Que es lo que intentaremos abordar en esta presentacion: En primer lugar, abordaremos el tema , en forma teórica, como y porqué los profesionales de la salud deben involucrarse en el control y tratamiento del tabaquismo. Y en la segunda parte, compartiremos con UDS, una experiencia nacional y personal, que no es única, porque seguramente, con variantes, se repite en muchos otros países. Hablaremos sobre la experiencia Uruguaya , y anlaizaremos si esa experiencia se tradujo o no en algún tpo de imacto.
Porqué y como
El tabaquismo continua siendo la principal causa, absolutamente evitable, de muerte y enfermedad, a nivel mundial, y la lista de trastornos vinculados al mismo , crece anualmente. La evidencia enseña que El tabaco no solo daña a quien consume sino también a quien se expone al humo del tabaco y que la dependencia al tabaco es , en sí misma, una enfermedad crónica, con tendencia a la recaida. El problema, es que a pesar de esta información, el tabaquismo continúa creciendo a nivel mundial, expandiéndose fundamentalmente a expensas de los países menos desarrollados. Y ello se debe, fundamentalmente al accionar del vector que promueve la epidemia, la industria tabacalera.
El tabaquismo es un problema complejo, que tiene impacto a diversos niveles: a nivel social, a nivel ambiental a nivel de la economía y el desarrollo de los países, pero fundamentalmente
El tabaquismo implica un severo problema sanitario a nivel mundial. Entonces, quienes deberías ser los que deberían estar más involucrados en su solucion?...
Por supuesto que el Gobierno, y los parlamentarios, deberían estar profundamente preocupados, e involucrados en la solución del problema. Pero la sociedad , en su conjunto, también. Aunque hay un grupo social, que tiene un compromiso profesional y social ineludible con el mismo: los profesionales de la salud.
Nosotros sabemos lo que produce el tabaco. También sabemos que hoy en día hay estrategias efectivas para enfrentar con éxito este problema, abordando los distintos aspectos del mismo: La prevencion del tabaquismo El abandono La proteccion de los no fumadores Y regulando, tanto los productos del tabaco, como a la propia industria tabacalera. Y también tenemos, una poderosa herramienta: El CMCT de la OMS, del cual ya son Estados partes más de 170 países, y cuya implementación acelerada ha sido , una de las medidas que la Cumbre de la ONU sobre las ENTs en el 2011, ha priorizado.
El propio CMCT, reconoce el importante papel que le compete a las organziaciones de profesionales de la salud en este tema.
Y esto no es casual. Porque además de ser los expertos “ en salud”, la Sociedad nos ve como Confiables, objetivos, políticamente neutrales. Somos respetados por los políticos y tomadores de decisión. Nos basamos en la evidencia científica para conducirnos. Los políticos están interesados en escucharnos sobre temas de salud, porque somos legítimos interlocutores de aquellos xxxxxx
El problema comienza cuando queremos usar el conocmiento q
Good…. I’m very glad to share this meeting with you. I thank to the organizers and to Pfizer for giving me this opportunity to speak.
This slide intend to show that having policies doesn’t mean they are effective to addressing certain problem, you need to implement effective solutions for being effective.
Not only improved health and economy but also international image!
PMI vs Uruguay. A case of corporative abuse against a small country Uruguay is the first country under international attack by a multinational tobacco company due to FCTC implementation. It is in fact the first international direct attack to FCTC.
For beating Uruguay they prepared a well planned strategy. Few days after they set their legal complaint a new Government took office in Uruguay. The new President was recent former smoker, very open to the dialogue, and trying to avoid any kind of conflicts, mainly international legal cases, as Uruguay was going out from a long and painful international litigation with his neighbour Argentina. That was an opportunity for PMI to offer the new Government a reasonable solution for avoiding another painful litigation. One thing that aggravated the situation, from the tobacco control point of view as that the new Government felt alone. No one offered help, but Civil Society, at that time.
But Civil Society gather intelligence and knew that hidden negotiations with PMI were happening and publicly denounced it to the big media, in July 7 2010 as well as communicated that situation to Key Opinion Leaders and Politicians.
