Global Threats Demand Global Solutions: Tackling the Tobacco Epidemic
Dr Derek Yach, Executive Director Noncommunicable Diseases and Mental Health, World Health Organization Geneva, Switzerland, June 15 2000
The global tobacco epidemic looms as a major threat to public health. In this presentation I will outline what drives the threat; define the likely impact of tobacco on public health; demonstrate through the recent statements and actions of governments and NGOs over the last few weeks that multiple efforts are underway to address the threat, before concluding that long-term success demands that strong global approaches need to complement national efforts.
What Drives the Threat?
Marketing: pervasive and ubiquitous
We all are aware of the pervasiveness of tobacco advertising and sponsorship. Many countries have banned tobacco adverts; others, like the USA have removed billboards, radio and TV adverts and even product placement in films. However, for many countries, even rudimentary protection against tobacco imagery does not exist. Instead, the Marlboro Man rides high over the cities of many countries in Asia, East and Central Europe and Latin America. New threats come from Internet advertising, satellite-television, international sports events and movies made outside of Hollywood.
A total and global ban on advertising and all forms of marketing is long overdue!
Smuggling and high prices
The World Bank's review of policies that really impact on tobacco use conclusively shows that price, effected through excise tax, is the most potent means of reducing consumption. Increased excise tax benefits the poor and the young more than the rich and brings in new sources of revenue to governments; for these reasons increased taxes are opposed openly and behind the scenes by the tobacco industry. Taxing the right products for the right reasons can be a very potent public health tool.
The result of tobacco industry pressure is that few countries have raised their prices to levels that would really reduce consumption. A recent review by colleagues at WHO shows that the real price of cigarettes in many countries developed and developing, have fallen far behind the inflation rate and have become relatively cheaper over the last decade.
An often-used argument by the tobacco industry for not increasing taxes is that it will lead to smuggling. Yet many studies have shown that price differentials across borders are only one determinant of smuggling: organised crime, weak customs controls of borders and even the possible participation of the tobacco industry are also important. In recent months, three major companies have been charged with smuggling: BAT by the UK government, Philip Morris by the Colombian and Ecuadorian governments and RJR by the Canadian government.
The UK government has stressed the need to address smuggling as a criminal activity and not drop prices in response to it: that robs governments of revenue, increases consumption and deaths!
Tobacco industry interference in public health
This audience does not need to be told about the profound way in which litigation against the tobacco industry has both exposed their past behaviour and led to the development of powerful hard hitting and effective counter-advertising. Similar approaches are spreading worldwide.
WHO and the World Bank will shortly conclude an intensive inquiry into how the policies of these international organizations have been adversely influenced by multiple actions by the tobacco industry over decades - actions that still continue today. Many countries have initiated such inquiries or are planning them. Yesterday, the UK House of Commons announced the results of its Inquiry and "welcomed the Framework Convention proposed by the World Health Organization and the Government's support for it." The House of Commons statement went on to say that:
"[A]ny success will be dependent on a responsible approach being taken by the tobacco companies. Depressingly, there is little sign of that in the cheap jibes made at WHO's expense by BAT. To call an organization committed to improving global health 'zealots' and a 'super-nanny' because of its concern about the 10 million deaths which will be caused by tobacco each year by the late 2020s seems to us bizarre. We hope that the other companies - and, belatedly, BAT - will work constructively with WHO… It would be a hollow victory if, as a result of more stringent action taken on tobacco control in the developed world, smoking related deaths were merely exported to the world's poorer nations."
The combined impact of these inquiries will be that the truth about how and why tobacco control policies have not been allowed to emerge will become clear. This should add impetus to new energy being devoted to tobacco control.
What is the Public Health Impact?
There are about 1.2 billion smokers in the world. The impact of tobacco use over several decades currently causes 4 million deaths a year. Because of the lag between tobacco use today and the appearance of tobacco's full health effects, patterns of tobacco use today will lead to about 10 million deaths from tobacco per year in the 2020s. And because 70 percent of tobacco users now live in developing countries, it is not surprising that 70 percent of tobacco deaths in the 2020s will occur in developing countries.
Epidemiological evidence was first derived from large-scale studies in the USA and UK. Now, the evidence also comes from China, India, South Africa and Brazil. An important difference between the USA and UK studies and those from developing countries is that the effects of tobacco occurred in developed countries after most infectious diseases were well controlled. In contrast, throughout much of the developing world, infectious diseases and under-nutrition co-exist with a rising incidence of tobacco-induced chronic diseases. The double burden imposes major challenges to health services.
The pressure to provide expensive forms of treatment for cancers, heart and chronic respiratory diseases could distort spending patterns in developing countries. For many, there is a need to give higher priority to effective prevention policies: these should start with those that bring in needed money-higher excise tax on tobacco products and should include those measures that do not cost government anything; such as bans on advertising and smoking in public places.
