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Apr 3, 2012 ... Poor Diet.  Limited access to healthy foods in poor communities .... 183 smoke- free recreation centers, playgrounds, and pools, affecting over ...
Center for Health Behavior Research University of Pennsylvania April 3, 2012

Unhealthy advertising in Philadelphia  Counting ads in a 4-month period in Austin, Los Angeles, and Philadelphia

Hillier, Health & Place, 2009

Key determinants of smoking  Climate  Normative behavior (up to 4 in 10 adults in some neighborhoods)  Aggressive marketing in poor communities  Access  High density of tobacco retailers, particularly near schools  High rate of illegal sales to youth

 Relatively low cigarette prices in Philadelphia

 Cessation resources  Most smokers try to quit on their own  Inadequate coverage for and use of quit aids  Limited availability and use of cessation counseling

Key determinants of obesity  Poor Diet  Limited access to healthy foods in poor communities  Easy availability and aggressive marketing of unhealthy foods  Higher relative price of healthy foods  Lack of Physical Activity Opportunities  Auto-based planning

 Disrepair and lack of safety in neighborhoods  Dramatic increase in indoor, screen-based activities

Overweight and Obesity in Philadelphia Overweight and Obesity Among Philadelphia Adults (18+) and Children (6-17), 2000 - 2010

70.0% 60.0%

62.3%

64.6%

64.3%

66.3%

60.3%

60.0%

50.0%

Adult overweight-obesity 46.9%

46.4% Percent

40.0% 39.6%

42.0%

39.6%

40.7%

30.0% Child overweight-obesity (6-17 years) 20.0%

10.0%

0.0% 2000

2002

2004

PHMC Household Health Survey, 2000-2010

2006

2008

2010

Diabetes and hypertension in Philadelphia Diabetes among Philadelphia Adults 14.0

13.0

Hypertension among Philadelphia Adults 13.3

38.0

12.0 12.0

36.0

10.9

P e r c e n t

35.8

2008

2010

34.0

10.2 10.0

35.7

34.0

32.7

9.4 P e r c e n t

8.0 6.0 4.0

32.0

31.3 29.6

30.0 28.0 26.0 24.0

2.0

22.0

0.0

20.0 2000

2002

2004

2006

2008

2010

PHMC Household Health Survey, 2000-2010

2000

2002

2004

2006

Smoking prevalence for 10 largest U.S. cities 25% 20% 20% 18% 17%

17%

16%

15%

14%

12%

Behavioral Risk Factor Surveillance Survey and local data sources, 2007

Philadelphia Chicago Phoenix San Antonio NYC Houston Dallas San Diego LA San Jose

Health and economic costs in Philadelphia Tobacco use

Poor Diet and Physical Inactivity

2,400 deaths per year

~2,000 deaths per year

$700 million in productivity losses annually

~$750 million in health care costs annually

Philadelphia Vital Statistics Reports, Philadelphia Department of Public Health Obesity health care costs estimated from Finkelstein et al, Health Affairs, 2009

How can we make it easier for Philadelphians to engage in healthy behaviors?

Health Impact Pyramid Examples Smallest Impact

Counseling & Education

Clinical Interventions

Long-lasting Protective Interventions Changing the Context Largest Impact

to make individuals’ default decisions healthy

Socioeconomic Factors Frieden T, AJPH 2009

Eat healthy, be physically active Rx for high blood pressure, high cholesterol, diabetes

Immunizations, brief intervention, cessation treatment, colonoscopy Fluoridation, 0g trans fat, iodization, smokefree laws, tobacco tax

Poverty, education, housing, inequality

How can we make it easier for Philadelphians to engage in healthy behaviors? Media Educational institutions

Built environment

Workplaces

Community retail environment and restaurants Legislation and regulation Insurers and health care providers

Schools – School Wellness Councils School Wellness Council Interventions, (November 2011) 140 Healthy classroom rewards 120 Healthy fundraisers 100

Socialized Recess 80

60

Classroom movement breaks

128 102

40

20

Healthy school stores

83 42 3

0

Philadelphia Department of Public Health, School District of Philadelphia

Afterschool programs – food and fitness policies • Food and fitness standards developed for over 207 afterschool programs, serving 20,000 low-income children • Structured physical activity opportunities in 94 recreation center afterschool programs • Healthier, more complete meals in 50+ recreation center afterschool programs

Built environment – smoke-free rec centers, playgrounds, pools • 183 smoke-free recreation centers, playgrounds, and pools, affecting over 2 million annual visits • 850 new smoke-free acres!

