10
Effective Health Promotion Against Tobacco Use
KARENSLAMA, CYNTHIACALLARD, YUSSUFSALOOJEE AND
BUNGONRITHIPHAKDEE
The development of tobacco control policies and programs has been shaped by two concurrent forces. The first is the public health tradition of evidence-based decision making, which compels the abandonment of ineffective strategies and the continuous improvement of effective ones. The second is the tobacco indus- try tradition of resisting public health initiatives in order to maintain tobacco sales. This on-going battle has slowed progress in reducing death and disease from tobacco. Nonetheless, after five decades of research on, and evaluation of public health strategies, a consensus on a set of effective measures to curb the tobacco epidemic has emerged (Jha & Chaloupka, 1999).
The lessons learnt in changing tobacco use behaviors have given impetus to the development of the science of health promotion. In the early stages health authorities relied on giving individuals “the facts,” but soon recognized that that this was not sufficient and that additional measures were needed. These included not only making health education more persuasive and motivating, but changing the environment so as to make “healthy choices, easy choices.”
Creating environments that allow people to choose not to use tobacco means enacting tobacco control legislation to limit tobacco industry marketing strategies, to regulate tobacco product contents and emissions, to regularly increase price through taxes, and to protect people from exposure to tobacco smoke in public places. It also means that tobacco control laws be enforced and that smuggling is kept under control.
Tobacco control seeks to change social norms and individual motivations related to tobacco use through media campaigns and other health education ini- tiatives, easy access to cessation treatment, community involvement, and lobby- ing and advocacy. Governments also had to recognize their changed role from one of non-intervention in private lifestyle decisions to one of principled acceptance of their public health responsibilities.
Indicators of the Effectiveness of Tobacco Control Programs
Tobacco control interventions try to influence the social, economic and environ- mental factors that affect a population’s use of tobacco. A fall in consumption
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should, in time, result in better health for populations as a result of both a reduction in premature death and disease from tobacco-related causes and the reallocation of resources used in the production of tobacco products. Evidence continues to build of the impact of government policy on tobacco use and of programs for ces- sation and prevention in a form that can be used for the Cochrane reviews (http://www.cochrane.org/reviews/en/topics/94.html).
A number of strategic performance indicators of the effectiveness of tobacco control interventions have been identified by the World Health Organization (WHO) (Chollat-Traquet, 1996). These are:
• Political outcomes – the number of policies and programs adopted and imple- mented by governments.
• Educational outcomes – public awareness of risks, attitudes on tobacco use and opinions towards policies.
• Environmental outcomes – increase in smoke-free environments, decreased availability and affordability of tobacco products.
• Behavioral outcomes – reductions in the prevalence of tobacco use, in consump- tion, increase in self-protective behavior (e.g., attempts to quit, use of smoke-free facilities) and personal involvement in tobacco control programs (e.g., advocacy or physician advice to patients to quit).
• Economic outcomes – impact on personal and public finance (e.g., lower house- hold spending on tobacco, reductions in medical care costs, improved productivity) and on business sectors.
• Health outcomes – improved quality of life, decreased tobacco-related morbid- ity and mortality for smokers and nonsmokers.
There is, typically, a considerable gap between changes in behavior and measura- ble improvements in health. The political, economic, social and behavioral impacts of these policies are better short- and medium-term indicators of progress.
Reducing levels of tobacco use is a fundamental goal of tobacco control inter- ventions. Adult per capita tobacco consumption and smoking prevalence are therefore the most frequently used measures of effectiveness. The utility of these measures as a link between behavioral changes and final health outcomes has been shown. In countries with long-standing tobacco control policies like the USA and UK, where large numbers of people have stopped smoking for decades, decreases in lung cancer and heart disease have been observed (Peto, Darby, Deo, Silcocks, Whitley & Doll, 2000; Jemal, Cokkinides, Shafey & Thun, 2003).
Countries where the tobacco epidemic has only recently spread can benefit from the current understanding of the tobacco industry to impede the industry’s attempts to delay implementation of legislative measures and to adopt policies and programs that affect people’s behaviors and counteract industry tactics. This means giving precedence to population measures over individual approaches.
Examples of population-based approaches will be demonstrated in the section on tobacco control in different parts of the world.