Global Solutions
I will use the experiences and actions of World No Tobacco Day this year to demonstrate the importance of clear and effective advocacy by leaders worldwide. I will show that a groundswell of local and national actions is moving the public health agenda ahead; and how this is occurring through the development and activation of innovative partnerships, networks and alliances. All these efforts are culminating in a global movement towards the Framework Convention on Tobacco Control (FCTC) - the world's first multilateral public health response to a global public health disaster waiting to happen.
Leaders Advocate for Action: May 31, 2000
World No Tobacco Day is now a process and an event. The process of getting ready for the event in May builds capacity in the international public health community to raise the levels of accuracy of the global debate on tobacco control. "Tobacco kills - Don't be Duped" was this year's leitmotif with a special focus on tobacco advertising and promotion in films, music and sports. It allowed the world to get a better picture of tobacco-industry backed duping of science, public health and government policy packaged as freedom and fun. The right information in the right hands lead to unprecedented visibility for tobacco control at a time when countries are preparing for negotiations on the FCTC. Around the world this single powerful message - Tobacco Kills - Don't be Duped - resonated and new actions and energy were injected into tobacco control.
Dr Brundtland unveiled a giant digital clock in Bangkok showing that at least 8 people die every minute from tobacco; she awarded the king of Thailand for his contribution to tobacco control. About 10,000 people marched and sang anti-tobacco songs. School children launched a global signature campaign calling for a global ban on tobacco advertising and sponsorship.
The Surgeon General of the USA, Dr Satcher, co-hosted a meeting with Reverend Jesse Brown in Philadelphia to highlight the way in which tobacco advertisements target minority groups.
In Lebanon, the First Lady urged action against tobacco promotion and advertising.
The Brazilian Minister of Health launched a massive multi-media campaign and announced increased excise taxes on tobacco products. A new 30-second TV spot shows a drug dealer in a slum explaining how he gets clients hooked on cigarettes.
David Byrne, European Union Commissioner for Health, called for strong support for new European Community regulations aimed at tobacco products when the vote occurred mid-June. He said that "now is a golden opportunity to put in place a regulatory framework for tobacco". In response, yesterday members of the European Parliament voted for a range of tough new measures that include warnings that cover 50% of the space on cigarette packs; removal of misleading information such as 'low tar' 'mild' and 'light'; and reductions in tar and nicotine.
The South African Health Minister Manto Tshabalala-Msinang announced that cigarette sales would be regulated, free distribution of cigarettes would be prohibited, and that all advertising would be banned. The laws will come into effect by early July.
In Canada, the Health Minister Allan Rock used World No Tobacco Day to unveil new cigarette packaging. The labels show, in graphic detail, the effects of smoking such as oral cancer, gum disease and clogged arteries.
Sports and Entertainment Personalities Join the Call for Action
Imran Khan, former captain of the Pakistan cricket team called on international sport—both players and organizers-- to stop accepting sponsorship from tobacco companies. He said that. "sports symbolize health and vitality and tobacco causes disease and death. These two cannot be associated."
In the USA, Eric Karros, the insider for the baseball team Dodgers (Los Angeles), joined a high school rally against tobacco promotion. He unveiled a public service advertisement featuring himself and other baseball players from the New York Yankees, Cleveland Indians, New York Mets and Boston Red Soxs talking about the importance of staying tobacco-free.
Super Model Christy Turlington and the music group Boyz 2 Men backed WHO's call to the world of international glitterati to move away from tobacco promotion and glamorization. Earlier in the year, Dr Jeffery Wigand, whose struggle against big tobacco is immortalized in the Hollywood film "The Insider" launched WHO's "Don't be Duped" global campaign to coincide with the release of the film in Hollywood.
Compelling Data Demands Action
Many countries used World No Tobacco Day 2000 to announce the outcome of new studies on tobacco prevalence. This is often a first and vital step towards comprehensive policy development. Four examples are given below.
The Cambodian National Centre for Health Promotion warned that cigarette advertising had increased by 400 percent since 1994, accounting for nearly half the advertising revenue of the country. Already 86 percent of rural men and 66 percent of urban men smoke.
New Greek statistics on smoking were released. One in ten teenagers smoke regularly, while 60 percent of men and 30 percent of women smoke. Smoking causes 30 percent of cancer deaths, and 20 percent of deaths from heart disease.
In China, new data shows that 20 percent of male schoolchildren smoke. By law, tobacco cannot be sold to children under 18, but 83 percent of children interviewed said no retailer had refused to sell them cigarettes. In response to the results of the survey, the government announced stronger action to protect youth.
