The Challenge, and the Promise, of Global Tobacco Control

Thomas J. Glynn, PhD

American Cancer Society

Washington, DC

Presented at the International Quitline Institute, Seattle, Washington, USA - October, 2011

Preaching to the Converted

Singing to the Choir

Carrying Coals to

Newcastle

Africa's Malaria Death Toll Still "Outrageously High"

How AIDS Changed America

With so many competing interests, is tobacco

actually important as a global issue?

So, are the tobacco control advocates crazy?

Are they just convinced that “my disease is more serious than your disease?”

Are they blinded by zealotry?

OR…

Do they have facts that other people don’t?

The answer may be that they DO have the facts. Consider that, if unchecked, the tobacco pandemic could in this century:

Kill one billion (1,000,000,000) people Overwhelm cancer and cardiac hospital

units Ravage the social well-being and finances

of millions of families And kill 1 of every 10 people now alive

Why is Tobacco Control Important as

a Global Issue?

The Disease Consequences of Tobacco Use Are

Universal

Tobacco Related Cancers

Oral cavity and pharynx Esophagus Larynx Lung, trachea and bronchus Urinary bladder Renal pelvis Uterine cervix Pancreas Kidney

Tobacco Related Cardiovascular Diseases

Hypertension Ischemic heart disease Atherosclerosis Pulmonary heart disease Aortic aneurysm Stroke

Tobacco Related Respiratory Diseases

Chronic bronchitis Emphysema Asthma Pneumonia

Tobacco Related Pediatric Diseases

Low birth weight Respiratory

distress syndrome Sudden infant

death syndrome

Secondhand Tobacco Smoke Problems Heart Disease Lung cancer Asthma attacks Bronchitis and pneumonia

(especially children) Coughs and croup

(especially children) Middle ear infections

(children)

Conclusion of the U.S. Surgeon General—2004

“Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general.”

Smoking and Second-Hand Smoke Damage Every Part of the Body

Smoking

Second-Hand Smoke

Why Hasn’t Tobacco Control Received the Global Attention it Needs?1) Tobacco use is viewed as a

personal choice and a personal failing

2) Most victims of tobacco-related disease die and disappear quickly

3) Families and victims are often ashamed to discuss their tobacco use

4) The tobacco pandemic has developed slowly and insidiously

Why Hasn’t Tobacco Control Received the Global Attention it Needs? (continued)5) Tobacco is old news6) Few strong tobacco control

advocacy groups have arisen7) The global effects of tobacco

use – health and economic – are not well known

8) The multinational tobacco companies have controlled the playing field.

“Tobacco use is unlike other threats to global

health. Infectious diseases do not employ

multinational public relations firms. There are

no front groups to promote the spread of cholera. Mosquitoes have no

lobbyists.” WHO Zeltner Report, 2000

Factoid Time

Global Smoking Prevalence

There are currently 1.3 billion smokers in the world – there will be 1.7 billion in 2025

Asia has the highest smoking rates in the world with overall country rates of up to 47%. China alone has over 300 million smokers that consume more than 1.7 trillion cigarettes a year – about 67% of the male population and 4% of the female population are smokers

One-third of the global population age 15 and older smokes

Distribution of world’s smokers

36%

64%

Industrialized countries

Developing countries

15%

85%IndustrializedcountriesDeveloping countries

2000

2025

WHO World Health Report 1999.

Tobacco deaths in the Industrialized and Developing

World, 2000 and 2030

2.1

2.17

3

0123456789

10

2000 2030

mil

lio

ns

Industrialized countries

Developing countries

While tobacco-related deaths will only increase slightly in the industrialized world during the next 30 years, they will more than triple in the developing world.

Globally, more than 600,000 million people alive today – about 10% of the world’s population – will die from smoking-related causes; half of these victims are now children

Every eight seconds a person dies of a smoking-related disease

Cigarettes kill half of all lifetime users, with half of these dying in middle age – between 35 and 69 years old, their most productive years

Global Smoking Deaths

Global Smoking Deaths (continued)

1 in 10 adult deaths worldwide are smoking related

Smoking diminishes health in more than 50 ways, at least 20 of which are fatal

In 2000, 4.83 million deaths worldwide were attributable to smoking: 1.69 million from cardiovascular disease, 970,000 from COPD, and 850,000 from lung cancer. This number will rise to 10 million by 2030

