Preventive Interventions: The cost-effective “Best-Buys”

Preventive Interventions:
The cost-effective “Best-Buys”
- Global advances in Tobacco Control -
Riyadh, 10 -12 September 2012

Douglas Bettcher, MD, PhD, MPH
Director, Tobacco Free Initiative
Director Ad Interim, Chronic Diseases and Health Promotion

WHY TOBACCO
CONTROL

Preventive interventions: the cost-effective “best-buys”|
Riyadh| 10-12 September, 2012

Tobacco and the NCD action plan:
4 risk factors, 4 noncommunicable diseases, 2 conditions
Cancer Chronic
respiratory
Diabetes diseases

Noncommunicable Cardiovascular Mental disorders
Diseases and disease
Injuries
Conditions
Physical
Risk factors inactivity Harmful use
of alcohol
Unhealthy
Tobacco
diets


86% of people who die from NCDs between the ages of 30 and 70
live in a developing country

Low-income High-income
countries countries
1.5 million 2.0 million
(11%) (14%)
Upper middle-
income countries
2.3 million
(16%)

Lower middle-
income countries
8.3 million
(59%)


Huge disparities exist across countries in relation to the probability of death from
an NCD between the ages of 30-70


The Tobacco Epidemic - Today

Source: WHO 2008


Tobacco kills… Tobacco kills ...

About 90% of all
22% of global deaths from
…nearly cancer chronic
6 million deaths, 71% obstructive lung
of all lung diseases and 42%
people cancer
of all chronic
respiratory
each deaths. disease are
attributable to
year. • 10% of cardiovascular
disease deaths cigarette
smoking.

Source: WHO Global status report on noncommunicable
diseases, 2010, http://www.who.int/nmh/publications/ncd_report2010
/en/


Exposure to second-hand smoke also kills

Distribution of
One third of adults are regularly total deaths
attributable to
exposed to second-hand tobacco SHS, 2004
smoke.

About 600 000 people die each year
as a result of exposure to second-
hand smoke.
• 430 000 are adults, of whom 64% are women
• 28% of the second-hand smoke deaths are
among children
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
.


The Tobacco Epidemic is About to Get Much
Worse…

Tobacco could kill
up to
If current 1 Billion
smoking patterns persons in the
Tobacco continue, the 21st Century
currently kills death toll from unless urgent
nearly 6 tobacco use will action is taken
Million/year but be:
this will increase • 2000–2025~150M
to over 8 • 2025 – 2050 ~ 300 M
• 2050 – 2100 > 500 M
Million/year in a
few decades.

THE SOCIO-ECONOMIC
IMPACT


New perspectives
The poorest people in developing countries are affected the most:
Example: Poorest people smoke the most

45 Smoking prevalence (2004)
Lowest household
40 income quintiles

35

30
(percentage)

25 Highest household
income quintiles
20

15

10

5

0

Low-income Lower-middle Upper-middle- High-income
countries Income income


OPPORTUNITIES
AND GLOBAL RESPONSE


Mechanisms for Tobacco Control
WHO Framework Convention on
Tobacco Control (WHO FCTC)


WHO Framework Convention on Tobacco Control:
An evidence-based tool to save lives
Objective:
“To protect present and future
generations
from the devastating health, social,
environmental and economic
consequences
of tobacco consumption and exposure
to tobacco smoke …
to reduce continually and substantially
the prevalence of tobacco use and
World No Tobacco Day Poster 2011
exposure to tobacco smoke.”


What is the WHO FCTC?
First global health treaty negotiated
176
under the auspices of WHO

176  Establishes tobacco control as a
priority on the public health agenda
 Provides a political and legal platform

Parties for adoption of sound, evidence based
tobacco control measures
 Introduces a mechanism for firm
country commitment and accountability
 Entry into force 27 Feb 2005
 176 parties covering about 87% of the world’s population


Demand reduction Supply reduction
provisions provisions
 Price and tax measures (Art.6)  Elimination of illicit trade (Art.15)
 Protection from secondhand smoke  Prohibition of sales to and by minors
(Art.8) (Art.16)
 Contents regulation (Art.9)  Support for viable crops for growers
 Disclosure of contents (Art.10) (Art.17)
 Packaging and labelling (Art.11)
 Education and awareness-raising
(Art.12)
 Advertising, promotion and
sponsorship (Art.13)
 Cessation programmes (Art.14)


