TOWARD A TOBACCO-FREE CALIFORNIA: Strategies for the 21st Century 2000-2003 Tobacco Education and Research Oversight Committee January 2000 Toward a Tobacco-Free California: Strategies for the 21st Century. 2000-2003 i Foreword On the tenth anniversary of • Members of the Master Plan Tobacco Education the passage of Proposition 99 (the Work Group: David M. Burns, and Research Oversight Tobacco Tax and Health Protection M.D., Jennie R. Cook, Gus T. Committee, 1999 Act of 1988), the Tobacco Education Dalis, Ed.D., Stanton A. Glantz, and Research Oversight Committee Ph.D., and Dorothy P. Rice; (TEROC) presents this fifth Master Jennie R. Cook, Chair • Susanne Hildebrand-Zanki, Plan pursuant to its legislative man- Voluntary Health Organization Ph.D., University of California, date (California Health and Safety Tobacco-Related Disease Code Section 104350-104480). As Lourdes Baézconde-Garbanati, Ph.D. Research Program; directed by the Legislature, this Voluntary Health Organization • Gerald Kilbert, Ed.D. and Rae Master Plan highlights the accom- Kine, California Department of David M. Burns, M.D. plishments and lessons learned by Education, Healthy Kids Tobacco Related Disease Research California’s Tobacco Control Program Program Office; Program during its ten-year history, and sets forth policy and budgetary recom- • Jon Lloyd and Bill Ruppert, mendations for the future. California Department of Health Gus T. Dalis, Ed.D. TEROC’s recommendations are Services, Tobacco Control California Department of Education intended to enhance the California Section, and others in the Tobacco Control Program’s effective- Tobacco Control Section, in par- Thomas C. Paton ness in meeting the Legislature’s ticular Dileep G. Bal, M.D., Doug General Public mandate to reduce tobacco use in Robins, April Roeseler, Carol California. To date, we are more than Russell, Robin Shimizu, and Dorothy P. Rice half-way toward our goal of a tobac- Colleen Stevens; Professional Education co-free state—per capita cigarette • The local programs in schools use has declined by 52%. To contin- and communities throughout George R. Rutherford, M.D., M.P.H. ue the significant movement toward California, without whom the University Faculty a tobacco-free California, TEROC Tobacco Control Program would strongly recommends that tobacco not exist. James W. Stratton, M.D., M.P.H. settlement resources be used to California Department of Health Services Finally, our appreciation is increase funding for the program. extended to Lisa K. Hunter, Ph.D., We would like to thank the many Kenneth A. Wesson Health & Education Communication individuals and their staffs for their Target Population Group Consultants, Berkeley, who served commitment to tobacco control and as consultant to the Committee and for their contributions to this plan. drafted this plan. — Jennie R. Cook, Chair January 2000 “Baby In Playpen” Television Ad, 1995 Statewide Media Campaign Table of Contents iii Table of Contents Foreword ..................................................................................................... i Executive Summary ................................................................................. 1 Chapter 1 Proposition 99 and Tobacco Control in California........................... 7 Establishment of the Program .................................................................... 7 Program Components.................................................................................. 7 Chapter 2 Ten Years of Progress ............................................................................. 11 Progress toward the Goal: Prevalence and Consumption........................ 11 Changes in the Social Environment ........................................................... 15 Program Accomplishments ......................................................................... 16 Chapter 3 Progress Toward TEROC’s 1997-2000 Recommendations............. 21 Chapter 4 Lessons Learned in Tobacco Control .................................................. 33 Overall Lessons from the Program............................................................. 33 Lessons in Health Education ...................................................................... 33 Lessons in Tobacco-Related Disease Research......................................... 35 Chapter 5 Strategies for the 21st Century: TEROC’s Recommendations for 2000-2003 ....................................... 37 References ................................................................................................. 47 “Gala.” Television Ad, 1998 Statewide Media Campaign Executive Summary 1 Executive Summary On the tenth anniversary of the year 1998-99 alone, annual per capi- Master Plan in 1997, the context for passage of Proposition 99 (the ta consumption decreased by 11.5%. tobacco control in California has Tobacco Tax and Health Protection Adult smoking prevalence in undergone major changes. Among Act of 1988), the Tobacco Education California has dropped by more than these is the national tobacco settle- and Research Oversight Committee 25% (from 26.7% in 1988 to 18.4% ment, in which the major tobacco (TEROC) presents this fifth Master in 1998), at a rate faster than the companies agreed to pay hundreds Plan pursuant to its legislative man- nation (prevalence in the United of millions of dollars annually to date. As directed by the Legislature, States went from 30.2% in 1988 to California and other states to settle this Master Plan highlights the accom- 24.7% in 1997). Smoking prevalence lawsuits accusing the tobacco indus- plishments and lessons learned by in 1998 translates to about 4.4 mil- try of fraudulently deceiving the California’s Tobacco Control Program lion smokers in California. public and causing serious harm. In during its ten-year history, and sets Between 1990 and 1993, the 1998, they signed the Master forth policy and budgetary recom- prevalence of cigarette smoking Settlement Agreement with 46 state mendations for the future. among youth aged 12-17 changed little. Since 1995, the youth smoking Background prevalence in the state has declined The California Tobacco Control by 12%. In general, youth prevalence Program was launched in the Spring has remained much lower than in of 1990, and became the largest the rest of the country—for example, tobacco control program in the world. among 10th grade youth who smoked California’s strategy is to create a in the past 30 days, smoking preva- social milieu and legal climate in lence increased by 6.7 percentage which tobacco use is regarded as points in California from 1991 to unacceptable. The program is imple- 1996, as compared with 10.2 per- “Industry Lies.” Billboard, 1999 Statewide mented through statewide public centage points in other states. Media Campaign. health and education networks and The reduction in tobacco con- supported by a research compo- sumption has led to immediate attorneys general. Among its provi- nent. California’s program is now an health benefits for Californians. For sions, the settlement requires the internationally recognized model of example, smoking cessation pro- industry to stop using billboard ads statewide tobacco control. duces almost immediate reductions as of April 22, 1999, and prohibits in heart attacks and strokes and low advertising and promotion strategies Progress Toward a birth-weight infants. Lung and that target youth. Tobacco-Free California bronchus cancer rates in California Since the settlement, the indus- When the Legislature passed AB declined 14.4% between 1988 and try has mounted a massive public 75 in 1989, it set the goal of reduc- 1996, compared with a decrease in relations campaign to clean its cor- ing tobacco use in California by 75% selected other states of only 4%. porate image. The message is that by the end of 1999. Over ten years, Women in California experienced a tobacco use is a fun, hip, and fully California has made impressive decrease in lung cancer incidence of legal activity for people 18 years of progress toward its ambitious goal. 6.7%, compared with an increase in age or older. While running ads sup- Per capita cigarette use has other states of 9.3%. posedly demonstrating their declined by more than a half, and good-citizen concern about smoking smoking among Californians has Changes in the Social by minors, the tobacco companies decreased at a rate faster than that Environment have sharply intensified their ad of the rest of the nation. In fiscal Since the publication of the last campaigns targeting women and Strategies for the 21st Century – 2000-2003 “Oral obsession had its place when you were young. At your age, it’s ridiculous. STOP SMOKING!” Health Through Art: Signs of Recovery, Alameda County Health Department, Oakland, California. 2 ethnic populations. Knowing that Tobacco Control Program has many 1996 and 1998. In these coun- Toward a Tobacco-Free California: youth “model up” to young adults, other notable achievements. Among ties, the percentage of adults the industry has also mounted lavish these are: who asked someone else not to advertising and promotional cam- smoke also increased. • The California Clean Indoor Air paigns that reach young adults in Act (AB 13) was successfully • The vast majority of Californians bars, night clubs, and other venues implemented. The Act includes (83% nonsmokers, 52% smokers) of the young single night life. the smoke-free bar-restaurant were not exposed to secondhand Another important change in provision that went into effect smoke at home or at work. California is the Proposition 10 on January 1, 1998. (California Children and Families • Sixty-six percent of all Act) tobacco tax increase of 50 cents • 74 policies and other local laws Californians in 1998 prohibit per pack of cigarettes passed by restricting tobacco advertising smoking in their homes. The voters in the November 1998 elec- have been passed by California proportion of smokers who pro- tion. Although Proposition 10 funds cities and counties. hibit smoking in their homes early childhood programs, the voter- increased from 22.1% in 1994 to • According to the independent imposed tax is evidence of the strong 38.3% in 1998, a 73.3% increase. evaluation of the program, there anti-tobacco mood in California. How- Non-smokers who prohibit smok- are statistically significant rela- ever, an industry-backed campaign in ing in their household also tionships between program support of an initiative to strike down increased, from 63.2% in 1994 to activities and smoking behavior. Proposition 10 is already underway, 73.4% in 1998, a 16% increase. For example, in counties where with the outcome to be decided in more adults were exposed to • Approximately 89% of children the March 2000 election. tobacco control messages under 6 years of age, and 87% of through at least two different all children and adolescents Program Accomplishments components (media, community, were protected from secondhand In addition to the significant and/or school), adult smoking smoke in the home in 1996. progress made toward reducing cig- prevalence declined between arette consumption, the California Executive Summary 3 • Almost 9 out of 10 Californians to students in grades 5, 7, 9, and placenta to adversely affect (87.7%) in 1998 preferred to eat 11 to assess alcohol, tobacco, pregnancy outcome; and how in smoke-free restaurants. and other drug use. best to intervene with smokeless tobacco users such as high school • Illegal sales of cigarettes to • The Tobacco Education Ethnic and college athletes. Research minors dropped sharply from Networks launched campaigns on secondhand smoke is cited in 30% in 1996 to 13% in 1998. against secondhand smoke nearly every chapter of the (such as the African American • Approximately 26% of the teens CalEPA report on environmental Tobacco Education Network’s who received cessation counsel- tobacco smoke. campaign, “Not in Mama’s ing from the California Smokers’ Kitchen”) and promoting a • Research is more closely Helpline achieved a 90-day quit tobacco-free lifestyle (such as linked to practice through the success. the Hispanic/Latino Tobacco establishment of the Community- Education Network’s World Academic Research Awards • Ninety-seven percent of all school No Tobacco Day). (CARA) and the School-Academic districts have a tobacco-free pol- Research Awards (SARA). icy prohibiting the use of tobacco • Research funded by the Tobacco- by all students, school staff, par- Related Disease Research Lessons Learned in ents, and visitors in district owned Program (TRDRP) has led to Tobacco Control or leased buildings, on district significant contributions to the Many lessons have been learned grounds, and in district vehicles. knowledge of the consequences in ten years about what works and of tobacco use. For example, • Forty-six percent of all school does not work in tobacco control. research has discovered how districts have administered the Overall lessons from California show nicotine affects the brain; how California Healthy Kids Survey that a tobacco control program works smoke components cross the “Truth Versus Advertising.” Print Ad, 1998 Statewide Media Campaign. best when it engages the public from school-based program staff should Recommendation 2: the beginning, aggressively exposes participate in training and the Expand the Tobacco Control tobacco industry deception and infrastructure network developed Program and strengthen its funda- influence, actively advocates for for community-based activities. mental structure, focus, and key smoke-free indoor policies, educates An effective tobacco research messages. The program should (a) about the public health importance program should support a compre- continue to anticipate, vigorously of increasing the cost of tobacco, hensive and balanced research expose, and counter tobacco indus- and involves the entire public. portfolio; be prepared to carry out try tactics; (b) continue to press for An effective community-based an extensive outreach effort to smoke-free workplaces, public Strategies for the 21st Century – 2000-2003 program must be large enough to increase proposals in social, behav- places, events, schools, and homes; compete effectively with the tobac- ioral and policy areas; fund the best (c) increase population-based co industry, even though it does not in relevant biomedical research; smoking cessation activities through match the industry dollar for dollar. and work closely with the agencies the media campaign, the California It employs an anti-tobacco media administering the health education Smokers’ Helpline, and coordination campaign that has a broad, general components of the tobacco control at the local community level; and market focus that directly confronts program. (d) implement strategies (including the tobacco industry and its surro- youth anti-tobacco advocacy to pro- gates. It emphasizes the negative Strategies for the 21st mote smoke-free environments) to aspects of tobacco use for every- Century: TEROC’s reduce youth demand for tobacco, one—adults and youth alike; Recommendations for rather than focusing primarily on promotes smoke-free environments, 2000-2003 youth access. and strengthens the nonsmoking TEROC recommends that the 4 norm and rights of nonsmokers. An California Tobacco Control Program Recommendation 3: effective program coordinates its build on its numerous significant Continue to strengthen and increase Toward a Tobacco-Free California: media campaign closely with com- strengths, and adopt the aggressive accountability of school-based munity-based activities, and tone and rapid response that have tobacco use prevention education responds quickly to changing indus- characterized its most notable suc- programs, consistent with principles try strategies with new media cesses. Most important, TEROC of effectiveness. messages. It emphasizes reducing strongly recommends that approxi- youth demand for tobacco in addi- mately 20% of the resources from Recommendation 4: tion to reducing youth access, and it the tobacco settlement payments to Increase collaboration and commu- uses youth organizations and schools the state be allocated on an annual nication among and between for youth-specific programs that uti- basis