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Global Tobacco Control

Joanna Cohen, PhD Director, Institute for Global Tobacco Control

Johns Hopkins University

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

Adverse Health Effects

Constituents of Tobacco Smoke

Surgeon General’s Reports on Smoking and Health

! “Smoking harms nearly every organ of the body”

! Statistically speaking, a lifetime smoker has what chance of dying from a smoking- related disease? a. 1 in 2 b. 1 in 5 c. 1 in 25 d. 1 in 100

Question

Answer

a. 1 in 2 ! Half of all long-term smokers will eventually be killed by tobacco, of these half will

die during the productive years of middle age, losing 20 to 25 years of life (Peto et al., 1994)

Health Effects Causally Linked to Smoking

Source: USDHHS. (2004, 2006, 2012). 7

Health Effects Causally Linked to Secondhand Smoke

Source: USDHHS. (2004, 2006, 2012). 8

Global Tobacco Epidemic

Global Cigarette Consumption Increased over 100 Times in One Century

Over Half of the World’s Smokers Live in Just Five Countries

! Percent of cigarette consumption

Rest of the world

42%

China 38%

China Cannot Be Ignored

Source: The Tobacco Atlas. (2015). 4

Cigarette Consumption by Region

Source: The Tobacco Atlas. (2015).

! Global cigarette consumption by WHO region: 1980–2013, in trillions

! The disproportionate increase in the number of cigarettes smoked in China is a combined effect of China’s population growth and an increase in smoking intensity. In 2013, an average smoker in China smoked 22 cigarettes a day, nearly 50% more than in 1980.

Cigarette Consumption (2014 or Latest Available)

Source: The Tobacco Atlas. (2015). 6

Male Smoking Prevalence (2013 or Latest Available)

Source: The Tobacco Atlas. (2015). 7

Female Smoking Prevalence (2013 or Latest Available)

Source: The Tobacco Atlas. (2015). 8

Male Deaths (% Due to Smoking, All Ages, 2010)

Source: The Tobacco Atlas. (2015). 9

Deaths, by Country Income

Source: The Tobacco Atlas. (2015).

! Proportion of global smoking-related deaths in high-, middle-, and low-income countries, all ages, 2010

! More than two thirds of tobacco deaths occur in low- and middle- income countries

! Tobacco killed 100 million people in the 20th century

! Tobacco use is the world’s single leading preventable cause of death ! Almost 6 million tobacco-caused deaths in 2011

! Tobacco kills up to half of lifetime smokers

! Smokers die an average of 14 years earlier than nonsmokers

! Without urgent action, 1 billion people will die from tobacco in the 21st century, exceeding 8 million deaths each year by 2030

Global Burden of Tobacco: Past, Present, and Future

11Source: The Tobacco Atlas. (2015).

! Tobacco killed 100 million people in the 20th century

! Tobacco use is the world’s single leading preventable cause of death ! Almost 6 million tobacco-caused deaths in 2011

! Tobacco kills up to half of lifetime smokers

! Smokers die an average of 14 years earlier than nonsmokers

! Without urgent action, 1 billion people will die from tobacco in the 21st century, exceeding 8 million deaths each year by 2030

! Every death from tobacco products is preventable!

Global Burden of Tobacco: Past, Present, and Future

12Source: The Tobacco Atlas. (2015).

Not a Funding Priority: Global Funding and Annual Deaths for Leading Causes of Death

Source: World Health Organization. (2007). 13

! We already do …

! Tobacco control

What If We Had an Intervention that Could Prevent 1 in 10 Deaths Worldwide?

! Please pause this presentation and watch the videos on the lecture home page ! John Oliver Exposes “Be Marlboro” ! Kids react to "Be Marlboro” ! Kids react to "Be Marlboro" (second video)

! Resume the presentation when you have finished watching the videos

Has the Tobacco Industry Stopped Aggressively Promoting Its Deadly Products?

Global Cigarette Market Share, 2008

Source: The Tobacco Atlas. (2015). 16

! $44.1B

! The 2013 profits of the top six tobacco companies are EQUIVALENT TO THE COMBINED PROFITS of The Coca-Cola Company, Walt Disney, General Mills, FedEx, AT&T, Google, McDonald’s and Starbucks in the same year

Tobacco Company Profits

Tobacco Industry Tactics: “Charitable” Giving

Source: The Tobacco Atlas. (2015). 18

Responses: Framework Convention on Tobacco Control

! A binding international legal instrument that establishes broad commitments and a general system of governance for an issue area (treaty)

! Specific measures designed to implement goals of the framework convention or further institutional commitments made through protocols ! Example: Framework Convention on Climate Change/Kyoto Protocol

What Is a Framework Convention?

