preventive interventions: the cost-effective “best-buys”
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Preventive Interventions: The cost-effective “Best-Buys”
- Global advances in Tobacco Control -
Riyadh, 10 -12 September 2012
Douglas Bettcher, MD, PhD, MPHDirector, Tobacco Free Initiative
Director Ad Interim, Chronic Diseases and Health Promotion
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
WHY TOBACCO CONTROL
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Chronic respiratory
diseases
Cardiovasculardisease
Diabetes
Cancer
Unhealthy diets
Tobacco
Harmful use of alcohol
Physical inactivity
Mental disorders
Injuries
Risk factors
Noncommunicable Diseases and Conditions
Tobacco and the NCD action plan:4 risk factors, 4 noncommunicable diseases, 2 conditions
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
High-income countries 2.0 mil-
lion (14%)
Upper middle-income coun-
tries2.3 million (16%)
Lower middle-income coun-
tries8.3 million(59%)
Low-income countries1.5 mil-lion
(11%)
86% of people who die from NCDs between the ages of 30 and 70
live in a developing country
14.2 million
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Huge disparities exist across countries in relation to the probability of death from an NCD between the ages of 30-70
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Source: WHO 2008
The Tobacco Epidemic - Today
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Source: WHO Global status report on noncommunicable diseases, 2010, http://www.who.int/nmh/publications/ncd_report2010/en/
Tobacco kills ...
…nearly 6 million people each year.
22% of global cancer deaths, 71% of all lung cancer deaths.• 10% of cardiovascular
disease deaths
About 90% of all deaths from
chronic obstructive lung
diseases and 42% of all chronic respiratory disease are
attributable to cigarette smoking.
Tobacco kills…
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Source: Global estimate of the burden of disease Mattias Oberg … [et al], WHO 2010, http://www.who.int/tobacco/publications/second_hand/global_estimate_burden_disease/en/index.html
.
Distribution of total deaths
attributable to SHS, 2004
One third of adults are regularly exposed to second-hand tobacco smoke.
About 600 000 people die each year as a result of exposure to second-hand smoke.• 430 000 are adults, of whom 64% are women• 28% of the second-hand smoke deaths are
among children
Exposure to second-hand smoke also kills
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
The Tobacco Epidemic is About to Get Much Worse…
Tobacco currently kills
nearly 6 Million/year but this will increase
to over 8 Million/year in a
few decades.
If current smoking patterns
continue, the death toll from tobacco use will
be: • 2000–2025~150M• 2025 – 2050 ~ 300 M• 2050 – 2100 > 500 M
Tobacco could kill up to 1
Billion persons in the 21st Century
unless urgent action is taken
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
THE SOCIO-ECONOMIC IMPACT
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
(per
cen
tage
)
Smoking prevalence (2004)
0
5
10
15
20
25
30
35
40
45
Low-income countries
Lower-middle
Income
Upper-middle-income
High-income
Lowest household income quintiles
Highest household income quintiles
New perspectives The poorest people in developing countries are affected the most:
Example: Poorest people smoke the most
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
OPPORTUNITIES AND GLOBAL RESPONSE
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Mechanisms for Tobacco Control
WHO Framework Convention on Tobacco Control (WHO FCTC)
A Global Treaty
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Objective:“To protect present and future
generations from the devastating health, social,
environmental and economic consequences
of tobacco consumption and exposure to tobacco smoke …
to reduce continually and substantially the prevalence of tobacco use and
exposure to tobacco smoke ”.
WHO Framework Convention on Tobacco Control: An evidence-based tool to save lives
World No Tobacco Day Poster 2011
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
What is the WHO FCTC?
First global health treaty negotiated under the auspices of WHO Establishes tobacco control as a priority on the public health agenda Provides a political and legal platform for adoption of sound, evidence based tobacco control measures Introduces a mechanism for firm country commitment and accountability
176 Parties
Entry into force 27 Feb 2005 176 parties covering about 87% of the world’s population
176
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Demand reduction provisions
Price and tax measures (Art.6) Protection from secondhand smoke
(Art.8) Contents regulation (Art.9) Disclosure of contents (Art.10) Packaging and labelling (Art.11) Education and awareness-raising
(Art.12) Advertising, promotion and
sponsorship (Art.13) Cessation programmes (Art.14)
Supply reduction provisions
Elimination of illicit trade (Art.15) Prohibition of sales to and by minors
(Art.16) Support for viable crops for growers
(Art.17)
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
BEST BUYS AND
GOOD BUYS
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Rationale – Why "best buys" for NCDs?
