Effective Interventions to Reduce Tobacco Use

Joy de BeyerTobacco 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)

2000 2030Developed 2 ~3Developing ~2 ~7World Total 4 ~10

1 in 2 of long-term smokers killed by their addiction 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

Smoking Attributable Deaths in All Ages in EU Mediterranean Countries 1955-2000

7

51

61

33

715

7566

1210

3

5758

21

0

10

20

30

40

50

60

70

80

1955 1965 1975 1985 1990 1995 2000

Ann

ual M

ale

Sm

okin

g de

aths

(100

0s)

PortugalSpainItalyGreeceFrance

Source: Peto, Lopez, 2001

Tobacco Related Deaths in Mediterranean Countries in 1990

Tracheal, Lung & Bronchial Cancer per 100,000 deaths

153229 241

368

704

992

1390

0

200

400

600

800

1000

1200

1400

Libya Lebanon Jordan Tunisia Egypt Algeria Morocco

MaleFemale

1.1 Billion Smokers Worldwide(1990-1995 estimate, million)

Males Females Total Developed 200 100 300 Developing 700 100 800

World 900 200 1.1 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

542

382 398

261

454

243

51%

37%33%

33%

25%19%

Portugal Italy Spain France Greece Turkey

Packs/smoker Prevalence

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

207 217 227 213173

256

243

20% 24% 25% 25%31% 33%

53%

Morocco Egypt Jordan Algeria Syria Tunisia Lebanon

Packs/smoker Prevalence

Protect YouthSmoking and Addiction Starts Young

Smoking Prevalence (%)among Youth in Selected EU Mediterranean Countries in 1990s

8%

6%6%5%5%

10%

5%4%

7%

5%

Greece (11-15) 1998

Spain (11-15) 1994

Italy (13-14)

1994

Portugal(11-15)1998

France(11-15)1998

Boys

Girls

Protect Youth:Smoking and Addiction Starts Young

Smoking Prevalence among Youth in Selected Mediterranean Countries 32%

16%14%13%11%

4%

11%7%9%

3%1%

Algeria (15 yrs) 1999

Lebanon(15-18)

1997 total

Egypt (14-18) 1998

Turkey (7-13) 1996

Syria (16) 1997

Jordan (12-18) 1997

Boys

Girls

Allocating Tobacco Expenditure to Other Goods and Services

Better Nutrition, Better Health: Evidence from Hungary

Additional Food a Smoker Could Buy Per Week if He/She Did Not Smoke in 1999

2.0 2.1 3.1

9.8

25.6

21.0

Pork Beef Chicken Apple Potato Flour

Kg/Week

High opportunity Cost: Evidence from Belarus

Smoking Expenditure as % of Total Income for a Typical Belarus Smoker

7% 10%

37%42%

0%

10%

20%

30%

40%

50%

1996 1999

If smoke only domestic brands If smoke only foreign brands

High opportunity cost: Evidence from Bulgaria

Tobacco expenditure as % of gross income and wages&salaries in Bulgaria

1997

1.8%

4.9%

1.6%

3.6%

1.1%

3.1%

0%

1%

2%

3%

4%

5%

6%

as % of gross income as% of wages &salaries

Low Middle High

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

No Ban

Ban

1450

1500

1550

1600

1650

1700

1750

1981 1991Year

Cig

aret

te c

onsu

mpt

ion

per c

apita

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: OTC sales, allowing advertising, licensing Conducting more studies on cost-effectiveness (especially in

low/middle income countries) Considering NRT subsidies for poorest smokers

Cessation Efforts: Health Care Professionals First

Smoking Prevalence Among Health Professionals and Medical Students in Mediterranean Countries 1990s

14

3034 37 37 39

4450 53

17

1

34

5 2

1713

29 3241

Prev

alen

ce ra

te %

Males Females

Physician rate: Greece, Italy, Malta, Spain, Turkey, Egypt, SyriaMedical 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

Tobacco Excise Tax Revenue in 1999

3.0

18.4

02468

101214161820

Other Med. EU Med.

Billi

on U

S $

EU Med: France, Greece, Italy, Portugal, SpainOther Med: Algeria, Cyprus, Egypt, Morocco, Jordan,Lebanon, Syria, Turkey, Tunisia,

Summary:

Modest action could achieve great gains for

public health

without hurting the economy