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Tobacco Control Informs Childhood Obesity Movement

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As industry, the public health community, government and others focus on the obesity crisis, the question often arises, “What can we learn from efforts to reduce tobacco use that might apply to obesity?” Bill Novelli provided his thoughts in a talk with the strategy committee of the newly-formed Voices for Healthy Kids on September 11, 2013.

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I’m pleased to be invited to speak to you about lessons from tobacco control that might be useful to your Voices for Healthy Kids advocacy collaboration.

Your goal, to reverse the childhood obesity epidemic by 2015, could not be more important. You are leaders in striving for a wellness society, so Americans will healthier and achieve physical, mental and emotional, social and financial well being.

That’s the great goal we all strive for – a well being America.

I recognize some of you from your bios, both Advisory Strategy Committee members and American Heart Association staff, and many of you know a lot about the tobacco wars.

I’ve been asked to talk about tobacco control in the expectation that there are lessons that can be applied to your work. I intend to leave time for questions and discussion. And I hope my comments will be of interest and of use as you go forward.

There are both similarities and differences between tobacco and obesity, as you know from your public health backgrounds.

Looking back to earlier days, local smoke-free coalitions consisting of loose-knit groups of community activists were the pioneers in tobacco control, in places like Arizona, California and Minnesota.

At the national level, the American Heart Association, American Cancer Society and American Lung Association came together to form a group called the Coalition on Smoking OR Health to work on tobacco issues and to support federal and state efforts. The organization didn’t have much in the way of resources, and the three parent organizations had many other priorities to worry about.

Meanwhile, the tobacco industry was enormous… and enormously wealthy.

  • They had a skilled army of Lawyers, lobbyists, PR and ad agencies;
  • And they had the Tobacco Institute, a front for the industry so it could speak with one voice, although individual tobacco companies often spoke for themselves.

And tobacco use among children was going up. The Marlboro Man and Joe Camel were everywhere, and a study showed that Joe Camel was as popular as Santa Claus.

In the mid-1990’s,  the FDA, under then- commissioner David Kessler, began to audaciously claim jurisdiction over tobacco, and all hell broke loose, with the industry attacking the very idea that tobacco could or should be regulated.

A number of public health advocates looked at the situation and decided they needed much more punch…as one of them put it, “A Tobacco Institute for the good guys.” That was the concept, and thanks to the Robert Wood Johnson Foundation, American Heart Association and the American Cancer Society, with some additional funding and help from other sources, the Campaign for Tobacco-Free Kids was born. The year was 1995. By 1996, we were in full operation.

The Campaign provided some support to state coalitions, and RWJF began Smokeless States, funded in 46 states, with full and part time staff and a charge to broaden and strengthen the state coalitions.

Individual states funded media and education campaigns and expanded their health department projects and community coalitions. The Smokeless States, the Campaign for Tobacco-Free Kids and others worked together and the movement grew, even as the industry pulled out all the stops.

The tobacco industry was big and bad, and it still is. The question we faced was this: How do you rally a nation – including policy makers, many of them taking lots of campaign money – against an industry that has enormous firepower and an addictive product, that can hire half the law firms and marketing communications agencies in the country…and that has what was then a seductive story:

  • Tobacco products are sexy and alluring;
  • Tobacco use is an individual choice and a right (after all, it is a legal product);
  • Disease is the smokers’ responsibility;
  • Government intrusion is bad;
  • The science about tobacco harm is in doubt;
  • Kids will be kids – they will experiment with tobacco products;
  • We – the industry – will take care of youth education;
  • Watch out, other companies and industries, like fast food; if they come down on us tobacco companies, you’re next;

It took a long time to find the right approach to reduce tobacco use among children and adults, but after much research, trial and error, the basics became clear. That didn’t make them any easier to achieve, but the strategies are:

  • Raise the price;
  • Smoke free public places;
  • Education to encourage kids not to experiment or become regular smokers;
  • Cessation help for adults;
  • Restrictions on tobacco marketing;

These strategies require:

  • Policy advocacy: legislative, regulatory and legal;
  • Solid science to support policy change;
  • Effective communication;
  • Strong coalitions (not easy to achieve. As someone said at a tobacco control meeting, “I know how to defeat the tobacco industry; make them work in coalitions!”);
  • Multiple approaches and change agents.

In 1997, state Attorneys General, with the participation of the Campaign for Tobacco-Free Kids, negotiated a huge settlement with the tobacco industry. It would pay $ 368.5 billion to the states in compensation, provide FDA oversight over tobacco and nicotine, have stronger warnings on cigarette packs, fund prevention and cessation campaigns, impose tobacco marketing restrictions and add big monetary penalties if youth smoking didn’t go down.

Major parts of the settlement required federal legislation, and it failed in the U.S. Senate after a long floor debate, partly because the administration and Congress tried to add more restrictions on the industry and partly because the public health community was divided.

Some public health advocates wanted to end the industry altogether, and others didn’t want Big Tobacco to receive immunity in the settlement from class action lawsuits or other protections.

After that, the Attorneys General went back to the table with the industry, and negotiated a lesser settlement that did not require legislation. It took another 11 years, until 2009, to achieve FDA jurisdiction over tobacco.

The Campaign, the American Heart Association, the American Cancer Society and many others who worked so hard to pass that legislation came away with a key session: you don’t need to and you can’t get everything you want. So don’t let the perfect be the enemy of the good. Ronald Reagan used to say that he would take 60 or 70 percent of what he could, and get the rest later. That’s a good way to think about advocating for social change.

Related to that is perhaps the strongest and most powerful lesson that can be learned: leadership really, really matters.

