Why have so many New Jersey smokers quit?

On June 13th I wrote about a comprehensive new report on tobacco use and tobacco control activities in each of the United States. As I live and work in New Jersey I was particularly interested in the fact that our cigarette smoking rate has fallen to 13.7%, the 3rd lowest in the country. In fact if you look at the 2 other states with lower cigarette smoking rates (Utah and California) you will see that they also had lower rates than New Jersey (21.4%) back in 1992-3, meaning that New Jersey has probably had the most impressive reduction in cigarette smoking in the country over the past 15 years.

The other figure that caught my attention was that New Jersey has the highest proportion of ever cigarette smokers who have successfully quit (62%), as compared with the national average of 52% and the lowest figure for West Virginia (40.7%). A reader commented on my earlier post by asking me to say why I think smoking has come down so much in New Jersey. So here are my thoughts.

First of all, we should acknowledge that NJ had a good proportion of ex-smokers (54%) back in 1992-3. The proportion continued in parallel with national trends to 1998-9, but then NJ started to pull ahead in 2003 and 2006/7. So that makes me think that while the state has always been relatively health conscious, some things happened since 1999 that helped significantly. Now I’d like to say its all because I moved to the state in 2000 (I’m joking) but in reality there were far more important things going on.

New Jersey’s Comprehensive Tobacco Control Program really got started in 2000, with $30 million annual funding for a few years. The state actually invested that money very wisely in a truly comprehensive program with components for youth prevention, media, community activities, evaluation, and (unlike many states) New Jersey quickly invested in smoking cessation services. This included a free quitline ( 1-866-NJSTOPS ), an excellent internet site; www.nj.quitnet.com , and a bunch of face-to-face smoking cessation clinics called “NJ Quitcenters”. In addition they gave funding focusing on helping pregnant women and school kids to quit smoking and provided training activities for health professionals so they could do a better job of helping their patients to quit. For example, the program I direct has treated over 4,000 smokers but also trained over 4,000 health professionals to help smokers quit. So all of that activity has helped.

But there have been some additional critical policy or legislative moves that have undoubtably played a part. Perhaps the most important of these has been a series of increases in state excise tax on cigarettes. In fact just yesterday, Governor Corzine signed the 2009-10 budget that included an additional 12.5 cents tax per pack of cigarettes taking the total state tax per pack to $2.70. There can be no doubt that the resulting increase in the price of cigarettes over the past 9 years has prompted many smokers to try to quit. When that is combined with public education and quit services, it has a potent effect. In addition, New Jersey legislators have also passed a series of laws that have helped tobacco control. The age of sale of tobacco in New Jersey is 19, and in 2006 almost every workplace in the state (except a few areas in casinos and cigar bars) became smoke free. But that important change probably came too late to influence the 2006-7 data very much.

One other major event probably had a negative effect on quit rates in New Jersey and that was the terrorist attacks in September 2001. The Twin Towers in Manhattan, New York were visible from a large part of northern New Jersey, and many people in the north of the state work in New York City and knew people who were affected by those events. The evaluation component of the state’s tobacco control program, led by my colleague Dr Cristine Delnevo, actually reported an increase in cigarette smoking among people aged over 45 in 2001, and this may have been caused by an unusually large proportion of middle-aged ex-smokers relapsing at that time.

So despite a few setbacks, New Jersey has generally done a good job of making smoking less attractive and helping addicted smokers to quit. That’s the good news. But over the past few years, with budget deficits and the lure of tobacco taxes, funding for tobacco control was cut from $30m to $7.6m. Some legislators who were perhaps more interested in the budget than public health made pronouncements that we have done enough tobacco control in New Jersey. The reality is that school kids in our state still smoke over 90 million cigarettes per year and most adult smokers try to quit but fail each year.

I believe that if the NJ State Comprehensive Tobacco Control Program is properly funded we will have the lowest smoking rates in the country within a few years, along with plummeting rates of lung cancer, myocardial infarctions and premature births.

To view the new national report, check out:
www.impacteen.org/tobaccodata.htm

To access a series of evaluation reports on tobacco control in New Jersey, check out:
http://sph2.umdnj.edu/tobweb/Link%20to%20TSERP%20Reports.htm

Labels: cigarette smoking, excise tax, jonathan foulds, New Jersey, smoking cessation

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Request for comment on FDA regulation

As many of you will know, President Obama recently signed the historic legislation that will give the U.S. Food and Drug Administration the authority to regulate tobacco products. In the coming months and years we will find out whether that legislation is able to truly help improve public health in this country as was intended. Interestingly, just today the FDA issued a request for public comment. So you can influence the process rather than just waiting to see what happens. I’ve copied the request for comment verbatim below so that those of you who want to can express your opinion.