to increase the program’s abili- school-based and public health- lize research-based strategies. ty to counter the tobacco industry’s based tobacco control programs. Effective school-based tobacco continued aggressive marketing of control programs seek broad tobacco in California, and to help Recommendation 5: community involvement and are those who use tobacco products The University of California’s integrated with other community- break the chains of their addiction. Tobacco-Related Disease Research based tobacco control programs. (The full text of these recommenda- Program should continue to encour- They concentrate activities in tions appears in Chapter 5.) age and fund research that makes middle/junior and senior high schools, specific contributions to tobacco rather than elementary schools, and Recommendation 1: control. adopt strategies that research shows Increase funding for the California to be effective. They utilize a Tobacco Control Program so that it Recommendation 6: competitive grants model in addi- can build on past successes and The Administration should implement tion to funding allocations based take advantage of new opportunities policies and procedures to assure on entitlement formulas. Finally, to reduce tobacco consumption rapid development and approval of rapidly. Executive Summary 5 the media campaign to permit the rate compliance with the California Recommendation 10: campaign to respond quickly to the Smoke-free Workplace Act in deci- Continue to coordinate Proposition changing environment. sions regarding bar license 99-financed programs with State, approvals, suspensions, and Federal, and other tobacco control Recommendation 7: renewals. initiatives. Medically-mediated nicotine-depen- dent treatment should be a benefit Recommendation 9: Recommendation 11: of the health care delivery system. The California Children and Settle the outstanding litigation left Families State Commission should over from the previous Recommendation 8: encourage local commissions to Administration to increase funding The Department of Alcoholic include objectives for tobacco con- for tobacco control efforts. Beverage Control should incorpo- trol in their strategic plans. “Leather Jacket.” Print Ad and Billboard, 1997 Statewide Media Campaign. “Better.” Television Ad, 1997 Statewide Media Campaign. Chapter 1 — Proposition 99 and Tobacco Control in California 7 Proposition 99 and Tobacco Control in California When the people of California Establishment of the Education and Research accounts is passed Proposition 99, the Tobacco Program carried out by the Tobacco Education Tax and Health Protection Act of In November 1988, California and Research Oversight Committee 1988, they created a comprehensive voters approved the historic ballot (TEROC), whose members are program to address the devastating initiative called Proposition 99 that appointed by the Governor, the and costly toll of tobacco use on the increased the tax on each pack of Legislature, and the Superintendent health of Californians. The history cigarettes sold in California by 25 of Public Instruction. of the program is the story of cease- cents, effective January 1, 1989. The The Tobacco Control Section less struggle against an industry that proposition established the Cigarette (TCS) of the California Department has deceived the public about the and Tobacco Products Surtax Fund, of Health Services (DHS) adminis- health effects and addictiveness of and specified that the funds would ters the public health aspects of the its products, and persists in aggres- be spent for: Health Education program. This network includes 61 sively marketing those products to (20% for community and school- local health departments, four eth- addict new generations of young based tobacco education and nic networks, 11 regional community Californians. prevention programs); Research linkage projects, approximately 90 This Master Plan expresses the (5% for research on tobacco-related community-based organizations, a Tobacco Education and Research diseases); Hospital Services (35% Oversight Committee’s assessment for treatment of medically indigent of the program’s progress and pro- hospital patients); Physician vides recommendations on how it can Services (10% for treatment of be improved. This is the fifth Master medically indigent patients by Plan in the history of the Tobacco physicians); Public Resources (5% Control Program, and is written as the for the protection of wildlife habitat program reaches its tenth anniver- and programs to enhance park and sary. The plan provides a brief recreation resources); and Unallo- overview of the program, reports on cated (25% to be distributed by the progress towards the legislative goal Legislature to any of the other of reducing tobacco consumption in accounts). the state by 75% within a decade,1 and describes other major accom- Program Components plishments since the inception of World No Tobacco Day. American Lung Association The Tobacco Control Program Superior Branch, North Valley Region. the program.2 The plan also presents was launched in the Spring of 1990 an analysis of the valuable lessons with funds from the Health statewide media campaign, and that have been learned along the Education Account. It became other statewide support systems. way, and sets forth recommenda- the largest tobacco control program The Healthy Kids Program Office tions to guide the program over the in the world. Oversight of the pro- (HKPO) of the California next three years. grams funded by the Health Department of Education (CDE) 1 Health and Safety Code Sections 104350-104480. 2 Previous Master Plans provide complete descriptions of the history and structural components of the Tobacco Control Program. They are avail- able from the Tobacco Control Section, Department of Health Services, Sacramento, CA, (916) 327-5425. administers the school-based com- Tobacco-Related Disease Research Figure 2 ponent of the program, which Program is listed on page 38 of this Tobacco Use Prevention involves 58 county offices of educa- report. Figures 1, 2, and 3 show the Education Funding Components, tion and nearly 1,000 school districts. comparative allocations for program California Department of The University of California components for these three institu- Education, 1999–2000 (millions) administers the Tobacco-Related tions. Disease Research Program (TRDRP) with funds from the Research Figure 1 Grades 4-8 Entitlement Account. TRDRP funds research 22% ($6) Strategies for the 21st Century – 2000-2003 Grades 9-12 Tobacco Control Section Competitive Grants that leads to improved approaches 54% ($15) Funding Components, Department to the prevention, diagnosis, and of Health Services, 1999–2000 treatment of tobacco-related illness (millions) and to increasing the effectiveness of the California Tobacco Control Administration 3% ($1) Other Local Assistance 2% ($.8) Program. Local Lead Agencies County Offices of Education 14% ($3.8) Competitive Grants The current budget for Fiscal Year 29% ($17.7) 29% ($17.4) Innovative Programs 5% ($1.5) 1999-2000 for the Department of Health Services, the California Media Campaign 33% ($19.6) Department of Education, and the Administration 2% ($1.0) Evaluation 7% ($4.4) 8 Toward a Tobacco-Free California: “Coffin.” Billboard, 1999 Statewide Media Campaign. Chapter 1 — Proposition 99 and Tobacco Control in California 9 Figure 3 California’s strategy is to create a social milieu and legal climate in which tobacco use is regarded as unacceptable—to denormalize smoking Tobacco-Related Disease Research and other tobacco use. This approach engages everyone—smokers and Program Funding Components, nonsmokers alike. University of California, 1999-2000 (millions) The community-based component of the Tobacco Control Program has four broad priority areas: Administration • Eliminate exposure to secondhand smoke 5% ($.3) • Counter pro-tobacco influences Competitive Research Grants 95% ($5.7) • Reduce the marketing and illegal sale of tobacco to youth • Provide cessation services The program’s media campaign promotes three core messages that are reinforced by local program activities: The activities of these three institutions together create a • The tobacco industry lies statewide coordinated, comprehen- • Secondhand smoke kills sive program that has changed social norms toward a smoke-free • Nicotine is addictive California. The school-based component of the program seeks to reduce the use of tobacco by youth by providing students with information and skills to help them resist the tobacco industry. The goals of the research component of the program are to enhance under- standing of tobacco use and tobacco-related diseases, and to develop more effective interventions for their prevention and treatment. “Jungle.” Television Ad, 1998 Statewide Media Campaign. Chapter 2 — Ten Years of Progress 11 Ten Years of Progress The California Tobacco Control This is twice as great as the population. For example, smoking Program is an internationally recog- decline during the same period cessation produces almost immedi- nized model of statewide tobacco in the rest of the nation. In fiscal ate reductions in heart attacks and control. In the ten years of its exis- year 1998-99 alone, annual per strokes (Lightwood and Glantz, tence, the program has made substan- capita consumption dropped 1997) and low birth weigh infants tial progress towards a tobacco-free by 11.5%. (Lightwood, Phibbs, and Glantz, California. This chapter describes 1999). The California Tobacco Control • Adult smoking prevalence in changes in smoking prevalence and Program has prevented 98,100 hos- California has dropped by more cigarette consumption, changes in pitalizations for heart attacks and than 25% (from 26.7% in 1988 the social environment regarding strokes (Lightwood and Glantz, to 18.4% in 1998), at a rate tobacco, and some of the major pro- 1997). The Department of Health faster than the nation (preva- gram accomplishments that are Services estimates that the declines lence in the United States went leading to a tobacco-free California. in smoking prevalence over the past from 30.2% in 1988 to 24.7% in ten years will save $3.2 billion in 1997). Smoking prevalence in Progress Toward the direct medical costs. 1998 translates to about 4.4 Goal: Prevalence and Lung and bronchus cancer rates million smokers in California. Consumption in California declined 14.4% between When the Legislature passed AB • Between 1990 and 1993, the 1988 and 1996, compared with a 75 in 1989, it set the goal of reducing prevalence of cigarette smoking decrease in SEER regions of only tobacco consumption in California among youth 12-17 years of age 4%.3 While women in California by 75% by the end of 1999. By com- changed little. Since 1995, the experienced a decrease in lung parison, the Health Objectives for youth smoking prevalence in cancer incidence of 6.7%, women the Nation seek to reduce adult California has declined by 12%. in other SEER regions experienced smoking prevalence to a level of In general, youth prevalence in an increase of 9.3%. 15% by 2000. California has made California has remained much 4 Adult Smoking Trends impressive progress toward its lower than the rest of the coun- In 1988, 26.7% of California ambitious goal. Per capita cigarette try (for example, among 10th adults smoked, compared with use has declined by more than a half grade youth, the prevalence of 18.4% in 1998. This is considerably since the program was launched in those who smoked in the past 30 lower than the latest (1997) nation- 1989, and smoking among Calif- days increased by 6.7 percentage al figure of 24.7%. Figure 4 ornians has decreased at a rate faster points in California from 1991 to compares adult smoking prevalence than that of the rest of the nation. 1996, as compared with 10.2 per- for California and the United States centage points in other states). Since the passage of Prop 99: between 1974 and 1998. The reduction in tobacco con- • The per capita consumption of sumption has led to immediate cigarettes has declined 52%. health benefits for the California 3 Surveillance, Epidemiology, End Results (SEER) registries in Connecticut, Detroit, Hawaii, Iowa, New Mexico, Seattle, Utah, and Atlanta were compared with the California Cancer Registry for this analysis. 4 Data for adult smoking behavior come from the California Adult Tobacco Survey (CATS), conducted annually since 1994 by the Cancer Surveillance Section of the DHS; and the California Tobacco Survey (CTS), conducted in 1990, 1992, 1993, 1996, and 1998 by the University of California, San Diego. These surveys are conducted with random samples of households through computer assisted telephone household interviews. CATS has a sample of 4,000 adults per year; CTS has 78,000 adults in each survey. Figure 4 Adult Smoking Prevalence for California and the United States, 1974–1998 50 40 PREVALENCE (%) 30 Strategies for the 21st Century – 2000-2003 United States California 20 10 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 YEAR Source: 1990-1993 CTS is weighted to 1990 California population, 1994-1998 BRFS/CATS is weighted to the 1990 California popultiaon. U.S. and California data from 1997 to 1988 from NHIS. Note definition change in 1995 to include more occasional smokers. Since the passage of Proposition 99 in 1988, California’s annual adult per capita cigarette consumption declined 52% from 126.6 packs per year to 61.3 packs per year. For the twelve months ending June 30, 1999 there was an 11.5% decline in the adult per capita consumption rate compared to the twelve months ending June 30, 1998. Per capita consumption in the United 12 States went from 154.8 packs per year in 1988 to 106.8 packs per year in 1999. Figure 5 displays the rate of cigarette consumption between 1980 and Toward a Tobacco-Free California: 1999 in California and the United States. Figure 5 Adult Per Capita Consumption of Packs of Cigarettes, California and the United States, Fiscal Years 1980–1998 250 200 PACKS/PERSON 150 100 United States California 50 80/81 81/82 82/83 83/84 84/85 85/86 86/87 87/88 88/89 89/90 90/91 91/92 92/93 93/94 94/95 95/96 96/97 97/98 98/99 YEAR Source: CA — California State Board of Equalization (packs sold). California Department of Finance (population). U.S. — U.S. Department of Agriculture. Note that CA data is by fiscal year (July 1 – June 30) and U.S. data is by clendar year. Age Since 1990, the prevalence of smoking has declined in each age group except for those between the ages of 18-24. Rates for ages 25-64 appear to have changed little since 1994, but these trends are affected by a change in the definition of “smoker” in 1996 to include more occasional smokers, which Chapter 2 — Ten Years of Progress 13 increases the prevalence of smoking by approximately 1%. Rates for the 18- 24 age group rose above the rates for the 25-44 and 45-64 age groups after 1995, and are increasing. The actual increase is less than it appears in Figure 6 because of the change in definition. Figure 6 shows adult smoking preva- lence by age group between 1990 and 1998. Figure 6 California Smoking Prevalence by Age Group, 1990–1998 25 20 PREVALENCE (%) 15 10 25-44 45-64 5 18-24 65+ O 1990 1991 1992 1992 1994 1995 1996 1997 1998 YEAR Source: 1990-1993 CTS is weighted to 1990 California population. 1994-1998 BRFS/CATS is weighted to the 1990 California popultiaon. Note definition change in 1995 to include more occasional smokers. Gender The prevalence of smoking among adult males and females has declined substantially since 1990, but the prevalence of smoking for both genders has remained fairly stable since 1994. Males have had consistently higher smoking prevalence rates than females with approximately the same difference in Tehama County Health Agency, prevalence in 1990 as in 1998. STATIS (Stand Tall Against Teen Issues), RB Round-up Parade. Figure 7 California Adult Smoking Prevalence by Gender, 1990–1998 30 25 20 PREVALENCE (%) 15 10 Male Female 5 O 1990 1991 1992 1992 1994 1995 1996 1997 1998 YEAR Source: 1990-1993 CTS is weighted to 1990 California population. 