BEST BUYS
AND
GOOD BUYS

Rationale – Why "best buys" for NCDs?
Consequent need to
develop:
NCD "best buy"
interventions that are cost-
effective, feasible, low-cost
Public health and Cost-effectiveness –
and appropriate to
economic burden – show indicates solutions but not implement within the
the size of the problem, but their constraints of the local
not how to address and feasibility, affordability and health system
reduce it acceptability Financial planning tool for
identifying resource needs
Price tag analysis to inform
global resource
mobilisation


The cost of action vs inaction
(in developing countries over the next fifteen years)
Cost of action: Cost of inaction:

US$ 170B US$ 7T
is the overall cost for
all developing countries is the cumulative
to scale up action lost output in
by implementing a set of developing countries
"best buy" interventions associated with NCDs
between 2011 and 2025, between 2011-2025
identified as priority
action by WHO

Reports are available at www.who.int/ncd


MPOWER: Six policies which
build on the WHO FCTC
and are an integral part of the
NCD Global Strategy Action Plan

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


Tobacco control is cost-effective

US$0.6 billion for all low- and middle-income
countries (US$0.11 per capita)
Monitor tobacco use and prevention
BEST BUYS Protect people from tobacco smoke
& Offer help to quit tobacco use
Warn about the dangers of tobacco
GOOD BUYS Enforce bans on tobacco advertising
Raise taxes on tobacco


Tobacco control is cost-effective

5·5 million deaths could be
averted over 10 years if these
elements of the WHO FCTC were
implemented in countries:
• increased taxes on tobacco products;
• enforcement of smoke-free workplaces;
• WHO FCTC-compliant packaging and labelling, with
public awareness campaigns about health risks;
• comprehensive ban on tobacco
advertising, promotion, and sponsorship.

at a cost of less than US$ 0.40 per person
in low income and lower-middle income countries


Estimates for the average annual cost of tobacco control best buy
interventions in all low- and middle-income countries (US$ 2008)

P
R
W
E
W

A study that modelled P, W, E, R for 23 countries
5.5 million deaths could be averted at less than US$ 0.40/person /year in low- and lower-middle-
income countries, and US$ 0.5–1.00 in upper-middle-income countries.


Status of MPOWER measures

Number of highest achieving countries in 2010

59

23

M 31 19 19
P 19 27
O
W
E
R


Progress is being made

3.8 billion people
(55% of the world’s
population)
are covered by at least one
MPOWER measure at the
highest level of achievement,
including
1.1 billion people
M
covered by a new policy
P
since 2008
O
W
E
R


MPOWER measures
bring smoking rates down rapidly


EMRO – countries with MPOWER measures
at the highest level of achievement

M Djibouti, Iran, Jordan, Lebanon, Morocco
P Iran, Libya, Pakistan
O Bahrain, Iran, Saudi Arabia, United Arab Emirates
W – labels: Djibouti, Egypt, Iran
W – campaigns: Egypt, Lebanon, Morocco
E Djibouti, Iran, Jordan, Kuwait, Qatar, Sudan, Syria, UAE
R West Bank and Gaza Strip

Iran implements strong pack warning labels

The Islamic Republic of Iran enacted a comprehensive
tobacco control law in 2006.

In 2008, the law was strengthened to require pictorial
warnings on all cigarette packages.

Warning labels cover 50% of the pack and include
graphic images of diseases caused by smoking.

Use of misleading terms, such as “mild” and “light” are
also banned.

As a result, Iran’s requirements fully meet the WHO
FCTC Article 11 guidelines and thus effectively warn
smokers about the risks to their health.


Jordan strengthens prohibitions on tobacco
advertising, promotion and sponsorship

Tobacco advertising and marketing had in theory been banned in Jordan since 1977,
but the enforcement was weak.

The 2008 legislation clarified and strengthened the law and added new provisions to
limit point-of-sale tobacco marketing, including bans on the sale of individual
cigarettes and sales through vending machines.

To strengthen enforcement, the Ministry of Health trained 35 health promotion
coordinators on practical and suitable methods for enforcing and implementing the
law and on procedures for inspections.

This successful model for enforcing advertising and marketing bans is ready to be
expanded to the rest of the region.


