Consumer Demand and the Maryland Clean Indoor Air Act

Earlier this month, Maryland joined the ranks of 12 other states, along with Puerto Rico and the District of Columbia, that have state laws in effect that require workplaces, restaurants, and bars to be 100 percent smoke-free. The Maryland Clean Indoor Air Act, which went into effect on February 1, 2008, prohibits smoking in virtually all indoor public places, including bars, restaurants, public meeting places, public transit vehicles, workplaces, and even private homes and vehicles that are used for child day care services.

Maryland applied the Consumer Demand perspective during the planning and implementation of the Clean Indoor Air Act. With the assistance of Consumer Demand co-chair Carlo DiClemente, Ph.D., Maryland implemented several of the Consumer Demand core strategies in order to build demand among smokers and help them quit successfully. Below are the strategies they used and how they implemented them at the state level.

Core Strategy #4: Seizing policy changes as opportunities for "breakthrough" increases in treatment and quit rates.

Maryland tobacco control officials took advantage of the new Clean Indoor Air Act as an opportunity to promote evidence-based tobacco cessation products and services and to increase treatment and quit rates. The goal of the implementation was not just to promote the new law. The goal was also to reach consumers and providers and get them to access the available cessation support resources.

In order to do this successfully, those involved had to join together disparate aspects of smoking control in the state. In Maryland, one of the challenges was making sure that tobacco control personnel were involved in the planning and implementation of the Clean Indoor Air Act. Implementation is usually focused on enforcement of the new regulation. Enforcement of the Clean Indoor Air Act is generally done by environmental safety and health officials, who are not connected with tobacco control personnel, within the same state agency.

In Maryland, the two offices within the Department of Health and Mental Hygiene in Maryland (DHMH) involved with the Clean Indoor Air Act are the Office of Safety and Health and the Office of Tobacco Control. The Office of Safety and Health is in charge of the implementation of the ban. The Office of Tobacco Control works on prevention and cessation and gives grants to the local health departments for tobacco control efforts. Public health officials from these two offices were able to collaborate and work together to not only implement the ban, but also to use it as an opportunity to promote evidence based tobacco cessation products and services.

Core Strategy #3: Marketing and promoting cessation products and services in ways that reach smokers-especially underserved smokers-where they are.

One of the ways the two DHMH offices worked together and applied Consumer Demand strategies was by marketing and promoting the ban to businesses and smokers in ways that effectively reached them. The two offices collaborated in developing the materials for bars and restaurants that kept smokers in focus. They created a logo and promotional materials including napkins, drink coasters, and window decals to promote the law.

They also made sure that access to quitline services and the local health departments was an integral part of the program and the messages sent out to the people of Maryland. The materials all have either the local health department contact information or 1-800-Quit Now on them to support smokers that want to quit.

The DHMH groups also held joint press conferences to promote the law to a wider audience. A media campaign was also created with a website, promotional videos of actual quitters' stories, and radio and TV ads to promote and support cessation (http://www.smokingstopshere.com/).

Core Strategy #1: Redesigning evidence-based products and services to better meet consumers' needs and wants.

Maryland also applied Consumer Demand strategies around the Clean Indoor Air Act by redesigning evidence-based products and services. Officials applied several of the IDEO Design Principles to redesign services and resources not only to assist smokers but also to support the needs of businesses and local public health officials during the implementation of the ban.

IDEO Design Principle # 4: Facilitate transitions
Public health officials created resources to facilitate the transition from smoking to smoke-free establishments for businesses, restaurants, bars, hotels, motels, and others. A website, www.mdcleanair.org, was created to help these business owners understand and prepare for the transition. This website provides general information on the regulations and a toolkit for business owners that includes various fact sheets, copies of the 'no smoking signs' that must be posted in bars and restaurants, forms, contact lists, and additional links and resources. Materials are also available in Spanish, Chinese, and Korean.

IDEO Design Principle # 1: Lower the bar
In addition to helping business owners prepare for the new law, public health officials also helped make it easier to access cessation services for consumers and providers. Maryland redesigned the quitline service to better meet the needs of tobacco users and providers by adding the "Fax to Assist" program to the quitline. This program allows healthcare providers to fax the names of smokers who are interested in quitting to the state Quitline provider so that their patients can receive up to four proactive telephone calls from the Quitline coaches. Over 10,000 letters were sent out to promote the program to health professionals in the state, including doctors, nurses, dentists, and hygienists. Providers can access the training program and get certified online at http://www.mdquit.org/index.php/fax_to_assist.

IDEO Design Principle # 6: Foster community
To help foster community and create a network among local public health officials, the Maryland DHMH provided funds to support the Maryland Quitting Use and Initiation of Tobacco (MDQuit) Resource Center, of which DiClemente is the director. The MDQuit Resource Center links professionals, providers and local programs to evidence-based, effective resources and tools to support tobacco control initiatives, focusing both on prevention and cessation. County and local public health officials turn to the center for assistance in offering programs, acquiring speakers for local groups, supporting outreach to health professionals, and accessing special materials developed for the Clean Indoor Air Act implementation. This extensive, collaborative network of tobacco prevention and cessation professionals provides a forum for sharing best practices throughout the state of Maryland.

