MAKE OREGON HEALTHIER: SAVING LIVES AND SAVING DOLLARS TOBACCO PREVENTION AND EDUCATION IN OREGON Program Report 2001-2003 Department of Human Services Health Services
Table of Contents Introduction 1 Program Goals 2 Program Components 2 Program Results 6 Cigarette Consumption 6 Adult Tobacco Use 7 Youth Tobacco Use 8 Protection from Exposure to Secondhand Smoke 9 The Future 10 Data Sources inside back cover If you would like additional copies of this report, or if you need this material in an alternate format, please call the Tobacco Prevention and Education Program at 503-731-4273 or (TTY) 503-731-4031
In November 1996, Oregon s electorate decisively passed Measure 44, which raised taxes on tobacco and dedicated 10% of the new revenue to tobacco prevention and education. Oregon s Tobacco Prevention and Education Program was launched in 1997 with a clear and simple mandate to reduce tobacco-related illness and death. During the past six years, the Program has addressed Oregonians concerns about the destructive effects of tobacco use with dramatic results. Compared with 1996, today in Oregon, there are: 75,000 fewer adult smokers 25,000 fewer youth smokers 2,200 fewer pregnant smokers 1.5 billion fewer cigarettes sold annually 60,000 fewer adults using smokeless tobacco Despite these gains, there is still much to be done. Each year in Oregon more than 6,000 people die from tobacco-related disease tobacco annually claims more lives than AIDS, drug and alcohol abuse, motor vehicle crashes, murders and fires combined. In 2002, 500,000 Oregon adults still smoked, and 60,000 adults chewed tobacco. For most smokers, addiction to tobacco began in their youth. Despite gains in preventing youth from starting to smoke, 50,000 Oregon youth still smoke and 17,000 chew tobacco. In addition to the cost of tobacco use to Oregonians in health and lives, tobacco also imposes a significant financial burden of particular concern in a time of serious economic difficulties in the state. Tobacco use cost Oregonians $1.8 billion in 2000. With such serious issues in the balance, the continued success of Oregon s Tobacco Prevention and Education Program is vital to the health of Oregonians and to the health of Oregon s economy. Since the program began, there are 75,000 fewer adult smokers 25,000 fewer youth smokers 2,200 fewer pregnant smokers 1.5 billion fewer cigarettes sold annually 60,000 fewer adults using smokeless tobacco In spite of these gains, tobacco use still costs Oregonians $1.8 billion annually in health-related expenses and lost productivity. I N T R O D U C T I O N 1
P R O G R A M Program Goals Save lives and save dollars. Since its inception, Oregon s Tobacco Prevention and Education Program has been a comprehensive program, addressing the issues of tobacco use with three specific goals: Prevent Youth Tobacco Use Reduce Adult Tobacco Use Protect Oregonians from Secondhand Smoke Program Components Hailed by the federal Centers for Disease Control and Prevention as a national model, Oregon s approach is to achieve each of its three goals through seven program components, each of which reinforces the others. 1) County and Tribal based Programs The Program supports community-based anti-tobacco-use efforts in counties and tribal communities. These programs bring together partners and stakeholders to work collaboratively to reduce tobacco use. County-based Programs. All 36 Oregon counties have active tobacco-free coalitions, most of which are facilitated by the county health department. Coalitions create workplans that fit with local needs and opportunities to: Reduce youth access to tobacco Create tobacco-free schools, workplaces, and public places Decrease promotion of tobacco products Link tobacco users who want to quit with help to do so In the current biennium ( 01-03) these community-based coalitions have: Worked with retailers to improve compliance with prohibitions against selling tobacco to minors Worked with health clinics and the public to promote Oregon s free tobacco cessation telephone service Supported local youth efforts to reduce tobacco company advertising at stores, community events and schools Worked with businesses and the Oregon Department of Human Services to implement Oregon s Smokefree Workplace Law Tribal-based Programs. American Indians have one of the highest tobacco use rates in Oregon. All nine federally recognized tribes in Oregon receive funds to implement tobacco prevention and educa- 2