  • National leaders are essential;
  • State and community leaders are also critically needed;
  • Kids can lead, and they do (youth advocates are an important change strategy);
  • People in the ranks can be leaders: parents, clergy, teachers and coaches are excellent examples;
  • Organizations must take leadership roles. The health of our children and therefore our future is at stake

A few minutes ago I talked about effective communication being essential for success.

  • Communication is necessary for policy reform; policy makers need to know there is support for change;
  • It is important to frame solutions to create hope and positive expectations;
  • Communication is needed to rally the troops: coalitions, educators, youth advocates, parents and professionals;
  • Communicating behavior change is difficult, especially when the completion has lots more media exposure and alluring messages — like the adorable couples in the Salem ads who really “enjoyed” the fresh, fun taste of menthol (obesity control faces this same challenge);
  • There was an evolution of youth tobacco control messages, largely through trial and error: tobacco will kill you (some of these messages backfired); just say “no” (why?); smokers and spitters stink (ho hum); Youth, you can and should rebel (not against teachers and parents, but against those “suits” in the tobacco companies who want to addict you and trap you into a lifetime of smoking).

Here are some lessons learned regarding effective communications:

  • Audience segmentation is important. Kids and adults are different: e.g. ethnicity, socio-economic status, geographically (Southern U.S.), self-image;
  • Continuity and reinforcement are necessary (so budgets are important, as you already know);
  • Media campaigns seem to work best when connected to community activities;
  • Message sources are important and their effectiveness may differ by audience segment (e.g., experts, appropriate celebrities, people like me )
  • Great stories, authentic and well told, will often resonate with kids.

I have learned that we need to plan and work at two levels: at the macro environmental level (to change social norms and expectations) and at the level of individual behaviors (which requires direct, face –to-face communication. And we need to do this in synergy.

I talked earlier about the big, bad tobacco industry…the Evil Empire. Childhood obesity doesn’t have the same competition, and that can be good and bad, as I think about it.

Let’s look at what your competition seems to be in your efforts at reversing childhood obesity. There’s a book you may have seen called “The Weight of the Nation, subtitled, “To Win, We Have to Lose,” by John Hoffman and Dr. Judy Salerno, until recently with the Institute of Medicine and now CEO of the Susan G. Komen Foundation. I use this book in my MBA course at Georgetown on corporate social responsibility.

Hoffman and Salerno look at the competition against overweight and obesity control, and they focus on four areas. The appropriate chapters are titled: “Big Food Companies vs. Us,” “Supermarkets vs. Us,” “Marketing vs. Us,” and “Fashion and Beauty Industries vs. Us.” Here’s what they say:

  • The big food companies dominate the American landscape, with lots of lobbyists, lawyers and plenty of clout. Ditto the big food-related trade associations. They sell healthy and unhealthy foods, and their additives, labeling, taste engineering, serving sizes and marketing all contribute to obesity and overweight. Is Big Food like Big Tobacco? The authors quote Kelly Brownell, now at Duke University, who said the tobacco industry promised to clean up its act and didn’t. He asks, “are we going to make that same mistake with the food industry: Are we going to let them say they’re doing good things when they’re really not?”

Some of my students did a paper on McDonalds and public responsibility, and had this to say: “The fundamental question facing McDonalds is, how does a company whose products are inherently bad for consumers effectively incorporate corporate social responsibility into its core strategy and do so in a genuine and meaningful way? McDonalds much find a way to link health foods to core goals (financially and strategically) of the company in order to have a chance at sustainable change in the minds of their consumers.”

  • Regarding “Supermarkets vs. Us,” the authors claim that supermarkets are skillful at making consumers buy more and buy high profit, processed foods. Who is responsible, the supermarkets or us? Almost 60 % of supermarket purchases are unplanned. But of course many people – especially those in many inner cities — aren’t tempted, because they don’t even have access to supermarkets.
  • In the chapter on “Marketing vs. Us,“ the authors say that the food industry spends over $ 30 billion a year on advertising – traditional and digital media, and there is strong evidence that for children, marketing works to establish food preferences, increase requests for purchases and drive up at least short term consumption. They say kids see 15 TV commercials per day for food products. Again, who is responsible and what can be done? Schools accept companies’ promotional material and the industry beat back even voluntary guidelines.
  • And regarding the “Fashion and Beauty Industries vs. Us, they say that fashion pictures are altered to make models look impossibly attractive, which creates body image problems for many ordinary people. Manufacturers alter clothing sizes so people think they still war the same size even though they gained considerable weight. Who’s responsible and what can and should be done?

This is a different form of competition from Big Tobacco. I believe that the tobacco industry can’t and shouldn’t be trusted. They’ve proved that, time and time again. But food, soft drink, retail and fashion companies – at least in my view – aren’t Evil Empires, despite their records and involvement in the obesity problem. I believe that they need to be at the table and part of solving childhood obesity. This requires a different set of strategies from tobacco control.

I have one more point to offer in terms of lessons learned. Although no public health coalition or collaborative can do everything at once, I have come to believe we need to think about major social challenges like tobacco and obesity on a world stage. It is very difficult to create state by state or nation by nation change in today’s global media and global economy.

So although you have your hands full in the U.S., perhaps you might consider collaborating internationally, as Matt Myers and the Campaign for Tobacco-Free Kids has with tobacco control advocacy and the American Heart Association and others have in addressing non-communicable diseases. Social behaviors today don’t seem to have national boundaries.

That’s my set of lessons learned. I hope they are helpful. I have a favorite haiku that goes like this, “problems worthy of attack, prove their worth by attacking back.” Tobacco and obesity are two of those big, tough problems. But we can make a difference by being smart, by using evidence-based strategies, through dogged perseverance and by providing real leadership.

I wish you every success, and stand ready to help if I can. Thanks for inviting me to be with you today. And now let’s have a discussion.