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Combating Tobacco Smoking

Combating Tobacco Smoking. Ann McNeill, PhD Honorary Senior Lecturer Independent consultant in public health. Sources:. www.treatobacco.net www.ash.org.uk . A resource. Global smoking.

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Combating Tobacco Smoking

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  1. Combating Tobacco Smoking Ann McNeill, PhD Honorary Senior Lecturer Independent consultant in public health annmcneill@clara.co.uk

  2. Sources: • www.treatobacco.net • www.ash.org.uk

  3. A resource

  4. Global smoking • There are an estimated 1.1 billion smokers worldwide, representing about a third of the adult global population • 800m in developing countries and most of these are men (700m) • In China there are about 300m smokers

  5. World cigarette production Source: US Department of Agriculture

  6. Who smokes?

  7. Smoking since 1948

  8. Smoking and deprivation UK CIGARETTE SMOKING BY DEPRIVATION 80 70 60 % prevalence 1973 50 40 1996 30 20 10 0 0 1 2 3 4 5 Poorest Most affluent DEPRIVATION SCORE Jarvis (1997)

  9. UK Smoking Summary • 28% men, 28% women smoked in 1996, decline in adults plateauing, possibly increasing again • No changes in young peoples’ smoking • No changes in pregnant womens’ smoking • Large socioeconomic differences

  10. Some impacts - Health • Of those who smoke regularly, around one half will die prematurely • Smoking caused 120,000 deaths in UK in 1995 • Smoking related diseases cost the NHS approx £1.5 billion a year in England

  11. Some impacts - Health • Cancer • Heart & Circulation • Respiratory • 20 fatal illnesses • 50 non-fatal illnesses • Widespread addiction

  12. Harm to others - 600 cases of Lung cancer 12,000 cases of heart disease Trigger to 3.4 million asthma sufferers Pregnancy complications and cot death 17,000 hospital cases per year in under-5s 3 million non smokers work in smokey conditions Health Impacts - Passive Smoking

  13. Cigarettes are among the leading causes of death in the United States 87% 82% 18% 40% (under 65) 21% (all ages) 33% 10% Source: 1989 Surgeon General's Report. Data from USA.

  14. Annual Deaths from Smoking Compared with Selected Other Causes in the United States Sources: (AIDS) HIV/AIDS Surveillance Report, 1998; (Alcohol) McGinnis MJ, Foege WH. Review: Actual Causes of Death in the United States.JAMA 1993;270:2207-12; (Motor vehicle) National Highway Transportation Safety Administration, 1998; (Homicide, Suicide) NCHS, vital statistics, 1997; (Drug Induced) NCHS, vital statistics, 1996; (Smoking) SAMMEC, 1995

  15. Why do people smoke? • The tobacco industry • Most smoke because they are addicted to nicotine (affects nearly every organ) • Recent expert reports show that tobacco delivered nicotine is as addictive as heroin, cocaine etc • Most smokers want to quit but cannot

  16. Key Findings • Tobacco dependence & withdrawal syndromes classified as substance use disorders under WHO ICD 10 • Nicotine dependence & withdrawal classified similarly under APA DSM IV • More common general term is addiction

  17. Why it is so hard to stop smoking 30 25 Cigarette 20 15 10 5 0 0 10 20 30 40 50 60 Rapid absorption of nicotine reinforces smoking behaviour Plasma nicotine (mg/mL) Time after smoking a cigarette (mins) 1. Royal College of Physicians, 2000.

  18. Why it is so hard to stop smoking The power of addiction All smokers ~70% want to stop1 ~2–3% succeed in stopping each year3 ~30% try each year2 1. Bridgwood et al., 2000. 2. West, 1997. 3. Arnsten, 1996.

  19. Addiction “The cigarette should be conceived not as a product but as a package. The product is nicotine.…Think of the cigarette pack as a storage container for a day’s supply of nicotine.…Think of a cigarette as a dispenser for a dose unit of nicotine. Think of a puff of smoke as the vehicle of nicotine.… Smoke is beyond question the most optimised vehicle of nicotine and the cigarette the most optimised dispenser of smoke.” • Philip Morris 1972

  20. Reducing this public health burden • Preventing young people taking up smoking (prevention) • Encouraging smokers to stop (cessation) • Harm reduction approaches

  21. Age at which smokers start US data 1991, Institute of Medicine

  22. 520 500 500 400 340 300 220 200 190 — Baseline — 100 If proportion of young adults taking up smoking halves by 2020 70 — 1950 2000 2025 2050 If adult consumption halves by 2020 Year Unless Current Smokers Quit, Tobacco Deaths will Rise Dramatically in the Next 50 years Estimated cumulative tobacco deaths 1950-2050 with different intervention strategies Tobacco deaths (millions) 0 World Bank. Curbing the epidemic: Governments and the economics of tobacco control. World Bank Publications, 1999. p80.

