Tobacco Control …

           Tobacco Control                                                                      at a glance


Why is reducing use of tobacco                            For example, 61% of Vietnamese smokers surveyed
                                                          in 1995 said they wanted to quit, and 44% had tried
a priority?                                               to quit (Jenkins et al, 1997). In China and in other
Tobacco is becoming one of the single biggest causes      developing countries, the average age at which
of death worldwide. By 2030 it is expected to kill 10     people begin to smoke is falling from early 20s to
million people per year; half aged 35-69. The             teens. Nicotine is highly addictive, so it is important
epidemic is increasingly affecting developing             to discourage smoking initiation, especially among
countries, where most of the world's smokers (82% or      young people. Because many of the expected deaths
950 million) live. Close to half of all men in low-       from tobacco use will be among the 1.1 billion
income countries smoke daily and this has been            people who now smoke, persuading and helping
increasing. For example, smoking prevalence among         people to quit is key to reducing disease and death
Chinese men increased from 40% in the 1950s to            from tobacco use.
63% in 1996 (Chinese Academy of Preventive
Medicine 1996). Women's smoking rates are also            The Framework Convention on
increasing fast. By 2030, developing countries will       Tobacco Control (FCTC)
account for 70% of all tobacco deaths. Many deaths
and much disease could be prevented by reducing           The FCTC was adopted by WHO member countries
smoking prevalence.                                       in May 2003. It will commit all countries that ratify it
                                                          to: eliminate all tobacco advertising, promotion and
Smoking and poverty. Episodes of ill health, the costs    sponsorship within 5 years (with a narrow exception
of health care, and premature death are frequently        for those nations whose constitutions prohibit a
cited by poor people as their gravest concerns, and       complete ban); require warning labels occupying at
as the precipitating cause that pushes families into      least 30% of the area of cigarette packs (and
poverty. Smoking prevalence tends to be higher            suggests 50% or more); prohibit misleading tobacco
among men with less education and lower incomes,          product descriptors such as "light" and "mild"; and
so they bear a greater health risk. Also, the             protect nonsmokers from tobacco smoke in public
opportunity cost of money spent on cigarettes is          places. The FCTC also urges strict regulation of
obviously higher for people living on low incomes ­       tobacco product contents; higher tobacco taxes,
money spent on tobacco products could help feed           global coordination to fight tobacco smuggling, and
families. Tobacco is often a significant part of family   promotion of tobacco prevention, cessation and
expenditure: low income households with at least one      research programs.
smoker in Bulgaria spent 10.4% of their total income
on tobacco products in 1995; urban households in          National tobacco control efforts are usually led by
Tibet spent 5.5% of their monthly disposable income       the Ministry of Health, associations of physicians and
on tobacco products in 1992; and in China, smokers        other health groups, or dedicated anti-smoking
in 2,716 households in Minhang district spent 17%         groups. NGOs, women's groups, youth groups,
of household income on cigarettes (Gong et al, JAMA       lawyers, economists and environmentalists play key
1995, 274:1232-4).                                        roles in some countries. Ministries of Finance,
                                                          Economic Planning and Taxation are important,
The harm from second-hand smoke to others,                because higher tobacco taxes are the single most
especially unborn and young children, further justifies   effective way to reduce use. Other stakeholders
intervening to reduce tobacco use. 710 million            include: Ministries of Agriculture and farmers,
children live in households where someone smokes          Ministries of Labor and Industry, employee groups,
(Lopez, WHO, 1999). Many smokers do not know              Ministries of Education, media, retailers, and sports
their risks, begin smoking at very young ages and         groups (sponsorship).
most later regret ever starting and would like to quit.




                                                                                                     June 2003
Cost Effective Interventions to reduce death and disease caused by tobacco use
Measures to reduce demand for tobacco products are highly cost effective ­ very high on the list of public health
"best buys"

Objective: Reduce tobacco use, to reduce death and disease caused by tobacco use.

Interventions                                           Beneficiaries/Target Groups                            Process Indicators
Higher taxes on cigarettes and other                    smokers                                                 price of cigarettes/bidis etc (adjust for
tobacco products                                                                                                 inflation)
                                                        potential smokers (especially youth)
                                                                                                                tax as % of final sales price

Non-price measures
Bans/restrictions on smoking in public                  non-smokers protected from second-hand                  smoke-free public spaces and places
and work places: schools, health                        smoke
facilities, public transport, restaurants,
cinemas etc.