1994-1998 BRFS/CATS is weighted to the 1990 California popultiaon. Note definition change in 1995 to include more occasional smokers. Race/Ethnicity Between 1990 and 1998, the prevalence of smoking declined among the major racial and ethnic groups. However, between 1994 and 1998, rates for all the groups except Hispanic did not change significantly. The rates for Hispanic Californians rose from 12% in 1994 to 15% in 1998. The prevalence for Non-Hispanic whites changed little from 1994 to 1998, hovering around 20%, the highest rates among the four race/ethnicity groups presented. For African Americans, the prevalence rate was highest in 1997 at 25% and declined to 19% in 1998. Asian/others have the lowest smoking rates at 13% Strategies for the 21st Century – 2000-2003 in 1998. Figure 8 California Age-Adjusted Smoking Prevalence by Race/Ethnicity, 1994–1998 25 20 PREVALENCE (%) 15 10 African American Asian/Other 14 5 White Toward a Tobacco-Free California: Hispanic O 1994 1995 1996 1997 1998 YEAR Source: 1994-1998 BRFS/CATS is weighted to the 1990 California popultiaon. Note definition change in 1995 to include more occasional smokers. Youth Smoking Trends5 Youth continue to become addicted to tobacco. Between 1990 and 1993, smoking among youth aged 12-17 remained relatively steady at around 9% at a time when teen smoking was increasing nationally. Between 1993 and 1995 adolescent smoking prevalence increased from 9% to 12.1%. Since 1995, 12- 17 year old smoking prevalence declined by 12%.6 “Oakland A’s Strike Out Smoking.” American Lung Association and 5 Data on youth smoking prevalence come from the California Youth Tobacco Survey (CYTS), Alameda County Tobacco Control, conducted annually with 2,000 youth (aged 12-17) by the Cancer Surveillance Section of the 1999. DHS; and from the California Tobacco Survey (CTS) conducted annually with 6,000 youth by the University of California, San Diego. 6 The increase from 1993 to 1994 corresponds with a change from CTS to CYTS data. Part of the increase may be an artifact of slight differences between the two surveys in data collec- tion methods and protocols. In addition, caution must be exercised when comparing California youth smoking data with youth smoking data for other states, the nation as a whole, or other countries because survey methods may be different (for example, telephone versus classroom-administered surveys). Chapter 2 — Ten Years of Progress 15 Figure 9 Changes in the Social Environment 30-Day Smoking Prevalence for California 12–17 Year Olds, Since the publication of the last Telephone Survey, 1990–1998 Master Plan in 1997, the context for 15 tobacco control in California has undergone some major changes. 12 Among these changes is the nation- al tobacco settlement. The major PREVALENCE (%) 9 tobacco companies agreed to pay 6 hundreds of millions of dollars CTS/CYTS annually to California and other 3 states to settle lawsuits accusing the tobacco industry of fraudulently O deceiving the public and causing 1990 1991 1992 1992 1994 1995 1996 1997 1998 YEAR serious harm by promoting the use 1990-1993 CTS weighted to 1990 California population with 4 race and 2 age groups. of unsafe products. In November 1994-1998 CYTS weighted to 1990 California population with 4 race and 3 age groups. is 95% Confidence Limits Note: The break in the trending indicates the change in surveys. 1998, they signed the Master Settlement Agreement (MSA) with No differences exist in youth smoking prevalence between males and 46 state attorneys general. females. Whites have had the highest youth smoking prevalence, followed by In addition to the payments, the Hispanics, Asians/others and African Americans. Differences by age group MSA mandates changes in the also exist. Since 1994, smoking prevalence in the 14-15 and 16-17 age groups behavior of the industry, including has declined but in the 12-13 age group it has increased. specific prohibitions against adver- Data that allow comparison of smoking rates among California tenth tising and promotion strategies that graders with smoking rates among tenth graders outside California from 1991 target youth. The most visible is the to 1996 indicate that the rates of smoking among the California youth are elimination of tobacco ads on bill- substantially lower. boards, effective April 22, 1999. The MSA also requires the tobacco Figure 10 industry to fund an independent foundation (subsequently named Percent of Tenth Grade Youth Who Smoked During the Past 30 Days, the American Legacy Foundation) 1991–1996 for five years to carry out a large 35 national anti-tobacco media cam- 30 paign directed at youth. The annual 25 settlement payments to California start out at nearly $1 billion and 20 PERCENT decline in future years in proportion 15 to declines in tobacco sales. Half of Other States 10 the annual payments to California California will go to local governments and 5 half to the state. The payments may O be used as the recipients choose. 1991 1992 1993 1994 1995 1996 YEAR The settlement provisions will have Source: Monitoring the Future Survey, 1992-1996 (a national classroom-administered survey). an impact on the policy environment, the media campaign, and local pro- gram planning in California. While the settlement dollars are large, they in fact represent only about 30 cents on the dollar repayment for the costs imposed by the tobacco industry on taxpayers for tobacco-related med- The tobacco industry is sponsor- through at least two different ical services (Zhang et al., 1999). It ing an initiative (Proposition 28) on components (media, community, is still imperative that every effort be the March 2000 ballot to repeal the and/or school). Only 2% of made to reduce tobacco use as Proposition 10 tobacco tax increase. adults, 5% of 8th graders and quickly as possible. Should their efforts succeed, tobac- 4% of 10th graders report no Since the settlement, the co consumption will increase to the exposure to any programs (pre- industry has mounted a massive benefit of the tobacco industry and liminary results, Wave 2 Data, public relations campaign to clean the detriment of the health of the Independent Evaluation). its corporate image. The message people of California. Strategies for the 21st Century – 2000-2003 • In counties with high multi-com- is that tobacco use is a fun, hip, ponent exposure, adult smoking and fully legal activity for people Program Accomplishments prevalence declined between 18 years of age or older. While In addition to these major changes 1996 and 1998. In these counties running ads supposedly demon- in the greater tobacco landscape, the there were increases in the per- strating their good-citizen concern Tobacco Control Program has re- centage of adults who asked about smoking by minors, the duced illegal sales of tobacco to youth, someone else not to smoke. By tobacco companies have sharply assisted communities in passing comparison, in counties with low intensified their ad campaigns anti-tobacco ordinances, increased to moderate multi-component targeting women and ethnic popu- the number of work sites and homes exposure, adult smoking preva- lations. Knowing that youth also that are smoke-free, and successful- lence remained constant or “model up” to young adults, the ly countered pro-tobacco influences increased (preliminary results, industry has also mounted lavish in communities in every region of Wave 2 Data, Independent advertising and promotional cam- the state. In addition, the indepen- Evaluation). 16 paigns that reach young adults in dent evaluation of the program shows bars, night clubs, and other venues that there are statistically significant • The proportion of smokers who Toward a Tobacco-Free California: of the young single night life. relationships between these out- prohibit smoking in their homes Another important change in comes and program activities.7 increased from 22.1% in 1994 to California is the tobacco tax increase Among the program’s notable 38.3% in 1998, a 73.3% increase. passed by voters in the November achievements are these: The proportion of non-smokers 1998 election. Effective on January 1, who prohibit smoking in their • The California Clean Indoor Air 1999, Proposition 10, the California household also increased, from Act (AB 13) was successfully Children and Families Act, increased 63.2% in 1994 to 73.4% in 1998, implemented. The Act includes the California tobacco surtax by 50 a 16% increase. Sixty-six percent the smoke-free bar and bar- cents per pack of cigarettes and an of all Californians in 1998 prohib- restaurant provision that went equivalent amount on other tobacco it smoking in their homes into effect on January 1, 1998. products. Although Proposition 10 (Department of Health Services, funds early childhood programs, the • 74 policies and other local laws 1999). voter-imposed tax is evidence of the restricting tobacco advertising • Approximately 89% of children strong anti-tobacco mood in have been passed by California under 6 years old, and 87% of all California, and the increased cost of cities and counties (Technical children and adolescents were tobacco itself is already making Assistance Legal Center, 1999). protected from secondhand inroads into consumption. • Most Californians were exposed smoke in the home in 1996. to tobacco control messages 7 Extensive detailed evaluation about the Tobacco Control Program may be found in two recent reports that are available from the Tobacco Control Section, Department of Health Services. They are Tobacco Control in California: Who’s Winning the War? (An Evaluation of the Tobacco Control Program, 1989-1996) (University of California, San Diego); and The Final Report of the Independent Evaluation of the California Tobacco Control Prevention and Education Program: Wave I Data, 1996-1997 (The Gallup Organization). Results from the Wave 2 Data from the Independent Evaluation Consortium are forthcoming. Chapter 2 — Ten Years of Progress 17 Figure 11 was 12.5% (Centers for Disease school (preliminary results, Wave Control, 1997). 2 Data, Independent Evaluation). Percent of Smokers Who Live with Children and Also Prohibit • The percent of smokers who • More than 9 out of 10 adults Smoking in Their Home, prefer to eat in restaurants that (91%) saw or heard at least one 1994-1998 are smoke-free substantially general media campaign ad in 49.6% increased from 44.3% in 1994 to 1998; 95% of eighth graders and 50 47.7% 44.2% 63.7% in 1998. For non-smokers, of tenth graders were exposed to 40 36.9% 39.0% the percent that prefer to eat in at least one ad (preliminary smoke-free restaurants has been results, Wave 2 Data, 30 PERCENT stable at around 93%. Almost 9 Independent Evaluation). 20 out of 10 Californians (87.7%) in 12.4% • Adults and youth with greater 1998 prefer to eat in smoke-free 10 exposure to the media were restaurants (Department of more likely to have anti-tobacco 0 1996 1994 1995 1996 1997 1998 Health Services, 1999). U.S. California attitudes and beliefs, and adults Source: U.S. combined BRFS data; CA-CATS. • Opinion leaders in education, were more likely to prefer Prepared by: California Department of Health Services, Tobacco Control Section, December 1999. law enforcement, government, smoke-free bars (preliminary business, and the media have a results, Wave 2 Data, • The proportion of smokers with high level of awareness of and Independent Evaluation). children living with them who participation in tobacco control • Adults with greater media cam- prohibit smoking in their home activities, and have high exposure paign exposure were more likely rose from 36.9% in 1994 to 49.6% to and recall of the statewide to ask someone not to smoke; in 1998 (Department of Health media campaign. They support youth with greater exposure had Services, 1998; California Adult the smoke free bar law. They also lower rates of tobacco use (ciga- Tobacco Survey, 1998). As shown support policies to conduct rettes, cigars, and smokeless in Figure 11, the comparable rate youth-buy stings, reduce smok- tobacco) in the past 30 days for the nation as a whole in 1996 ing on TV and in films, and ban (preliminary results, Wave 2 tobacco promotional items at Data, Independent Evaluation). Chico Heat baseball players, “Spit-Free Ambassadors.” CALIFORNIA’S • On May 31, 1999, the joint ethnic The California Joint Ethnic Tobacco ETHNIC NETWORKS networks gathered together to Education Network’s Statement is: To assure that the Tobacco celebrate World No Tobacco Day, United in Truth Control Program is meeting the with a focus on the entertainment (Are You Listening?) needs of the state’s diverse ethnic industry. Two individuals from Strategies for the 21st Century – 2000-2003 We, the Joint Ethnic Networks of population, the program’s competitive the Screen Actor’s Guild spoke the State of California, representing grant program specifically targets to over 100 multi-ethnic youth African Americans, African nation- ethnic populations in funding about ways to contact the enter- als, American Indians, Asians, community-based tobacco control tainment industry to discuss Pacific Islanders and Hispanic/Latinos, projects. To facilitate these programs tobacco use and portrayal in the come today united in truth, and effectively, four ethnic networks are industry. speak with one voice to expose the funded as convener organizations for • November 9, 1999, the joint deliberate manipulation by the African Americans, Hispanic/Latino ethnic networks held a press tobacco industry of our women, our populations, Asian/Pacific Islanders, conference in Los Angeles to children, our families and our com- and American Indians. These orga- address issues such as Philip munities. While tobacco companies nizations work to build a strong Morris’s $40 million Virginia try to blind our people by misrepre- statewide coalition among their Slims ad campaign, Marlboro senting themselves as good respective populations that will help Milds, ETS, and the current corporate citizens, they continue to 18 develop the leadership capacity of activities of this corporation to push their deadly products targeting their communities, stimulate coordi- cleanse its public image. Over 30 ethnic communities. Are you listen- Toward a Tobacco-Free California: nated tobacco control activities, and community-based organizations ing? The tobacco industry’s bottom promote the development of effec- and over 16 media outlets were line is profit, not the health and tive community-based tobacco brought together for an aware- well-being of people of color. No control projects. Each network is ness campaign. dollars or public relations campaign funded to support mini-grants. can buy credibility, erase the pain, The ethnic networks have shown • In August, 1998, a Multiethnic heal the wounds or bring back lives they are very effective in promoting Youth Summit was held for over lost to the tobacco industry. We program objectives in their respective 100 Hispanic/Latino, African stand in support of FDA regulation, communities. They have also acted American, American Indian, and in support of the research on sec- as a powerful force in joint efforts, Asian/Pacific Islander youth. ondhand smoke and in support of as in the following initiatives: This advocacy training confer- exposing the continued blatant, ence was planned, organized, deceptive marketing to communities and delivered by youth. of color. The rich traditions of our elders, our languages, and our her- itage are ours to pass on, not the tobacco industry’s to distort. Are you listening? We have spoken! Chapter 2 — Ten Years of Progress 19 • Research funded by the Tobacco- cells, and creating a new class neering studies that demon- Related Disease Research Program of anticancer agents (Illudins) strated how smoke behaves has led to significant contribu- which are more toxic than and is distributed through tions to the knowledge of the conventional chemotherapy. buildings via ventilation sys- consequences of tobacco use. tems, to studies that showed — The relationships of smoking Sample research topics include: the detrimental health effects by pregnant women and of secondhand smoke expo- — How nicotine affects the adverse health effects on preg- sure. The work of TRDRP brain, the receptors involved, nancy outcome, how smoke researchers is cited in nearly the mode of action