After five decades of research on and evaluation of public health strategies, a set of population measures defined as effective by health authorities throughout the
world has been agreed and codified in an international treaty for health protection by governments and sets global standards for the production, marketing and use of tobacco products (WHO, 2003). The WHO Framework Convention on Tobacco Control (FCTC) entered into force in February, 2005, and has been ratified by 138 nations, as of September 1, 2006.
There is great variability in the population measures that have been adopted and in the general acceptance of tobacco use in society, or by governments. The existence of the WHO FCTC and its ratification is an example of a new consen- sual end-point. Whether or not the measures included in the treaty are adopted and enforced will be the result of civil society demand and government readiness.
Effective Tobacco Control Programs in Different Regions
Tobacco Control in the Americas
The American Regional Office of the World Health Organization (the Pan American Health Organization, PAHO) defines effective tobacco control measures as those that prevent initiation, increase quitting, reduce consumption and exposure to toxins by smokers who continue to smoke and which protect non- smokers from exposure to second-hand smoke (PAHO, 2006). PAHO considers the most cost-effective tobacco control measures to be imposing higher tobacco taxes, ending tobacco advertising and promotion, ensuring smoke-free environ- ments and requiring strong, graphic health warnings on tobacco packaging. PAHO recognizes that these measures have diverse and mutually strengthening impacts:
smoke-free environments protect nonsmokers, assist quitting by smokers and reduce the social acceptability of smoking, which helps prevent smoking initiation.
PAHO cautions governments that only implementing programs for specific groups to stop smoking or prevent starting can deplete resources but may have limited impact on the population in the absence of broader policy measures.
Countries and sub-national jurisdictions in the PAHO region have taken very different approaches to tobacco control, and have achieved varying levels of success. Canada has had most of the elements of the Framework Convention on Tobacco Control in place (with significant levels of funding) since 2001. Severe restrictions on tobacco promotions were phased into effect during this period;
large graphic health warnings were required on all cigarette packages; most work- places and public places became smoke-free; taxes on cigarettes were increased;
community programs were expanded and public education enhanced. Support for quitters was provided through a network of quit-lines, community programs, and health services. Support for community change (such as smoke-free bylaws) was provided through federal funding to non governmental organizations and other levels of government. Some provinces implemented school-based programs, but attempted to address the poor evidence of their success by focusing on “engaging”
youth to create smoke-free culture in their schools rather than “teaching” them about smoking. During this period, for the first time in modern Canadian history,
the number of smokers fell (from 6 million to 5 million, and from a prevalence rate of 25% to 20% of the population over 15 years of age). Cigarette consumption has fallen almost as dramatically. The appropriate attribution of this success to the varying elements of this comprehensive campaign has not yet been determined (Health Canada, 2005).
Other jurisdictions have taken very different approaches and achieved significant successes. California, for example, which does not have the power to impose graphic cigarette warnings or to ban advertising, has developed a different mix of compre- hensive strategies. California has focused on ensuring a high volume of activities and programs, on smoke-free public and private spaces, on denormalizing tobacco com- panies, on establishing appropriate programs for minority populations, and on the provision of cessation services. California has seen significant reductions in smok- ing following the implementation of tax increases, smoke-free policies, mass media and community programming. The California government reports that Californians now smoke approximately half as many cigarettes as smokers in the rest of the United States (California Department of Health Services, 2006), and that the chief challenge in achieving this has been the opposition and tactics of the “relentless”
tobacco industry.
Some South American jurisdictions have launched or implemented tobacco control programs, which include advertising bans, e.g., Brazil, and smoke-free measures (Da Costa e Silva Goldfarb, 2003); Uruguay, and graphic warning labels; e.g., Brazil, Uruguay, Venezuela.
