Ireland's contribution to the global battle against tobacco use and future challenges

1
Ireland's contribution to the global battle
against tobacco use and future challenges

• Dr Douglas Bettcher
• Director, Tobacco Free Initiative
• World Health Organization

2
Tobacco Use A Global Threat
3
Tobacco Use A Pandemic Disease
Source WHO 2008
4
Projections of cancer mortality WHO projections
worldwide
5
The Tobacco Epidemic A Shifting Burden
Source WHO 2008
6
Rising Consumption in Developing Countries
Source WHO 2008
7
The Global Tobacco Crisis
Source WHO 2008
8
Aspects of Tobacco Use
9
The poor smoke the most
Smoking prevalence in Chennai, India (bidis and
cigarettes)
Source Gajalakshmi, Jha et al 1997
10
Tobacco increases poverty among its users
Monthly Expenditure-Tobacco Vs. Nutritious Food
of the Street Children in Mumbai, India
Source Path Canada 2003
11
Tobacco Use A Preventable Burden
12
The Tobacco Epidemic is About to Get Much Worse

• Tobacco currently kills 5 million/yr but this
  will increase to 10million/yr in a few decades
• If current smoking patterns continue, the death
  toll from tobacco use will be (Peto, WHA 2008)
• 2000 2025 150 M
• 2025 2050 300M
• 2050 2100 gt 500M
• TOTAL for 21st Century 1 billion (half the deaths
  in middle age)
• TOTAL for 20th Century 0.1 billion

13
....Unless we act now
14
Mechanisms for Tobacco Control
15
WHO Framework Convention on Tobacco Control (WHO
FCTC)

• First global health treaty negotiated under
  auspices of WHO adopted in 2003
• 162 parties
• Entry into force - 27 Feb 2005
• Ireland signed on 16 Sep 2003
  ratified on 7 Nov 2005

16
WHO FCTC

• A breath of fresh air to re-invigorate tobacco
  control efforts
• Establishes tobacco control as a priority on the
  public health agenda
• Provides an evidence-based tool for adoption of
  sound tobacco control measures
• Introduces a mechanism for firm country
  commitment and accountability

17
WHO FCTC and MPOWER

• An evidence-based tool for tobacco control

r
p
w
Article 6, 15
Article 8
Article 11, 12
e
o
m
Article 20, 21
Article 13
Article 14
18
WHO FCTC and mpower

• WHO Framework Convention on Tobacco Control (WHO
  FCTC)
• Foundation stone in the global fight against the
  tobacco epidemic
• mpower Six policies for tobacco control
• Key entry point for scaling up tobacco control
• Help countries build on WHO FCTC commitments
• Integral part of the WHO Action Plan for the
  Prevention and Control of Non-Communicable
  Diseases

19
MPOWER Six Policies to Reverse the Tobacco
Epidemic

• 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

20
mpower Highlights

• warn
• Changing the image of tobacco
• Role of pack warnings
• enforce
• Comprehensive bans and full enforcement needed
• Implementing effective prohibitions
• raise
• Higher taxes increase government revenues
• Higher taxes help the young and poor
• Higher taxes do not increase smuggling

• monitor
• Importance of monitoring data
• Characteristics of effective monitoring systems
• protect
• Case for smoke free environments
• Characteristics of effective smoke free policies
• Countering tobacco industry opposition
• offer
• Primary care
• Quit lines
• Pharmacological treatment

21
Source WHO Report on the Global Tobacco
Epidemic, 2008 The MPOWER package. Geneva,
World Health Organization, 2008
22
Only 5 of World Covered by Effective Tobacco
Control Policies
Source WHO Report on the Global Tobacco
Epidemic, 2008 The MPOWER package. Geneva,
World Health Organization, 2008
23
IRLELAND'S DRAMATIC IMPACTON THE HISTORY Of
SMOKE-FREE POLICY
24
Period 1 Pre World War 1
cigarette market growing rapidly
tobacco industry cigarette marketing strategies
Bonsack machine for making cigarettes in the US
major price discount
Anti cigarette League
25
Period 2 1914-1950

