5
Preventing Cancers (and Other Diseases) by Reducing Tobacco Use

Cigarette smoking and other forms of tobacco use impose a large and growing global public health burden. Worldwide, tobacco use kills nearly 5 million people annually—about one third from cancer and two thirds from other diseases—accounting for 1 in every 5 male deaths, and 1 in 20 female deaths, over age 30. On current smoking patterns, annual tobacco deaths will rise to 10 million by 2030, about 3 million of which will be from cancer. If current smoking patterns persist, with about 30 percent of all young adults (50 percent of men and 10 percent of women) becoming smokers and most not giving it up, then the 21st century is likely to see 1 billion tobacco deaths, most of them in today’s developing countries. In contrast, the 20th century saw 100 million deaths caused by tobacco, most of them in developed countries.

This report is about cancer control. In the case of tobacco, however, cancer is just one of the ways in which tobacco kills, and interventions to reduce tobacco use will have much broader benefits than just in terms of cancer. In this chapter the health effects of tobacco—overwhelmingly cardiovascular diseases, cancers, and respiratory diseases—and the benefits of stopping tobacco use are considered together, not separately.

Before discussing the interventions that can reduce tobacco use, the landmark Framework Convention on Tobacco Control (FCTC) is introduced. Global tobacco control efforts have been unified by the FCTC, an international treaty negotiated by the World Health Organization (WHO). The treaty calls for tobacco control measures that are firmly rooted in evidence, and creates an organization of all parties to monitor its progress and promote its implementation. This report recommends that all countries



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Cancer Control Opportunities in Low- and Middle-Income Countries 5 Preventing Cancers (and Other Diseases) by Reducing Tobacco Use Cigarette smoking and other forms of tobacco use impose a large and growing global public health burden. Worldwide, tobacco use kills nearly 5 million people annually—about one third from cancer and two thirds from other diseases—accounting for 1 in every 5 male deaths, and 1 in 20 female deaths, over age 30. On current smoking patterns, annual tobacco deaths will rise to 10 million by 2030, about 3 million of which will be from cancer. If current smoking patterns persist, with about 30 percent of all young adults (50 percent of men and 10 percent of women) becoming smokers and most not giving it up, then the 21st century is likely to see 1 billion tobacco deaths, most of them in today’s developing countries. In contrast, the 20th century saw 100 million deaths caused by tobacco, most of them in developed countries. This report is about cancer control. In the case of tobacco, however, cancer is just one of the ways in which tobacco kills, and interventions to reduce tobacco use will have much broader benefits than just in terms of cancer. In this chapter the health effects of tobacco—overwhelmingly cardiovascular diseases, cancers, and respiratory diseases—and the benefits of stopping tobacco use are considered together, not separately. Before discussing the interventions that can reduce tobacco use, the landmark Framework Convention on Tobacco Control (FCTC) is introduced. Global tobacco control efforts have been unified by the FCTC, an international treaty negotiated by the World Health Organization (WHO). The treaty calls for tobacco control measures that are firmly rooted in evidence, and creates an organization of all parties to monitor its progress and promote its implementation. This report recommends that all countries

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Cancer Control Opportunities in Low- and Middle-Income Countries TABLE 5-1 Estimated Smoking Prevalence (by gender) and Number of Smokers, 15 Years of Age and Over, by World Bank Region, 2000   Smoking Prevalence (percentage) Total Smokers World Bank Region Males Females Overall Millions Percentage of All Smokers East Asia and Pacific 63 5 34 429 38 Europe and Central Asia 56 17 35 122 11 Latin America and the Caribbean 40 24 32 98 9 Middle East and North Africa 36 5 21 37 3 South Asia 32 6 20 178 15 Sub-Saharan Africa 29 8 18 56 6 Low and middle income 49 8 29 920 82 High income 37 21 29 202 18 SOURCE: Reprinted, with permission, from Jha et al. (2006). Copyright 2006 by the World Bank. ratify the FCTC, which requires them to implement its provisions. The evidence supporting the interventions recommended by the FCTC are reviewed later in this chapter. One caveat for this chapter is that the evidence on the effectiveness of interventions is largely from studies and programs in high-income countries. In recent years, some more research has been conducted in LMCs, but overall, the body of this evidence is relatively small. The assumption is made that behavior will be similar in LMCs and high-income countries, but clearly, direct observation and study in those countries is needed to ensure that interventions are working and, if not, new approaches are developed to respond to local conditions. PREVALENCE AND EFFECTS OF SMOKING1 Smoking Prevalence More than 1.1 billion people worldwide smoke tobacco. Smoking prevalence is highest in Europe and Central Asia (35 percent of adults), but overall, about 82 percent of smokers are in LMCs (Table 5-1) (Jha et al., 2006). Globally, male smoking far exceeds female smoking; the gender difference is smallest in high-income countries. 1 The sections on the effects of tobacco and on interventions are based on Jha et al. (2006), the chapter on tobacco addiction from the report Disease Control Priorities in Developing Countries.