Global Smoking Deaths (continued)

Smokers are twice as likely to die prematurely from any cause and 6.5 times more likely to die of lung cancer, compared to nonsmokers

No other consumer product is as dangerous or kills as many people when used as intended. Tobacco kills more than AIDS, legal drugs, illegal drugs, road accidents, murder, and suicide combined

Tobacco is expected to kill 8.4 million people annually by 2020, and 10 million people in 2030, if current consumption does not change

Economic Effects of Tobacco Use

By 2010, the WHO estimates the annual global cost of tobacco to be US$500 billion – a figure higher than the GDP of 174 of 192 UN members

Smoking-related costs can contribute up to 15% of total health-care costs in developed countries

Japanese male smokers, for example, incur 11% more medical costs than never smokers and have increased inpatient medical-care costs 33% higher in smokers than never smokers

Economic Effects of Tobacco Use (continued)

As much as ten percent of family income in some parts of the world is spent on tobacco, limiting needed expenditures on food, clothing, education, and shelter

A 1996 study – 15 years ago – estimated that total annual medical and social costs of tobacco use in Hong Kong were one-quarter of the total healthcare budget – and prevalence has risen since then

For nearly 50% of the world’s population, a pack of Marlboros costs approximately half of a family’s daily income

The tobacco pandemic is preventable and its effects reversible:

1) The global tobacco control community has identified those areas which must be

addressed in order to turn the tide of the tobacco pandemic

2) It is possible to document what the health and economic effects of turning the tide would be; and

3) We know what needs to be done

Good News

Framework Convention on Tobacco Control: First Treaty

Negotiated under WHO

Objective:

“to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke”

FCTC: History

May 1999: World Health Assembly Resolution

October 2000: First Intergovernmental Negotiating Body

February 2003: Final Intergovernmental Negotiating Body

May 2003: World Health Assembly Unanimous Approval

FCTC Milestones Entry into Force - February 27, 2005 Signature by Member States (180) Ratification by Member States (172)

representing 87% of World Population Conference of the Parties (COP):

1st Session February 2006, Geneva 2nd Session June 2007, Bangkok 3rd Session November 2008, Durban 4th Session November 2010, Punta del Este

Why is the FCTC important?

The FCTC is the world’s first treaty to address a public health issue.

The FCTC offers the best change to address tobacco control globally.

The FCTC has, and will continue to, generate tobacco control advocacy in every country in the world.

The FCTC Mantra

Sign

Ratify

Implement

Enforce

Evaluate

Measures Relating to the Reduction of the Supply of Tobacco

Illicit Trade in Tobacco Products (Art. 15) Sales to and by Minors (Art. 16)

Measures Relating to Reduction of Demand for Tobacco

Price and tax Measures (Art. 6) Protection from Exposure to Tobacco Smoke (Art.8) Regulation of Contents of Tobacco Products (Art. 9) Regulation of Tobacco Product Disclosures (Art.10) Packaging and Labeling of Tobacco Products (Art. 11) Education, Communication, Training and Public

Awareness (Art. 12) Tobacco Advertising, Promotion and Sponsorship (Art.

13) Tobacco Dependence and Cessation (Art. 14)

Salvo que los fumadores actuales lo dejen, las muertes por tabaco aumentarán

dramáticamente en los próximos 50 años

— Línea de base

— Si la proporción de adultos jóvenes que empiezan a fumar se reduce a la mitad para el año 2020

Si la consumición por adultos se reduce a la mitad para 2020

—

Año

Mu

erte

s p

or

tab

aco

(en

mill

on

es)

World Bank. Curbing the epidemic: Governments and the economics of tobacco control. World Bank Publications, 1999. p80.

Muertes por tabaco acumulativas estimadas entre 1950-2050 con diferentes estrategias de intervención

How Many Smokers Are Affected by Article 14?

There are 1.3 billion smokers worldwide More than 50% of these smokers – or more

than 650 million – want to stop This is equivalent to more than 200x the

entire population of Uruguay

Trends in cigarette consumption and lung cancer mortality, US, 1900-2005

0

1000

2000

3000

4000

5000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000Year

0

20

40

60

80

100

Num

ber

of c

igar

ette

s pe

r ca

pita

Lun

g ca

ncer

dea

th r

ate

per

100,

000

Cigarette Consumption

Lung CancerMen

Lung CancerWomen

FCTC – Article 14

Demand Reduction Measures Concerning Tobacco Dependence and Cessation

Each Party shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence.

