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Tuesday, March 2, 2010

Global Tobacco Epidemic

100 million dead in the 20th century. Currently 5.4 million deaths every year. Unless urgent action is taken: By 2030, there will be more than 8 million deaths every year. By 2030, more than 80% of tobacco deaths will be in developing countries. One billion estimated deaths predicted during the 21st century.

The above statistics are scary, indeed. "Reversing this entirely preventable epidemic must now rank as a top priority for public health and for political leaders in every country of the world," according to Dr Margaret Chan, WHO Director-General.

Tobacco is the only legal consumer product that can harm everyone exposed to it–and it kills up to half of those who use it as intended. Yet, tobacco use is common throughout the world due to low prices, aggressive and widespread marketing, lack of awareness about its dangers, and inconsistent public policies against its use. Most of tobacco’s damage to health does not become evident until years or even decades after the onset of use. So, while tobacco use is rising globally, the epidemic of tobacco-related disease and death has just begun.

The global consensus that we must fight the tobacco epidemic has already been established by more than 150 Parties to the WHO Framework Convention on Tobacco Control. Now, the WHO Report on the Global Tobacco Epidemic gives countries a roadmap that builds on the WHO Framework Convention to turn this global consensus into a global reality through MPOWER, a package of six effective tobacco control policies.

To support MPOWER, WHO and its global partners are providing new resources to help countries stop the disease, death and economic damage caused by tobacco use. When implemented and enforced as a package, the six policies will prevent young people from beginning to smoke, help current smokers quit, protect non-smokers from exposure to second-hand smoke and free countries and their people from tobacco’s harm.

The MPOWER package entails:

Monitor tobacco use and prevention policies. Assessment of tobacco use and its impact must be strengthened. Currently, half of countries – and two in three in the developing world – do not have even minimal information about youth and adult tobacco use. Data on other aspects of the epidemic, such as tobacco-related disease and death, are also inadequate. Good monitoring provides information about the extent of the epidemic in a country, as well as how to tailor policies to specific country needs. Both global and country-by-country monitoring are critical to understanding and reversing the tobacco epidemic.

Protect people from tobacco smoke. All people have a fundamental right to breathe clean air. Smoke-free places are essential to protect non-smokers and also to encourage smokers to quit. Any country, regardless of income level, can implement smoke-free laws effectively. However, only 5% of the global population is protected by comprehensive smoke-free legislation. In most countries, smoke-free laws cover only some indoor spaces, are weakly written or are poorly enforced. Once enacted and enforced, smoke-free laws are widely popular, even among smokers, and do not harm businesses. Only a total ban on smoking in public places and workplaces protects people from second-hand smoke and helps smokers quit.

Offer help to quit tobacco use. Most of the world’s more than one billion smokers – about a quarter of all adults – are addicted. Many want to quit, but few get the help they need. Services to treat tobacco dependence are fully available in only nine countries, with 5% of the world’s population. Countries must establish programmes providing low-cost, effective interventions for tobacco users who want to escape their addiction.

Warn about the dangers of tobacco. Despite conclusive evidence, relatively few tobacco users understand the full extent of their health risk. Comprehensive warnings about the dangers of tobacco can change tobacco’s image, especially among adolescents and young adults. Graphic warnings on tobacco packaging deter tobacco use, yet only 15 countries, representing 6% of the world’s population, mandate pictorial warnings (covering at least 30% of the principal surface area) and just five countries, with a little over 4% of the world’s people, meet the highest standards for pack warnings. More than 40% of the world’s population lives in countries that do not prevent use of misleading and deceptive terms such as “light” and “low-tar”, even though conclusive scientific evidence – which has been known to the tobacco industry for several decades – shows that such products do not reduce health risks. This first report has not assessed public education campaigns, which, if hard-hitting, sophisticated and sustained, are highly effective.

