Tobacco in Latin America: The Challenges and the Opportunities Neal Brandes, MHS Donald Sharp, MD USAID and Office on Smoking and Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention

While staffing, programmatic, and financial constraints preclude large scale anti-tobacco efforts, USAID will: contribute to policy/ program discussions in international and national fora strengthen appropriate linkages between global anti- tobacco efforts and relevant performance goals in the Agency Strategic Plan have the latitude in Missions and AID/W to design and implement high impact anti-tobacco activities to attain objectives and that are consistent with the Agency Strategic Plan and other USG policies not support tobacco production or related agribusiness Source: ADS 210 USAID Guidance on Tobacco

WHO has convened its member states to negotiate the first international health treaty that will be submitted to national governments as early as 2002 advocacy opportunity on the health burden of tobacco tool to assist national governments to access resources and organize tobacco control efforts coordinate actions and facilitate evidenced based practice across borders Framework Convention for Tobacco Control

"The Challenges" Cultural, Political Economic, and Historical Agent Vector Host Incidental Host Tobacco Product Manufacturers Smoker / Chewer Tobacco Products Involuntary Smoker Environment 3Global Tobacco Use Trends 3LAC Tobacco Use 3Health Effects 3Economic Effects 3The Tobacco Industry

"The Opportunities" !Framework Convention for Tobacco Control !Effective tobacco interventions !Potential to integrate interventions into existing activities

Tobacco Addiction Starts Early in Life Source: Chinese Academy of Medicine 1997, Gupta 1996, US Surgeon General Reports, 1989 and 1994, Authors’ calculations Every day 80,000 to 100,000 youths become regular smokers China (males,1996) India (males, 1995) US (both sexes, born ) US (both sexes, born ) Age Cumulative uptake in percent

World Health Organization Tobacco is predicted to be the leading cause of disease burden in the world.” In 1995 By 2030

A Model of the Cigarette Epidemic Source: WHO, 1995

Summary of Global Tobacco Mortality ! Since 1950, tobacco has killed more than 60 million people in developed countries !Now, four million deaths worldwide per year • By about 2025, ten million deaths per year –3 million in developed countries –7 million in developing countries ! Half a billion people now alive will be killed by tobacco products

Adult Smoking Prevalence in Latin America

Percent Change in Cigarette Consumption during for Selected LAC Argentina Brazil Colombia Chile Costa Rica Dominican Republic Ecuador Guatemala Mexico Venezuela Peru(90-97) Paraguay (96-99)Uruguay (96-99) % change THE WORLD BANK

Lung CancerIschaemicCerebraovascularCOPD thousands Number of Deaths from Various Diseases in LAC THE WORLD BANK

Children and Tobacco Exposed to ETS and maternal smoking before birth Contributes to low birth weight Exposed to ETS during infancy and childhood –Half of all children, 700 million, live with smoker Household money spent on tobacco instead of education and medical care Emotional pain and financial insecurity from loss of a parent who dies early due to tobacco. 250 million children alive in the world today will eventually be killed by tobacco Environment must change: non-smoking should be the social norm and easy choice

ETS Increases the Risk of Many Childhood Diseases Pneumonia, coughs and colds, croup, bronchitis, and bronchiolitis Asthma: new onset Asthma attacks: increased frequency and severity Impaired lung function, future respiratory problems Middle-ear infections, which can lead to reduced hearing Sudden infant death syndrome (SIDS), especially if mother smokes during pregnancy Source: World Health Organization, United States EPA, California EPA

Global Youth Tobacco Survey, Ages 13-15, 1999

Which Interventions are Effective? Measures to reduce demand Higher cigarette taxes Non-price measures: consumer information, cigarette advertising and promotion bans, warning labels and restrictions on public smoking Increased access to nicotine replacement (NRT) and other cessation therapies THE WORLD BANK

Recent Trends in Cigarette Consumption and Real Price/Pack in Venezuela, ,000 4,000 6,000 8,000 10, million pieces real price/pack of 20 million piecesreal price/pack THE WORLD BANK