Egypt restructures and increases tobacco excise taxes and
earmarks additional revenues to fund health programmes
In 2010, Egypt replaced its tiered tax system with a uniformly applied 40% ad valorem excise
tax as well as a single specific tax rate of Egyptian £ 1.25 (USD 0.20) per pack of cigarettes.
Total taxes per pack by an average of 87%, which increased the average retail price by an
estimated 44%. This increase on cigarettes could reduce cigarette consumption by 21% and
smoking prevalence by more than 10%, and hence reduce the number of adult smokers by
about 893 000 and prevent about 208 000 premature deaths.

Egypt’s approach to reaching the dual
goals of reduced tobacco consumption
and increased resources to spend on
health can provide invaluable lessons
for other countries.


Plain packaging
initiative takes off

Australia’s High Court
dismissed a legal
challenge from the
tobacco industry.

From December 2012,
Australia will be the first
country to sell cigarettes
only in drab, olive-green
plain packaging.


UN High-level Meeting on NCDs (New York, 19-20 September 2011)
LANDMARK EVENT ATTENDED BY:

113 Member States

34 Presidents and Prime-Ministers

54 Vice-Presidents, Deputy Prime-Ministers,
Ministers of Foreign Affairs and Health

11 Heads of UN Agencies

Hundreds of representatives from civil society


The UN POLITICAL DECLARATION ON NCDs

We, Heads of State and Government and representatives of States and Governments,
assembled at the United Nations from 19 to 20 September 2011, to address the
prevention and control of non-communicable diseases worldwide, with a particular
focus on developmental and other challenges and social and economic impacts,
particularly for developing countries,

38. Recognize the fundamental conflict of interest between the
tobacco industry and public health;

43.(c) We therefore commit to:
Accelerate implementation by States parties of the
WHO Framework Convention on Tobacco Control


The UN POLITICAL DECLARATION ON NCDs
commits Member States

 Advance the implementation of multisectoral, cost-effective
population-wide interventions in order to reduce the impact
of the common NCD risk factors
Tobacco use
Unhealthy Diet
Physical Inactivity
Harmful Use of Alcohol

 Interventions: Population- or individual- based measures
('best-buys') that are very cost-effective,
feasible and low-cost


11 voluntary global targets presented in the revised WHO Discussion Paper

Premature mortality from NCDs
25% reduction

Raised blood Salt/
pressure Tobacco smoking Physical inactivity
sodium intake
25% 30% 10%
30%

Generic Drug therapy
Raised
Obesity Fat intake Alcohol medicines and and
cholesterol technologies counselling
0% 15% 10%
20% 80% 50%

Target adopted by the World Health Assembly
Targets with wide support
Targets with support for further development

Tobacco Industry - A Mutating Vector

Epidemiological models - Tobacco use & Malaria infection


WHO FCTC ARTICLE 5.3
In setting and implementing their public health policies with respect to tobacco
control, Parties shall act to protect these policies from commercial and other vested
interests of the tobacco industry in accordance with national law.

Forms of Tobacco Industry Interference

Manoeuvering Exaggerating Manipulating Fabricating Discrediting Intimidating
to hijack the the economic public opinion support proven governments
political and importance of to gain the through front science with litigation
legislative the industry appearance of groups or the threat
process respectability of litigation


"We have evidence, and we have instruments"
Dr Margaret Chan, Director-General of the World Health Organization
Keynote address at the 15th World Conference on Tobacco or Health, Singapore, 20 March 2012

"As a tool for fighting back, we "And we have an enemy, […] the
have the WHO FCTC. We have a tobacco industry, has changed its face
practical, cost-effective way to and its tactics. Tactics aimed at
scale up implementation of undermining anti-tobacco
provisions in the treaty on the campaigns, and subverting the WHO
ground. […] the best-buy and FCTC, are no longer covert or cloaked
good-buy measures for by an image of corporate social
reducing tobacco use set out in responsibility. They are out in the open
the MPOWER package." and they are extremely aggressive"

"[…] full implementation of the "I called on heads of state and
WHO FCTC would deliver the government to stand rock-hard
single biggest preventive blow to against the despicable efforts of
heart disease, cancer, diabetes, the tobacco industry to subvert
and respiratory disease." this treaty."


TOBACCO FREE INITIATIVE
TOWARDS A TOBACCO FREE WORLD


Preventive Interventions: The cost-effective “Best-Buys”

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