Comprehensive bans on advertising and                   smokers and potential smokers                           laws, regulations, extent to which
promotion of all tobacco products, logos                (especially youth)                                       respected/enforced
and brand names1
                                                        societal attitudes to smoking

Better consumer information: counter-                   smokers and potential smokers                           knowledge of health risks, attitudes to
advertising, media coverage, research                                                                            smoking
findings                                                societal attitudes to smoking

Large, direct warning labels on                         smokers                                                 % of box surface covered by label,
cigarette boxes and other tobacco                                                                                message, color/font specifications
products
Help for smokers who wish to quit,                      smokers                                                 number of ex-smokers
including increased access to Nicotine
Replacement (NRT) and other cessation
therapies

Impact / surveillance Indicators for tobacco use (from survey data):

adult smoking prevalence: % of people 15 and older who use any tobacco product at least once a day (daily/regular smoker)
or occasionally, % who have ever smoked

intensity: average number of cigarettes (and other tobacco products) smoked/used daily

quit behavior: % who used to smoke, but currently do not smoke at all

youth use: % of young people who currently use any tobacco product (defined as having used a tobacco product on one or
more days during the past 30 days),

initiation age: age at which current and ex-smokers first started to smoke at least one cigarette a day

Note: A Global Youth Tobacco Survey is being implemented in many countries with support from WHO and CDC. See:
http://tobacco.int/en/youth/gyts/html (on the WHO website) or http://www.cdc.gov/tobacco/research_data/youth/gytsfact-
sheets.pdf (CDC website)




1
    If full bans are impossible, strong restrictions, and significant counter-advertising should be pursued.
The evidence shows:                                             might be considered, and/or targeted cessation
                                                                programs.
(useful information)
s   The best results are achieved when a comprehen-         s   Many smokers want to quit, and could use help.
    sive set of measures to reduce the use of tobacco           Most people who quit do so without help, but
    are implemented together. Many countries have               nicotine addiction makes quitting very hard. Quit
    succeeded in reducing smoking prevalence                    rates can be substantially increased through
    dramatically, and consequently reduced cancers,             advice from health care providers, telephone "quit-
    heart disease and other circulatory diseases,               lines", formal and informal support-groups, and
    respiratory diseases, and low birth weight                  cessation therapies including nicotine-replacement
    incidence.                                                  (NRT). Over-the-counter (non-prescription) sales
                                                                improve access to NRT. There are many potential
s   Price increases are the most effective and cost-            opportunities for cessation advice and support:
    effective deterrent ­ especially for young people           e.g. as part of TB treatment.
    and others with low incomes, who must, of
    necessity, be highly price responsive. A price rise     s   What works for youth? The most effective tool to
    of 10% decreases consumption by about 8% in                 reduce/deter use of tobacco products by young
    low- and middle-income countries. Higher taxes              people: price increases. Bans on tobacco product
    will generate additional government revenue.                sales to young people are difficult and costly to
                                                                enforce. Policies should be tailored to affect the
s   In almost all countries, as people switch expendi-          usual sources from which young people get their
    tures from tobacco to other goods, there will not           cigarettes or other tobacco products. For example,
    be net job losses. As demand for tobacco products           some countries have reduced youth access to
    falls, jobs lost in tobacco farming, manufacturing          tobacco products (especially cigarettes) by
    and distribution, are offset by new jobs created in         banning sales through vending machines. Free
    other sectors in response to changed expenditure            distribution of tobacco products and promotional
    patterns. Some countries (Malawi and Zimbabwe)              products (T-shirts, school note books etc) should be
    and areas within other countries whose economies            strictly banned.
    depend heavily on tobacco, may need help in
    adjusting to new consumption patterns.                  s   Health warnings on cigarette packages should be
                                                                large (cover at least 30% of the surface area and
s   Erosion in global demand for tobacco will                   preferably 50% or more), clear (e.g., black on
    probably be slow and gradual, in the face of                white), in local languages, and have a set of
    growing population numbers, rising incomes,                 specific required messages that change
    social norms, addiction, and advertising and                periodically. Information on the adverse health
    promotion of tobacco use.                                   impact of tobacco use and the benefits of quitting
                                                                should be widely disseminated.
s   Most measures to reduce supply are ineffective
    (prohibition, youth access restrictions, crop           s   The tobacco industry argues that advertising and
    substitution efforts and trade restrictions). Control       promotion affects market share and not overall
    of smuggling is the exception, and is the key               prevalence levels, but countries that have
    supply-side measure to pursue.                              implemented comprehensive bans on all
                                                                advertising and promotion have reduced tobacco
s   Will poor smokers be hurt by tobacco product                use much more quickly and to lower levels than
    price increases? Those who decide to quit or cut            other countries. Partial bans are not effective ­ if
    back their use of tobacco products will gain health         only a partial ban is politically feasible, then there
    and income. People who do not reduce or quit                is a very strong case for mandating counter-
    smoking in the face of price increases will pay             advertising (e.g the Fairness Doctrine in the USA,
    more. If this is an important issue, compensating           and in South Africa where the state radio
    tax/price cuts in other products (eg basic foods)           corporation gave free air time every day for anti-
                                                                smoking messages, while continuing to benefit
    from substantial cigarette advertising revenues.         cigarette sales. But there are many good success
s   Efforts to reduce smoking face formidable                stories that could be replicated with political will,
    obstacles: nicotine addiction; social pressures;         and broad support. Modest action could save
    aggressive cigarette marketing and promotion;            millions of lives and avert much disease, including
    other pressing health problems; overestimates of         among poor people, without long-term harm to
    the economic importance of tobacco; and the              economies.
    vested interests of those who live and profit by