of nicotine components cross the placen- every chapter of the CalEPA on the receptors, the conse- ta, and when during the report on environmental quences of brain changes in pregnancy exposure to smoke tobacco smoke, and also response to nicotine expo- is the most detrimental. formed the scientific basis for sure, and the addictive nature — Who uses smokeless tobacco California’s Clean Indoor Air of nicotine. products and how best to Act (AB 13). — Improving the risk, diagnosis, intervene with users such as — Research has identified risk and treatment of diseases high school and college ath- factors that promote smoking attributable to smoking, such letes. Research has led to behavior and developed tai- as emphysema, heart disease, interventions that have been lored interventions that are and cancer. Research on novel adopted by the national linguistically and culturally cancer treatments include Association of College and appropriate, contributing to using the body’s immune sys- High School Athletes. understanding differences in tem to fight tumor growth, — Research on secondhand smoking patterns and preva- genetically altering cancer smoke, beginning with engi- lence among California’s diverse racial and ethnic pop- ulations. — Policy research showed that (1) smoking bans in restau- rants did not reduce revenues; (2) a 10% increase in cigarette prices would lead to an average drop in consumption of 4%, research that was used to estimate the impact of the MSA in California; (3) in 1993, the direct cost of smoking in California was $264 per capita and $1,981 per smok- er for a total of $8.7 billion on tobacco-related health care, of which 43% is born “Kick Butts.” American Lung Association Billboard. by public sources. “Nicotine Soundbites.” Television Ad, 1994 Statewide Media Campaign Chapter 3 — Progress Toward TEROC's 1997-2000 Recommendations 21 Progress Toward TEROC’s 1997-2000 Recommendations In its last Master Plan, Renewing — Voice (television, outdoor): a the Commitment, TEROC made series of ads that present real ten recommendations for the years people who have suffered real 1997-2000. This chapter assesses losses because of tobacco the progress made regarding these use. Two ads include brothers recommendations. who lost their dad to cancer. Progress Toward — I Miss My Lung, Bob The American Nonsmokers’ Recommendation 1: (print/outdoor): a satire of Rights Foundation’s Community Vigorously expose the Marlboro ads with a cow- tobacco industry tactics. boy describing another Advocacy Mobilization Project Much progress has been made consequence of smoking. (CAMP) helps agencies eliminate statewide and at the local level toward and/or expose tobacco industry • Several ads exposing the tobacco interference in California. When pro- this recommendation. Exposing industry were also produced for tobacco industry tactics remains a tobacco influences in the community various ethnic communities; for priority of the Tobacco Control are identified, the project develops example: Program, and further gains are and implements appropriate strate- expected. — Puppet Show (television, gic responses. Materials that assist Asian American): the manip- communities include fact sheets Media Campaign ulative tactics of the industry on recent industry activities in • As recommended by TEROC, are exposed as children California, and two video documen- several ads produced during the watching a puppet show find taries (“Fighting Back: Communities first years of the Tobacco Control themselves manipulated by Beating Big Tobacco” and “The Program that confront tobacco strings held by the hands of a industry tactics have been re- tobacco industry executive. Hidden War: Big Tobacco Fights approved for use. Among these Back.”) — Leather Jacket (print/outdoor, effective and hard-hitting televi- Hispanic): the consequences sion ads are “Insurance,” “Nicotine of tobacco use are under- Sound Bites,” “Industry Spokes- scored with the skeletal person,” and “A Few More Good remains of a young smoker, still Years.” The billboard, “Lies,” was wearing the leather jacket pur- also re-approved. chased with tobacco coupons. • New general-market ads were The text reads, “Are you dying aired in 1998 and 1999 that for this leather jacket?”. expose the tactics used by the Project SMART (Sponsorship tobacco industry: Mission: Avoid Reliance on — They’re Getting Smarter Tobacco) Money (television): an ad that Project SMART Money is a demonstrates how the indus- statewide campaign to eliminate or try continually changes its prevent tobacco sponsorship, phil- tactics to attract new young anthropy, and signage from public smokers. sport, civic and cultural events and The Tobacco Industry organizations. Approximately 13% toward the tobacco industry increased Monitoring Project is a of the events in California received from 1996 (83%) to 1998 (90%). Proposition 99 effort of the tobacco sponsorship in 1996— Annenberg School for primarily sports, auto, or boating Progress Toward Communication at the events (Independent Evaluation Recommendation 2: University of Southern 1998). Tobacco companies also use Press for smoke-free sponsorships and charitable dona- workplaces and homes. California (with Social tions to improve their image in the Substantial progress has been Marketing Associates and community. Project SMART Money made in the establishment of Strategies for the 21st Century – 2000-2003 Hodgson Communications). goals are to counter and diminish smoke-free workplaces and homes: The project reviews past and the prestige of the tobacco industry present tobacco industry • In January 1998, the final phase in the community’s eyes, and of the California Clean Indoor Air marketing, business, and decrease and eventually eliminate Act (AB 13) went into effect public influence practices, tobacco industry sponsorship of when smoking in bars and bar- and discloses its findings to public events. A community assess- restaurant combinations became the public. Selected project ment was conducted to identify illegal. Implementation of this activities include on-site tobacco industry sponsored events, law is supported through media and Internet investigations and strategies to wean these com- campaign ads, local publicity, of documents from the munity events from dependency on bartender and bar employee tobacco dollars have been created Minnesota tobacco trial and education, and enforcement by each community. other tobacco industry docu- efforts. ments released from other School-based Programs 22 • In 1998, the vast majority of lawsuits; investigation of The Independent Evaluation of California adults (83% nonsmok- the Tobacco Control Program found Toward a Tobacco-Free California: the use of the Internet by the ers, 52% smokers) were not industry to market its prod- that the percentage of 8th graders exposed to secondhand smoke at who reported negative attitudes ucts and promote a “smoking home or at work. culture;” review of significant new tobacco industry adver- The Tobacco-Free Challenge Project. tising campaigns that attempt to manipulate specif- ic target audiences; and investigation of other topics such as tobacco industry retail distribution practices, slotting and point of purchase practices, and phil- anthropic and community donations. Chapter 3 — Progress Toward TEROC's 1997-2000 Recommendations 23 • Sixty-six percent of all Three projects funded by the California Department of Education Californians in 1998 prohibited educate students about tobacco industry tactics. The Triple T smoking in their homes. Smokers Project (Teens Tackle Tobacco), developed by the Napa County who prohibit smoking in their Office of Education and the Napa Valley Unified School household increased 73.3% from District, engages students in projects that require personal state- 1994 to 1998. Non-smokers who ments in the form of bumper stickers, bus placards, posters, prohibit smoking in their house- mobile murals, promise letters, and/or storybooks with tobacco- hold have also increased 16% from 1994 to 1998 (Department free messages. Modeled after strategies utilized by the tobacco of Health Services, 1999). companies and media to “hook” young people on tobacco, the pro- ject employs the same techniques, with students working to get • Counties that put the most effort tobacco-free “advertisements” out to their friends, family, and into their secondhand smoke community. programs showed the most change between 1996 and 1998 in reduc- San Mateo County Office of Education’s Anti-Tobacco Media ing exposure at home and work. Blitz is a social marketing campaign for high schools which uses • In 1998, close to 88% of many different media formats to create anti-tobacco messages to Californians prefer to eat in students. The program’s goal is to design and implement a student- smoke-free restaurants. The per- produced anti-tobacco media campaign that counters the pro-tobacco cent of smokers that prefer to messages in many different formats—graphics, live performances, eat in restaurants that are smoke- video and audio playbacks, music, and peer-led discussion. free substantially increased from 44.3% in 1994 to 63.7% in 1998. The Rim of the World Unified School District’s Project For non-smokers, the percent A•B•C•D (Analyze, Beware, Create, Disseminate) provides that prefer to eat in smoke-free hands-on training for students in grades 7–8 to build strategies in restaurants has been stable at reducing the acceptance and use of tobacco. Students learn to ana- around 93% (Department of lyze and beware of the dangers inherent in tobacco use and Health Services, 1999). understand the role the media plays in influencing tobacco-related behavior. They use multi-media techniques to create counter-tobac- • According to recent surveys, Hispanics and those with less co-use public service announcements, and they disseminate education are at highest risk for anti-tobacco messages to their school community by participating exposure to secondhand smoke in computer animation, video production, web page development, at work. Males, African and marketing workshops. Americans, and those with a high school education are at highest risk for exposure to sec- ondhand smoke at home. • There is increased community pressure for smoke-free toddler playgrounds, outdoor group events, shared living facilities (apartments, condominiums), lobbies, and bus stops. The Tobacco Education Media Campaign created a variety of Progress Toward ethnic television, radio, billboard and print ads that address Recommendation 3: secondhand smoke. Among the ads produced between 1997 and Accelerate cessation 1999 are: of smoking in persons between the ages of Long Ride (African American television ad): Secondhand 20 and 39. smoke and its link to the onset of asthma is revealed in a Smoking prevalence rates stabi- father-son relationship. lized for 25-44 year olds (20.2% in 1996 to 20.4 % in 1998), but preva- Strategies for the 21st Century – 2000-2003 Too Little (African American television ad): Secondhand lence in 18-24 year olds rose from smoke and its link to bronchitis is revealed in a mother- 20.6 % in 1996 to 22.0% in 1998. daughter relationship. Although rates for young adults Showed Me the Way (African American print/outdoor ad): aged 20 to 39 were not reduced, both the community-based and The positive influence of a non-smoking parent is displayed as research components of the pro- an adult son proclaims, “My father never had to tell me not to gram are devoting considerable smoke. He showed me the way.” resources to cessation efforts. Gravesite (Hispanic television ad): A man kneeling beside • Eight studies on youth cessation the grave of a recently lost loved one expresses dismay that his are funded by the Tobacco- cigarette smoking caused that death. Related Disease Research Program (TRDRP). Specific Auction (Hispanic radio ad): At an auction, bidders are 24 target audiences are Spanish- offering the diseases of loved ones in exchange for being able speakers, athletes, substance- to smoke. Toward a Tobacco-Free California: abusing adolescents, Lake County Crowded Room (Asian American radio ad): The dangers of (rural) adolescents, and teens in secondhand smoke are revealed in a spot designed to educate general. Among the media being smokers about not lighting up in public places. tested are websites and a three- dimensional “chat room.” You’re Not the Only One Being Harmed (Asian American • Radio and print ads promote print/outdoor ad): A foreground image of a father-figure smok- smoking cessation and the ing is contrasted by a family in the background, who is California Smokers’ Helpline. For suffering from the smoke. example, Jungle and A Way Out of the Smoking Jungle are ads directed at Asian Americans that The Fresno County Economic Opportunities Commission offer a cessation solution to Rural Tobacco Prevention Program targets Spanish-speak- those who feel “lost in a jungle” ing pregnant women, their infants, and the family for an of smoking. This campaign innovative program to reduce exposure to secondhand smoke. sparked the greatest volume of Individual mothers-to-be and their partners sponsor a “baby calls to the Asian Helpline. shower” in their home and provide a meal for their guests. At • A media campaign funded by the shower, harmful effects of secondhand smoke on the mother Proposition 10 will include many and her unborn baby, as well as other children and family ads on tobacco control, in partic- members are discussed. Techniques on how a mother could ular to promote smoking deal with someone smoking in her home are also demonstrat- cessation to pregnant women. ed, and each participant receives a baby shower cake and The ads will refer viewers to the incentives for their participation; the baby receives a t-shirt California Smokers’ Helpline. stating “I’m smoke free.” • The California Smokers’ Helpline has offered smoking cessation Chapter 3 — Progress Toward TEROC's 1997-2000 Recommendations 25 counseling services statewide “Smoke-Free Nightspots Are Good for Health and Good for since 1992. A Teenline has been Business,” says BREATH—The California Smoke-Free Bar in operation since June 1996. Program. This project of the American Lung Association of About 100 teen smokers called Contra Costa-Solano is funded to conduct educational the Helpline each month. programs and work with the hospitality industry as well as Approximately 27% of the teens government and private entities across the state to support who received Helpline counsel- smoke-free bars, gaming clubs, and nightspots. The project ing achieved a 90-day quit success. has created BREATH Membership Coalitions of bar and bar/restaurant employees in three regions of the state, and • Medi-Cal has started to pay for founded Musicians for Smoke-Free Air. City attorneys, county Nicotine Replacement Therapy in counsels and district attorneys, bar owners and employees, conjunction with counseling, with and Proposition 99 grantees have attended BREATH trainings the California Smokers’ Helpline throughout the state. The project also responds to individual acting as the primary source of requests for assistance. the required counseling. Progress Toward Recommendation 4: “STARS For the 21st Century”—Seeking Tobacco Strengthen school-based Alternatives with Realistic Solutions is a project of the tobacco use prevention American Lung Association of Sacramento designed to education programs decrease tobacco use in entertainment productions. Among the consistent with emerging project’s activities are a “young ambassadors” campaign to research. reach studio and network executives and creative talent advo- There has been some progress cates for increasing the number of movies and television toward this recommendation: programs with zero tobacco use, and an After Oscars Smoke- • The prevalence of youth smoking free Gala will offer a smoke-free environment to actors, is lower in California than in other writers, and directors. states. The average difference between California and other states between 1991 and 1996 Since 1991, staff of the Ventura County Public Health was 6.5 percentage points for 8th Tobacco Education Program and the Ventura County graders and 9.1 percentage points Superintendent