When Civil Society was expecting to talk to President Mujica to explain the risks of this behavior, the Minister of Health announced to the media that the Government would flexibilize some tobacco control measures in order to avoid the legal case.
A political storm happened. Current and former President, both from the same political Party , face due to tobacco control measures. A very hard week… where not only FCTC implementation, but also COP 4 that would be held in Uruguay, were in danger.
Impact on medical doctors tobacco consumption prevalence
Health professionals have a prominent role to play in tobacco control. They have the trust of the population, the media and opinion leaders, and their voices are heard across a vast range of social, economic and political arenas. At the individual level, they can educate the population on the harms of tobacco use and exposure to second-hand smoke. They can also help tobacco users overcome their addiction. At the community level, health professionals can be initiators or supporters of some of the policy measures described above, by engaging, for example, in efforts to promote smoke-free workplaces and extending the availability of tobacco cessation resources. At the society level, health professionals can add their voice and their weight to national and global tobacco control efforts like tax increase campaigns and become involved at the national level in promoting the WHO Framework Convention on Tobacco Control (WHO FCTC). In addition, health professional organizations can show leadership and become a role model for other professional organizations and society by embracing the tenants of the Health Professional Code of Practice on Tobacco Control.
The Critical Importance of Health Care Worker Leadership in the Tobacco Control Movement in Uruguay -- Eduardo Bianco, M.D.
The critical importance of healthcare worker leadership in the tobacco control movement The Uruguayan Case Dr Eduardo Bianco, MD. Centro de Investigación para la Epidemia del Tabaco- CIET The Tobacco Epidemic Research Centre Uruguay 1
Outlines Why and how HCP should involve on tobacco control and treatment? A real world story: Uruguayan’s medical doctor engagement on tobacco control and treatment. Did it work? 2
The tobacco epidemic The leading preventable cause of death and diseases worldwide. The list of conditions caused by tobacco consumption has grown. 1 Those who consume tobacco are not the only ones exposed to its negative effects. There is conclusive evidence linking passive smoking to an increased risk of many adult and children diseases . 2 Tobacco dependence itself is a chronic relapsing disease and frequently requires proper treatment 3 But… tobacco consumption continues to increase worldwide, expanding to less- developed countries The tobacco industry, the vector of the epidemic, has a huge potential market in developing countries:, weaker tobacco control measures and find a great number of possible new customers. 1.The Health Consequences of Smoking: A Report of the Surgeon General, 2004 2. DRAFT Health Effects Assessment for ETS. SRP Review. 2005 3. International Statistical Classification of Diseases and Related Health Problems, 10th revision,WHO, 2003. 4
The tobacco epidemic A social problem. A environmental problem. An economic and development problem.BUT MAINLY…. 5
…IS A HUGE GLOBAL HEALTH PROBLEMWho should take care about it ? 6
Of course … Government and legislators . Society at large. But one group of professionals has a special role to play: HEALTH CARE WORKERS 7
We have the knowledge Implementing a comprehensive, continuous, sustainable and adequately funded tobacco control strategy. Tobacco control efforts should be focused on several fronts: • preventing people from taking up tobacco consumption; • promoting cessation; • protecting non-smokers from the exposure to tobacco smoke; and • regulating tobacco products and preventing Tobacco Industry Interference. We have the tool: ACCELERATING FCTC IMPLEMENTATION. 8
PREAMBLE OF THE WHO FCTC HIGHLIGHT HCP ROLE “…Emphasizing the special contribution ofnongovernmental organizations and othermembers of civil society not affiliated with thetobacco industry, including health professionalbodies, women’s, youth, environmental andbodiesconsumer groups, and academic and health-careinstitutions, to tobacco control efforts nationallyand internationally and the vital importance oftheir participation in national and internationaltobacco control efforts…” 9