Core Strategy #6: Combining and integrating as many of these strategies as possible for maximum impact.

This year, Maryland took advantage of one of the best ways to build consumer demand for tobacco cessation products and services: combining and integrating as many strategies as possible. In addition to passing the Clean Indoor Air Act, the Maryland Legislature approved and signed into law a $1 per pack increase in the cigarette tax. On January 1, 2008, Maryland's cigarette tax increased to $2 per pack. Maryland is now one of nine states with cigarette taxes of $2 or more. The increased tax along with the smoking ban should help to encourage smokers to quit and, with the promotion of cessation resources, help to increase demand for evidence-based products and services.

With various state groups working together on the Clean Indoor Air Act, disparate aspects of smoking control were united and together, these officials were able to promote the ban and reach out to businesses, consumers, and providers and encourage them to access the available support resources. People in Maryland will now have clean, smoke-free air while working, dining, shopping, or relaxing throughout the state. For more information on the Clean Indoor Air Act or for additional resources, visit the MDQuit Resource Center at http://www.mdquit.org/.

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Carlo DiClemente, Ph.D., Professor and Associate Chair, Department of Psychology at the University of Maryland and Co-Chair, Consumer Demand Strategic Planning Committee

Carlo C. DiClemente, Ph.D. is an internationally known psychologist, best known as the co-author of the Transtheoretical Model of Behavioral Change. The Transtheoretical Model of Behavioral Change serves as the basis for research into health and addictive behaviors and a guide for interventions and treatment programs. His most recent book, Addiction and Change, offers a view into the process of both the initiation and modification of addictive behaviors.

Dr. DiClemente has experience as a clinician, researcher, and teacher. He is Professor and Associate Chair of the Department of Psychology at the University of Maryland and a Fellow of the American Psychological Society. He is past president of the Division on Addictions of the American Psychological Association. He is also a member of the editorial boards of several journals including the International Journal of Health Psychology, Preventive Medicine, and Psychology of Addictive Behaviors.

Carlo is the co-chair of the Consumer Demand Roundtable Strategic Planning Committee and is very active is promoting consumer demand for tobacco cessation products and services. His most recent work involves preparing for the Maryland Clean Indoor Air Act of 2007.

Q1: How did you get involved with NTCC?

I have been involved with tobacco control since my dissertation at the University of Rhode Island and have worked with many of the individuals and the organizations in the NTCC. However, it was my involvement with the Consumer Demand Initiative spearheaded by Tracy Orleans and the group of organizations that supported this initiative that introduced me to the NTCC group, which is supported by the same organizations that supported Consumer Demand.

From my perspective, NTCC is a terrific vehicle for communication and collaboration among the critical organizations involved in tobacco control to maximize our impact and coordinate our efforts. My involvement has been primarily as the co-chair of the Consumer Demand Group that has been trying to change how we offer tobacco cessation products and services to current smokers.

Q2: You are a member of the Consumer Demand Strategic Planning committee and you have been involved with this initiative since its inception. Why is Consumer Demand so important?

There are three reasons that we need to refocus on smokers as the consumers of the products and services of our tobacco control efforts. First, although we have had significant success over the past 30 years in reducing the numbers of smokers in the population and reducing the overall prevalence of smoking, there are continuing smokers and a new generation of smokers who have grown up with all the warnings, messages, and policy restrictions that exist. They have learned to smoke around the restrictions and represent an interesting and new population of smokers that will likely need new interventions and information to become motivated to quit.

Second, with the increasing success of policy initiatives both in reducing smoking and passive smoke exposure, there seems to be a greater gap between tobacco control efforts and the smoker. Smokers feel nagged and often bullied which is counterproductive to reaching them with messages of help and especially with new products and services that are empirically based. They are turning to a variety of methods and means that are not effective instead of coming to services that are science-based and provide the best practices so their success rates suffer and a sense of hopelessness grows.

Finally, the tobacco companies have increased their efforts to attract and keep smokers with new products and services that are very creatively marketed. They have a very sophisticated consumer perspective. Tobacco control cannot afford to ignore the smoker as the individual on the journey of cessation and as the consumer of our services if we are to increase our reach, engagement and effectiveness with individuals who smoke.

Q3: What has been the biggest impact of the Consumer Demand Initiative on the field of tobacco cessation?

I think it has brought a number of leaders together and provided a forum and process to discuss innovation. Such collaboration is helping to shift the focus from our more self-righteous science-based laboratory approaches to one that looks through the eyes of those who have to struggle with the challenge of stopping an addiction and who have to access and use the materials, medications, and messages we produce.

