases the risk of many other types of cancer, including
     cancers of the throat, mouth, pancreas, kidney, bladder, and cervix.
    People who smoke are up to six times more likely to suffer a heart attack
     than nonsmokers, and the risk increases with the number of cigarettes
     smoked. Smoking also causes most cases of chronic obstructive lung
     disease, which includes bronchitis and emphysema.
    In the United States, approximately 38,000 deaths each year are caused by
     exposure to secondhand smoke.
Tobacco Use in the US, 1900-2000

                                    5000                                                                                                                                                       100

                                    4500                                                                                                                                                       90
 Per Capita Cigarette Consumption




                                                                                                                                                                                                     Age-Adjusted Lung Cancer Death
                                    4000                                                                                                                                                       80
                                                                              Per capita cigarette
                                    3500                                                                                                                                                       70
                                                                              consumption
                                    3000                                                                                                                                                       60




                                                                                                                                                                                                                  Rates*
                                                                                                                                                     Male lung cancer
                                    2500                                                                                                             death rate                                50

                                    2000                                                                                                                                                       40

                                    1500                                                                                                                                                       30
                                                                                                                                                                     Female lung
                                    1000                                                                                                                                        20
                                                                                                                                                                     cancer death
                                                                                                                                                                     rate
                                    500                                                                                                                                                        10

                                      0                                                                                                                                                        0
                                           1900
                                                  1905
                                                         1910
                                                                1915
                                                                       1920
                                                                              1925
                                                                                     1930
                                                                                            1935
                                                                                                   1940
                                                                                                          1945
                                                                                                                  1950
                                                                                                                         1955
                                                                                                                                1960
                                                                                                                                       1965
                                                                                                                                              1970
                                                                                                                                                     1975
                                                                                                                                                            1980
                                                                                                                                                                   1985
                                                                                                                                                                          1990
                                                                                                                                                                                 1995
                                                                                                                                                                                        2000
                         *Age-adjusted to 2000 US standard population.
                                                                                                                 Year
                         Source: Death rates: US Mortality Public Use Tapes, 1960-2000, US Mortality Volumes, 1930-1959, National
                         Center for Health Statistics, Centers for Disease Control and Prevention, 2002. Cigarette consumption: US
                         Department of Agriculture, 1900-2000.
Second-Hand Smoke (SHS)

    Public Health Issue
        Contains over 4,000 chemicals including 69 known
         carcinogens
        Group A Carcinogen (like asbestos and benzene)
        Health Effects: Adults
             Lung cancer
             Coronary heart disease
        Health Effects: Children
             Lower respiratory tract infections in children < 18 months
              old each year
             Middle ear infections
             Asthma
             SIDS
Even Brief Exposure to SHS Poses
Serious Health Risks
    Even brief exposure to SHS can:
        result in upper airway changes in healthy persons
        lead to more frequent asthma attacks in asthmatic
         children
    Just 30 minutes of exposure to SHS can:
        increase risk of blot clots
        slow the rate of blood flow through the coronary
         arteries
        injure blood vessels and interfere with their repair
Who Smokes – By Education and Income
   Current Population Survey - Tobacco Use Supplement
  Smoking Status by Demographic Characteristics 1965 and 1999.
                            Current Smokers        % Decline
                              1965       1999
  Race/Ethnicity
   White                      41.9       23.5         44%
   African-American           45.2       24.7         45%
   Other                      39.8       19.9         50%
  Education (Years)
   1–8, Elementary            36.7       19.1         48%
   9–11, Some HS                         38.1         18%
                            [ 46.7 ]
   12, HS Graduate                       28.6         39%
   1–3, Some College          44.0       24.4         45%
   4, College Graduate        39.8       13.2         67%
   5+, Post-Graduate          32.8        8.5         74%
  Family Income (quintile)
   Lowest                     33.8       30.9          9%
   2                          42.9       28.7         33%
   3                          46.1       25.0         46%
   4                          46.4       21.4         54%
   Highest                    43.6       16.6         62%
Homeless
    About one-third to one-half of the 750,000
     homeless individuals in the U.S. have chronic
     diseases, and more than half lack health
     insurance. Homeless individuals have a life
     expectancy of between ages 42 and 52, according
     to National Health Care for the Homeless Council.
    Among the homeless, the cigarette smoking rate
     is an alarming 70% or more; these rates are 3
     times higher than national average. Two of the
     three leading causes of death among homeless
     persons, heart disease and cancer are tobacco
     related
Homeless (Cont.)