Professional Societies Are CredibleThey Are Trusted and Valued, Because They: Are seen as trustworthy, objective and politically neutral Are known and respected by policy makers Draw information and experience from scientific evidence Policy makers are interested to hear from them Are legitimate to speak on behalf of those they purport to represent or those affected by the issue 10
HOW TO GET IT DONE: Advocacy To support, plead, defend a cause To express your views to: Create a shift in the environment Mobilize resources Change public opinion, or Influence someone’s perception or understanding of an issue 11
Health Professional´s Roles Role model Clinician Educator Scientist Leader Opinion-builder Watch out for tobacco industry activities 12
Barriers to health professional involvement in tobacco control 1. Lack of knowledge and skills about tobacco and tobacco control. 2. Lack of organizational leadership. 3. Tobacco consumption among health professionals. 13
Health Professional Societies Do/Could/Should: Raise awareness of importance of TC/SC among HCPs Bridge research and policy Promote, develop and disseminate evidenceEmpower their Advocate for members policy change Develop and implement clinical guidelines Communicate clear messages Deliver training Be a platform to share evidence, information, concerns, good practices 14
What We Really Need to Do Now Is:Plan and Act ! Make a clear, basic, action plan with relevant stakeholders, including: People directly affected by the problem (smokers & their families) Decision makers Groups interested in solving the problem (tobacco control coalitions, other professional societies, etc) Identify few clear key messages to push forward Be aware of the policy making processes. To have influence, you need to: Know them Respect them Use them 15
Level of InterventionIndividual level Clinical Practice, research, trainer Local Level SFE and provide treatment at local health facilitiesNational Level Engaging National Medical Association, Scientific AssociationsRegional Level Engaging Regional Medical/Scientific Networks 16
A real world story: Uruguayan medical doctorsengagement in tobacco control and treatment . 17
The pioneers Dr Saralegui Padrón (60-70s). Prof. Dr. Helmut Kasdorf (80-90s) Prof. Dr. Milton Portos and Dr. Beatriz Goja created first Smoking Cessation Clinic at the Public School of Medicine in 1989. 1997, first Smoking Cessation Program at the pre-paid Health Care System (At the Spanish Association in Montevideo). 18
The influence of the International tobacco control community• 1998: IAHF- Heart & Stroke Foundation Trainthe Trainers workshop in Ottawa, Canada.•1999: European Congress Tobacco and Health,Las Palmas, GC, Spain.• 2000: 11th WCTOH in Chicago, US. WHO-FCTC negotiating process began. 19
Was the tobacco epidemic a problem for Uruguay? Uruguay : one of the highest tobacco consumption prevalence in L.A. 1 5.000 people died yearly due to tobacco related diseases. 2 The highest lung cancer mortality in men in L.A. 3 The highest COPD prevalence in L.A. 4 Argentina and Uruguay with the highest ETS indoor air contamination levels. 5 Ineffective tobacco control dispositions. No accurate data on the tobacco consumption prevalence. Well organized tobacco industry lobby.1. Organización Panamericana de la Salud (OPS). El tabaquismo en América Latina, Estados Unidos y Canadá (Período 1990-1999).OPS, Junio 2000.2. Comisión Honoraria para la Salud Cardiovascular. Datos de Mortalidad por Tabaquismo en Uruguay, 2000-2002. Área de Epidemiología y Programación.• Mackay, J ; Jemal, A; Lee, N; Parkin, D. The Cancer Atlas (2006). American Cancer Society.• Dres. Adriana Muiño, María Victoria López Varela, Ana María Menezes. Prevalencia de la enfermedad pulmonar obstructiva crónica y sus principales factores de riesgo: proyecto PLATINO en Montevideo. Rev Med Uruguay 2005; 21: 37-48. http://wwwscielo.edu.uy/pdf/rmu/v21n1/v21n1a06.pdff5. Navas-Cien,A. JAMA. 2004;291:2741-2745 20
Uruguay – MD engagement Timeline • Creation of a Tobacco Control Commission from the Medical Union Association. • Engaging in WHO-FCTC: SMU sent submission. • Built a National Tobacco Control Alliance: Civil Society, MOH, PAHO WNTD celebrations: Sports and Tobacco Started to ‘dream’: Uruguay first smoke free country in LA Participating in Regional FCTC related events.2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011• First National TC Forum• Medical Survey on Tobaccoconsumption:27%• MD educational process.• Identify journalists.• Identify a champion at theMOH. 21