  23. Interventions • School health education • Restricting sales to minors • Advertising bans • Price rises • No smoking policies • Media & community-wide campaigns • Cessation interventions • Product modification

  24. Assessing interventions • Efficacy • Effectiveness • Reach • Cost-effectiveness

  25. Smoking Kills: A White Paper on Tobacco • To reduce smoking among children & young people • To help adults, especially the most disadvantaged, to give up • To offer particular help to pregnant women who smoke • (Lack of harm reduction apps)

  26. Targets • To reduce smoking among children from 13% to 9% by 2010 (2005 -11%) • To reduce adult smoking from 28% to 24% by 2010 (2005 - 26%) • To reduce smoking among pregnant women from 23% to 15% by 2010 (2005 - 18%)

  27. Prevention • Why do young people smoke? • sociodemographic variables • peer & sibling smoking • parental smoking & support • low academic achievement, alienation • rebelliousness • lack skills to resist offers, low self-esteem

  28. Prevention • Why do young people smoke? • Many young smokers are already dependent on nicotine • They want to stop, have tried and failed • They inhale and take in substantial doses of nicotine from their cigs • Experimenters highly likely to become regular daily smokers

  29. Prevention • Unanswered questions… • is there a minimum dosage of nicotine necessary • is daily use a prerequisite to dependence • are there gender/ethnic differences • are there genetic factors involved

  30. Prevention • School programmes • health hazards did not affect smoking • social learning theory based programmes delay onset for 4-10 years • when programmes implemented in real life they have been shown to be ineffective • comprehensive programmes dealing with range of health issues may be > effective

  31. Prevention • Restricting sales to minors • laws rarely enforced - v expensive • young people still easily buy tobacco • evasion rife - ID card forgery, asking others to buy for them • a few intensive campaigns have worked, but divert attention from tobacco industry to retailers/children & drugs field shows inadequacy of supply issues

  32. Illegal sales recommendations • Unpaid media to encourage retailers to comply with the law • Work with magistrates to encourage higher fines • Restrict retail outlets for tobacco? • Fine the industry rather than retailers for illegal sales

  33. Advertising bans • Total ban on advertising, sponsorship, promotion is necessary • Tobacco industry circumvent partial bans • Some evidence that advertising bans reduce young people’s smoking • Govt reported showed advertising bans reduce cigarette consumption

  34. How it works - part 1 Younger adult smokers are the only source of replacement smokers... If younger adults turn away from smoking, the industry must decline, just as a population which does not give birth will eventually dwindle. (RJ Reynolds, 1984)

  35. How it works - part 2 A cigarette for the beginner is a symbolic act. I am no longer my mother's child, I'm tough, I am an adventurer, I'm not square … As the force from the psychological symbolism subsides, the pharmacological effect takes over to sustain the habit. (Philip Morris,1969)

  36. Examples of Marketing

  37. Examples of Marketing

  38. Appeal to kids

  39. Tobacco sponsorship

  40. Advertising bans • EU Directive adopted on 22 June 1998 struck down by European Court of Justice • UK enacting own ban following a private members bill which is currently going through the Houses of Parliament

  41. Taxation • Price inversely related to consumption • May have an influence on young people’s smoking • UK has high tax policy • Goal - balance this with real support for those wanting to quit - hypothecation?

  42. Price of 20 cigarettes in 2000 Price = £4.14 Taxes = £3.34

  43. Affordability of cigarettes

  44. EU tobacco taxation

  45. Smuggling • Increased from 3% 96/97 to 22% 2000 • 80% containers, 20% white van • Loss to revenue £3.8 bn • £35m over three years to combat tobacco smuggling • Extra customs officers • Tougher penalites

  46. Responses - Smuggling • Treat Smuggling as a criminal activity • Big Tobacco benefits from smuggling • Canadian Government is suing RJ Reynolds • The DTI is investigating BAT

  47. No smoking policies • Growing evidence of effectiveness of workplace bans • Reduces passive smoking exposure • Associated with increases in productivity

  48. UK approach • Voluntary action preferred over legislation • Public places charter developed with the hospitality industry, problem pubs • Approved Code of Practice (legal guidance for workplaces) stalled • Opposition DTI & DCMS

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