    Many of those working with homeless people do not regard
     smoking as a priority.
     As a result of their low income, they use tobacco in an even
     more hazardous way: hand-rolled cigarettes without filters;
     recycled tobacco from butts; group smoking, a cigarette passing
     from mouth to mouth. They also leave shorter butts by smoking
     the cigarette down as close to the filter or to the end as possible.
    Many homeless people who smoke want to quit.
    There is real opportunity for helping this population.
    Actions include: recognizing that smoking is a major cause of ill
     health among homeless people; offering a tobacco-free
     environment; making smoking cessation services more
     accessible to homeless smokers; and providing resources to
     those who want to quit.
                                             Prevalence of Cigarette Smoking Among Youth1,
                                              Texas’ Public Schools 2001, 2005, 2007, 2009
                                           Percent of Students Who Smoked One or More Cigarettes in the Past 30 Days

                     40



                     35



                     30



                     25
Weighted Percent %




                                                                                                                                      2001
                                                                                                                                      2005
                     20
                                                                                                                                      2007
                                                                                                                                      2009

                     15



                     10



                     5



                     0
                                 Males                  Females            White Non-Hispanic Black Non-Hispanic   Hispanic   Texas

                     1Youth is defined as a student in public schools ranging in age from 15-18 years old.
                     Data Source: Texas Department of State Health Services, Center for Health Statistics
                     http://www.dshs.state.tx.us/chs/yrbs/query/yrbss_form.shtm
Economic Data
Economic Cost

    In 1998/1999, Texas Smoking-Attributable
     Costs = $10.09 billion
        Direct Medical expenditures - $4.55 billion
        Lost Productivity costs - $5.54 billion
    In 1998, about 15% ($1,265,000,000 or
     $543.87 per recipient) of all Texas Medicaid
     expenditures were spent on smoking-related
     illnesses and diseases. (includes state and
     federal contributions to Medicaid)
           Potentially Preventable Hospitalizations
                 Tobacco-Related Diseases
                  Travis County, 2005-2008

Hospitalizations for Number of      Average       Total          Average
Adult Residents of Hospitalizations Hospital     Hospital       $ Impact
  Travis County                     Charge       Charges          for all
                                                                   Adult
                                                                Residents
Angina (without procedures)    228     $16,104    $3,671,690       $5
Congestive Heart Failure      5,942    $24,905   $147,986,462     $207
Asthma                        1,951    $17,931   $34,983,318       $49

Chronic Obstructive
Pulmonary Disease             2,075    $24,393   $50,615,186       $71

TOTAL                         10,196   $22,790   $237,256,656     $751
Economic Costs Due To Smoking
Travis County, 2007
  584 deaths caused by smoking among adults
                   35+ years

    Loss   of future earnings and productivity of
                     $165.4 million

    2004   Direct Health Care Costs for Travis
                County- $243 million
Smokefree Laws:
Employer Economic Issues
  Absenteeism
  Illness and discomfort among non-smokers to
   SHS
  Health insurance and life insurance costs and
   claims
  Smoke pollution (increased cleaning and
   maintenance costs)
        The US EPA estimates that smokefree restaurants
         can expect to save about $190 per 1,000 square
         feet each year in lower cleaning and maintenance
         costs.

                                                            25
Smokefree Laws:
Employer Economic Issues
    Liability
        Workers Compensation
             Employee filed claims
             Increased employer premiums
        Disability Discrimination
             Failing to provide a ―reasonable accommodation‖ (e.g
              worker with asthma)
        Failure to Provide a Safe Workplace
    Secondhand smoke cases have been filed
     against the hospitality industry, and won or
     settled favorably