Resources                                                s   http://worldbank.org/tobacco for economics of
                                                             tobacco notes on selected countries, country-
People in the World Bank and IMF                             specific data, slide presentations, useful websites
                                                             (see especially WHO/TFI and CDC)
s   HDNHE's tobacco team: Joy de Beyer, Ayda
    Yurekli, Sabrina Huffman. Maureen Law is the         s   Details of tobacco control activities in health
    HNP Sector Board member responsible for                  projects funded by World Bank from Sabrina
    tobacco. Email: jdebeyer@worldbank.org,                  Huffman, HDNHE, World Bank. Email:
    ayurekli@worldbank.org                                   shuffman@worldbank.org

s   IMF fiscal department (Peter Heller and Emil         s   A good data base of tobacco prevalence studies
    Sunley, for help in assessing the potential for          and other country-specific data is being developed
    tobacco tax increases and discussion with Ministry       by WHO/CDC/World Bank/American Cancer
    of Finance and other tax authorities.                    Society ­ available in July 2001 at
                                                             http://worldbank.org/tobacco also at CDC and
Documents and data                                           WHO/TFI websites

s   "Curbing the Epidemic: Governments and the           s   At a glance fact sheets on strong reasons to make
    Economics of Tobacco Control", World Bank,               smoke-free workplaces and how to go about doing
    1999. Development in Practice Series. On line at:        it, and on tobacco pack information are available
    http://worldbank.org/tobacco, or hard copy from          online at www.worldbank.org/phataglance and
    the Infoshop, or HDNHE's tobacco team. Short,            www.worldbank.org/tobacco
    readable and clear. Analyzes and summarizes the
    research and key economic and social issues          "How to" toolkit for analysis of economic issues
    relating to tobacco control. Also available in 18
    other languages, and a "key messages" summary        Explains in detail how to analyze tobacco
    brochure, and powerpoint slides are available.       price/consumption relationship, tax rates and
                                                         revenues, options for setting and administering
s   "Tobacco Control in Developing Countries", Jha       tobacco taxes, smuggling, employment, and impact
    and Chaloupka, OUP for the World Bank and            on the poor. Describes data needs and sources,
    WHO, 2000. Detailed background papers for            analytic model specification, and interpretation of
    "Curbing the Epidemic". Available online at          estimation results. Available (in draft) from World
    www.worldbank.org/tobacco                            Bank tobacco team, and at
                                                         www://worldbank.org/tobacco




 Expanded versions of the "at a glance" series, with e-linkages to resources and more information, are
 available on the World Bank Health-Nutrition-Population web site: www.worldbank.org/hnp