dual use of smokeless tobacco and cigarettes: a public health warning sign
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Dual Use of Smokeless Tobacco and Cigarettes: A Public Health Warning Sign. Centers for Disease Control and Prevention Office on Smoking and Health. Terry F. Pechacek, PhD Associate Director for Science. 68 th Annual Kansas Public Health Association Conference Wichita, Kansas - PowerPoint PPT PresentationTRANSCRIPT
Dual Use of Smokeless Tobacco and Cigarettes:A Public Health Warning Sign
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68th Annual Kansas Public Health Association ConferenceWichita, KansasSeptember 22, 2011
Terry F. Pechacek, PhDAssociate Director for Science
Centers for Disease Control and PreventionOffice on Smoking and Health
The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
The responsibility for all of the presented material rests exclusively with the author.
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Presentation Overview The problem: stalled in a steady
state Trends in smoking Overview of smokeless tobacco Trends in use of tobacco products Trends in smokeless tobacco use Trends in dual use Conclusions & implications
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A Steady State
Too Few SmokersQuitting
Too Many YouthStarting to Smoke
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The Problem Slowing of decline in youth
smoking rate Slowing of decline in adult
smoking rate decline Increasing smoking initiation
rates Increasing rates of smokeless
tobacco use among high school boys and young adult men
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Emerging Changes in Tobacco Use Use of other tobacco products
besides cigarettes Pattern of using two or more
tobacco products Dual use of cigarettes and
smokeless tobacco is special concern
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The Bottom Line
Progress in reducing tobacco use among both youth and adults has slowed in recent years
Smokeless use and dual use are part of the problem
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When will we take the handle off the tobacco pump?
1854 - Dr. John Snow removed the pump handle from Broad Street water pump to stop a Cholera Epidemic in London
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Product, Price, Promotion, Placement*
PRODUCT – Certain features of tobacco products appeal to youth & young adults
PRICE – Youth and young adults are especially price sensitive
PROMOTION – Youth are more sensitive to advertising and promotional campaigns
PLACEMENT – Strategic placement of youth-oriented images and brands in media, advertising, and retail environments
*Source: Cummings KM, Morley CP, Horan JK, Steger C, Leavell N-R. Marketing to America’s Youth: evidence from corporate documents. Tobacco Control 2002;11(Suppl 1):i5-i17.
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Overview Cigarette Use Smokeless Tobacco Use Dual Tobacco Use
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Cigarette Use
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0
10
20
30
40
50
60
Year
Current Cigarette Smoking* Among Adults By Sex, U.S.—1955-2010
*Estimates since 1992 include some-day smoking. Sources: 1955 Current Population Survey; 1965-2006 National Health Interview Survey 2010
Males
Females
54.2
21.5
24.5
17.3
Per
cent
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Average Annual Rates of ChangeNHIS 1974-2010
1974 adj. (37.8%) – 2010 (19.4%) = -0.51% 1974 (37.1%) – 1990 (25.5%) = -0.73% 1990 adj. (26.2%) – 1997 (24.7%) = -0.21% 1997 (24.7%) – 2004 (20.9%) = -0.54% 2004 (20.9%) – 2010 (19.4%) = -0.25% 1990 adj. (26.2%) – 2010 (19.4%) = -0.34%
*adj (definition change in 1992 – adjusted estimates used in analysis of rates of change)
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Prevalence (%) of daily and less than daily smoking among U.S. adults (ages 18+ years old) -- 2002-2009 NHIS, BRFSS, and NSDUH20
0220
0320
0420
0520
0620
0720
0820
09
2002
2003
2004
2005
2006
2007
2008
2009
0
2
4
6
8
10
12
14
16
18
20
NHIS NSDUH BRFSS
DAILY SMOKING
*
* Confidence intervals around 2002 and 2009 estimates do not overlap.
LESS THAN DAILY SMOKING
*
*
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• Persons who reported smoking at least 100 cigarettes during their lifetime and who, at the time of the survey, reported smoking cigarettes every day.