tion programs. Their efforts are designed to decrease tobacco use by American Indians, while respecting the sacred use of tobacco in their cultures. 2) Comprehensive School-based Programs During the current biennium, 32 school districts, representing more than one-third of Oregon students, received funding to implement comprehensive tobacco education programs. Students in these districts benefit from proven effective tobacco prevention curricula, school policies that aim to eliminate the use of tobacco on campus and at school events, and special resources for teachers and parents, including training and cessation support. Research has shown that school-based programs are effective when they are reinforced by adult role models and other cues from the environment. Thus, the other program components are critical in reducing youth tobacco use. 40,000 people have called the Oregon Tobacco Quit Line since 1998. 3) The Oregon Tobacco Quit Line: 1-877-270-STOP More than 6,000 studies indicate that treating nicotine dependence as a part of routine medical care is an effective way to address tobacco addiction. Clinics and doctors help patients to quit by discussing the health effects of tobacco and offering advice and assistance. Assistance can include help from a patient s insurer for counseling programs and pharmacotherapy (patches and prescription drugs) for nicotine addiction. The Tobacco Prevention and Education Program helps health professionals and tobacco users alike through the Oregon Tobacco Quit Line, which is designed to serve in partnership with private health care systems. This toll-free statewide telephone-based assistance program helps users quit tobacco. More than 40,000 people have called the Quit Line for help. Tobacco users receive personalized counseling that is proven to be effective. First, the Quit Line assesses the caller s motivation, tobacco use history and previous quit attempts in order to provide personalized advice. 3
P R O G R A M The Quit Line also mails callers a Quit Kit that includes tobacco substitutes, referrals, and information specific to the users needs. The Quit Line helps callers access counseling and medications available through the individuals health insurance and the community. Uninsured callers receive cessation counseling and medication directly through the Quit Line. In follow-up surveys of Quit Line callers, three-fourths of those reached reported they had success in reducing their tobacco use. Twenty percent are tobacco-free after six months. This success rate is more than double that of people who try to quit on their own. 4) Multicultural Outreach and Education The Tobacco Prevention and Education Program works with populations that have high rates of tobacco use, that have been targeted by tobacco companies or that have unique cultural needs. Four multicultural organizations receive funding to provide ongoing consultation about how most effectively to reduce tobacco use in their communities. These organizations also help find tobacco prevention opportunities specific to their communities and identify community leaders who can be champions for tobacco prevention. For example, through the Urban League of Portland an anti-smoking campaign based on the principles of Kwanzaa was implemented in the African-American community. 5) Statewide Public Awareness and Education Campaign Increased public awareness of the dangers of tobacco use and secondhand smoke encourages smokers to call the Quit Line and reinforces other components of the Program. As part of the campaign, more than 50,000 commercials have aired on radio and television throughout the state during the last biennium. These commercials have reached at least 95% of the target audience at least 100 times. Research has shown that television ads are the most effective way to drive calls to the Quit Line. Broadcast commercials have reached 95% of our target audience more than 100 times. 4 Significant savings are realized by regularly using advertisements produced by the Centers for Disease Control and Prevention and other states. Oregon s special needs are also addressed through production of a small number of our own ads, such as those targeted to rural chew tobacco users and those that inform the public
about the Oregon Smokefree Workplace Law. It is particularly noteworthy that we have negotiated with broadcasters for more than 50% additional airtime at no additional cost. The paid media coverage is amplified by scheduled news releases and press conferences. Special efforts are also made to raise awareness among certain populations those that have high tobacco use rates or are targeted by the tobacco industry. For example, in this biennium four Hispanic cable channels were added to the media buy, expanding Spanish-language cable media outlets from three to seven channels. 6) Program Evaluation Program outcomes are measured using a wide variety of data sources, including tax revenue data, self-report surveys, focus groups, and specific research projects. These data help guide refinement and development of the Program and help ensure that funds are expended in the most effective way. The high scientific quality of these evaluation activities is enhanced by an external advisory board of distinguished experts in tobacco control. 7) Statewide Coordination and Leadership The Tobacco Prevention and Education Program is complex, encompassing a wide range of partners and activities. Program activities and contracts are carefully monitored to ensure effective implementation. Coordination among program components and across the state is essential in order to achieve maximum benefits and ensure accountability. 5
