Tobacco Epidemic and PH Responses

7/28/2019 Tobacco Epidemic and PH Responses

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Global Tobacco Epidemic and

Public Health Response

Joanna Cohen, PhD

Director, Institute for Global Tobacco ControlBloomberg Professor of Disease Prevention

Johns Hopkins Bloomberg School of Public Health


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Outline

Profile of global tobacco use

Current and projected tobacco-related mortality

and economic burden

Role of the tobacco industry

Public health tools to combat tobacco use


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Tobacco and Smokeless Tobacco

Come in Many Forms


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www.tobaccoatlas.org4


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Global Cigarette Consumption in

One Century Increased over 100 Times

Tobacco Atlas, 2012, www.tobaccoatlas.org

10 20 50 100300

600

1000

1686

2150

3262

4453

5328

5711 5884

0

1000

2000

3000

4000

5000

6000

1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2009

Billionsofcigarettes


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Nearly 2/3 of the Worlds Smokers

Live in Just 10 Countries


Percent of cigarette consumption

42%

Rest of theworld

38%

China

7%

Russia

5%US

4%

Indonesia

4%

Japan


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Male Smoking Prevalence

(2010 or latest available)



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Female Smoking Prevalence

(2010 or latest available)



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Smoking and Secondhand SmokeDamage Every Part of the Body

Smoking

Secondhand Smoke


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Tobacco: The Only Risk Factor Shared

by Four Major Non-communicable Diseases

Tobacco useUnhealthy

diets

Lack of

physical

activity

Use of alcohol

Cardiovascular

Diabetes

Cancer

Chronic

Respiratory



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Global Burden of Tobacco

Past and Present

Tobacco killed 100 million people in the 20th century

Tobacco use is now the worlds single leading preventable

cause of death Kills more people than HIV/AIDS, TB, and malaria combined

Responsible for >15% of deaths among men and 7% among women 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

non-smokers

WHO Report on the Global Tobacco Epidemic, 2008, http://www.who.int/tobacco/mpower/gtcr_download/en/index.htm

MMWR April 12, 2002, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5114a2.htm


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More Than 600,000 Deaths Caused

by Secondhand Smoking, 2004

26% 47% 28%156,000 281,000 166,000

Men Women Children

75% of secondhand smoke deaths

occur among women and children



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Economic Burden of Tobacco-related Diseases

Direct Cost of Smoking

Nearly 5% of

U.S. healthcare dollars

is spent on treatment of

tobacco-related diseases

$2,803 million

Canada

$96,000 millionUSA

$5,700 million

Mexico



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Future Global Burden of Tobacco

Without urgent action, 1 billion people will diefrom tobacco in the 21st century 500 million deaths among persons alive today

Unchecked, worldwide deaths from tobacco products

will exceed 8 million a year by 2030

Every death from tobacco products

is preventable!

WHO Report on the Global Tobacco Epidemic, 2008: http://www.who.int/tobacco/mpower/gtcr_download/en/index.html


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Vector of Disease

Environment

Host

Vector = Tobacco

industry

Agent

Cohen, et al. AJ PM 2010;39:352-6tobacco.health.usyd.edu.au/assets/pdfs/tobacco-industry/trustus.pdf


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Trend in Tobacco ProductionProduction Quantity in Million Metric Tons, 19652009

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0

1965 1970 1975 1980 1985 1990 1995 2000 2005 2009

China

BrazilIndia

ArgentinaUnited States


Inmillionmetrictons


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Global Cigarette Market Share, 2008

Company Cigarettes(billions)

Share of globalmarket

China National Tobacco Company 2,143 38.3%

Philip Morris International 869 15.5%

British American Tobacco 830 14.8%

Japan Tobacco 612 10.9%

Imperial (UK) 329 5.9%

Altria/Philip Morris USA 169 3.0%

Korea Tobacco & Ginseng (S. Korea) 102 1.8%

RJ Reynolds 90 1.6%

Callard C.Tobacco Control 2010; 19:285-90


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Tobacco Company Revenue and Profits