• Source: CDC. Vital Signs: Current Cigarette Smoking Among Adults Aged ≥ 18 Years—US, 2005-2010. MMWR 60 (Early Release); 1-6
Percentage of daily smokers* aged ≥18 years, by number of cigarettes smoked per day (CPD) and
year, NHIS, United States, 2005--2010
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Current High School Cigarette Smoking And Projected Rates If Decline Had Continued, U.S. 1991-2009
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
0
5
10
15
20
25
30
35
40
45YRBS HS SMK* Projected HS SMK**
Year
Perc
ent
8%
*High school students who smoked on 1 >/ of the 30 days preceding the survey--United States, CDC. Youth Risk Behavior Survey, 1991-2009.**Projected High School students who smoked 1 or more days of past 30 days if 1997-2003 decline had been maintained.
3 million fewer youth and youngAdults would be smokers
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Past Year Initiation of Cigarette Use Among Youth and Young Adults: 2004 to
2009
6.8 6.6 6.65.9 6.2 6.2
7.1 7.4
8.77.9 8.3 8.6
0123456789
10
2004 2005 2006 2007 2008 2009
12-17 Years Old18-25 Years Old
Source: SAMHSA and NSDUH, 2004, 2005, 2006, 2007, 2008, 2009
* Initiation is defined as smoking cigarettes for the first time in the past year.
Perc
ent
Year
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2002 2003 2004 2005 2006 2007 2008 2009 20100.0
0.5
1.0
1.5
2.0
2.5
1.3 1.4 1.4 1.4 1.51.3 1.4 1.5 1.4
0.60.6 0.7 0.8
0.9
0.91.0
1.01.0
Past Year Cigarette Initiates among Persons Aged 12 or Older, by Age at First Use: 2002-2010
Numbers in Millions
17
1.9+2.0+
2.1+2.3
2.4 2.4
2.2
Initiated at Age 18 or Older
Initiated Prior to Age 18
+ Difference between this estimate and the 2010 estimate is statistically significant at the .05 level.
Note: Due to rounding, the stacked bar totals may not add to the overall total.
2.52.4
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Overview of Smokeless Tobacco
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Types of Smokeless Tobacco Chewing tobacco Dry snuff Moist snuff Dissolvables
– Lozenges, orbs, sticks, strips
Substance Abuse and Mental Health Services Agency, Office of Applied Studies. The NSDUH Report: Smokeless tobacco use, initiation, and relationship to cigarette smoking: 2002 to 2007. Rockville, Maryland: SAMHSA, March 5, 2009.
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New Smokeless Products Have Broader Appeal Spitless Discreet Flavored Packaged in novel, attractive ways Blur the line between tobacco
& non-tobacco products Cigarette brand extensions Heavily promoted
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Smokeless Tobacco: Health Effects Contains at least 28 carcinogens Oral cancer Esophageal cancer Pancreatic cancer Fatal heart attacks Premature birth & low birthweight
International Agency for Research on Cancer. Smokeless tobacco and some tobacco-specific N-nitrosamines. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Volume 89. Lyon, France: IARC, 2007.European Commission Health & Consumer Protection Directorate-General, Scientific Committee on Emerging and Newly Identified Health Risks. Health effects of smokeless tobacco products. Brussels, Belgium: European Commission, 2008.National Toxicology Program. NTP report on carcinogens background document for smokeless tobacco. National Toxicology Program, 1997.
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Smokeless Tobacco: Addiction Contains nicotine Highly addictive Increasing intensity of use “Graduation” to brands with higher
nicotine levels
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Major Cigarette Manufacturers Now Dominate Smokeless Market
Reynolds American acquired the Conwood Company in 2006– Grizzly, Kodiak, Hawken
Altria acquired the U.S. Smokeless Tobacco Company in 2008– Copenhagen, Skoal, Red Seal, Husky
Reynolds and Altria have also introduced their own brands.