R E S U L T S Program Results Oregon s Tobacco Prevention and Education Program is evaluated by measuring changes in tobacco use from 1996 the year prior to implementation of the Program to the present. Oregon s results are then compared to the nation to assess the Program s effectiveness. During these six years, there has been a dramatic reduction in tobacco use in Oregon. Fewer adults, pregnant women, and youth are smoking. Use of smokeless tobacco is also down substantially. And, far fewer Oregonians are exposed to secondhand smoke in the workplace and in the home. Saving Lives and Saving Dollars For each year Oregon maintains the tobacco use reductions already achieved, 1,800 lives and $540 million is saved in Oregon s future. Cigarette Consumption Annual per capita cigarette consumption in Oregon has declined approximately 30% since 1996. This means that in 2001, Oregonians smoked 1.5 billion fewer cigarettes than they would have without this drop. Oregon s decline in cigarette consumption is far steeper than that of the nation. 6
Adult Tobacco Use Cigarette Smoking 75,000 fewer adult Oregonians smoke today than in 1996. The percentage of adults who smoke was 23.4% in 1996 and 20.4% in 2002 (preliminary data) a 13% decline. The national decline in adult smoking was 8% from 1996-2001. Smokeless Tobacco 60,000 fewer adult Oregonians use smokeless tobacco today than in 1996. The percentage of adult males who use smokeless tobacco was 9.4% in 1996 and 4.9% in 2002 (preliminary data)---a 48% decline. Tobacco Use Among Pregnant Women 2,200 fewer pregnant Oregonian women used tobacco in 2001 than in 1996 a decline of 28% or almost three times the national rate of decline. 1,300 fewer Oregon Health Plan enrollees used tobacco during pregnancy in 2001 than in 1996. In 2001, Oregon saved over $1 million in caring for low birthweight babies because fewer mothers smoked during pregnancy. The decline in the prevalence of smoking among pregnant women in Oregon resulted in estimated savings of $1.3 million in neonatal medical expenditures in 2001 and an estimated 57 fewer low birthweight infants. 7
Youth Tobacco Use R E S U L T S 8 Cigarette Smoking 25,000 fewer children smoke cigarettes today than in 1996. Between 1996 and 2002, the percentage of Oregon 8th grade students who smoke fell 47%, and the percentage of 11th grade students who smoke fell 26%. Oregon s results are consistent with those of the nation, with two exceptions: the steep declines in youth smoking began earlier in Oregon, and the percentage of Oregon 11th grade students who smoke is lower than that of the nation. In addition, Oregon schools that have implemented a comprehensive tobacco prevention program have had even greater declines in youth smoking. Smokeless Tobacco 2,600 fewer 11th grade males use smokeless tobacco today than in 1997. The percentage of 11th grade male students in Oregon who use smokeless tobacco dropped from 22.7% in 1997 to 12.5% in 2002 a 45% decline. The national drop in smokeless tobacco use is estimated to be 20% ( 96-01).
Protection from Exposure to Secondhand Smoke Secondhand smoke is a serious health issue affecting children and adults. It causes about 10% of all tobacco-related deaths, increases the risk of heart disease and lung cancer, and leads to higher rates of asthma, ear infections, chronic bronchitis, pneumonia, and Sudden Infant Death Syndrome. In 2001, 86% of Oregonians agreed that people should be protected from secondhand smoke. At work Smokefree Workplace Law. As a result of Oregon s new clean indoor air law, which was passed by the 2001 legislature, more than 95% of Oregon s workers are now protected from exposure to secondhand smoke in indoor workplaces. Bars, bingo halls, tobacco retailers, bowling centers, and hotel rooms are exempted from the requirement to be smokefree. At home Smoking is not allowed in four out of five homes in Oregon. From 1997 to 2001, the percentage of homes where indoor smoking was not allowed increased from 71% to 81%. In 2000, indoor smoking was prohibited in 95% of homes with women who had recently given birth. 9
The Future and investing wisely for it F U T U R E Oregon s Tobacco Prevention and Education Program is successfully saving lives and saving dollars. The Program is costeffective and a good investment in Oregon s future. For each year Oregon maintains the reductions already achieved, $540 million is saved in Oregon s future. Despite the measured successes of Oregon s Tobacco Prevention and Education Program, there are continuing challenges ahead in the next biennium. Tobacco use remains a significant problem in Oregon. In 2000, tobacco use was associated with more than 6,000 deaths and $1.8 billion in economic costs including direct medical costs and lost productivity due to tobacco-related illnesses and premature death. Since the latter part of 2001, there has been a