1. Harvard University Initiative for Global Health Global Health Challenges Social Analysis 76: Lecture 18

2. Harvard University Initiative for Global Health Tobacco Burden of Tobacco Interventions for Tobacco Control Tobacco Control History and Future Alcohol Burden of Alcohol Interventions for Alcohol Control Alcohol Control Policy

3. Harvard University Initiative for Global Health

5. 1)US, UK, Australia, Canada, NZ, and now much of Western Europe have declining levels of tobacco consumption. US a 50% decline for males in 40 years. Young age-groups particularly women are stable or increasing. 2)Rising or stable levels in Eastern Europe and former Soviet Union. 3)Dramatic increases in consumption in East and South-East Asia. 4)Poorest countries starting to increase. Tobacco Consumption Trends

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8. Tobacco Burden of Tobacco Interventions for Tobacco Control Tobacco Control History and Future Alcohol Burden of Alcohol Interventions for Alcohol Control Alcohol Control Policy

9. Harvard University Initiative for Global Health 1)Interventions to prevent individuals from starting to smoke. 2)Interventions to encourage smoking cessation and/or decrease quantity of cigarettes. 3)Limit exposure to second-hand smoke – interventions targeting environmental tobacco smoke often contribute to 1 and 2. Three Classes of Interventions

10. Harvard University Initiative for Global Health Most effective intervention to reduce initiation of smoking and the quantity of tobacco consumed is to raise the price of tobacco through taxation. Price elasticity of tobacco consumption ranges from -0.3 to -0.5. In other words, a 10% increase in price will decrease consumption by 3% to 5%. Taxation of cigarettes varies dramatically across countries and within countries e.g. in the US cigarette taxes range from 2.5 cents in Kentucky to $2.05 in New Jersey. Taxation

11. Harvard University Initiative for Global Health 1)Clean indoor air – evidence that smoking bans induce smokers to quit or decrease consumption. 2)Tobacco product labelling – e.g. Canada has aggressive labelling 3)Advertising bans 4)Restriction on sales to minors 5)Smoking cessation programs with nicotine replacements 6)Counter-advertising Other Interventions

12. Harvard University Initiative for Global Health Tobacco Burden of Tobacco Interventions for Tobacco Control Tobacco Control History and Future Alcohol Burden of Alcohol Interventions for Alcohol Control Alcohol Control Policy

13. Harvard University Initiative for Global Health

14. Surgeon-General’s Report in early 1960s identified smoking as a major health hazard. Efforts to control tobacco had limited effect until the issue of environmental tobacco smoke was used to move for smoke free indoor environments. The rise of non- smokers rights fueled by the health effects (relatively small) of ETS was critical to creating political acceptance of clean indoor air legislation. In 1994, Attorneys General of Mississippi and Minnesota sued large tobacco companies to recover costs to their states Medicaid programs of treating tobacco related illness. US Tobacco Control

15. Harvard University Initiative for Global Health April 1998, Master Settlement Agreement finalized between 46 states Attorneys General and four major tobacco companies. $206 billion to be paid over 25 years and used by each state at its own discretion. Amount going to fund tobacco control programs small (6%) but increased tobacco control expenditure nationally. 41% of the funds have gone to pay for medical care and 40% for non-health related expenditures. US Tobacco Control (2)

16. Harvard University Initiative for Global Health As part of the MSA, large number of tobacco company documents were released to the public. These documents have revealed consistent attempts to fund counter ‘science’, fund actors to smoke in movies, fund disinformation campaigns for the public and to lobby against global initiatives such as the Framework Convention on Tobacco Control. US Tobacco Control (3)

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18. As tobacco consumption has declined in the US and other Western markets, focus of marketing of tobacco has turned to developing countries. Enormous increase in tobacco consumption in East Asia, Latin America, and Middle-East. In 1998, WHO began effort to create a binding global treaty on tobacco control: the Framework Convention for Tobacco Control. This effort was spearheaded by Derek Yach now at Yale University. Global Tobacco Control

