preventive interventions: the cost-effective “best-buys”

Preventive Interventions: The cost-effective “Best-Buys”

- Global advances in Tobacco Control -

Riyadh, 10 -12 September 2012

Douglas Bettcher, MD, PhD, MPHDirector, Tobacco Free Initiative

Director Ad Interim, Chronic Diseases and Health Promotion

Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012

WHY TOBACCO CONTROL


Chronic respiratory

diseases

Cardiovasculardisease

Diabetes

Cancer

Unhealthy diets

Tobacco

Harmful use of alcohol

Physical inactivity

Mental disorders

Injuries

Risk factors

Noncommunicable Diseases and Conditions

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


High-income countries 2.0 mil-

lion (14%)

Upper middle-income coun-

tries2.3 million (16%)

Lower middle-income coun-

tries8.3 million(59%)

Low-income countries1.5 mil-lion

(11%)

86% of people who die from NCDs between the ages of 30 and 70

live in a developing country

14.2 million


Huge disparities exist across countries in relation to the probability of death from an NCD between the ages of 30-70


Source: WHO 2008

The Tobacco Epidemic - Today


Source: WHO Global status report on noncommunicable diseases, 2010, http://www.who.int/nmh/publications/ncd_report2010/en/

Tobacco kills ...

…nearly 6 million people each year.

22% of global cancer deaths, 71% of all lung cancer deaths.• 10% of cardiovascular

disease deaths

About 90% of all deaths from

chronic obstructive lung

diseases and 42% of all chronic respiratory disease are

attributable to cigarette smoking.

Tobacco kills…

http://www.who.int/nmh/publications/ncd_report2010/en/


Source: Global estimate of the burden of disease Mattias Oberg … [et al], WHO 2010, http://www.who.int/tobacco/publications/second_hand/global_estimate_burden_disease/en/index.html

.

Distribution of total deaths

attributable to SHS, 2004

One third of adults are regularly exposed to second-hand tobacco smoke.

About 600 000 people die each year as a result of exposure to second-hand smoke.• 430 000 are adults, of whom 64% are women• 28% of the second-hand smoke deaths are

among children

Exposure to second-hand smoke also kills

http://www.who.int/tobacco/publications/second_hand/global_estimate_burden_disease/en/index.html


The Tobacco Epidemic is About to Get Much Worse…

Tobacco currently kills

nearly 6 Million/year but this will increase

to over 8 Million/year in a

few decades.

If current smoking patterns

continue, the death toll from tobacco use will

be: • 2000–2025~150M• 2025 – 2050 ~ 300 M• 2050 – 2100 > 500 M

Tobacco could kill up to 1

Billion persons in the 21st Century

unless urgent action is taken


THE SOCIO-ECONOMIC IMPACT


(per

cen

tage

)

Smoking prevalence (2004)

0

5

10

15

20

25

30

35

40

45

Low-income countries

Lower-middle

Income

Upper-middle-income

High-income

Lowest household income quintiles

Highest household income quintiles

New perspectives The poorest people in developing countries are affected the most:

Example: Poorest people smoke the most


OPPORTUNITIES AND GLOBAL RESPONSE


Mechanisms for Tobacco Control

WHO Framework Convention on Tobacco Control (WHO FCTC)

A Global Treaty


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

176 Parties

Entry into force 27 Feb 2005 176 parties covering about 87% 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)


BEST BUYS AND

GOOD BUYS


Rationale – Why "best buys" for NCDs?

