Curbing the Tobacco Epidemic in ECA Global, Regional and Country-base Evidence By Betty Hanan Senior Operations Officer World Bank World Bank ECA Regional PCU Conference, Warsaw, Poland September 9, 2001 In the ECA region and the rest of the world, there are millions of deaths and a huge burden of disease caused by tobacco use. Despite this, many governments have been afraid to try to discourage smoking, because they fear that the economy might suffer. A few years ago, the World Bank asked a group of expert economists to look carefully at the facts and the evidence to answer the question: "What is the economic impact of tobacco control?" A wealth of evidence, research and facts are clearly summarized in "Curbing the Epidemic: governments and the economics of tobacco control", published by the World Bank in English in 1999 (in Washington DC), and now, in May 2001, published in several languages, including Russian, Polish, Hungarian, Turkish for the World Bank. The "bottom line" of the study is that tobacco control could save millions of lives, without damage to most economies.

Why is Tobacco Control a Priority in the World? 1.1 billion smokers worldwide, 800 million smokers in developing countries. By 2030, tobacco is expected to be the single biggest cause of death worldwide, accounting for about 10 million deaths per year Burden is shifting towards developing world Globally, 80,000 to 100,000 youths start smoking every day Smokers do not know the risks Tobacco is addictive and difficult to quit About 1.1 billion people smoke worldwide. By 2025, the number is expected to rise to more than 1.6 billion. In the high-income countries, smoking has been in overall decline for decades. In low- and middle-income countries, by contrast, cigarette consumption has been increasing. Four million deaths this year, growing to ten million deaths annually by 2020 - more than the total deaths from malaria, tuberculosis, maternal and major childhood conditions combined. Smoking-related deaths used to be concentrated in high-income countries. But this is changing fast. By 2020, seven million of the ten million deaths will occur in developing countries, including here, in Hungary. Most smokers start young. In the high-income countries, about eight out of 10 begin in their teens. While most smokers in low- and middle-income countries start in the early twenties, the peak age of uptake in these countries is falling. Globally it is estimated that everyday 80,000 to 100,000 youth start smoking. Smokers clearly perceive benefits from smoking, such as pleasure and the avoidance of withdrawal, and weigh these against the private costs of their choice. But there is evidence that many smokers are not fully aware of the high risks of disease and premature death from tobacco use. Tobacco is addictive and it is difficult to quit without help.

1.1 Billion Smokers Worldwide (1990-1995 estimate, million) Males Females Total Developed 200 100 300 Developing 700 100 800 World 900 200 1.1 Bil. The number of smokers in low- and middle-income countries are increasing. Based on 1995 estimates 72% of - 800 million- worlds’ 1.1 billion smokers live in developing countries.

Burden of Tobacco Deaths Shifting World: Annual Tobacco deaths (in millions) 2000 2030 Developed 2 ~3 Developing ~2 ~7 World Total 4 ~10 1 in 2 of long-term smokers killed by their addiction 1/2 of deaths in middle age (35-69) Since 1950, tobacco has killed more than 60 million people in developed countries Tobacco killed 4 million people worldwide last year about 7% of all deaths. By about 2025, tobacco will be responsible for ten million deaths per year, and 70% of these deaths will happen in the developing world, and 30% - 3 million- in developed countries. By then, tobacco will cause almost 11% of all deaths in the developing world, and 17.7% of all deaths in developed countries. Half a billion people now alive will be killed by tobacco products, and half of the deaths will happen prematurely.

Why should Tobacco Control be a Priority in ECA? 150 million smokers live in the ECA region 12% of the world’s 1.1 billion smokers – 18% of smokers from developing countries. Tobacco attributable deaths and diseases are increasing fast in ECA region. Smokers in ECA region starts very early and smoke heavily compared to smokers in other regions Tobacco control measures are still not effective, or not implemented effectively in most ECA countries There is not enough tobacco control research and projects in the region. Tobacco epidemic is rapidly emerging in the ECA region, faster than any other region in the World. 12% of the world’s smokers live in the ECA region. Most smokers start early, ECA is not an exception, but youth become heavy smoker much faster in the ECA region. More and more countries in the ECA region are implementing tobacco control measures, but they are either not enough or implemented ineffectively. The World Bank has been supporting tobacco control research and projects but given the seriousness of the epidemic in the region, still more needs to be done.

Higher Smoking Prevalence in ECA Countries Almost all smokers in the ECA region, especially men are hooked to smoking. Women has been following their counterparts in developed countries by picking up smoking in the region. More than half of the male population are smoker in Bulgaria, Armenia, Turkey, Latvia, Belarus, Slovakia, Georgia, Kyrgyz Rep. And Russian Federation. Prevalence has been increasing in most of these countries.