“FDA NOTE TO CORRESPONDENTS
For Immediate Release: June 30, 2009
Media Inquiries: Siobhan DeLancey, 301-796-4668, siobhan.delancey@fda.hhs.gov
Consumer Inquiries: 888-INFO-FDA
FDA Seeks Public Input on Tobacco Regulation
The U.S. Food and Drug Administration announced today that it is seeking public input on the implementation of its historic new authority overseeing tobacco products in the United States. In a Federal Register notice, the agency invites the public to provide information and share views on a wide range of topics, from product content to advertising and marketing. All public comments will be posted online.

"We're interested in receiving input from across the country as the FDA begins to implement this important new authority intended to reduce the enormous toll of suffering and death caused by tobacco products in the United States," said Dr. Margaret A. Hamburg, Commissioner of Food and Drugs. "We look forward to the public's response."
The Federal Register notice can be viewed at: http://www.federalregister.gov/OFRUpload/OFRData/2009-15549_PI.pdf.
For more information about the FDA and tobacco regulation, see: http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm168412.htm.
ADDRESSES:

Submit electronic comments to http://www.regulations.gov.

Submit written comments to the Division of Dockets Management (HFA305), Food and
Drug Administration, 5630 Fishers Lane, rm. 1061, Rockville, MD 20852. “

Labels: FDA, jonathan foulds, regulation, tobacco

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Smokefree Movies for Kids

As many of you may know, the famous tobacco control scientist and advocate, Professor Stan Glantz, has over the past few years been focusing on the issue of depictions of smoking in movies. Part of the concern stems from good evidence that young people are highly influenced by movies due to their cultural value and glamorous nature. The other part stems from a history of use of “product placement” in movies. This refers to the movie producers agreeing to include a specific product in their movie in return for some incentive (typically money). A famous example of this is a letter from Sylvester Stallone agreeing to smoke particular brands of cigarettes in his movies for $500,000. So when one combines the financial power of the tobacco industry with product placement we end up with a hell of a lot more gratuitous smoking in movies than is necessary.

Of course the movie companies and many movie enthusiasts argue about the need for art to imitate life etc etc. However numerous examples demonstrate that to be a lot of nonsense. Professor Glantz points to depictions of Marlboro cigarettes being dragged around or used by aliens in movies like Men In Black. Is it really true that those aliens prefer Marlboros and so showing the brand was necessary for the movie to be accurate? Mmm….I doubt it.

My favorite example comes from the film “A Beautiful Mind”. The movie stars Russell Crowe in the lead role portraying the (still living and working) Princeton University professor, John Nash. In real life, John Nash suffered from schizophrenia but did not smoke. In the movie he suffered from schizophrenia, but smoked. I’m not sure why the producers changed this aspect of reality or what it added to the movie.

But these are details. Professor Glantz’ main point is that movies made to be viewed by kids do not need to include smoking, and therefore should be given an R rating if they do, just as they are if they depict illicit drug use. Note that an R doesn’t stop people under 17 from seeing the movie in a movie theater. It just means they need to be accompanied by an adult. It also doesn’t ban smoking from movies, it just means that movies with smoking in them will receive an R rating, just as sex, drugs, cursing and certain types of violence will get a movie an R rating. Of course the movie industry is very clear that a large part of its audience is kids and particularly teens. The net effect of the rating changes professor Glantz is recommending would be that gratuitous smoking will be taken out of many movies and particularly those aimed at kids.

I must admit that I didn’t initially pay much attention to this proposal, and my natural inclination was to doubt whether it really was worth the effort. But while I was at the UK National Smoking Cessation Conference in London last week I heard Professor Glanz talk about this idea and I came around to thinking its maybe not as extreme as I first thought. In fact he convinced me that it’s a reasonably sensible idea that would likely result in thousands fewer teens taking up smoking. Sometime soon the full audio recording of Professor Glantz’ presentation will be posted on the conference website along with his slides. I’ll post the link when its available, but for now those interested in this subject may want to check out the following website:
http://smokefreemovies.ucsf.edu/

Labels: jonathan foulds, movies, smokefree, Stan Glantz

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FDA Regulation of Tobacco: What Does it Mean?

