Tobacco in Latin America:The Challenges and the Opportunities

Neal Brandes, MHSDonald Sharp, MD

USAID andOffice on Smoking and Health

National Center for Chronic Disease Prevention and Health PromotionCenters for Disease Control and Prevention

While staffing, programmatic, and financial constraints preclude large scale anti-tobacco efforts, USAID will:

• contribute to policy/ program discussions in international and national fora

• strengthen appropriate linkages between global anti-tobacco efforts and relevant performance goals in the Agency Strategic Plan

• have the latitude in Missions and AID/W to design and implement high impact anti-tobacco activities to attain objectives and that are consistent with the Agency Strategic Plan and other USG policies

• not support tobacco production or related agribusiness

Source: ADS 210

USAID Guidance on Tobacco

WHO has convened its member states to negotiate the first international health treaty that will be submitted to national governments as early as 2002

• advocacy opportunity on the healthburden of tobacco

• tool to assist national governmentsto access resources and organizetobacco control efforts

• coordinate actions and facilitateevidenced based practice acrossborders

Framework Convention for Tobacco Control

"The Challenges"

Cultural, PoliticalEconomic, and

Historical

Agent

Vector Host

Incidental Host

Tobacco ProductManufacturers

Smoker / Chewer

Tobacco Products

InvoluntarySmoker

Environment

Global Tobacco Use Trends

LAC Tobacco Use

Health Effects

Economic Effects

The Tobacco Industry

"The Opportunities"

Framework Convention for Tobacco Control

Effective tobacco interventions

Potential to integrate interventions into existing activities

Tobacco Addiction Starts Early in Life

Source: Chinese Academy of Medicine 1997, Gupta 1996, US Surgeon General Reports, 1989 and 1994, Authors’ calculations

Every day 80,000 to 100,000 youths become regular smokers

China (males,1996)

India (males, 1995)

US (both sexes, born 1952-61)

US (both sexes, born 1910-14)

0

20

40

60

80

100

15 20 25

Age

Cu

mu

lati

ve u

pta

ke in

pe

rce

nt

World Health Organization

Tobacco is predicted to be the leading cause of disease burden in the world.”

In 1995

By 2030

A Model of the Cigarette Epidemic

Source: WHO, 1995

Summary of Global Tobacco Mortality

Since 1950, tobacco has killed more than 60 million people in developed countries

Now, four million deaths worldwide per year

By about 2025, ten million deaths per year

– 3 million in developed countries

– 7 million in developing countries

Half a billion peoplenow alive will be killedby tobacco products

Adult Smoking Prevalence in Latin America

0

10

20

30

40

50

60

70

Pe

ru

Bra

zil

Ha

iti

Me

xico

Bo

livia

Do

mic

an

Re

pu

blic

Ec

ua

do

r

El S

alv

ad

or

Gu

ate

ma

la

Ho

nd

ora

s

Nic

ara

gu

a

Pa

rag

ua

y

Pe

rce

nt

Male Female

Percent Change in Cigarette Consumption during 1990-1999 for Selected LAC

28

-39

22

70

21

-74

2 3 0

-11-12-28

-58

-100

-80

-60

-40

-20

0

20

40

60

80

100

Arg

en

tina

Brazil

Co

lom

bia

Ch

ile

Co

sta R

ica

Do

min

ican

Rep

ub

lic

Ec

uad

or

Gu

atem

ala

Mexico

Ve

nezu

ela

Pe

ru(90

-97)

Pa

rag

ua

y (96-9

9)

Uru

gu

ay (96

-99)

% c

ha

ng

e

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793

550

209

348

249

34 61

484

342

5397

627

439

82145125

0

200

400

600

800

1000

Lung Cancer Ischaemic Cerebraovascular COPD

tho

usa

nd

s

1990

2000

2010

2020

Number of Deaths from Various Diseases in LAC

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Children and Tobacco

• Exposed to ETS and maternalsmoking before birth

• Contributes to low birth weight

• Exposed to ETS during infancy and childhood

– Half of all children, 700 million,live with smoker

• Household money spent on tobacco instead of education and medical care

• Emotional pain and financial insecurity from loss of a parent who dies early due to tobacco.

• 250 million children alive in the world today will eventually be killed by tobacco

• Environment must change: non-smoking should be the social norm and easy choice

ETS Increases the Risk of Many Childhood Diseases

• Pneumonia, coughs and colds, croup, bronchitis, and bronchiolitis

• Asthma: new onset

• Asthma attacks: increased frequency and severity

• Impaired lung function, future respiratory problems

• Middle-ear infections, which can lead to reduced hearing

• Sudden infant death syndrome (SIDS), especially if mother smokes during pregnancy

Source: World Health Organization, United States EPA, California EPA

Global Youth Tobacco Survey, Ages 13-15, 1999

22.5

44.4

32.8

21.9

43.5

34.7

0

10

20

30

40

50

60

Prevalence of current smoking Exposure to environmental tobaccosmoke at home

Pe

rce

nt

Barbados

Costa Rica

Venezuela

Which Interventions are Effective?