Smoking Starts Early Source: WHO Smoking starts early. When the youth smoking prevalence is examined in ECA countries, there is a horrifying picture. In 1995, 56% and 21% of 14 to 16 yrs old boys and girls were smokers in Armenia. Similarly, in 1996, 14% of 7 to 13 years old boys and 9% of 7-13 yrs old girls were smoker in Turkey. Similar pictures can be seen in Belarus, Bulgaria, and Hungary where the data is available. These kids are the future adult smokers. Source: WHO

Heavy smokers: Youth Youth in ECA region does not only start smoking early, but also become heavy smokers at their youth. In 1999, 13% of 16 year olds were smoking 6 to 10 cigarettes a day in Bulgaria and 3% of 16 year old kids smoked 21 cigarettes a day. That level is much higher than adult consumption level in other parts of the world.

Higher cigarette consumption Smokers in ECA region smoked 16.3% of the world cigarette consumption where only 8% of the world population lives. Source: World Bank estimation

Heavy Adult Smokers in ECA On average smokers in Romania, Bulgaria, Poland and Czech Rep. smoke more than a pack per day. Source: World Bank estimation

Male Lung Cancer Mortality in Selected ECA Countries Age standardized rate/100,000 Tobacco is responsible more than 96% of lung cancer deaths. In ECA region, lung cancer mortality among men has been increasing and predicted to be increasing in the future, in Bulgaria, Former Yugoslavia, Romania, and Hungary. Given the high prevalence and level of smoking, this is not surprising. Source: International Agency for Research on Cancer

Smoking Attributable Deaths in Central Asia Countries In Central Asia, smoking was responsible for 34% of total deaths in Kazakhstan, 19% in Kyrgyz Rep., 13% in Uzbekistan, 6% in Tajikistan, and 12% in Turkmenistan in 1995. During 1985-95, smoking related deaths increased in Kazakhstan, Kyrgyz Rep., and Uzbekistan.

Which interventions are effective? Measures to reduce demand Higher cigarette taxes Non-price measures: Increase consumer information: dissemination of research findings, warning labels, counter-advertising Comprehensive ban on advertising and promotion Restriction on smoking in public and work places Cessation help (NRT) There is clear evidence to show what works, and what doesn’t in reducing tobacco use. The evidence from many countries points clearly to a set of tobacco control measures that are effective and very cost-effective in reducing the demand for tobacco products. Raising cigarette taxes is the most cost-effective measure to reduce cigarette consumption. In addition to raising the price, there are a range of other effective measures that governments could employ. These include comprehensive bans on advertising and promotion of tobacco; information measures such as mass media counter-advertising, prominent health warning labels, the publication and dissemination of research findings on the health consequences of smoking as well as restrictions on smoking in work and public places and increased access and affordability for nicotine therapy products and other cessation therapies.

Cessation Treatments Cessation support from health professionals is key NRTs double the effectiveness of cessation efforts Quit lines, community support, etc., work Governments may increase accessibility and affordability of NRTs by: Over the counter (OTC) sales, allowing advertising, licensing Conducting more studies on cost-effectiveness (especially in low/middle income countries) Considering NRT subsidies for poorest smokers Nicotine treatment therapies have a particular importance. There are 1.1 billion smokers around the world who are addicted to nicotine. Evidence show that large numbers of smokers want to quit smoking and have tried at least once to quit. It is important to help those who want to quit. Nicotine replacement therapy (NRT) and other cessation interventions markedly increase the effectiveness of cessation efforts and also reduce individuals’ withdrawal costs. Yet in many countries, NRT is difficult to obtain. If NRT were more widely available, it could help to reduce demand substantially. Evidence also shows that advice from health professionals to patients to quit can make a substantial difference, but there is also a clear need in many countries to reduce the number of smokers among health professionals themselves.

Health Professionals and Smoking in ECA But we need to educate our educated population first, especially our health professionals. In the ECA region, smoking prevalence among health professionals is very high. Source: World Health Organization

Tobacco Control Strength in ECA Region Low level Middle level High level Azerbaijan Armenia Bosnia and Herzego. Kazakhstan Albania Bulgaria Tajikistan Belarus Czech Rep. Turkmenistan Croatia Cyprus Georgia Estonia Kyrgyz Rep. Hungary Macedonia Latvia Moldova Lithuania Romania Poland Russian Fed. Slovenia Slovakia Ukraine Yugoslavia, FR (Serb/Mont) Uzbekistan Turkey When the tobacco control measures are examined, more and more countries are implementing tobacco control measures, but implementing such measures is the big question. World Bank Estimation

Key recommendations Governments: adopt multi-pronged strategy, tailored to each country Help current smokers by increasing access to cessation therapies Increase health professionals’ awareness and information, on tobacco related issues Increase tobacco control measures, ban advertising and promotion, restrict smoking in public and work places, restrict youth access to tobacco products, etc. Increase consumer information and tobacco control projects. Governments should adopt comprehensive tobacco control policies which are tailored to each country. Bans on smoking in workplaces and public spaces, comprehensive bans on advertising and promotion of tobacco products, better information to educated and uneducated population, health professionals, and consumers, and large and strong health warnings on packages all help reduce smoking significantly. Governments should support tobacco control projects to help smokers and smokers to be.