Top 6 Companies, 2010


$0.00$10.00

$20.00

$30.00

$40.00

$50.00

$60.00

$70.00

$80.00

$90.00

$100.00

Altria/PhilipMorrisUSA

Imperial Tobacco British AmericanTobacco

Japan TobaccoInternational

Philip MorrisInternational

China NationalTobacco

Corporation

Total profit $ 35.1 billionTotal revenue $346.2 billion

3.9

2

4.2

1.57.5

16

20.5 36.4 53.9 64.4 60.2 75.7

100

90

80

70

60

50

40

30

20

10

Inbillions,U

SD


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$9.9 billion was spent on cigarette advertisingand promotion >$34 for every man, woman, and child

83% of the tobacco companies marketing budgets are

spent on price discounts, coupons, and retail value-added promotions

In general, in the United States, tobacco companies

spent almost twice as much on marketing as junk food,

soda, and alcohol companies combined

Marketing in the United StatesCigarette Marketing Expenditures, 2008


http://www.tobaccopolicycenter.org/2012/01/11


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Undue Influence

Genius comes from hard work.

Tobacco helps you to be successful.



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WHO Report on the Global Tobacco Epidemic, 2008 http://www.who.int/tobacco/mpower/2008/en/index.html


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Conclusions

The tobacco epidemic will cause the most harm to low- andmoderate-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 the developing world

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 epidemics impacts

This will create aperfect stormof future tobacco-caused diseaseand death, unless there is a strong response from

the public health community


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Global Tobacco Surveillance System:

From Data to Action

Samira Asma, DDS, MPH

Chief, Global Tobacco Control BranchOffice on Smoking and Health

Centers for Disease Control and Prevention

23


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A set of globally standardized surveysMonitoring not only the problem of tobacco use,

but also tobacco control solutions

Enhance capacity to design, implement, monitor an

evaluate tobacco control policies

GTSS: Global Tobacco Surveillance System


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WHO FCTC Monitoring Protocol 20.2

integrate tobacco surveillance programs intonational, regional, and global health surveillance

programs so that data are comparable and can be

analyzed at the regional and international levels,

as appropriate.


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GLOBAL YOUTH TOBACCO SURVEY

GLOBAL ADULT TOBACCO SURVEY

TOBACCO QUESTIONS FOR SURVEYS

GTSS: Global Tobacco Surveillance System


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Largest public health surveillance system School-based surveys of students 1315 years

Self-administered using global standard protocol

National, state or provincial

180 countries/sites completed

GYTS: Global Youth Tobacco Survey

19992012


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1 in 10 students currently smoke cigarettes 1 in 10 students currently use other tobacco

products

1 in 4 smokers first tried by age 10

2 in 3 smokers want to quit 4 in 10 students exposed to secondhand smoke in

homes and over half in public places

GYTS: Global Youth Tobacco Survey

Key Findings

Centers for Disease Control and Prevention. Global Youth Tobacco Surveillance, 2000-2007. 2008 Jan 25. MMWR 2008; 57/ss-1


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GATS: Global Adult Tobacco Survey

20082012

Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspx

Nationally representative

household surveys

Active in 31 countries

Covers 66% of worlds population

Covers 68% of worlds smokers


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GATS in numbers 1 million household level data

350,000 household interviews

50 languages and dialects

3,600 fieldworkers trained

3,000 handhelds 1,500 fieldwork days


65 million data points collected

representing 3.6 billion people!



