Global Tobacco Epidemic and Public Health Response

Joanna Cohen, PhD

Director, Institute for Global Tobacco Control Bloomberg Professor of Disease Prevention Johns Hopkins Bloomberg School of Public Health

Outline
Profile of global tobacco use Current and projected tobacco-related mortality and economic burden Role of the tobacco industry Public health tools to combat tobacco use

Tobacco and Smokeless Tobacco Come in Many Forms

www.tobaccoatlas.org

Global Cigarette Consumption in One Century Increased over 100 Times

6000
5328 5711 5884

5000

4453

Billions of cigarettes

4000
3262

3000
2150

2000 1000 0
10 1880 20 1890 50 1900 100 1910 300 1920 1000 600

1686

1930

1940

1950

1960

1970

1980

1990

2000

2009

Tobacco Atlas, 2012, www.tobaccoatlas.org 5

Nearly 2/3 of the Worlds Smokers Live in Just 10 Countries

5% US 4% 4% Indonesia Japan

Percent of cigarette consumption

7% Russia

42% Rest of the world 38% China

Tobacco Atlas, 2012, www.tobaccoatlas.org 6

Male Smoking Prevalence (2010 or latest available)

Tobacco Atlas, 2012, www.tobaccoatlas.org 7

Female Smoking Prevalence (2010 or latest available)

Tobacco Atlas, 2012, www.tobaccoatlas.org 8

Smoking and Secondhand Smoke Damage Every Part of the Body Secondhand Smoke

Smoking

Tobacco: The Only Risk Factor Shared by Four Major Non-communicable Diseases

Tobacco use Cardiovascular Diabetes Cancer Chronic Respiratory

Unhealthy diets

Lack of physical activity

Use of alcohol

Tobacco Atlas, 2012, www.tobaccoatlas.org 10

Global Burden of Tobacco Past and Present

Tobacco killed 100 million people in the 20th century Tobacco use is now the worlds single leading preventable cause of death
Kills more people than HIV/AIDS, TB, and malaria combined Responsible for >15% of deaths among men and 7% among women

Almost 6 million tobacco-caused deaths in 2011 Tobacco kills up to half of lifetime smokers Smokers die an average of 14 years earlier than non-smokers

WHO Report on the Global Tobacco Epidemic, 2008, http://www.who.int/tobacco/mpower/gtcr_download/en/index.htm MMWR April 12, 2002, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5114a2.htm 11

More Than 600,000 Deaths Caused by Secondhand Smoking, 2004

Men Women Children

26%
156,000

47%
281,000

28%
166,000

75% of secondhand smoke deaths occur among women and children

Tobacco Atlas, 2012, www.tobaccoatlas.org 12

Economic Burden of Tobacco-related Diseases Direct Cost of Smoking

$2,803 million Canada $96,000 million USA

Nearly 5% of U.S. healthcare dollars is spent on treatment of tobacco-related diseases

$5,700 million Mexico

Tobacco Atlas, 2012, www.tobaccoatlas.org 13

Future Global Burden of Tobacco

Without urgent action, 1 billion people will die from tobacco in the 21st century
500 million deaths among persons alive today Unchecked, worldwide deaths from tobacco products will exceed 8 million a year by 2030

Every death from tobacco products is preventable!

WHO Report on the Global Tobacco Epidemic, 2008: http://www.who.int/tobacco/mpower/gtcr_download/en/index.html 14

Vector of Disease

Host

Vector = Tobacco industry

Agent

Environment

Cohen, et al. AJPM 2010;39:352-6 tobacco.health.usyd.edu.au/assets/pdfs/tobacco-industry/trustus.pdf 15

Production Quantity in Million Metric Tons, 19652009

3.5 3.0 In million metric tons 2.5 2.0 1.5 1.0 0.5 0
1965 1970 1975 1980 1985 1990 1995 2000 2005

Trend in Tobacco Production

China

Brazil India United States Argentina

2009

Tobacco Atlas, 2012, www.tobaccoatlas.org 16

Global Cigarette Market Share, 2008

Company China National Tobacco Company Philip Morris International British American Tobacco Japan Tobacco Imperial (UK) Altria/Philip Morris USA Korea Tobacco & Ginseng (S. Korea) RJ Reynolds
Callard C. Tobacco Control 2010; 19:285-90 17