Implications– Increased resources for promotion– Ability to draw on existing retail programs– Smokeless extensions of cigarette brands
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Advertising Expenditures In 2006, U.S. smokeless manufacturers spent
$354 million on advertising and promotion Up from $251 million in 2005 Preceded acquisitions of main smokeless
manufacturers by Reynolds and Altria Compares to $10.5 billion spent on cigarette and
smokeless products advertising in 2008
Federal Trade Commission. Smokeless Tobacco Report for the Year 2006; Cigarette Report for 2006.
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Potential Promotion Messages Use smokeless to sustain nicotine
addiction in smoke-free places Complement cigarette use with use
of smokeless extension of same brand Use smokeless as aid in cessation Switch to smokeless as safer
alternative (harm reduction) Switch to smokeless as more socially
acceptable alternative Common denominator: many of these messages
appear to target smokers
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Snus ads “Boldly go everywhere” “Bar-friendly” “Encore-friendly” “Fancy hotel-friendly” “Enjoy taxicabs,
subways, and bar hopping”
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Snus Ads Advertisements picturing smokefree places like
airplanes and concert venues “Pleasure for wherever”
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Potential Trajectories of Smokeless & Cigarette Use
Smokers switch to smokeless, then quit all tobacco use
Smokers switch to smokeless, subsequently become exclusive long-term smokeless users
Smokers initiate smokeless use while continuing to use cigarettes (dual use)
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Potential Adverse Population Effects Increased initiation of smokeless tobacco use
– Some users could later switch to cigarettes Increased relapse of former smokers to tobacco
use– Could take up smokeless use, then relapse
back to cigarettes Continued smoking by smokers who would
otherwise have quit– Instead of using no tobacco products, end up
smoking and using other tobacco products
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Health Implications of Dual Use Prolonging smoking substantially
increases risk Duration is a stronger determinant of risk
than intensity Use of smokeless in addition to cigarette
adds further layer of risk Combined effects are unknown,
worrisome
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Trends in Use of Any & Multiple
Tobacco Products
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Percentage of High School Students Who Reported Current Cigarette and Tobacco
Use,* 1991-2009
43.440.2
33.9
27.5 28.425.7 26
27.530.5
34.8 36.4 34.8
28.5
21.9 2320 19.5
0
5
10
15
20
25
30
35
40
45
50
1991 1993 1995 1997 1999 2001 2003 2005 2007 2009
Any Tobacco Use† Cigarette Use
Source: National Youth Risk Behavior Survey, 1991 – 2009* Smoked cigarettes on > 1 of the 30 days preceding the survey† Current cigarette use, current smokeless tobacco use, or current cigar use
Perc
ent
Year
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Large Cigarweigh > 1.36 grams
Wide variety of cigar products
Small cigars weigh less than or equal to 1.36 grams
Features common to cigarettes, such as shape, length (70 to 100 mm), and use of filter tips
CigarilloConsidered a “large” cigar for taxation purpose
Source: Cristine Delnevo, UMDNJ School of Public Health
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Per Capita Consumption of Cigars (Number of Sticks) – 2000-2010
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
0
10
20
30
40
50
60
Cigars-SmallCigars-Large
Source: US Department of Treasury; Alcohol and Tobacco Tax and Trade Bureau
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Trends in Smokeless Tobacco
Use
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Who Uses Smokeless Tobacco? Males Teens and young adults Rural residents Residents of the South and Midwest American Indians
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Substance Abuse and Mental Health Services Agency, Office of Applied Studies. The NSDUH Report: Smokeless tobacco use, initiation, and relationship to cigarette smoking: 2002 to 2007. Rockville, Maryland: SAMHSA, March 5, 2009.