Enforce bans on tobacco advertising, promotion and sponsorship. The tobacco industry spends tens of billions of dollars world-wide each year on advertising, promotion and sponsorship. Partial bans on tobacco advertising, promotion and sponsorship do not work because the industry merely re-directs its resources to other non-regulated marketing channels. Only a total ban can reduce tobacco consumption and protect people, particularly youth, from industry marketing tactics. Only 5% of the world’s population currently lives in countries with comprehensive bans on tobacco advertising, promotion and sponsorship. About half the children of the world live in countries that do not ban free distribution of tobacco products.

Raise taxes on tobacco. Raising taxes, and therefore prices, is the most effective way to reduce tobacco use, and especially to discourage young people from using tobacco. It also helps convince tobacco users to quit. Only four countries, representing 2% of the world’s population, have tax rates greater than 75% of retail price. And although more than four out of five high-income countries tax tobacco at 51–75% of retail price, less than a quarter of low- and middle-income countries tax tobacco at this rate. A 70% increase in the price of tobacco could prevent up to a quarter of all tobacco-related deaths world-wide. A 10% price increase may cause a 4% drop in tobacco consumption in high-income countries and an 8% drop in low- and middle-income countries, with tobacco tax revenue increasing despite reduced consumption. Higher taxes can provide countries with funding to implement and enforce tobacco control policies and can pay for other public health and social programmes.

For 3.8 billion people living in the low- and middle-income countries for which information is available, total national tobacco control expenditure was only US$ 14 million per year. In contrast, tobacco tax revenue for these same countries was US$ 66.5 billion. In other words, for every US$ 5,000 in tobacco tax revenue, these countries spent about US$ 1 for tobacco control. Per capita expenditure on tobacco control in low- and middle-income countries with available information was less than one tenth of one cent and about a half a cent, respectively.

The MPOWER package provides tools to take action. What is needed now is the resolve by political leadership, governments and civil society in every country to adopt and enact these six policies that have been proven to reduce tobacco use and its resulting burden of disease and death. Citizens strongly support tobacco control measures, even in countries with high levels of tobacco use. In China, for example, the world’s largest producer and consumer of tobacco, a recent survey found that most urban residents support establishing smoke-free public places, banning tobacco advertising, promotion and sponsorship, and raising tobacco taxes.

Tobacco control is not expensive. Tobacco taxes increase government revenues. Enforcement of smoke-free laws and advertising, promotion and sponsorship bans do not require large expenditure. Cessation services can be integrated into the general health-care system.

To counteract the tobacco epidemic, countries must have the political will to adopt and enforce MPOWER. Despite strong evidence of effectiveness of and public support for tobacco control measures, only about one in five countries has fully implemented any of the key five policies – smoke-free environments, treatment of tobacco dependence, health warnings on packages, bans on advertising, promotion and sponsorship, and tobacco taxation – at a level that provides full protection for their populations, and not a single country has implemented all six at the highest level. If countries implement and enforce MPOWER, they can prevent millions of people from being disabled or killed by tobacco.

Economics of Tobacco

Although the tobacco industry claims it creates jobs and generates revenues that enhance local and national economies, the industry’s overriding contribution to any country is suffering, disease, death – and economic losses. Tobacco use currently costs the world hundreds of billions of dollars each year.

Tobacco-related deaths result in lost economic opportunities. In the United States, these losses are estimated at US$ 92 billion a year. Lost economic opportunities in highly populated, developing countries – many of which are manufacturing centres of the global economy – will be severe as the tobacco epidemic worsens, because half of all tobacco-related deaths occur during the prime productive years. The economic cost of tobacco-related deaths imposes a particular burden on the developing world, where four out of five tobacco deaths will occur by 2030.1 Data on tobacco’s impact on global health-care costs are incomplete, but it is known to be high. In the United States, annual tobacco-related health-care costs are US$ 81 billion, in Germany nearly US$ 7 billion and in Australia US$ 1 billion.

The net economic effect of tobacco is to deepen poverty. The industry’s business objective – to get more customers addicted – disproportionately hurts the poor. Tobacco use is higher among the poor than the rich in most countries, and the difference in tobacco use between poor and rich is greatest in regions where average income is among the lowest.

