Tobacco Control: Big Fast Benefits Stanton A. Glantz, PhD Professor of Medicine University of California San Francisco
Australia (December 2012)
Australian Government, Department of Health 2015
The California Situation Low taxes (33 rd in US) Few ad restrictions Weak, obsolete warning labels
Accelerated prevalence decline
Accelerated consumption decline
Lower youth smoking
The California Model Social norm change
The California Model Key messages Secondhand smoke kills Nicotine is addictive The tobacco industry lies Industry Spokesman
Deaths from Secondhand Smoke Heart disease 37,000 Lung cancer 3,000 Other cancers 13,000 Source: Wells,1998
Heart Disease: Epidemiology About 30% increase in risk if married to smoker or work in smoking workplace
Nonlinear Dose-Response Pope et al, Circulation, 2009
Helena, Montana Population of city: 28,306 Population of Helena Zip Codes: 46,943 Total Population of Study area: 65,913 Geographically isolated population Next nearest cardiologist: 60 miles
AMI Admissions Significant Drop in AMI Admissions while Ordinance in Effect 60 50 40 Helena Outside Helena Ordinance 30 20 10 0 1998 1999 2000 2001 2002 2003 Year
Literature continued to build 43 studies of 33 laws As of July 2012 Many endpoints Acute myocardial infarction Angina, other heart disease Stroke Asthma COPD Other pulmonary
Risk of Hospital Admission Stronger laws Bigger effects 1,2 1 0,8 0,6 0,4 0,2 0 7 7 32 1 4 5 2 1 5 4 4 11 Coronary events (AMI, ACS, ACE, IHD) Other heart disease (angina, CHD, SCD) Cerebrovascular accidents Respiratory disease Workplaces Workplaces and restaurants Workplaces and restaurants and bars
Also reduces Complications of pregnancy Neonatal complications
0 Ambulance Calls (Casinos) 20 40 60 80 100 Ambulance calls 2000 2002 2004 2006 2008 2010 2012 2014 Year
Age-Adjusted Heart Disease Mortality (deaths/100,000) Heart Disease Mortality 200 180 United States - California California 160 140 120 Prop 99 Tax increase 100 1979 1984 1989 1994 Year
Age-Adjusted Heart Disease Mortality (deaths/100,000) Effect on Mortality 175 155 59,000 fewer deaths (9%) 135 115 1,500 unnecessary deaths 95 1979 1984 1989 Year 1994
Age adjusted incidence (cases/100,000/year) Effect on Lung Cancer Incidence 73 71 San Francisco Bay Area 69 67 65 63 61 Anti-tobacco program 14% reduction 59 57 55 1975 1980 1985 1990 1995 2000
Health Care Savings Attributable to CA Tobacco Control
1989 through 2008 Tobacco Control Program cost $2.4 billion Save $243 billion in health costs 12% of total health costs in 2008 Reduced cigarette sales by 6.8 billion packs Worth $28.5 billion in to tobacco industry
The View from Afar A California Phenomenon Health fanatics Puritans Foreign to European (and other) traditions and sensibilities
1989
1989
1989
Philip Morris 1993
1993
1993
1993
E-cigarettes
Ecigs to quit
E-cigarettes = less quitting
What about the hard core? People who can not or will not quit Expect as prevalence drops Quitting drops Cigs/day stays same or increases
10 20 30 40 50 10 20 30 40 50 10 20 30 40 50 US: More quitting United States 1993 1996 1999 2002 2003 2007 10 15 20 25 30 10 15 20 25 30 2011 10 15 20 25 30 Smoking Prevalence (%)
EU: More quitting
US: Lower consumption 10 15 20 25 United States 1993 1996 1999 2002 2007 2011 10 15 20 25 10 15 20 25 30 10 15 20 25 30 10 15 20 25 30 Smoking Prevalence (%)
EU: Lower consumption
So softening not hardening
What about kids?
Current smoking/e-cigarette use (NYTS) 20 16 12 8 4 0 2004 2006 2009 2011 2012 2013 2014 Current Cigarette only Current Dual Use
E-cig use predicts smoking Nonsmokers at baseline 1 year longitudinal follow-up Smoking at follow-up Study Place Age Odds of Smoking Wills Hawaii 15 2.87 (2.03-4.05) Primack US 16-26 8.3 (1.2-58.6) Leventhal Southern California 14 2.73 (2.00-3.73) Gmel Switzerland 20 (male) 6.02 (2.81-12.88) OVERALL 3.21 (2.33-4.43)
E-cigs likely to prolong tobacco epidemic Restoring social acceptability Depressing quitting among smokers Attracting kids to nicotine Likely to progress to smoking Even if they don t it s a bad thing
The bottom line Possible to get large rapid drops in smoking Immediate and substantial health benefits Immediate and substantial economic benefits