Article related to TobaccoControl at the NationalMedical Bulletin 22
2003 Creation of the Uruguayan Smoke Free Network (RULTA): consolidate CS movement. FCTC gets to the Parliament for discussion.2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 • The battle for FCTC ratification. • A tobacco control lobbyist at the Parliament. • Mobilizing medical doctor at the Parliament and Political Parties. Dr. Tabaré Vázquez. • Using the power of the media 24
2004 -SMU challenged FNR Are you going to help smokers to quit? Jan 2, 2004: Smoking cessation program for patients from FNR. Feb: Media awareness campaign. March: they doubted… April: SC program opened to the general public . Sept: 9 weekly SC groups (word of mouth spreading). July: sent letter to the Parliament asking for FCTC ratification. 26
EL PAIS: Treaty against deadSep, 2003 El País 27
SMU looks for a quick approval of anti- tobacco treaty A mistake…that helped a lot! Jun 9, 2004 28
2004-2005Congress approved FCTC RatificationSept 9- Uruguay ratified2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 FNR: Training and offering medication for free. More than 100 SC programmes around the country. In 2010, almost 20.000 treated 29
2005 • Dr. T. Vazquez took office as President • MOH Advisory Commission advice Minister of Health on FCTC Implementation and request Dr Vazquez as speaker on WNTD 2005.2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 • Jan: Creation of the MOH TC • President Vazquez Launched first Decrees to advisory Commission implement FCTC at national level. • Other advisors suggest not applying the smoking ban to all of locations and facilities. 30
Getting the ‘impossible’ just needs more time…• Small business criticized theregulation: ‘It is unfair. Better yougo directly to a total ban’•Shopping mall surveys: less than4% of customers against a totalsmoking ban.•A Parliamentarian TobaccoControl Workshop in B. Aires(August 18, 2005).• First, international speakersparticipated in a Workshop at theCongress and, then visit Vazquezat the Presidency (August 17).• Sept 5, Pte Vazquez launched anew decree on SFE. 31
2005 -2006 A champion at the Uruguay became first Smoke Free Country in Congress: Americas Region Dr. Miguel Asqueta2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011• At same time Dr Bacheletwas President of Chile…it is Creation of The Tobacco Epidemicnot yet a Smoke Free Country Research Centre – CIET Uruguay 32
The tobacco epidemic research center • Developing high quality research • Capacity building • Disseminating information. • Advocacy • Multidisciplinary : physicians, lawyers, psychologist, economists, journalists, dentists, sociologists, academics, stakeholders, etc. 33
2007 • Advocating for a Comprehensive TC law development at the Congress. • The importance of the a MD to champion at the Congress • New evaluation of Tobacco consumption in MD: 17% • 2nd MD and Tobacco Workshop2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 • CIET/SMU and others launched RESPIRA Uruguay (Breathes Uruguay)-.Youth Exhibition. 34
BREATHES URUGUAY• Dr. Chan (WHO) visited and requestedtaking the interactive exhibition to COP 3 (South Africa) 35
Respira is still a valuable educational resource from Uruguayan’s Government perspective Governmental Educational Webpage. Feb 9, 2012 Recently a Scotish delegation visit Respira to reproduce the exhibition there 36
Proactively and reactively SMU advocated at the Parliament for a Comprehensive National Tobacco Control Law/ Nov 2007 1. The Tobacco Industry representative MainTobacco lobbyst 2. Advertising Associations 3. National Medical AssociationSMU 37
2008 • March: A comprehensive national tobacco control law passed. • CS wrote President Vázquez asking for hosting COP 4 (as a protective measure) • Respira Uruguay in COP 3 in South Africa2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 38
WHO MPOWER- Feb 2008:Uruguay as a tobacco control leader 39
