Think Globally, Act Locally: The Global Tobacco Pandemic

Artwork by Darwin L. © 2010 American Academy of Pediatrics (AAP) Children's Art Contest. Support for the 2009 and 2010 AAP Children's Art Contest was from the Flight Attendant Medical Research Institute.

Welcome

Continuing Medical Education Credit• The American Academy of Pediatrics (AAP) is accredited by the Accreditation

Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

• The AAP designates this live activity for a maximum of 1.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

• This activity is acceptable for a maximum of 1.50 AAP credits. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Members of the American Academy of Pediatrics.

• The American Academy of Physician Assistants (AAPA) accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™from organizations accredited by ACCME. Physician assistants may receive a maximum of 1.50 hours of Category 1 credit for completing this program.

• This program is accredited for 1.50 NAPNAP CE contact hours of which 0.25 contain pharmacology (Rx) content per the National Association of Pediatric Nurse Practitioners (NAPNAP) Continuing Education Guidelines.

At the conclusion of this activity, participants should be able to:

• Discuss the impact of tobacco on the global population, including health consequences

• Describe how pediatricians are combating the tobacco epidemic worldwide

• Explain what is being done globally to reduce the impact of the tobacco pandemic

Think Globally, Act Locally: The Global Tobacco Pandemic

Artwork by Darwin L. © 2010 American Academy of Pediatrics (AAP) Children's Art Contest. Support for the 2009 and 2010 AAP Children's Art Contest was from the Flight Attendant Medical Research Institute.

Welcome

Disclosure Statement

• Neither I nor any member of my immediate family has a financial relationship or interest (currently or within the past 12 months) with any entity producing health care goods or services consumed by, or used on, patients related to the content of this CME activity.

• I do not intend to discuss an unapproved/investigative use of a commercial product/device.

Effective tobacco control strategies in other countries will reduce rates of tobacco use

in my country

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Strongly Agree Agree Neutral Disagree StronglyDisagree

N= 121

Importance of Global Health

• Diseases have no boundaries

• Better health, increased productivity

• Improved economic development

• Enhanced global security

Tobacco Control and the MDGs

• Use is on the rise among those in impoverished countries

• Money is spent on tobacco instead of other vital needs

• Improve health and economic burdens by preventing premature deaths

• Solutions already exist and can be implemented with MDGs

How does Tobacco Control impact the MDGs?

• Focus on cultivating food, not tobacco (1)

• No child labor, make attending school appealing (2)

• Give women more control over household finances (3)

• Offer smoking cessation to parents (4 + 5)

• Offer cessation help along with HIV/TB treatment (6)

• Prevent deforestation, cigarette butt litter (7)

• Countries create action plans supported by intl orgs (8)

Two Questions

• How can we advance the international tobacco agenda to protect more children from tobacco use and exposure to secondhand smoke?

• And what can we learn from our global colleagues?

Ruth Etzel, MD, PhD, FAAP

Disclosure Statement

• Neither I nor any member of my immediate family has a financial relationship or interest (currently or within the past 12 months) with any entity producing health care goods or services consumed by, or used on, patients related to the content of this CME activity.

• I do not intend to discuss an unapproved/investigative use of a commercial product/device.

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Global Causes of Death

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Tobacco LowerRespiratoryInfections*

DiarrhealDiseases*

PerinatalConditions*

Tuberculosis AIDS

Dea

ths

in M

illio

ns

* WHO World Health Report 2002

Tobacco: A killer at large

…tobacco is the only legally available consumer product that kills people when it is used as intended…

C. Everett Koop, MDSurgeon GeneralU.S. Public Health Service

The Coming Epidemic

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2000 2025

1.1

1.64bi

llions

of s

mok

ers

Rise in Smokers Worldwide

Source: Peto R, Lopez AD, Liu B. Global tobacco mortality. Paper presented at 10th World Conference on Tobacco or Health, 24-28 Aug 1997; Beijing, China

