Mark Parascandola, PhD, MPH

Program Director

Tobacco Control Research Branch

Behavioral Research Program

Division of Cancer Control and Population Sciences

Introduction to the Global Tobacco

Epidemic and Tobacco Control

2

“cigarette smoking is a

health hazard of sufficient

importance…to warrant

appropriate remedial

action”

3

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

0

1

2

3

4

5

in thousands

WWI

Great

Depression

First scientific

studies linking

smoking and lung

cancer

First SG Report

FCC Fairness

Doctrine

Cigarette Ad

ban

Beginning of NS

Rights

Movement

SG report on ETS

NRT goes OTC

Master Settlement

Agreement

WW II

U.S. Per Capita Cigarette Consumption during 20th century and Major Events

4

Source: Lopez AD, Collishaw NE, Piha T. A descriptive model of the cigarette epidemic in developed countries. Tobacco Control, 1994; 3: 242-247.

The Four Stages of the Tobacco Epidemic

5

Adult (≥ 15 Years) Smoking Prevalence by WHO Region

Global Overall Prevalence: 41.1% of males and 8.9% of females

Source: World Health Statistics, 2010, WHO.

6

Global Tobacco Mortality is Growing and Shifting to the Developing World

▪ Tobacco use kills about 7 million people annually

worldwide.

▪ Tobacco-related deaths are expected to rise to 8

million by 2030, and more than 80% of deaths

will occur in low and middle-income countries

(LMICs).

▪ Countries increasingly face a “double burden” of

disease: diseases of poverty and chronic

diseases caused by risk factors such as tobacco

use.

▪ Tobacco use and exposure among women in

LMICs is rising threatening to impede or reverse

efforts to improve maternal and child health.

7

Per Capita Cigarette Consumption Among People Age 15 Years and Older, Globally and by Country Income Group, 2000–2013

Note: Country income group classification based on World Bank Analytical Classifications for 2013.

Source: Based on data from Euromonitor International 2016.

8

Prevalence of Current Tobacco Use Among Adults Age 15 and Older, by Wealth Quintile, 2008–2010

Note: Data are from the Global Adult Tobacco Survey 2008–2010.

Source: Palipudi et al. 2012

9

https://cancercontrol.cancer.gov/brp/tcrb/monographs/21/index.html

The Economics of Tobacco and Tobacco Control

Tobacco use imposes an enormous health and economic burden on the global workforce Tobacco use remains one of the world’s leading causes of preventable premature death, including death from cancer. Globally, there are 1.1 billion tobacco smokers age 15 or older, and tobacco use burdens economies with more than US$ 1 trillion in health care costs and lost productivity annually.

10

Emergence of Smokeless

Tobacco

11

ST Marketing 1970s

▪ US Tobacco Company national

marketing campaign for Copenhagen,

Skoal, Happy Days moist chewing

tobacco

▪ Enlisted sports stars: Walt Garrison,

Carlton Fisk, Shep Messing, Bobby

Murcer, Earl Campbell

▪ Cigarette advertising ban in 1970, but

did not extend to ST

▪ ST marketing emphasized alternative to

smoking

12

US Smokeless Tobacco Company Sponsors the 1980 Winter Olympic Games in Lake Placid

13

US consumption of cigarettes vs smokeless tobacco,1981-1991

14

What Impact Did ST Sports Marketing Have?