of Schools Office have created and conduct- for 10th graders (Monitoring the ed facilitator trainings for a peer-conducted cessation Future Survey, 1991-1996). program called “Tobacco? No, Thanks!” (TNT). During the Overall youth smoking prevalence in California (age 12-17) has past two years of its implementation, TNT has produced an declined 12% since 1995. overall quit rate of roughly 35% and nearly 50% of the entire participant group reported reduced consumption. The partner- • The California Student Survey ship between public health and the schools, and the use of (Attorney General’s Office) peers in implementing the program, have contributed to the showed a 2% decrease in 30-day success of this cessation program. smoking prevalence rates for students in grades 7 and 11 between 1995 and 1997, while national rates for youth in grade 8 increased during the same period. • 97% of school districts have a tobacco-free policy prohibiting “No Ifs, Ands, or Butts,” developed by the Culver City the use of tobacco by all stu- Unified School District, is a holistic approach to tobacco pre- dents, school staff, parents, and vention and reduction through on-site cessation, after-cessation visitors in district-owned or support groups, intensive education, peer counseling, special- leased buildings, on district ized programs for pregnant/parenting teens, risk reduction grounds, and in district vehicles. District and county office super- through intervention, and strong support systems. intendents must sign an assurance that their tobacco-free policy is being enforced. Strategies for the 21st Century – 2000-2003 Smokeless School Days (Learning How to Kick Butts), Enforcement problems are iden- developed by the Los Gatos-Saratoga and Campbell Union tified through the coordinated High School Districts, has proven to be a successful alternative compliance review or individual to punitive disciplinary measures directed at students caught complaints. The percentage of using tobacco on campus. The program goals are to bring stu- school districts certified as dents closer to deciding to quit and to provide students with the tobacco-free by CDE increased tools to do so. It has been included in the American Cancer from 95% to 97% in 1999. Society’s “Resource Guide to Youth Tobacco Cessation.” • By December 1999, 46% of school districts have adminis- tered the California Healthy Kids The Medicine Wheel Project, developed by the Resources for Survey. The self-report instru- Indian Student Education, works to prevent the use of com- ment is for grades 5, 7, 9, and mercial tobacco products while emphasizing “who” Indian people 11, and gives an assessment of 26 are, the traditions of sacred plants, how Indian students empow- alcohol, tobacco and other drug use. The extended tobacco mod- Toward a Tobacco-Free California: er themselves through leadership and role modeling within their community. The program goal is to empower youth to make edu- ule is required for districts that received TUPE competitive cated, healthy choices which honor a traditionally-based lifestyle. grant funds. • A CDC guideline for instructional “The Basement Bums” Adventures in Life Skills, developed content of tobacco use preven- by the San Francisco Unified School District, is an engaging tion education specifies teaching CD-ROM educational series presenting real-life scenarios to “negative physiologic and social middle school students while teaching important life skills such consequences of tobacco use, social influences on tobacco use, as communication. The program goal is to provide innovative peer norms regarding tobacco technology and extension activities to enhance health education use, and refusal skills.” Eighty- programs aimed at reducing tobacco use among youth. eight percent of 5th, 8th, and 10th grade teachers provided instruction about negative physi- Project LIFE (Look Into Future Effects), developed by the ologic consequences of tobacco Poway Unified School District, is a full semester class offered use; 64% social influences; 57% for credit at continuation high schools. The course work focuses social consequences; 50% peer on Biology, English, and elective credits for community service. norms; 51% refusal skills. Other highlights include weekly interaction with seniors at a • CDE is publishing Getting residential care facility, hospital tours, guest speakers, and Results: California Action adventure learning. The program goal is to reduce and/or elimi- Guide to Tobacco Use nate tobacco use among teens. Prevention Education and pro- viding accompanying training to county offices of education and districts to help them select Chapter 3 — Progress Toward TEROC's 1997-2000 Recommendations 27 research-based strategies and The Missing Link (Personal/Social Skills Lessons) is a materials for tobacco use pre- set of nine middle school and nine high school personal/ vention education. The Healthy social skills lessons that were developed by the Los Angeles Kids Resource Center provides County Office of Education. The lessons are intended to research summaries of effective augment prevention curricula, and are research-based and programs, and the Healthy Kids user friendly. The program goal is to empower students with Program Dissemination Center the skills needed to prevent, delay, and/or reduce involvement gives information about where effective programs can be seen with tobacco as well as alcohol, other drugs, and violence. A in action. controlled evaluation of the lessons demonstrated significant impact on students’ marijuana use, combined alcohol and • In TUPE-funded projects, school tobacco use, and attitudes toward tobacco use. districts are required to: — base programs on assessment of the tobacco-related behav- ior of students Project SCAT (Schools and Community Against — establish measurable goals Tobacco), developed by the Nevada Joint Union High and objectives School District, involves students and adults in a collabora- tive effort to influence attitudes about tobacco use. Program — design and implement pro- components are designed to reach a wide representation of grams based on research or school and community residents through several venues: evaluation that provides evi- dence that the programs interactive sessions presented by parent educators and youth prevent or reduce tobacco educators to elementary and middle school students; the use among youth Lifesaver Lab, a health science experience for upper elemen- tary students; public service announcements and dramas — evaluate programs periodical- involving middle and high school students aired on local ly to assess progress, and radio stations; and a mock trial related to a tobacco issue strengthen the goals and the program accordingly that is produced for the community by high school students, local attorneys and a judge. • The Tobacco-Related Disease Research Program (TRDRP) cre- ated a new research award mechanism designed for schools and academic institutions to work together. The School- Academic Research Award (SARA) is co-funded by TRDRP and the California Department of Education. Grants from SARA will increase research-based prevention and cessation approaches. • Funding for high school grants has been released on time at the “Like Father, Like Daughter.” Billboard, 1995 Statewide Media Campaign. beginning of each fiscal year dur- ing the last two years. Project CHALK, developed Progress Toward Progress Toward by the Public Health Recommendation 5: Recommendation 6: Institute and funded by the Implement more effective Generate and adopt addi- Tobacco-Related Disease control of tobacco sales tional smoking prevention Research Program, focuses on to minors. and cessation strategies the community surrounding Substantial progress has that are relevant to the stores that sell tobacco to been achieved toward this recom- many racial and ethnic mendation: populations in California. minors. Community resi- Substantial progress has been Strategies for the 21st Century – 2000-2003 dents distributed flyers and • Illegal sales to minors dropped made toward this recommendation: posters that encouraged the sharply from 30% in 1996 to community to speak up and 13% in 1998. • The Tobacco Education media object when they observe a campaign has produced a variety • The Attorney General’s Office sale of tobacco to a child. of ethnic television, radio, out- has pursued enforcement action door and print ads since the against five of the larger whole- campaign began in 1990 to salers/distributors who did not address specific tobacco issues fulfill the legal requirement to with various ethnic communities. report the names of all retailers One way to implement effec- Ads are produced by advertising to whom they supply tobacco tive control of tobacco sales to agencies that target a specific products. minors is to educate elected ethnic group. Examples of many • Although the rate of illegal sales of these ads are given in previ- officials and other key opinion 28 as measured in annual purchase- ous sections of this report. leaders who make and enforce attempt surveys has gone down, policies. The Educating Key • In May 1999, the African Toward a Tobacco-Free California: preliminary data from the Inde- Opinion Leaders project American Tobacco Education pendent Evaluation (1999) show of the American Lung Network began a campaign that 89% of tenth grade youth Association of California called “Not in Mama’s Kitchen” reported in 1998 it is still easy to to address the serious issue of works to increase support for obtain tobacco products from com- environmental tobacco smoke. community norm change mercial as well as social sources Over 1,400 pledges to celebrate strategies among these leaders (e.g., friends, family, or strangers). a smoke free Mother’s Day were through enforcement of exist- Most commonly, teens obtain their received in response to 10,000 ing tobacco control policies cigarettes from non-commercial cards that were mailed. (such as smoke-free work- sources, especially from friends. places, illegal sales to minors, • As part of the Asian and Pacific • In this recommendation, TEROC Islander Tobacco Education and advertising and sponsor- noted that DHS’s ability to con- Network’s (APITEN) campaign ship restrictions); and through duct random compliance checks to encourage organizational and development of strategies such is limited because the Expanded festival adoption of tobacco con- as prohibiting self-service dis- Exchange Agreement allowing trol policies, the Hmong New plays and addressing tobacco the State Board of Equalization Year Celebration in Fresno licensing issues. to share tobacco tax receipt adopted a tobacco-free policy. information with DHS had not been approved. The agreement • The American Indian Tobacco to share information recom- Education Network (AITEN) is mended by TEROC as a means conducting a campaign to to increase the effectiveness of increase smoke-free policies on the implementation of the tribal lands, and to establish STAKE Act has still not been smoke-free areas and events at reached. pow-wows and other tribal gath- erings. Chapter 3 — Progress Toward TEROC's 1997-2000 Recommendations 29 • The Hispanic/Latino Tobacco tobacco use; ethnic differences A tobacco control project Education Network (H/LaTEN) in cigarette smoking dynamics in Long Beach, Khmers Youth Council worked with various among youth; tobacco control in Against Tobacco spon- Spanish language radio station Latino communities; predictors sored by the Cambodian disc jockeys in Southern of smoking in Latino and African Association of America, California to promote a tobacco- American youth; preventing is helping Cambodian tem- free lifestyle and cessation smoking in California Pacific Rim ples adopt a smoke-free messages on World No Tobacco youth; and smoking cessation in Day. Live radio interviews were the Vietnamese community. policy for the outside areas conducted among youth advo- immediately adjacent to cates. In April 1999, the H/LaTEN the temple, and to offer Progress Toward smoking education and recognized the Hispanic/Latino Recommendation 7: prevention classes on the Tobacco Free Advocates of the Link Proposition 99- Century—62 heroes/sheroes in premises. Presentations to financed research and the categories of youth leaders, Buddhist monks and their evaluation efforts closely parents, community leaders, lay counterparts, ajars, with Tobacco Control media representatives, business about the Cambodian cul- Program activities. representatives, and sports fig- ture, Buddhism, and Major progress can be reported ures who are living examples of tobacco control are the first in linking research and evaluation to tobacco-free role models and action. steps toward meeting the advocates. project’s objectives. • Results of the Independent • Research projects funded by the Evaluation of the Tobacco Control Tobacco-Related Disease Program are used by the Depart- Research Program investigate ment of Health Services and the racial and ethnic differences in California Department of the use, prevention, and cessa- Education to modify their tobacco tion of tobacco. For example, one control activities. For example, the study tests the hypothesis that Educating Key Opinion Leaders racial discrimination accounts for Project (described previously) differences between Caucasians was developed in response to and African Americans in smok- Wave 1 findings of the Independent ing prevalence, age of initiation Evaluation that a high percentage of smoking, degree of nicotine of opinion leaders in the state addiction, difficulty quitting favored individual rather than smoking, and stage of readiness population-based strategies for to quit smoking. The researchers reducing tobacco use. hypothesize that African Americans who experience fre- • The Tobacco-Related Disease quent discrimination differ from Research Program (TRDRP) Caucasians on all five variables. established Community- Data from this research can be Academic Research Awards used to design new, culturally- (CARA) to stimulate and sup- tailored smoking prevention and port collaborations between cessation programs for African community-based organizations Americans. and academic investigators to Other studies investigate topics perform scientifically rigorous such as smoking and depression research. Research supported in Chinese Americans; Hmong by this program investigates cultural practices and patterns of tobacco control issues that are identified as important by specif- a result of a tobacco surtax increase 1, 1999, expressed concerns about ic communities in the state, are and a manufacturers’ price increase the settlement and briefly explored likely to produce results that are caused by the Master Settlement the advisability of backing out of it. meaningful to specific communi- Agreement. He has since established a Tobacco ties, and use methods that are Litigation Unit in the Department of • Voters passed Proposition 10 in relevant, culturally sensitive, and Justice which he plans to maintain November 1998 to increase the appropriate in terms defined and over the coming years to ensure tax on cigarettes by 50 cents per accepted by the interested com- tobacco industry compliance with pack, and an equivalent amount munities. the Master Settlement Agreement Strategies for the 21st Century – 2000-2003 on cigars, pipe tobacco and provisions, including the restrictions • Through CARA and other award smokeless tobacco. This tax on the marketing of tobacco prod- mechanisms, TRDRP has funded went into effect on January 1, ucts to youth. behavioral research that has 1999. direct application to program • The Proposition 10 tax increase interventions. Twenty-nine per- triggered an additional Progress Toward cent of the 1999 research awards Proposition 99 increase in the Recommendation 10: were for this type of research (out tax on non-cigarette tobacco Coordinate Proposition of 66 new projects, 7 were for products equivalent to 50 cents 99-financed programs social/behavioral/youth research, per pack, effective July 1, 1999. with other State and 5 were CARA awards, and 7 were Thus, for non-cigarette tobacco Federal tobacco control related to public policy). taxes (which account for about