Current Tobacco Use – Worldwide

• Almost 1 billion men smoke cigarettes – 35% developed countries– 50% developing countries

• 250 million women smoke cigarettes – 22% developed countries – 9% developing countries

Every day, 80,000-100,000 young people around the world become addicted to tobacco

1 in 3 will die from a tobacco-related disease

Current tobacco use: Young people (13-15 years)

Sources: Global Youth Tobacco Survey

Health Behavior in School-Aged Children

Other national and multinational surveys

UNDERLYING FACTORS

Poverty

Environmental Degradation

Poor Nutrition

Poor Housing

Advertising of Tobacco Products

CHILD CHILD

HEALTH

UNDERLYING FACTORS

Poverty

Environmental Degradation

Poor Nutrition

Poor Housing

Advertising of Tobacco Products

CHILD CHILD

HEALTH

HEALTH CARE

UNDERLYING FACTORS

Poverty

Environmental Degradation

Poor Nutrition

Poor Housing

Advertising of Tobacco Products

CHILD CHILDHEALTH

ADVOCACY

Outline

• Children’s vulnerability

• Multiple health effects– Lower respiratory illnesses– Infections– Childhood cancer

• Vector control

Short stature-closer to ground

Hand to mouthactivity

Increased air intake

Increased skin surface area

Altered excretion

Increased foodintake andmetabolic rate

Ongoing organdevelopment

Long “shelf life”

How Children are Different

CHILDREN’S UNIQUE PHYSICAL VULNERABILITY

Inhale more pollutants per kilogram of body weight than do adults

Because airways are narrower, irritation from tobacco smoke can result in proportionately greater airway obstruction

www.vh.org/pediatric/provider/pediatrics/ElectricAirway/Diagrams/AirwayDIaneterEdema.jpg

RESPIRATORY DEVELOPMENT:CONTINUES POSTNATALLY THROUGH LINEAR GROWTH

10 X 106 Alveoli300 X 106 Alveoli

(age 8)

Source: Dietert Environmental Health Perspectives, 2000

2 to 8

Maternal smoking delays in utero immune development; less mature immune system (less cytokines) increases risk of

asthma/atopy at 6 years

Source: Macaubas et al. Lancet 2003;362:1192-97.

3rd generational effect: in utero smokingEarly Asthma Risk Factor Study (USA)

Subset of 4082 children recruited from schools≈ 20% exposed to in utero smokingIf maternal grandmother smoked, mother does not:

– asthma Odds Ratio 1.8 (95% CI 1.0 - 3.3)If maternal grandmother smoked, mother smokes

– asthma Odds Ratio 2.6 (95% CI 1.6 - 4.5)

Source: Li, et al. Chest 2005;127:1232-1241

Epigenetic effects

Postnatal Secondhand Smoke Exposure

• ↑ LRI in infancy

Meta-analysis of 60 studies• Father: Odds ratio 1.22 (1.10 - 1.35)• Mother: Odds ratio 1.58 (1.45 - 1.73)• Both Parents: Odds ratio 1.62 (1.38 - 1.89)• Household: Odds ratio 1.54 (1.40 – 1.69)

• ↑ ear infections in early childhood

• ↑ childhood asthma

Meta-analysis of 38 studies↑ incident asthma 6-18 yrs (1.33, CI 1.14-1.56)

Sources: Jones, Respir Res 2011, Vork, Envir Health Persp, 2007

SIDsRSV/ BronchiolitisMeningitis

Infancy

Low Birth WeightStillbirth

In utero

AsthmaOtitis MediaFire-related Injuries

Influencesto StartSmoking

Nicotine Addiction

CancerCardiovascular DiseaseCOPD

Adulthood

Adolescence

Childhood

The Life Cycle of the Effectsof Smoking on Health

Source: Aligni CA, Stodal JJ. Tobacco and children: An economic evaluation of the medical effects ofparental smoking. Arch Pediatr Adolesc Med. 1997;151:652

