Tobacco as a Public Health Problem

Transcription

1 Tobacco as a Public Health Problem Matthew J. Carpenter, PhD Medical University of South Carolina Hollings Cancer Center Department of Psychiatry & Behavioral Sciences

2 What would YOU do? As a clinician? As a policy maker? (banning tobacco is not an option)

3 Organization 1) Tobacco Use & Harms 2) Policy General Regulatory Issues Taxation Smokefree Packaging 3) Cessation 4) Alternative Tobacco Products

4 Tobacco Use Around the World 1 billion smokers in the world Almost half of the world's children breathe air polluted by tobacco smoke. More than 80% of the world's smokers live in lowand middle-income countries Tobacco use kills 5.4 million people a year - an average of one person every six seconds - and accounts for one in 10 adult deaths worldwide Tobacco kills up to half of all users Source: WHO 2008

5 8 Leading Causes of Death in the World: Tobacco a Risk Factor for 6 Hatched areas indicate proportions of deaths that are related to tobacco use. Sources: WHO; 2008 Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to PLoS Medicine, 2006, 3(11): e442

6 Nearly two thirds of the world s smokers live in 10 countries 42% of world s smokers Source: WHO 2008

7 A Closer Look at China World s largest consumer of tobacco (300 million) 1 million tobacco-related deaths annually (2 million by 2020) 465% increase in lung cancer deaths in past 30 years > 50% of population exposed to SHS ~100k annual deaths from exposure to SHS 40% Prevalence 60% Total Males Females 20% 0% Source: tobaccofreecenter.org

8 A Closer Look at India 120 million tobacco consumers bidis comprise 48% of tobacco market 1 million tobacco-related deaths annually 40%, 27% of youth exposed to SHS in public, home Direct healthcare costs (2004): 1.2 billion USD 40% Prevalence 60% Total Males Females 20% 0% Source: tobaccofreecenter.org

9 Annual Cigarette Consumption per person 15+ * # of cigarettes smoked per capita 3,000 2,500 2,000 1,500 1, Ukraine Russia Spain Japan Poland USA * Among 50 most populous nations Source:

10 Economic Costs vs. Cigarette Consumption Worldwide * $ Millions (US) 180, , , , ,000 80,000 60,000 40,000 20,000 0 USA Annual Per Capita Cigarette Consumption: 2007 (age 15+) * Among 50 most populous nations Source:

11 Current Smoking Prevalence Prevalence (%) South Carolina US Source:

12 POLICY: General Regulatory Environment

13 Framework Convention on Tobacco Control World s first public health treaty (WHO), the FCTC became international law (2/2005), committing countries to: Ban all tobacco advertising, promotion and sponsorship (with an exception for nations with constitutional constraints) Place large, graphic health warnings on cigarette packs Implement measures to protect non-smokers from secondhand smoke Increase the price of tobacco products, which reduces smoking among both youth and adults Combat cigarette smuggling Regulate the content of tobacco products Signing Countries (as of 1/2011): 168 (> 85% of world population) US has signed (agreement), but not ratified (bound to follow) Source: Campaign for Tobacco Free Kids

14 Regulatory Environment in U.S. Master Settlement Agreement (1998) Agreement Between Tobacco Industry and 46 States Attorneys General: A payment of $206 billion to the states, spread out over a 25 years $1.5 billion payment over 10 yrs to support state antismoking measures $250 million payment over 10yrs to fund research into reducing youth smoking (American Legacy Foundation) Permanent limitations on cigarette advertising Ban on the use of cartoon characters (such as Joe Camel) in advertising Ban on cigarette branded merchandise Limits on tobacco industry sponsorship of sporting events (such as the Virginia Slims tennis tournament) The dissolution of tobacco trade organizations Source: Jones & Silvestri (2010). Chest, 137,

15 Master Settlement Agreement (1998) 2006 Expenditures among 46 states within MSA: U.S. S.C. Mean Median Amount Rank Debts/Budget Shortfall $37,970,198 0 $74,329,662 7th General Purposes 1 $29,311,600 $11,589, Health $40,219,631 $16,424, Infrastructure $11,954, Tobacco Control $5,909,025 $2,852, TOTAL $125,364,981 $90,187,749 $74,329, ex: education, social services Source: Jones & Silvestri (2010). Chest, 137,

16 FDA Regulatory Environment for Tobacco prior to 2009 There was none!

17 Regulation of Nicotine & Tobacco Pharmaceutical Industry Tobacco Industry Subject to FDA review of efficacy n/a Subject to FDA review of side effects Subject to FDA review of marketing Subject to FDA review of health claims Uneven Playing Field Until Now: Family Smoking Prevention and Tobacco Control Act (June 2009)

