1.  2011 Johns Hopkins Bloomberg School of Public Health Special Populations: Update Stephen A. Tamplin, MSE Department of Health, Behavior and Society Institute for Global Tobacco Control

2.  2011 Johns Hopkins Bloomberg School of Public Health Objective To highlight new or recent developments related to tobacco control in “special populations”  Tobacco and poverty  Tobacco and youth  Women and tobacco  The role of nurses in tobacco control 2

3.  2011 Johns Hopkins Bloomberg School of Public Health Messages from Previous Lectures—Tobacco and Poverty 84% of smokers live in developing and transitional economy countries The poor smoke the most and bear most of the economic and disease burden of tobacco use Smoking prevalence among men is higher in low- and middle-income countries (about 50%) Tobacco contributes to poverty at the individual and household levels:  Opportunity cost  Lost earnings due to higher risk of illness  Risks of tobacco farming 3

4.  2011 Johns Hopkins Bloomberg School of Public Health Messages from Previous Lectures—Tobacco and Poverty Tobacco contributes to poverty at the national level:  High health care costs  Lost productivity  Loss of foreign exchange  Smuggling  Environmental degradation Breaking the tobacco-poverty relationship requires consideration of:  The local context  Relationships and partnerships  Local champions  The need to situate interventions in the social development climate  Timing 4

5.  2011 Johns Hopkins Bloomberg School of Public Health New Knowledge Regarding Tobacco and Poverty Meta-analysis involved the review of 9,500 references, of which 765 were included Overall objective was to assess the association between income level and tobacco consumption, tobacco expenditures and morbidity, and mortality attributed to tobacco Compared high-income groups with low-income groups on four factors:  Prevalence of tobacco use  Quantity of tobacco consumed  Incidence of disease and death attributed to tobacco  Household expenditures on tobacco 5 Source: Ciapponi, A. (2011).

6.  2011 Johns Hopkins Bloomberg School of Public Health New Knowledge Regarding Tobacco and Poverty The major conclusion: there is an inverse relationship between income level and tobacco use prevalence (particularly in the last two decades) and its related consequences  Smoking prevalence: low-income people (both genders) smoke more than high-income people  Tobacco-attributable deaths and diseases: “… statistically significant higher risk at decreasing income strata.”  Tobacco spending related to total expenditures: “… an inverse relationship … between income level and the proportion of tobacco spending related to total expenditures.” 6 Source: Ciapponi, A. (2011).

7.  2011 Johns Hopkins Bloomberg School of Public Health New Knowledge Regarding Tobacco and Poverty Causes for disparity are “… still under discussion …” but several factors are alluded to:  Relative deprivation inside societies  Tobacco as a marker of social status  Tobacco price structures Greater efforts to reduce tobacco use among the poor are needed The association between tobacco and poverty should be repeatedly assessed as implementation of the WHO’s FCTC is likely to modify the current situation 7 Source: Ciapponi, A. (2011).

8.  2011 Johns Hopkins Bloomberg School of Public Health Messages from Previous Lectures—Tobacco and Youth The majority of all long-term tobacco users start as youth  Nearly one-fourth have their first cigarette before age 10 There is no single image of youth tobacco use “Tobacco is a communicated disease … through advertising and sponsorship ….” (WHO, 2000) The tobacco industry targets youth by selling “coolness,” “independence,” and “lifestyle” 8

9.  2011 Johns Hopkins Bloomberg School of Public Health Messages from Previous Lectures—Tobacco and Youth We know how to reduce youth tobacco use:  Smoke-free laws  Increasing taxes and retail prices  Strong sustained public education campaigns  Powerful graphic health warnings  Curtailing tobacco marketing  Expanding access to cessation  Involving the community and health care professionals 9

10.  2011 Johns Hopkins Bloomberg School of Public Health New Knowledge Regarding Tobacco and Youth The Global Tobacco Surveillance System Atlas (2009), Global Youth Tobacco Survey (GYTS), 1999-2008  12% of boys and nearly 7% of girls currently smoke cigarettes  Susceptibility to initiate cigarette smoking is higher than current smoking rates in most regions  19% said they were susceptible to start smoking within the next year  12% of boys and 8% of girls use other tobacco (e.g., pipes, water pipes, cigars, smokeless tobacco, and bidis) besides cigarettes  In relation to boys, 8 of 165 countries surveyed reported a prevalence ≥ 30%  In relation to girls, 6 of the surveyed countries reported a prevalence ≥ 30% 10 Source: U.S. Centers for Disease Control and Prevention. GYTS Data. (2008).

11.  2011 Johns Hopkins Bloomberg School of Public Health New Knowledge Regarding Tobacco and Youth The Global Tobacco Surveillance System Atlas (2009), Global Youth Tobacco Survey (GYTS), 1999-2008 (surveys of students aged 13-15 years):  55% of the students surveyed reported exposure to secondhand smoke in public places during the previous week  Fewer than 5% of people are protected by comprehensive smoke-free laws  4 in 10 youth were exposed to secondhand smoke in their homes with 43% having at least one smoking parent  8 in 10 students favor a ban on smoking in public places and 69% of current youth smokers would like to quit 11 Source: U.S. Centers for Disease Control and Prevention. GYTS Data. (2008).

