Tobacco Epidemic and PH Responses
Transcript of 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
Tobacco Atlas, 2012, www.tobaccoatlas.org
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)
Tobacco Atlas, 2012, www.tobaccoatlas.org
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Female Smoking Prevalence
(2010 or latest available)
Tobacco Atlas, 2012, www.tobaccoatlas.org
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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
Tobacco Atlas, 2012, www.tobaccoatlas.org
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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
Tobacco Atlas, 2012, www.tobaccoatlas.org
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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
Tobacco Atlas, 2012, www.tobaccoatlas.org
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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
Tobacco Atlas, 2012, www.tobaccoatlas.org
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
Tobacco Atlas, 2012, www.tobaccoatlas.org
$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
Tobacco Atlas, 2012, www.tobaccoatlas.org
http://www.tobaccopolicycenter.org/2012/01/11
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Undue Influence
Genius comes from hard work.
Tobacco helps you to be successful.
Tobacco Atlas, 2012, www.tobaccoatlas.org
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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
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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
GATS: Global Adult Tobacco Survey
65 million data points collected
representing 3.6 billion people!
Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspx
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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
GATS: Global Adult Tobacco Survey
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
GATS: Global Adult Tobacco Survey
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
Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspx
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
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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
Tobacco Atlas, 2012, www.tobaccoatlas.org
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
Tobacco Atlas, 2012, www.tobaccoatlas.org
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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
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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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http://www.cdc.gov/about/grand-rounds