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Percentage of High School Students, by Sex, Who Reported Current Smokeless
Tobacco Use,* 1995-2009
Source: National Youth Risk Behavior Surveillance Surveys, 1995 – 2009* Used chewing tobacco, snuff, or dip on 1 of the 30 days preceding the survey
Perc
ent
Year
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Percentage of Male High School Students Who Reported Current
Smokeless Tobacco Use* by Ethnicity, 1995-2009
Source: National Youth Risk Behavior Surveillance Survey, 1995 – 2009*Used chewing tobacco, snuff, or dip on 1 of the 30 days preceding the survey **Non-Hispanic
1995 1997 1999 2001 2003 2005 2007 20090
5
10
15
20
25
30
White Male**Black Male**Hispanic MaleWhite Female**Black Female**Hispanic Female
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Percentage of Smokeless Tobacco Use in the Past Month among Persons 18-25
years of age, by sex: 2004-2009
2004 2005 2006 2007 2008 20090
2
4
6
8
10
12Males Females
Source: SAMHSA, 2004-2009, NSDUH
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Percentage of Youth 12-17 and 18-25 Initiating Smokeless Tobacco Use, Among
Those Eligible for Initiation, 2004-2009
0
0.5
1
1.5
2
2.5
3
2004 2005 2006 2007 2008 2009
12-17 Years of Age18-25 Years of Age
Source: SAMHSA, 2004 to 2009, NSDUH
Perc
ent
Year
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Trends in Prevalence of Smokeless Tobacco Use: Grades 8, 10 and 12
Source: Monitoring the Future survey, 2000-2010Question text: “Have you ever used smokeless tobacco?”; “How frequently have you used smokeless tobacco during the past 30 days?”
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100
5
10
15
20
25
30 Grade 8 Grade 10 Grade 12
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Trends in 30 day Prevalence of smokeless tobacco use by sex: Grade 12
Source: Monitoring the Future survey, 2000-2010Question text: “How much do you think people risk harming themselves (physically or in other ways) if they use smokeless tobacco regularly?”
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 201002468
1012141618 Males Grade 12 Females Grade 12
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Trends in 30 day Prevalence of smokeless tobacco use by Race/Ethnicity: Grade 12
Source: Monitoring the Future survey, 2000-2010Question text: “How much do you think people risk harming themselves (physically or in other ways) if they use smokeless tobacco regularly?”
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100
2
4
6
8
10
12
14white African American Hispanic
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Trends in Attitudes about Regular Smokeless Tobacco Use: grades 8 and 10
Disapproval
Source: Monitoring the Future survey, 2000-2010Question text: “Do you disapprove of people using smokeless tobacco regularly?”
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 201072
74
76
78
80
82
84Grade 8 Disapproval Grade 10 Disapproval
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Trends in Dual Use
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Percentage of High School Students Who Were Current SLT Users Who Were Also
Current Smokers: 1995-2009
1995 1997 1999 2001 2003 2005 2007 20090
102030405060708090
Total MalesWhite Males Hispanic Males
Source: National Youth Risk Behavior Survey 1995-2009
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Percentage of High School Students Who Reported Current Any Tobacco Use* and Current Poly Tobacco
Use† by Race/Ethnicity and Sex: 2009
Total White Black Hispanic Other Male Female0
2
4
6
8
10
12
14
16
18 Only One Tobacco Product Any Two Tobacco ProductsAll Three Tobacco Products
Source: National Youth Risk Behavior Survey, 2009*Any Tobacco Use: Current use of one or more tobacco products (cigarettes, cigar, SLT).† Poly Tobacco Use: Current use of 2 or more tobacco products (cigarettes, cigar, SLT).