Cigarettes (billions) 2,143 869 830 612 329 169 102 90

Share of global market 38.3% 15.5% 14.8% 10.9% 5.9% 3.0% 1.8% 1.6%

Tobacco Company Revenue and Profits Top 6 Companies, 2010

Total profit Total revenue $ 35.1 billion $346.2 billion
16

$100.00 100 $90.00 90 $80.00 80

In billions, USD

$70.00 70 $60.00 60 $50.00 50 $40.00 40 $30.00 30 $20.00 20 $10.00 10 $0.00 20.5 36.4 3.9 2

4.2

1.5

7.5

53.9
British American Tobacco

64.4
Japan Tobacco International

60.2
Philip Morris International

75.7
China National Tobacco Corporation

Altria/PhilipMorris Imperial Tobacco USA

Tobacco Atlas, 2012, www.tobaccoatlas.org 18

Cigarette Marketing Expenditures, 2008 $9.9 billion was spent on cigarette advertising and promotion
>$34 for every man, woman, and child

Marketing in the United States

83% of the tobacco companies marketing budgets are spent on price discounts, coupons, and retail valueadded promotions In general, in the United States, tobacco companies spent almost twice as much on marketing as junk food, soda, and alcohol companies combined

Tobacco Atlas, 2012, www.tobaccoatlas.org http://www.tobaccopolicycenter.org/2012/01/11 19

Undue Influence

Genius comes from hard work. Tobacco helps you to be successful.

Tobacco Atlas, 2012, www.tobaccoatlas.org 20

WHO Report on the Global Tobacco Epidemic, 2008 http://www.who.int/tobacco/mpower/2008/en/index.html 21

Conclusions
The tobacco epidemic will cause the most harm to low- and moderate-income countries with high population
Tobacco use is growing fastest in these countries, fueled by steady population growth The tobacco industry is expanding its advertising, marketing, and promotion to the developing world Many of these countries have fewer resources to respond to the health, social, and economic problems caused by tobacco use, which will exacerbate the tobacco epidemics impacts This will create aperfect stormof future tobacco-caused disease and death, unless there is a strong response from the public health community

22

Global Tobacco Surveillance System: From Data to Action

Chief, Global Tobacco Control Branch Office on Smoking and Health Centers for Disease Control and Prevention

Samira Asma, DDS, MPH

23

GTSS: Global Tobacco Surveillance System

A set of globally standardized surveys Monitoring not only the problem of tobacco use, but also tobacco control solutions Enhance capacity to design, implement, monitor an evaluate tobacco control policies

24

WHO FCTC Monitoring Protocol 20.2

integrate tobacco surveillance programs into national, regional, and global health surveillance programs so that data are comparable and can be analyzed at the regional and international levels, as appropriate.

25

GTSS: Global Tobacco Surveillance System

GLOBAL YOUTH TOBACCO SURVEY

GLOBAL ADULT TOBACCO SURVEY

TOBACCO QUESTIONS FOR SURVEYS

26

GYTS: Global Youth Tobacco Survey 19992012

Largest public health surveillance system School-based surveys of students 1315 years Self-administered using global standard protocol National, state or provincial 180 countries/sites completed

27

GYTS: Global Youth Tobacco Survey Key Findings

1 in 10 students currently smoke cigarettes 1 in 10 students currently use other tobacco products 1 in 4 smokers first tried by age 10 2 in 3 smokers want to quit 4 in 10 students exposed to secondhand smoke in homes and over half in public places

Centers for Disease Control and Prevention. Global Youth Tobacco Surveillance, 2000-2007. 2008 Jan 25. MMWR 2008; 57/ss-1 28

GATS: Global Adult Tobacco Survey 20082012

Nationally representative household surveys Active in 31 countries

Covers 66% of worlds population Covers 68% of worlds smokers

Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspx 29

GATS: Global Adult Tobacco Survey

GATS in numbers

1 million household level data 350,000 household interviews 50 languages and dialects 3,600 fieldworkers trained 3,000 handhelds 1,500 fieldwork days

65 million data points collected representing 3.6 billion people!

Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspx 30

GATS: Global Adult Tobacco Survey Standard Protocol

Core questionnaire and optional questions Sampling design Series of manuals and guidelines Expert review committees
Questionnaire review Sample design and weighting

Electronic data collection

31

GATS: Global Adult Tobacco Survey Key Findings

794 million adults currently use tobacco 350 million exposed to secondhand smoke at work 5 in 10 current smokers plan to quit or thinking about quitting 2 in 10 noticed cigarette marketing in stores where cigarettes are sold

Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspx Adult Awareness of Tobacco Advertising, Promotion, and Sponsorship-14 countries. MMWR 2012; 61(20) 32

Tobacco Use by Gender

Prevalence (%) Russian Federation Bangladesh China Ukraine Philippines India Turkey Viet Nam Thailand Egypt Poland Uruguay Mexico Brazil 0 10 20 Bangladesh Poland 58.0 52.9 Russian Federation India 50.2 Uruguay 49.2 Turkey 47.9 Brazil 47.9 Ukraine 47.6 Philippines 46.4 Thailand 38.1 Mexico 37.3 Viet Nam 30.7 China 25.0 Egypt 22.0
60.6

Monitor

28.7 24.4 21.7 20.3 19.8 15.2 13.3 11.3 10 9.1 7.9 3.6 2.4 0.6 0 10 20 30 40 50 60 70

30

40

50

60

70

Male
Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspx 33

Female

Exposure to Secondhand Smoke at Workplace

70 60 50

Protect

63.3

62.2

59.9

55.9

Percentage (%)

40 30 20 10 0

37.3

34.9

33.6

33.1

32.6

29.9

27.2

23.3 18.6 16.5

Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspx In the past 30 days preceding the survey 34

Former Smokers Who Quit

50 45 40 35
46.9 42.0 36.5 32.0 28.8 26.5 25.9 23.5

Offer Help

Percentage (%)

30 25 20 15 10 5 0

21.5 18.3 17.8 16.6 12.8 12.6

Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspx Current smokers who made a quit in the past 12 months 35

Thought about Quitting Smoking Because of Warning Labels on Cigarette Packages

80 70 60
67.0 66.7 65.0 58.5 57.6 46.3 43.3 42.9 37.4 32.9 31.7 31.5 28.6 17.7

Warn

Percentage (%)

50 40 30 20 10 0

Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspx Among those who noticed health warning on cigarette packages in the past 30 days preceding the survey 36

Noticed Cigarette Marketing in Stores

60 50 40

Enforce

53.7 43.6 36.5 33.2

Percentage (%)

30 20 10 0

30.4 20.9 20.5 13.9 10.7

8.6

8.0

6.7

4.1

2.7

Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspx In the past 30 days preceding the survey 37

Affordability

Raise

9% 8% 7% 6%

8.1%

Percentage (%)

5% 4% 3% 2% 1% 0% 0.7% 1.0% 1.2% 1.5% 1.7% 1.8% 2.1% 2.2% 2.2% 2.3% 2.3% 2.5% 2.7% 3.3%

5.0%

Global Adult Tobacco Survey, 2008-2010, http://apps.nccd.cdc.gov/GTSSData/default/default.aspx Affordability as the relative income price - Median price paid per 2000 sticks as % of per capita GDP 38

TQS: Tobacco Questions for Survey 20102012

3 to 22 questions MPOWER focus Integration, standardization, and comparability

39

Current Tobacco Users Aged 25 Years, Bangladesh

Global Adult Tobacco Survey, 2009 NCD Risk Factor Survey, 2010
80 70
69.7 54.3 70.0

Prevalence (%)

60 50 40 30 20 10 0

51.0 39.1

34.4

Overall
Global Adult Tobacco Survey, 2008-2010 Bangladesh 2010. ISBN 978-92-9022-393-1 NCD, Non-communicable diseases

Male

Female

40

Data Dissemination

http://apps.nccd.cdc.gov/GTSSData/default/default.aspx 41

What Gets Measured, Gets Done

Globally standardized survey data on tobacco control is available for 180 countries
Unprecedented cross-country comparisons Tracking not only the problem, but also the solutions