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Core questionnaire and optional questions

Sampling design

Series of manuals and guidelines

Expert review committees

Questionnaire review Sample design and weighting

Electronic data collection


Standard Protocol


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794 million adults currently use tobacco 350 million exposed to secondhand smoke at work

5 in 10 current smokers plan to quit or thinking

about quitting

2 in 10 noticed cigarette marketing in stores wherecigarettes are sold


Key Findings

Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspxAdult Awareness of Tobacco Advertising, Promotion, and Sponsorship-14 countries. MMWR 2012; 61(20)

M i


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MonitorTobacco Use by Gender

60.6

58.0

52.9

50.2

49.2

47.9

47.947.6

46.4

38.1

37.3

30.7

25.022.0

0 10 20 30 40 50 60 70

Russian FederationBangladesh

China

Ukraine

Philippines

India

TurkeyViet Nam

Thailand

Egypt

Poland

Uruguay

MexicoBrazil

Male Female


28.724.4

21.7

20.3

19.8

15.2

13.311.3

10

9.1

7.9

3.6

2.4

0.6

0 10 20 30 40 50 60 70

BangladeshPoland

Russian Federation

India

Uruguay

Turkey

BrazilUkraine

Philippines

Thailand

Mexico

Viet Nam

China

Egypt

Prevalence (%)


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63.3 62.259.9

55.9

37.334.9

33.6 33.1 32.6 29.927.2

23.3

18.616.5

0

10

20

30

40

50

60

70

Percentage(%)

ProtectExposure to Secondhand Smoke at Workplace

Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspxIn the past 30 days preceding the survey


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Offer HelpFormer Smokers Who Quit

46.9

42.0

36.5

32.0

28.826.5 25.9

23.5

21.518.3 17.8 16.6

12.8 12.6

0

5

10

15

20

25

30

35

40

45

50

Percentage(%)

Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspxCurrent smokers who made a quit in the past 12 months

Warn


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WarnThought about Quitting Smoking Because of

Warning Labels on Cigarette Packages

67.0 66.7 65.0

58.5 57.6

46.343.3 42.9

37.432.9 31.7 31.5

28.6

17.7

0

10

20

30

40

50

60

70

80

Percentag

e(%)

Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspxAmong those who noticed health warning on cigarette packages in the past 30 days preceding the survey


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EnforceNoticed Cigarette Marketing in Stores

53.7

43.6

36.533.2

30.4

20.9 20.5

13.910.7

8.6 8.0 6.74.1 2.7

0

10

20

30

40

50

60

Percentage(%)

Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspxIn the past 30 days preceding the survey


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RaiseAffordability

Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspxAffordability as the relative income price - Median price paid per 2000 sticks as % of per capita GDP

Percentage(%)

0.7%1.0%

1.2%1.5% 1.7%

1.8%2.1% 2.2% 2.2% 2.3% 2.3%

2.5% 2.7%

3.3%

5.0%

8.1%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%


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3 to 22 questionsMPOWER focus

Integration, standardization, and comparability

TQS: Tobacco Questions for Survey

20102012

C t T b U


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Current Tobacco Users

Aged 25 Years, Bangladesh

54.3

69.7

39.1

51.0

70.0

34.4

0

10

20

30

40

50

60

70

80

Overall Male Female

Prevalence

(%)

Global Adult Tobacco Survey, 2009NCD Risk Factor Survey, 2010

Global Adult Tobacco Survey, 2008-2010

Bangladesh 2010. ISBN 978-92-9022-393-1

NCD, Non-communicable diseases


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Data Dissemination

http://apps.nccd.cdc.gov/GTSSData/default/default.aspx


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What Gets Measured, Gets Done

Globally standardized survey data on tobacco control isavailable for 180 countries Unprecedented cross-country comparisons

Tracking not only the problem, but also the solutions


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International Advances in Tobacco Control

Michael Eriksen, ScD

Dean, Institute of Public HealthGeorgia State University


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There ARE Effective and Proven Strategies

100 million global deaths can be prevented

by the end of the century

through a group of policy and regulatory interventions

This number of lives saved is possible

through a modest prevalence decline

(from 25% to 20%),

using the assumption that 1/3 of users

will die from smoking related diseases

Frieden T, Bloomberg M. Lancet 2007;369:175861


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There ARE Evidence-Based Interventions

