Tobacco Control: developing and implementing a national program E Tursan d’Espaignet S Pujari Comprehensive Information Systems for Tobacco Control Tobacco Free Initiative WHO Geneva tursandespaignet@who.int, pujaris@who.int,

A property of tobacco "… tobacco is the only legal product that maims and kills a large proportion of its users when used exactly as intended by the manufacturer"

Set of 9 voluntary global targets Raised blood pressure 25% Salt/ sodium intake 30% Tobacco Physical inactivity 10% Harmful use of alcohol Drug therapy and counseling 50% Premature mortality from NCDs 25% reduction Mortality morbidity and Risk factors National systems response Diabetes/obesity 0% 25% relative reduction in overall mortality from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases Indicator Unconditional probability of dying between ages 30 and 70 from, cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases

Set of 9 voluntary global targets Raised blood pressure 25% Salt/ sodium intake 30% Tobacco Physical inactivity 10% Harmful use of alcohol Drug therapy and counseling 50% Premature mortality from NCDs 25% reduction Mortality morbidity and Risk factors National systems response Diabetes/obesity 0% 30% relative reduction in prevalence of current tobacco use in persons aged 15+ years Indicators 1. Prevalence of current tobacco use among adolescents 2. Age-standardized prevalence of current tobacco among persons aged 18+ years

Global monitoring framework, including indicators (paragraph 61) and voluntary global targets (paragraph 62) Mortality between ages 30 and 70 due to CVD, cancer, diabetes, or chronic respiratory disease 25% relative reduction Indicators with targets Raised Blood Pressure 25% relative reduction Tobacco 30% relative reduction Salt/sodium 30% relative reduction until 5gm/day Physical inactivity 10% relative reduction Overweight/obesity (adult, child, adolescent) Policies to virtually eliminate trans fats and to reduce marketing of unhealthy foods to children Raised total cholesterol Other WHO core indicators Cervical cancer screening Raised blood glucose/diabetes Vaccination: HPV, Hepatitis B Adult per capita consumption of alcohol and heavy episodic drinking Availability of basic technologies and medicines Low fruit and vegetable intake Access to palliative care Cancer incidence, by type Multidrug therapy for CVD risk reduction Other country-specific indicators of NCD and related issues including social determinants of health

Proposed global tobacco target under consideration by Member States Indicator: Prevalence of current tobacco smoking among persons aged 15+ years Target: 30% relative reduction in prevalence of current tobacco smoking between 2010 and 2025 Example: Prevalence for country X in 2010 = 20% Absolute reduction by 2025 = 30% of 20% = 6% Target for 2025 = 20 -6 = 14%

The Antidote: The WHO FCTC Carefully constructed comprehensive antidote aimed at controlling demand for and supply of tobacco products The target to be achieved through full implementation of the WHO FCTC and, (in particular, demand reduction measures including high tobacco product tax, large pictorial health warning labels, comprehensive smoke-free legislation, and bans on all forms of tobacco advertising, promotion and sponsorship).

Protect people from tobacco smoke through smokefree environments 14 mpower: A package of measures each reflecting one or more provisions of the WHO FCTC Articles Description 20 Monitoring 8 Protect people from tobacco smoke through smokefree environments 14 Offering help to quit 11 & 12 Warning about dangers of tobacco 13 Enforcing bans on promotion, sponsorship and advertising 6 Raising taxes on tobacco

Assessing implementation of demand reduction tobacco control policies WHO report on the global tobacco epidemic, 2011                                               Assessing implementation of demand reduction tobacco control policies 2008 Report 2009 Report 2011 Report

m: HOW TO GET TO THE TOP AND STAY THERE WHO and CDC provide assistance with surveys such as - Global Youth Tobacco Survey Global School Health Survey Global Adult Tobacco Survey STEPwise Survey - Tobacco Questions for Surveys (to be included in other surveys) 11

m: Evaluation of Monitoring Status 12

m: How would you assess monitoring status in 2008 Global Report Your country has done: a national Youth Tobacco Survey in 2001 and 2004 A national Adult tobacco survey in 2003 and 2007 (Global Adult Tobacco Survey, STEPS, National Health Survey) 13

m: Example of Monitoring status in 2008 Global Report Your country has done: a national Youth Tobacco Survey in 2001 and 2004 A national Adult tobacco survey in 2003 and 2007 (Global Adult Tobacco Survey, STEPS, National Health Survey) 14

m: How would you assess the same information for the 2010 Global Report Your country has done: a national Youth Tobacco Survey in 2001 and 2004 A national Adult tobacco survey in 2003 and 2007 (Global Adult Tobacco Survey, STEPS, National Health Survey) 15