Source: Leung et al. Arch Intern Med 2010;170:287-292

Passive Smoking Increases the Incidence Rate of Active Tuberculosis (TB) and Culture-Confirmed TB

Increased Risk of Infectious Disease

• Maternal smoking increases the risk of invasive meningococcal disease among children

Risk Ratio 2.9

(95% CI 1.5 – 5.7)

Ref: Yusuf HR et al. Am J Public Health 1999

Hookah Smoking and Infectious Diseases

Resurgence of use around

the world, most notably

among youth.... Sharing a

hookah may increase the risk

of transmission of

tuberculosis, viruses such as

herpes or hepatitis, and

other illnesses.http://www.lung.org/stop-smoking/tobacco-control-advocacy/reports-resources/cessation-economic-benefits/reports/hookah-policy-brief.pdf

Paternal Smoking and Childhood Cancer Cancer Relative Risk CI, p-valueRhabdomyosarcoma 3.9 p=0.003

Brain 2.0 1.0-4.1

Infant leukemia 1.56 1.03-2.36

All types (1953-55) 1.89 highest tertile 0.84-4.24, p=.001

All types (1971-76) 1.63 highest quintile 1.23-2.15, p=.001

All types 1.7 highest tertile 1.2-2.5, p=.006

ALL 3.8 highest tertile 1.3-12.3 p=.01

Lymphoma 4.5 highest tertile 1.2-16.8 p=.07

Brain 2.7 highest tertile 0.8-9.99 p=.14

All types 1.77 highest quintile 0.94-3.34, p=.02

Astroglial 1.4 1.1-1.9

Sources: John et al, Am J Epidemiol 1991, Ji et al, J Natl Cancer Inst 1997

Global burden of disease from second-hand smoke (SHS)

Exposure to second-hand smoke at home:young people (13-15 years)

Source: Global Youth Tobacco Survey

Individuals exposed to second-hand smoke (%)World, 2004

Globally, more than a third of all people are regularly exposed to the harmful effects of smoke

40%

35%33%

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5%

10%

15%

20%

25%

30%

35%

40%

45%

Children Females Males

Per

cent

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osed

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HS

Source: WHO/The Lancet 2011

World-wide burden of disease from second-hand smoke

More than 600,000 death per year worldwide are caused by second-hand smoke – this is more than 1% of all deaths.

165,000 of these deaths are among children.

Smokers put 1.8 billion nonsmokers at risk. In 2004, this led to:

• 379,000 deaths from ischemic heart disease

• 165,000 deaths from lower respiratory infections

• 36,900 deaths from asthma

• 21,400 deaths from lung cancer

Source: WHO, The Lancet, 2011

Disease burden from secondhand smoke by region, in 2004

“Tobacco use is unlike other threats to global health. Infectious diseases do not employ multinational public relations firms. There are no front groups to promote the spread of cholera. Mosquitoes have no lobbyists.”

-- WHO Zeltner Report, 2000

Increased Health Care Costs

In high income countries, annual tobacco-attributable health care costs estimated at between 6% and 15% of total health care costs

Very few estimates for low income countries

Why is tobacco control important for children?

Most tobacco use starts before age of 18, and ¼ of them before the age of 10.

Youth underestimate the risks of tobacco and the likelihood of addiction.

If current trends continue, 250 million children and teenagers alive TODAY will die from tobacco –related diseases.

Source: What in the world works?, WHO, 1999

The Tobacco Epidemic in China

China has 0.3 billion current smokers, about a third of the world’s total number of smokers, 0.74 billion people suffer from exposure to secondhand smoke, and among them 0.18 billion are children and adolescents

China: Youth SmokersIt is estimated that 130 million youths are current smokers, and more than 400 million attempt to smoke

Yout

h C

urre

nt S

mok

ers

(%)

Source: 2008 China Tobacco Control Report, China CDC

Total Boys Girls

A Vector-Borne Disease

Primary vector by which tobacco reaches children is advertising that pervades their environments

The Tobacco Industry uses packaging of tobacco products to target youth

“Sweet Dreams”

“If you are not allowed it, but

really want it, then you can have it!”