42

International Advances in Tobacco Control

Michael Eriksen, ScD

Dean, Institute of Public Health Georgia State University

43 43

There ARE Effective and Proven Strategies

100 million global deaths can be prevented by the end of the century through a group of policy and regulatory interventions This number of lives saved is possible through a modest prevalence decline (from 25% to 20%), using the assumption that 1/3 of users will die from smoking related diseases

Frieden T, Bloomberg M. Lancet 2007;369:175861 44

There ARE Evidence-Based Interventions

Sustained funding of comprehensive programs Excise tax increases 100% smoke-free policies Comprehensive ad restrictions Aggressive media campaigns Cessation access

45

WHO Report on the Global Tobacco Epidemic, 2008, http://www.who.int/tobacco/mpower/2008/en/index.html 4646

46

http://www.who.int/fctc/e 47

Smoke-Free Areas Doubled from 2008 to 2010

Tobacco Atlas, 2012, www.tobaccoatlas.org 48

Public Support for Comprehensive Smoking Bans in Bars and Restaurants after Implementation
100%

80%

Public support

60% 40% 20%

0% New Zealand New York City California Ireland Uruguay

WHO MPOWER Report 2008, http://www.who.int/tobacco/mpower/2008/en/index.html 49

Impact of Pictorial Warnings on Brazilian Smokers

Changed their opinion about health consequences of smoking

Want to quit as a result

Approve of health warnings

Datafolha Instituto de Pesquisas, 2002, Tobacco Atlas, 2012, www.tobaccoatlas.org 50

Plain Packaging in Australia

Plain packaging to be implemented by December 1, 2012, pending ongoing litigation

51

Health Warning Labels

2008

*Percent of principal display area of cigarette package legally mandated to be covered by health warning The Tobacco Atlas, 3rd Edition, 2008, www.tobaccoatlas.org 52

Marketing Bans
2007

53

* Direct and indirect advertising bans, 2007 ** Four, five or six direct bans and at least one indirect ban ***One, two or three direct bans or at least one indirect ban The Tobacco Atlas, 3rd Edition, 2008

Comprehensive Advertising Bans Amplify Other Interventions

Average change in cigarette consumption 10 years after introduction of advertising bans in 2 groups of countries
14 countries with a comprehensive ban 78 countries without a ban -1% -9%

Change in cigarette consumption

54

0% -1% -2% -3% -4% -5% -6% -7% -8% -9% -10%

Saffer H. Tobacco advertising and promotion. In: Jha P, Chaloupka FJ, eds Tobacco control in developing countries. Oxford, Oxford University Press, 2000

Tobacco Prices and Consumption South Africa and Morocco

55

Walbeek C. 2003. Tobacco excise taxation in South Africa (left graph), http://ped.sagepub.com/content/12/4_suppl/25.long Aloui O. 2003. Analysis of the economics of tobacco in Morocco (right graph) http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-1095698140167/Aloui-Analysis_ofwhole.pdf

Tobacco Prices and Taxes

The Tobacco Atlas, 3rd Edition, 2008, www.tobaccoatlas.org 56

Change in Affordability of Tobacco Products by WHO Region, 20002010

Tobacco Atlas, 2012, www.tobaccoatlas.org 57

Tobacco Control is Underfunded

170 150 130 110 90 70 50 30 10 -10 1.36 High-income 17.6 0.013 Middle-income 5.43 0.001 167.57 Per capita total tax revenue from tobacco products Per capita public spending on tobacco control

USD per capita

Low-income

58

Most of the Worlds People Are Not Yet Fully Protected Against Tobacco Harms
30% 25% Share of world population 20% 15% 11 10% 5% 0% Smoke-free environments 14 15 28

28 Increase 20082010

13

8
8 6

5 5
Cessations programs Warning labels Mass media Advertising bans

Taxation

World Health Organization 59

 Interactive maps, downloadable data, Power points, country fact sheets Upcoming editions: Arabic, French, Spanish, Chinese Sign up @TobaccoAtlas.org for alerts of upcoming editions, new features

60

Conclusions
Internationally, tobacco control policy initiatives have been broadly accepted Evidence-based prevention best practices-the MPOWER package- have been codified Challenges to implementation include
Global underfunding of tobacco control Regional, country-to-country, and within country variability in policies and enforcement Ongoing industry marketing and influence

61

http://www.cdc.gov/about/grand-rounds

62