This discussion has been enriched by the inclusion of individuals who were involved in marketing. In particular, Peter Coughlan, from the IDEO marketing and transformation group, opened our eyes to the world of consumer design principles that have been so successful in the business marketplace. The Consumer Demand strategies and principles that have been published and disseminated from this initiative are the new tools that Consumer Demand has brought to the field of Tobacco Control and have the potential to transform the way we do business.

Q4: Given the current efforts going on in Maryland around the recent Clean Indoor Air Act (CIAA), which one of the 6 core strategies for increasing consumer demand do you think will be most effective in reaching Maryland smokers?

The key strategies for building consumer demand we are using and hope will be successful are #4 "seizing policy changes as opportunities for "breakthrough" increases in treatment use and quit rates" and #6 "Combining and integrating as many of these strategies as possible for maximum impact". At least these are the ones we are betting on to help our smokers.

Q5: What was the most difficult aspect of implementing the clean indoor air act in MD?

The challenge of seizing policy changes as opportunities is making sure that tobacco control is involved in the planning and implementation of the clean indoor act. Generally, the implementation is focused on enforcement of the regulations and responding to complaints or violations. Enforcement is generally done by environmental safety and health officials who are not connected with tobacco control personnel in the same state agency.

In Maryland, the officials from both sides of this divide within the Department of Health and Mental Hygiene met this challenge and worked together in developing the materials sent out to bars and restaurants and kept the smoker in focus. They have made sure that access to services of the Quitline and the local health departments was an integral part of the program and the messages sent out to the people of Maryland.

Q6: How can counties and local health departments take advantage of the Maryland Quitting Use and Initiation of Tobacco (MDQuit) Resource Center?

The MDQuit Resource Center is really built for the local health departments and to increase access to the best practices in the field of tobacco control, focusing both on prevention and cessation. County needs assessments drive our training offerings. Counties turn to the center for assistance in offering programs, acquiring speakers for local groups, supporting outreach to health professionals (dentists, physicians, dental technicians, hospitals, nurses) in the county, and accessing special materials developed for the Clean Indoor Air Act Implementation that include the state LOGO on a window cling, napkins, coasters, and other materials to deliver to local bars and restaurants.

MDQuit also hosts a website, which posts communications about the best practices of various counties and an online training program for the Fax to Assist program. This program allows healthcare providers to fax the names of smokers who are interested in quitting to our state Quitline provider so that their patients can receive up to 4 proactive telephone calls from the Quitline coaches. County smoking control personnel are also updated through our website on news and research advances related to tobacco control.

Q7: What do some of the more unconventional partners, like IDEO and the XPrize Foundation, bring to the field of tobacco cessation?

As I have already mentioned, IDEO and groups like the XPrize Foundation bring innovative thinking and perspectives that challenge us. Clearly there are innovations that are occurring every year in our research and in product development in the field of tobacco control. However, most of us practitioners and scientists think incrementally, like how can we do things a little better? Our unconventional partners push us beyond the comfort zone, expand our views of the possible, and help us to envision "big, hairy, audacious goals".

Q8: What has been the most challenging aspect of your work in tobacco control?

My biggest challenge has been dealing with the slow and stumbling pace of change in tobacco cessation. I have been involved in many studies that have been successful but produce long term success rates of 10%, 20%, even 30% that are disappointing to someone who desires more significant sustained change. Patience, persistence, a broader perspective on the journey of cessation, and making sure to look at lifetime success rates has helped ease the frustration of this challenge.

Q9: What has been the most rewarding aspect of your work in tobacco control?

The most rewarding aspect of this work is seeing the prevalence rates of smoking decreasing and knowing that there are over 40 million former smokers here in the United States. Also, knowing that smoking control strategies and lessons learned in our studies are helping smoking control programs in many countries around the world is encouraging. It is very satisfying to know that my work may have contributed in some way to understanding and supporting this process of change.

Q10: Now that the Maryland clean indoor air act has gone into effect, what are some upcoming projects you will be working on?

We are just finishing a mailing to over 10,000 physicians in the state encouraging them to renew efforts to reach smokers who may be motivated by the tax increase that went into effect in January and the CIAA that went into effect in February. We are encouraging them to do the 5 As, to use the Fax to Assist program, or to motivate and offer Quitline or referrals to the local health departments.

We are also talking with Myra Muramoto to see if we can use her Helpers Program here in Maryland, seeing how we can support college and community coalitions and make them more effective, and developing some prevention training programs to see if we can help the local health departments be more effective in offering middle school and high school prevention and cessation services.

We are also focusing on special populations to see how we can reach them more effectively. A county perspective seems to be helpful in segmenting populations and targeting and reaching subpopulations.

Finally, we are continuing to evaluate state prevalence data and will be helping to evaluate smoking control efforts. There is always plenty to do it seems.