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Cancer Control Opportunities in Low- and Middle-Income Countries While overall smoking prevalence continues to increase in many LMCs, many high-income countries have witnessed decreases, most clearly in men. A study in 36 mostly western countries, from the early 1980s to the mid-1990s, suggested that the decrease in smoking prevalence among men was due both to the lower prevalence of starting smoking in younger age groups, as well as adults quitting smoking. Among women, there was little overall change in smoking prevalence because the increasing prevalence of smokers in younger age cohorts counterbalanced increasing cessation in older age groups (Molarius et al., 2001). Health Consequences of Smoking It is often taken for granted that the harm done by tobacco is well understood. But the magnitude of tobacco’s harm is widely underestimated. More than 50 years of epidemiologic study of smoking-related diseases have led to three key messages for individual smokers and for policy makers (Doll et al., 2004; Peto et al., 2003). They are: The eventual risk of death from smoking is high, with about one-half of long-term smokers eventually dying from their addiction. About half of all tobacco deaths occur between ages 35 and 69—in middle age—about 20 to 25 years sooner than the deaths of nonsmokers. Cessation works: Adults who quit before middle age avoid almost all the excess hazards of continued smoking. The evidence is heavily weighted toward high-income countries, so it is not surprising that governments and individuals in LMCs have found it less relevant. However, as more studies are undertaken in those countries, a similar picture emerges, with somewhat different local details, depending on the other major risk factors and patterns of death. Studies in a wide range of countries, preferably long-term prospective studies (see Chapter 3), are needed to increase our understanding of these details and to tailor tobacco control interventions and messages. Current Mortality from Smoking and Future Projections An estimated 5 million deaths were caused by tobacco in 2000 (Ezzati and Lopez, 2003), about half (2.6 million) in low-income countries. Males accounted for 3.7 million deaths, three quarters of the total. About 60 percent of male and 40 percent of female tobacco deaths occurred in middle age (ages 35 to 69). The patterns of causes of these deaths differ between high- and low-income countries. In high-income countries and former socialist economies,

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Cancer Control Opportunities in Low- and Middle-Income Countries nearly half (450,000) of the 1 million middle-aged male tobacco deaths were from cardiovascular disease, and about half that number (210,000) from lung cancer. In contrast, in low-income countries, the leading causes of death among the 1.3 million male tobacco deaths were cardiovascular disease (400,000), chronic obstructive pulmonary disease (200,000), other respiratory disease (chiefly tuberculosis, 200,000) and lung cancer (180,000). Future increases in tobacco deaths worldwide are expected to arise from increased smoking by men in developing countries, and by women worldwide. The increases will be a product of population growth and increased age-specific tobacco mortality rates, the latter relating to both smoking duration and the amount of tobacco smoked. Peto and others (Peto et al., 1994) have made the following calculation: If the proportion of young people taking up smoking continues to be about half of men and 10 percent of women, then there will be about 30 million new long-term smokers each year. Half of these smokers will eventually die from smoking. However, conservatively assuming that “only” about one-third of smokers die as a result of smoking, then smoking will eventually kill about 10 million people a year. Thus, for the 25-year period from 2000 to 2025, there will be about 150 million tobacco deaths or about 6 million deaths per year on average; from 2025 to 2050, there will be about 300 million tobacco deaths, or about 12 million deaths per year. Further estimations are more uncertain, but based on current smoking trends and projected population growth, from 2050 to 2100 there will be an additional 500 million tobacco deaths. These projections for the next three to four decades are comparable to retrospective and early prospective epidemiological studies in China (Liu et al., 1998; Niu et al., 1998), which suggest that annual tobacco deaths will rise to 1 million before 2010 and 2 million by 2025, when the young adult smokers of today reach old age. Similarly, results from a large retrospective study in India suggest that 1 million annual deaths are expected from male smokers by 2025 (Gajalakshmi et al., 2003). With other populations in Asia, Eastern Europe, Latin America, the Middle East, and, less certainly, sub-Saharan Africa showing similar growth in population- and age-specific tobacco death rates, the estimate of some 450 million tobacco deaths over the next five decades appears to be plausible. Benefits of Smoking Cessation Smoking cessation reduces the risk of death from all tobacco-related diseases. The study of smoking habits, including cessation, with the longest follow-up is of doctors in the United Kingdom. Of those doctors who stopped smoking, the risk of lung cancer fell steeply over time (Doll et al., 2004; Peto et al., 2000) (Figure 5-1). These results are mirrored in a recent multicenter study of men in four European countries, which found that

