Anthony D. So, MD, MPA Program on Global Health and Technology Access Sanford School of Public Policy Duke University. September 20, 2012

Transcription

1 Anthony D. So, MD, MPA Program on Global Health and Technology Access Sanford School of Public Policy Duke University September 20, 2012

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3 Wait, Wait Don t tell me! Which of the following is NOT true? 1. Bull Durham is actually the name of a brand of cigarettes from the 1800s 2. Washington Duke and his sons started out farming tobacco on their family farm 3. James B Duke started the industry norm of devoting high proportions of profits to advertising 4. The American Tobacco Company is still one of the major tobacco companies in the world, producing Lucky Strike and Pall Mall Cigarettes

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5 Why Tobacco Control? 9 Deaths Worldwide (millions) Tobacco- Related Diseases Tuberculosis HIV Respiratory Infections Diarrhoeal Diseases Perinatal Conditions Nutritional Deficiencies Cause of Death Murray and Lopez (1996)

6 Shifting Geography of Tobacco Control Source: Tobacco Atlas

7 The New Woman: Winston ad from South Africa Source: Yussuf Saloojee, Posted to Campaign for Tobacco Free Kids Web site

8 Source: Lopez, Collishaw and Piha. A descriptive model of the Cigarette epidemic in developed countries. Tob Control 1994; 3:

9 Joe Camel Source: RJ Reynolds, Joe Camel with caption Ambassador of Smooth, available from /adgallery

10 Household Income and Tobacco Low income households with at least one smoker in Bulgaria spent on average 10.6% of their total income on tobacco products. The lowest income group in Indonesia spent 15% of their total expenditure on tobacco. The average amount spent by poor households in Morocco on tobacco was virtually the same as the amount spent on education, and more than half the amount spent on health. Source: WHO, Tobacco and Poverty: A Vicious Circle, 2004.

11 Smoking is More Common Among the Less Educated in India (Men, Chennai) 80 Smoking Prevalence (%) Illiterate <6 yrs 6-12 yrs >12 yrs Source: Gajalakshmi, CK et al. Patterns of Tobacco Use and Health Consequences, Background Paper for Curbing the Epidemic: Governments and the Economics of Tobacco Control, World Bank, 1999.

12 Symmetry and Asymmetry Globalization cascade: Trade>>>Consumption>>>Epidemiology Symmetry of tobacco promotion Asymmetry in the response: Lag effect Capacity to make an informed response Impact of tobacco prevention and intervention for the poor Need for a philanthropic response specific to the local context

13 Forces of Globalization Between 1999 and 2009, tobacco production grew by 83% in Malaysia, 89% in Malawi, and by over 100% in Laos, while US production has decreased by 38% In developing countries tobacco consumption is increasing by about 3.4% per annum, while in developed countries it is decreasing by 0.2% per annum. Today more than half of tobacco related deaths occur in the developed world. By 2025, 7 out of 10 lives lost will occur in developing countries.

14 Source: UN Comtrade

15 Source: UN Comtrade

16 The Global Village If the world were a village of 1000 people, it would include 584 Asians; 150 Europeans ; 124 Africans; 84 Latin Americans; 52 North Americans; and 6 Australians and New Zealanders. In this 1000 person village, 229 adults 173 men and 56 women smoke. Further, 115 of the smokers are Asian, 28 are European, and 28 are African. (Yach and Bettcher, 2000)

17 Per Capita and Total Cigarette Consumption by Region Average Per Capita Consumption, 2007 Global Cigarette Consumption Asia & Australia Cigarettes per year % 9% 14% 8% 57% Eastern Europe & Former Soviet Union The Americas Western Europe Africa South America Caribbean Oceania & Australia Asia Middle East Canada and US Europe Source: Tobacco Atlas

18 Wait Wait. Did They Really Say That? Which of the following never happened? A. A research study, paid for by Phillip Morris, concluded that dead smokers save money in the Czech Republic. B. A BAT document noted that: Thinking about Chinese smoking statistics is like trying to think about the limits of space. C. Brooke Shields said, Smoking kills. If you re killed, you ve lost a very important part of your life.

