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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 Ann McNeill, PhD Honorary Senior Lecturer Independent consultant in public health annmcneill@clara.co.uk
Sources: • www.treatobacco.net • www.ash.org.uk
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
World cigarette production Source: US Department of Agriculture
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)
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
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
Some impacts - Health • Cancer • Heart & Circulation • Respiratory • 20 fatal illnesses • 50 non-fatal illnesses • Widespread addiction
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
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.
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
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
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
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.
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.
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
Reducing this public health burden • Preventing young people taking up smoking (prevention) • Encouraging smokers to stop (cessation) • Harm reduction approaches
Age at which smokers start US data 1991, Institute of Medicine
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.
Interventions • School health education • Restricting sales to minors • Advertising bans • Price rises • No smoking policies • Media & community-wide campaigns • Cessation interventions • Product modification
Assessing interventions • Efficacy • Effectiveness • Reach • Cost-effectiveness
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)
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%)
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
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
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
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
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
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
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
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)
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)
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
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?
Price of 20 cigarettes in 2000 Price = £4.14 Taxes = £3.34
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
Responses - Smuggling • Treat Smuggling as a criminal activity • Big Tobacco benefits from smuggling • Canadian Government is suing RJ Reynolds • The DTI is investigating BAT
No smoking policies • Growing evidence of effectiveness of workplace bans • Reduces passive smoking exposure • Associated with increases in productivity
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