Tobacco Control in Europe
In Europe, as in other areas in the world, there is great diversity in tobacco control progress. The European Union has not adopted a full tobacco control agenda as recommended in the EU commissioned report on tobacco control (Aspect Consortium, 2004), but various directives have pushed the agenda forward for legislation on stricter product regulation, tobacco advertising bans and eliminating duty-free sales within the European community. The WHO Regional Office for Europe has developed a database of indicators of national tobacco control programs available on their website (WHO EURO). Most countries in Europe have introduced tobacco control legislation, 20 countries have total tobacco taxes over 70% of retail price, and 48 have bans on advertising in at least some of the following: media, press, point of sale, sports. The first country-wide comprehen- sive clean air policies were instigated in Ireland, with Norway and Scotland following the lead. Malta, Sweden, and Italy have enacted comprehensive bans with designated smoking rooms in bars and restaurants. England and other parts of the UK will have comprehensive bans in 2007. While the prevalence of smok- ing has been dropping for many years among men and women in Scandinavia and Northern Europe, women’s smoking rates in some Southern and Eastern European countries are still rising (Slama, 2004). The differences in progress are still emerg- ing in mortality rates, as Eastern Europe overtook Western Europe in tobacco mortality among men (Heartstats, 2000). European Union Directives against
tobacco advertising and sponsorship, misleading descriptors, more pertinent and visible health warnings, etc., have influenced the countries of Eastern Europe into developing tobacco control measures at a much faster rate than might otherwise be expected. The most pertinent international factor in progress is the Framework Convention on Tobacco Control, of which 38 out of 54 countries in Europe are Parties, as of June, 2006. Parties include Germany, the country that has been a major barrier to developing policy measures for tobacco control within the European Union (23 Parties out of 25 countries) and in influencing similar poli- cies among neighbors to the East. So the window is open for progress. Countries around Europe vary greatly in their appreciation of the role of tobacco industry in the growth of tobacco use across the continent; many European governments use tobacco company school prevention campaigns; within all countries of course, there are pro-tobacco forces in government and in civil society.
Tobacco Control in Africa
Tobacco is, at present, not a major cause of death in Africa. Tobacco consump- tion rates are still comparatively low on the continent, so primary prevention of the epidemic is possible. However, African governments have traditionally given low priority to prevention just as most nations do.
By 1999, about half the governments in sub-Saharan Africa had taken some steps to regulate tobacco. Some 20 countries have enacted laws regulating smok- ing in public places, 16 require health warnings on tobacco products and 10 have total or strong partial bans on tobacco advertising and promotion. However, apart from South Africa, Botswana, Mauritius, and Mali most countries have not passed comprehensive tobacco control laws and the legislation is weak.
South Africa has made the most progress in regulating tobacco, with consumption falling by 33% between 1990 and 2000. The South African Parliament prohibited all tobacco advertising, sponsorship, and promotions in 1999. No advertisement may contain trademarks, logos, brand names, or company names of tobacco products.
The law also bans smoking in all enclosed places, including workplaces, and the free distribution of tobacco products, and awards or prizes to induce the purchase of tobacco. The government has also increased tobacco excise taxes for “health reasons,” so as to discourage consumption (Saloojee, 2000).
In 1996 Mali prohibited the advertising of tobacco products in most media, and smoking in public places requires health warnings and ingredient disclosure on cigarette packs. Mauritius enacted similar legislation in 1995.
Tobacco Taxes and Smuggling
The most cost-effective way to control tobacco, especially in low-income coun- tries, is to raise the price of cigarettes through increasing tobacco taxes. The World Bank estimates that an increase of 10 per cent in the price of a pack of cigarettes across all sub-Saharan African countries would persuade 3 million smokers in the region to quit smoking and prevent 0.7 million premature deaths from diseases caused by smoking (Jha & Chaloupka, 1999).
Every tobacco tax decision is therefore a health decision, and maintaining the price of tobacco above the rate of increase in real (inflation-adjusted) incomes is an impor- tant public health goal. Between 1990 and 2000 the real price of cigarettes in eight African countries increased by an average of 2.14 per cent annually (Table 10.1), which is well below the rate of increase in countries with progressive tobacco control policies like France (9.25%), Hong Kong (8.63%), or Australia (6.54%) (Guindon, Tobin & Yach, 2002). The rate of tobacco taxes in African countries is also low compared to say the European Union (EU). The EU adopted a directive in 1992 that fixed a minimum tax level of at least 70% of the retail price of a pack of cigarettes. In ten African countries, for which data was available, in 1999 the average tax was 46% of the retail price. The rate was lowest in Nigeria (32%) and highest in Ghana (66%) (Jha & Chaloupka, 1999).
Recognizing the implications that higher taxes and prices have on their sales volumes, the tobacco manufacturers have strongly opposed these through various strategies, including smuggling.
The once-secret internal tobacco industry documents reveal the industry’s prac- tices. These show that the tobacco companies not only colluded with smugglers by knowingly supplying them with cigarettes, but also centrally organized the process and collected hundreds of millions of pounds worth of black market proceeds (Campbell & Maguire, 2001). The tobacco companies monitored and watched over the smuggling of their brands in about 30 African countries including Benin, Cameroon, Central African Republic, Nigeria, Niger, and Sudan.