initiatives. • TRDRP and the California 10% of tobacco sales), an California’s Tobacco Control 30 Department of Education have increase of $1.00 has been Program has a history of coordinat- created the School-Academic achieved. ing its efforts with other initiatives Toward a Tobacco-Free California: Research Award (SARA) that is such as the Robert Wood Johnson’s • The Master Settlement designed for schools and acade- Smokeless States Program, the Next Agreement caused the tobacco mic investigators to work Generation Alliance, and tobacco companies to increase the together. control initiatives sponsored by the wholesale price of a pack of ciga- Centers for Disease Control and • TRDRP also established disserta- rettes by 45 cents, effective Prevention (CDC), the U.S. Depart- tion research awards to support December 1999. The companies ment of Education, the Center for the dissertation research of doc- have raised the price further Substance Abuse Prevention, and toral candidates who wish to since then. the National Cancer Institute. The pursue tobacco-related research. program has recently created rela- In this category, research on the Progress Toward tionships with several new efforts: application of social/behavioral Recommendation 9: sciences and public policy areas The California Attorney • Master Settlement Agreement: is encouraged. General should oppose CDC is leading an effort to any settlement of tobacco encourage settling states to litigation that benefits the devote a portion of their tobacco Progress Toward tobacco industry. settlement payments each year Recommendation 8: Attorney General Dan Lungren to tobacco control and other Increase the surtax on chose to sign the Master Settlement public health initiatives. The tobacco products by at Agreement in November, 1998 Department of Health Services, least $1.00 per pack. despite opposition by TEROC and Tobacco Control Section The purchase prices of tobacco the greater national public health (DHS,TCS) is assisting states in products increased substantially as community. Attorney General Bill designing effective tobacco con- Lockyer, who took office on January trol programs. Chapter 3 — Progress Toward TEROC's 1997-2000 Recommendations 31 • The California Department of • DHS,TCS is working with the regulation of cigarettes as drug Education’s TUPE program CDC to make California’s tobac- delivery devices. Currently, this relies heavily on CDC’s guide- co surveillance data more involves enforcement of the fed- lines for school-based tobacco comparable to those of the fed- eral requirement that tobacco use prevention education pro- eral government and other states. retailers check the identification grams. CDE staff are in close of anyone attempting to purchase • DHS,TCS is working closely with communication with CDC’s tobacco products who appears to the American Legacy Foundation Office on School Health and be 26 years of age or less. that was set up under a provi- attend relevant national meet- sion of the Master Settlement • The Tobacco-Related Disease ings and conferences. Agreement to administer a Research Program (TRDRP) • DHS,TCS has a new grant from national tobacco research and interacts with and coordinates CDC to provide technical assis- tobacco use prevention program communication with the National tance to other states working to targeting youth. Cancer Institute, National set up their own tobacco control Institute of Drugs and Alcohol, • DHS (through its Food and Drug program. TCS staff attend and and the Network of Tobacco Use Branch) has a contract with the participate in CDC sponsored Research Funders (NOTURF) to federal government to carry out workshops, conference, and tele- increase the utility of tobacco- enforcement of parts of the U.S. conferences. related research dollars. Food and Drug Administration’s “Industry Spokesman.” Television Ad, 1990/1999 Statewide Media Campaign. Chapter 4 — Lessons Learned in Tobacco Control 33 Lessons Learned in Tobacco Control Many lessons have been learned smoke and restrict tobacco product to $20.59 by the tobacco indus- in ten years about what works and marketing and sales. try (Pierce et al., 1998b). does not work in tobacco control. Overall lessons from California The most important lesson of the show that a tobacco control pro- California experience is that it is gram works best when it: possible to rapidly reduce tobacco • Engages the public from the consumption despite the aggressive, beginning, as with the political lavishly funded marketing and pro- campaign for the Proposition 99 motion of tobacco products that tax; continues in the state even today. • Increases the cost of tobacco, Overall Lessons from such as the tax increases from the Program Proposition 99 and Proposition The increased cost of tobacco 10; products from the Proposition 99 • Involves the entire public, tax, and most recently from the particularly the nonsmoking additional Proposition 10 tax, has majority, to reinforce the idea of Advertisement, California clearly contributed to the declines a smoke free society. Smokers Helpline in consumption seen in California during this period. Analysis of a lon- Lessons in Health • Employs an anti-tobacco gitudinal sample of data from the Education media campaign with a California Tobacco Survey gives fur- California’s Tobacco Control broad, general market focus ther insight into what elements of Program conducts health education that directly confronts the the program have been successful through community-based and tobacco industry and its sur- (Pierce et al., 1994). The predictors school-based programs. There are a rogates. The California media of progress towards cessation are number of lessons that are specific campaign and local programs having a smoke-free workplace, to each arena. stress nonsmoking norms and believing that secondhand smoke is educate the public and policy dangerous (not just annoying), liv- Community-Based Prevention makers about the dangers of ing in a smoke free home, and An effective community-based passive smoking. Comparisons of having available cessation support tobacco control program: California’s results to other such as that offered by the • Is large enough to compete states indicate that a general California Smokers’ Helpline. effectively with the tobacco market campaign emphasizing Local tobacco control programs industry, even though it does the tobacco industry’s deceptive and the statewide media campaign not match the industry dollar practices and the critical impor- have clearly played a major role in for dollar. In the early years of tance of smoke-free indoor this progress by helping shape the the California program (1989- environments is more effective discussion over tobacco issues with 93), expenditures were than a youth-centered campaign strong anti-industry messages, by approximately $3.35 per capita, that concentrates on preventing emphasizing the adverse health compared to $17.50 by the kids from buying cigarettes effects of secondhand smoke and tobacco industry. In the later (Department of Health Services, the addictiveness of tobacco, and by years (1993-96), California only 1998). This conclusion stands in advocating for policies that protect spent $2.08 per capita compared stark contrast to the prevailing Californians from secondhand national rhetoric, which sug- • Promotes smoke-free envi- the media campaign and other gests that all public health can ronments, and strengthens statewide activities with the hope to do is prevent kids from the nonsmoking norm and community-based programs that starting to smoke and waiting a rights of nonsmokers. are key to program success. generation for the problem of Promoting smoke-free environ- • Emphasizes reducing youth tobacco use to resolve. There is ments is a powerful intervention demand for tobacco in addi- no reason to wait this long. to reduce tobacco consumption tion to reducing youth access Teens are best spoken to as and increase smoking cessation. to tobacco. The success in adults and addressed as an ele- Public appreciation of the dan- Strategies for the 21st Century – 2000-2003 reducing the frequency with ment of a larger campaign. gers of secondhand smoke can which stores sell to minors has lead to the voluntary adoption of • Emphasizes the negative not resulted in reductions in a smoke-free home policy even aspects of tobacco use for either the ease with which ado- in homes occupied by smokers. everyone—adults and youth. lescents can obtain cigarettes or In California, the resulting explo- In the media campaign, youth in adolescent smoking preva- sion in local clean indoor air are most influenced by mes- lence. Promising approaches for ordinances, followed by the state sages directed at the general reducing adolescents’ demand smoke-free workplace law, pro- population, rather than by ads for tobacco include involving tected nonsmokers from speaking directly to them. The youth in policy advocacy and secondhand smoke and created tobacco industry uses the linking school- and community- an environment that made it eas- “You’re too young to smoke” based programs. Clearly, the ier for people to stop smoking. message to make youth see program must also continue to smoking as a way to “enter the • Responds quickly to changing address the factors in the social 34 adult world.” The program industry strategies with new environment that are creating should counter this approach by media messages. The period of and reinforcing youth demand Toward a Tobacco-Free California: emphasizing the negative greatest decline in tobacco use for tobacco products, including aspects of tobacco use for was associated with the ability of product price, sales practices, everyone—adults and youth— the program to develop and advertising and promotional and by offering youth entry to a place ads quickly, and to adjust activities, and the modeling of smoke free adult world. counter-messages and respond tobacco-use behavior on televi- rapidly to changing strategies of sion and in movies. • Coordinates the media cam- the tobacco industry. When the paign closely with • Uses youth organizations and process became bogged down community-based activities schools for youth-specific with many levels of approvals, that support statewide mes- programs that utilize months to years passed between sages locally. While the media research-based strategies. new ads. The media lost its flexi- campaign is the most visible These are particularly appropri- bility to counter the tobacco component of the California ate venues for youth-specific industry and support the needs Tobacco Control Program, the programs that utilize effective of the local programs. When the community-based programs are research-based education strate- approval process for the media equally important. The media gies for engaging youth in campaign and other program campaign helps educate the anti-tobacco advocacy and lead- activities is streamlined (in public and create an environ- ership activities. terms of numbers of people who ment supportive of tobacco are involved and length of time School-Based Prevention control, but the local communi- for approval), the program is Effective school-based tobacco ty programs make the able to respond to the tobacco control programs—which in permanent social change that is industry quickly and effectively. California are called Tobacco Use moving tobacco use out of A streamlined approval process Prevention Education programs: California. also allows good integration of Chapter 4 — Lessons Learned in Tobacco Control 35 • Seek broad community of the competitive grants model • Support a comprehensive and involvement and are integrat- improves program effectiveness balanced research portfolio ed with other in grades 6 through 8. which divides the available community-based tobacco resources equally between • Participate in training and control programs. Messages in social/behavioral and policy the infrastructure network the school programs should research on the one hand and developed for community- stress the same themes that biomedical and nicotine depen- based activities. Personnel work in the community and dence research on the other. from school-based tobacco media components of the pro- control programs should be • Be prepared to carry out an gram so that school and knowledgeable about and extensive outreach effort to community activities reinforce included in public health increase the quantity and quality each other. These themes training and the infrastructure of proposals in the social, behav- include the social denormaliza- network that support com- ioral, and policy areas, especially tion of tobacco use and the munity-based activities. with respect to studying tobacco serious health risks of exposure Alternatively, staff from local use. Such outreach expands and to secondhand smoke. community-based programs supports the research infrastruc- • Concentrate activities in should be knowledgeable about ture in social/behavioral and middle/junior high and high and attend county and/or school policy sciences and encourages schools, rather than elemen- district tobacco use prevention investigators in these fields to tary schools. Very young education training. submit proposals. children are generally anti- • Adopt strategies that • Fund the best in relevant tobacco and there is little room research shows to be effec- biomedical research that helps for a program effect. While theo- tive. There is research evidence elucidate the mechanisms of retically desirable to start anti- that information-only instruction- tobacco’s detrimental health tobacco education early, there al approaches to tobacco use effects, and improves early diag- is no evidence that this effect prevention are ineffective. nosis and effective treatments carries over into adolescence, Programs that utilize social influ- for tobacco-related diseases. when tobacco becomes an issue. ence approaches and couple Scarce resources are better • Work closely with the agen- information with the develop- spent on older children. cies administering the health ment of personal and social skills education components of the • Utilize a competitive grants show remarkable results in tobacco control program to model in addition to funding deterring tobacco use by youth. ensure that information is dis- allocations based on entitle- seminated and to stay apprised ment formulas. Funding Lessons in Tobacco- of emerging research issues that allocations based on enrollment Related Disease Research should be addressed. Research (or other entitlement formulas) Many lessons about tobacco that investigates newly emerging do not necessarily lead to effective research have been learned by the areas, such as cessation pro- tobacco control programs unless University of California’s Tobacco- grams for youth, tobacco control effective accountability procedures Related Disease Research program. in health care settings, cultural are utilized. TEROC also believes A tobacco research program should: determinants of tobacco use, that the increased accountability and targeted interventions in diverse communities should be encouraged. “I Miss My Lung, Bob.” Billboard, 1998 Statewide Media Campaign. Chapter 5 — Strategies for the 21st Century: TEROC’s Recommendations for 2000-2003 37 Strategies for the 21st Century: TEROC’s Recommendations for 2000-2003 TEROC recommends that the secondhand smoke, and thereby to • funding enforcement of tobacco California Tobacco Control Program further reduce the incidence of lung control laws that cannot be fund- build on its numerous significant cancer, heart disease, emphysema, ed with Proposition 99 money; strengths, and adopt the aggressive and other tobacco-related deadly dis- • increasing program capacity to tone and rapid response that have eases. In doing so, it will increase the reach high-risk diverse popula- characterized its most notable suc- substantial benefits already gained in tions of California. cesses. Most important, TEROC reducing suffering, loss of life, and strongly recommends that approxi- economic costs caused by tobacco. The Master Settlement Agree- mately 20% of the resources from Increased funding will strengthen ment, while providing approximately the