Public health and economic burden – show
the size of the problem, but not how to address and
reduce it
Cost-effectiveness – indicates solutions but not
their feasibility, affordability and
acceptability
Consequent need to develop:
NCD "best buy" interventions that are cost-effective, feasible, low-cost
and appropriate to implement within the constraints of the local
health systemFinancial planning tool for identifying resource needsPrice tag analysis to inform
global resource mobilisation
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
US$ 170B is the overall cost for all developing countries to scale up action by implementing a set of "best buy" interventions between 2011 and 2025, identified as priority action by WHO
US$ 7T
is the cumulative lost output in developing countries associated with NCDs between 2011-2025
The cost of action vs inaction (in developing countries over the next fifteen years)
Cost of action: Cost of inaction:
Reports are available at www.who.int/ncd
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
MPOWER: Six policies whichbuild on the WHO FCTCand are an integral part of the NCD Global Strategy Action Plan
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
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
BEST BUYS &
GOOD BUYS
Monitor tobacco use and prevention
Protect people from tobacco smoke
Offer help to quit tobacco use
Warn about the dangers of tobacco
Enforce bans on tobacco advertising
Raise taxes on tobacco
US$0.6 billion for all low- and middle-income countries (US$0.11 per capita)
Tobacco control is cost-effective
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Tobacco control is cost-effective
5·5 million deaths could be averted over 10 years if these elements of the WHO FCTC were implemented in countries:• increased taxes on tobacco products;• enforcement of smoke-free workplaces; • WHO FCTC-compliant packaging and labelling, with
public awareness campaigns about health risks; • comprehensive ban on tobacco advertising, promotion,
and sponsorship.
at a cost of less than US$ 0.40 per person in low income and lower-middle income countries
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Estimates for the average annual cost of tobacco control best buy interventions in all low- and middle-income countries (US$ 2008)
R
W
E
P
W
A study that modelled P, W, E, R for 23 countries 5.5 million deaths could be averted at less than US$ 0.40/person /year in low- and lower-
middle-income countries, and US$ 0.5–1.00 in upper-middle-income countries.
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
59
31
23
19 271919
Number of highest achieving countries in 2010
MPOWER
Status of MPOWER measures
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
3.8 billion people (55% of the world’s
population) are covered by at least one MPOWER measure at the
highest level of achievement, including
1.1 billion people covered by a new policy
since 2008
MPOWER
Progress is being made
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
MPOWER measures bring smoking rates down rapidly
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
M Djibouti, Iran, Jordan, Lebanon, Morocco
P Iran, Libya, Pakistan
O Bahrain, Iran, Saudi Arabia, United Arab Emirates
W – labels: Djibouti, Egypt, Iran
W – campaigns: Egypt, Lebanon, Morocco
E Djibouti, Iran, Jordan, Kuwait, Qatar, Sudan, Syria, UAE
R West Bank and Gaza Strip
EMRO – countries with MPOWER measures at the highest level of achievement
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
The Islamic Republic of Iran enacted a comprehensive tobacco control law in 2006.
In 2008, the law was strengthened to require pictorial warnings on all cigarette packages.
Warning labels cover 50% of the pack and include graphic images of diseases caused by smoking.
Use of misleading terms, such as “mild” and “light” are also banned.
As a result, Iran’s requirements fully meet the WHO FCTC Article 11 guidelines and thus effectively warn smokers about the risks to their health.
Iran implements strong pack warning labels
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Tobacco advertising and marketing had in theory been banned in Jordan since 1977, but the enforcement was weak.
The 2008 legislation clarified and strengthened the law and added new provisions to limit point-of-sale tobacco marketing, including bans on the sale of individual cigarettes and sales through vending machines.
To strengthen enforcement, the Ministry of Health trained 35 health promotion coordinators on practical and suitable methods for enforcing and implementing the law and on procedures for inspections.
This successful model for enforcing advertising and marketing bans is ready to be expanded to the rest of the region.