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Cancer Control Opportunities in Low- and Middle-Income Countries FIGURE 5-1 Stopping works: Cumulative risk of lung cancer mortality in U.K. males, 1990 rates. SOURCE: Reprinted, with permission, from Peto et al., 2000. Copyright 2000 by the BMJ Publishing Group Ltd. quitting smoking at age 40 avoided 80 to 85 percent of the excess risk of lung cancer (Crispo et al., 2004). Smoking cessation is uncommon in most developing countries, but there is some evidence that, among Chinese men, quitting also reduces the risks of dying from all causes together and at least from vascular disease specifically (Lam et al., 2002). Among doctors in the United Kingdom, the benefits of quitting were greatest in those who quit

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Cancer Control Opportunities in Low- and Middle-Income Countries before middle age, but were still significant in those who quit later (Doll et al., 2004). Current tobacco mortality statistics reflect past smoking behavior, given the long delay between the onset of smoking and the development of disease. The only way to prevent a substantial proportion of tobacco deaths before 2050 is for adult smokers to stop. For example, if the per-capita adult consumption of tobacco (mainly from people quitting entirely) could be cut in half by 2020 (akin to the declines in adult smoking in the United Kingdom), about 180 million premature tobacco deaths would be averted. Continuing to reduce the percentage of children who start to smoke will prevent many deaths, but its main effect will be on mortality rates in 2050 and beyond (Figure 5-2) (Jha and Chaloupka, 2000a; Peto and Lopez, 2002). FIGURE 5-2 Tobacco deaths in the next 50 years under current smoking patterns. SOURCE: Reprinted, with permission, from Jha and Chaloupka, 2000a. Copyright 2000 by the BMJ Publishing Group Ltd.

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Cancer Control Opportunities in Low- and Middle-Income Countries THE FRAMEWORK CONVENTION ON TOBACCO CONTROL The FCTC is a pillar in tobacco control. The FCTC, adopted by the World Health Assembly (WHA), the WHO governing body, in May 2003, is the world’s first global health treaty (WHO, 2003). The idea for an international instrument for tobacco control first arose at the annual WHA in 1995, in response to the globalization of tobacco and the increases in tobacco use, particularly among women and in LMCs. The following year, the WHA adopted a resolution calling for the WHO Director-General to initiate development of a Framework Convention on Tobacco Control. Work did not begin in earnest until 1999, and was adopted by the WHA and then opened for signatures in June 2003 and remained open until June 29, 2004. The treaty came into force in February 2005, 90 days after the 40th country (Peru) had signed and ratified it. Countries that have ratified the FCTC are obligated, under international law, to enact its provisions. Countries that did not sign the treaty can still join by “accession,” a one-step process equivalent to ratification. As of July 2006, 134 countries, including 108 LMCs, had become parties to it by ratification or the legal equivalent (accession, acceptance, approval, or formal confirmation). A total of 52 countries (including the United States) have signed but not ratified the FCTC (WHO, 2006). Entering into force triggered another provision of the FCTC, which was the first meeting of the “Conference of the Parties,” a formal body on which all signatories are represented, to be held within one year. The 2-week meeting took place in February 2006. The conference will meet regularly to review national reports and generally promote the FCTC, including promoting the financial aspects of treaty activities. The FCTC includes provisions for both demand reduction and supply reduction, based on sound evidence that they are effective in reducing tobacco use. Key provisions are the following: Advertising, sponsorship, and promotion Parties to the treaty must ban tobacco advertising, promotion, and sponsorship, as far as permitted by their constitutions. Where constitutions do not allow this, restrictions on all advertising, promotion, and sponsorship must be adopted. Packaging and labeling of tobacco products The treaty obligates parties to adopt and implement large, clear, visible, legible, and rotating health warnings and messages on tobacco products and their outside packaging, occupying at least 30 percent of the principal display areas. Protection from exposure to tobacco smoke Parties must adopt and implement (in areas of national jurisdiction)