tobacco settlement payments to tobacco control efforts by: the state be allocated on an annual • increasing the capacity to assist basis to increase the program’s abili- smokers of all ages in quitting; ty to counter the tobacco industry’s continued aggressive marketing of • increasing the reach and fre- tobacco in California, and to help quency of the media campaign those who use tobacco products which is needed to effectively break the chains of their addiction. counter the massive marketing and public relations activities of Recommendation 1: the tobacco industry, and to Increase funding for the prompt increased quit attempts California Tobacco Control by smokers; Health Through Art: Signs of Recovery, Alameda Program so that it can County Health Department, Oakland, CA. • increasing activities directed build on past successes toward enactment of local tobac- and take advantage of $1 billion a year for state and local co control policies, especially new opportunities to California governments, only reim- policies establishing smoke-free reduce tobacco burses taxpayers about 30 cents on public areas and policies restrict- consumption rapidly. the dollar for the cost to taxpayers ing point of sale advertising; TEROC recommends that the for treating tobacco-related illness- annual funding for the California • increasing the capacity of the es. Failure to reduce tobacco use Tobacco Control Program from Department of Health Services will condemn California taxpayers to Proposition 99 be augmented by to coordinate with local projects more than a $2 billion annual sub- $105 million from the tobacco settle- and schools; sidy of the tobacco industry through ment payments to the State of Medi-Cal and other government pay- • increasing program presence in California. There are several critical ments. Every dollar spent on the middle and high schools where reasons for this request. In general, California Tobacco Control Program adolescents are most vulnerable this increase in funding will expand saves $3 in medical costs and anoth- to emulating what they perceive the overall capability of California’s er $5 in smoking-attributable as adult behaviors and to finding tobacco control efforts to further indirect costs (Department of ways to rebel; reduce tobacco use and exposure to Health Services, 1999). Most important, the California control programs (Centers for grams recommended by TEROC Tobacco Control Program has saved Disease Control, 1999). TEROC (using the 1999-2000 budget lives and improved the health of considered these recommendations amount of $126,800,000 as the pre- Californians, and will continue to in writing this Master Plan. In gener- augmentation base) is $231,793,000, do so. al, TEROC’s recommended which is slightly above CDC’s mini- The U.S. Centers for Disease budgetary amounts are slightly mum recommendation of Control and Prevention has published above the minimum levels recom- $211,403,000. This is well below the “best practice” recommendations for mended by the CDC. CDC’s maximum recommended program components and funding The total budget for tobacco budget level of $545,492,000 for a Strategies for the 21st Century – 2000-2003 levels for effective state tobacco control and tobacco research pro- state with California’s population. Recommended Budget for the California Tobacco Control Program, Based on CDC’s Best Practices (in thousands) CDC CDC 99-00 00-01 00-01 Best Practices Best Practices Current Additional New Proposed Recommendation Recommendation Budget Budget Funds (GF) Budget Total Low High Comments UC Research 36,726 7,500 44,226 N/a N/a 20% increase to cover infla- tion since Prop 99 passed (allowing for drop in tobacco consumption) California Department 27,044 6,000 33,044 25,663 38,494 20% increase to cover inflation Of Education (CDE) since Prop 99 passed 38 Local Assistance (allowing for drop in tobacco consumption) plus for adding Toward a Tobacco-Free California: grades 6-8 to high school competitive grant program. TCS staff support 3,224 2,000 5,224 Staff for CDE and TCS to CDE staff support 967 500 1,467 administer increase in pro- 4,191 2,500 6,691 7,179 19,235 gram funding and for CDE to administer competitive grants. TCS Local Programs— 35,116 62,000 97,116 117,899 346,204 To cover LLA enforcement of includes LLAs, competitive existing local ordinances and grants, enforcement, AB 13, increase for Helpline statewide, and cessation. cessation services, TCS technical assistance/- statewide services, etc. TCS media 17,816 22,000 39,816 32,269 96,805 TCS statewide media to increase reach into rural and ethnic communities, and to increase youth advocacy for reducing demand. TCS evaluation 3,905 5,000 8,900 14,357 38,470 Independent evaluation of schools, local programs, media. Increase evaluation efforts to obtain county and ethnic specific data. Food and Drug STAKE 2,000 0 2,000 14,036 26,284 Act compliance Total UC 36,726 7,500 44,226 N/a N/a Total TCS/CDE 90,072 97,500 187,567 211,403 565,492 Total Overall 126,798 105,000 231,793 211,403 565,492 Chapter 5 — Strategies for the 21st Century: TEROC’s Recommendations for 2000-2003 39 Recommendation 2: interventions will “spill down” to ensure that new techniques to pro- Expand the Tobacco younger ages (i.e., 12-17), since mote tobacco to youth are not Control Program and teens view young adults as role mod- employed. strengthen its fundamen- els. Moreover, the tobacco industry In addition, the industry contin- tal structure, focus, and presents smoking as a way for teens ues to promote tobacco in ways not key messages. to “grow up,” and TEROC believes prohibited by the settlement. For The California Tobacco Control that this type of youth-focused cam- example, tobacco industry cam- Program follows a research-based paign will therefore be more effective paigns of “accommodation” of comprehensive approach that utilizes than a teen-focused campaign which smokers continue, and bars are multiple channels of intervention— could be inadvertently reinforcing increasingly used as venues for the media; community-based the industry’s message. advertising and promotions such as organizations; schools; universities; All statewide and local activities distribution of free cigarettes. public health departments at the should continue to communicate TEROC recommends that these and state, regional and local levels; and and reinforce the media campaign’s other new industry tactics be numerous other state departments, key messages: exposed and countered through the agencies, organizations and commis- statewide media campaign, enforce- • The tobacco industry lies. sions. The program operates at ment of smoke-free bars, and other statewide, regional, and local levels • Nicotine is addictive. appropriate local efforts. to reach the general population of • Secondhand smoke kills. b. Continue to press for smoke- California. The increased budget free workplaces, public TEROC is recommending will greatly TEROC also recommends that places, events, schools, and increase the program’s ability to the program continue to implement homes. expand and strengthen its successful strategies to counter tobacco indus- structure, focus, and messages, and try tactics, promote smoke-free Secondhand smoke is the third to effectively coordinate its numer- environments, and support tobacco leading cause of preventable death ous aspects. use cessation. In addition, TEROC in the nation (Parmley and Glantz, The program is based on the recommends that the program shift 1991). TEROC recommends that belief that the primary prevention of the emphasis of its focus on reduc- California continue its campaign for smoking initiation is best accom- ing youth access to reducing youth smoke-free workplaces and homes plished by incorporating youth as demand for tobacco. The recom- by increasing public education part of a larger movement to a mendations on program focus are about the effects of secondhand smoke-free society for everyone. described below. smoke, and enforcing policies relat- TEROC recommends that the pro- ed to secondhand smoke. There are a. Continue to anticipate, vigor- gram’s activities and messages several actions to be taken. ously expose, and counter continue to be crafted to reach a Parents should be educated in tobacco industry tactics. broad general audience of all ages culturally and linguistically appropri- and to account for linguistic and The Master Settlement Agreement ate ways about the effects of cultural factors. signed by the California attorney secondhand smoke on their children Within this broad focus, specific general and the tobacco industry on and other family members, and program components should also November 23, 1998 mandates encouraged to make their homes and address groups whose current changes in the behavior of the cars smoke free. This will not only smoking prevalence is dispropor- tobacco industry in the state, and protect nonsmoking adults, children, tionately high. For example, in 1998 specifically prohibits the tobacco and youth from secondhand smoke, smoking prevalence in young adults industry from using advertising and but also help smokers to stop. (ages 18-24) was 22%, higher than promotion strategies that target Efforts to fully implement and for any other adult age group and youth. TEROC recommends that enforce state and local smoke-free higher than in 1997. New media ads tobacco control advocates closely workplace laws should be continued and other programmatic efforts monitor industry activities in order and extended. This should include should be designed for this group of to expose lack of adherence to the attention to voluntary policies among young adults. The effect of these provisions of the Agreement, and to Indian nations for environments that are free of commercial tobacco. The campaign, coupled with the Efforts to reduce youth access to Attorney General’s Office should California Smokers’ Helpline and tobacco succeeded in lowering the continue to encourage local district supported at the community level, rate of illegal sales in California to attorneys to prosecute violations of is a cost-effective process for help- 13% in 1998. Large randomized trials the California Smoke-free Workplace ing large numbers of people stop (Rigotti et al., 1997) that successfully Act (Labor Code 6404.5). smoking. TEROC recommends sev- reduced buy rates by teens, howev- Local efforts should also be eral steps. er, failed to demonstrate a decrease directed at increasing the number of First, the media campaign should in youth smoking. One reason smoke-free zones and venues at place additional emphasis on mes- seems to be that a relatively large Strategies for the 21st Century – 2000-2003 outdoor locations, for example, sages that promote cessation and proportion of teens who smoke do amusement parks, fair grounds, the California Smokers’ Helpline. not purchase the cigarettes they concerts, sporting events, etc. However, when cessation ads are smoke. Fifty-eight percent of teens Efforts should be made to increase aired, the Helpline is inundated with who had ever smoked say they get the number of smoke-free apart- calls. Current funding limitations for their cigarettes from others such as ments, townhouses, and condos that the Helpline prevent promoting it as friends and family members (Pierce provide smoke-free units, prevent heavily as would be optimal to maxi- et al., 1998a). In addition, the strong seepage between housing with mize the number of people who stop emphasis on reducing youth access shared walls, and do not share ven- smoking every year. In addition, a is leading to counterproductive tilation systems. new Proposition 10 media campaign strategies such as criminalizing chil- Finally, specific efforts should be plans to refer viewers to the dren, and has shifted the focus to directed at teens in both DHS and Helpline, which will greatly increase children rather than the tobacco CDE programs to reduce their the number of calls. The Helpline industry. 40 acceptance of secondhand smoke. capacity needs to be expanded to The most effective use of These should include involving serve the full demand that can be resources to decrease smoking is to Toward a Tobacco-Free California: youth in advocacy activities around generated by the media campaign. reduce demand. TEROC therefore secondhand smoke, and assisting As a necessary step in the cessa- recommends that strategies to their efforts to alert other youth of tion process, local projects (local reduce youth demand for tobacco the adverse health effects of expo- lead agencies, ethnic networks, and be increased, and that these strate- sure and their right to smoke-free competitive grantees) provide gies include active engagement of air. Tobacco-free policies in school direct services to special popula- youth in anti-tobacco use advocacy buildings, grounds, and vehicles tions and coordinate with other activities. should be vigorously enforced. local cessation activities (e.g., hospi- Program efforts to reduce youth tal-based cessation services, access to tobacco should focus on c. Increase population-based school-based pre-cessation and ces- maintaining compliance with federal smoking cessation activities sation programs like Smokeless and state law. TEROC recommends through the media campaign, Saturdays). Funding for local tech- that the Administration sign an the California Smokers’ nical assistance should be increased Expanded Exchange Agreement Helpline, and coordination at to meet the anticipated increased allowing the State Board of the local community level. need generated by the media cam- Equalization to share tobacco tax Smoking cessation is the desired paign and the Helpline. receipt information with the outcome of all initiatives and activi- Department of Health Services d. Implement strategies ties of California’s Tobacco Control (DHS). This agreement would allow (including youth anti-tobacco Program that create new social DHS to enumerate fully the uni- advocacy to promote smoke- norms around the use of tobacco. verse of tobacco retailers in order to free environments) to reduce The California Tobacco Survey avoid non-response bias in retailer youth demand for tobacco, (Pierce et al., 1998a) indicates that compliance estimates, and will rather than focusing primari- a large number of smokers are increase the effectiveness of the ly on youth access. poised to quit. Past experience has STAKE Act implementation. demonstrated that the media Chapter 5 — Strategies for the 21st Century: TEROC’s Recommendations for 2000-2003 41 Recommendation 3: education be emphasized in the that CDE make every effort to Continue to strengthen middle/junior high years. In addition, involve schools in the competitive and increase account- Proposition 99 funds are decreasing. process, and that districts be ability of school-based In order to maximize the impact and allowed to use a portion of their tobacco use prevention increase the accountability of the grades 6-8 entitlement funds to sup- education programs, con- TUPE program, TEROC recommends port grant-writing for competitive sistent with principles of that legislation be enacted to focus its funds, if this activity does not erode effectiveness. entitlement component on grades 6-8 tobacco prevention activities. In The California Department of for a “basic” program, and to increase order to administer this program Education (CDE) administers its competitive grants program to effectively, CDE staffing at the state Proposition 99 funds for Tobacco include grades 6-12. Two-thirds of level needs to be increased to both Use Prevention Education (TUPE). TUPE funds should be used for mid- administer and provide technical Currently, as mandated by law, dle and high school competitive assistance to the competitive grades 4 through 8 receive TUPE grants, and one-third to entitlement grantees. funding as an entitlement (based on grants for grades 6-8. With such a To improve the effectiveness of enrollment) while grades 9-12 system, baseline programs in grades TUPE, TEROC recommends that receive funds through a competitive 6-8 could be supplemented with com- CDE continue to support schools to grant process. petitive grant funds in the crucial strengthen their programs consistent