Measures to reduce demand

• Higher cigarette taxes

• Non-price measures: consumer information, cigarette advertising and promotion bans, warning labels and restrictions on public smoking

• Increased access to nicotine replacement (NRT) and other cessation therapies

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Recent Trends in Cigarette Consumption and Real Price/Pack in Venezuela, 1994-1998

0

2,000

4,000

6,000

8,000

10,000

1994 1995 1996 1997 1998

mill

ion

pie

ces

0

5

10

15

20

25

30

rea

l pri

ce/

pa

ck o

f 2

0

million pieces real price/pack

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Non-price Measures to Reduce Demand

• Increase Consumer Information: health effects of ETS and active smoking, benefits of cessation, dissemination of research findings, warning labels, counter-advertising

• Comprehensive ban on advertising and promotion

• Restrictions on smoking in public and work places

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NRT and Cessation Therapies

• NRT doubles the effectiveness of cessation efforts

• Governments may widen access to NRT and other cessation therapies by:

– reducing regulation

– conducting more studies on cost-effectiveness (especially in low/middle income countries)

– considering NRT subsidies for poorest smokers

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Per Capita Cigarette Consumption TrendsFour Comprehensive Program States versus U.S. Total, 1984-1999

0

20

40

60

80

100

120

84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99

July 1 - June 30 Fiscal Year

Pac

k S

old

Per

Cap

ita

Program Implementation

4 States withComprehensivePrograms

US Total

Interventions that May be Less Effective at Reducing Consumption

MOST MEASURES TO REDUCE SUPPLY

• Prohibition

• Youth access restrictions

• Crop substitution

• Trade restrictions

• Control of smuggling is the only exception and it is the key supply-side measure

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Summary of General Recommendations

• Advocacy for FCTC

• Governments: adopt multi-pronged strategy, tailored to each country

• Cigarette tax increases: 2/3 to 4/5 of retail price

• Consumer information, research, advertising and promotion bans, warning labels and restrictions on public smoking

• Widen access to NRT and other cessation therapies

• International Agencies: review policies, sponsor research and programs, address cross-border issues and support the FCTC

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Possible USAID Tobacco Control Interventions in LAC

• Background setting in LAC

– Tobacco control (TC) efforts complement programs in other areas

– Limited resources for new initiatives

– Wide variety of interest levels among LAC countries

• Begin with integrating TC into ongoing programs

– Framework Convention on Tobacco Control

– Behavior Change Communication

– Family Planning/reproductive health

– Maternal & child health

– Adolescent health

– Healthy People/Healthy Cities

– Tuberculosis control

Illustrative Tobacco Control Interventions

• Demographic Health Surveys

• Global Youth Tobacco Surveys

• General education messages about tobacco

– Include with other mass media education programs

– Counter-advertising messages if funds allow

• Prevention messages for youth and youth adults

– Need for research on country-specific prevention messages

– Education about association with other high-risk behaviors

– Comprehensive school health programs

– Parental, community, and health professional involvement

Illustrative Tobacco Control Interventionscontinued

• Cessation messages and support

– Pre- and post-natal clinics

– Pediatric clinics

– Comprehensive school health programs

• ETS messages: health effects and importance of avoiding exposure

– Pre- and post-natal clinics

– Pediatric clinics

– Increase smoke-free public schools, transportation, buildings, and worksites

Resources for Tobacco Control Technical Assistance and/or Information

CDC www.cdc.gov/tobacco

PAHO www.paho.org

WHO www.who.org

www.tobacco.org

Smoking Prevalence by Education Level in Peru, 1997

0

10

20

30

40

50

60

70

no education primaryeducation

secondaryschooling

universityeducation

pre

vale

nc

e ra

te

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Integration of Tobacco Control Interventions with Tuberculosis Programs

• Integrate global TB and tobacco programs

– Inclusion of tobacco screening and cessation to DOTS and DOTS Plus strategies

– Prioritization for the treatment of tobacco dependence among TB patients

• Increase awareness of the interaction between tuberculosis and tobacco use

• Provide ongoing research on the association between tuberculosis and tobacco use

Global Youth Tobacco Survey in LAC

• 1999Barbados, Costa Rica, Venezuela

• 2000Argentina, Brazil, Caribbean Islands, Chile, Columbia, Dominican Republic, Guatemala, Mexico, Peru

• 2001Brazil, Colombia, Ecuador, Panama, Haiti, Guatemala, Dominican Republic, Jamaica

Total Lung and BronchusAge-Adjusted Cancer Rates

50

55

60

65

70

75

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

California Cancer Registry (CCR)

Surveillance, Epidemiology, and End Results (SEER)

Rate per 100,000

Trends Between Real Cigarette Price and Consumption in Argentina, 1989-1995

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1989 1990 1991 1992 1993 1994 1995

Rea

l pri

ce/

pac

k

48

50

52

54

56

58

60

62

Pa

ck o

f C

on

sum

pti

on

/ca

pit

a

Real Price Consumption/capita

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