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20. After nearly 5 years of negotiations, the FCTC was passed by the World Health Assembly in May 2003. For countries who sign the treaty, the strictures are binding on all signatores once 40 countries have ratified the treaty. The FCTC includes provisions to impose restrictions or bans on advertising, sponsorship and promotion; establish new packaging and labelling of tobacco products, establish clean indoor air controls and strengthen legislation to clamp down on smuggling. FCTC

21. Harvard University Initiative for Global Health FCTC Update The treaty closed for signature on 29 June 2004. The WHO FCTC entered into force on 27 February 2005. The first session of the Conference of the Parties to the WHO FCTC was on 6-17 February 2006. Signatories to the WHO FCTC: 168 Parties to the WHO FCTC: 141 The WHO FCTC is currently deposited at the United Nations Headquarters in New York. The Treaty remains open for ratification, acceptance, approval, formal confirmation and accession indefinitely for States wishing to become parties to it.

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23. Tobacco Burden of Tobacco Interventions for Tobacco Control Tobacco Control History and Future Alcohol Burden of Alcohol Interventions for Alcohol Control Alcohol Control Policy

24. Harvard University Initiative for Global Health Risks and cardiovascular benefits of alcohol use depend on the volume of alcohol and the pattern of consumption. For males, 2 drinks a day 5-7 days per week reduces risk of cardiovascular disease. The same volume of alcohol per week consumed in a binge drinking pattern increases risk of CVD death. In all regions other than EUR A, the net effect of alcohol consumption is to increase CVD risk. Quantity and Pattern

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29. Tobacco Burden of Tobacco Interventions for Tobacco Control Tobacco Control History and Future Alcohol Burden of Alcohol Interventions for Alcohol Control Alcohol Control Policy

30. Harvard University Initiative for Global Health 1)Control over the distribution and sale of alcoholic beverages – the following have some evidence to support their effectiveness: limits on hours of sale, limits on number of places of sale, minimum purchasing age, more restricted availability of high strength beverages, training servers, rationing the amount an individual can purchase per month. 2)Taxation of alcoholic beverages – price elasticity of demand appears to vary according to main beverage. 3)Drinking-Driving countermeasures – legislated legal blood alcohol limits, random breath testing, administrative license suspensions. Interventions

31. Harvard University Initiative for Global Health 4)Brief advice by health care professionals – several studies have demonstrated effectiveness for decreasing alcohol consumption. 5)Various efforts to reduce harm of alcohol consumption such as adding thiamine to beer. 6)There is no evidence that the following are effective: alcohol education, alcohol public information campaigns, alcohol-free events promotion. Interventions

32. Harvard University Initiative for Global Health Tobacco Burden of Tobacco Interventions for Tobacco Control Tobacco Control History and Future Alcohol Burden of Alcohol Interventions for Alcohol Control Alcohol Control Policy

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34. Temperance movement in the US led to prohibition from 1919 to 1933. Illegal use grew during the 1920s but alcohol use was still quite low. Prohibition was ended during the Depression for a range of reasons. Alcohol control movement is to this date profoundly affected by the failure of prohibition. Prohibition

35. Harvard University Initiative for Global Health Two facts illustrate why tackling alcohol as a risk is much harder than tobacco. First, overall volume of consumption is the most important factor in the occurrence of alcohol problems so that blunt instruments like taxes will work to reduce the harm of alcohol. Second, unlike tobacco, moderate regular responsible use of alcohol is not necessarily harmful and may be beneficial. The debate is between targeted interventions for high risk drinkers or drinking-driving versus interventions to decrease overall consumption. Policy Issues

36. Harvard University Initiative for Global Health For many non-communicable disease risks such as diet, physical activity, tobacco, and alcohol, there are a number of clear examples of the tension between individual liberty and efforts that will enhance overall social welfare or the public good. When are limitations on individual liberty justified? Are individual risk factor profiles always individual choices? Or do individuals adopt the behaviour patterns of their parents and the community around them? How do we explain higher risk factor exposure in poor households as compared to rich households? Individual Liberties vs Public Health