TABLE10.1. Cigarette price in selected African countries
–10 –5 0 5 10
Senegal Cote d'Ivoire Zimbabwe Cameroon Kenya Gabon Nigeria South Africa
Change in the real price of a pack of local brand cigarettes between 1990–2000
% Change
Source: Saloojee, 2004.
During the negotiations on the Framework Convention of Tobacco Control, the African region was a staunch proponent of evidence-based regulations. African governments formed a common front, pressing both for progressive regulatory measures (advertising bans, tax increases, restrictions on smoking in public places, anti-smuggling measures, etc.,) and for provisions to assist in providing alternative livelihoods for tobacco workers. The common front included both tobacco growing and non-tobacco growing countries. By June, 2006, 27 of 46 countries in the WHO-AFRO region had ratified the FCTC.
Tobacco Control in Southeast Asia
Tobacco use has increased considerably in the Southeast Asia region, dispropor- tionately affecting the poor. With one of the highest smoking prevalence rates in the developing world, especially amongst men, it is estimated that over half of Cambodian and Laos men smoke and around more than one third of adult men in Vietnam, Thailand and Malaysia. With the region’s population base of almost 500 million, and a total trade of US$ 720 billion (ASEAN website), it is a big market and prime target for the transnational tobacco companies as they seek to expand their markets and to compensate for a declining market in many devel- oped western countries. But in recent years, governments of the region have shown interest in the need for strong and effective national tobacco control poli- cies. Getting tobacco control policies put in place is a big step forward and get- ting effective enforcement and implementation is usually a next step.
Thailand, Singapore, and Malaysia are the countries in the region that have the most extensive population measures for tobacco control, including comprehensive tobacco control legislation, mass education campaigns, research to develop an evidence base, and tobacco cessation programs. These countries are regularly obliged to amend their tobacco control policies to counter new marketing and promotion strategies of tobacco companies which use loopholes in laws already in place. Countries which have not adopted comprehensive tobacco control policies such as Cambodia, Vietnam, Philippines, Laos, and Indonesia have nevertheless seen policy initiatives put forward.
Key measures to curb the increasing prevalence of tobacco use in this region are the same as in other parts of the world: tobacco taxation, total bans on tobacco advertising, sponsorship and promotions, prominent health warnings on tobacco packaging, smoke free workplaces and public places and public awareness campaigns. However success and progress vary from country to country.
One of the World Bank recommendations to all governments for controlling tobacco is to raise tobacco taxes, but it has not been easy to convince policy mak- ers in Southeast Asia to increase taxes on cigarettes, due to opposition from the tobacco industry. When this was discussed in Thailand, studies were put forward which showed that cigarette price increases would decrease the number of Thai children starting to smoke as well as providing additional government revenue.
These studies helped to convince the cabinet to approve increasing cigarette taxes from 55% to 60% in late 1993. The government has continued to raise cigarette
taxes every other year since then, because as tobacco taxes have increased and government revenues have increased, tobacco consumption has decreased. The current excise tax on cigarettes in Thailand is 79% of the retail price.
Policy and action to ban smoking in public places and workplaces in Southeast Asia are expected to help to establish a non-smoking norm. In addition, although women for the most part do not smoke, as there is high smoking prevalence among men, smoke-free policy would protect women from passive smoking. The reduction in exposure to tobacco from banning smoking in public places and workplaces has been the object of reflection by the tobacco industry. According to a Philip Morris internal document from 1992, “if smoking were banned in all workplaces, the industry’s average consumption would decline, and the quitting rate would increase . . .” (Hieronimus, 1992).
Thailand, for example, has extended its smoking ban to all air-conditioned dining premises and 18 other kinds of public places, such as hotel lobbies, Internet cafes, barbershops and beauty salons. Singapore first banned smoking in cinemas and theaters in 1970 and extended the ban to include air-conditioned restaurants in 1989 and air-conditioned shopping centers in 1995. Starting July of next year, the smoking ban will also cover entertainment outlets such as pubs, discos and karaoke lounges, but operators will be allowed to have a designated smoking room. In the Philippines, the Tobacco Regulation Act of 2003 includes an absolute smoking ban in all public places including bars and restaurants; phas- ing out of tobacco advertisements by January 2007, with a total ban on any form of tobacco advertising by July 2008. Indonesia is planning to prohibit smoking in public places such as public transit, and government and private buildings.