                                                                     26
Smokefree Laws:
Employer Economic Issues
  Accidents, property damage and fires (plus related
   insurance costs)
  Matches and cigarettes account for 12% and 9% of
   outdoor fires (According to CleanUp.org.au, "a
   cigarette butt can smolder for up to three hours
   causing a grass fire or even a bushfire―)
  The National Fire Protection Association found that in
   1998 smoking materials caused 8,700 fires in non-
   residential structures resulting in direct property
   damage of $60.5 million.
  According to a study by the Department of
   Epidemiology and Preventive Medicine at the
   University of California, "Smoking causes an estimated
   30% of U.S. and 10% of global fire death burdens."
  Landlords and restaurants with smokefree premises
   have negotiated lower fire and property insurance      27
   premiums.
Green and Tobacco-Free
  According to the Smithsonian Institute, "it takes ten
   years for one cigarette butt to degrade."
  According to Eco Recycle, "50% of all litter in urban
   areas is tobacco-related products including butts,
   cellophane wrapping, foil inserts and packaging."
  According to Cigarette Litter Org, "4.5 trillion cigarette
   butts are littered worldwide every year."
  According to the Texas Department of Transportation:
   "130 million butts will be tossed out in Texas alone this
   year.―
  San Francisco - spends over $6 million annually to
   clean cigarette litter
Texas Employer Costs of Smoking
 Estimated annual EXCESS absence and productivity
   cost per smoker $2,625 (not including health costs)
  Smoke breaks $2,261
     26 minutes per day more than non-smokers
      (Source: Study by Halpern and Rentz) multiplied by
      the Texas average hourly wage $19.76 (Source:
      Bureau of Labor Statistics, May 2009)
  Absences $364
     2.3 days of additional absences (Source: Study by
      Halpern and Rentz) multiplied by Texas average
      hourly wage of $19.76. (Source: Bureau of Labor
      Statistics, May 2009)
Comprehensive smoke-free workplace
laws reduce cigarette consumption

     Tobacco-free environments reduces smoking prevalence by 3.8%
      and helps ex-smokers by eliminating cues to smoke and (Study
      by Fichtenberg and Glantz).


  Excerpts from Philip Morris internal documents
     ―…total prohibition of smoking in the workplace strongly affects
      industry volume. Smokers facing these restrictions consume
      11%-15% less than average and quit at a rate that is 85% higher
      than average...Milder workplace restrictions, such as
      smoking only in designated areas, have much less impact on
      quitting rates and very little effect on consumption.”
     ―…financial impact of smoking bans will be tremendous –three to
      five fewer cigarettes per day per smoker will reduce annual
      manufacturer profits a billion dollars plus per year.‖
Tobacco Industry Expenditures

  In 2006 the Tobacco Industry spent $12.49
   billion on advertising and promotion in the U.S.
  Approximately $1.01 billion was spent in
   Texas in 2006 (over $2.76 million every single
   day)
  Approximately $41.75 million was spent in
   Travis County in 2006 ($114,400 every single
   day)
Corner Store by Anderson HS
Criteria for Evaluating Economic
Studies
    Based on objective data (i.e. sales tax)
    Includes data for a sufficient time period
     before and after the ordinance
    Accounts for underlying economic trends
    Uses appropriate statistical methods
    In peer-reviewed literature
    Source of funding




                                                  33
Texas Economic Studies
Methods
    Quarterly data obtained from the Texas
     Comptroller‘s Office
        Taxable restaurant, bar and mixed beverage sales
        Total retail sales
    Linear regression model to assess the
     economic impact of clean indoor air
     ordinances




                                                            34
                                   Figure 1. Gross Restaurant, Bar and Mixed Beverage Revenues
                                            By Fiscal Quarter*—El Paso, Texas, 1990-2002
                             140

                             120
Gross Revenue ($ Millions)




                             100

                              80

                              60
                                                                         Smoking Ban in effect January 2, 2002
                              40

                              20

                               0
                                1990        1992           1994           1996           1998          2000   2002
                                                                           Year
                                             Restaurants          Bars       Mixed Beverage Revenues
                                          * First fiscal quarter of each year is January 1 –March 31
                                                                                                                 35
                              Figure 2. Restaurant, Bar and Mixed Beverage Revenues, Percent of
                                           Total Retail Revenues by Fiscal Quarter*—
                                                   El Paso, Texas, 1990-2002

                            10%
% of Total Retail Revenue




                            8%


                            6%


                            4%                                         Smoking Ban in effect January 2, 2002


                            2%


                            0%
                              1990       1992           1994            1996            1998         2000      2002
                                                                          Year
                                           Restaurants          Bars       Mixed Beverage Revenues

                                        * First fiscal quarter of each year is January 1 –March 31               36
           Austin Total Bar Sales by Quarter
                                               Ordinance

40000000
30000000
20000000
10000000
       0
      00


              01


                     02


                            03


                                   04


                                          05


                                                   06
     20


             20


                    20


                           20


                                 20


                                        20


                                                 20
                                                      37
             Austin Mixed Beverage Sales
                                                  Ordinance
35000000
30000000
25000000
20000000
15000000
10000000
 5000000
       0
           2000


                  2001


                           2002


                                  2003


                                         2004


                                                2005


                                                         2006
                         Total    Bars   Restaurants
                                                                38
Summary

    2003 study offered a comprehensive view of all available studies on the
     economic impact of smoke-free workplace laws (Over 97 studies, including 34
     with smoke-free bars)
    The study concluded that:

     “All of the best designed studies report no impact or a positive
     impact of smoke-free restaurant and bar laws on sales or
     employment. Policymakers can act to protect workers and
     patrons from the toxins in secondhand smoke confident in
     rejecting industry claims that there will be an adverse economic
     impact.”


