The Role of Research in Tobacco Control

Mark Parascandola, PhD, MPHEpidemiologistTobacco Control Research BranchUS National Cancer Institute

"cigarette smoking

is a health hazard

of sufficient

importance … to

warrant

appropriate

remedial action,"

U.S. per capita cigarette consumption during this century and major events affecting trends

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

0

1

2

3

4

5

in thousands

WWI

Great

Depression

First scientific studies linking smoking and lung cancer

First SG Report

FCC Fairness

Doctrine

Cigarette Ad ban

Beginning of NS

Rights Movement

SG report on ETS

NRT goes OTC

Master Settlement Agreement

WW II

Evolution of U.S. Tobacco Control Efforts• Information/education campaigns – helped some people

to quit, but fewer than expected. Why? Tobacco is addictive, quitting not easy. Tobacco industry effectively countered under-resourced public health efforts.

• Provide help to individuals to quit and discourage youth from starting – some impact, but less than expected. Why? Both individual and environmental determinants of smoking behavior. Tobacco industry far more resources than public health to shape environment.

• Comprehensive efforts – focused on the individual and the broader environment, using multiple channels and approaches to all sectors of the social environment. When public health has resources to compete with tobacco industry, significant progress can be made.

Source: NCI Tobacco Control Monograph No. 1. Strategies to Control Tobacco Use in the United States: A Blueprint for Public Health Action in the 1990’s. Dec. 1991.

Trends in age-standardized lung cancer death rate

Jemal et al., JNCI; 2008, 100(23)

The Global Tobacco Control Laboratory• Ongoing introduction of many new tobacco control

policies driven by the Framework Convention on Tobacco Control (FCTC), but policies and timelines differ widely across countries

• Diverse and changing conditions in patterns of tobacco use, cultural and social attitudes, economic forces, and healthcare environments

• An enormous “natural experiment” is currently under way– Opportunity for studying the impact of different policies in

different environments and understanding what worksExpanding tobacco control research and research capacity

in the developing world is crucial to reducing the disproportionate burden of tobacco use and cancer.

Global Tobacco Epidemic Continuum

Global Tobacco Mortality is Growing and Shifting to the Developing World

• Tobacco use kills about 6 million people annually worldwide.

• Tobacco-related deaths are expected to rise to 8 million by 2030, and more than 80% of deaths will occur in low and middle-income countries (LMICs).

• Countries increasingly face a “double burden” of disease: diseases of poverty and chronic diseases caused by risk factors such as tobacco use.

• Tobacco use and exposure among women in LMICs is rising threatening to impede or reverse efforts to improve maternal and child health.

Challenges to Reducing Tobacco Use in LMICs

• Low public knowledge, lack of resources for increasing knowledge: • High tobacco use rates among health professionals;

training in tobacco control and prevention is uncommon• Diverse and new tobacco products, both smoked and

smokeless• Inadequate resources for research, interventions (policy

and program), and advocacy• Resistance to tobacco control from governments who

profit from tobacco sales or taxation• Tobacco industry presence strong and may be increasing;

trade and investment treaties empower tobacco industry and allies

International Tobacco Control Policy Evaluation Project (ITC)

The ITC measures the psychosocial and behavioral impact of national level policies of the FCTC, studying:

• Health warning labels and package descriptors

• Smoke-free legislation• Pricing and taxation of tobacco

products• Communication and education• Cessation• Tobacco advertising and

promotion

Source: http://www.itcproject.org/about

NCI Monograph 19: The Role of Media

“The total weight of evidence – from multiple types of studies,

conducted by investigators from different disciplines, and

using data from many countries – demonstrates a causal relationship between

tobacco advertising and promotion and increased

tobacco use.”

Research Questions and Opportunities

Tobacco Products •Understand the changing variety of tobacco products and their characteristics, from traditional locally-made products to large scale manufactured products•Understand how products are produced, distributed, sold and marketed and how these factors influence tobacco use•Understand the public health impact of alternative nicotine delivery systems, including e-cigarettes Public Health Impact•patterns of smoking behavior, product type, concurrent health risks, and the social and policy environment. •Research to better estimate the burden of tobacco related disease in countries where robust data is lacking•Understand how differences in products, patterns of use, population characteristics, and environment contribute to variations in risks of smoking around the world

Behavior and Patterns of Use•Research around how cultural and socioeconomic transitions contribute to changes in tobacco use, including increasing smoking among women where it is historically low•Research on the factors that drive changes in smoking behavior among youth, including targeted marketing

Research Questions and Opportunities

Effective Policies•Understand how evidence-based policies are being implemented and their impact on tobacco use and health outcomes, including what are the most effective policies for a particular environment•Research on the most effective tax structures and policies in different environments

Interventions•Research on development and evaluation of low-cost cessation interventions for resource poor environments and underserved populations •Research to better measure and assess strategies to reduce secondhand smoke exposure for vulnerable populations, including non-smoking women and children

Economics and Trade•Research to assess the economic impact of tobacco use and to evaluate the economic impact of tobacco control measures•Research on the interrelationships between tobacco and poverty•Research to understand the impact of trade and investment agreements on tobacco control policies•Research on the nature of tobacco farming and the potential for crop substitution