For the poor, money spent on tobacco means money not spent on basic necessities such as food, shelter, education and health care. The poorest households in Bangladesh spend almost 10 times as much on tobacco as on education. In Indonesia, where smoking is most common among the poor, the lowest income group spends 15% of its total expenditure on tobacco. In Egypt, more than 10% of household expenditure in low-income homes is on tobacco. The poorest 20% of households in Mexico spend nearly 11% of their household income on tobacco. Medical costs from smoking impoverish more than 50 million people in China.

The poor are much more likely than the rich to become ill and die prematurely from tobacco-related illnesses. This creates greater economic hardship and perpetuates the circle of poverty and illness. Early deaths of primary wage earners are especially catastrophic for poor families and communities. When, for example, a 45-year-old Bangladeshi man who heads a low-income household dies of cancer from a 35-year bidi habit, the survival of his entire family is at stake. His lost economic capacity is magnified as his spouse, children and other dependants sink deeper into poverty and government or extended family members must take on their support.

Helping the addicts

People who are addicted to nicotine are victims of the tobacco epidemic. Among smokers who are aware of the dangers of tobacco, three out of four want to quit. Like people dependent on any addictive drug, it is difficult for most tobacco users to quit on their own and they benefit from help and support to overcome their dependence.

Countries’ health-care systems hold the primary responsibility for treating tobacco dependence. Treatment includes various methods, from simple medical advice to pharmaco-therapy, along with telephone help lines known as quit lines, and counselling. These treatment methods have differing cost efficiencies, and do not have a uniform impact on individual tobacco users. Treatment should be adapted to local conditions and cultures, and tailored to individual preferences and needs.

In most cases, a few basic treatment interventions can help tobacco users who want to quit. Three types of treatment should be included in any tobacco prevention effort: (i) tobacco cessation advice incorporated into primary health-care services; (ii) easily accessible and free quit lines; and (iii) access to low-cost pharmacological therapy.

Integrating tobacco cessation into primary health care and other routine medical visits provides the health-care system with opportunities to remind users that tobacco harms their health and that of others around them. Repeated advice at every medical visit reinforces the need to stop using tobacco.

Well-staffed quit lines should be accessible to a country’s entire population through toll-free phone numbers and waivers of access charges for mobile phone users. Quit lines are inexpensive to operate, easily accessible, confidential and can be staffed for long hours; many tobacco users may be unable or unwilling to call during business hours. Quit lines also can help introduce users to other tobacco dependence treatment, such as counselling and nicotine replacement therapy. Additionally, quit lines can reach individuals in remote places and can be tailored to specific population groups. For example, the United Kingdom’s Asian Quit Line receives 20 000 calls a year and reaches 10% of all South Asian tobacco users in that country.

In addition to medical advice and quit lines, effective treatment can also include pharmacological treatment such as nicotine replacement therapy in the form of patches, lozenges, gum and nasal sprays, and prescription medications such as bupropion and varenicline. Nicotine replacement therapy is usually available over-the-counter, whereas other drugs require a doctor’s prescription for them to be dispensed.

Nicotine replacement therapy reduces withdrawal symptoms by substituting for some of the nicotine absorbed from tobacco. Bupropion, an anti-depressant, can reduce craving and other negative sensations when tobacco users cut back or stop their nicotine intake. Varenicline attaches to nicotine receptors in the brain to prevent the release of dopamine, thus blocking the sensations of pleasure that people can experience when they smoke.

Pharmacological therapy is generally more expensive and considered to be less cost effective than physician advice and quit lines, but it has been shown to double or triple quit rates.

Cessation programmes provide a significant political advantage by enabling governments to help those most directly affected by the epidemic at the same time that they are enacting new restrictions on tobacco. They generally encounter few political obstacles and help foster a national policy of opposition to tobacco use, an important step in creating a tobacco-free society. Governments can use some tobacco tax revenues to help users free themselves from addiction.

