dr. carmen audera-lopez - apsresp.org · dr. carmen audera-lopez. tobacco control in the western...

Acting Team Leader Tobacco Free

Initiative WHO WPRO Manila

Oversee and manage Tobacco Free Initiative

(TFI) Regional Programme for accelerating

FCTC implementation in the countries of the

Region. Manage TFI-WPRO human and

financial resources Work in 37 countries and territories of the WHO-WPRO

Master in Public Health

Specialised in Developing Countries

Escuela Nacional de Sanidad. Madrid, Spain 1996-1997

Medical Doctor Degree

Facultad de Medicina de la Universidad Complutense

of Madrid. Madrid, Spain Sep 1973-July 1979

Dr. Carmen Audera-Lopez

Tobacco Control in the Western Pacific Region

Are we winning the battle?

Carmen Audera-Lopez-WPRO

Outline of the presentation

The tobacco epidemic

The effects of tobacco use

The global response

The big enemy in this battle

The way forward

4 |FCTC Workshop WPR- Fiji 2014

WHO Regional Office for the Western Pacific

Western Pacific Region

Australia

Brunei Darussalam

Cambodia

China

Cook Islands

Fiji

Japan

Kiribati

Lao People's Democratic Republic

Malaysia

Marshall Islands

Micronesia (Federated States of),

Mongolia

Nauru

New Zealand

Niue

Palau

Papua New Guinea

Philippines

Republic of Korea

Samoa

Singapore

Solomon Islands

Tonga

Tuvalu

Vanuatu

Viet Nam



The tobacco epidemic in our part of the

world

In the West Pacific Region

There are an estimated 430 million smokers or about one third of the world's smokers (a fourth of the world’s population)

Highest rates of male smoking, and the fastest increase of tobacco use among women and young people.

It is estimated that two people die every minute from tobacco-related disease

50% of women and children are exposed to second hand smoke



Age-standardized prevalence estimates for tobacco smoking among males

and females aged 15 years and over in the Western Pacific, 2011



Youth smoking rates



Current tobacco use in men and women in

ASEAN countries

WHO Report on the Global Tobacco Epidemic, 2013



Current tobacco use in boys and girls

WHO Report on the Global Tobacco Epidemic, 2013



Stages of the tobacco epidemic



Trends in smoking and lung cancer in Japan

Bull WHO 2013, 91:332-340



Slower rise of smoking among women

Has been attributed to social

disapproval of women who

smoke and to women’s lower

social and economic status.

RISKS: As women’s

empowerment continue, there

is potential link to increased

smoking among women and

to the ways in which the

tobacco industry is

capitalizing on societal

changes to target women.






The global response


The way forward



TOBACCO USE IS A RISK FACTOR FOR 6 OF 8 LEADING

CAUSES OF DEATH IN THE WORLD

5.3 M



Chronic respiratory

diseases

Cardiovasculardisease

Diabetes

Cancer

Unhealthydiets

Tobacco

Harmful use of alcohol

Physical inactivity

Mental disorders

Injuries

Riskfactors

Noncommunicable Diseases and Conditions

Tobacco and the NCD action plan:4 risk factors, 4 noncommunicable diseases, 2 conditions



Smokers body



Diseases caused

by smoking



The tobacco industry has deliberately made smoking glamorous and the norm.

Few women are aware of

gender-specific health risks

◙ cervical cancer

◙ osteoporosis

◙ early menopause

◙ miscarriage

◙ ectopic pregnancy

◙ infertility



Smoking during pregnancy

• Spontaneous abortion

• Ectopic pregnancy

• Low-birth weight babies

• Perinatal mortality

• Long-term effects on growth and development of the child

• AND carries a risk to the mother herself

Accounts for an increase in :

Pregnant women who smoke as few as 5 cigarettes per day are likely to have low birth weight babies



Second Hand Smoke

We have a high tolerance for

second hand smoke exposure:

Of the 600 000 yearly deaths from

second hand smoke exposure---

167,000 or 28% are children



Exposing an infant to

second-hand smoke

greatly increases the

child’s risk of:

• asthma

• pneumonia

• bronchitis

• fluid in the

middle ear

Second Hand Smoke



Associations between tobacco and TB

A Qualitative Systematic Review Jointly

Conducted by WHO and The Union in 2007

concluded that:

– A link between active and passive tobacco

smoking and TB outcomes such as infection,

response to treatment, relapse rates, and

mortality is evident.

– Active smoking is significantly associated with

recurrent TB and TB mortality.



Tobacco-attributable mortality rates in the

Philippines, the Western Pacific and worldwide

Source: WHO Global Report: mortality attributable to tobacco, 2012.



