TALKING DIRTY, TALKING TURKEY: PUBLIC HEALTH AND TOBACCOJ. Gary Wheeler, MD

Chief Medical Officer, Arkansas Dept. of Health

May 10, 2018

OBJECTIVES

• 1. Identify targets for intervention based on surveillance of tobacco use• A. youth surveillance

• B. literature on youth initiation

• C. mechanisms of cessation by adults

• 2. Understand social communication strategies to optimally counter market the tobacco industry• A. Cold Turkey quitting

• B. Branding youth as tobacco free

CURRENT (2015) YOUTH CIGARETTE USE

• Defined as using cigarettes on one or more of the past 30 days.

• United States National Survey 2015: 10.8% The difference between Arkansas and the U.S. is statistically significant.

• Arkansas 2015: 15.7%

• Median of 37 Participating States: 10.8%

• Range of Participating States: 4.8% to 18.8%

• Only West Virginia and Kentucky were higher than Arkansas.

Percentage of High School Students Who Currently

Smoked Cigarettes,* Arkansas YRBS 1995-2015†

INITIATION OF CIGARETTE USE

• Defined as smoked a whole cigarette before the age of 13 years.

• United States National Survey 2015: 6.6% The difference between Arkansas and the U.S. is statistically significant.

• Arkansas 2015: 13.1%

• Median of 35 Participating States: 7.8%

• Range of Participating States: 4.3% to 13.1%

• Arkansas was the highest state.

CURRENT FREQUENT CIGARETTE USE

• Defined as using cigarettes on 20 or more of the past 30 days.

• United States National Survey 2015: 3.4% The difference between Arkansas and the U.S. was not statistically significant.

• Arkansas 2015: 6.1%

• Median of 37 Participating States: 3.6%

• Range of Participating States: 1.5% to 7.4%

• West Virginia was higher than Arkansas.

• Youth Risk Behavior Survey (YRBS) 16

SMOKELESS TOBACCO USE

• Defined as using chewing tobacco, snuff, or dip on one or more of the past 30 days.

• United States National Survey 2015: 7.3% The difference between Arkansas and the U.S. is statistically significant.

• Arkansas 2015: 10.6%

• Median of 34 Participating States: 8.6%

• Range of Participating States: 3.0% to 13.4%

• Nine states were higher than Arkansas.

CURRENT CIGAR USE

• Defined as using cigars, cigarillos, or little cigars on one or more of the past 30 days.

• United States National Survey 2015: 10.3% The difference between Arkansas and the U.S. is statistically significant.

• Arkansas 2015: 14.2%

• Median of 33 Participating States: 10.4%

• Range of Participating States: 6.8% to 16.5%

• Only Mississippi was higher than Arkansas.

CURRENT ELECTRONIC VAPOR PRODUCTS USE

• Defined as e-cigarette, e-cigar, e-pipe, vape pipes, vaping pens, e-hookahs, and/or hookah pens use at least 1 day in the past 30 days.

• United States National Survey 2015: 24.1% The difference between Arkansas and the U.S. was not statistically significant.

• Arkansas 2015: 26.4%

• Median of 35 Participating States: 23.5%

• Range of Participating States: 15.3% to 31.2%

• Six states were higher than Arkansas.

JUULS

FDA APRIL 24, 2018

• FDA cites 40 retailers for violations related to youth sales of JUUL e-cigarettes

• Agency announces a new blitz of retail establishments targeting youth sale violations

• Agency takes new action to examine youth appeal of JUUL

• Agency takes steps to foreclose online sales of JUUL to minors

• These are the first steps in a new effort aimed at stopping youth use of e-cigarettes

YOUTH INITIATION

•Addiction potential

• Social environment

•Marketing

NDIT STUDY (CANADA)

Predictors: Individual

• Young age

• Single parent family

• Stress

• Impulsivity

• Low self-esteem

• Poor school performance

• Susceptibility to advertising

• Addictiveness

• Alcohol use

• Use of other tobacco

Predictors: Contextual

• Smoking by parents

• Smoking by sibs

• Smoking by friends

• Smoking by school staff

• Attending a smoking tolerant school

NDIT STUDY (CANADA)

• Other findings

• 17% of novice smokers were tobacco dependent

• Dependence could develop in 4mths

• Slower metabolizers (CYP2A6) of nicotine had higher rates of dependence

• Ability to quit was positively affected by package warnings, male sex, team sports, increased age

INITIATION OF E-CIGARETTES

• Middle and high school students, 2013-14

• Surveyed 340 ever users in Fall 2013

• If still using in Spring of 2014, examined predictors defined in Fall for continued use:

• YOUNGER, USE TRADITIONAL CIGARETTES

• LOW COST

• USE ANYWHERE

• INTENT TO QUIT TRADITIONAL CIGARETTES• Bold KW et al. Pediatrics 2016:138:e20160895

ROLE OF ADULTS

• 50 state review-Molly Miller, Bob DeLongchamp

• Relative benefits of adult smoking rate, poverty, college education, per-cent African-American and Hispanic, cigarette tax rate, smoke free laws, literacy, state funding for tobacco

• Adult smoking rate (BRFSS) had greatest impact on rates of youth smoking (YRBS, use in last 30 days)

• Clean indoor air laws also important

ROLE OF MARKETING

†Promotional expenditures and “others” included point of sale, promotional

allowances, sampling distribution, specialty item distribution, public entertainment, direct mail,

endorsements/testimonials, Internet, coupons, retail value added

Cokkinides V et al CA Cancer J Clin 2009: 59:352-365.