                                             Scollo M, et al, Review of the quality of studies on the
                                          economic effects of smoke-free policies on the hospitality
                                                       industry, Tobacco Control (2003); 12:13-20.
                                                                                              39
Poor Quality Literature on Smoke-Free
Bars and Restaurants

   Supported by Tobacco Industry
   Survey of bar owners on predicted impacts or
    anecdotal information
   Bizarre time periods or inappropriate control
    groups for comparison
   Non-peer reviewed




                                                    40
Plausibility

   In Texas there are over 4 times as many adult
    non-smokers as smokers
   Prior experiences
         Airline bans
         Movie theatres
     Texas Adult Survey




                                                    41
Texas Adult Survey (BRFSS)
2009
    If there were a total ban on smoking in
     restaurants, would you eat out:
        More often       27%
        Less often        6%
        No difference    67%




                                               42
Texas Adult Survey (BRFSS)
2009
    If there were a total ban on smoking in bars
     and music clubs, would you go to bars and
     music clubs:
        More often       19%
        Less often        8%
        No difference    73%




                                                    43
―Back in 2002, when the City Council was weighing Mayor Michael R.
Bloomberg‘s proposal to eliminate smoking from all indoor public
places, few opponents were more fiercely outspoken than James
McBratney, president of the Staten Island Restaurant and Tavern
Association.

He frequently ripped Mr. Bloomberg as a billionaire dictator with a
prohibitionist streak that would undo small businesses like his bar and
his restaurant. Visions of customers streaming to the legally smoke-
filled pubs of New Jersey kept him awake at night.

Asked last week what he though of the now two-year-old ban, Mr.
McBratney sounded changed. ―I have to admit,‖ he said sheepishly,
―I‖ve seen no falloff in business in either establishment.‖ He went on to
describe what he once considered unimaginable: Customers actually
seem to like it and so does he.
                          New York Times Feb 6, 2005               44
CDC Communities
Putting Prevention
to Work Grant
Austin/Travis County CPPW
Award
    Awarded $7.47 Million over 2 years to address
     tobacco
    One of 44 communities selected (out of 263
     applicants)
    Extremely tight timelines
    Expectation to perform
    ―The world is watching‖
    Implications for future funding
Health Care Reform Legislation

SEC. 4002 PREVENTION AND PUBLIC HEALTH FUND
  (a) PURPOSE.—It is the purpose of this section to establish a Prevention and
   Public Health Fund (referred to in this section as the ‗‗Fund‘‘), to be
   administered through the Department of Health and Human Services, Office
   of the Secretary, to provide for expanded and sustained national investment
   in prevention and public health programs to improve health and help restrain
   the rate of growth in private and public sector health care costs.

 (b) FUNDING.—There are hereby authorized to be appropriated to the Fund,
   out of any monies in the Treasury not otherwise appropriated—
     (1) for fiscal year 2010, $500,000,000;
     (2) for fiscal year 2011, $750,000,000;
     (3) for fiscal year 2012, $1,000,000,000;
     (4) for fiscal year 2013, $1,250,000,000;
     (5) for fiscal year 2014, $1,500,000,000; and
     (6) for fiscal year 2015, and each fiscal year thereafter, $2,000,000,000.
CPPW Strategies

Emphasize high-impact,
 broad-reaching
Policy,
Environmental
Systems changes
Policy, Systems & Environmental
Change


   What they mean is,
      overcome the
   Stickiness Problem.
                       Exercise Participation
                       Effect of Short Bouts, Home Treadmills
                       (Jakicic et.al., JAMA 282, 16)

                      240
Exercise (min/week)




                                                                ?
                      180                                                  LB
                                                                           SB
                      120                                                  SBT



                      60
                            0            6              12      18
                                              months
                                                             mark.fenton@verizon.net
                       Exercise Participation
                       Effect of Short Bouts, Home Treadmills
                       (Jakicic et.al., JAMA 282, 16)