Public health and economic burden – show

the size of the problem, but not how to address and

reduce it

Cost-effectiveness – indicates solutions but not

their feasibility, affordability and

acceptability

Consequent need to develop:

NCD "best buy" interventions that are cost-effective, feasible, low-cost

and appropriate to implement within the constraints of the local

health systemFinancial planning tool for identifying resource needsPrice tag analysis to inform

global resource mobilisation


US$ 170B is the overall cost for all developing countries to scale up action by implementing a set of "best buy" interventions between 2011 and 2025, identified as priority action by WHO

US$ 7T

is the cumulative lost output in developing countries associated with NCDs between 2011-2025

The cost of action vs inaction (in developing countries over the next fifteen years)

Cost of action: Cost of inaction:

Reports are available at www.who.int/ncd


MPOWER: Six policies whichbuild on the WHO FCTCand are an integral part of the NCD Global Strategy Action Plan

Monitor tobacco use and prevention policies

Protect people from tobacco smoke

Offer help to quit tobacco use

Warn about the dangers of tobacco

Enforce bans on tobacco advertising, promotion

and sponsorship

Raise taxes on tobacco


BEST BUYS &

GOOD BUYS

Monitor tobacco use and prevention

Protect people from tobacco smoke

Offer help to quit tobacco use

Warn about the dangers of tobacco

Enforce bans on tobacco advertising

Raise taxes on tobacco

US$0.6 billion for all low- and middle-income countries (US$0.11 per capita)

Tobacco control is cost-effective


Tobacco control is cost-effective

5·5 million deaths could be averted over 10 years if these elements of the WHO FCTC were implemented in countries:• increased taxes on tobacco products;• enforcement of smoke-free workplaces; • WHO FCTC-compliant packaging and labelling, with

public awareness campaigns about health risks; • comprehensive ban on tobacco advertising, promotion,

and sponsorship.

at a cost of less than US$ 0.40 per person in low income and lower-middle income countries


Estimates for the average annual cost of tobacco control best buy interventions in all low- and middle-income countries (US$ 2008)

R

W

E

P

W

A study that modelled P, W, E, R for 23 countries 5.5 million deaths could be averted at less than US$ 0.40/person /year in low- and lower-

middle-income countries, and US$ 0.5–1.00 in upper-middle-income countries.


59

31

23

19 271919

Number of highest achieving countries in 2010

MPOWER

Status of MPOWER measures


3.8 billion people (55% of the world’s

population) are covered by at least one MPOWER measure at the

highest level of achievement, including

1.1 billion people covered by a new policy

since 2008

MPOWER

Progress is being made


MPOWER measures bring smoking rates down rapidly


M Djibouti, Iran, Jordan, Lebanon, Morocco

P Iran, Libya, Pakistan

O Bahrain, Iran, Saudi Arabia, United Arab Emirates

W – labels: Djibouti, Egypt, Iran

W – campaigns: Egypt, Lebanon, Morocco

E Djibouti, Iran, Jordan, Kuwait, Qatar, Sudan, Syria, UAE

R West Bank and Gaza Strip

EMRO – countries with MPOWER measures at the highest level of achievement


The Islamic Republic of Iran enacted a comprehensive tobacco control law in 2006.

In 2008, the law was strengthened to require pictorial warnings on all cigarette packages.

Warning labels cover 50% of the pack and include graphic images of diseases caused by smoking.

Use of misleading terms, such as “mild” and “light” are also banned.

As a result, Iran’s requirements fully meet the WHO FCTC Article 11 guidelines and thus effectively warn smokers about the risks to their health.

Iran implements strong pack warning labels


Tobacco advertising and marketing had in theory been banned in Jordan since 1977, but the enforcement was weak.

The 2008 legislation clarified and strengthened the law and added new provisions to limit point-of-sale tobacco marketing, including bans on the sale of individual cigarettes and sales through vending machines.

To strengthen enforcement, the Ministry of Health trained 35 health promotion coordinators on practical and suitable methods for enforcing and implementing the law and on procedures for inspections.

This successful model for enforcing advertising and marketing bans is ready to be expanded to the rest of the region.

Jordan strengthens prohibitions on tobacco advertising, promotion and sponsorship


In 2010, Egypt replaced its tiered tax system with a uniformly applied 40% ad valorem excise tax as well as a single specific tax rate of Egyptian £ 1.25 (USD 0.20) per pack of cigarettes.

Total taxes per pack by an average of 87%, which increased the average retail price by an estimated 44%. This increase on cigarettes could reduce cigarette consumption by 21% and smoking prevalence by more than 10%, and hence reduce the number of adult smokers by about 893 000 and prevent about 208 000 premature deaths.