ROLE OF MARKETING

•E-cigarettes advertising:

• 2010 5.6 million

• 2014 115.3 million

INTERVENTIONS THAT WORK

• Normalization

• Clean air regulations

• Advertising Regulation (around schools, POS)

• Price

• elasticity

• No taxes (e-cigs)

• Cheaper products (smokeless, e-cigs)

• Access

• Voluntary-TARGET, CVS (2013)

• Legal-e.g e-cigs (ENDS) Act of Arkansas, Act of US (2015)

CLEAN AIR REGULATIONS AND YOUTH SMOKING

• …implementing smoking bans through policies, regulations, and laws, as well as other coordinated efforts that establish smokefree social norms (USDHHS 2000; Task Force on Community Preventive Services [TFCPS] 2005; NIH [National Institutes of Health] State-of-the-Science Panel 2006; Bonnie et al. 2007; Centers for Disease Control and Prevention [CDC] 2007; National Cancer Institute [NCI] 2008).

• Chapter 6, 2012 Surgeon General’s report

CLEAN AIR NORMALIZATION

• Although there is a prevalent belief that providing effective warnings to youths requires approaches different from those used for adults, broad educational efforts that reach all age groups have been shown to be more effective in influencing youth behavior than efforts targeted specifically at them.

• WHO, http://www.who.int/tobacco/control/populations/youth/en/index1.html

ADVERTISING BANS

• Limited bans are not associated with drops in smoking; comprehensive bans are (substitution effect)

• Family Smoking Prevention and Tobacco Control Act of 2009. Bans flavorings in cigarettes (not cigars or ENDs and not menthol)

• Bans on use of menthol and flavorings are proposed particularly for cigars, little cigars, hookah, and ENDs.

• POS, outdoor, storefront (First amendment issues)

PRICE/ELASTICITY

• 17 low and middle income countries (S. Africa, Egypt, Russia, Mexico, Peru, India, China, etc) Ten per cent increase in price would reduce consumption by 7.4-10.9%

• Kostova, Tobacco Control 2011;20:419e424.

• RJ Reynolds: If prices were 10% higher, 12-17 incidence [youth smoking] would be 11.9% lower

• R.J. Reynolds Executive D. S. Burrows, “Estimated Change In Industry Trend Following Federal Excise Tax Increase,” September 20, 1982, Bates No. 501988846/8849

ENDS

Youth utilization Costs

• Average national cost for pack a day smoker

• $2250

• Average national cost for equivalent e-cigs

• $1400

• Average cost for vaping

• $ 300

Dallas Morning News, July 10, 2014

SOCIAL MARKETING

RESCUE: SOCIAL BRANDING

•Profile youth

• Identify population using social media

•“Value identify” the population

•Capture the population with brand

•Utilize values to imprint behavior

DOWN AND DIRTY ACTIVITIES

• Sponsor rural events

• Rodeo, mudding, ATV events, county fairs

• Branded gear

• Targeted digital advertising on Facebook, Youtube

• Luke Bryan, Bass Pro, and Carhartt

• Social media campaigns

• Aligned to values—personal freedom, love of country and family

• Traditional media

DOWN AND DIRTY EXAMPLES

• https://www.facebook.com/DownandDirtyAR/videos/360334144420132/

• The Hunt

• https://www.facebook.com/DownandDirtyAR/videos/394242694362610/

• My Hometown

CESSATIONadults

HOW ADULTS QUIT IN ARKANSAS

OPTIONS FOR QUITTING

• Quitlines

• NRT, Chantix

• Brief Tobacco Interventions

• Counselling

• Hypnosis and other alternatives

• E-cigs, ENDS

• Cold Turkey

MATH

• Per cent of smokers who use Quitline successfully

3,000 /560,000= 0.53%

Per cent of smokers who try to quit in a year

560,000 x 47%= 263,000

Who might quit cold turkey?

2/3 x 263,000 or ~175,000 chances to help someone quit

ADULT TOBACCO SURVEY RESULTS

• 1) Unassisted quitters (cold turkey) are the largest group of successful quitters

• 2) Successful CT quitters were younger, unmarried, healthier, refractory to e-cigarettes, and possibly less addicted to nicotine.

• 3) Further mining the cultural features of this group may allow development of counter marketing that will lead unassisted quitters to cessation. In addition, confirming that certain methods of unassisted quitting (e.g. sudden vs gradual nicotine reduction) may become part of messaging that may make it more impactful.

•

DEVELOPING NEW STRATEGIES FOR QUITTING: COLD TURKEY

• Reviewed the literature to capture features of quitters to use to develop messaging

• Sum above with survey results

• Draft messages

• Conduct focus groups to test messages and to gain additional insights

• Counter-marketing creation in cooperation with CJRW

I am a proud quitter. If I can do it, you can too.

I take it one day at a time. Working on our family farm

helps. The kids love the open space, and I love the hard

work

and the fresh air.