50

FCTC – Article 14

Towards this end, each Party shall endeavor to: Design and implement effective programs aimed at promoting the

cessation of tobacco use, in such locations as educational institutions, health care facilities, workplaces, and sporting environments;

Include diagnosis and treatment of tobacco dependence and counseling services on cessation of tobacco use in national health and education programs, plans and strategies, with the participation of health workers, community workers and social workers as appropriate;

Establish in health care facilities and rehabilitation centers programs for diagnosing, counseling, preventing and treating tobacco dependence; and

Collaborate with other Parties to facilitate accessibility and affordability for treatment of tobacco dependence including pharmaceutical products pursuant to Article 22. Such products and their constituents may include medicines, products used to administer medicines and diagnostics when appropriate.51

KEY COMPONENTS OF A SYSTEM TO HELP TOBACCO

USERS QUIT

46. Quitlines. All Parties should offer quitlines in which callers can receive advice from trained cessation specialists. Ideally they should be free and offer proactive support. Quitlines should be widely publicized and advertised, and adequately staffed, to ensure that tobacco users can always receive individual support. Parties are encouraged to include the quitline number on tobacco product packaging.

Article 14 History/Timetable

53

July 2007: COP II calls for

background document on

tobacco dependence treatment

July 2007 – November 2008: FCTC Secretariat

develops background document

November 2008 – September 2009: FCTC Secretariat develops draft A14

guidelines

September 2009 – December 2009:

UK prepares updated, final A14 draft and submits it to FCTC Secretariat

March 2010 – November 2010: FCTC Secretariat

finalizes A14 text and submits it to all FCTC

Parties for consideration

November 2010 and beyond:

All FCTC Parties now obligated to

implement A14

November 2008: COP III accepts

background document and calls

for draft A14 guidelines

September 2009: 1st meeting of the

A14 Working Group, in Seoul, Korea,

considers A14 draft

February 2010: 2nd meeting of A14 Working Group, in

Auckland, NZ, finalizes A14 text

November 2010: COP IV meets in Punta del Este,

Uruguay, discusses and adopts A14

Article 14 Highlights

A14 is a guideline for the development of guidelines, not a guideline in itself

A14 text recognizes the interaction of A14 with Articles 6,8,11-13, 15 and 22

A primary principle of A14 is that tobacco dependence treatment is a key component of any national tobacco control program

All Parties to A14 must agree to develop national tobacco dependence treatment guidelines

Guidelines developed under A14 must meet the needs and circumstances of Parties at all income levels

All Parties to A14 must address tobacco use among their health care providers, especially physicians

54

Article 14 Highlights (cont.)

All Parties to A14 are encouraged to address tobacco dependence treatment at both the population and the individual level

All Parties to A14 are encouraged to use a stepwise, rather than simultaneous, approach to implementing all aspects of a national tobacco dependence treatment scheme

All parties to A14 must develop an evaluation plan, and adjust their approaches according to the results of this evaluation of their A14 implementation

55

Article 14 Challenges Strong draft guidelines from the A14 Working Group Parties interested and willing to support A14 at COP IV Approval of guidelines at COP IV Assuring effective implementation of the guidelines at the

country and regional levels Guidelines Monitoring and Evaluating Partnerships with groups at national, regional, and

international levels: Medical associations Scientific societies Businesses Others

Prevention of tobacco industry interference

56

• Sub- Saharan Africa

• China• Japan• Southeast Asia• Latin America• North Africa

• Eastern Europe

• Southern Europe

• Western Europe, UK• USA• Canada• Australia

Countries in each stage

Adapted from: Lopez AD, Collishaw NE, Piha T. A descriptive model of the cigarette epidemic in developed countries. Tobacco Control, 1994, 3:242-247.

STAGE 1 STAGE 2 STAGE 3 STAGE 4

Four Stages of the Tobacco Pandemic

Lung Cancer Incidence: Men

Micro/Poly=Micronesia/Polynesia; NZ=New Zealand; Temp=Temperate; Trop=Tropical.Adapted from Parkin et al. CA Cancer J Clin. 1999;49(1):33-64.