For more information on the Clean Indoor Air Act or for additional resources, visit the MDQuit Resource Center at http://www.mdquit.org/.

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Colorectal Cancer Occurs Earlier in those Exposed to Tobacco Smoke: Implications for Screening

A recent study finds that individuals with a history of long-term, heavy tobacco use were diagnosed with colorectal cancer at a significantly younger age than individuals who had never smoked. These findings were recently published in the Journal of Cancer Research and Clinical Oncology.

In this study, researchers evaluated the age at diagnosis of colorectal cancer among individuals exposed to tobacco smoke. The 3,540 patients evaluated each completed a questionnaire about factors that may have impacted their overall health. Smokers were stratified based on different smoking exposures.

The researchers found that individuals who currently smoked had the youngest age at diagnosis of colorectal cancer when compared with nonsmokers (age 57 versus 64). In addition, former smokers followed current smokers, being diagnosed earlier than nonsmokers. They also found that among individuals who never smoked, those exposed to second-hand smoke were diagnosed at a significantly earlier age when compared with individuals who had never been exposed to smoke.

Researchers concluded that individuals with a history of long-term, heavy tobacco use were significantly younger at the time of colorectal diagnosis than non smokers. These findings support screening for colorectal cancer at earlier ages among individuals with a history of tobacco exposure.

For more information, see web link:
Journal of Cancer Research and Clinical Oncology, February 2008

Smoking's Effects on Genes May Play a Role in Lung Cancer Development and Survival

Smoking plays a role in lung cancer development, and now scientists have shown that smoking also affects the way genes are expressed, leading to alterations in cell division and regulation of immune response. Notably, some of the changes in gene expression persisted in people who had quit smoking many years earlier. These findings by researchers at the National Cancer Institute (NCI) appeared in the Feb. 20, 2008, issue of PLoS ONE.

"Smoking, we are well aware, is the leading cause of lung cancer worldwide," said NCI Director John E. Niederhuber, M.D. "Yet, a mechanistic understanding of the effects of smoking on the cells of the lung remains incomplete. This study demonstrates an important piece of this complicated puzzle. Greater understanding of the genetic alterations that occur with smoking should provide greater insight into the development of cellular targets for treating, and possibly preventing, lung cancer."

To investigate the effects of smoking on gene activity in lung tissue, the researchers examined the gene expression profiles - patterns of gene activity - in early-stage lung tumors and non-tumor lung tissue of smokers, former smokers, and people who had never smoked cigarettes. Adenocarcinoma tumor samples were evaluated in this study because adenocarcinoma is the most common type of lung cancer, and it occurs in both smokers and people with no history of smoking. The participants were 44 to 79 years of age, and 28 were current smokers, 26 were former smokers, and 20 had never smoked.

Using microarray techniques, which allow researchers to look at the activity of thousands of genes simultaneously, they identified 135 genes that were differently expressed in tumors of smokers vs. people who had never smoked. Among these genes, 81 showed decreased expression and 54 showed increased expression in tumor tissue.

Looking at non-tumor lung tissues, the research team found decreased activity for 73 genes and increased activity for 25 genes in current smokers. The genes most affected by smoking play a role in immune response-related processes, possibly as a lung defense mechanism against the acute toxic effects of smoking. However, non-tumor tissues seem to be able to recover from the effects of smoking. The researchers did not identify significant changes in the immune response-related genes in former smokers.

"Our data provide clues on how cigarette smoking affects the development of lung cancer, indicating that the very same mitotic genes known to be involved in cancer development are altered by smoking and affect survival. More studies are needed to confirm that the gene expression changes are due to smoking and affect tumor development or progression," Maria Teresa Landi, M.D., Ph.D., in NCI's Division of Cancer Epidemiology and Genetics, the first author of the study report. "If confirmed, these genes could become important targets for preventing and treating lung cancer."

For more information, see web link:
NIH News Release, February 19, 2008

State Medicaid Coverage for Tobacco-Dependence Treatments - United States, 2006

In the February 8, 2008 issue of MMWR, CDC released the results of the 2006 survey on state Medicaid coverage for tobacco-dependence treatments. Periodically, the types of tobacco-dependence treatments covered by Medicaid have been reported from surveys conducted by the Center for Health and Public Policy Studies at the University of California, Berkeley.

Based on these survey results, the CDC report recommends that Medicaid coverage for tobacco-dependence treatment must increase substantially. Currently, approximately one third of adult Medicaid recipients smoke. A Healthy People 2010 national health objective calls for total health-insurance coverage for evidence-based tobacco-dependence treatments in all 51 Medicaid programs (objective 27-8b). If this objective is to be achieved, coverage must be increased.