19 Source: Example of indirect advertising in Thailand, Campaign for Tobacco Free Kids Web site

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22 Wait wait don t tell me! Which of the following tactics were not used by the tobacco industry? A. In Hong Kong, smokers use empty packs of cigarettes as free passes into discos. B. Magicians were sent into bars in the U.S. to create a buzz about a new menthol cigarette. C. British American Tobacco employed scantily clad women to light the free promotional cigarettes given to teenagers in Gambia. D. In Romania, a logo for Camel is silhouetted inside traffic lights, materializing when lights turn green.

23 Florida s Truth Campaign PSAs on tobacco and globalization

24 Potential Barriers to Funders Entering Tobacco Control Tobacco as an issue of personal choice Unfinished agenda of communicable disease Dislocation of tobacco dependent livelihoods Aversion to advocacy Risk of confrontation Geographic bounds Vertical public health issue Investment concerns...

25 Hope on the Horizon: New Funding Sources Health promotion foundations (e.g., Thailand Health Promotion Foundation or ThaiHealth) New Philanthropic Initiatives Bloomberg Foundation Bill and Melinda Gates Foundation

26 Trading Tobacco for Health

27 Smoking Prevalence in Southeast Asia Graph 1: Smoking Prevalence in South East Asia Men Women Cambodia Indonesia Malaysia Thailand Vietnam Source: Tobacco control country profiles, SEATCA. & NIS Tobacco survey, 2004

28 Trading Tobacco for Health Program Strategy Networking Building the local evidence base Enhancing local capacity ThaiHealth Southeast Asian Tobacco Control Alliance Regional, collaborative research program ASEAN Fellows program

29 SEATCA s 3H Strategy HEAD HAND HEART

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31 Networking Across developed and developing countries Global Partnerships for Tobacco Control Across sectors of civil society Consumers International People s Health Assembly Across Southeast Asia Southeast Asian Tobacco Control Alliance, with ASH/Thailand as regional hub APACT

32 Collaborative Research Program (RF-ThaiHealth) River Kwai [2002] In-country visits [2001] Bangkok [2001] WCTOH [2000] Ayutthaya [2000] Johns Hopkins/ University of Illinois, Chicago ASH/Thailand

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35 In Malay, Marlboro, I m impotent.

36 Malaysia World Cup Soccer and tobacco media ads, June 2002 ASEAN-wide workshop, Penang, September 2002 Ban on tobacco advertising, January 2003 Health promotion fund

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38 Cambodia Adventist Development Relief Agency (ADRA) and National Center for Health Promotion Buddhist Institute of Cambodia Declaration on Buddhist teachings and tobacco

39 MPOWER Monitor tobacco use and prevention policies Protect people from tobacco smoke Offer help to quit tobacco use Warn about the dangers of tobacco Enforce bans on tobacco advertising, promotion and sponsorship Raise taxes on tobacco

40 Measuring Success Latency of disease role of surrogate measures Piggyback evaluation Capture of prevention gains Importance of stories Change in absorptive capacity Spillover effects in capacity building

41 Risks and Challenges Local political challenges: changes in government, state tobacco monopolies Integrating a vertical public health issue into broader development concerns Policy translation of research Livelihood issues Local sustainability

42 Framework Convention on Tobacco Control (FCTC) To support prevention, we have the WHO Framework Convention on Tobacco Control. This is now one of the most widely supported treaties in the history of the United Nations. This is primary prevention at its best." Dr. Margaret Chan Director General, World Health Organization

43 UN Summit on Non Communicable Diseases (NCD), September 2011 Tobacco s place in the global discussion on NCDs: the Four by Four framework World Lung Foundation and Americans for Non Smokers Rights groups utilize event to raise awareness on link between tobacco use and noncommunicable diseases The WHO s follow up document after the Summit: a discussion paper on the Solidarity Tobacco Contribution Tobacco a consistent topic during the Summit

44 Trade and Tobacco How do we link trade liberalization to policy relevant outcomes? Stringency may directly affect outcomes and may mediate industry influences Stringency also an outcome of industry influences Trade Liberalization Lower Product Prices Relaxed Regulatory Stringency Premature Deaths Cigarette Consumption Increased Prevalence Health Impacts Weakened Enforcement