Jordan strengthens prohibitions on tobacco advertising, promotion and sponsorship
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
In 2010, Egypt replaced its tiered tax system with a uniformly applied 40% ad valorem excise tax as well as a single specific tax rate of Egyptian £ 1.25 (USD 0.20) per pack of cigarettes.
Total taxes per pack by an average of 87%, which increased the average retail price by an estimated 44%. This increase on cigarettes could reduce cigarette consumption by 21% and smoking prevalence by more than 10%, and hence reduce the number of adult smokers by about 893 000 and prevent about 208 000 premature deaths.
Egypt’s approach to reaching the dual goals of reduced tobacco consumption
and increased resources to spend on health can provide invaluable lessons
for other countries.
Egypt restructures and increases tobacco excise taxes and earmarks additional revenues to fund health programmes
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Plain packaging initiative takes off
Australia’s High Court dismissed a legal
challenge from the tobacco industry.
From December 2012, Australia will be the first country to sell cigarettes only in drab, olive-green
plain packaging.
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
113 Member States
34 Presidents and Prime-Ministers
54 Vice-Presidents, Deputy Prime-Ministers, Ministers of Foreign Affairs and Health
11 Heads of UN Agencies
Hundreds of representatives from civil society
UN High-level Meeting on NCDs (New York, 19-20 September 2011)
LANDMARK EVENT ATTENDED BY:
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
We, Heads of State and Government and representatives of States and Governments, assembled at the United Nations from 19 to 20 September 2011, to address the prevention and control of non-communicable diseases worldwide, with a particular focus on developmental and other challenges and social and economic impacts, particularly for developing countries,
38. Recognize the fundamental conflict of interest between the tobacco industry and public health;
43.(c) We therefore commit to: Accelerate implementation by States parties of the
WHO Framework Convention on Tobacco Control
The UN POLITICAL DECLARATION ON NCDs
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Advance the implementation of multisectoral, cost-effective population-wide interventions in order to reduce the impact of the common NCD risk factors
Tobacco useUnhealthy Diet
Physical InactivityHarmful Use of Alcohol
Interventions: Population- or individual- based measures ('best-buys') that are very cost-effective, feasible and low-cost
The UN POLITICAL DECLARATION ON NCDs commits Member States
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Raised blood pressure
25%
Salt/sodium intake
30%
Tobacco smoking30%
Physical inactivity10%
Obesity0%
Fat intake15%
Alcohol10%
Raised cholesterol
20%
Generic medicines and technologies
80%
Drug therapy and
counselling50%
Premature mortality from NCDs25% reduction
Target adopted by the World Health Assembly
Targets with wide support Targets with support for further development
11 voluntary global targets presented in the revised WHO Discussion Paper
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Epidemiological models - Tobacco use & Malaria infection
Tobacco Industry - A Mutating Vector
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
Manoeuvering to hijack the political and
legislative process
Exaggerating the economic importance of the industry
Manipulating public opinion
to gain the appearance of respectability
Fabricating support
through front groups
Discrediting proven science
Intimidating governments with litigation or the threat of litigation
Forms of Tobacco Industry Interference
In setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested
interests of the tobacco industry in accordance with national law.
WHO FCTC ARTICLE 5.3
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
"As a tool for fighting back, we have the WHO FCTC. We have a
practical, cost-effective way to scale up implementation of
provisions in the treaty on the ground. […] the best-buy and
good-buy measures for reducing tobacco use set out in
the MPOWER package."
"And we have an enemy, […] the tobacco industry, has changed its face and its tactics. Tactics aimed at undermining anti-tobacco campaigns, and subverting the WHO FCTC, are no longer covert or cloaked by an image of corporate social responsibility. They are out in the open and they are extremely aggressive"
"[…] full implementation of the WHO FCTC would deliver the
single biggest preventive blow to heart disease, cancer, diabetes,
and respiratory disease."
"I called on heads of state and government to stand rock-hard against the despicable efforts of the tobacco industry to subvert this treaty."
Dr Margaret Chan, Director-General of the World Health OrganizationKeynote address at the 15th World Conference on Tobacco or Health, Singapore, 20 March 2012
"We have evidence, and we have instruments"
Preventive interventions: the cost-effective “best-buys”| Riyadh| 10-12 September, 2012
TOBACCO FREE INITIATIVETOWARDS A TOBACCO FREE WORLD
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