New Zealand provides a good example for government action. Following a lobbying campaign by the tobacco control community, the country went from offering virtually no tobacco cessation treatment to one of the world’s most advanced initiatives in only five years, with government spending on smoking cessation rising from almost zero to US$ 10 million per year. The initiatives include a national quit line that is now one of the busiest in the world, subsidized nicotine replacement therapy and quit services focusing on the minority Maori population.

Implementation status

Only 86 of 193 Member States have recent, nationally representative data for both adults and youths. More than half of the world’s population lives in areas that lack even minimally adequate recent information on tobacco use. Monitoring systems are particularly weak in low- and middle-income countries; high-income countries are more likely to collect at least minimally adequate monitoring information (73% of countries) than are middle- (43%) or low-income (24%) countries. However, basic monitoring need not be expensive, and is within reach of virtually all countries.

In 44 of the 127 countries with recent and representative adult surveys, data were collected through international survey tools such as the World Health Survey or WHO’s STEPwise approach to Surveillance (STEPS). Out of these 127 countries, 25 have sub-national Global Youth Tobacco Survey data and 68 have national Global Youth Tobacco Survey data.

Smoke-free environments are crucial for protecting the health of smokers and non-smokers alike, as well as for sending a clear message that smoking in public places is not socially accepted. Smoke-free laws protect workers from chemicals that cause cancer and change the way blood clots and flows to the heart, and they provide a strong incentive for smokers to quit. Only completely smoke-free places, without any indoor smoking areas and with effective enforcement, can protect workers and the public and also encourage smokers to quit. Exceptions make enforcement difficult and negate the effectiveness of smoke-free laws.

Although an increasing number of countries have passed legislation mandating smoke-free environments, the overwhelming majority of countries have no smoke-free laws, very limited laws or ineffective enforcement.

More than half of countries, accounting for nearly two thirds of the population of the world, allow smoking in government offices, workplaces and other indoor places. Consequently, most office workers worldwide are forced to breathe other people’s tobacco smoke. Only 24 (13%) of the 179 countries and 1 territory protect restaurant workers from tobacco smoke; although any country can implement smoke-free laws, the proportion of high-income countries with smoke-free restaurants (12 of 41, 29%) is more than three times higher than the proportion of low- and middle-income countries (and one territory) with similar measures (12 of 139, 9%).

Of the countries reporting smoke-free laws that are moderate or complete, only one third have even moderate levels of enforcement documented (scores of 3 or higher out of 10). Only four countries achieved a score of 8 or higher (out of 10 possible points) and only two countries – Uruguay and New Zealand – had both comprehensive smoke-free laws and an enforcement score of 8 or higher. Many countries with completely smoke-free environments are in Europe.

Some countries have made great strides protecting citizens from second-hand smoke. In March 2004, Ireland became the first country in the world to create and enjoy smoke-free indoor work-places and public places, including restaurants, bars and pubs. Within three months, Norway’s smoke-free legislation entered into force. Since then, these examples have been followed by many countries including Italy and Uruguay, along with many cities across the globe. Most people in Canada, Australia and the United States are protected by State or local smoke-free legislation.


In summary, only around 5% of the world’s population is covered by any one of the key interventions of effective advertising, promotion and sponsorship bans, smoke-free spaces, prominent pack warnings, protection from deceptive and misleading advertising, promotion and sponsorship, and cessation support. Governments collect more than US$ 200 billion in tobacco tax revenues and have the financial resources to expand and strengthen tobacco control programmes. Further tobacco tax increases can provide additional funding for these initiatives.

The number of people killed each year by tobacco will double over the next few decades unless urgent action is taken. But just as the epidemic of tobacco-caused disease is man-made, people – acting through their governments and civil society – can reverse the epidemic.

Tobacco is unique among today’s leading public health problems in that the means to curb the epidemic are clear and within our reach. If countries have the political commitment and technical and logistic support to implement the MPOWER policy package, they can save millions of lives.

Because the tobacco industry is far better funded and more politically powerful than those who advocate to protect children and non-smokers from tobacco and to help tobacco users quit, much more needs to be done by every country to reverse the tobacco epidemic. Unless urgent action is taken, more than one billion people could be killed by tobacco during this century.

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