18 FDA Regulatory Environment for Tobacco Now Family Smoking Prevention and Tobacco Control Act (2009): FDA oversight of the labeling and marketing claims of tobacco industry Funding & incentives for development of new smoking cessation products Restrictions on sale, distribution, advertising and marketing of tobacco to kids/teens Prohibition on sales of flavored cigarettes Requirements to clarify Light and Low tar are no less harmful than regular Prominent display of health warnings Establish the FDA Center for Tobacco Products (and Tobacco Products Advisory Committee)

19 POLICY: Taxation

20 Cost of 1 pack Marlboro Cigarettes * 5 Highest 5 Lowest U.S. $ $0.38 * Among 50 most populous nations Source:

21 Effects of Taxation on Prevalence: The Most Effective Measure? A 10% price increase reduces demand by: 4% in high-income countries 1 8% in low or middle-income countries 1 Young people and the poor are the most price responsive 1 California increased state excise tax from 37 to 87 in 1999 (also coincided with MSA) from : cigarette consumption 2.4 packs per capita per quarter tax revenues $2.1million 2 Sources: 1 Chaloupka et al. (2002). Tob Cont, 11, i62-i72. 2 Sung et al. (2005). Am J Public Health, 95,

22 Tobacco Control The Good (?) News: Cigarette Tax : $0.07 (lowest in nation) 2010: $0.57 State Tax Rank State Tax Rank State Tax Rank AL $ KY $ ND $ AK $ LA $ OH $ AZ $ ME $ OK $ AR $ MD $ OR $ CA $ MA $ PA $ CO $ MI $ RI $ CT $ MN $ SC $ DC $ MS $ SD $ DE $ MO $ TN $ FL $ MT $ TX $ GA $ NE $ UT $ HI $ NV $ VT $ ID $ NH $ VA $ IL $ NJ $ WA $ IN $ NM $ WV $ IA $ NY $ WI $ KS $ NC $ WY $ National Average: $1.45 / pack Median: $1.34 / pack Tobacco States (KY, VA, NC, SC, GA, TN) $0.49 / pack Other: $1.57 / pack

23 POLICY: Smokefree

24 Smoking Restrictions: The Air WE Breathe Pre (2006) Fine Particulate Air Pollution (PM2.5 in micrograms per cubic meter) Post (2008) Charleston City Mount Pleasant North Charleston* Charleston, SC: Smoke-free July 2007 Mt. Pleasant: Smoke-free September 2007 *North Charleston: NO Smoke-free Ordinance* Source: Byrd, Carpenter, Travers (in press). Journal of the South Carolina Medical Association

25 Smoking Restrictions: Effects on Health Respiratory health of bartenders pre/post smokefree legislation (n=53): 1 Baseline Follow-Up (~8wks) Prevalence of Sx: Any respiratory sx 74% 32% Wheezing 32% 15% Dyspnea 19% 8% Cough 53% 23% Forced Vital Capacity Meta-analysis of the effects of smokefree laws on acute myocardial infarction(8 studies) 2 19% reduction in AMI (95% CI: 14% - 24%) Sources: 1 Eisner, et al. (1998). JAMA, 280, Glantz, (2008). Prev Med, 47,

26 Smoking Restrictions: Effects on Prevalence Current Population Survey (N=48,584) Quit Successful Cessation Attempts 6+ Months OR 95% CI OR 95% CI Home smoking ban (referent = none) Partial Total Work Smoking Ban (referent = less than a work area ban) Smokefree Source: Farkas, et al. (1999). Tob Cont, 8,

27 Do Smokefree Laws Hurt Businesses? No Conclusion of Negative Impact? YES NO Included an objective 19% 81% outcome measure (37 studies) Funded by source independent 0% 100% of tobacco industry (60 studies) Peer reviewed (24 studies) 4% 96% Met ALL standards for 0% 100% high quality study (21 studies) Source: Scollo, et al. (2003). Review of the quality of studies on the economic effects of smoke-free policies on the hospitality industry. Tobacco Control, 12,

28 POLICY: Packaging

29 Big Words + Gory Pictures = Deterrent?

30 Regulatory Environment for Tobacco: Packaging Last US legislation for warning labels on cigarettes: 1984 Survey of 572 current smokers ages in US: 56% could identify at least 3 (of 4) warning messages What type of HWL do you think would be most effective?

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32 Regulatory Environment for Tobacco: Packaging The Canadian system (50% of package covered): Text (since 1994)

33 Regulatory Environment for Tobacco: Packaging The Canadian system (50% of package covered): Text + Graphic (since 2000)

34 Regulatory Environment for Tobacco: Packaging The Canadian system- What effect?? Survey of 616 smokers in Ontario: Source: Hammond, et al. (2003). Tob Cont, 12,

35 SMOKING CESSATION

36 Two Ways to Increase Cessation: 1. Increase Quit Attempts 2. Increase Success per Attempt

37 Incidence of 24hr Quit Attempts Source:

38 Summary of Medication Effectiveness # Arms Estimated ORs Estimated Abstinence Rate Placebo Monotherapies Nicotine patch (6-14 wks) Long term patch (>14wks) Nicotine Gum (6-14 wks) Long term Gum (>14 wks) High dose patch (>25mg) Nicotine Inhaler Nicotine Nasal Spray Varenicline 2mg Varenicline 1mg Bupropion Fiore M, et al. Treating tobacco use and dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: US Public Health Service, 2008.