The Hungarian Gallup Institute published results showing that smoking prevalence among women 18-24 years increased from 25 percent in 1995 to 42 percent in 2000. 41 percent of those under 30 are regular smokers. Among Gypsy children, the prevalence is twice as high as that of the average population.
Selected Local and National Actions Announced
Proof of real commitment is reflected in new laws, higher taxes and innovative community actions. Diverse initiatives were reported on World No Tobacco Day from all WHO's six regions. A selection of these is provided below.
Malaysia: the Health Minister Chua Jui Meng, said that smoking among Malaysia's teens was rising due to the influence of deceptive advertising. He called for a ban on all forms of cigarette advertising and promotion.
India: the first tobacco website in Hindi was launched.
Switzerland: sharp increases in excise taxes and the start of a series of new measures aimed at stopping youth starting were announced.
Uganda: the parliamentary committee on social services called on the Ministry of Health to introduce bans on smoking in hospitals and confined places, to ban tobacco advertising, to tax cigarettes heavily, and to force the industry to place conspicuous and clear warning labels on their products.
Korea: antismoking groups urged the government to totally ban cigarette advertising in order to protect youth and adolescents from becoming addicted to tobacco.
Australia: the government unveiled new anti-tobacco advertisements aimed at young women. Young women are particularly prone to smoking, with 44 percent of 18-25 year-olds smoking. The new advertisements track cigarette smoke inhaled by a young woman through to her lung—a healthy lung is cut open and a large quantity of liquid tar were poured into it, representing the amount of tar a smoker would inhale during a lifetime of smoking.
Dubai: leading doctors hosted a free and open seminar on the hazards of smoking.
Russia, Sri Lanka and Uganda announced results of their national Quit & Win competitions.
Mauritius and Spain launch court cases against the tobacco industry.
Partnerships, Networks and Alliances
A truly sustainable global debate on tobacco, such as the one unfolding around us, is possible only when meaningful interaction occurs between all constituents who have a stake in health and are willing to stand up for it. WHO's leadership role comes in seeking to unlock value at every step. The United Nations Inter-Agency Task Force on Tobacco Control is now led by WHO. The group's principal remit is to ensure that the need for demand reduction takes root in the United Nations food, labour, trade, and children's organizations to reflect the multisectoral nature of global tobacco control.
The World Bank and the IMF, both early backers of WHO's tobacco control initiative, continue to work closely with TFI's evolving responsibilities. The Bank's report "Curbing the Tobacco Epidemic - Governments and the Economics of Tobacco Control," is a key advocacy tool for policy change as it provides essential tax and fiscal information for governments.
WHO recognizes that strong support from the NGO community is essential to secure a robust and meaningful public health treaty which will make a concrete impact on the tobacco epidemic. Following Dr Brundtland's call for active involvement of civil society in WHO's decision-making in general, a growing global alliance of NGO's is operational in a large number of countries.
The United Nations Foundation, TFI's single largest external donor, supports projects ranging from NGO and media advocacy to youth and national capacity-building. The Rockefeller Foundation has just announced a major grant for capacity-building in South-East Asia, and pharmaceutical companies are providing support in their area of expertise.
Government support for tobacco control remains small compared to other programmes, but is steadily increasing. Canada, Finland, Sweden, Japan, USA, the United Kingdom, Norway, Australia, New Zealand, France and the Netherlands are now supporting WHO's worldwide efforts.
Bringing it Together: Framework Convention on Tobacco Control
The WHO Framework Convention on Tobacco Control (FCTC) aims to address the global dimensions of tobacco control. The FCTC's future benefits to countries will be many. The most important one is that with the Convention as a pathfinder and co-ordination vehicle, national public health policies, tailored around national needs, can be advanced without being undone by transnational phenomena such as those fuelled by the tobacco industry. Thus it could ensure that advertising and marketing does not cross borders-leading to equal protection for all. It could tighten methods of preventing smuggling; facilitate global exchange of knowledge about what works best to control tobacco; and build global consensus about the future challenges of regulating tobacco products.
The process of developing the multisectoral FCTC is already raising the platform for global action against tobacco and focusing attention on a truly global public health threat. As Dr Brundtland said: "the FCTC is a global response to a global challenge".
Already, two Intergovernmental Working Groups comprising officials from ministries of health and finance, trade, foreign and social affairs have met in Geneva to define the broad parametres of what should go into this multilateral treaty. These technical preparatory meetings were attended by 114 Member States (October 1999) and then 146 Member States (March 2000), representing well over 95 percent of the world's people. Just last month all 192 Member States of WHO unanimously adopted a resolution that moves the process on towards full negotiations in October.
Thus we are now close to the start of historic negotiations on WHO's very first multilateral convention. The size of the public health threat, the need for the widest possible support for decisive action and the urgency for serious action make the FCTC more then just another treaty: it is a global public health movement!
We urge all of you here today to join this movement.