Egypt’s approach to reaching the dual goals of reduced tobacco consumption

and increased resources to spend on health can provide invaluable lessons

for other countries.

Egypt restructures and increases tobacco excise taxes and earmarks additional revenues to fund health programmes


Plain packaging initiative takes off

Australia’s High Court dismissed a legal

challenge from the tobacco industry.

From December 2012, Australia will be the first country to sell cigarettes only in drab, olive-green

plain packaging.


113 Member States

34 Presidents and Prime-Ministers

54 Vice-Presidents, Deputy Prime-Ministers, Ministers of Foreign Affairs and Health

11 Heads of UN Agencies

Hundreds of representatives from civil society

UN High-level Meeting on NCDs (New York, 19-20 September 2011)

LANDMARK EVENT ATTENDED BY:


We, Heads of State and Government and representatives of States and Governments, assembled at the United Nations from 19 to 20 September 2011, to address the prevention and control of non-communicable diseases worldwide, with a particular focus on developmental and other challenges and social and economic impacts, particularly for developing countries,

38. Recognize the fundamental conflict of interest between the tobacco industry and public health;

43.(c) We therefore commit to: Accelerate implementation by States parties of the

WHO Framework Convention on Tobacco Control

The UN POLITICAL DECLARATION ON NCDs


Advance the implementation of multisectoral, cost-effective population-wide interventions in order to reduce the impact of the common NCD risk factors

Tobacco useUnhealthy Diet

Physical InactivityHarmful Use of Alcohol

Interventions: Population- or individual- based measures ('best-buys') that are very cost-effective, feasible and low-cost

The UN POLITICAL DECLARATION ON NCDs commits Member States


Raised blood pressure

25%

Salt/sodium intake

30%

Tobacco smoking30%

Physical inactivity10%

Obesity0%

Fat intake15%

Alcohol10%

Raised cholesterol

20%

Generic medicines and technologies

80%

Drug therapy and

counselling50%

Premature mortality from NCDs25% reduction

Target adopted by the World Health Assembly

Targets with wide support Targets with support for further development

11 voluntary global targets presented in the revised WHO Discussion Paper


Epidemiological models - Tobacco use & Malaria infection

Tobacco Industry - A Mutating Vector


Manoeuvering to hijack the political and

legislative process

Exaggerating the economic importance of the industry

Manipulating public opinion

to gain the appearance of respectability

Fabricating support

through front groups

Discrediting proven science

Intimidating governments with litigation or the threat of litigation

Forms of Tobacco Industry Interference

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.

WHO FCTC ARTICLE 5.3


"As a tool for fighting back, we have the WHO FCTC. We have a

practical, cost-effective way to scale up implementation of

provisions in the treaty on the ground. […] the best-buy and

good-buy measures for reducing tobacco use set out in

the MPOWER package."

"And we have an enemy, […] the tobacco industry, has changed its face and its tactics. Tactics aimed at undermining anti-tobacco campaigns, and subverting the WHO FCTC, are no longer covert or cloaked by an image of corporate social responsibility. They are out in the open and they are extremely aggressive"

"[…] full implementation of the WHO FCTC would deliver the

single biggest preventive blow to heart disease, cancer, diabetes,

and respiratory disease."

"I called on heads of state and government to stand rock-hard against the despicable efforts of the tobacco industry to subvert this treaty."

Dr Margaret Chan, Director-General of the World Health OrganizationKeynote address at the 15th World Conference on Tobacco or Health, Singapore, 20 March 2012

"We have evidence, and we have instruments"


TOBACCO FREE INITIATIVETOWARDS A TOBACCO FREE WORLD

preventive interventions: the cost-effective “best-buys”

Health & Medicine

costeffective bestbuysriyadh

tobacco kills tobacco

muchworse tobacco

exposureto tobacco smoke

tobacco control riyadh

prevalence of tobacco

fctcpreventive interventions

tobacco epidemic todaysource