Malaysia is currently launching a campaign drive in several cities in the country to ensure the strict enforcement of anti-smoking laws in the country. Vietnam has banned smoking in government buildings, schools, and hospitals and is consider- ing extending this to all public places. Smoking was also banned at the Southeast Asian Games hosted by Vietnam in December, 2003. In the Lao People’s Democratic Republic, the Lao school of Medicine declared the faculty to be smoke-free.
Cambodia has strengthened community action by engaging religious leaders to play an active role in creating smoke free temples and encouraging smoking ces- sation among monks. Utilizing Buddhist principles and the influence of Buddhist monks has not only raised awareness among Buddhists but also garnered support in advocacy for smoke free public places and FCTC ratification.
Asia exemplifies the variable end-points of tobacco control endeavors. Despite setbacks, progress is being made throughout the region – albeit at various speeds – to protect the public health through tobacco control efforts.
Tobacco Control in Other Regions
Similar variation and progress can be found in the other regions of the world not included in this report. All regions of the world include countries of very high tobacco consumption and rising tobacco-related mortality rates. In the Western
Pacific area, Australia, and New Zealand have created societies where many in the population are not drawn to tobacco use. In the Eastern Mediterranean Region, great increases in tobacco use have encouraged governments to enact legislation for tobacco control.
Issues in Measuring Effectiveness
The extent of national legislation and its enforcement is one of the best indicators of the strength of tobacco control forces in a country. Success in getting legislation enacted requires protracted media advocacy, winning community support, and strong lobbying of legislators. The advocacy “process”, however, remains poorly documented. The lessons that have been learnt by countries that have successfully (or unsuccessfully) tackled tobacco are not easily generalized and passed on to others.
In assessing what works in tobacco control a number of factors that may ameliorate outcomes need to be taken into consideration. Firstly, evaluations may be time-sensitive, with results varying with time. Interventions need time to be implemented, time to exert their effects, and with time there may be an erosion of the effect. Outcomes may thus be very different if evaluated after a few weeks, a few months or a few years. Some policies too may reduce tobacco use more rapidly than others. For example, price increases produce results rel- atively quickly, while the effects of an advertising ban may take longer to become apparent. Policies often also have a major impact when first introduced, and then as populations either become sated or familiar with the measure the impact declines.
Secondly, competing influences, or societal influences unrelated to the inter- vention, may undermine the impact of a measure. For instance, the public may receive mixed messages as a result of industry disinformation campaigns, which may dilute the effect of an educational intervention. The industry also uses counter-strategies to make continuation of tobacco use easier for smokers (such as price-discounting and promotions, or advocating for smoking and non- smoking areas in public places). In the face of such challenges effective programs may only be able to stabilize smoking prevalence or may act to minimize an increase. The success of an intervention should therefore not just be measured in terms of declines in prevalence, but against the expected prevalence rates in the absence of the intervention. Few systematic attempts have been made to incorpo- rate industry actions into evaluation methods for tobacco control programs.
Thirdly, tobacco control programs are often introduced as a comprehensive package and separating out the part played by the individual components is not always possible. For instance, if a ban on tobacco advertising and tax increases are introduced concurrently, the impact of the ban on declines in youth smoking may be difficult to measure. On the other hand, there may also be synergy between interventions. For example, a reduction in adult smoking may change the normative environment, so that there is less explicit modeling of smoking as an
adult behavior and thus reduce smoking by youth. Determining the optimal pol- icy mix for any given society remains a challenge.
Fourthly, the introduction of tobacco control laws is almost always preceded by public debate and the educational value of these debates may contribute significantly to reductions in tobacco usage.
Finally, there is a need for more and better data particularly from lower-income countries. Often there is no baseline data, insufficient information on the quality of the intervention or the extent of implementation, and little information on tobacco industry counter measures.
Conclusions
The Ottawa Charter for health promotion recommends healthy public policy, sup- portive environments, strengthened community action, development of personal skills and reorientation of health services as key elements of the health promotion movement to protect the public from the harms of tobacco use. Countries around the world are slowly enacting these measures. With the WHO FCTC, the nations of the world have been given the opportunity to join together to fight a pervasive and powerful industry and to counteract the progression in tobacco use that is still occur- ring. The treaty contains current standards of best practice, but the goals of tobacco control strategies and the application of agreed measures need frequent updating to respond to both the tobacco industry and the evolution of tobacco use in populations.
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