Tobacco impact on poverty

Tobacco

attributable

deaths and

diseases

impose a

high

economic

cost

The

poor are

the ones

who

smoke

the most

Tobacco

worsens poverty

among its

users: money

spent on

tobacco

opportunity cost

Increased health

expenditure due

do disease

reduced access

to essential

goods such as

education and

health care



Opportunity Cost

2.3%

0.9%

1.4%

2.7%

6.3%

7.1%

2.5% 12.5%

64.3%

Food

Clothing

Housing

Health

Education

Utilities

Transport &

CommunicationTobacco

Other expenses

Poor

households

spend more

on Tobacco

than on

Education,

Health and

Clothing

Source: Upcoming WHO publication

Monthly expenditure by poorest households, Philippines, 2003



Opportunity cost

Minutes of labour to purchase

0

10

20

30

40

50

60

70

80

Chile China Colombia India Russia Thailand

Min

ute

s

1 kg Rice Pack 20 local cigarettes

Source: Economist Intelligence Unit, 2006



Prevalence by income groups

China

0

10

20

30

40

50

Q1 Q2 Q3 Q4 Q5

%

Daily smokers All smokers

Source: World Health Survey 2006

Note: Q1-Q5: Lowest-Highest income groups






The global response


The way forward



Global response to the tobacco epidemic



Mechanisms for Tobacco Control

WHO Framework Convention on

Tobacco Control (WHO FCTC)



Objective:“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.”

WHO Framework Convention on Tobacco Control:An evidence-based tool to save lives

World No Tobacco Day Poster 2011



What is the WHO FCTC?

First global health treaty negotiated under the

auspices of WHO

Establishes tobacco control as a priority on the

public health agenda

Provides a political and legal platform for

adoption of sound, evidence based tobacco

control measures

Introduces a mechanism for firm country

commitment and accountability.

It is a dynamic model of global standard setting.

179 Parties

Entry into force 27 Feb 2005

179 parties covering about over 90% of the world’s population

176



Demand reduction

provisions

Price and tax measures (Art.6)

Protection from secondhand smoke

(Art.8)

Contents regulation (Art.9)

Disclosure of contents (Art.10)

Packaging and labelling (Art.11)

Education and awareness-raising

(Art.12)

Advertising, promotion and

sponsorship (Art.13)

Cessation programmes (Art.14)

Supply reduction

provisions

Elimination of illicit trade (Art.15)

Prohibition of sales to and by minors

(Art.16)

Support for viable crops for growers

(Art.17)



MPOWER - a tool to assist countries with WHO FCTC

demand reduction measures

-



Supply reduction measures

Control of illicit trade

Sales to and by minors

Crop substitution



The state of selected tobacco control policies

in the world-GT

Creation of smoke-free public places and workplaces continues to be the most commonly established measure at the highest level of achievement



Raise Taxes on Tobacco (Art 6)

Raising the price

of tobacco

regularly is one

of the most

effective

tobacco control

measures

• On average, a 10% price increase on a pack of cigarettes would be expected to reduce demand for cigarettes by about 4% in high-income countries and by 4% to 5% in low- and middle-income countries

• Children and adolescents are also more sensitive to price increases than adults, allowing price interventions to have a significant impact on this age group.

EFFECT

• Price increase will have a negative effect on revenue

• Tax increase will have a negative effect in smugglingMYTH

• When tobacco taxes rise, tax revenues increase.

• High tobacco taxes are not the cause for increased smuggling.

FACTS

Taxation



Taxes- SinTax



Affordability = GDP per capita / CPI of tobacco.

A rising affordability index reflects average income rises faster

than tobacco prices.

Vietnam

Source: Guindon et al, 2010



Price of the most popular brand in international dollars In

tern

atio

nal

do

llars



Taxes in WPR

Half of the WPR countries have taxes over 50% of retail price



Single stick sale

A challenge!



Article 8 Protection from second

hand smoke

100% Smoke free policies

• The World Bank estimates that smoking restrictions reduce overall tobacco consumption by an estimated 4-10%.

• Smoke free workplaces may reduce overall tobacco consumption by as much as 29%.

• The number of cigarettes smoked by people who continue to smoke is also likely to fall.

EFFECT

• 100% tobacco-free public places damage profits of cafés and restaurantsMYTH

• Smoke-free laws do not damage the profits of catering and drinking establishments.

• Evidence has shown that smoke-free laws have no impact or a positive impact on sales and employment. Studies reporting a negative impact were commissioned by the tobacco industry.

• Smoke-free laws can help businesses improve their profits by increasing worker productivity – less breaks and absenteeism due to illness – and decreasing costs associated with permitting smoking, including medical and insurance costs.

• Smoke-free environments are good for health, business and the economy

FACTS

SMOKE FREE POLICIES



Legislation Fully Enforced Moderately

enforced

Not yet enforced No data

Complete Brunei

New Zealand

Singapore

Mongolia Nauru Australia (national

level)

Marshall Islands

PNG

6-7 Public places Palau Viet Nam

Malaysia

Cambodia

Solomon Islands

Samoa

3-5 Public Places Cook Islands

Fiji

Philippines

Tuvalu

Lao

Up to 2 public

Places

China

Rep of Korea

Japan

Kiribati

Micronesia

Niue

Tonga

Vanuatu

Smoke free Legislation and Enforcement in WPR



Smoke free cities

Of the 100 largest cities in the world 43 are in WPR (29 in China)

Of the 43 only 4 have comprehensive smoke free Policies (Hong

Kong, Melbourne, Singapore and Sydney)

We have other examples of smaller cities that are smoke free in

Malaysia, Philippines, China, Fiji,…



Smoke-free

Cities ASEAN Network (SCAN)

Launched in Davao during a Regional Workshop organised by

SEATCA in collabotaion with WPR0 in 2013

SCAN is a coalition of countries in the ASEAN, that will support each

other and strengthen policies and efforts on 100% smoke-free places

(FCTC Article 8).