Non-price Measures to Reduce Demand Increase Consumer Information: health effects of ETS and active smoking, benefits of cessation, dissemination of research findings, warning labels, counter-advertising Comprehensive ban on advertising and promotion Restrictions on smoking in public and work places THE WORLD BANK

NRT and Cessation Therapies NRT doubles the effectiveness of cessation efforts Governments may widen access to NRT and other cessation therapies by: – reducing regulation – conducting more studies on cost-effectiveness (especially in low/middle income countries) – considering NRT subsidies for poorest smokers THE WORLD BANK

Per Capita Cigarette Consumption Trends Four Comprehensive Program States versus U.S. Total, July 1 - June 30 Fiscal Year Pack Sold Per Capita Program Implementation 4 States with Comprehensive Programs US Total

Interventions that May be Less Effective at Reducing Consumption MOST MEASURES TO REDUCE SUPPLY Prohibition Youth access restrictions Crop substitution Trade restrictions Control of smuggling is the only exception and it is the key supply-side measure THE WORLD BANK

Summary of General Recommendations Advocacy for FCTC Governments: adopt multi-pronged strategy, tailored to each country Cigarette tax increases: 2/3 to 4/5 of retail price Consumer information, research, advertising and promotion bans, warning labels and restrictions on public smoking Widen access to NRT and other cessation therapies International Agencies: review policies, sponsor research and programs, address cross-border issues and support the FCTC THE WORLD BANK

Possible USAID Tobacco Control Interventions in LAC Background setting in LAC –Tobacco control (TC) efforts complement programs in other areas –Limited resources for new initiatives –Wide variety of interest levels among LAC countries Begin with integrating TC into ongoing programs –Framework Convention on Tobacco Control –Behavior Change Communication –Family Planning/reproductive health –Maternal & child health –Adolescent health –Healthy People/Healthy Cities –Tuberculosis control

Illustrative Tobacco Control Interventions Demographic Health Surveys Global Youth Tobacco Surveys General education messages about tobacco –Include with other mass media education programs –Counter-advertising messages if funds allow Prevention messages for youth and youth adults –Need for research on country-specific prevention messages –Education about association with other high-risk behaviors –Comprehensive school health programs –Parental, community, and health professional involvement

Illustrative Tobacco Control Interventions continued Cessation messages and support –Pre- and post-natal clinics –Pediatric clinics –Comprehensive school health programs ETS messages: health effects and importance of avoiding exposure –Pre- and post-natal clinics –Pediatric clinics –Increase smoke-free public schools, transportation, buildings, and worksites

Resources for Tobacco Control Technical Assistance and/or Information CDCwww.cdc.gov/tobacco PAHOwww.paho.org WHOwww.who.org

Smoking Prevalence by Education Level in Peru, no educationprimary education secondary schooling university education prevalence rate THE WORLD BANK

Integration of Tobacco Control Interventions with Tuberculosis Programs Integrate global TB and tobacco programs –Inclusion of tobacco screening and cessation to DOTS and DOTS Plus strategies –Prioritization for the treatment of tobacco dependence among TB patients Increase awareness of the interaction between tuberculosis and tobacco use Provide ongoing research on the association between tuberculosis and tobacco use

Global Youth Tobacco Survey in LAC 1999 Barbados, Costa Rica, Venezuela 2000 Argentina, Brazil, Caribbean Islands, Chile, Columbia, Dominican Republic, Guatemala, Mexico, Peru 2001 Brazil, Colombia, Ecuador, Panama, Haiti, Guatemala, Dominican Republic, Jamaica

Total Lung and Bronchus Age-Adjusted Cancer Rates California Cancer Registry (CCR) Surveillance, Epidemiology, and End Results (SEER) Rate per 100,000

Trends Between Real Cigarette Price and Consumption in Argentina, Real price/pack Pack of Consumption/capita Real PriceConsumption/capita THE WORLD BANK