Results from the survey indicate that 39 (76.5 percent) state Medicaid programs (including the District of Columbia) covered some form of tobacco-dependence treatment (i.e., medication or counseling) for all Medicaid recipients and one state program provided coverage for all recommended treatments. In addition, four states reported offering coverage for pregnant women only. Of the 39 programs that offered any coverage to their entire Medicaid population, all covered some pharmacotherapy: bupropion (Zyban) (37 programs), nicotine patches (36), nicotine gum (34), varenicline (Chantix) (32), nicotine nasal spray (30), nicotine inhalers (30), and nicotine lozenges (28).

Seventeen states covered some form of tobacco-cessation counseling services for their entire Medicaid population. An additional 10 states covered counseling services for pregnant women only. Of the 17 states that covered group counseling, 10 covered it for all their Medicaid enrollees, and seven covered group counseling for pregnant women only. Of the 25 states that covered individual counseling, 14 covered the entire population, and 11 covered individual counseling for pregnant women only. The three states that covered telephone counseling covered it for their entire Medicaid population.

From 2005 to 2006, two states (Alaska and Massachusetts) added coverage, one state (Delaware) expanded existing coverage to include the nicotine lozenge, and one state (Oklahoma) expanded existing coverage to include individual counseling. Varenicline (Chantix), which was approved by the Food and Drug Administration (FDA) as a tobacco-dependence treatment in 2006, was added as a covered benefit in 32 states.

For more information, see web link:
MMWR Weekly , February 8, 2008 / 57(05);117-122

New Study Shows Tobacco Control Programs Cut Adult Smoking Rates

Greater investments in state tobacco control programs are independently and significantly associated with larger and more rapid declines in adult smoking prevalence, according to a study by researchers at Centers for Disease Control and Prevention (CDC) and RTI International. Researchers were able to quantify the link between comprehensive tobacco control programs and a decrease in adult smoking - observing a decline in prevalence from 29.5 percent in 1985 to 18.6 percent in 2003.

The study, "The Impact of Tobacco Control Programs on Adult Smoking," is the first of its kind to use multi-state survey data on smoking to examine the association between cumulative state tobacco control program spending and changes in adult smoking prevalence.

The study, published in the February 2008 issue of the American Journal of Public Health, analyzed data from all 50 states and the District of Columbia and found that among individual states the declines in adult smoking prevalence were directly related to increases in state per person investments in tobacco control programs.

While increases in the cost of cigarettes have been shown previously to lead to declines in smoking rates, this new study finds that state program funding had an effect on adult smoking, independent of price.

According to the study, if all states had started in 1995 to fund their tobacco control programs at either the minimum or optimal levels recommended by the CDC in Best Practices for Comprehensive Tobacco Control Programs, there would have been 2.2 million to 7.1 million fewer smokers by 2003.

The study also found that increases in both tobacco control program expenditures and cigarette prices were effective in reducing smoking prevalence among adults, with tobacco control program expenditures somewhat more effective in reducing smoking prevalence among adults aged 25 or older, while increases in cigarette prices had a stronger effect on 18- to-24-year-old smokers.

"These results show that if states consistently fund programs at recommended levels-outlined in Best Practices for Comprehensive Tobacco Control Programs-they could substantially reduce adult smoking prevalence, and thus reduce smoking-related morbidity, mortality, and economic costs," said Terry Pechacek, Ph.D., associate director for science, Office on Smoking and Health, CDC, and one of the authors of the study.

For more information, see web link:
CDC Press Release January 30, 2008

Depressive Symptoms and Smoking Cessation after Hospitalization for Cardiovascular Disease

In a recent study in Archives of Internal Medicine, researchers found that moderate to severe depressive symptoms during hospitalization for acute cardiovascular disease (CVD) are associated with rapid relapse to smoking after discharge and lower rates of smoking cessation at long-term follow-up.

Although smoking cessation is essential for prevention of secondary (CVD), many smokers who are hospitalized for primary CVD do not stop smoking after hospitalization. Mild depressive symptoms are common during hospitalization for CVD. Researchers hypothesized that depressive symptoms measured during hospitalization for acute CVD would predict return to smoking after discharge from the hospital.

Researchers analyzed data from a placebo-controlled, double-blind, randomized trial of bupropion hydrochloride therapy in 245 smokers hospitalized for acute CVD. All subjects received smoking counseling in the hospital and for 12 weeks after discharge. Depressive symptoms were measured during hospitalization with the Beck Depression Inventory (BDI), and smoking cessation was biochemically validated at 2-week, 12-week, and 1-year follow-up.

Researchers found that 22 percent of smokers had moderate to severe depressive symptoms during hospitalization. These smokers were more likely to resume smoking by 4 weeks after discharge than were smokers with lower BDI scores. Smokers with low BDI scores were more likely to remain abstinent than were those with high BDI scores at 3-month follow-up (37 percent vs. 15 percent) and 1-year follow-up (27 percent vs. 10 percent).

Moderate to severe depressive symptoms during hospitalization for acute CVD are independently associated with rapid relapse to smoking after discharge and lower rates of smoking cessation at long-term follow-up. Researchers found that the relationship was mediated in part by the stronger nicotine withdrawal symptoms experienced by smokers with higher depressive symptoms.