Health Warnings

http://www.smoke-free.ca/warnings/warningsimages/Hongkong/family-english.jpg

http://www.smoke-free.ca/warnings/warningsimages/Hongkong/family-english.jpg



Philippines GHW



Tobacco Advertising Promotion

and SponsorshipComprehensive ban on all kinds of direct and indirect TAPS has

proven to reduce tobacco consumption

WNTD 2013:TAPS



Enforce Bans on Tobacco Advertising,

Promotion and Sponsorship

Comprehensive ban on all

kinds of direct and indirect

TAPS has proven to reduce

tobacco consumption



Corporate social responsibility activities

Such as making donations to charities to appear as good

corporate citizens



Packaging is advertising



Packaging



In the Western Pacific

Region, 19 out of 27

countries have

implemented tobacco

advertising ban on

national television, radio

and print media.

However, advertising

with significant influence

over youth e.g. point of

sales advertising, brand

stretching and product

placement remains

unregulated.

TAPS-Progress in our Region



Point of sale advertising



Tobacco Dependence Treatment

Tobacco cessation advice incorporated into

primary and routine health-care service

Strengthening Health Systems



During prenatal care

WHO recommendations for the prevention and

management of tobacco use and second-hand

smoke exposure during pregnancy



By the end of 2007, DOTS was

being applied in more than 180

countries, covering 94% of the

world’s population

By the end of 2007, Almost the

entire population of the Asia

Pacific Region had access to

DOTS

About 5.8 million new and

relapse TB cases notified

under DOTS in 2011. Even if

only 20% of them use tobacco,

the DOTS programmes could

reach >1 million tobacco users

a year

DOTS programmes have the potential to reach

more than 1 million tobacco users a year

Source: Global Tuberculosis Report 2012



Tobacco

dependence

treatment



Sales by minors

Sale to minors



New products



The global e-cigarettes market is

rapidly expanding

• $US 3 billion spent on e-cigarettes globally in 2013*

– US sales doubling every year**

– E-cigs sales forecast to increase 17-fold by 2030*

*Euromonitor International

**‘Vape ’em if you got ’em: A challenge to Big Tobacco’, The Economist, March 23 2013






The global response


The way forward



Tobacco Industry Interference

Very strong tobacco industry interference in many countries.Great lack of awareness!!!



If it wasn’t for the tobacco industry wanting to make a big profit we would have finished with the tobacco epidemic



Targeting Developing World Markets

Tobacco companies have adopted aggressive strategies to expand global trade

and achieve market penetration in developing countries and emerging market

economies

They entered Latin American markets in 1960s

Those of the newly industrialized economies of Asia in the 1980s

Markets of Africa, China, and Eastern Europe in the 1990s

Youth and women are the prime targets for these campaigns.

–



Epidemiological models

Tobacco use & Malaria infection

Cultural, historical,

economic &

political factors

Tobacco products

&Tobacco smoke

Smokers &

Involuntary smokers

VECTOR

AGENT ENVIRONMENT

Tobacco manufacturers and Anopheles mosquito

are both vectors to disease.

Infected host

Infected

blood

Parasite

Plasmodium

HOST



Tobacco Industry - A Mutating Vector

"The tobacco industry's mutative processes reflect the

tobacco industry's primary role as the sole vector of the

leading preventable cause of death in world today."

Tobacco industry remains unchallenged in many countries

Some strategies have been employed for decades; some for few years – depending on the level of acceptance of industry interference in each country

Source: Successes and new emerging challenges in tobacco control: addressing the vector, Tobacco Control, March 2012



WHO FCTC

Article 5.3

In setting and implementing their public health

policies with respect to tobacco control, Parties shall act to

protect these policies from commercial and other vested

interests of the tobacco industry in accordance with

national law.



World No

Tobacco Day

31st May

2012

Stop Tobacco

Industry

Interference in

Tobacco

Control



COUNTERACTING TOBACCO INDUSTRY

INTERFERENCE

-






The global response


The way forward



Males prevalence rates-current smokersP

reva

len

ce c

urr

ent

smo

kin

g



Females prevalence rates-current

smokers

Pre

vale

nce

cu

rren

t sm

oki

ng



Tobacco end game: Single digit

In Australia smoking prevalence 14 years and older,

declined from 15.1% to 12.8% between 2010 and 2013

Hong Kong adult smoking rates 11.8%

Brunei adult smoking rates 13%

Singapore adult smoking rates 14%



2015-2019 RAP

- Sustainable capacity

- Policy development and efficient enforcement

- Multisectorial engagement

FIVE YEAR REGIONAL ACTION PLAN

dr. carmen audera-lopez - apsresp.org · dr. carmen audera-lopez. tobacco control in the western...

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