Built environment – safer walking and biking • 2 new north-south bike lanes and an education & enforcement campaign for an area with a day-time population of 250,000 • Over 28,000 2nd and 5th graders provided pedestrian and bicycle safety lessons

Built environment – planning and zoning • Encouraging the incorporation of fresh food markets into commercial and mixed-use developments by offering density bonuses that don’t count the square footage of those markets against the maximum buildable area (14-603(7)) • Requiring the provision of secure bicycle parking in developments above a certain size, and allowing the removal of 1 automobile space in exchange for the provision of 5 bicycle parking spaces (14-804)

Retail – preventing youth tobacco sales & use • Penalties raised for merchants that sell tobacco to minors • Over 2,000 tobacco merchants educated about youth sales prevention

• New tobacco retailer permitting requirement • The public can report retailers by calling 1-888-99-SMOKE or online

Retail – Philly Food Bucks & Healthy corner stores • 10 new farmers’ markets in low-income neighborhoods • $2 of free fruits and vegetables for every $5 of SNAP benefits • 435% increase in SNAP redemption at farmers’ markets

• Over 600 corner stores selling healthier products, impacting 750,0000 Philadelphians • 83 mini conversions completed • On average, each store introduced 20+ new products as a result of a conversion

Healthy corner stores

• • •

635 enrolled 423 with at least 4 new products 83 with mini-conversions

Workplaces – promoting and supporting quit attempts • City of Philadelphia • Expanded insurance coverage to include 6 of 7 FDA approved smoking cessation medications, affecting 7,000 employees and dependents

Workplaces – healthy vending • City of Philadelphia • Over 260 vending machines undergoing changes—healthier mix, smaller sizes, calorie labeling, and healthy marketing—affecting 25,000 employees

Workplaces – healthy vending Employers that have developed or implemented healthy beverage vending standards, June 2011

HUP

31,000

City of Philadelphia

25,000

Einstein

Total Employees Impacted: 69,114

7,200

PA Hospital

2,700

Horizon House

1,115

KPMG

857

Fox Rothschild

497

SRSY

445

Congreso

300 0

5,000

10,000

15,000

20,000

Number of Employees Impacted

25,000

30,000

35,000

Insurers and health care providers – promoting and supporting quit attempts •

4 of the 5 Medicaid Managed Care Organizations in Philadelphia agreed to provide coverage for 5 (or more) of the 7 FDA-approved smoking cessation medications, expanding access for approximately 80,000 lowincome Philadelphia smokers



More than tripling of Quitline use and NRT for 10,000 Philadelphians Callers to 1-800-QUIT-NOW for Philadelphia County Counseling only

Counseling + NRT

4000 3500 3000

2500 2000

NRT Giveaway

1500

NRT Giveaway

1000 500 0 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2010

2011

2012

Media campaigns  Do you know what your kids are drinking?  Raising awareness about the negative health effects of sugary drinks and encouraging people to cut back

 ~24 million impressions

 Quit with help. Quit for good.  Motivating smokers to quit with assistance, like counseling or medications.

 ~50 million impressions

“Time for a Change” (TV)

“Last Pack” (TV)

Buses and subway

Buses and subway

Media Recall of Get Healthy Philly Media Campaigns, 2010 - 2012

80% 70% 60%

Percent

50%

Tobacco

40%

Sugary Drinks

30%

20% 10% 0% 1

2

3

4

5

6

7

Month

8

9

10

11

12

13

14

15

The Annenberg Public Policy Center and School of Communications, University of Pennsylvania

Media – Do you know what your kids are drinking?

Amount of sugar

High

Low

Jordan et al, Annenberg Public Policy Center

Media – Do you know what your kids are drinking?

Intention

High

Low

Jordan et al, Annenberg Public Policy Center

Media – Quit with help. Quit for good. No recall

< 4x wk recall

≥ 4x wk recall

100%

Percent

80%

60%

40%

20%

0% Talked about the ad

Sought info on quitting Hornik et al, Annenberg School of Communications

Media – Quit with help. Quit for good. No Recall

< 4x Wk Recall

>=4x Wk Recall

100%

T2 Quit

Percent intending to quit

90% 80% 70% 60% 50% 40% 30% 20% 10% 0% No T1 Quit

Yes T1 Quit Hornik et al, Annenberg School of Communications

Legislation and regulation • On 12/23/10, Mayor Nutter signed Bill No. 100634 into law, increasing penalties from $100 to $250 for illegal sales of tobacco products to youth • Passed 15 – 0 by City Council • On May 23, 2011, Mayor Nutter signed an executive order making all recreation centers, playgrounds, and pools 100% smoke-free • In June 2011, City Council passed an ordinance that will require all tobacco retailers to obtain a permit from the Department of Public Health

Menu labeling and exemption from federal preemption  Philadelphia adopted its menu labeling ordinance (080167-A) on November 19, 2008.

 The menu labeling requirements became effective January 1, 2010. Menu boards

Menus

Calories must be displayed directly on the menu board next to each food or beverage item.

Calories, sodium, saturated fat, trans fat, and carbohydrates must be displayed directly on the menu next to each food or beverage item.

Additional nutrition information must be available upon request.

What’s the Problem with Sodium?

What’s the Problem with Sodium? Average sodium in items served at Philadelphia sit-down restaurants, 2011 912

Kid's meals

1114

Senior meals

1759

Other entrees

1930

Appetizers

2213

Burgers and sandwiches 0

500

1000 1500 Milligrams of sodium

2000

2500

Drexel University School of Public Health, Philadelphia Department of Public Health

New initiatives  Point of purchase warnings

 Smoke-free spaces  Housing, parks

 Salt reduction  Take-out Chinese restaurants  Media campaign

 Healthy food procurement  Schools, afterschools  City agencies

 Healthy supermarkets  Value-based insurance design

Questions?