"Free cigarettes for the armed forces"
rudimentary case-control study
(Germany) SMOKING CAUSED LUNG CANCER
Over 70 - cigarette smoking men
Over 25 cigarette smoking women)
SOCIAL NORMS not in front
of women rich people smoking rooms
Lucky Strike "cigarettes for women"
26
Period 3 1950-1963
FIRST SOLID EVIDENCE
- 5 CASE CONTROL STUDIES -

TOBACCO INSTITUTE
UK (1962) and USA (1964) take the lead in
concluding a causal association between
smoking and lung cancer
"medical audience should weigh the evidence
and make up their own minds about which to
believe"
New England Journal of Medicine
27
Period 4 1963-1979
FIRST SIGN OF HIGH LEVEL POLITICAL CONCERN -
BUNDESTAG RESOLUTION -

TOBACCO INDUSTRY PRESSURES programme for
"protecting the health concerns of non-smokers
in the different settings of life" in Germany
NOT IMPLEMENTED
Bulgaria, Singapore, Norway, US Arizona, Minnesota
smoking restrictions
3 WHA resolutions reports/recommendations
WHO, US Surgeon General, Australian Council
28
Period 5 1980-1992
SOME EVIDENCE - SOME ACTION

• more studies (15) on the effects of SHS
• (e.g. Hirayama 1981 - non-smoking women living
• with smoking husbands - double risk of lung
  cancer)
• some US flights non-smoking
• 1986
• IARC report
• U.S. Surgeon General 1st report entirely on
  SHS
• 2 general resolutions and 1 recommendation - WHA

29
Period 7 1992-2003
MORE EVIDENCE - MORE ACTION

• Environmental Protection Agency (USA) Report
  (1992)
• California state (USA) 1st comprehensive SF
  Workplace law
• (1995, and bars and taverns only from 1998)
• Other countries adopt SF laws
• India, Uganda, Delaware state (USA)

SHS - MAJOR HUMAN CARCINOGEN
30
2003The WHO FCTC Article 8

• Protection from exposure to tobacco smoke
• 1. Parties recognize that scientific evidence has
  unequivocally established that exposure to
  tobacco smoke causes death, disease and
  disability.
• 2. Each Party shall adopt and implement in areas
  of existing national jurisdiction as determined
  by national law and actively promote at other
  jurisdictional levels the adoption and
  implementation of effective legislative,
  executive, administrative and/or other measures,
  providing for protection from exposure to tobacco
  smoke in indoor workplaces, public transport,
  indoor public places and, as appropriate, other
  public places.

31
Period 8 Post 2003
2004 - Ireland - the first country to enact a
comprehensive smoke-free workplace law nationwide
More and more countries and jurisdictions follow
Ireland's model
other 15 countries worldwide most provinces and
many territories in Canada 16 US states
comprehensive SF laws
32
IRELANDEarly initiatives and consistent
commitment in tobacco control

• Public Health Act 2004
• (Tobacco Amendment)

• Public Health (Tobacco) Act, 2002
• Independent Office of Tobacco Control, 31 May
  World No Tobacco Day 2002
• "Towards a Tobacco Free Society" Policy Report,
  2000

• Tobacco (Health Promotion and Protection) Act
  1988
• Tobacco Products (Control of Advertising,
  Sponsorship and Sales Promotion) Act, 1978
• European Communities Act 1972
• The Children's Act in 1908

33
CHANGING THE FACE OF SMOKE FREE POLICIES
IRELAND

• the smoke-free policy in Ireland - built on
  consistent commitment and previous wide-ranging
  tobacco control legislation by banning
  advertising and raising the legal age for sales
  to 18 years
• Ireland - model in recognizing that tough tobacco
  control legislation is essential and effective in
  reducing the numbers of people smoking, in
  particular children
• it proved that
• political courage makes it possible!!
• SF law - popular and widely accepted
• (95 compliance with SF workplace legislation)

