23179 Tobacco Control Why is Reducing Use of Tobacco a Priority? Tobacco use is one of the single biggest causes of death worldwide. It kills more than 5 million people per year – more than TB, AIDS and malaria combined (source: WHO 2008), and deaths are rising. Many deaths and much disease could be prevented by reducing smoking prevalence. The epidemic increasingly affects developing countries, where most of the world’s smokers (84% or 1 billion) live. By 2025, developing countries will account for 80% of all tobacco deaths. Close to half of all men in low-income countries smoke daily and this has been increasing. Women’s smoking rates are also increasing fast. Smoking and poverty. Smoking prevalence tends to be higher among men with less education and lower incomes, so they bear a greater risk of associated illness, lost work time, and premature death. Illness, health care costs, and death of breadwinners are among the gravest concerns of poor people, and often a precipitating cause of their poverty. Money spent on tobacco products diverts scarce resources from food and other necessities. Tobacco can be a significant part of family expenditure: nearly 11% among the poorest 20% of households in Mexico, and 15% of the total expenditure of Indonesia’s lowest income group. The poorest households in Bangladesh spend nearly ten times as much on tobacco as on education (WHO, 2008). The harm from second-hand smoke (SHS) on others further justifies intervening to reduce tobacco use. There is no safe level of exposure to second-hand smoke (SHS), especially for unborn and young children. SHS contributes to a range of diseases, increasing the risk of coronary heart disease by 25-30% and the risk of lung cancer in non-smokers by 20-30% (US HHS Department, 2006). Nicotine is highly addictive, so it is important to discourage smoking initiation, especially among young people. Because many of the expected deaths from tobacco use will be among the 1.3 billion people who now smoke, persuading and helping people to quit is key to reducing disease and death from tobacco use. The Framework Convention on Tobacco Control (FCTC) The FCTC, negotiated under the auspices of WHO, is one of the most widely embraced treaties in UN history. It entered into force in February 2005, with 171 contracting parties by October 2010. It establishes tobacco control as a public health priority, and provides a mechanism for firm country commitment and accountability. Countries that ratify the FCTC undertake to: eliminate all tobacco advertising, promotion and sponsorship within 5 years (with a narrow exception for nations whose constitutions prohibit a complete ban); require health warning labels occupying at least 30% of the area of cigarette packs; prohibit misleading tobacco product descriptors such as “light” and “mild”; and protect nonsmokers from tobacco smoke in public places. The FCTC also urges strict regulation of tobacco product contents; higher tobacco taxes, global coordination to fight tobacco smuggling, and promotion of tobacco prevention, cessation and research programs. It also includes measures to combat illicit trade in cigarettes, and to support economically viable alternatives to tobacco growing. National tobacco control efforts are usually led by the Ministry of Health, association of physicians and other health groups, or dedicated anti-smoking groups. NGOs, women’s groups, youth groups, lawyers, economists and environmentalists play key roles in some countries. Ministries of Finance, Economic Planning and Taxation are important, because higher tobacco taxes are the single most effective way to reduce use. Other stakeholders include: Ministries of Agriculture and farmers, Ministries of Labor and Industry, employee groups, Ministries of Education, media, retailers, sports groups (sponsorship). February 2011 Cost Effective Interventions to reduce death and disease caused by tobacco use Measures to reduce demand for tobacco products are highly cost effective – very high on the list of public health “best buys” Objective: Reduce tobacco use, to reduce the death and disease it causes. Interventions Higher taxes on cigarettes and other smokers  price of cigarettes/bidis etc (adjust tobacco products for inflation) potential smokers  cost of 100 packs relative to GDP (especially youth) (affordability)  tax as % of final sales price Non-price measures Bans on smoking in public and work non-smokers  smoke-free public spaces and places: schools, health facilities, public protected from places transport, restaurants, cinemas etc. second-hand smoke Comprehensive bans on advertising and smokers and  laws, regulations, extent to which promotion of all tobacco products, logos potential smokers respected/enforced and brand names (especially youth) societal attitudes to smoking Better consumer information: counter- smokers and  knowledge of health risks, attitudes advertising, media coverage, research potential smokers to smoking findings societal attitudes to smoking Large, direct warning labels on cigarette smokers  % of box surface covered by label, boxes and other tobacco products message, color/font specifications, pictures/pictograms Help for smokers who wish to quit, smokers  number of ex-smokers including increased access to Nicotine Replacement (NRT) and other cessation therapies Impact / surveillance Indicators for tobacco use (from survey data): adult smoking prevalence: % of people 15 and older who use any tobacco product at least once a day (daily/regular smoker) or occasionally, % who have ever smoked intensity: average number of cigarettes (and other tobacco products) smoked/used daily quit behavior: % who used to smoke, but currently do not smoke at all youth use: % of young people who currently use any tobacco product (defined as having used a tobacco product on one or more days during the past 30 days), initiation age: age at which current and ex-smokers first started to smoke at least one cigarette a day Note: Click here for standard definitions for prevalence surveys from WHO The CDC’s Global Surveillance Surveys have collected data in many countries with support from WHO and February 2011 the Canadian Public Health Association (CPHA). See: http://www.cdc.gov/tobacco/global/gtss/ (CDC website) The Evidence Shows (useful information)  The best results are achieved when a comprehensive set of measures to reduce tobacco use are implemented together. Many countries have succeeded in reducing smoking prevalence dramatically, and consequently reduced cancers, strokes, heart disease and other circulatory diseases, respiratory diseases, and low birth weight incidence.  