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Cancer Control Opportunities in Low- and Middle-Income Countries or promote (at other jurisdictional levels) effective measures to prevent exposure to tobacco smoke in indoor workplaces, public transport, indoor public places, and, as appropriate, other public places. Illicit trade in tobacco products Parties must adopt and implement effective measures to eliminate illicit trade, illicit manufacturing, and counterfeiting of tobacco products. INTERVENTIONS TO PREVENT SMOKING Hundreds of millions of premature tobacco deaths could be avoided if effective interventions were applied widely in LMCs. The measures that have proven effective in reducing tobacco use, mainly in high-income countries thus far, are: tobacco tax increases, timely dissemination of information about health risks from smoking, restrictions on smoking in public places and workplaces, comprehensive bans on advertising and promotion, and increased access to cessation therapies. Price and nonprice interventions are, for the most part, highly cost-effective in high-income countries, with less evidence available from LMCs. The interventions discussed here are divided into those aimed at reducing the demand for tobacco and those aimed at reducing tobacco supply. Interventions to Reduce Demand for Tobacco The following sections review the evidence on the impact of interventions to reduce demand for tobacco, including a discussion of each intervention’s effect on initiation of smoking and smoking cessation. As has been stated, much of the evidence is from high-income countries. Tobacco Taxation Nearly all governments tax tobacco products, but at widely varying levels. In some places, taxes are specific or per unit, and elsewhere, they are expressed as a percentage of wholesale or retail prices (ad valorem taxes). Taxes tend to be absolutely higher and account for a greater share of the retail price (two-thirds or more) in high-income countries (Figure 5-3). Tobacco taxes are much lower, and account for less than half of the final price of cigarettes, in most LMCs. More than 100 studies from high-income countries clearly demonstrate that increases in taxes on cigarettes and other tobacco products lead to significant reductions in cigarette smoking and other tobacco use (Chaloupka et al., 2000). The reductions in tobacco use that result from higher taxes and prices reflect the combination of increased smoking cessation, reduced relapse, lower smoking initiation, and decreased consumption among

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Cancer Control Opportunities in Low- and Middle-Income Countries FIGURE 5-3 Average cigarette price, tax, and percentage of tax share per pack, by income group, 1996. SOURCE: Reprinted, with permission, from Jha et al. (2006). Copyright 2006 by the World Bank. continuing tobacco users. Studies of price elasticity of demand (i.e., how sensitive sales volume is to price) from the United States, United Kingdom, Canada, and other high-income countries have generally produced estimates that range from –0.25 up to an upper limit of –0.50, indicating that a 10 percent increase in cigarette prices could reduce overall cigarette smoking by 2.5 percent to 5 percent (Chaloupka et al., 2000; Gallus et al., 2006; U.S. DHHS, 2000). Studies from LMCs have produced mixed results, however, some suggesting a greater price elasticity in such countries (Jha et al., 2006) while others suggest a smaller effect in some LMCs. A study in China and Russia, for example, using longitudinal data (as opposed to most studies, which have used aggregate data) found price elasticity estimates ranging from 0 to –0.15 (i.e., including a possibility of no effect) (Lance et al., 2004). Laxminarayan and Deolalikar (2004) examined the impact of tobacco prices on decisions to begin or quit smoking in Vietnam, using household survey data from the early and late 1990s. They found that decisions may be more complex than in high-income countries because a larger array of tobacco products—including nonmanufactured, local products—enlarges the choices people may