                      240
Exercise (min/week)




                      180                                                  LB
                                                                           SB
                      120                                                  SBT



                      60
                            0            6              12      18
                                              months
                                                             mark.fenton@verizon.net
Self-help vs. Commercial
Weight Loss Programs
     (Heshka et.al., JAMA 289, 14; April 9, 2003)

                    0
Weight Change, kg




                    -1
                    -2
                    -3
                    -4
                    -5
                                                        Self-help
                    -6
                                                        Commercial
                    -7
                         0   6            12   18         24
                                 months

                                                    mark.fenton@verizon.net
MAPPS Strategies

  Media,
  Access,
  Pricing,
  Point of Purchase   Prompts,
  Social Support
Media
Access: Tobacco-Free Policies
and Laws
  Only way to protect non-smokers from secondhand
   smoke
  Saves lives and prevents heart attacks (up to 17%
   average reduction in heart attack hospitalizations
   where smoke-free laws enacted)
  Changes the social norm
  Helps motivate smokers to quit
  Worker safety issue - not ―personal nuisance‖
 All workers deserve equal protection
  Smoke-free workplace laws don‘t hurt business
  No trade-off between health and economics
Access

    Tobacco-Free Worksite Policies
    Support Tobacco-Free School Policies
    Tobacco-Free Parks and Recreation
    Disparities focus – Tobacco-Free policies with
     supporting cessation services for:
         Human service agencies
         Integral Care,
         Homeless Shelters
         Public Housing
    Tobacco –Free Healthcare Facilities (with system changes to
     promote cessation)
    Tobacco-Free University Policies
100% Smokefree Ordinances

    28 States – Arizona, California, Colorado,
     Connecticut, Delaware, Hawaii, Iowa, Illinois, Kansas
     (July 2010), Maine, Maryland, Massachusetts,
     Michigan (May 2010), Minnesota, Montana,
     Nebraska, New Hampshire, New Jersey, New
     Mexico, New York, North Carolina, Ohio, Oregon,
     Rhode Island, Utah, Vermont, Washington and
     Wisconsin have passed 100% smokefree legislation
     that cover restaurants and bars.
    Many major centers for tourism now totally smoke-
     free including: Washington D.C., Los Angeles, San
     Francisco, San Diego, New York City, Boston


                                                             57
100% Smokefree in Texas (25)

    Abilene, Alton, Austin, Baytown, Beaumont,
     Benbrook, College Station, Copperas Cove,
     Corpus Christi, Dallas, El Paso, Flower
     Mound, Galveston, Granbury, Houston,
     Laredo, Marshall, Pearland, Plano, San
     Antonio, Socorro, Southlake, Tyler, Vernon,
     Victoria




                                                   58
                                                    Total Cigarette Sales and Cigarette Prices


                              30000
                                                                                                                                  $3.70

                              28000
Total Sales (million packs)




                                                                                                                                  $3.20




                                                                                                                                          Real Cigarette Price
                              26000

                                                                                                                                  $2.70
                              24000


                                                                                                                                  $2.20
                              22000


                                                                                                                                  $1.70
                              20000



                              18000                                                                                               $1.20
                                      1970   1973   1976   1979     1982     1985     1988   1991   1994     1997   2000   2003
                                                                                    Year

                                                           Cigarette Sales (million packs)   Real Cigarette Price
Point-Of-Purchase

  Restrict point of purchase advertising
  Labeling/ signage/ placement to discourage
   consumption of tobacco
Social Support

  Promote the Statewide Telephone Quitline
   (Including Free Nicotine Replacement)
               1-877-Yes-Quit
  Create a Community Cessation Resource
   Available for Referral
Typical Long-Term Abstinence Rates

         Intense     Brief   Minimal
         Therapy     Therapy Therapy

 Medication   25%      12%      8%

 No Medication 12%      6%       4%
Typical Usage Rates

              Intense   Brief     Minimal
              Therapy   Therapy   Therapy

 Medication     1%        8%       11%

 No Medication 1%         7%       72%
Cessation services save lives and are an
important part of a comprehensive program
  • 70% of U.S. adult smokers report they want to
    quit
  • Quitting is hard, but most Americans who have
    ever smoked have already quit
  • Immediate health benefits to quitting, even in
    long-time smokers
  • Telephone counseling (quitlines) and low out-of-
    pocket costs for treatment increase
    uptake
  • Cessation services can double or triple quit rate
    –
Outcomes
Heart Attack Deaths Decline 3 Times Faster in
    County with Anti-Tobacco Campaign


                                Heart Attack Death Rates, age-adjusted

                          140

                          120
    Per 100k population




                          100

                           80

                           60

                           40

                           20

                            0
                                2000         2001          2002        2003



                                 Harris County      Jefferson County   TEXAS
How Can We Work Together
NEW COMPANY U.S. POLICY (2009)

  In support of our current policy and the health and welfare of its
  employees, the use of all tobacco products on COMPANY
  property is prohibited. This policy shall apply to all people,
  including contractors and visitors, visiting or working at all
  COMPANY U.S. locations.

