The Role of Research in Tobacco Control Mark Parascandola, PhD, MPH Epidemiologist Tobacco Control Research Branch US National Cancer Institute

"cigarette smoking is a health hazard of sufficient importance … to warrant appropriate remedial action," This year marks half a century since the first report of the US Surgeon General on Smoking and Health. The report concluded that cigarette smoking caused lung cancer and other diseases and that the hazard was great enough “to warrant appropriate remedial action.” Similar reviews have been produced by experts around the world and there is now an overwhelming body of research documenting many adverse effects of tobacco use, as well as the effectiveness of tobacco control policies and interventions. Some countries – including the US and UK -- have seen dramatic reductions in tobacco use and related health effects over the past few decades. However, 50 years later, many research gaps remain, and new questions have appeared. 2

U.S. per capita cigarette consumption during this century and major events affecting trends First SG Report Cigarette Ad ban SG report on ETS First scientific studies linking smoking and lung cancer Master Settlement Agreement WW II FCC Fairness Doctrine Beginning of NS Rights Movement Great Depression There are important lessons to be learned from the history of the tobacco epidemic This chart shows the evolving pattern of overall cigarette consumption in the U.S. through the 20th century. Cigarette smoking increased dramatically in the first half of the century, as cigarettes became less expensive, more easily available, and widely marketed. In the 1950s as epidemiologic studies began to show a link between cigarette smoking and lung cancer. 1964 Surgeon Generals report on smoking and health marked a turning point. However, it was not the report itself, but the progression of new policies and programs to prevent smoking initiation and aid cessation, and the change in attitudes toward smoking in public places, that led to a sustained drop in cigarette consumption. WWI NRT goes OTC 3

IARC HANDBOOKS OF CANCER PREVENTION International Agency for Research on Cancer World Health Organization Volume 12 Methods for Evaluating Tobacco Control Policies IARC 2008

Evolution of U.S. Tobacco Control Efforts Information/education campaigns – helped some people to quit, but fewer than expected. Why? Tobacco is addictive, quitting not easy. Tobacco industry effectively countered under-resourced public health efforts. Provide help to individuals to quit and discourage youth from starting – some impact, but less than expected. Why? Both individual and environmental determinants of smoking behavior. Tobacco industry far more resources than public health to shape environment. Comprehensive efforts – focused on the individual and the broader environment, using multiple channels and approaches to all sectors of the social environment. When public health has resources to compete with tobacco industry, significant progress can be made. Comprehensive tobacco control programs have evolved over a period of decades. 1960s, following 1964 SG – provide the public with accurate information about smoking and this will discourage large numbers of people from smoking (warning labels, education programs) Result: some people did quit, but many fewer than was expected. Why? A. The tobacco industry and its vast marketing resources overwhelmed information from the public health community. B. Quitting is not easy. Because nicotine is addictive, simply telling people to stop smoking is not sufficient. By mid 1970s/1980s: A. Organized programs to help people quit (cessation clinics, medication). B. School-based programs to discourage youth from starting to smoke. These programs were important but also limited because they focused on creating change only at the individual level (focused on helping individuals to change behavior and make choices) However, as we saw in the ecologic model, environmental determinants of smoking behavior are just as powerful (peers, tobacco industry, media, policies, culture). Thus, a more comprehensive approach was needed. Source: NCI Tobacco Control Monograph No. 1. Strategies to Control Tobacco Use in the United States: A Blueprint for Public Health Action in the 1990’s. Dec. 1991. 5

Trends in age-standardized lung cancer death rate The lowest mortality was found in Utah (33.7 per 100,000 men and 16.9 per 100,000 women), and the highest mortality was found in Kentucky (111.5 per 100,000 men and 55.9 per 100,000 women). Jemal et al., JNCI; 2008, 100(23)

The Global Tobacco Control Laboratory Ongoing introduction of many new tobacco control policies driven by the Framework Convention on Tobacco Control (FCTC), but policies and timelines differ widely across countries Diverse and changing conditions in patterns of tobacco use, cultural and social attitudes, economic forces, and healthcare environments An enormous “natural experiment” is currently under way Opportunity for studying the impact of different policies in different environments and understanding what works Expanding tobacco control research and research capacity in the developing world is crucial to reducing the disproportionate burden of tobacco use and cancer.

Global Tobacco Epidemic Continuum But countries are at different stages along this continuum in experience the tobacco epidemic. Some are still experiencing a rise in tobacco use and have not yet seen the full impact of this trend on population health. However, this doesn’t mean that countries at the beginning of the curve are destined to follow the same trajectory as those high income countries at the far end of the spectrum (US, UK, Australia, etc). In fact, there is a great opportunity for prevention by intervening early to reduce smoking prevalence, particularly in sub-Saharan Africa where tobacco use rates remain relatively low.