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Cancer Control Opportunities in Low- and Middle-Income Countries make. Higher cigarette prices might divert smokers to products that are less expensive, but potentially equally detrimental to health. Studies using survey data have concluded that half or more of the effect of price on overall cigarette demand results from reducing the number of current smokers (U.S. DHHS, 1994; Wasserman et al., 1991). Higher taxes increase both the number of attempts at quitting smoking and the success of those attempts (Tauras and Chaloupka, 2003). A study in the United States (Tauras, 1999) suggested that a 10 percent increase in price would result in an 11 to 13 percent shorter smoking duration or a 3.4 percent higher probability of cessation. According to recent studies, there is an inverse relationship between price elasticity and age, with estimates for youth price elasticity of demand up to three times those of adults (Gruber, 2003; Ross et al., 2001). Several recent studies have begun to explore the differential impact of cigarette prices on youth smoking uptake, concluding that higher cigarette prices are particularly effective in preventing young smokers from moving beyond experimentation into regular, addicted smoking (Emery et al., 2001; Ross et al., 2001). In the United States and the United Kingdom, increases in the price of cigarettes have had the greatest impact on smoking among the lowest income and least educated populations (Townsend et al., 1994; U.S. DHHS, 1994). Furthermore, it was estimated that smokers in U.S. households below median income level are four times more responsive to price increases than smokers in households above median income level. Overall, the evidence strongly supports the premise that price affects behavior, in many cases very strongly. However, the evidence is still largely from high-income countries. It cannot be assumed that the impacts will be the same in LMCs, where so many aspects of life differ from those in high-income countries. As more evidence directly relevant to LMCs accumulates, patterns may emerge that reflect differences from the effects seen in high-income countries. Policy decisions should improve as more such information becomes available. The current recommendation of the FCTC, to increase tobacco taxes, is still well supported, but the magnitude of the impact and the specifics of effects appear likely to vary from place to place, possibly very considerably. Restrictions on Smoking Over the past three decades, as the quantity and quality of information about the health consequences of exposure to passive smoking has increased, many governments, especially in high-income countries, have restricted smoking in a variety of public places and private worksites. Increased concern about the consequences of passive smoking exposure,

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Cancer Control Opportunities in Low- and Middle-Income Countries particularly to children, has led many workplaces to adopt voluntary restrictions on smoking. These restrictions reduce nonsmokers’ exposure to passive tobacco smoke, but also reduce smokers’ opportunities to smoke. Additional reductions in smoking, especially among youth, will result from the changes in social norms that are introduced by adopting these policies (U.S. DHHS, 1994). In high-income populations, comprehensive restrictions on cigarette smoking reduced population smoking rates, possibly by as much as 5 to 15 percent (see Woolery et al. [2000] for a review of the effects of indoor smoking bans on youth smoking rates; see Levy et al. [2001]) for the results of simulation modeling of the impacts of smoking bans). As with higher taxes, both the prevalence of smoking and cigarette consumption among current smokers are reduced. According to Levy and colleagues (2001), no-smoking policies are most effective when strong social norms against smoking help to make smoking restrictions self-enforcing. The evidence is not entirely consistent with overall smoking declines as a result of smoking bans, however. A recent systematic review of workplace interventions for smoking cessation (Moher et al., 2005) included a subset of studies of indoor smoking bans that confirmed the decrease in smoking at work by smokers, and a corresponding decrease of exposure to environmental tobacco smoke. The evidence was less clear, however, about an overall decrease in smoking. The applicability of findings related to smoking restrictions in high-income countries to conditions in LMCs is, as for other aspects, somewhat uncertain. Smoking bans are still rare in LMCs, so little to no direct evidence is yet available. To the extent that workplaces themselves differ between high-income countries and LMCs, different results might be expected. Nonetheless, the existing evidence should be sufficient to support the FCTC recommendation of smoking bans wherever feasible, with the caveat that impacts should be evaluated. Health Information and Counteradvertising The 1962 report by the British Royal College of Physicians and the 1964 U.S. Surgeon General’s Report were landmark tobacco control events. These publications resulted in the first widespread press coverage of the scientific links between smoking and lung cancer. The reports were followed, in many high-income countries, by policies requiring health warning labels on tobacco products, which were later extended to tobacco advertising. The message did reach some LMCs as well, such as Malaysia (Box 5-1), with little delay. Research from high-income countries indicates that these initial reports and the publicity that followed about the health consequences of smoking led to significant reductions in consumption, with initial declines of between