For more information, see web link:
Archives of Internal Medicine, 2008, Volume 168, Issue 2

Almost 165,000 in the UK Heed Ban and Quit Smoking

Nearly 165,000 smokers managed to kick the habit in the summer of 2007 with the help of NHS Stop Smoking Services, a report by The Information Centre for health and social care (The IC) reveals.

Half the 327,800 who used the service successfully quit between April and September 2007, a period which coincided with the introduction of the smoking ban in most public places in England on July 1.

This is a 28 percent increase in the number of successful quitters and a 29 percent increase in the number of people setting a quit date through NHS Stop Smoking Services compared to the same period in 2006.

The findings from the report, "Statistics on NHS Stop Smoking Services in England, April to September 2007," are based on the number of smokers setting a quit date and the number who successfully quit by a four week follow-up.

Most of those setting a quit date (74 percent) received only nicotine replacement therapy to help them quit, such as patches. A further 10 percent received only the drug Champix (varenicline), while 4 percent only received the drug Zyban (bupropion). Less than 1 percent received both NRT and Zyban.

Other key findings were:

• Of the 8,619 pregnant women who set a quit date, 4,084 successfully quit.
• Success at the four-week follow up increased with age, from 37 percent of those aged under 18, to 59 percent of those aged 60 and over.

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New Generation of Tobacco Products Threatens Efforts to Reduce Tobacco Use, Save Lives in U.S., Report Warns

A new report issued last week by a coalition of public health organizations warns that an insidious new generation of tobacco products is threatening efforts to reduce tobacco use in the United States.

The report, "Big Tobacco's Guinea Pigs: How an Unregulated Industry Experiments on America's Kids and Consumers," was issued by the American Cancer Society Cancer Action Network, American Heart Association, American Lung Association and Campaign for Tobacco-Free Kids, with funding by the Robert Wood Johnson Foundation.

The report describes how tobacco manufacturers take advantage of the lack of government regulation to design and market products that recruit new youth users, create and sustain addiction to nicotine, and discourage current users from quitting. Responding to declining smoking rates and growing restrictions on smoking, tobacco manufacturers are finding novel ways to entice new users, especially children, and discourage quitting.

To stop the tobacco industry's harmful practices and protect public health, leading public health organizations urge Congress to pass pending legislation granting the U.S. Food and Drug Administration (FDA) authority to regulate tobacco products and their marketing.

The report details key trends including:

• Flavored products: Cigarettes, smokeless tobacco, and so-called "little cigars" have been introduced in many candy, fruit, and alcohol flavors that mask the harshness of the products and make them appealing to children.
• Novel smokeless products: New smokeless tobacco products, some in teabag-like pouches and even in dissolvable, candy-like tablets, have been marketed as ways to help smokers sustain their addiction where they cannot smoke.
• Targeted products and marketing: New products and marketing, such as R.J. Reynolds' Camel No. 9, are aimed at women, girls and other populations.
• Unproven health claims: To discourage smokers from quitting, and possibly entice new or former smokers, increasing numbers of products have been marketed with unproven and misleading claims that they are less harmful than traditional cigarettes.
• Undisclosed product designs: The report also details how tobacco manufacturers control nicotine delivery to maximize addiction, while using flavorings and other additives to make their products milder, easier to inhale and more attractive to children and first-time smokers.

For more information, see external PDF:
"Big Tobacco's Guinea Pigs: How an Unregulated Industry Experiments on America's Kids and Consumers"

APHA Adopts Policies on Tobacco, Climate Change, Trans Fat, and More

The American Public Health Association (APHA) recently adopted 20 policies addressing a broad range of issues in public health from tobacco-free schools and global climate change to including eye care in disaster preparedness and a ban on lead-based paint. Following are descriptions of the tobacco related measures approved by the Association's Governing Council during last year's 135th Annual Meeting in Washington, D.C., Nov. 3-7.

Smoking cessation to prevent vision loss: APHA recommends that the U.S. Surgeon General warn of vision loss and potential blindness on cigarette packages, that insurance carriers cover smoking cessation and that health education materials include information on the increased risk of blindness associated with tobacco use and secondhand smoke. APHA also urges that national professional health care organizations support providing information about the link between smoking and eye diseases in prevention counseling and that tobacco cessation materials include information on the link between smoking and secondhand smoke exposure and an increased risk of blindness.

Tobacco-free schools: APHA calls for strengthening the Pro-Children Act and similar laws by incorporating the Centers for Disease Control and Prevention's definition of a tobacco-free school and prohibiting tobacco promotional items at schools. APHA urges state legislatures and boards of education to adopt tobacco-free school laws or policies. APHA also calls on the Federal Trade Commission and U.S. Surgeon General to support efforts to track tobacco marketing and advertising abroad, especially those that specifically target children. APHA supports tobacco cessation interventions for employees of school districts and schools.