flattening of the downward trend in tobacco use, both in Oregon and the nation. This may be a result of increased anxiety around Sept. 11, 2001 and the uncertain economic conditions. In the latter part of 2002, there have been early indications of continued declines in tobacco use in Oregon. Not funded by MSA revenue. In 1998, Attorneys General from 46 states signed the Master Settlement Agreement (MSA) with tobacco companies that resulted in annual payments to states. Oregon s share of the MSA is about $150 million per biennium. None of these dollars is dedicated to tobacco prevention activities in Oregon. The Oregon program has been funded from Measure 44 tobacco taxes $18 million in the current biennium. Measure 20, the tobacco tax enacted in November 2002, dedicated a onetime amount of $2 million to tobacco prevention for 2002-2003. In future biennia, the net effect of Measure 20 will be to make no change in the level of tobacco prevention funding prior to Measure 20. Because of decreased tobacco use, program funding is projected to decrease 18% next biennium. The Program s success in reducing tobacco use results in a decrease in tobacco tax revenues available for tobacco prevention. 10
Because of reduced revenue, Program funding from tobacco taxes is projected to decline about 18% in the next biennium. Experience from other states has shown that decreases in tobacco prevention funding lead to more tobacco use. Moreover, the Centers for Disease Control and Prevention recommends a minimum biennial budget for tobacco prevention in Oregon that is more than twice the current budget. The Oregon Tobacco Prevention and Education Program plays an important role in maintaining and improving the health of all Oregonians and the state s economic productivity. Oregon voters in 1996 and subsequent Legislative Assemblies have recognized the importance of supporting this program. Adequate funding in the future is critical for the Program to continue its current success. Experience from other states has shown that decreases in tobacco prevention funding lead to more tobacco use. 11
Tobacco Prevention Technical Evaluation Advisory Committee Members Ed Lichtenstein, PhD Committee Chair Oregon Research Institute Tom Becker, MD, PhD Department of Public Health Oregon Health Sciences University David Burns, MD School of Medicine University of California, San Diego David Fleming, MD Office of the Director Centers for Disease Control and Prevention Clara Pratt, PhD Family Policy Program Oregon State University Terry Pechacek, PhD Office on Smoking and Health Centers for Disease Control and Prevention Dorothy Rice Institute for Health and Aging University of California Lawrence Wallack, PhD School of Community Health Portland State University
Data Sources I. Information regarding cigarette consumption comes from: Oregon Department of Revenue Cigarette Tax Receipts. Data on the number of cigarettes smoked by Oregonians are estimated by tobacco tax revenue collected by the Oregon Department of Revenue. The Department of Revenue s Monthly Receipt Statements include data on cigarettes tax collections. Packs of cigarettes sold are calculated by taking the cigarette tax receipts total divided by tax rate per pack. Packs per capita is calculated by dividing the total number of cigarettes packs sold by the population estimate for Oregon. Data on cigarette consumption for the nation come from Research Triangle International (RTI), using cigarette tax revenue data from each state. II. Information regarding adult tobacco use, including: prevalence of tobacco use, smokers' interest in quitting, attitudes toward tobacco, questions regarding exposure to environmental tobacco smoke and attitudes about exposure to ETS, information about smokers' perceptions of health care providers assistance in helping people quit smoking and related topics come from: Behavioral Risk Factor Surveillance System (BRFSS) The Behavioral Risk Factor Surveillance System is an ongoing random-digit dialed telephone survey of adults concerning health behaviors. The BRFSS was developed by the Centers for Disease Control and Prevention (CDC) and is conducted in all states in the U.S. Each year, between 3,000 and 7,000 adult Oregonians are interviewed. The data are weighted to represent all adults aged 18 years and older. A core set of questions is asked in every state, and each state may add questions to the survey. The Oregon survey includes an additional fifty questions on attitudes and behaviors regarding tobacco. Definition of adult smoking prevalence: BRFSS survey respondents are considered current smokers if they answered "yes" to the question: "Have you smoked at least 100 cigarettes in your lifetime?", and "every day or some days" to the question, "Do you now smoke every day, some days, or not at all?" III. Information regarding youth tobacco use including: prevalence of youth tobacco use by school grade and youth access to tobacco comes from the following surveys: Youth Risk Behavior Survey The