Post on 14-Dec-2015
Effective Interventions to Reduce Tobacco Use
Joy de Beyer
Tobacco Control Coordinator
World Bank
Meeting of Mediterranean Countries, Malta, September 2001
Outline
• Why intervene to reduce tobacco use ?
• Which interventions are effective, and how do we know?
• Which interventions are not effective?
• Who are the key stakeholders ?
Why intervene to reduce tobacco use ?Large and growing number of deaths from tobacco
World: Annual Tobacco Deaths (millions)
2000 2030Developed 2 ~3Developing ~2 ~7World Total 4 ~10
1 in 2 of long-term smokers killed by their addiction 1/2 of deaths in middle age (35-69)
Source: Peto, Lopez, and others 1997; WDR 1993
Tobacco Attributable Deaths in EU Countries
in the Mediterranean Region Smoking Attributable Deaths in All Ages in EU
Mediterranean Countries 1955-2000
7
51
61
33
715
75
66
1210
3
5758
21
0
10
20
30
40
50
60
70
80
1955 1965 1975 1985 1990 1995 2000
An
nu
al M
ale
S
mo
kin
g d
ea
ths
(1
00
0s
)
Portugal
Spain
Italy
Greece
France
Source: Peto, Lopez, 2001
Tobacco Related Deaths in Mediterranean Countries in 1990
Tracheal, Lung & Bronchial Cancer per 100,000 deaths
153229 241
368
704
992
1390
0
200
400
600
800
1000
1200
1400
Libya Lebanon Jordan Tunisia Egypt Algeria Morocco
MaleFemale
1.1 Billion Smokers Worldwide(1990-1995 estimate, million)
Males Females Total
Developed 200 100 300
Developing 700 100 800
World 900 200 1.1 Bil.
Why should governments intervene?Economic rationale – “market failures”
• People do not know the risks of tobacco use
• Most smokers start young – protect youth
• Nicotine is VERY addictive
• Tobacco users impose costs on others– second hand smoke harms non-smokers– children and infants need protection– health care costs (families and government)– opportunity cost for families
3 strong reasons for governments to intervene
• Deter children from smoking
• Protect non-smokers from others’ smoke
• Provide adults with good information so they can make well-informed choices
Heavy Smokers and High Prevalence Rate in EU in 1999
542
382 398
261
454
243
51%
37%
33%
33%
25%
19%
Portugal Italy Spain France Greece Turkey
Packs/smoker Prevalence
Smoking Prevalence (1990s) and Consumption (1999) in Selected Mediterranean Countries
207 217 227213
173
256
243
20% 24% 25% 25%31% 33%
53%
Morocco Egypt Jordan Algeria Syria Tunisia Lebanon
Packs/smoker Prevalence
Protect YouthSmoking and Addiction Starts Young
Smoking Prevalence (%)among Youth in Selected EU Mediterranean Countries in 1990s
8%
6%6%5%5%
10%
5%4%
7%
5%
Greece (11-15) 1998
Spain (11-15) 1994
Italy (13-14)
1994
Portugal(11-15)1998
France(11-15)1998
Boys
Girls
Protect Youth:Smoking and Addiction Starts Young
Smoking Prevalence among Youth in Selected Mediterranean Countries 32%
16%14%13%11%
4%
11%7%
9%
3%1%
Algeria (15 yrs) 1999
Lebanon(15-18)
1997 total
Egypt (14-18) 1998
Turkey (7-13) 1996
Syria (16) 1997
Jordan (12-18) 1997
Boys
Girls
Allocating Tobacco Expenditure to Other Goods and Services
Better Nutrition, Better Health: Evidence from Hungary
Additional Food a Smoker Could Buy Per Week if He/She Did Not Smoke in 1999
2.0 2.1 3.1
9.8
25.6
21.0
Pork Beef Chicken Apple Potato Flour
Kg/Week
High opportunity Cost: Evidence from Belarus
Smoking Expenditure as % of Total Income for a Typical Belarus Smoker
7% 10%
37%42%
0%
10%
20%
30%
40%
50%
1996 1999
If smoke only domestic brands If smoke only foreign brands
High opportunity cost: Evidence from Bulgaria
Tobacco expenditure as % of gross income and wages&salaries in Bulgaria
1997
1.8%
4.9%
1.6%
3.6%
1.1%
3.1%
0%
1%
2%
3%
4%
5%
6%
as % of gross income as% of wages &salaries
Low Middle High
Effective interventions to reduce tobacco use
• Higher cigarette taxes• Non-price measures: Consumer information, large clear warning labels Comprehensive bans on cigarette advertising and
promotion, or counter-advertising Restrictions and bans on smoking in workplaces and
other public places
• Help for people who want to quit Better access to cessation therapies such as nicotine
replacement (NRT), etc
Interventions that are not effective in reducing tobacco use
Most “supply side” measures:– Prohibition– Youth access restrictions– Crop substitution– Trade restrictions
Control of smuggling is the exception.
It is the key supply-side measure.
An effective measure:Complete Ban on Tobacco Advertising and Promotion Consumption trends in countries with such bans v. those with no bans n=102 countries)
1
No Ban
Ban
1450
1500
1550
1600
1650
1700
1750
1981 1991Year
Cig
are
tte c
on
su
mp
tio
n
per
cap
ita
Current smokers need help! Cessation Treatments
• Cessation support from health professionals is key
• NRTs double the effectiveness of cessation efforts
• Quit lines, community support, etc., also work • Governments may increase accessibility and affordability
of NRTs by: OTC sales, allowing advertising, licensing Conducting more studies on cost-effectiveness (especially in
low/middle income countries) Considering NRT subsidies for poorest smokers
Cessation Efforts: Health Care Professionals First
Smoking Prevalence Among Health Professionals and Medical Students in Mediterranean Countries 1990s
14
3034 37 37 39
4450 53
17
1
34
5 2
1713
2932
41
Pre
va
len
ce
ra
te %
Males Females
Physician rate: Greece, Italy, Malta, Spain, Turkey, Egypt, SyriaMedical Student rate: Algeria (male+female), Morocco, Tunisia,Cardiologist: France
Key stakeholders – Ministry of Finance: Tobacco Tax Revenues
– Customs Administration: Smuggling, Border Control
– Ministry of Labor: Farmers and Manufacturing Labor
– Ministry of Agriculture: Tobacco Production
– Ministry of Education: Youth education on tobacco
– Smokers: Low prices, variety and appealing products
– Producers: Profit, market share, sales
– Ministry of Trade: Export earnings from tobacco
Ministry of Finance: Tobacco is a good source of government tax revenue
Tobacco Excise Tax Revenue in 1999
3.0
18.4
02468
101214161820
Other Med. EU Med.
Bil
lio
n U
S $
EU Med: France, Greece, Italy, Portugal, SpainOther Med: Algeria, Cyprus, Egypt, Morocco, Jordan,Lebanon, Syria, Turkey, Tunisia,