Global Tobacco Mortality is Growing and Shifting to the Developing World Tobacco use kills about 6 million people annually worldwide. Tobacco-related deaths are expected to rise to 8 million by 2030, and more than 80% of deaths will occur in low and middle-income countries (LMICs). Countries increasingly face a “double burden” of disease: diseases of poverty and chronic diseases caused by risk factors such as tobacco use. http://www.who.int/tobacco/mpower/2009/en/index.html Tobacco use and exposure among women in LMICs is rising threatening to impede or reverse efforts to improve maternal and child health. 11

Challenges to Reducing Tobacco Use in LMICs Low public knowledge, lack of resources for increasing knowledge: High tobacco use rates among health professionals; training in tobacco control and prevention is uncommon Diverse and new tobacco products, both smoked and smokeless Inadequate resources for research, interventions (policy and program), and advocacy Resistance to tobacco control from governments who profit from tobacco sales or taxation Tobacco industry presence strong and may be increasing; trade and investment treaties empower tobacco industry and allies At the same time, tobacco control efforts in LMICs face substantial challenges distinct from those of high income countries.

International Tobacco Control Policy Evaluation Project (ITC) The ITC measures the psychosocial and behavioral impact of national level policies of the FCTC, studying: Health warning labels and package descriptors Smoke-free legislation Pricing and taxation of tobacco products Communication and education Cessation Tobacco advertising and promotion The International Tobacco Control Policy Evaluation Project (the ITC Project) is the first-ever international cohort study of tobacco use and the impact of tobacco control policies. Its overall objective is to measure the psychosocial and behavioral impact of key national level policies of the WHO Framework Convention on Tobacco Control (FCTC). The ITC project is one example of a methodology that takes advantage of this “natural experiment” to evaluate the impact of tobacco control policies. The ITC Project is a collaborative effort with international health organizations and policymakers in more than 20 countries so far, inhabited by more than 50% of the world's population, 60% of the world's smokers, and 70% of the world's tobacco users. This is a unique endeavor with support from many sources, but can serve as a model for research to evaluate tobacco control policies. Source: http://www.itcproject.org/about

NCI Monograph 19: The Role of Media “The total weight of evidence – from multiple types of studies, conducted by investigators from different disciplines, and using data from many countries – demonstrates a causal relationship between tobacco advertising and promotion and increased tobacco use.” NCI also has a role in synthesizing evidence and producing reports, such as our Tobacco Control Monograph series. Not to toot our own horn, but these sorts of documents, like reports of the US Surgeon General or WHO reports, can wield substantial authority. Monograph 19 was the first such government report to conclude that that tobacco advertising increases tobacco use. This may seem obvious, but having such documents is essential to countering opposition from the tobacco industry to large scale public health actions.

Research Needs and Opportunities Over the past decade there have been number of previous efforts to outline key research needs and opportunities to inform global tobacco control efforts, including FCTC implementation. One key role this consortium of cancer organizations and funders could play is to promote an ambitious, forward-looking research agenda to build the evidence base for tobacco control in LMICs. We have developed a preliminary set of research questions, drawing on previous efforts, as a starting point.

Research Questions and Opportunities Tobacco Products Understand the changing variety of tobacco products and their characteristics, from traditional locally-made products to large scale manufactured products Understand how products are produced, distributed, sold and marketed and how these factors influence tobacco use Understand the public health impact of alternative nicotine delivery systems, including e-cigarettes   Public Health Impact patterns of smoking behavior, product type, concurrent health risks, and the social and policy environment. Research to better estimate the burden of tobacco related disease in countries where robust data is lacking Understand how differences in products, patterns of use, population characteristics, and environment contribute to variations in risks of smoking around the world Behavior and Patterns of Use Research around how cultural and socioeconomic transitions contribute to changes in tobacco use, including increasing smoking among women where it is historically low Research on the factors that drive changes in smoking behavior among youth, including targeted marketing

Research Questions and Opportunities Effective Policies Understand how evidence-based policies are being implemented and their impact on tobacco use and health outcomes, including what are the most effective policies for a particular environment Research on the most effective tax structures and policies in different environments Interventions Research on development and evaluation of low-cost cessation interventions for resource poor environments and underserved populations Research to better measure and assess strategies to reduce secondhand smoke exposure for vulnerable populations, including non-smoking women and children Economics and Trade Research to assess the economic impact of tobacco use and to evaluate the economic impact of tobacco control measures Research on the interrelationships between tobacco and poverty Research to understand the impact of trade and investment agreements on tobacco control policies Research on the nature of tobacco farming and the potential for crop substitution