Marketing Lies of the Tobacco Industry

“We do not market to children or use any images or content that might appeal to minors.”

“We put health warnings on all our marketing materials and packaging.”

“All our marketing respects global standards of decency as well as local cultures, traditions and practices.”

Tobacco AdvertisingMarketing motivates potential (young) users to try tobacco and become long-term addicts.

Pediatricians can discuss the un-glamorous effects of tobacco use with their patients.

Complete bans on marketing and promotion are a powerful weapon.

Ensure that your organizations do not partner with the tobacco industry.

“This is a market with tremendous potential. The rate of population growth is 2.2 percent each year, and 40 percent of the population is under 18.”

-- Philip Morris Turkey, 1997

The cigarette package“A cigarette package is unique because the customer carries it around with him all day…it’s a part of a smoker’s clothing, and when he saunters into a bar and plunks it down, he makes a statement about himself.”

John Digianni, cigarette package designerSource: Wakefield et al, 2002

China: tobacco packaging

Use of Picture Warnings on Cigarette Packages

Venezuela

Source: http://www.smoke-free.ca/warnings/Venezuela%20-%20warnings.htm

Evidence from Brazil

• 54% of smokers had changed their opinion on the health consequences of smoking as a result of the warnings

• 67% of smokers said the warnings made them want to quit

• Impact was greater among groups with lower levels of income and education

http://www.who.int/tobacco/healthwarningdatabase/en/index.html

Evidence from Thailand

• 81% of youth (age 13-17) said that new pictorial warnings made them think more about the health impacts of smoking

• More than half of smokers (53%) said that the pictorial warnings made them think “a lot” about the health risks

• Nearly half (44%) of smokers said that the pictorial warnings made then “a lot” more likely to quit over the next month

http://www.who.int/tobacco/healthwarningdatabase/en/index.html

Evidence from Canada

• 58% of smokers thought more about the health effects of smoking as a result of the warnings

• 44% of smokers said the warnings had increased their motivation to quit

• 27% of smokers smoked less inside their homes as a result of the warnings

http://www.who.int/tobacco/healthwarningdatabase/en/index.html

Evidence from Singapore

• 71% of smokers said they knew more about the health effects of smoking as a result of the warnings

• 28% said they smoked fewer cigarettes as a result of the warnings

• 14% said they avoided smoking in front of children as a result of the warnings

http://www.who.int/tobacco/healthwarningdatabase/en/index.html

WHO World No Tobacco Day campaign materials are available for your use.

Fifteen countries with the greatest number of tobacco users

China

India

Indonesia

Russia

Bangladesh

BrazilMexicoTurkeyPakistanEgypt

UkrainePhilippinesThailandVietnamPoland

-Bloomberg Initiative to Reduce Tobacco Use

“We must try to stop the development towards a Third World commitment against tobacco. We must try to get all or at least a substantial part of Third World countries committed to our cause….We must try to mitigate the impact to WHO by pushing them into a more objective and neutral position.”

-- BAT internal document, 1979

A possible approach

Doctors have come a long way on the road to tobacco control

Ask your Doctor, RJ Reynolds, 1947

2013

Practitioner Effectiveness

• 7-10% of smokers spontaneously quit with success

• 13% of smokers quit after an appropriately-designed brief message from a healthcare provider

• Up to 30% of smokers quit using guideline recommended treatment

The 5 “A”s for the Pediatrician

Asking: Do you smoke? Where do you smoke? Is the child exposed to tobacco smoke at home or anywhere else?

Advising: You must at least say “I want you to quit” in some way

Assessing: Have you considered quitting? Assess importance, confidence and readiness?