On Friday 12th June, the US Senate voted in favor of a bill that gives the Food and Drug Administration the power to regulate tobacco products. President Obama (who as a Senator was a sponsor of the bill, as was John McCain) has indicated he will sign the bill into law.

Public health advocates have been fighting for FDA regulation of tobacco for over 15 years. However, not every public health advocate has supported this particular piece of legislation, and the fact that Philip Morris Tobacco Company supported it caused many to have doubts. But now that the bill is finally going to be law, what will it mean? As a guide to this, I’d recommend that you read the slides from a paper by Mitch Zeller at the recent Virginia Youth Tobacco Conference. Much of this post is adapted from his slides. These outline the key parts of the bill and what they mean in some detail and are worth a careful read, (Mitch Zeller is the former Associate Commissioner and Director of the Office of Tobacco Programs at the Food and Drug Administration). Download his slides from:
http://www.vcu.edu/idas/VYTP%202009%20Presentations1.html

The bill does not require FDA to regulate tobacco exactly the same way it does pharmaceuticals (drugs and devices), partly because it would be impossible for any tobacco product to demonstrate that it is safe and effective for its purpose. So instead the legislation creates a new, parallel set of rules and procedures just for tobacco, but using much of the same regulatory framework that was created for drugs. The new standard around which the tobacco bill is based is THE PROTECTION OF PUBLIC HEALTH.

-Section 904 mandates that FDA will receive brand-specific information on ingredients, nicotine delivery, and any smoke constituent FDA identifies as harmful or potentially harmful

- Companies must also provide FDA with all documents developed after the bill is enacted related to health, toxicological, behavioral, or physiologic effects of current or future products.

- FDA also has the right to request any such industry document produced prior to the enactment of this law.
- FDA can issue performance standards to prohibit or limit the allowable levels of substances in a finished tobacco product. FDA is granted this power in section 907. Products that don’t comply with the levels established in product standards can’t be sold.
- Nicotine cannot be banned but it can be reduced to very low levels.
- FDA needs to have supporting science to back up any standards it requires, or any ingredients it wants banned.

Clearly the tobacco product standards are going to be a key part of regulation of tobacco. Here’s what the bill says on these:

TOBACCO PRODUCT STANDARDS.—The Secretary may adopt tobacco product standards…if the Secretary finds that a tobacco product standard is appropriate for the protection of the public health. This finding shall be determined with respect to the risks and benefits to the population as a whole, including users and non-users of the tobacco product, and taking into account—
(A) the increased or decreased likelihood that existing users of tobacco products will stop using such products; and
(B) the increased or decreased likelihood that those who do not use tobacco products will start using such products.

Note that a component of a tobacco product may be banned if it is decided that it “may be harmful”. Thus absolute certainty and proof is not the standard required.

However, there are also provisions that appear to be designed to protect the industry from inappropriate standards, and some have argued that these open up a Pandora’s Box of potential legal appeals over key issues. For example, the required change to a tobacco product must be technically achievable, and must not create an increased demand for contraband or counterfeit products that do not meet the required standard. So for example if it was decided that no cigarette could contain more than 0.1mg of nicotine, the industry lawyers may appeal on numerous grounds, including that it is not technically feasible and it would create a demand for black market normal nicotine cigarettes.

•Any product (even if only test-marketed) or product modification that was introduced after February 15, 2007 is considered a new product that must be evaluated by FDA.

•A provision in section 910 allows a product introduced up to 21 months after the bill is signed into law to remain on the market unless FDA makes a determination that such a product is not substantially equivalent to a product marketed prior to February 15, 2007. (This is to allow FDA sufficient time to set up procedures and gather expertise in order to evaluate products).

- So in less than 2 years time FDA will need to be ready to make relatively fast decisions (<90 days) on all new products. (I suspect we are going to see an increase in new product launches over the next 2 years for that reason).

- ·The bill bans the use of terms like “light,” “low tar,” “mild,” and similar terms.

·Section 911 of the bill requires any express or implied harm reduction claim, including an exposure reduction claim, to be evaluated by FDA prior to marketing.

·Approval for such a claim is subject to a very high standard of scientific substantiation. Industry opponents of the bill, and public health advocates of expanded use of smokeless tobacco, have complained that the standard in this section is too high.