“To protect present and future generations from the devastating health, social, environmental, and economic consequences of tobacco consumption and exposure to tobacco smoke … to reduce continually and substantially the prevalence of tobacco use and exposure to tobacco smoke.”

— FCTC Article 3

Framework Convention on Tobacco Control: Overall Objective

Source: World Health Organization. (2005); Image source: World Health Organization. (2005). 4

! First global public health treaty negotiated under the auspices of the World Health Organization

! First global response to chronic disease

! Adopted by WHA on May 21, 2003; entered into force on Feb 27, 2005

! 180 countries have ratified the treaty

Framework Convention on Tobacco Control

5Image source: World Health Organization. (2003).

! The tobacco epidemic has spread globally through many complex factors with cross- border effects, including trade liberalization and direct foreign investment

! Faced with increasing regulation and greater awareness of smoking health risks in many developed countries, tobacco multinationals are searching for more markets in developing countries

Why Have a Treaty?

! Introduction

! Objectives, guiding principles, and general obligations

! Measures related to the reduction of demand for tobacco

! Measures related to the reduction of supply for tobacco

! Protection of the environment

! Questions related to liability

! Scientific and technical cooperation and communication of information

FCTC Final Treaty Text

7Image source: World Health Organization. (2003).

FCTC Articles— Demand Reduction

! Article 6: Price and tax

! Article 8: Smoke-free public places

! Article 9: Contents of tobacco products

! Article 10: Tobacco product disclosures

! Article 11: Packaging and labelling

! Article 12: Education, training

! Article 13: Advertising, promotion and sponsorship

! Article 14: Smoking cessation

! Article 15: Illicit trade

! Article 16: Sales to and by minors

! Article 17: Support for alternative livelihoods

! Article 5.3: Avoiding tobacco industry interference

FCTC Articles—Supply Reduction

Tobacco Industry Tactics: Signatories and Parties to WHO FCTC

Source: The Tobacco Atlas. (2015). 10

! Conference of the Parties (COP) to the WHO Framework Convention on Tobacco Control ! Governing body of the WHO FCTC, comprised of all Parties to the Convention;

regularly reviews the implementation of the Convention; may also adopt protocols, annexes, and amendments to the Convention

! Intergovernmental Negotiating Body (INB) ! Draft and negotiate the proposed Framework Convention and possible related

protocols

! Convention Secretariat ! Supports Parties in fulfilling their obligations under the Convention, providing the

necessary support to the COP and translating the decisions of the COP into program activities

FCTC Implementation Process

! WHO Report on the Global Tobacco Epidemic

! Conference of Parties (COP) Report

! Framework Convention Alliance (FCA) Monitor

! Country reports

Monitoring FCTC/MPOWER Implementation

Responses: MPOWER

! MPOWER reflects and builds on the WHO Framework Convention on Tobacco Control

! The six policies of WHO MPOWER package summarize strategies to reduce tobacco use. Builds upon 30 years of experience from U.S. and other countries. (NCI Monograph 1,16,17) ! Link to National Cancer Institute Web site is

available on lecture home page in CoursePlus

MPOWER: A Policy Package for Global Tobacco Control

! Monitor tobacco use and prevention policies

! Protect people from tobacco smoke

! Offer help to quit tobacco use

! Warn about the dangers of tobacco

! Enforce bans on tobacco advertising, promotion, and sponsorship

! Raise taxes on tobacco

mPower

Source: WHO Report on the Global Tobacco Epidemic, 2008: Link available on lecture CoursePlus site. 3

! Accurate monitoring is essential

! Need precise national and global data on tobacco use

! Should measure effectiveness of tobacco control policies

! Strong monitoring should be: ! Recent or ! Representative data for both adults and youths ! Survey every five years

Monitor Tobacco Use and Prevention Policies

! Global Tobacco Surveillance System (GTSS) ! Global Youth Tobacco Survey ! Global School Personnel Survey ! Global Health Professions Student Survey ! Global Adult Tobacco Survey

Monitoring Tobacco Use—GTSS (WHO and CDC)

5Image source: GTSS Atlas. (2009).

