June 1, 2010

The Right Tools for the Job.

One billion people around the globe do it. And more and more people join them each day.

I am talking about smoking. The negative effects of smoking and tobacco use are indisputable -- smoking kills. It causes cancer. It causes emphysema. It causes heart attacks. It causes increased blood pressure and heart rate. It causes adverse reproductive outcomes. During pregnancy, it decreases gestational age at birth and decreases birth weight. Sincerely, the list goes on and on and on.

Tobacco is the only legal consumer product in the world that kills when used exactly as intended by the manufacturer. In fact, there are more than 4000 chemicals in tobacco smoke, of which at least 250 are known to be harmful and more than 50 are known to cause cancer. 

Despite this knowledge, the effects of this addictive habit are staggering. Smoking-related illnesses claim more American lives than alcohol, car accidents, suicide, AIDS, homicide, and illegal drugs, combined. Globally, tobacco kills more than five million people a year, or an average of one person every six seconds. Smoking accounts for one in every 10 adult deaths. Smokers enjoy a 50-50 chance that they will eventually die of a tobacco-related disease, that is, if they are not killed by a bus or in a freak accident otherwise. The annual death toll is projected to rise to eight million by 2030 barring effective controls to stem the global tobacco "epidemic." In sum, tobacco use is one of the biggest public health threats the world has ever faced.

To confront these harrowing statistics, the World Health Organization adopted the global Framework Convention on Tobacco Control in 2003, which has since become one of the most widely embraced treaties in UN history with 168 country signatory parties. Yesterday, May 31st, commemorated World No Tobacco Day, one among many days designated by the organization to bring global focus and attention to a particular health issue. As its name indicates, the goal of World No Tobacco Day is to bring global awareness to the problem of tobacco use and to encourage users to quit.

Nice idea, but here is what they are up against.

Despite indisputable proof that smoking kills, World Health Organization studies show that few people truly understand the specific health risks of tobacco use or know that it even holds negative health consequences at all. While numbers of tobacco users in high-income and upper middle-income countries continue to decrease, where presumably knowledge of these latent risks is more generalized, total consumption of tobacco products continues to increase in other parts of the globe. More than 80% of the world's one billion smokers live in low-and middle-income countries, where very little knowledge exists about the inherent dangers of smoking, and accordingly, the burden of tobacco-related illness and death is the heaviest. As if an example is needed of the dangers of people being wholly unaware of the negative health consequences of using or smoking tobacco, a video surfaced last week on the UK Sun's website of a reporter's footage of an "addicted" cigarette smoking 2 year old in a Sumtran village in Indonesia. First introduced to this habit by his father at the young age of 18 months, this toddler now allegedly smokes up to 40 cigarettes a day (ie: close to two packs). His addiction manifests in angry burst of screaming and hitting his head against a wall, when cigarettes are withheld from him by his parents.

As the Salon's Mary Elizabeth Williams rightly points out, while a "child's welfare is still first and foremost his parents' responsibility," perhaps those of us in the western world who know better should not "get comfortable in the knowledge that we'd never even expose our own babies to cigarettes, let alone hand them a pack," but rather "redirect a little of that indignation toward a profitable industry that's worked so hard to pour smoke down those little lungs." I concur. But also, I reserve some of my sense of indignation over this story towards public policy and civic leaders lacking the vision and political will to utilize the arsenal of tools available and proven effective in curbing rates of tobacco usage. 

It is now widely accepted as fact that there is no safe level of second-hand tobacco smoke. Under the guiding ethos that every person should be able to breathe smoke-free air (as well as adding an extra hurdle to smokers partaking in this habit themselves), there was a recent title wave of smoke-free laws to protect the health of non-smokers in many American and European cities, including the recent extension of these indoor smoking prohibitions in bars (gasp!). It felt like a step back in time to land in Dar es Salaam where there are no such prohibitions to smoking in bars and restaurants. Unfortunately, this is more the rule than the exception. Globally, only 5.4% of people are protected by comprehensive national smoke-free laws. Of the 100 most populous cities only 22 are smoke free. This is a sad demonstration of public policy leadership, given that second-hand smoke causes 600,000 premature deaths per year, and what's more depressing, in 2004, children accounted for 28% of the deaths attributable to second-hand smoke.

Beyond this unwelcome second-hand smoke when enjoying a cocktail, I was shocked to learn how cheap cigarettes are here. Following cigarette packs with an average price tag well over US$8 in most American cities, a pack of cigarettes here runs under US$2. It is proven that tobacco taxes are the most effective way to reduce tobacco use, especially among young people and poor people (dare I remind you Tanzania is one of the poorest countries in the world). A tax policy that increases tobacco prices by 10% decreases tobacco consumption by about 4% in high-income countries and by up to 8% in low- and middle-income countries. In other words, a "vice tax" is an effective way to curb usage rates. Only 21 countries, representing 6.2% of the world's population, have tobacco tax rates greater than 75% of the retail price. Shockingly, in countries with available information, tobacco tax revenues are 173 times higher than spending on tobacco control.

Hard-hitting anti-tobacco advertisements and graphic pack warnings reduce the number of children who begin smoking and increase the number of smokers who quit. Following the use of pictorial warnings in Brazil, Canada, Singapore, and Thailand, studies consistently demonstrated the use of these pictures significantly increased people's awareness of the harms of tobacco use. Despite proof that pictures are more powerful deterrents than words on tobacco packaging warnings, only 19 countries, representing 24% of the world’s population, mandate pictorial warnings. Just 15 countries, representing 7.6% of the world's population, meet the highest standards for pictorial warnings, which dictate that these color warnings cover at least half of both the front and back of cigarette packs. Bans on tobacco advertising, promotion, and sponsorship are also proven to reduce tobacco consumption. Only 26 countries, representing 8.8% of the world’s population, have comprehensive national bans on tobacco advertising, promotion and sponsorship, and moreover, 27% of the world's population live in countries that do not ban free distribution of tobacco products.

Those that are aware of health risks related to tobacco use, usually state their intention and desire to quit. Where this is the case, counseling and medication doubles the chance that a "quitting" smoker will succeed. However, national comprehensive health-care services supporting cessation are available in only 17 countries, or rather, are only available to 8.2% of the world's population. There is no cessation assistance at all in 29% of low-income countries and 8% of middle-income countries. 

This year's World No Tobacco Day was focused on gender and tobacco, using the day to draw particular attention to the harmful effects of tobacco marketing and smoke on women and girls. To curb the "sex" appeal of industry advertising, the World Health Organization developed a series promotional and educative posters aimed at debunking this perception. While creative and slick, I am not sure these anti-smoking advertisements stand a chance against the powerful promotional advertisements of the tobacco industry.









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