Leveling the Playing Field

Leveling the Playing Field Who s Using, Who s Not and How to Narrow the Gap Ilana M. Knopf, J.D. Albany Hilton, Kerry M. Snyder, J.D. January 28, 2015 Public Health Advocacy Institute at Northeastern University School of Law 360 Huntington Avenue, 117CU Boston, MA 02115 tobaccopolicycenter.org

Objectives Participants will be able to articulate: Which NY subpopulations endure the highest rates of tobacco use & why this is every community s problem. How environments contribute to tobacco use and exacerbate use disparities. How point of sale policies can promote fairness by providing individuals in all communities a fair shot at quitting. 2

Terms Disparities-differences in health status (or tobacco use) closely linked with disadvantage. Health Equity-opportunity for everyone to reach full health potential regardless of socially determined circumstance. Social Justice-people treated equitably; fair allocation of community resources and sharing of common burdens. 3

Disparities in Smoking Prevalence among New York Adults (2013) Bottom Line: Smoking behavior is concentrated among those in low socioeconomic circumstances and those reporting poor mental health (groups that often overlap) New York State Department of Health, Bureau of Tobacco Control, StatshotVol.8, 4 No. 2 (February 2015)

Health Equity 5

Health Equity Why Should We Care? Tobacco use is concentrated among low-income, low-education and those reporting poor mental health. Disproportionate disease and death among this population are economic burdens on all. Taking action to reduce this disproportionate burden of disease and death will improve the health and quality of life for all. Unfair for health to be determined by social/economic circumstances. 7

Which is more effective medical advances or social change? Reducing disparities between adults with high school education or less and college-educated adults would have saved more lives than those saved through medical advances during the same period. Woolf, et al., Giving Everyone the Health of the Educated: An Examination of Whether Social Change Would 8 Save More Lives than Medical Advances, 97 AM. J. PUB. HEALTH 679 (2007)

Effect of Education on Life Expectancy Individuals with lower levels of education have shorter life expectancies and their life expectancies are declining (while those of better-educated are increasing) Olshansky, et al., Differences in Life Expectancy Due to Race and Educational Differences 9 Are Widening, and Many May not Catch up, 31 HEALTH AFFAIRS 1803, 1807 (2012)

Life Expectancy by Neighborhood 10

Smoking and the Cost to New York State Every year, tobacco-related health care costs New Yorkers $10.4 billion, of which Medicaid covers $6.62 billion. Lost productivity from smoking annually costs NYS more than $7.33 billion. Campaign for Tobacco Free Kids, The Toll of Tobacco in New York, September 25, 2015 11

Why Do Health Disparities Persist in Low-SES Communities? INDUSTRY-DRIVEN environmental triggers and cues undermine ability to cope with stressors Disproportionate number of smokers Normalization of behavior Poor access to cessation services INDUSTRY-DRIVEN retail environment 12

How does the Tobacco Industry exacerbate stressors on low-ses communities? Industry Tactics: Alliances Front groups Campaign funding Philanthropy Public relations Intimidation Lobbying Legislative action Buying expertise Advertising 13

Tobacco Industry Strategies: Making Alliances and Building Loyalty Stifling Resistance Employment of minorities Funding community organizations and agencies Funding political and civic campaigns Funding cultural events Funding education Supporting minority publications Sponsoring sporting events 14

Tobacco Industry Strategies: Targeted Product Marketing 15

Tobacco Industry Strategies: Targeted Product Marketing 16

Tobacco Industry Strategies: Targeted Product Marketing 17

Tobacco Industry Strategies: History of (and Continued) Deceit [S]ubstantial evidence establishes that Defendants have engaged in and executed and continue to engage in and execute a massive 50- year scheme to defraud the public, including consumers of cigarettes, in violation of RICO. -Judge Kessler Defendants knew [their statements were false] and made the statements with the intent to deceive. -U.S. Court of Appeals for D.C. Circuit 18

Tobacco Industry Strategies: Point of Sale Marketing Product o Includes product characteristics, e.g. flavor Price o Includes price promotions and discounts Place o Product availability Promotion o Marketing 19

Tobacco Industry Strategies: Point of Sale Marketing Focus Communities More retailers in low-ses neighborhoods (urban and rural) More advertising at stores located in low-ses and minority communities (particularly for menthol products) More price promotions/lower prices in retailers located in minority and low- SES communities 20