2009 • SMU elected as host of 2011 WMA General Assembly, asked for Tobacco Control as topic for the Scientific Session. • Tobacco Control Commission asked to organize the event and request to the Executive Committee to develop actions to set MD tobacco consumption below 10%. • Creation of the Uruguayan Society of Tabaccology2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 • Development of the National Guidelines for Smoking Cessation and Treatment. • Uruguayan Cardiology Society and its commitment to tobacco control influenced South American Cardiology Society to set Tobacco Control as priority topic in 2010 Regional Congress. • Creation of Alerta Tabaco (Tobacco Alert network). 40
Feb 2010:PMI vs URUGUAY PMI : URUGUAY VIOLATES INVESTMENT BILATERAL AGREEMENT SWITZERLAND-URUGUAY ICSID- International Centre for Settlement of Investments Disputes. 1. The prohibition of using different presentations of a brand. 2. Health warnings that cover 80% of the packaging. 3. Images do not fit reality.**PMI has quit this claim 41
A WELL PLANNED STRATEGY • A new Government, open to dialogue. • A recent painful international litigation with Argentina . • They offered a “reasonable” solution . INGRAVESCENT• New Government felt alone. 42
Civil Society Intelligence gathering… Civil Society denounced Government was negotiating with PM and there would be a set back July 7, 2010 43
Minister of Health publicly announced the set back July 25, 2010 July 23 , 2010 44
SMU and Civil Society rejected set backin tobacco control policy July 25-26 2010 45
MUJICA and VÁZQUEZ FACED BY TOBACCO CONTROL POLICY 46
2010 • October- South American Congress of Cardiology: “ For a Smoke Free South America”, in Montevideo. Congress with a Plenary on Tobacco Control and Treatment. • November- COP 4 in Punta del Este, Uruguay. SMU as representative of WMA.2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 • Anecdote: President of the Uruguayan Cardiology Society , the evaluation of the smoking ban impact on the AMI admissions , and the 2010 Cardiology Congress in Venezuela. 47
2011 • SMU convened creation of the National NCD Alliance. • WMA General Assembly Scientific Sesion: Tobacco Control. • MD tobacco consumptiom prevalence survey2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 48
Tobacco consumption prevalence 35% Medical Doctors 27% 1 30% Adults 25% 20% 17% 1 Youth 15% 10% 2 5% 9.8% 0% 1998 2001 2006 2009 1. Encuestas Junta Nacional de Drogas 1. SMU, Sindicato Médico del Uruguay2. ENPTA 2008-CIET y GATS 2009 2. CIET; SMU; FEMI, Federation of Medical Doctors of Inland Cities 50
2011 MD tobacco consumption survey Attempts to quit last year: 61% Received help to quit: 33% Intention to quit: • National Tobacco Control Policy support: 78,8% strongly agree, 18,3% agree 51
2011 MD tobacco consumption survey• SMOKING CESSATION TRAINING: 46,6%• ALWAYS OFFER PATIENTS ADVICE TO QUIT: 82%• INITIATE TREATMENT • SENT PATIENTS TO SPECIALIZED SMOKING CESSATION PROGRAMMES 52
SFE impact on AMI admissions in Uruguay 22%Hospital admissions for acute myocardial infarction before and after implementation of a comprehensivesmoke-free policy in Uruguay. E. Sebrie´, E.Sandoya, A. Hyland, E. Bianco, S. A Glantz, K M Cummings,Tobacco Control (addmited, to be published in short). 53
Trade and Economic Impact Annual Tobacco Sales* TOBACCO FISCAL REVENUES* 350 300 250 200 150 100 50 0 2004 2005 2006 2007 2008 2009 2010 2011* Data from Fiscal Authority US$ million dollar 54
Uruguay´s Tobacco Control Policies: A regional model. SFE legislations: Most of S.A. and C.A. countries passed SFE laws. 6 are already implementing that. Regional Cooperation. “Pilot Case”: First evaluations showed that FCTC implementation works… even in a Latin American country. 55
Conclusions Health professionals have a prominent role to play in tobacco control. Have the trust of the population, the media and opinion leaders, and our voices are heard across a vast range of social, economic and political arenas. At the individual level, we can educate our patients on the harms of tobacco use and exposure to second-hand smoke and help tobacco users overcome their addiction. At the community level, we can be initiators or supporters of some of the main tobacco control policy measures, for example, promoting smoke-free workplaces and extending the availability of tobacco cessation resources. At the society level, we can add our voice and experience to national and global tobacco control efforts . Health professional organizations can show leadership and become a role model for other professional organizations and society by embracing the tenants of the Health Professional Code of Practice on Tobacco Control. 56