Tobacco Control in a Global Environment
October 26, 2000: Framework Convention on Tobacco Control
Jeffrey Koplan, MD, MPH, Director, Centers for Disease Control and Prevention
Dr. Koplan began by setting the stage domestically. The United States has not seen major declines in the prevalence of smoking among adults since the early 1990s, but smoking prevalence among youth appears to have peaked in the mid-1990s and may be beginning to decline. In addition, per capita cigarette consumption has declined over the past 15 years.
A comprehensive approach—one that combines educational, clinical, regulatory, economic, and social strategies—has emerged as the guiding principle for future efforts to reduce tobacco use. Evidence shows that multifaceted state tobacco control programs are effective in reducing tobacco use, in part because they bring about a shift in social norms and reduce the broad cultural acceptability of tobacco use. Comprehensive approaches combine community interventions, counter marketing, and program policy and regulation. The overall efficacy of these emerging statewide programs will depend in some ways on public health advances at the national level. A number of states have effectively reduced cigarette smoking through comprehensive tobacco control programming. For example:
- In California, the per pack excise tax on cigarettes increased from $0.10 to $0.35 in January 1989 to fund the new tobacco control program. With only a slight change in the state excise tax between 1990 and 1998 ($0.02 increase in 1994), the rates of tobacco use continued to decline two to three times faster than in the rest of the country. Over the past 10 years, per capita consumption of cigarettes in California has declined by more than half. The tax increase had an initial impact on consumption, whereas the comprehensive program ensured a more sustained and significant decline over time.
- Massachusetts has shown that implementing comprehensive statewide tobacco control programs can result in substantial reductions in tobacco use. The rates of smoking for youth and adults have shown significant declines. Per capita consumption has declined over 30% since 1992 when the program started.<
- Oregon has achieved impressive initial declines in per capita consumption after implementation of a 1996 voter-supported initiative to raise tobacco taxes and authorize funding of a statewide tobacco prevention and education program. Between 1996 and 1998, per capita cigarette consumption declined 11.3% (or 10 packs per capita) in Oregon.
- Florida's statewide anti-tobacco campaign that combines a counter marketing media campaign, community-based activities, education and training, and an enforcement program was effective in reducing teen tobacco use. Tobacco use among middle school students in Florida declined from 18.5% in 1998 to 11.1% in 2000—an overall 40% reduction. For high school students, current cigarette use declined from 27.4% in 1998 to 22.6% in 2000—an overall reduction of 18%. However, cigarette price increases during the study period may also have contributed to the decline in Florida's teen smoking prevalence.
A successful comprehensive approach requires the continued collaboration of all the agencies and organizations represented here today.
Dr. Koplan acknowledged that the global public health community has been very successful in working in a coordinated fashion to reduce the harm caused by infectious diseases. However, to date, there has yet to be a concerted effort to reduce the burden caused by noncommunicable diseases or the risk factors that cause these diseases, especially tobacco use.
The consequences of tobacco use have become an issue of global concern far beyond the confines of national boundaries. The global tobacco epidemic will soon become the leading cause of preventable and premature death worldwide. Currently, there are about 1.2 billion smokers over the age of 15 in the world. Approximately 80% of the world's smokers live in developing countries. According to WHO, more than 4 million people in the world die each year from diseases caused by tobacco use.
Without effective comprehensive tobacco prevention and control efforts, by the year 2030, the death toll will increase to as many as 10 million people each year, with 7 million of the deaths occurring in the developing world. It is estimated that by 2030, tobacco use will exceed HIV/AIDS and diarrheal diseases as the leading cause of disability adjusted life years.
Not only will health effects be devastating and unprecedented, unfettered global tobacco use will result in dire economic consequences and will be a threat to sustainable development, as has been recently pointed out by the World Bank in the book, Curbing the Epidemic.
Although the projections are dire, success in eradicating and controlling other global health menaces as well as the complete preventability of tobacco-caused diseases suggests that a concerted and coordinated effort to control tobacco use will have a profound effect in changing the course of public health globally. The time is right to launch a global and coordinated effort to reduce the burden of tobacco use. CDC has a number of current activities under way and ambitious future plans to advance global tobacco control to try to prevent the burden of tobacco-related death and disease projected for the developing world. These activities can be divided into three main categories: surveillance, information management, and capacity building.
Dr. Koplan described the cornerstone to successful disease prevention and health promotion programs as surveillance. Nowhere is this more true than for tobacco control in the United States, where valid and reliable data, particularly on children, have truly made a difference.
CDC was asked by WHO to support their global surveillance efforts, particularly in relation to their first grant from the United Nations Foundation, which funded seven countries. In response to WHO's request, CDC modified its Youth Tobacco Survey and created the Global Youth Tobacco Survey (GYTS), a school-based, tobacco-specific survey focusing on adolescents aged 13 to 15. In Fiscal Year 2000-2001, the GYTS will have been conducted in more than 70 countries. Dr. Koplan recognized the National Cancer Institute's financial support of the GYTS as a good example of the kind of interagency collaboration this committee should be supporting, that will be essential to addressing the problem of tobacco use globally.
Dr. Koplan stated that data have only limited utility if they are not used and made widely available. In this regard, CDC is in the process of developing a global tobacco data warehouse based on its successful STATE System, which will make every country's tobacco-specific data widely available on the Internet. This will include not only traditional public health measures such as a country's GYTS results but also their tobacco control laws, tax rates, and other economic data.
The third element of CDC's strategy, and central to public health programming, is building the capacity of countries to do effective tobacco control work. Similar to the experience in the United States, where progress in tobacco control greatly accelerated when a public health infrastructure was developed, CDC firmly believes we can advance global tobacco control efforts by building capacity in selected countries as well as in the multilateral organizations that support those countries. Currently, CDC supports a person to work exclusively on global tobacco control in the United Nations System in New York, WHO Headquarters in Geneva, and the WHO Regional Office in Zimbabwe; CDC hopes to send a person to the WHO Country Office in Beijing. With future funding, Dr. Koplan hopes to expand this strategy to all WHO Regional Offices, selected countries, and key multilateral organizations.
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