Tobacco becomes a serious issue middle-school years. Implementing with the U.S. Department of Educa- when young people reach adoles- this recommendation will require tion’s national Principles of Effective- cence, and the Centers for Disease changes to the implementing legis- ness, which require schools to: Control and Prevention (CDC) rec- lation for Proposition 99. • Base programs on a thorough ommends that tobacco prevention TEROC further recommends assessment of objective data about the drug, alcohol, tobacco, and violence problems in the schools and communities served. • With the assistance of a local or regional advisory council, estab- lish a set of measurable goals and objectives, and design pro- grams to meet those goals and objectives. • Design and implement programs for youth based on research or evaluation that provides evidence that the strategies used prevent or reduce drug use (including tobacco), violence, or disruptive behavior among youth. • Evaluate programs periodically to assess progress toward achieving goals and objectives, and use the evaluation results to refine, improve, and strengthen the program, and to refine goals The Cambodian Association of America’s Kmers Against Tobacco Project con- and objectives as appropriate. ducted tobacco education with monks, ajars, and worshipers at Wat Vipasnaram, Long Beach, CA. Recommendation 4: from recruiting students in school specific contributions to Increase the collaboration for after-school community advo- tobacco control. and communication cacy projects, to a project that is Collaboration should be contin- among and between fully planned and implemented ued and expanded between TCS, school-based and public by teachers, students, and com- CDE, and TRDRP to conduct health-based tobacco con- munity-based program staff. research such as the Community- trol programs. • Conduct cross-program meet- Academic Research Awards (CARA) Among the strengths of the and the School-Academic Research ings and trainings. TUPE California Tobacco Control Program Awards (SARA). TRDRP research Strategies for the 21st Century – 2000-2003 Coordinators from county offices are the activities at the community should continue to be linked to of education should participate level. Public health activities are Tobacco Control Program activities. in statewide and regional tobac- planned and implemented by local There is a need for more research co control meetings and lead agencies, regional linkage pro- in the area of social, behavioral, and summits, which in the past have jects, ethnic networks, and other policy change. More of this research been largely limited to people community organizations funded by should address questions about the associated with the DHS compo- the Department of Health Services mechanisms of control and influ- nent of the California Tobacco (DHS), while school-based programs ence used by the tobacco industry Control Program. Representatives receive funding to districts and to maintain tobacco-friendly poli- from the local lead agencies counties from the California cies, to influence public opinion, to should also participate in Department of Education (CDE). promote tobacco use by young statewide and regional tobacco While a great deal has been adults, and to make tobacco retail- use prevention education work- accomplished by the statewide pro- ers advertise, promote, and display shops sponsored by the CDE. 42 gram, TEROC believes that it would their products. The research should be substantially strengthened by • Facilitate communication provide timely information that local Toward a Tobacco-Free California: increased rapid communication and within each funding network. programs can use in their efforts to collaboration between and among DHS should increase ways to reduce the use of tobacco products. all program entities: DHS, CDE, facilitate communication local lead agencies (LLAs), county between the state and local pro- Recommendation 6: offices of education, and other local grams, and among its contractors The Administration should tobacco control programs (including and grantees. DHS should con- implement policies and school-based programs). An increased tinue to ensure that they are procedures to assure budget can greatly improve the pro- aware of other DHS-funded rapid development and gram’s ability to expand collaboration tobacco activities in their locale. approval of the media and communication. CDE should also increase ways campaign to permit the Among the ways to increase com- to facilitate communication campaign to respond munication and collaboration are: between the state and TUPE- quickly to the changing funded programs, among environment. • Involve youth in anti-tobacco In the early years of the pro- advocacy projects. Research TUPE-funded programs, and gram, approval of the media shows that projects that involve between county offices of educa- campaign was the responsibility of youth in advocating for anti- tion and local school district the Department of Health Services tobacco policies are highly TUPE coordinators. (DHS) and subject to the same DHS promising in reducing youth approval procedures and TEROC prevalence (Edwards et al., Recommendation 5: oversight as other aspects of the 1992). Florida’s tobacco control The University of program. This approval process program, for example, has used California’s Tobacco- allowed the campaign to be highly this approach effectively. Youth Related Disease Research responsive to the changing world of advocacy projects are ideal Program should continue tobacco and to create ads that were arenas for collaboration between to encourage and fund both timely and aggressive. It also schools and public health organi- research that makes allowed input from local lead zations. Collaboration can range Chapter 5 — Strategies for the 21st Century: TEROC’s Recommendations for 2000-2003 43 agencies and community-based tobacco control projects regarding the potential effectiveness of ads with their constituents. TEROC appreciates the policy decision of the current Administration to allow the presentation of all pro- posed media campaign projects to TEROC, as this review is essential to the exercise of TEROC’s over- sight function. Nevertheless, the media approval process remains slow and cumbersome. As a result, it is difficult to coordinate the media campaign with other aspects of the program and respond to changes in the tobacco industry’s strategy. TEROC recommends that the Administration implement policies and procedures to assure rapid development and approval of the media campaign, and that TEROC and local tobacco control programs “How Many?” Television Ad, 1997 Statewide Media Campaign. continue to be involved in the devel- opment of the campaign. Based on dence treatment or referral ser- 850,000 people who work in the past experience, TEROC hopes that vices. TEROC recommends that the hospitality industry in California. the total approval process would State adopt policies to enhance Moreover, bars are important take no longer than 30 days. While nicotine-dependence treatment venues for current tobacco promo- the specific policies to achieve this activities for Medi-Cal beneficiaries tion, and the tobacco industry has rapid turnaround are open, TEROC and health insurance programs for worked to reduce compliance with notes that the policy of delegating state employees. The State should this law. State and local media cam- this responsibility to DHS would be also encourage private insurers to paigns should create an environment the simplest and one of proven provide coverage for nicotine- that supports and motivates local effectiveness. dependence treatment services as enforcement efforts. part of their standard benefit plan. Discussions with local health Recommendation 7: departments and other local Medically-mediated Recommendation 8: enforcement officials suggest that nicotine-dependence The Department of involvement of the Department of treatment should be a Alcoholic Beverage Alcoholic Beverage Control (ABC) benefit of the health Control should incorpo- in smoke-free bar compliance care delivery system. rate compliance with the efforts would be beneficial. In addition to the efforts of the California Smoke-free TEROC therefore recommends Tobacco Control Program to promote Workplace Act in deci- that the ABC include compliance population-based smoking cessa- sions regarding bar with the California Smoke-free tion, State policies should encourage license approvals, suspen- Workplace Act as a criterion for the inclusion of medically-mediated sions, and renewals. approval, renewal, or suspension of nicotine-dependence treatment Enforcement of smoke-free bar on-site liquor licenses. Implementing (NDT) as part of the health care provisions of the California Smoke- this recommendation will probably delivery process. Medi-Cal managed free Workplace Act should be a require action by the Governor to care plan providers are currently priority. Secondhand tobacco smoke instruct the ABC to do this. required to provide nicotine-depen- is a serious health risk for the Recommendation 9: to increase smoking cessation and the American Legacy Foundation, The California Children and education of the consequences of and others. Families State Commission secondhand smoke to young chil- should encourage local dren are particularly vital for Recommendation 11: commissions to include families as part of this initiative, and Settle the outstanding objectives for tobacco recommends that the State litigation left over from control in their strategic Commission strongly encourage the previous Administration plans. local commissions to include tobac- to increase funding for The California Children and co-related objectives in their tobacco control efforts. Strategies for the 21st Century – 2000-2003 Families State Commission is implementation guidelines. There is $32.531 million in charged with implementing restricted reserve funds from the Proposition 10, the Children and Recommendation 10: Americans for Nonsmokers’ Rights Families Act that is funded by a 50 Continue to coordinate (ANR II) lawsuit. Corollary to cent tax on cigarettes and a com- Proposition 99-financed increasing funding allocations for mensurate tax on other tobacco programs with State, the program, TEROC recommends products. This is an early childhood Federal, and other tobac- that the Governor release the ANR development program, but since it co control initiatives. II restricted reserve funds, and set- is funded by a tobacco tax, it is The Proposition 99 tobacco con- tle the Just Say No to Tobacco appropriate to include tobacco con- trol programs are most effective Dough (SAYNO) suit. trol elements in its guidelines and when they link into the energy, The plaintiffs in the ANR II law- programming. research, and activities of organiza- suit (Americans for Nonsmokers’ The State Commission’s guide- tions and initiatives with similar Rights, the American Lung 44 lines for implementation of the goals. The programs have estab- Association, American Cancer California Children and Families Act lished relationships with the Society, and American Heart Toward a Tobacco-Free California: by the county commissions include voluntary health organizations, the Association) have all stated in writ- the following objectives related to Centers for Disease Control and ing that they will drop their suit if tobacco use: Prevention, the U.S. Department of the funds are appropriated as speci- Education, the Center for Substance fied in Proposition 99. Thus, there • Reduce cigarette smoking among Abuse Prevention, the National would be no continuing litigation in pregnant women. Institutes of Health, the Robert Wood this case. • Increase smoking cessation dur- Johnson Foundation’s Smokeless The SAYNO lawsuit, which the ing pregnancy. States Program, including California’s State won at trial, is under appeal. Next Generation Alliance, and the This case seeks reimbursement of • Increase smoking cessation by Campaign for Tobacco Free Kids. the Health Education Account for new mothers. TEROC recommends that the pro- funds alleged to have been illegally • Increase providers advising gram continue to actively coordinate spent on medical services. The ANR smoking cessation for pregnant with these initiatives, and to forge II Restricted Reserve is in the women and new mothers. ties with entities such as the new Health Education Account, and can- Proposition 10 California Children not be used to reimburse the Health • Increase the proportion of pedia- and Families Commissions (State Education Account. Thus, regard- tricians and family physicians and local), the California Attorney less of the outcome of the SAYNO that inquire about second hand General, the National Association of litigation, these funds will not be smoke exposure in the home. Attorneys General in reference to involved. TEROC believes that objectives the Master Settlement Agreement, Chapter 5 — Strategies for the 21st Century: TEROC’s Recommendations for 2000-2003 45 “Zeppo Kicks the Habit.” California Smokers’ Helpline. “How Many?” Television Ad, 1997 Statewide Media Campaign. References 47 References Centers for Disease Control (1997). Edwards, C.C., Elder, J.P., de Moor, Parmley, W. and Glantz, S.A. Passive Morbidity and Mortality Weekly C., Wildey, M.B., Mayer, J.A., and smoking and heart disease: Epidem- Review, 46, 1038-1043. Senn, K.L. (1992). Predictors of iology, physiology, and biochemistry. participation in a school-based anti- Circulation, 83 (1), 1-12. Centers for Disease Control and tobacco activism program. Journal Prevention (1999). Best practices of Community Health, 17, 283- Pierce, J., Evans, N., Farkas, A.J., for comprehensive tobacco control 289. Zhu, S.H., Choi, W.S., Berry, C.C., programs. Atlanta, GA: U.S. Distefan, J.M., White, M.M., Soroko, Department of Health and Human Independent Evaluation Consortium S., and Navarro, A. (1998a) Tobacco Services, Centers for Disease (1998). Final Report of the Indepen- control in California: Who’s win- Control and Prevention, National dent Evaluation of the California ning the war? An evaluation of Center for Chronic Disease Tobacco Control Prevention and the Tobacco Control Program, Prevention and Health Promotion, Education Program: Wave I Data, 1989-1996. La Jolla, CA: University Office of Smoking and Health. 1996-1997. Rockville, MD: The of California, San Diego. Gallup Organization. Department of Health Services, Pierce, J., Gilpin, E.A., Emery, S.L., Tobacco Control Section (1999). Independent Evaluation Consortium White, M.M., Rosbrook, B., and Fast Facts. Sacramento, CA: (in press). Final Report of the Berry, C.C. (1998b). Has the Department of Health Services. Independent Evaluation of the California Tobacco Control Program California Tobacco Control and reduced smoking? Journal of the Department of Health Services Education Program: Wave 2 Data, American Medical Association, (November 1999). Cost benefits of 1998, with Wave 1 and Wave 2 280 (10), 893-898. the California Tobacco Control Data comparisons, 1996-1998. Program, 1990-1998. Analysis by Rockville, MD: The Gallup Rigotti, N.A., DiFranza, J.R., Chang, the Tobacco Control Section, Data Organization. Y., Tisdale, T., Kemp, B., and Singer, Analysis and Evaluation Unit. D. (1997) The effect of enforcing Lightwood, J.M. and Glantz, S.A. tobacco-sales laws on adolescents’ Department of Health Services, (1997). Short-term economic and access to tobacco and smoking Tobacco Control Section (1998). A health benefits of smoking cessation: behavior. New England Journal of Model for Change: the California Myocardial infarction and stroke. Medicine, 337, 1044-1051. Experience in Tobacco Control. Circulation, 96 (4), 1089-1096. Sacramento, CA: Department of Zhang, X., Miller, L., Max, W., and Health Services. Lightwood, J.M. Phibbs, C., and Rice, D.P. (1999). Cost of smoking Glantz, S.A. (1999, submitted). to the Medicare Program, 1993. Short-term health and economic Health Care Financing Review, benefits of smoking cessation: Low 20 (4), 179-196. birth weight. Pediatrics. Front Cover: “Like Father, Like Daughter.” Billboard, 1995 Statewide Media Campaign.
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