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Cancer Control Opportunities in Low- and Middle-Income Countries TABLE 5-3 Potential Impact of Price Increase of 33 Percent, Increased NRT Use, and a Package of Nonprice Measures, 2000     Change in number of deaths in millions   Smoking attributable deaths in millions 33% price increase NRT effectiveness Nonprice intervention effectiveness World Bank Region Low elasticity High elasticity 1.0% 5.0% 2% 10% East Asia and Pacific (percent) 173 –9.6 (–5.5) –27.5 (–15.9) –1.4 (–0.8) –6.9 (–4.0) –2.8 (–1.6) –13.8 (–8.0) Europe and Central Asia (percent) 51 –2.8 (–5.6) –8.1 (–16.0) –0.4 (–0.8) –2.1 (–4.0) –0.8 (–1.6) –4.1 (–8.1) Latin America and the Caribbean (percent) 40 –2.3 (–5.8) –6.7 (–16.8) –0.3 (–0.8) –1.7 (–4.2) –0.7 (–1.7) –3.4 (–8.5) Middle East and North Africa (percent) 13 –0.8 (–5.8) –2.2 (–16.6) –0.11 (–0.8) –0.6 (–4.2) –0.2 (–1.7) –1.1 (–8.4) South Asia (percent) 62 –2.9 (–9.5) –8.5 (–27.7) –0.4 (–1.4) –2.2 (–7.2) –0.9 (–2.8) –4.3 (–13.9) Sub-Saharan Africa (percent) 23 –1.3 (–5.4) –3.7 (–15.9) –0.2 (–0.8) –0.9 (–4.0) –0.4 (–1.6) –1.8 (–7.9) Low- and middle-income (percent) 362 –19.7 (–5.4) –56.8 (–15.7) –2.9 (–0.8) –14.3 (–4.0) –5.7 (–1.6) –28.6 (–7.9) High-income (percent) 81 –2.1 (–2.6) –8.5 (–10.6) –0.6 (–0.8) –3.1 (–3.8) –1.2 (–1.5) –6.1 (–7.6) World (percent) 443 –21.8 (–4.9) –65.3 (–14.8) –3.5 (–0.8) –17.4 (–3.9) –6.9 (–1.6) –34.7 (–7.8) SOURCE: Reprinted, with permission, from Jha et al. (2006). Copyright 2006 by the World Bank. tobacco control interventions would occur after 2010, but a substantial number of deaths could be avoided even before then. No attempt has been made in this analysis to examine the impact of combining the various packages of interventions (e.g., price increases with NRT, or NRT and other nonprice interventions). A number of studies have compared the impact of price and nonprice interventions, but few empirical attempts have been made to assess how these interventions might interact. While price increases may be the most cost-effective antismoking intervention, policy makers should use all the tools at their disposal to counter smoking. Nonprice measures may be required to reach the most heavily dependent smokers, for whom medical and social support in stopping will

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Cancer Control Opportunities in Low- and Middle-Income Countries TABLE 5-4 Range of Cost-Effectiveness Values for Price Increase, Nicotine Replacement Therapies, and Nonprice Interventions (2002 US dollars per DALY Saved), by World Bank Region, 2000   Smoking attributable deaths in millions 33% price increase NRTs with effectiveness of 1% to 5% Nonprice interventions with effectiveness of 2% to 10% World Bank Region Low-end estimate High-end estimate Low-end estimate High-end estimate Low-end estimate High-end estimate East Asia and Pacific 173 2 30 65 864 40 498 Europe and Central Asia 51 3 42 45 633 55 685 Latin America and the Caribbean 40 6 85 53 812 109 1,361 Middle East and North Africa 13 6 89 47 750 115 1,432 South Asia 62 2 27 54 716 34 431 Sub-Saharan Africa 23 2 26 42 570 33 417 Low- and middle-income 362 3 42 55 761 54 674 High-income 81 85 1,773 175 3,781 1,166 14,572 World 443 13 195 75 1,250 233 2,916 SOURCE: Reprinted, with permission, from Jha et al. (2006). Copyright 2006 by the World Bank. be necessary. Furthermore, these nonprice measures may be effective in increasing social acceptance and support of tobacco price increases. Comprehensive Tobacco Control Programs In recent years, several governments, mostly in high-income countries, have adopted comprehensive programs to reduce tobacco use, often funded by earmarked tobacco tax revenues. These programs have similar goals for reducing tobacco use, including preventing initiation among youth and young adults, promoting cessation among all smokers, reducing exposure to passive tobacco smoke, and identifying and eliminating disparities among population subgroups (U.S. DHHS, 1994). These programs have one or more of four key components: (1) community interventions engag-

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Cancer Control Opportunities in Low- and Middle-Income Countries FIGURE 5-4 Potential impact of tax increases, nicotine reduction therapies, and nonprice interventions on tobacco mortality, 2000–2050, among the world’s smokers in 2000. NOTE: Price increases assume a high price elasticity (–1.2 for low- and middle-income countries and –0.8 for high-income countries). SOURCE: Reprinted, with permission, from Jha et al. (2006). Copyright 2006 by the World Bank.

