CANCER PREVENTION INSTITUTE OF CANADA

Last updated: 15-Jan-2007

Tobacco Control: Lessons Learned

Several reviewers have recently examined the multi-decade anti-tobacco campaign with a view to abstracting lessons that may be applicable to obesity and other public health challenges. Such lessons not only provide a conceptual context for the preceding intervention summary, but anticipate the evaluation of obesity strategies in the next section of this report.

The important insights derived by Mercer and colleagues in 2003 will offer a framework for the following summary: [1]

General Insights on Comprehensive Strategies

Physician intervention, including brief advice, counselling and pharmacotherapy, is seen to be one of the most effective and cost-effective of all disease prevention strategies; the “returns” in terms of benefits are quicker and the overall public health impact is larger in the short-term compared with any other component in a comprehensive program. One obstacle is that clinical help for smoking is a vastly underutilized resource.

More importantly, neither physician efforts nor any other sectoral intervention were able to single-handedly thwart the “broad cultural acceptability” of tobacco use and the ubiquitous social cues to smoke. Supportive systemic changes and social denormalization of both the tobacco industry and the smoking habit were required to achieve the population-based cessation rates that have been observed in developed countries.

No single component of a comprehensive program can account for all the significant changes with respect to tobacco; each intervention, from media advocacy to school programs to social support systems, is enhanced synergistically by the presence of other components.

The one possible exception to the preceding principle is tobacco product price increases (usually through taxation), which has been shown to have a strong and sustained effect independent of other interventions; control through pricing has been shown to be more significant than any media campaign.

Whether interventions involve taxation or other more experimental forms of environmental engineering, senior levels of government must shape their efforts to maximize support for policies and programs operating in local jurisdictions and targeted communities; there must be multi-level, integrated strategizing to ensure the greatest impact on risk factor reduction.

The Influence of Social Determinants

Tobacco control has also taught policy-makers that care needs to be taken with the impact of interventions on lower-income populations. For instance, taxation may lead to unintended consequences: rather than quitting in the face of higher prices, low income smokers may simply switch to cheaper brands or further strain their household budgets (e.g., taking away from purchasing food).[2] There is even evidence that the tobacco industry is exploiting these social dynamics by positioning cheaper brands as still being high-quality and therefore increasing the attractiveness of such brands to low-income smokers who feel constrained to choose them.[3]

It is commonly recognized that tobacco control, including media advocacy and other forms of health education, needs to be as tailored as much as possible to address the needs of particular audiences.[4] People of lower socioeconomic status represent a unique challenge because they often do not have the resources to respond to counter-advertising in the same way as those of higher education.[5] The real and ironic possibility is that certain forms of health messages may be preferentially taken up by those with higher incomes, and thus actually ends up exacerbating social health inequalities.

Community-Based Interventions

The effect of community programs may be relatively small, but given the large number of smokers and the serious health impacts, the public health benefit may still be high: “the moderate efficacy of community programs is more than offset by their substantial reach.”[6]

A critical aspect of community-based planning is the building of “capacity,” i.e., increasing the number of organizations and local jurisdictions engaged in cessation education and tobacco control, plus ensuring adequate financial and organizational resources for all effective efforts over a long time frame.

Another key consideration is special populations of high risk. Above all, focusing on younger generations and reducing the development of behavioural risk factors in the first place are essential to permanently turning the tide on smoking.

Community interventions, as already noted, need to comprise multiple components to produce synergistic effects. They also need to be sustained over the long haul, but not without suitable surveillance and evaluation of results, and frequent fine-tuning.

School-based Interventions

As habits such as smoking often get established early, school programs have been useful tools in reducing risk factor incidence. Identifying social influences which promote smoking among youth, and teaching suitable counter-measures, have been particularly useful.

The effectiveness of school programs is increased when there is a sustained multi-stage approach, starting in primary school, intensifying in middle school, and offering “booster” sessions in high school.

Parent involvement in school and other community programs is often a key element in their success.

Clinical Interventions and Management

Even the “brief advice” interventions advocated for physician practices may not be used unless other staff in the clinic are recruited and trained to be partners in the process (e.g., intake interviews, physician prompting, administering referrals and follow-up).

Disincentives such as poor reimbursement of physicians for their time and patients for any out-of-pocket expenses are a barrier to expanding smoking cessation programs in the clinical setting, despite their clear effectiveness.

Regulatory and Economic Interventions

Where there are regulations, e.g., restricting minors’ access to tobacco or clean indoor air policies, then enforcement has often made the difference between modest and more significant effectiveness.

The power of “macro-environmental” economic interventions in tobacco control, especially taxation, has already been noted. Marketing restrictions have also been very effective.

Conclusion

There are many critical lessons from tobacco control strategies in the last 4 decades that are highly applicable to other arenas of health promotion.

The US Institute of Medicine has identified the following key elements associated with a successful prevention program: [7]

• Interventions must address the fundamental behavioural and social causes of disease, illness and disability.

• Multiple approaches must be used simultaneously – education, social and community support, laws, economic incentives and disincentives.

• Multiple levels of influence must be accessed: individuals, families, schools, workplaces, communities, nations.

• Interventions must recognize special needs of specific target risk groups such as teens, seniors, at-risk communities.

• Interventions must have long durations because change takes time and needs to be constantly supported for each subsequent generation.

• Interventions need to involve a variety of sectors that are not traditionally associated with “health,” such as business, engineering, law, media and others.

In particular, these lessons provide a map to move forward into the new frontier of obesity control. There have been passing references, however, to the current and absolute differences between obesity and smoking. These vital distinctions will be highlighted further as the report now turns to the other major risk factor challenge in B.C. and the whole developed world. The desire, indeed, the necessity, is to see the same progress on obesity as has been achieved in the area of smoking.

[1] Mercer SL, Green LW, Rosenthal AC et al. Possible lessons from the tobacco experience for obesity control American Journal of Clinical Nutrition 2003; 77(Suppl): S1073-82.

[2] Thomson GW, Wilson NA, O’Dea D et al. Tobacco spending and children in low income households. Tobacco Control. 2002; 11:372-5.

[3] Tackling health inequalities. Action on Smoking and Health. 2001. Available at http://www.ash.org.uk /html/policy/response.html (accessed January 2005).

[4] Crampton P, Salmond C, Woodward A, Reid P. Socioeconomic deprivation and ethnicity are both important for anti-tobacco health promotion. Health Education & Behavior. 2000; 27(3):317-27.

[5] See for example the Alberta-based report Poverty and Health Care Reform. 2002. Available at http://www.ywcaofcalgary.com/pdf/PovertyHealthReform.pdf (accessed January 2005).

[6] Mercer SL, Green LW, Rosenthal AC et al. Possible lessons from the tobacco experience for obesity control American Journal of Clinical Nutrition 2003; 77(Suppl): S1073-82. See the discussion on “reach” and other evaluation criteria in the conclusion of this report.

[7] Institute of Medicine, Promoting Health: Intervention Strategies from Social and Behavioral Research, 2000.