34
IRELAND'S ROLE IN THE GLOBAL TOBACCO CONTROL

• SMOKE-FREE IRELAND
• CHANGED THE FACE
• OF THE SMOKE FREE POLICIES
• IN THE 21st CENTURY

35
Working Together to address future challenges
inspired by Ireland's Best Practice
36
2008 WHO REPORT on the global tobacco epidemic
37
Smoke-free coverage in specific places
Health Care 106 countries 50 of world population
Educational 106 countries 71
Government offices 79 countries 40
Indoor offices 59 countries 37
Universities 66 countries 41
Restaurants 21 countries 8
Pubs and bars 18 countries 23
38

• 2007 - WHO Policy recommendations on protection
  from exposure to second-hand tobacco smoke
• 2007 - WHO FCTC COP2 Guidelines on protection
  from exposure to tobacco smoke
• 2008- WHO MPOWER package (Protect people from
  tobacco smoke)

39
2007 WHO Policy Recommendations - grounded on
Ireland's Best practice -

• Developed to
• Respond to the unquestionable dangers to SHS
• Assist the WHO FCTC implementation process
• Provide guidance to growing number of countries
  and jurisdictions interested in becoming
  smoke-free
• Describe the problem and the solution
• Draw on international experiences and best
  practice
• Make four key recommendations

40
2007 WHO Policy Recommendations

• Implementing 100 SFE in any indoor workplaces
  or public areas
• Universal protection by law
• Proper implementation and adequate enforcement of
  the law
• Public education to reduce SHS exposure in homes

• simple
• clear
• enforceable
• comprehensive

41
2007 WHO FCTC Article 8 Guidelines- Ireland
takes the lead again -

• Developed by the Parties to support Article 8
  implementation
• Consistent with scientific evidence and best
  practice
• Establish high standard of accountability of the
  treaty compliance
• Assist parties in promoting highest standard of
  health
• The consultation meeting to complete the
  guidelines for the implementation of Article 8
  was hosted by the Department of Health and
  Children of Ireland (1 - 3 Nov 2006).

42
2008 IARC RESEARCH 11 statements on
effectiveness of smoke-free policies

• IMPLEMENTATION OF SMOKE-FREE POLICIES
• Decrease second-hand smoke exposure
• At the workplace
• Decrease cigarette consumption in continuing
  smokers
• Decrease the prevalence of adult smoking
• Decrease tobacco use in youths
• Decrease respiratory symptoms in workers
• Do not decrease the business activity of the
  restaurant and bar industry
• Decrease heart disease morbidity
• Voluntary smoke-free home policies
• Decrease children's second-hand smoke exposure
• Decrease adult smoking decrease smoking in youths

The Lancet Oncology, doi10.1016/S1470-2045(08)70
167-0 IARC Handbook Volume 13 Working Group and
IARC Secretariat
43
Future challenges - globalizing Ireland's
success -

• Stimulate all countries to enforce comprehensive
  smoke-free policies following Ireland's model,
  IARC, WHO Policy Recommendations
• Address tobacco control from a development
  perspective and include tobacco control work in
  development programmes and activities
• Mainstream gender perspectives on tobacco control
  policies and reflect gender perspective in
  national policies

44
Future challenges

• Bring tobacco control, NCD prevention and
  treatment perspectives together more effectively
• Integrate Tobacco Control in Health Care Systems
  - entry points for scaling up tobacco cessation
  services in PHC systems (National Stop TB
  Programme, Cancer, Maternal Child health,
  Cardiovascular disease, Diabetes)
• Implement the MPOWER policies as a package to
  implement the WHO FCTC and help reverse the
  tobacco epidemic

45
IRELAND

• STRONG,
• POSITIVE,
• CONSTRUCTIVE AND
• SUPPORTIVE ROLE
• FOR A TOBACCO FREE WORLD

46
IRELAND
Minimal
Moderate
Complete
Complete
Complete
NEW CHALLENGE implementing all MPOWER policies
as a package
47
Encouraging Ireland to go further

• Continue to increase tobacco prices through
  taxation (to at least 75 of the retail price)
• Introduce "points-of-sale" legislation -
  
  
  
• no advertising or display of tobacco
  products permitted in
  retail outlets
• Mandate picture health warnings on tobacco
  packages, in accordance with the Guidelines for
  the implementation of Article 11 of the WHO
  FC TC
• Ban product placement of tobacco products in
  TV and films

48
Tobacco Free Initiative

• .for a tobacco free world