Assisting: Find help or give it yourself

Arranging: Following up at each visit,

taking ownership of the problem

Screening, Brief Intervention and Referral

• Institutionalizes screening (as a vital sign)

• Knowledge of referral resources in your local community

• Or, reliance on national or state Quitlines

• 1-800-QUIT-NOW

Protect children from tobacco smoke

Advocate for 100% smoke-free public places.

Encourage voluntary measures among parents to make homes 100% smoke free.

Some countries have prohibited smoking in cars (e.g. Australia, Bahrain, Canada, Cyprus, Mauritius, South Africa and UAE).

Pediatricians can urge policy makers to take action to protect the population

Less than 11% of the world lives in jurisdictions with comprehensive smoke-free laws at present.

• Need completely smoke-free environments in all indoor workplaces, public places and public transport;

• Need voluntary smoke-free home policies, for countries that already have smoke-free laws;

• This cannot wait!

Source: WHO/The Lancet 2011

Global Tobacco Control

> 80% of the world's smokers live in low- and middle-income countries

Cessation interventions are not common in many systems

Pediatric leadership often influential in policy for children’s health

Pediatricians: A Strong Voice for Children

Thank you for your work toward a tobacco-free world

Flowers instead of cigarettes

Rosa Sandoval, MPA

Disclosure Statement

• Neither I nor any member of my immediate family has a financial relationship or interest (currently or within the past 12 months) with any entity producing health care goods or services consumed by, or used on, patients related to the content of this CME activity.

• I do not intend to discuss an unapproved/investigative use of a commercial product/device.

1. Tobacco Epidemic

2. The WHO FCTC – International legally binding treaty

3. The Latin-American experience regulating tobacco use and exposure to secondhand smoke

Tobacco:

Unique legal product that used as intended by their manufacturers kills up to half of its consumers.

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 deaths10% of cardio-vascular disease deaths

90% of all deaths from chronic

obstructive lung diseases

42% of all chronic respiratory diseaseare attributable to cigarette smoking.

Exposure to secondhand smoke also kills

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 prematurely as a result of exposure to second-hand smoke.

adult male, 26%

adult female, 46% children,

28%

Risk factor for six of the eight leading causes of death

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,

Tobacco could kill up to 1 Billion persons in the 21st Century unless urgent action is taken

The WHO FCTC – International legally binding treaty

• It is a new approach in international health cooperation: uses a global legal framework to address a globalized epidemic

• Ratified by 176 countries in the world .

• Traditional methods as individual interventions by health care professionals are no match for the tobacco industry’s power and transnational reach

What is the FCTC?

Ratified

82% countries in the Americas have ratified

General Obligations

• a “floor”, not a “ceiling” (Art. 2)

• Each Party shall: (Art. 5)

o National coordinating mechanism for tobacco control.

o Protect their public health policies with respect to tobacco control from commercial and other vested interests of the tobacco industry [There is a fundamental and irreconcilable conflict between TI and public health]

Art. 6

Parties recognize that price and tax measures are an effective way of reducing tobacco consumption in particularly young persons;

o Make it expensive relative to products and to family income

o Higher taxes/prices reduce tobacco prevalence (% of smokers) and tobacco consumption among those who continue smoking

Average Price of the most sold brand, Excise tax per pack Per income level 2010

Source: WHO GTCR III

Costa Rica, 2012

Art. 8Ban smoking in all indoor public places and

workplaces

• Legislation protecting from secondhand smoke• Parties recognize that tobacco exposure causes

death and illness

Countries with 100% smoke-free laws

- Consistent with Art. 8 of the FCTC

1. Uruguay (2005/2008)2. Panama (2008)3. Canada (2008)4. Guatemala (2008)5. Colombia (2008/2009)6. Trinidad & Tobago (2009)7. Perú (2010)8. Honduras (2010)9. Barbados (2010)10. Venezuela (2011)11. Argentina (2011)12. Ecuador (2011)13. Brasil (2011)14. Costa Rica (2012)15. Chile (2013)16. Surinam (2013)