Number of Cases per 100,000 PopulationWestern AfricaEastern AfricaMiddle Africa

MelanesiaSouth Central Asia

Northern AfricaCentral America

Trop. South AmericaSouthern AfricaSoutheast Asia

CaribbeanWestern Asia

ChinaJapan

Other East AsiaAustralia/NZ

Micro/PolyWestern Europe

Temp. South AmericaSouthern EuropeNorthern Europe

2.24.9

6.57.8

12.012.9

19.324.1

29.129.729.830.5

34.738.9

40.447.6

52.554.155.1

58.859.1

69.6

0 20 40 60 80

North AmericaEastern Europe

Region

75.9

Incidence of Lung Cancer in Men by World Region

Lung Cancer Incidence: Women

Micro/Poly=Micronesia/Polynesia; NZ=New Zealand; Temp=Temperate; Trop=Tropical.Parkin et al. CA Cancer J Clin. 1999;49(1):33-64.

Incidence of Lung Cancer in Women by World Region

Number of Cases per 100,000 Population

Middle AfricaWestern AfricaEastern Africa

South Central AsiaNorthern Africa

MelanesiaWestern Asia

Trop. South AmericaSouthern Europe

Temp. South AmericaSouthern AfricaCentral AmericaWestern EuropeSoutheast Asia

CaribbeanEastern Europe

JapanOther East Asia

ChinaAustralia/NZ

Micro/PolyNorthern Europe

North America

Region

0.80.9

2.02.62.6

3.75.2

7.27.37.67.77.98.2

9.310.110.3

11.211.6

13.416.1

17.320.2

0 10 20 30 40

32.9

21st Century Tobacco Control Challenges

CHALLENGES TO INCREASE• Support for/adherence to the World Health

Organization Framework Convention on Tobacco Control

• Tobacco excise taxes/unit price of tobacco• Access to comprehensive treatment for

tobacco dependence• Media-based tobacco countermarketing

campaigns• Regulation of all tobacco products• Health warnings on tobacco packaging• Availability of tobacco health/economic

information to the general public• Primacy of health over commerce in trade

agreements• Basic and applied tobacco control research• Extent and accuracy of tobacco

epidemiologic data• Litigation aimed at the tobacco industry

CHALLENGES TO DECREASE• Physician and other health care

provider tobacco use• Targeting of women for increased

tobacco use• Exposure to secondhand smoke• Illicit trade and smuggling of tobacco• Duty-free and reduced-cost sales of

tobacco• Tobacco advertising, promotion, and

sponsorship• Misleading tobacco product

claims/descriptors• Targeting of youth for increased

tobacco use• Subsidies for tobacco production and

sales• Youth access to tobacco

Good News (continued)

1) What areas need to be addressed?

We need to INCREASE:

Support for the Framework Convention on Tobacco Control

Taxes/price of tobacco Access to affordable tobacco

dependence treatment Regulation of tobacco products

Good News (continued)

Size and strength of health warnings Primacy of health over trade Basic and applied research Litigation aimed at the tobacco industry Comprehensive tobacco control campaigns Collection of epidemiological data Availability of tobacco health and economic

information to the public

Good News (continued)

1) What areas need to be addressed?

We need to DECREASE:

Physician and other health care provider tobacco use

Targeting of women Exposure to secondhand smoke Cigarette smuggling

Good News (continued)

Duty free and other low cost sales of tobacco

Advertising and promotion of tobacco Misleading claims and descriptions Targeting of children and youth Youth access to tobacco Agricultural subsidies

Good News (continued)

Developing a new generation of tobacco control leaders Raising the profile of tobacco control on global health and

development agendas Considering strategic alliances with NCD efforts Harnessing and integrating modern communications

technology into global tobacco control efforts Developing new and more sophisticated methods of

tracking and countering the plans of the multinational tobacco companies

Focusing more effort on linguistic needs and culturally appropriate interventions

Promoting the development of strong advocacy skills Obtaining additional resources, both financial and in-kind.

Other Leading Challenges Included:

Good News (continued)

As many as 200 million premature deaths will be avoided in the next 50 years

Lung cancer could virtually disappear as a public health menace

Global heart disease risks would be reduced by as much as 25%

Over time, global life expectancy would rise by 3-5 years

Trillions of dollars will be saved from healthcare expenditures and redirected to research and public health

2) What will the effects of turning the tide be?

Thank you