Leveling the Playing Field through Tobacco Control Recognizing that health disparities are largely a result of historical circumstances and inequitable distribution of resources (past and present). Recognizing that health disparities have a social or economic cause, rather than a biological one. 26

Leveling the Playing Field through Tobacco Control Enforcing policies fairly across neighborhoods, census tracks, counties, etc. Stressing fair access to resources and the sharing of common burdens across all, rather than shouldered disproportionately by a small group 27

Leveling the Playing Field through Tobacco Control Examine public health through a fairness lens; making it easier for peoplaae to access support and make healthier choices will: Improve overall public health Increase fairness o Counteract industry influence/burden 28

Summary of the Problem 30

Summary of the Problem 31

Summary of the Problem 32

Tobacco Control: What Works 33

Why Do Health Disparities Persist in Low-SES Communities? INDUSTRY-DRIVEN environmental triggers and cues undermine ability to cope with stressors Disproportionate number of smokers Normalization of behavior Poor access to cessation services INDUSTRY-DRIVEN retail environment 34

Tobacco Control: Our Sphere of Control? Biology & Genetic Environment Employment & Working Conditions Personal Health & Coping Skills Health Services Healthy Child Development Income & Social Status Education Social Support Networks Neighborhood & Physical Environment 35

What Works: Change Environments Disrupt existing tobacco-norming environments where we live, work, play tobacco point of sale Support health-promoting environments tobacco-free spaces point of sale 36

What Works: Change Environments Level the Playing Field Multi-unit Housing Workplaces Recreation and other outdoor air Smoke and Tobacco Free Spaces 37

What Works: Change Environments Level the Playing Field The Retail Environment Causes Youth Initiation Undermines Cessation Reduce exposure to tobacco marketing 38

Why Do Disparities Persist in Low-SES Communities? 39

What Works for Target Population: Change Environments, Level the Field AVOID TRIGGERS any form of stimuli that initiates the desire to engage in addictive behavior. Triggers may prompt an individual to slip-up and use a substance or engage in a behavior that they otherwise are trying to avoid 40

What Works: Change Environments (Sales Environment) Billions $10 $8 Tobacco Industry Marketing Expenditures $415,472,294 $889,690,159 $6 $4 $8,298,333,637 POS Marketing $2 $0 POS Marketing-price promotions POS Marketing-non-price promotions Non-POS Marketing 42

What Works: Policy Response (Sales Restrictions) 43

What Works, the Details: POS Policy Options and How Each Works TYPE PRICE POINT OF SALE MARKETING NUMBER LOCATION 44

What Works, the Details: POS Policy Options and How Each Works RESTRICT POINTS OF SALE NUMBER of sales outlets 45

What Works, the Details: POS Policy Options and How Each Works TYPE of sales outlets RESTRICT POINTS OF SALE 46

What Works, the Details: POS Policy Options and How Each Works RESTRICT POINTS OF SALE LOCATION of sales outlets 47

What Works, the Details: POS Policy Options and How Each Works Sales PRICE RESTRICT POINTS OF SALE 48

What Works, the Details: POS Policy Options and How Each Works TYPE PRICE POINT OF SALE MARKETING NUMBER LOCATION 49

TYPE PRICE POS ACCESS Marketing (AGE) PRODUCT NUMBER SIGNS (NEUTRL) LOCATION 50

What Works, the Details: POS Policy Options and How Each Works Strategies to reduce exposure to tobacco point of sale marketing: Tobacco retail licensing ordinance Stand-alone ordinance 51

TOBACCO-FREE TOBACCO - FREE OUTDOORS TYPE PRICE MEDIA POS Marketing INDOORS NUMBER LOCATION HOUSING TOBACCO-FREE TOBACCO-FREE 52

TOBACCO-FREE TOBACCO - FREE MISC OUTDOORS TYPE PRICE MEDIA ACCESS POS Marketing (AGE) MISC PRODUCT (FLAVOR) INDOORS NUMBER SIGNS (NEUTRAL) LOCATION HOUSING TOBACCO-FREE TOBACCO-FREE 53

What Works: Leveling the Playing Field 54

Reducing Health Inequities Public Health Values Marketing Values The good we secure for ourselves is precarious and uncertain until it is secured for all of us and incorporated into our common life. Jane Addams Public Health Advocacy Institute at Northeastern University School of Law 55