▪ 1980: medical experts began documenting a rise in ST

use among male high school and college athletes

▪ 1978 – 1985: Moist snuff sales increased 55% while

cigarette sales dropped

▪ 1981: D. Winn (NCI) study of ST and oral cancer in US

▪ 1986: Surgeon General report on The Health

Consequences of Smokeless Tobacco Use

▪ 1986: Comprehensive Smokeless Tobacco Health

Education Act

▪ ST warning label

▪ Ban on TV and radio advertising

15

Required warnings for cigarettes (1985) and for smokeless (1986)

Cigarettes: ‘surgeon general’s

warning’

Smokeless tobacco: ‘warning’

Smoking causes lung cancer, heart

disease, emphysema, and may

complicate pregnancy

This product may cause mouth

cancer

Quitting smoking now greatly

reduces serious risks to your health

This product may cause gum

disease and tooth loss

Smoking by pregnant women may

result in fetal injury, premature birth,

and low birth weight

Proposed: this product contains

nicotine and is addictive

Cigarette smoke contains carbon

monoxide

Compromise: this product is not a

safe alternative to cigarettes

16

Smokeless Tobacco

▪ A global problem, present in at least 70 countries, affecting

>300 million people. Vast majority of users (89%) reside in

South-East Asia. India has the largest number of users (220

million).

▪ Disease risk varies across countries and regions, likely due in

part to differences between ST products and patterns of use.

▪ Marketing of ST varies around the world. In high-income

countries, marketing is often aimed at promoting “dual-use” of

ST and cigarettes.

▪ Policies and programs aimed at ST use prevention and

cessation are generally weaker than those for smoked tobacco

products

▪ Significant knowledge gaps remain including: surveillance of

use, product characterization, health consequences, effective

program and policy interventions.

Source: NCI's Centers for Disease Control and Prevention: 2014 Report on Smokeless Tobacco and Public Health: A Global

Perspective, 2014.

17

Global Tools for Tobacco

Control

18

WHO Framework Convention on Tobacco Control (FCTC)

▪ First global health treaty negotiated by the World Health

Organization (WHO)

▪ First “legal instrument” designed to reduce tobacco-related

deaths and disease around the world

▪ Unanimously adopted by WHO’s 192 Member States on May

21, 2003

▪ Entered into force on February 2005

▪ 180 countries are Parties to the treaty

▪ Governing body: Conference of the Parties (COP), meets

regularly and establishes detailed “guidelines” for

implementation of specific FCTC articles. Technical assistance

by WHO.

Latest Party:

Zimbabwe

March 4, 2015

Source: WHO Framework Convention on Tobacco Control: Tobacco taxes can be used to finance the Sustainable Development Goals,

2015.

20

Share of the World Population Covered by Selected Tobacco Control Policies, 2015

Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level. For the definitions of these

highest categories, refer to the WHO Report on the Global Tobacco Epidemic, 2015: Raising Taxes on Tobacco.

Source: World Health Organization 2015

Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level. For the definitions of these

highest categories, refer to the WHO Report on the Global Tobacco Epidemic, 2015: Raising Taxes on Tobacco.

Source: World Health Organization 2015

21

Challenges to Reducing Tobacco Use in LMICs

▪ Low public knowledge, high barriers to

increasing knowledge:

▪ Lack of resources for education campaigns

▪ High rates of illiteracy, especially among women/girls

▪ Governments dealing with more pressing issues

▪ High tobacco use rates among health professionals; training in tobacco control

and prevention is uncommon

▪ Diverse and new tobacco products, both smoked and smokeless

▪ Inadequate resources for research, interventions (policy and program), and

advocacy

▪ Resistance to tobacco control from governments who profit from tobacco

sales or taxation

▪ Tobacco industry presence strong and may be increasing; trade and

investment treaties empower tobacco industry and allies

22

Median Price of a Pack of Cigarettes, by Country Income Group, 1990–2011

Notes: Using the official exchange rate, the prices of local brands of cigarettes, as collected by the Economist Intelligence Unit, were converted to

U.S. dollars (not adjusted for inflation). Countries were discarded from the dataset if more than approximately one-third of the time series data were

missing, if the country experienced a serious bout of hyperinflation or introduced a new currency, or if price data were so unstable over time that

they were simply not credible. With these countries removed, the subsequent analysis was performed on 40 countries. Data were collected from

large urban areas and may not reflect the full range of prices within the country.

Source: Economist Intelligence Unit 2012.

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