For more information, see web link:
Medical News Today February 15, 2008

Pennsylvania Tobacco Users Urged to 'Quit For Love' This Valentine's Day

A Lancaster, PA couple's video blogs documenting their efforts to quit using tobacco are now being featured on the Pennsylvania Department of Health's new tobacco cessation website, www.DeterminedToQuit.com.

Angela and Justin Williams have been married for a little more than a year and are determined to quit smoking together, not just for themselves but also for their young daughter.

"We want Pennsylvanians to follow this couple's journey in helping each other quit their addiction to tobacco once and for all," said Secretary of Health Dr. Calvin B. Johnson. "Give your loved ones the gift of health this year by making the decision to quit smoking or by offering them the additional support they will need to be successful in their quit attempt."

DeterminedToQuit.com offered a selection of free Valentine's Day e-cards to encourage loved ones to quit smoking. Pennsylvania couples who are determined to quit for love this year can also post their photos in the photo gallery section of the site by e-mailing photos to pictures@determinedtoquit.com throughout the month of February.

The website is part of ongoing activities by the department to help Pennsylvanians quit, or not start, using tobacco products and to curb the retail sale of tobacco to minors.

For more information, see web link:
PRNewsWire February 12, 2008

Sheraton Hotels to Go Smokeless

Sheraton Hotels & Resorts and Four Points by Sheraton Hotel brands will ban smoking at more than 300 hotels and resorts throughout the U.S., Caribbean and Canada.

The new policy follows one implemented at Westin Hotels & Resorts, which became smoke-free in 2006. Westin and Sheraton are both owned by Starwood Hotels & Resorts.

Some 8,000 rooms at the hotels will be cleaned, including treatments for air conditioning, walls, rugs, upholstery and hard surfaces.

Smoking will also be banned in public areas in the hotels but there will be a designated outdoor area at each property for guests who smoke.

There are already 70 Sheraton and Four Points by Sheraton hotels in the U.S., Canada & Caribbean that are smoke-free. Both hotel brands expect to be completely smoke-free in the U.S. and Canada by December 31.

For more information, see web link:
Associated Press , February 11, 2008

WHO Releases New Report on Global Tobacco Control Efforts

The World Health Organization (WHO) released new data showing that while progress has been made, not a single country fully implements all key tobacco control measures, and outlined an approach that governments can adopt to prevent tens of millions of premature deaths by the middle of this century.

In a new report which presents the first comprehensive analysis of global tobacco use and control efforts, WHO finds that only 5 percent of the world's population live in countries that fully protect their population with any one of the key measures that reduce smoking rates. The report also reveals that governments around the world collect 500 times more money in tobacco taxes each year than they spend on anti-tobacco efforts. It finds that tobacco taxes, the single most effective strategy, could be significantly increased in nearly all countries, providing a source of sustainable funding to implement and enforce the recommended approach, a package of six policies called MPOWER.

The six MPOWER strategies are:

1. Monitor tobacco use and prevention policies
2. Protect people from tobacco smoke
3. Offer help to quit tobacco use
4. Warn about the dangers of tobacco
5. Enforce bans on tobacco advertising, promotion and sponsorship
6. Raise taxes on tobacco

"While efforts to combat tobacco are gaining momentum, virtually every country needs to do more. These six strategies are within the reach of every country, rich or poor and, when combined as a package, they offer us the best chance of reversing this growing epidemic," said Dr. Margaret Chan, Director-General of WHO.

The report finds that tobacco use already kills 5.4 million people a year and the epidemic is worsening, especially in the developing world where more than 80 percent of tobacco-caused deaths will occur in the coming decades. Unless urgent action is taken, one billion people will die worldwide from tobacco use this century.

Other key findings in the report include:

• Only 5 percent of the global population is protected by comprehensive national smoke-free legislation and 40 percent of countries still allow smoking in hospitals and schools;
• Only 5 percent of the world's population lives in countries with comprehensive national bans on tobacco advertising and promotion;
• Just 15 countries, representing 6 percent of the global population, mandate pictorial warnings on tobacco packaging;
• Services to treat tobacco dependence are fully available in only nine countries, covering 5 percent of the world's people;
• Tobacco tax revenues are more than 4000 times greater than spending on tobacco control in middle-income countries and more than 9000 times greater in lower-income countries. High- income countries collect about 340 times more money in tobacco taxes than they spend on tobacco control.

Robert Wood Johnson Foundation Awards Tobacco Policy Change Grants, Targeting Communities Hardest Hit by Health Risks

The Robert Wood Johnson Foundation (RWJF) recently announced almost $600,000 in new grants to support policies aimed at decreasing tobacco use and exposure and addressing other public health problems. The grants will be awarded to 12 partnerships nationwide whose work helps people most directly affected by tobacco and additional public health threats.