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Cancer Control Opportunities in Low- and Middle-Income Countries ing a diverse set of local organizations; (2) countermarketing and health information campaigns; (3) program policies and regulations (e.g., taxes, restrictions on smoking, bans on tobacco advertising, and access to better cessation treatments); and (4) surveillance and evaluation of potential issues, such as smuggling (U.S. DHHS, 1994). Programs have placed differing emphasis on these four components, with substantial diversity among the types of activities supported within each component. Recent analyses from the United States and United Kingdom clearly indicate that these comprehensive efforts have been successful in reducing tobacco use and in improving public health (Farrelly et al., 2003; Townsend et al., 1994; U.S. DHHS, 1994). In California, for example, the state’s comprehensive tobacco control program has produced a rate of decline in tobacco use double that seen in the rest of the United States. As with other aspects of tobacco control, the impacts of comprehensive tobacco control may be different in LMCs than they are in high-income countries, which differ in much more than simply economic status. The following discussion is presented with the understanding that efforts to develop comprehensive tobacco control in LMCs should be accompanied by adequate monitoring and evaluation to ensure that the efforts are worthwhile. The cost of implementing control programs is relatively low and certainly affordable for high-income countries. Table 5-5 provides the estimated total costs of implementing price and NRT interventions by World Bank region. Current estimates of the costs of implementing a comprehensive tobacco control program range from $2.50 to $10 per capita in the United States. The Centers for Disease Control and Prevention (CDC) recommends spending $6 to $16 per capita for a comprehensive tobacco control program in the United States (CDC, 1999). Canadian spending on tobacco control programs was approximately $1.65 per capita in 1996 (Pechmann et al., 1998). At the highest recommending spending level ($16 per capita) in the United States, annual funding for a comprehensive tobacco program would equal 0.9 percent of U.S. public spending, per capita, on health. Constraints to Effective Tobacco Control Policies Use of the effective interventions described here is uneven and limited (see a more formal analysis in Chaloupka et al., 2001). World Bank data reveal that there is ample room to increase tobacco taxes: In 1995 the average percentage of all government revenue derived from tobacco tax was 0.63. Middle-income countries averaged 0.51 percent of government revenue from tobacco taxes, while lower income countries averaged 0.42 percent. An increase in cigarette taxes of 10 percent globally would raise cigarette tax revenues by nearly 7 percent, with relatively larger increases in revenues in high-income countries, and smaller increases in revenues in LMCs (Sunley

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Cancer Control Opportunities in Low- and Middle-Income Countries TABLE 5-5 Estimated Cost of Price Intervention and Nicotine Replacement Therapy Programs by World Bank Region     Cost for price increase (millions 2002 US$) Cost of NRTs ($25 to $150) (millions 2002 US$)   GDP (billions 2002 US$ ) Low-end estimate High-end estimate To treat 1% of current smokers To treat 5% of current smokers World Bank Region $25 $50 $150 $25 $50 $150 East Asia and Pacific 1,802 360 901 1,079 2,158 6,474 5,395 10,791 32,372 Europe and Central Asia 1,136 227 568 318 635 1,906 1,588 3,176 9,529 Latin America and the Caribbean 1,673 335 836 250 500 1,500 1,250 2,500 7,499 Middle East and North Africa 694 139 347 84 169 506 422 843 2,530 South Asia 655 131 327 2,312 1,926 3,853 11,558 2,312 1,926 Sub-Saharan Africa 319 64 159 868 723 1,447 4,340 868 723 Low- and middle-income 6,256 1,251 3,128 13,565 11,305 22,609 67,827 13,565 11,305 High-income 25,992 5,198 12,996 3,034 2,529 10,114 15,172 3,034 2,529 World 32,253 6,451 16,126 16,600 13,833 32,723 82,999 16,600 13,833 GDP = Gross domestic product. SOURCE: Reprinted, with permission, from Jha et al. (2006). Copyright 2006 by the World Bank.

