Tobacco Control in Europe: What Works Thomas E. Novotny, MD MPH

Most smokers live in developing countries Source: Jha et al, 2002, AJPH Current smokers in 1995 (in millions) RegionNumber Low/Middle income 933 High Income 209 World 1,142

Smoking is more common among the less educated Smoking prevalence among men in Chennai, India, by education levels Source: Gajalakshmi and Peto 1997

Tobacco Control in Developing Countries and Curbing the Epidemic The World Bank WHO

Effective interventions: Demand reduction n Higher cigarette taxes; n Non-price measures : consumer information, research, cigarette advertising and promotion bans, warning labels, and restrictions on public smoking; n Increased access to nicotine replacement (NRT) and other cessation therapies.

Taxation is an effective measure to reduce demand n Higher taxes induce quitting and prevent starting n A 10% price increase reduces demand by: u 4% in high-income countries u 8% in low or middle-income countries n Young people and the poor are the most price responsive

Cigarette price-consumption relationship: So. Africa,

Non-price measures to reduce demand n Increase consumer information: dissemination of research findings, warning labels, counter-advertising n Comprehensive ban on advertising and promotion n Restrictions on smoking in public and work places n Increase access to nicotine-replacement therapies (NRT)

Health information reduces the demand for cigarettes Source: Kenkel and Chen, 2000

Comprehensive advertising bans reduce cigarette consumption Consumption trends in countries with such bans vs. those with no bans (n=102 countries) Source: Saffer, 2000

Effect of Smoke-free Workplaces on Smoking Behavior n International study, Ficthenberg and Glantz, BMJ July 2002; n Totally smoke-free workplaces associated with 3.8% reductions in prevalence and 3.1 fewer cigarettes smoked per day. n To achieve similar results in US and UK, taxes would have to increase to $1.11 and GBP4.26 n Italy, Ireland, Norway, Brunei, and others now smoke-free (to varying degrees).

Ineffective interventions: Most supply side measures n Prohibition n Youth access restrictions n Crop substitution n Trade restrictions n Control of smuggling is the only exception

Unless current smokers quit, smoking deaths will rise dramatically over the next 50 years Source: Peto and Lopez, 2001

Effectiveness of cessation Increase in 6 month Intervention quit rates (%) n n Brief advice to stop by clinician 2 to 3 n n Adding NRT to brief advice 6 n n Intensive support plus NRT 8 Source: Raw et al., 1999; AHCPR, 1999

Source: CMH, 2001 Cumulative deaths avoided (millions) before age 60 with interventions in low and middle-income countries, Infectious and maternal conditions ($26-46 billion/year) Adult smoking cessation (self- financing) Year

Key Ethical Principles Related to Global Public Health n Autonomy- individual choice u requires resolution of information asymmetry and voluntary choice n Beneficence- do no harm and also prevent harm n Justice- esp. distributive justice u fair, equitable and appropriate distribution of social goods including political rights

Tobacco is Not an Equal Opportunity Killer n Smoking affects young, the poor, depressed, uninsured, less educated, blue-collar, and minorities most in the US; n Addiction affects those with the least information about health risks, with the fewest resources to resist advertising, and the least access to cessation services; n Those below poverty line are >40% more likely to smoke than those above poverty line.

What’s Wrong With This Picture? n Tobacco industry contributes five times as much to Republican candidates as to democratic candidates; n No global leadership from US DHHS; n Small funds channeled from CDC and NIH through World Bank, WHO, and other organizations, but not from USAID; n More is known about the health consequences of tobacco use and the effectiveness of tobacco control than any other risk factor. More is known about the vectors than ever before.

Global Tobacco Control Key questions for global tobacco control research and practice: u What is ethical basis for tobacco control? u What is the optimal policy mix for tobacco control? u What is the US role in u global tobacco control?

Summary n Tobacco mortality is growing, with higher burden among poor n Specific market failures support government intervention n Demand measures are the most cost effective n Helping adults quit is as important as preventing starting n Control of smuggling is major supply-side intervention n Poor implementation of effective interventions in lower income countries—needs international cooperation n US has an ethical, scientific, and public health responsibility to lead and not to just passively follow global Tobacco Control through the FCTC.

Framework Convention on Tobacco Control n First treaty negotiated under WHO; n Agreement by consensus at 2003 World Heath Assembly (192 countries); n Takes effect February 27, 2005!! n So far, 168 have signed, >90 ratified; NOT U.S. n Depends on developing national policies in accordance with obligations; n Advertising ban, warning labels, misleading information on labels, taxation, clean-indoor air policy, liability, smuggling controls, etc.