m: Example of Monitoring status in 2010 Your country has done: a national Youth Tobacco Survey in 2001 and 2004 A national Adult tobacco survey in 2003 and 2007 (Global Adult Tobacco Survey, STEPS, National Health Survey) 16

http://www.who.int/tobacco/surveillance/policies/en/index.html

p: Evaluation of Smoke free Status 22

Examples of Protection against SHS interventions Smokefree public places - restaurants, bars, public transport, health care facilities, indoor work places, etc Examples: Australia: Illegal to smoke in a (private) vehicle with a minor present Mauritius; Illegal to smoke in a (private) vehicle if another person present 23

Evidence on support for protection against SHS Legislation implemented Legislation passed

o: Evaluation of Dependence Treatment Status 25

Warning against dangers of tobacco exposure Legislate for adequate warnings on packets of cigarettes - both sides covering average of 50% - selected effective fonts and colours and all local languages - rotating images

Attitude Towards Warnings Pack warnings are effective, especially with pictures and covering half of pack Most people are unaware of full range of health risks from tobacco use, second-hand smoke exposure Anti-tobacco ads help change image of smoking Latest approaches: Consideration of plain packaging Australia and moves in France for same 3/4 approve of warnings More than half changed opinions 2/3 want to quit Most tobacco users do not understand the full extent of their health risk – because they haven’t been told People may know generally that tobacco use is harmful, but they thing they can reduce or stop tobacco use before health problems occur. The reality is that most tobacco users will be unable to quit, and up to half will die from tobacco-related illnesses Comprehensive, graphic warnings about the dangers of tobacco can change tobacco’s image, especially among adolescents and young adults Governments and NGOs should launch anti-tobacco counter-advertising campaigns in all forms of media to publicize the full extent of tobacco’s dangers Pictorial health warnings on the packaging of all tobacco products are one of the most effective types of warning. Use of pictures with graphic depictions of disease and other negative images has greater impact than words alone, and is critical in reaching the large number of people worldwide who cannot read. Strong health warnings on tobacco packages, particularly pictorial warnings, are an important information source for young people Impact of pack warnings in Brazil

Database of Images WHO Tobacco Free Initiative http://www.who.int/tobacco/healthwarningsdatabase/en/index.html 18 28

w: Evaluation of Health Warnings Status 29

Enforce legislation prohibiting advertising, promotion and sponsorship Adopt and apply effective and efficient legislation that prohibits all forms of advertising, promotion, and sponsorship, both Direct, and Indirect forms

Evidence on Impact of banning advertising Comprehensive advertising bans amplify effects of other interventions 9 times faster reduction in consumption with ban after 10 yrs

Examples of bans on advertising No billboards No television, radio, internet (difficult) No print media In Turkey, not allowed to show cigarette smoking on television - smoking blotted out 20 32

e: Evaluation of Bans on Advertising, Promotion & Sponsorship 33

Monitoring enforcement of banning ad bans Only 9% of the worlds population live in countries with strong advertising bans and other forms of promotion and sponsorship

Raise taxes: Increase price of tobacco through tax increases TFI led initiative: Assist Member States to increase the rate of taxation (two thirds to four fifths of the retail price) Increase in price Increase in revenues Reduction in consumption Examples Singapore (68%), Thailand (62%), Australia (62%) Only 6% of the world population live in countries where taxes account for more than 75% of the retail price WHO reviews the current tax structures and the potential to increase and improve (simpler, easy to administer) it with a view to decrease consumption and increase revenues. The World Bank recommends a tax of between two thirds to three quarters of the retail price.

Evidence of raising taxes on consumption and tax revenues Consumption of cigarettes Excise tax rate Excise tax revenues

r: Evaluation of Tobacco Tax levels 37

How can WHO-TFI help countries? Assess and build capacity to take action across: Monitoring of prevalence and outcomes Protect against second hand smoke Offer help to quit Warn against dangers of tobacco Enforce legislation against advertising and promoting tobacco Raise taxes so that they make up at least 75% of retail price 25 38

The Tobacco Epidemic Using data from 2004 mortality recoWHO currently estimates just under six million deaths each year or one death every six seconds Will cause the death of more than 8 million people in the year 2030 or one death every four seconds Likely result in more than one billion deaths (1,000,000,000 deaths) during the 21st century http://www.who.int/tobacco/publications/surveillance/rep_mortality_attributable/en/index.html

Thank you tursandespaignet@who.int 37 40