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Sequence of Initiation of Smokeless Tobacco and Cigarette Use among Persons Who Had Ever Used Both Smokeless Tobacco and Cigarettes: 2004 to 2007
Source: SAMHSA, 2004 to 2007 NSDUHs
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Percentages of Cigarette Use among Past Month Smokeless Tobacco Users, by
Age Group: 2002 to 2009
Source: SAMSHA, 2002-2009 NSDUHs
Total
Aged 12 to 17
Aged 18 to 25
Aged 26 or Older
0 10 20 30 40 50 60 70
39
51.8
65.8
29.9
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Conclusions & Implications
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Conclusions New smokeless products have broader
appeal These products are being heavily marketed,
including to smokers Smokeless tobacco use is on the increase Many smokeless users also smoke cigarettes Smokeless use and dual use are
concentrated in white teen boys and white young adult men
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Cause for Concern Exclusive smokeless tobacco use pose
significant health risks in itself Dual use of smokeless tobacco and
cigarettes poses additional risks Dual use may delay smoking cessation or
make it more difficult– Prolong duration of smoking– Keep people in the smoking population
Duration of smoking is the most important determinant of risk
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Cause for Concern Dual use may also facilitate pattern of light
smoking among young adults–Nondaily smoking– “Social” or “recreational smoking”
This pattern poses particular challenges to cessation
People may not perceive themselves to be smokers
Part of a broader pattern of polytobacco use Other product combinations may pose risks
too
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Implications Emerging trends in smokeless and dual use
threaten to reverse progress towards reducing tobacco use and its health burden
We need to keep a close eye on these trends and monitor their population impact
We need to monitor use of all tobacco products, not just cigarettes
We need to monitor use of combinations of tobacco products, rather than monitoring use of each product in isolation
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When will we take the handle off the tobacco pump?
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End GoalWhat is the final destination?
Tobacco Use is a Minor Public Health Nuisance
Timeline: This Generation (not by 22nd century)
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AZ
WY
ORID
MT
UTNV
WA
CA
TX
AROK
ND
LA
KS
IANE
SD
CO
NM
MO
MN
TN
AL
KY
OH
MS
MI
IN
GA
FL
PA
ME
NY
WV VA
NC
SC
VT
CT
D.C.
RI
NJ
MDDE
NHMA
IL
WI
AK
HI
Ban in worksites,restaurants, and bars (n=26)
Ban in two of three locations (n=4)
Laws in effect as of June 1, 2011*
Less comprehensiveor no restrictions (n=21)
Source: CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System.
State Smoke-Free Indoor Air Laws for Private Worksites, Restaurants, and Bars
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AZ
WY
ORID
MT
UTNV
WA
CA
TX
AROK
ND
LA
KS
IANE
SD
CO
NM
MO
MN
TN
AL
KY
OH
MS
MI
IN
GA
FL
PA
ME
NY
WV VA
NC
SC
VT
D.C.
NJ
MDDE
NHMA
IL
WI
AK
HI 50-99 cents per pack$1.00-$1.49 per pack$1.50-$1.99 per pack$2.00-$2.99 per pack
CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System.
<50 cents per pack
Chicago$3.66
NYC$5.85
CTRI $3.46
State Cigarette Excise Tax Rates – 2011
≥ $3.00 per pack
Anchorage$4.20
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Hard hitting media campaigns
http://www.youtube.com/watch?v=SfAxUpeVhCg
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Support for Smokers Who Want to Quit
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Family Smoking Prevention and Tobacco Control Act of 2009
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Immediate impact of a comprehensive approach:
youth and adult smoking rates in NYC
Source: BRFSS 1993 – 2001; NYC Community Health Survey 2002 – 2009; and NYC YRBS 2001 - 2010
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100
5
10
15
20
25
AdultYouth
Perc
ent
3-yr. average 3-yr. average 3-yr. average
21.6% 21.5% 21.7% 21.5%
19.2% 18.3%
18.9%
17.5%16.9%
15.8%
City and State tax increases
Smoke-freepolicy Media
campaign
17.6%
14.8%
11.2%
8.5% 8.4%
15.8%
State and Federal Tax increases
7%
14%
Terry F. Pechacek, Ph.D.Associate Director for ScienceOffice on Smoking and Health
Phone: (770) 488-5701Fax: (770) 488-5767E-mail: [email protected]: www.cdc.gov/tobacco
For More Information...
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The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.