12.  2011 Johns Hopkins Bloomberg School of Public Health Messages from Previous Lectures—Women and Tobacco 12% of women smoke (22% in high-income countries; 9% in low- and middle-income countries)  By 2025, about 20% of women will smoke Smoking has negative effects on nearly every system of a woman’s body Tobacco farming and processing exploit the labor of women and girls The tobacco industry targets women by selling “coolness,” “independence,” “sex appeal,” and “lifestyle” 12

13.  2011 Johns Hopkins Bloomberg School of Public Health Messages from Previous Lectures—Women and Tobacco 13 Policy recommendations Ratify and implement the FCTC Design empowering messages and ads for improving women’s health Promote tobacco control policies that address social and economic issues Monitor women’s and men’s tobacco use rates Conduct further research on the health effects of tobacco use on women Build capacity and engage women and girls in conducting tobacco control research Program recommendations Implement gender- and age- specific tobacco control programs Provide information on occupational health and safety for women and girls Engage women in designing and delivering programs

14.  2011 Johns Hopkins Bloomberg School of Public Health New Knowledge Regarding Women and Tobacco Women comprise about 20% of the world’s 1+ billion smokers In half the countries surveyed by the Global Youth Tobacco Survey, there is no difference in rates of youth smoking based on gender Smoking is responsible for 12% of male deaths and 6% of female deaths in the world In a recent retrospective study (Oberg, M. et. al., 2011) of the world burden of disease from exposure to secondhand smoke, the authors concluded that women comprised almost 50% of the deaths attributable to secondhand smoke in 2004 14 Source: U.S. Centers for Disease Control and Prevention. GYTS Data. (2008); Oberg et. al., (2011).

15.  2011 Johns Hopkins Bloomberg School of Public Health New Knowledge Regarding Women and Tobacco Tobacco advertising increasingly targets women and girls:  Glamour  Sophistication and style  Luxury  Class and quality  Romance and sex  Sociability  Enjoyment and success  Health and freshness  Emancipation  Being slim 15

16.  2011 Johns Hopkins Bloomberg School of Public Health Specialty Packs Aimed at Women Specialty packs and formulations (“light,” “slim,” and “super- slim”) target the female market  For example, about 100 special women’s brands have been introduced to the Russian market where the prevalence of smoking among women is increasing rapidly 16

17.  2011 Johns Hopkins Bloomberg School of Public Health Specialty Packs Aimed at Women 17 Source: Institute for Global Tobacco Control. (2011).

18.  2011 Johns Hopkins Bloomberg School of Public Health New Knowledge Regarding Women and Tobacco While policy design may be gender-neutral, the policies may affect women and men very differently  It is important that the WHO FCTC be implemented through a gender perspective as part of a country’s political and development agenda:  Monitor tobacco use by gender  Protect girls and women of all ages from tobacco smoke  Offer help to assist women in quitting tobacco use  Warn women and girls about the dangers of tobacco  Enforce bans on tobacco advertising, promotion, and sponsorship by empowering women to identify and counter these influences  Raise taxes on tobacco, with the active participation of women leaders 18

19.  2011 Johns Hopkins Bloomberg School of Public Health Messages from Previous Lectures—The Role of Nurses Over 11 million nurses in the world have the power to make a huge difference Nurses enjoy public trust and can be pivotal partners Barriers to nursing involvement in tobacco control:  Smoking status of nurses themselves  Limited tobacco control content in nursing school education  Not traditionally a part of nursing practice  Lack of knowledge and fear of causing patient/visitor stress  Lack of professional leadership 19

20.  2011 Johns Hopkins Bloomberg School of Public Health Messages from Previous Lectures—The Role of Nurses Opportunities for involvement in tobacco control:  Nurses need to move beyond bedside care to influence the policy making process  Become advocates and get involved—World No Tobacco Day, supporting smoke-free public places, etc.  Integrate tobacco control interventions into current practice  Implement curriculum changes in nursing schools  Create workplace committees to enhance awareness  Include “smoking status” as a vital sign on patient records  Support improving the quality of cessation treatment 20

21.  2011 Johns Hopkins Bloomberg School of Public Health New Knowledge Regarding the Role of Nurses There are now over 17 million nurses worldwide Research indicates that tobacco cessation activities can be effectively provided by nurses (Rice and Stead, 2008) Continuous declines in smoking rates among nurses have been documented in countries where regular data has been recorded over time (e.g., the United States, New Zealand, and Australia) However, research conducted among nursing students in some countries has found contemporary tobacco usage rates higher than that of the general population (Smith and Takahashi, 2008) 21

22.  2011 Johns Hopkins Bloomberg School of Public Health 22 New Knowledge Regarding the Role of Nurses Challenges (Smith, 2010):  The rate of smoking among nurses remains unacceptably high in some countries  Strategic directions for tobacco control in nursing are needed  The provision of educational programs in the workplace and the addition of tobacco control programs to the nursing education curricula  Further research is needed to determine the most effective educational strategies

23.  2011 Johns Hopkins Bloomberg School of Public Health Summary While progress has been made in controlling tobacco use among special populations, the tobacco industry remains relentless in its pursuit of new customers among the poor, youth, and women The overall burden of the tobacco epidemic is increasingly being borne by the poor Controlling the tobacco epidemic among special populations requires a concerted, collaborative effort across sectors  In this context, the leadership of a fully engaged, non- smoking, 100% smoke-free health sector is essential stamplin@jhsph.edu 23