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Cancer Control Opportunities in Low- and Middle-Income Countries et al., 2000). Despite this, price increases have been underused. Guindon and colleagues (2002) studied 80 countries and found that the real price of tobacco, adjusted for purchasing power, fell in most developing countries from 1990 to 2000. Why is there so much variation in tobacco control policies? The political economy of tobacco control has been inadequately studied. A few plausible areas of interest are outlined here. First, the recognition of tobacco as a major health hazard appears to be the impetus for most of the tobacco control policies in many high-income countries. There is some evidence that improved national capacity and local needs assessment could increase the likelihood that tobacco control measures will be adopted. For example, econometric analyses in South Africa geared to local policy needs substantially increased the willingness of the country to implement tobacco control policies (Abedian et al., 1998). Second, tobacco control budgets are only a fraction of what is required. Funding is needed not so much to implement programs, but to counter tobacco industry tactics and to build popular support for control. Third, the most obvious constraint to tobacco control is political opposition, but this is difficult to quantify. Opposition from the tobacco industry is well organized and well funded (Pollock, 1996). A key political tool for addressing political opposition is earmarking tobacco taxes. Earmarking has been successful in several countries, including Australia, Finland, Nepal, and Thailand. Of the 48 countries currently in the WHO European Region, 12 earmark taxes for tobacco control and other public health measures. The average level of allocation is less than 1 percent of total tax revenue (WHO, 2002). Earmarking does introduce clear restrictions and inefficiencies on public finance, and for this reason alone most macroeconomists do not favor earmarking, no matter how worthy the cause. However, earmarking tobacco taxes can be justified if governments use these funds to benefit those who pay for tobacco control policies and programs, and secure public support for new or higher tobacco taxes. Earmarked taxes also have a political function in that they help to concentrate political winners of tobacco control, and thus influence policy. Earmarked funds that support broad health and social services (e.g., other disease programs) broaden the political and civil society support base for tobacco control. In Australia, broad political support among the Ministries of Sports and Education helped to convince the Ministry of Finance that raising tobacco taxes was possible. Indeed, once an earmarked tax was passed, the Ministry of Finance went on to raise tobacco taxes further without earmarking (Galbally, 1997). Additionally, targeting revenue from tobacco taxes to other health programs for the poorest socioeconomic groups could produce double health gains—reduced tobacco consumption combined with increased access to and use of health services. In China, a 10 percent increase in cigarette taxes would decrease consumption by 5 percent and increase

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Cancer Control Opportunities in Low- and Middle-Income Countries government revenue by 5 percent. These increased earnings could finance a package of essential health services for one-third of China’s poorest 100 million citizens in 1990 (Saxenian and McGreevey, 1996). Monitoring the Effects of Tobacco (and Other Important Risk Factors) Understanding trends in the use of tobacco and its consequences is important to understanding population health generally, and to determining how well interventions are working to reduce tobacco use. It is possible to do this through economical long-term studies of large samples of the population. Such prospective studies (described in Chapter 3) should be considered an integral part of cancer (and other chronic disease) control. SUMMARY AND RECOMMENDATIONS There is no real disagreement about the health effects of tobacco: At least half of all long-term smokers eventually die from tobacco-related disease, including, but not limited to, cancer. Also incontrovertible, but not as well appreciated, is that stopping smoking reduces the risk of tobacco-related death enormously. The question is how to get current smokers to stop (most important) and how to discourage nonsmokers (young people and adults) from taking up smoking. A relatively large body of evidence, most from high-income countries, supports both “demand-” and, to a lesser extent, “supply-” side interventions. These are the interventions that are included in the FCTC, and endorsed by this report. The most important step is ratification of the FCTC by as many countries as possible, at which time they will be obligated to adopt its provisions. RECOMMENDATION 5-1. Every country should sign and ratify the Framework Convention on Tobacco Control and implement its provisions, most importantly: Substantial increases in taxation to raise the prices of tobacco products (goal is to have taxes at 80 percent or higher of retail price) Complete advertising and promotion bans on tobacco products Mandating that public spaces be smoke free Large, explicit cigarette packet warnings in local languages (which also helps to reduce smuggling) Support of counteradvertising to publicize the health damage from tobacco and the benefits of stopping tobacco use

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