  ―COMPANY property‖ shall refer to all COMPANY property,
  whether owned or leased, including office buildings, facilities,
  parking lots, personal vehicles on COMPANY properties. This
  policy is applicable 24 hours a day, 7 days a week.

  COMPANY‘s security team shall inform all contractors and
  visitors of policy. Leadership and site management team shall
  inform all employees of this policy and of disciplinary measures
  for noncompliance.



                                                                       68
WHY TOBACCO FREE?

  Provide environment supportive of health
  Reduce site maintenance costs and support
   COMPANY‘s Green initiative




                   DELL CONFIDENTIAL           69
TFC Project Plan Summary
 1.   Gather employer benchmarking information
 2.   Develop cross-functional team representing key departments at
      all US sites (Facilities/EHS, Security, HR/Legal, and Benefits)
 3.   Develop detailed communication plan & share with
      stakeholders
 4.   Implement enhanced Tobacco Cessation Resources
 5.   Collect and address team concerns (interviews/updates)
 6.   Review information about smoking from employees through
      Employee Storm
 7.   Finalize policy and enforcement
 8.   Train US Security, HR, and managers
 9.   Reinforce Tobacco-free message
        •   World No Tobacco Day May 31st- COMPANY Global Communication
        •   June- Announce US Tobacco-Free Campuses effective 1/1/09
        •   July-October- Communication Non-Tobacco User Discount
        •   Great American Smoke Out November 20, 2008.
                                                                                       70
        •   January 1st, 2009- US Tobacco Free Campuses & Premium Discount take effect
           Tobacco Free Campus Roles

               Employee                                Manager                                 Security
       Comply 100% with the TFW Policy         Serve as champion and advocate          Remind TFW policy violators of
       As with all Company Policies,            for the TFW Policy                       their need to comply with the
        employees have an obligation to         Provide employee with cessation          TFW while on companyl
        report any violations to security,       information if/when applicable           property
        immediate supervisor, any member        Work with Security, HRG to              Document and report violations
        of management, HR or Ethics.             resolve reported policy violations       of Tobacco-Free Campus policy
       Ask co-workers to respect the           Document                                 to the Security,
        policy, as appropriate                   conversations/corrective action          Supervisor/Manager or
                                                 for each policy violation                designated site Manager, as
                                                Make sure employee questions             applicable
                                                 are promptly answered/resolved



                   HRG                                 Facilities                     Employee Relations
        Coach, educate and support             Establish and maintain Tobacco          Coordinate and promptly resolve
         managers and employees                  Free Workplace signage by                escalated TFW policy
         regarding the TFW policy and            1/1/09 and thereafter.                   violations/communications
         expectations                           Coordinate the removal of               Lead TFW policy interpretations
        Work with Security, Management          current smoking signage by               and consistent applicability
         and ER to promptly resolve and          1/1/09                                   efforts
         document reported incidents            Disassemble current smoking
                                                 areas, ashtrays and smoking
                                                 equipment by 1/1/09
Company Policy
  In support of our current policy and the health and welfare of its
  employees, the use of all tobacco products on COMPANY property is
  prohibited. This policy shall apply to all people, including contractors and
  visitors, visiting or working at all COMPANY U.S. locations.

  ―COMPANY property‖ shall refer to all COMPANY property, whether
  owned or leased, including office buildings, facilities, parking lots,
  personal vehicles on COMPANY properties. This policy is applicable 24
  hours a day, 7 days a week.

  COMPANY‘s security team shall inform all contractors and visitors of
  policy. Leadership and site management team shall inform all
  employees of this policy and of disciplinary measures for
  noncompliance.
How Can We Work Together?
  Share best practices
  Share tools – Employee Survey
  Coordinate cessation support
  Leverage your agency‘s activities
Next Steps:

  Full out effort to implement ARRA tobacco
   initiatives
  Work together on:
        Tobacco-Free Policies
        Cessation support
        Other activities