•Under the bill, a claim can only be approved if a company can demonstrate that the product, as actually used by consumers, will “significantly reduce harm” to individuals, and benefit the health of the population as a whole taking into account both users and non-users of tobacco products.
•FDA must take into account the unintended population level effects from proposed claims, such as:
–Decreased interest in quitting
–Increased interest in initiating use of the product among ex-smokers and those who never used tobacco products
–The risks and benefits to users of the product compared to the use of NRT and other products designed to treat tobacco dependence

Other parts of the bill state that:

• Cigarette packages will have warning labels that cover 50 percent of the front and rear. The word "warning" must be included in capital letters.

• Any remaining tobacco-related sponsorships of sports and entertainment events will be banned, as will giveaways of non-tobacco items with the purchase of a tobacco product. A federal ban will be imposed on all outdoor tobacco advertising within 1,000 feet of schools and playgrounds.

• Point-of-sale advertising will be limited to adults-only facilities, and remaining vending machines will disappear except in places restricted to adults. Retailers who sell to minors will be subject to federal enforcement and penalties.

• Tobacco sweetened by candy flavors or any herb or spices such as strawberry, grape, orange, clove, cinnamon or vanilla will be banned.

·The entire FDA regulatory program is to be funded by tobacco industry user fees…really more of a market share allocation by company.
·The program budget grows from $85 million in Year 1, to $235 million in Year 2, to $450 million in Year 3, and ultimately to $712 million in Year 11 and subsequent years.


So although it has taken a tremendous amount of work for over a decade to get this bill passed, in reality the heavy work is just about to start. The tobacco industry and their lawyers have been anticipating this for a long time and will already have a game plan ready to roll out. From the moment the bill is signed the clock is ticking. FDA will need to appoint someone to be in charge of this new part of the agency, and start putting together teams with experience in regulating, and experience in nicotine and tobacco. This will include scientists, regulators and I suspect many lawyers. How this is implemented will depend very much on the individuals who are appointed to key positions.

85 million new dollars in one year may sound like a lot of money, but it will be a challenge for a new government bureaucracy to spend that money efficiently and effectively in a short space of time from a standing start. Even such mundane things as finding new office space can be a challenge. New space will be required to house the new tobacco team, but they will likely need to be close enough to existing FDA offices to stay linked and make use of existing FDA expertise.

As I have stated in previous posts, I believe the bill’s advantages greatly outweigh its disadvantages. However, the key here is how it is implemented. Only time will tell. It is going to be a very interesting next few years for tobacco control in the United States.

Labels: FDA, jonathan foulds, Mitch Zeller, nicotine regulation, tobacco

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2009 Virginia Youth Tobacco Program Conference Presentations

I was recently invited to speak at the Virginia Youth Tobacco Program’s Annual Conference in Richmond, Virginia. My topic was whether snus (smokeless tobacco) might help some smokers to quit smoking. Drs Thomas Eissenberg (Victoria Commonwealth University) and Dr Lois Beiner (University of Massachusetts) also gave presentations in the same session on the topic of smokeless tobacco (and particularly snus). Dr Eissenberg's presentation showed that most of the snus products launched so far in the USA deliver relatively low nicotine levels, and Dr Beiner's presentation showed that most Americans (wrongly) believe that smokeless tobacco is at least as harmful to health as cigarettes, and that relatively few are using these new smokeless products. Of course if the products deliver relatively little nicotine, and the population believes them to be just as harmful as cigarettes its really no surprise that few smokers are switching to them. Why would they? I continue to be perplexed as to why many tobacco control experts have great difficulty in admitting that many forms of smokeless tobacco are much less harmful than cigarettes (no lung cancer or respiratory diseases, and lower rates of virtually every other tobacco-caused illness than smoking, makes it at least 95% less harmful)

When people are speaking at conferences they typically try to summarize their views and data in pictorial slides much more than when writing in journals. It is often a lot easier to “get” the main points by checking out their slides than by reading the articles! It is therefore particularly helpful that the organizers of this conference have made almost all of the conference slide presentations freely available as powerpoint files.

Because the conference was organized with parallel sessions I wasn’t able to see every presentation but in addition to the speakers on snus (mentioned above) being very good, I also thought that Gary Giovino’s presentation on the epidemiology of tobacco use in young people, and Mitch Zeller’s presentation on FDA regulation of tobacco were particularly interesting. Many of the slide presentations at this conference are well worth a look.

You can find, download, or just view all of the powerpoint slide presentations from the conferences via the link below:


http://www.vcu.edu/idas/VYTP%202009%20Presentations1.html

Labels: conference, jonathan foulds, slides, tobacco, Virginia, youth

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