YRBS was developed by the Centers for Disease Control and Prevention and has been administered in a sample of Oregon schools every other year since 1991. The sample size has varied between 1,600 and 32,000 and the final data are weighted to more accurately represent the Oregon high school and middle school populations. The questionnaire assesses behavioral risks in Oregon high school students (grades nine through 12) in the areas of vehicle safety, weapon carrying and violence, tobacco use, alcohol use, other drug use, sexual activity and pregnancy, HIV knowledge and attitudes, eating behaviors, nutrition, exercise, and access to health care including use of school-based health centers. A sample of middle school students (grades 6 through 8) was added in 1997. Oregon Public School Drug Use Survey This anonymous survey has been administered bi-annually since 1986 by the Oregon Office of Alcohol and Drug Abuse Programs (OADAP) through the Oregon public school system. It is modeled after the ongoing national surveys of the National Institute on Drug Abuse and has included eighth and eleventh graders since 1986; a sixth grade sample was added in 1994. Schools are randomly sampled using a stratified sample design. The questionnaire assesses community characteristics, tobacco use, drug use, alcohol use, drug/alcohol use in student s peer and family network, refusal skills, susceptibility to future use, and attitudes toward school and family. Oregon Healthy Teens Survey Since 2000, the above two youth surveys have been combined into a single annual survey. In 2002, approximately 13,000 8th graders from 120 middle schools and 9,000 11th graders from 90 high schools were surveyed. Definition of youth smoking prevalence: Smoking prevalence in 6th, 8th and 11th graders is defined as the percentage of students who smoked one or more cigarettes in the preceding month. IV. Information regarding the number of women who used tobacco during their pregnancy comes from: Birth Certificate Statistical File. Data from the Birth Certificate Statistical File are coded from birth certificates collected by the State Registrar and represent all births occurring in Oregon and all births occurring out-of-state to Oregon residents. This database includes parental identifying and demographic information, conditions of the newborn, congenital anomalies, medical factors of pregnancy, method of delivery, complications of labor and delivery, tobacco use, drinking, or illicit drug use during pregnancy, antenatal and intrapartum procedures, and payor source. The birth data analyzed for this report consist of births to Oregon residents. V. Information about the morbidity, mortality and economic costs related to tobacco use comes from: Death Certificate Statistical File. The Death Certificate Statistical File includes all deaths occurring in Oregon and deaths occurring out-of-state to Oregon residents. Data are obtained from death certificates that are collected by the State Registrar. he data are used to examine trends in mortality and causes of death. Variables in this database include cause of death, decedent s identifying information, date and place of death, occupation of the decedent, whether the death was related to tobacco use, education of decedent, marital status of decedent, and county, place, and date of injury (if applicable). The mortality data analyzed for this report consist of deaths of Oregon residents. Definition of a smoking-related death: Physician responds "yes" or "probably" to the following question on the death certificate: "Did tobacco use contribute to the death?" Smoking-Attributable Morbidity, Mortality and Economic Costs (SAMMEC) SAMMEC is a computer software program developed by the Centers for Disease Control and Prevention to calculate several measures of the impact of cigarette smoking for the entire U.S. and for each state. Using state-specific data on smoking prevalence (from the BRFSS), overall mortality rates, and population data, SAMMEC generates the number of deaths and death rates due to smoking, years of life lost due to premature death from cigarette smoking, and lost productivity (earnings) due to illness and premature death from smoking-related diseases. Calculation of future reductions in mortality and economic costs: Reductions in cigarette consumption are applied to current tobaccorelated deaths and economic costs to estimate future reductions in mortality and economic costs. VI. Information regarding County, School and Tribal progress toward program implementation comes from periodic Progress Reports submitted by the staff of the county coalitions, schools and tribes to the Department of Human Services. Information regarding Quit Line utilization is derived from periodic reports from the Quit Line staff to DHS. A more detailed description of these data sources can be found in Oregon Tobacco Facts, available at http://www.ohd.hr.state.or.us/tobacco/facts00 or by calling the Tobacco Prevention and Education Program at 503-731-4273.