! National and subnational estimates of: ! Tobacco use ! Exposure to secondhand smoke ! Quit attempts ! Impact of tobacco control and prevention initiatives

! Intended to enhance the capacity of countries to design, implement, and evaluate tobacco control and prevention programs

! Face-to-face household survey of men and women age 15 years and older using standard protocols

! Funding provided by the Bloomberg Philanthropies

The Global Adult Tobacco Survey

! No safe level of secondhand smoke

! Smoke-free environments protect nonsmokers’ health, help smokers quit, and encourage smoke-free homes

! Completely smoke-free indoor areas with no exceptions

! Smoke-free laws very popular and do not harm business

Protect People from Tobacco Smoke

Smoke-Free Legislation

Smoke-Free Environments—Highest Achieving Countries, Territories and Areas, 2014

Source: The Tobacco Atlas. (2012). 9

Offer Help to Quit Tobacco Use

! Nicotine is highly addictive

! Many want to quit, but can’t

! Health care system has primary responsibility to treat tobacco dependence

! Even brief cessation support increases quitting, including physician advice, quitlines and self-help materials

! Nicotine replacement therapy can double quit rates

Tobacco Dependence Treatment

Tobacco Dependence Treatment—Highest Achieving Countries, 2014

Warn about the Dangers of Tobacco

! Most people are unaware of full range of health risks from tobacco use, secondhand smoke exposure

! Anti-tobacco ads help change image of smoking

! Pack warnings are effective, especially with pictures and covering half of pack

! Impact of pack warnings in Brazil

! An example of plain cigarette packaging; the brand information is in a standard font, and the health warning dominates

Plain Packaging Law Went into Effect in Australia in December, 2012

Warning Labels

!2008

! *Percent of principal display area of cigarette package legally mandated to be covered by health warning

Health Warning Labels about the Dangers of Tobacco—Highest Achieving Countries, 2014

Source: The Tobacco Atlas, 3rd Edition. (2008). 16

Graphic Packet Warning Labels

Label Characteristics

Biggest Warnings

Mass Media Campaigns

Anti-Tobacco Mass Media Campaigns—Highest Achieving Countries, 2014

Enforce Bans on Tobacco Advertising, Promotion, and Sponsorship

! Tens of billions of dollars spent each year to promote tobacco

! Advertising increases sales, illness, and death

! Bans effective only if comprehensive

! Comprehensive advertising bans amplify effects of other interventions

Bans on Tobacco Advertising, Promotion, and Sponsorship

Source: The Tobacco Atlas, 3rd Edition. (2008). 23

Taps Bans, Number of Countries Legislating Each Characteristic

Enforce Bans on Tobacco Advertising, Promotion, and Sponsorship—Highest Achieving Countries, 2014

Raise Taxes on Tobacco

! Increasing tobacco taxes is best way to cut consumption ! Especially among young and poor

! Tobacco taxes generally well accepted

! Higher tobacco taxes reduce consumption

! Tax rates vs. consumption, South Africa

Total Tax on Cigarettes

!Tobacco Atlas, 2012, www.tobaccoatlas.org

Cigarettes Have Become Less Affordable in High- and Middle-Income Countries But More Affordable in Low-Income Countries, 2008–2014

Global Picture

The State of Selected Tobacco Control Policies in the World, 2014

! Nearly 2.8 billion people or 40% of the world’s population are covered by at least one MPOWER demand reduction measure at the highest level of achievement

Share of the World Population Covered by Selected Tobacco Control Policies, 2014

. 3

National Tobacco Control Programs

Tobacco Control Is Underfunded

! Governments collect nearly US$269 billion in tobacco excise tax revenues each year, but spend only around US$1 billion combined on tobacco control—with 91% of this spent in high-income countries

Question ! What was/is the role of international cooperation in initiating, supporting, and funding tobacco control efforts across the globe?

! Capacity

! Coordination

! Implementation

! Surveillance: adherence to letter and spirit of requirements

! Priorities of funders

Challenges

Summary ! Smoking causes damage to nearly every organ of the body

! There is no safe level of secondhand smoke exposure

Summary ! The tobacco epidemic will cause the most harm to low- and moderate-income countries with high population

! Tobacco use is growing fastest in these countries, fueled by steady population growth

! The tobacco industry is expanding its advertising, marketing, and promotion to these countries

! Many of these countries have fewer resources to respond to the health, social, and economic problems caused by tobacco use, which will exacerbate the tobacco epidemic’s impacts

! This will create a ‘perfect storm’ of future tobacco- caused disease and death, unless there is a strong response

Summary ! Internationally, tobacco control policy initiatives have been broadly accepted

! Effective policies to curb tobacco use exist

! Need political will and advocacy to implement effective strategies

! Evidence-based policy interventions—the MPOWER package— have been codified

! Challenges to implementation include: ! Global underfunding of tobacco control ! Regional, country-to-country, and within country

variability in policies and enforcement ! Ongoing industry marketing and influence

Thank You!