Effective Interventions to Reduce Tobacco Use Joy de Beyer Tobacco Control Coordinator World Bank Meeting of Mediterranean Countries, Malta, September 2001

Outline Why intervene to reduce tobacco use ? Which interventions are effective, and how do we know? Which interventions are not effective? Who are the key stakeholders ?

Why intervene to reduce tobacco use ? Large and growing number of deaths from tobacco World: Annual Tobacco Deaths (millions) Developed 2 ~3 Developing ~2 ~7 World Total 4 ~10 u 1 in 2 of long-term smokers killed by their addiction u 1/2 of deaths in middle age (35-69) Source: Peto, Lopez, and others 1997; WDR 1993

Tobacco Attributable Deaths in EU Countries in the Mediterranean Region Source: Peto, Lopez, 2001

Tobacco Related Deaths in Mediterranean Countries in 1990 Tracheal, Lung & Bronchial Cancer per 100,000 deaths

1.1 Billion Smokers Worldwide ( estimate, million) Males Females Total Developed Developing World Bil.

Why should governments intervene? Economic rationale – “market failures” People do not know the risks of tobacco use Most smokers start young – protect youth Nicotine is VERY addictive Tobacco users impose costs on others –second hand smoke harms non-smokers –children and infants need protection –health care costs (families and government) –opportunity cost for families

3 strong reasons for governments to intervene Deter children from smoking Protect non-smokers from others’ smoke Provide adults with good information so they can make well-informed choices

Heavy Smokers and High Prevalence Rate in EU in 1999

Smoking Prevalence (1990s) and Consumption (1999) in Selected Mediterranean Countries

Protect Youth Smoking and Addiction Starts Young

Protect Youth: Smoking and Addiction Starts Young

Allocating Tobacco Expenditure to Other Goods and Services Better Nutrition, Better Health: Evidence from Hungary

High opportunity Cost: Evidence from Belarus

High opportunity cost: Evidence from Bulgaria

Effective interventions to reduce tobacco use Higher cigarette taxes Non-price measures: Consumer information, large clear warning labels Comprehensive bans on cigarette advertising and promotion, or counter-advertising Restrictions and bans on smoking in workplaces and other public places Help for people who want to quit Better access to cessation therapies such as nicotine replacement (NRT), etc

Interventions that are not effective in reducing tobacco use Most “supply side” measures: –Prohibition –Youth access restrictions –Crop substitution –Trade restrictions Control of smuggling is the exception. It is the key supply-side measure.

An effective measure: Complete Ban on Tobacco Advertising and Promotion Consumption trends in countries with such bans v. those with no bans n=102 countries) 1

Current smokers need help! Cessation Treatments Cessation support from health professionals is key NRTs double the effectiveness of cessation efforts Quit lines, community support, etc., also work Governments may increase accessibility and affordability of NRTs by: uOTC sales, allowing advertising, licensing uConducting more studies on cost-effectiveness (especially in low/middle income countries) uConsidering NRT subsidies for poorest smokers

Cessation Efforts: Health Care Professionals First Physician rate: Greece, Italy, Malta, Spain, Turkey, Egypt, Syria Medical Student rate: Algeria (male+female), Morocco, Tunisia, Cardiologist: France

Key stakeholders –Ministry of Finance: Tobacco Tax Revenues –Customs Administration: Smuggling, Border Control –Ministry of Labor: Farmers and Manufacturing Labor –Ministry of Agriculture: Tobacco Production –Ministry of Education: Youth education on tobacco –Smokers: Low prices, variety and appealing products –Producers: Profit, market share, sales –Ministry of Trade: Export earnings from tobacco

Ministry of Finance: Tobacco is a good source of government tax revenue EU Med: France, Greece, Italy, Portugal, Spain Other Med: Algeria, Cyprus, Egypt, Morocco, Jordan,Lebanon, Syria, Turkey, Tunisia,

Summary: Modest action could achieve great gains for public health without hurting the economy