Art. 11Big, graphic, and strong health

warnings

Every person should be informed of the consequences for their health of tobacco use, addictive nature and mortal threat posed by tobacco consumption and exposure to tobacco smoke

PERU

Before Now

1. CANADA 2. BRASIL3. CUBA (no picture)4. CHILE5. PANAMA6. URUGUAY7. JAMAICA (no picture)8. VENEZUELA9. BOLIVIA 10. COLOMBIA11. MEXICO12. Estados Unidos13. PERU14. HONDURAS15. NICARAGUA16. ARGENTINA17. ECUADOR18. El SALVADOR19. COSTA RICA20. SURINAM

Countries with laws establisihing graphic HW of at least 50%

- Consistent with Art. 11 of the FCTC-

Art. 13

Total ban on tobacco Advertising, Promotion and Sponsorship To be effecctive, it needs to have a broad scope. Contemporary marketing communication involves an integrated approach to advertising and promoting the purchase and sale of goods through direct marketing, public relations, sales promotion, personal selling and online interactive marketing methods.

Brand stretching

Source: CTFKhttp://www.tobaccofreekids.org/ad_gallery/category/japan_tobacco/P15

Source: CTFKhttp://www.tobaccofreekids.org/ad_gallery/category/marlboro/P45

Promotion at point of sale

Total Ban:1.Panamá (2008)2.Colombia (2009)3.Brasil (2011)*4.Chile (2013)5.Surinam (2013)*

Countries with a ban on tobacco advertising, promotion and sponsorship

- Consistent with Art. 13 of the FCTC-

• Offer cessation services (Art. 14)

• Information and Education (Art.12)

• Surveillance of the tobacco epidemic, monitor interventions to control it (Art. 20)

• Combat illicit trade (Art. 15- Protocol approved)

Tobacco control Legislation in Latin-Americakeys of a successful process (2003-2013)

1. Solid scientific evidence2. International legally binding treaty

• Unified international standards3. Use of different means for legislation (national vs subnational;

multi-measure vs one measure; legislative vs executive)4. Trained and coordinated civil society5. Constant training for Ministry of Health focal points6. Donors

Challenges

1. Tobacco Industry interference: controversy about effectiveness of the measures/ obstruct approval of measures/ delays implementation

2. New strategies:1. Legal challenges– domestic and international2. Use of trade agreements

3. New technologies– e-cigarette

4. Tobacco Industry interference

LinksFCTC:http://www.who.int/fctc/text_download/en/index.htmlGuidelines approved by Parties: http://www.who.int/fctc/protocol/guidelines/adopted/en/

WHO Report on the Glabal Tob Epidemic:http://www.who.int/tobacco/global_report/en/index.html

PAHO Regional Report on Tobacco Control:http://new.paho.org/hq/index.php?option=com_content&view=article&id=4457&Itemid=1231&lang=en

World No tobacco Day videohttp://www.who.int/campaigns/no-tobacco-day/2013/en/index.html

Facebook: http://www.facebook.com/PAHOTobaccoControl

Twitter: #AméricaLibredeTabaco #TobaccoFreeAmericas#TabacoyMentiras #TobaccoandLies

Questions?

Artwork by Elizabeth G. © 2010 American Academy of Pediatrics (AAP) Children's Art Contest. Support for the 2009 and 2010 AAP Children's Art Contest was from the Flight Attendant Medical Research Institute.

2013 AAP Children’s Art Contest!

• US entries: grades 3-5, 6-8, 9-12

• International entries: ages 13-18

• Winners receive up to USD500

• Lesson planning info available for educators

www.aap.org/artcontest

AAP Richmond Center• Visit us: www.aap.org/richmondcenter

– Advocacy Workshop at 2013 ICP in Melbourne-globaltobacco@aap.org

– Tobacco Prevention Policy Tool– State/Country-specific resources– Funding opportunities– Tobacco control listserv– Downloadable PowerPoint presentations

• Contact us: richmondcenter@aap.orgwww.facebook.com/aaprichmondcenter