This announcement marks the fourth round, and a total of $12 million of funding for the Foundation's Tobacco Policy Change initiative. Previous funding supported policy advocacy to reduce tobacco use and exposure in communities, regions and states. This year, RWJF has expanded the scope of the initiative to promote tobacco and other public health policies that help people lead healthier lives. This includes policies that provide access to healthy foods, increase physical activity, reduce the number of uninsured, and address other pressing public health needs in communities.

Round 4 projects will be established in communities that are disproportionately affected by public health threats or a lack of public health resources. Efforts in Alabama include increasing support for statewide smoke-free legislation and promoting policies to reduce obesity in the state. In New Orleans's lower 9th Ward, a project will focus on limiting the number of tobacco retailers established during its rebuilding period and creating a commission to advocate for public health policies. A Tobacco Policy Change project in Indiana will support smoke-free policy efforts in 20 rural communities and promote expanding access to health care coverage for the uninsured in those areas.

For more information, see web link:
RWJF News Release February 06, 2008

State Health Department Ad Campaign Urges Doctors: 'Don't Be Silent About Smoking'

The New York State Department of Health recently unveiled its "Don't Be Silent About Smoking" ad campaign, urging health care providers to make quitting a priority for their patients who smoke. The $1.3 million cutting-edge campaign features graphic images of health care providers with their mouths stitched or taped shut to dramatize how doctors can help their patients quit by discussing smoking.

State Health Commissioner Richard F. Daines, M.D., said, "We want to challenge clinicians across the state to take time at every office visit to talk to their patients who smoke." Studies have found that when health care providers take the time to talk to their patients about smoking and offer assistance with quitting, long-term success can be dramatically increased.

"Doctors spend a lot of time treating smoking-related health problems. If we did a better job at helping our patients who want to quit, we could save thousands of lives and alleviate a great deal of suffering," Commissioner Daines said.

"The Medical Society of the State of New York, working with the Department of Health, has stepped forward to provide education to physicians regarding the use of the 5As ("ask, advise, assess, assist, and arrange for follow -up") to approach their patients to encourage them to quit smoking. The program has been quite successful," said Dr. Robert Goldberg, D.O., president of MSSNY. "Now it is time for the payor community to move forward as well to provide coverage for patients to enable physicians to continue and to expand smoking cessation counseling in their practices.

"The "Don't Be Silent About Smoking" campaign ads will be featured in medical journals such as The Journal of the American Medical Association (JAMA), on medical websites, in major newspapers and in other publications throughout the state. The campaign began on February 1, 2008 and will run through June 2008. During the first week in February, several full-page ads appeared in the Science Times section of The New York Times and other New York newspapers.

The "Don't Be Silent About Smoking" campaign was created by Better World Advertising in collaboration with the state Health Department Tobacco Control Program and its 19 cessation centers across the state. The campaign's website, http://www.TalkToYourPatients.org, offers easy-to-access information and resources to help health care providers assist their patients who smoke.

For more information, see web link:
New York State Department of Health Press Release February 1, 2008

University of Maine Project Aims to Help Smokers

Maine's anti-tobacco website, www.tobaccofreemaine.org, is the focus of an ambitious new project at the University of Maine that aims to make it easier for more people to get the information they need to stop smoking or to dissuade a loved one from starting.

The project, funded with a one-year $100,000 grant from the American Legacy Foundation, focuses on developing an Internet-based program that can simplify the language and the ideas used on any website, eliminate distracting graphics, and translate photographs and charts into words that can be read aloud by a computerized voice.

The web-based software will not change the actual content of any site, but individuals may use it to translate existing content into a more understandable form.

"There's a rule of thumb that the language used for public readership should target a fourth- to sixth-grade reading ability," UM Stephen Gilson said. For many individuals, even that level is too high, he said.

When the researchers tested state-sponsored public health websites in all 50 states, as well as the Centers for Disease Control and Prevention site, they found that most of them contained language - including word choice, sentence structure and other elements - that would challenge the average high school graduate.

"If you write at a level people aren't fully able to understand, then the information might as well not be there at all," Gilson said.

While the information on the sites may be credible and comprehensive, some of the language is too high-level for the people who are most likely to need it. In addition, most of the sites reviewed offered few, if any, options for users with visual impairments, mental retardation or other challenges.

So for a user with reading or comprehension difficulties, the new software might replace the word "policies" with the word "rules." Other options that might be offered to users through new translation program include the ability to enlarge or eliminate graphics and a simplified way of navigating through the different "pages" of information on a given site.

UM project coordinator Robert Kitchin stressed that the new software - which will have its own website or "portal" - will have no content of its own but instead will enhance users' ability to understand and make use of information posted on the Internet.

With a strong interest in public health and concern for the high rate of smoking among people with physical and mental disabilities, the research team hopes the project eventually will have a far-reaching impact in public health and beyond.

For more information, see web link:
Bangor Daily News January 29, 2008

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