39 Summary of Medication Effectiveness # Arms Estimated ORs Estimated Abstinence Rate Placebo Combination Therapies Long term patch + ad lib NRT (gum or spray) Patch + Bupropion Patch + Inhaler Fiore M, et al. Treating tobacco use and dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: US Public Health Service, 2008.

40 Most People Who Quit Do So On Their Own Myth: Quitting on Own is Most Effective Method Efficacy Reach Impact % Quit at 6 months (# using) (Total # Quitters) Cold Turkey 3% 22,800, ,000 OTC NRT 14% 4,000, ,000 Behav. Tx 24% 395,000 94,800 Source: Shiffman, S., Mason, K., & Henningfield, J. (1998). Annual Review Pub Health, 19,

41 Cessation in its Simplest Form P QA x P Quit Method x P success/method P QA P Quit Method P success/method Impact 1 # years to prevalence by 50% 2 Unaided quit attempts NRT-Aided quit attempts Increase all assumptions by 25%? Annual cessation rate: Source: Amodei & Lamb (2008). 1.6% unaided quitting Psych. Addict. Behaviors 2% NRT aided quitting Vol. 22, % intensified cessation 2 assumes initiation rate = death rate

42 ALTERNATIVE TOBACCO PRODUCTS

43 Non-Cigarette Tobacco Around the World BIDIS - small amount of sun-dried, flaked tobacco, often flavored, hand wrapped in dried leaf, tied with string. Bidis deliver more tar and CO than manufactured cigarettes because users are forced to puff harder to keep them lit. Predominant in India/South Asia KRETEKS - clove-flavored cigarettes widely that contain a wide range of exotic flavorings and eugenol, which has an anesthetic effect, allowing for deeper and more harmful smoke inhalation. Predominant in South Asia. WATER PIPES - also known as shisha, hookah, narghile, these operate by water filtration and indirect heat. Flavored tobacco is burned in a smoking bowl covered with foil and coal. The smoke is cooled by filtration through a basin of water and consumed (often communally) through a hose and mouthpiece. Predominant in Africa, Mediterranean (and the US???)

44 Non-Cigarette Tobacco: Hookahs Due to the mode of smoking, including frequency of puffing, depth of inhalation, and length of the smoking session, hookah smokers may absorb higher concentrations of the toxins found in cigarette smoke. A typical 1-hr hookah session ~ inhaling times the volume of smoke inhaled with a single cigarette. Associated cancers 1 Lung cancer Esophageal cancer Gastric cancer Heart disease and respiratory illness 2 Risk of spread of infectious disease 3 Sources: 1 Knishkowy &Amitai (2005). Pediatrics;116: Maziak et al (2004). Tob Cont;13: Munch et al. (2003). Int J Tuberc Lung Dis;:

45 Hookah Use Not Prevalent in the U.S.? Smith, Curbow & Stillman, 2007 Think Again Primack, Sidani, Agarwal, Shadel, Donny, Eissenberg, 2008 Eissenberg, Ward, Smith Simone, & Maziak, 2008 Grekin & Ayna, 2008 State Maryland Pennsylvania Virginia Michigan Sample Census of Freshman Random Sample Grad & Undergrad Intro to Psychology Students Psychology Students Sample Size WP Use Ever Past Month 28% 15.3% 40.5% 9.5% 48.4% 20.4% 15.1% Slide Courtesy of Erin Sutfin, PhD (Wake Forrest Univ)

46 Oral, non-combustable, lower nitrosamine tobacco products Snus: Not your father s smokeless tobacco Safer, but not safe Decreased cancer incidence Step towards cessation?

47 Conventional PREPs Total Tobacco-Specific Nitrosamine Level (μg/g product wet weight) Smokeless Tobacco Conventional Cigarettes Oral Non- Combustible PREP Skoal (long cut) 9.2 Copenhagen (long cut) 7.5 Copenhagen (snuff) 4.8 Marlboro (full) 6.3 Camel (full) 5.2 Marlboro (light) 4.6 Camel Snus (original) 1.15 Ariva 0.19 Stonewall 0.28 Medicinal Nicotine Nicotine (4 mg) Patch Nicotine (4 mg) Gum Source: Stepanov, et al. (2006). Nicotine and Tobacco Research, 8,

48 The Future: Tobacco as a Global Health Problem

49 20 th century: 100 million tobacco-related deaths worldwide 21 st century: Projected 1 billion

50 What would YOU do? As a clinician? As a policy maker? (banning tobacco is not an option)