Price increases are the most effective and cost-effective deterrent – especially for young people and others with low incomes, who must, of necessity, be highly price responsive. A price rise of 10% will decrease consumption by as much as 8% in low- and middle-income countries. Higher taxes generate additional government revenue.  In almost all countries, as people switch expenditures from tobacco to other goods, there will not be net job losses. As demand for tobacco products falls, jobs lost in tobacco farming, manufacturing and distribution, are offset by new jobs created in other sectors in response to changed expenditure patterns. Some countries (Malawi and Zimbabwe) and areas within other countries whose economies depend heavily on tobacco may need help in adjusting to new consumption patterns.  Global demand for tobacco continues to rise; the effects of tobacco control measures are offset by growing population numbers, rising incomes, social norms, addiction, and tobacco product advertising and promotion.  Most measures to reduce supply are ineffective (prohibition, youth access restrictions, crop substitution efforts and trade restrictions). Control of illicit production and trade in tobacco products is the exception, and is the key supply-side measure to pursue. Several countries have effectively reduced illicit cigarette production and trade using modern techniques of tracking and tracing.  Will poor smokers be hurt by tobacco product price increases? Data show that people with lower incomes are more responsive to price increases (WHO 2010).Those who quit or smoke less gain health and income. People who do not reduce or quit smoking in the face of price increases will pay more. If this is an important issue,) targeted cessation programs might be considered.  Many smokers want to quit, and could use help. Most people who quit do so without help, but nicotine addiction makes quitting hard. Quit rates can be substantially increased through advice from health care providers, telephone “quit-lines”, formal and informal support-groups, and cessation therapies including nicotine-replacement (NRT). Over-the-counter (non-prescription) sales improve access to NRT. There are many potential opportunities for cessation advice and support: e.g. as part of TB treatment.  What works for youth? Youth tobacco use typically reflects trends in the population as a whole, so population-wide approaches can have a large impact on youth tobacco use. Society’s attitudes to tobacco use influence young people's behavior. Where tobacco use is normalized, visible, and socially accepted, youth tobacco use is higher. The most effective tool to reduce/deter use of tobacco products by young people: price increases. Bans on tobacco product sales to young people are difficult and costly to enforce, and miss the many other sources from which youth get cigarettes. Youth tobacco education programs in schools, while politically popular, have not demonstrated much impact in reducing use. Focusing anti-tobacco educational initiatives on children could weaken a more comprehensive population-wide approach that could have greater long-term impact.  Information on the adverse health impact of tobacco use and the benefits of quitting should be widely disseminated. Health warnings on cigarette packs should be large (cover at least 30% of the surface area and preferably 50% or more), clearly visible, in local languages, and have a set of specific required messages that change periodically. FCTC (Article 11) requires warnings on all tobacco products. Article 11 guidelines recommend best practices, including pictorial warnings, required by 38 countries as of 2010. Graphic images -particularly those that elicit a strong emotional response- make February 2011 health warnings more effective in motivating behavior change. Key resources  “Curbing the Epidemic: Governments and the Economics of Tobacco Control ”, World Bank, 1999. Development in Practice Series. On line at: http://worldbank.org/tobacco, (various languages)  WHO Framework Convention on Tobacco Control. Geneva, 2003 http://www.who.int/fctc/text_download/en/index.html  WHO Report on the Global Tobacco Epidemic, Geneva, World Health Organization. The MPOWER package 2008 and Implementing smoke-free environments 2009  At a glance fact-sheets: (1) strong reasons and how to make workplaces smoke-free (2) Tobacco pack information (3) Quitlines, on-line at www.worldbank.org/phataglance and www.worldbank.org/tobacco  “How to” toolkit for analysis of economic issues : Explains in detail how to analyze tobacco price/consumption relationship, tax rates and revenues, options for setting and administering tobacco taxes, smuggling, employment, and impact on the poor. Describes data needs and sources, analytic model specification, and interpretation of estimation results. www://worldbank.org/tobacco > Tools  WHO Technical Manual on Tobacco Tax Administration. Geneva, World Health Organization, 2010  http://worldbank.org/tobacco, and http://www.who.int/tobacco/en/ Other references  Behan DF et al. Economic effects of environmental tobacco smoke. Schaumburg, IL, Society of Actuaries, 2005 http://www.soa.org/research/life/researcheconomic-effect.aspx.  Cains T et al. Designated “no smoking” areas provide from partial to no protection from environmental tobacco smoke. Tobacco Control, 2004, 13:17–22.  “Tobacco Control in Developing Countries”, Jha and Chaloupka (editors), OUP for the World Bank and WHO, 2000. Detailed background papers for “Curbing the Epidemic” .  U. S Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Atlanta. US Department of Health and Human Services, Center for Disease Control and Prevention. 2006 February 2011