Sustained funding ofcomprehensive programs

Excise tax increases

100% smoke-free policies

Comprehensive adrestrictions

Aggressive media campaigns

Cessation access
http://www.nap.edu/catalog/11795.html


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4646

WHO Report on the Global Tobacco Epidemic, 2008, http://www.who.int/tobacco/mpower/2008/en/index.html


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http://www.who.int/fctc/e


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Smoke-Free Areas Doubled from 2008 to 2010


Public Support for Comprehensive Smoking Bans in


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Public Support for Comprehensive Smoking Bans in

Bars and Restaurants after Implementation

WHO MPOWER Report 2008, http://www.who.int/tobacco/mpower/2008/en/index.html

New Zealand New York City California Ireland Uruguay

0%

20%

40%

60%

80%

100%

Publicsupport


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Impact of Pictorial Warnings on Brazilian Smokers

Datafolha Instituto de Pesquisas, 2002,Tobacco Atlas, 2012, www.tobaccoatlas.org

Want to quitas a result

Approve ofhealth warnings

Changed their opinion abouthealth consequences of smoking


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Plain Packaging in Australia

Plain packaging to be

implemented by

December 1, 2012,

pending ongoinglitigation


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Health Warning Labels

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

The Tobacco Atlas, 3rd Edition, 2008, www.tobaccoatlas.org

2008


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Marketing Bans

* Direct and indirect advertising bans, 2007

** Four, five or six direct bans and at least one indirect ban

***One, two or three direct bans or at least one indirect banThe Tobacco Atlas, 3rd Edition, 2008

2007

Comprehensive Advertising Bans


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Comprehensive Advertising Bans

Amplify Other Interventions

Saffer H. Tobacco advertising and promotion. In: Jha P, Chaloupka FJ, eds Tobacco control in developing countries. Oxford, Oxford

University Press, 2000

-10%

-9%

-8%

-7%

-6%

-5%

-4%

-3%

-2%

-1%

0%

Average change in cigarette consumption 10 years afterintroduction of advertising bans in 2 groups of countries

Chang

eincigaretteconsumption

14 countries with a comprehensive ban 78 countries without a ban

-9%

-1%

Tobacco Prices and Consumption


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Tobacco Prices and Consumption

South Africa and Morocco

Walbeek C. 2003. Tobacco excise taxation in South Africa (left graph), http://ped.sagepub.com/content/12/4_suppl/25.long Aloui O.

2003. Analysis of the economics of tobacco in Morocco (right graph)

http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-1095698140167/Aloui-Analysis_of-whole.pdf


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Tobacco Prices and Taxes

The Tobacco Atlas, 3rd Edition, 2008, www.tobaccoatlas.org

Change in Affordabili ty of Tobacco Products


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Change in Affordabili ty of Tobacco Products

by WHO Region, 20002010



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Tobacco Control is Underfunded

167.57

17.6

5.431.36 0.013 0.001

-10

10

30

50

70

90

110

130

150

170

High-income Middle-income Low-income

Per capita total tax revenue fromtobacco products

Per capita public spending on

tobacco control

USDpercapita

Most of the Worlds People Are Not Yet


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Most of the World s People Are Not Yet

Fully Protected Against Tobacco Harms

World Health Organization

5

13 8

28

56

0%

5%

10%

15%

20%

25%

30%

Smoke-free

environments

Cessations

programs

Warning labels Mass media Advertising

bans

Taxation

Shareofworld

population

11

14

15

28

6

8

P O W E R

Increase 20082010


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Interactive maps, downloadable data, Power points, country

fact sheets

Upcoming editions: Arabic, French, Spanish, Chinese

Sign up @TobaccoAtlas.org for alerts of upcoming editions,new features

C l i


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Conclusions

Internationally, tobacco control policy initiatives havebeen broadly accepted

Evidence-based prevention best practices-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

htt // d / b t/ d d


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Tobacco Epidemic and PH Responses

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