WPC 2k BDT Z#|m""m^+9FVV999Va+9+0VVVVVVVVVV00aaaL|rr|i_||9C|i||_|r_i||||i909PV9LVLVL9VV00V0VVVV9C0VV|VVLR"R]9+999998999999S9V0xJxJxJxJxJrrJiJiJiJiJ8.8.8.8.{SxSxSxSxS{S{S{S{SxSxJ{V|VxSxS{S`S|L|L|LrLrLrLrL|ViLiLiLiL|V|V|V|V|V|V|V|V9.909090z]C|Vi0i0i0i.i0|V|c|V|V|V|V|r9r9r9_CZA_C_Ci0i0i0|V|V|V|V|V|V||ViLlJiL|Vi0|Vr9_Ci0|V|V|V|V|VNDgFdddgF9CgggEEggzzddd~rrEgdF"m^>R{{RRR{>R>E{{{{{{{{{{RR{沥`{RER{R{nnR{EREΉ{n`R{{{na6aR>RR)RRRPRRRRRRxRExxxxxkkkkk]C]C]C]Cxxxxxx{xxx{{{nnnnnnnn{{{{{{`C`E`E`Eډ{EEE]E{{nnn`]``RRR{nknEn`R{{{NV>{R{{{{{{JQ{Txxx{TEP{{{RR{{xxxȉR{xT"m^3ETggEEEgt3E39gggggggggg99ttt[~rEP~rr~•~E9E`gE[g[g[Egg99g9ggggEP9gggg[c)coE3EE"EEECEEEEEEdEg9YYYYYY~Y~Y~Y~YC8C8C8C8ddddddddddYggdddsd[[[[[[[g~[~[~[~[ggggggggE8E9E9E9oPg~9~9~9~8~9gvggggEEErPkNrPrP~9~9~9gggggg•g~[Y~[g~9gErP~9gggggNH3]gE[ggggg9@gFdddgF%C[[gEEggzzdddwrrE[dF2fZ2  `I y.X8+,wX\  P6P?xxx,2x6X@`7X@ 7nC3,4Xn4  pX AP>,U`4  p 7iC3,ƒXi\  P6XPZ 5hC3,-Xh*f9 xr XX 6jC3,D3Xj9 xOX"m^3EVggEEEg3E39ggggggggggEEg~~~~E[r~~gr~~rrP9PWgEgg[g[9gg99[9ggggPP9g[[[PR9RoE3EE"EEECEEEEEEdEg9zdzdzdzdzdYzYzYzYzYC8C8C8C8dddddddddoYzdggdoYdzd~g~g~g[[[[g~[~[~[~[ggggggggE8E9E9E9d[[r9r9r9o8r9gzgggg‰~P~P~PgPdNgPgPr9r9r9ggggggr[rPoNrPgr9g~PgPr9r[r[gggNH3lgPgggggg9@gFdddgF,CrrgEEggzzdddkggErdFTimes New RomanCourierTimes New Roman BoldTimes New Roman ItalicTimes New Roman Bold Italic"m^3PrggEEEgu3E39ggggggggggEEuuugPg~~r~~~E9EugEgg[g[Egr99g9rgggPP9r[g[PH-HuE3EE"EEECEEEEEEdEg9ddddd•YYYYYN8N8N8N8oddddoooozYdggdzYdzdggg[[[[g[[[[ggggggrrP8P9P9P9kgg~9~9~9zF~9rrrgg•PPPrPoNrPrP~9~9~9rrrrrr~[~PzN~Pg~9rPrP~9~[~[ggrNH3ggPgggggg7>gCdddgC9CgggEEggzzdddsrrEgdC2 b #Xn4  p4X#    @I -  @   6&6&StandardHPLAS4.PRSX\ 6&6&StandardHPLAS4.PRSX\  CHAPTER I THE TOBACCO PANDEMIC #Xi\  P6ƒXP# 55In the early 1950's, widely read and accepted scientific papers were published concluding that smoking is the major cause of lung cancer. Since that time, scientific evidence has continued to accumulate to the point where more than 25 diseases, a majority of which are lifethreatening, are now known or strongly suspected to be causally related to smoking. It has also been concluded that tobacco use, in all its forms greatly increases the risk of premature death from a number of chronic diseases. 55Even those who do not smoke are still affected by tobacco. Involuntary exposure to tobacco smoke puts nonsmokers at increased risk of lung cancer and a number of other diseases. Tobacco is thus a major contributing factor to many diseases, and is the largest preventable cause of premature death in many countries. 55Currently, tobacco products kill about 3 million people around the world each year, and this number is increasing. Unless current smoking patterns are reversed, the World Health Organization (WHO) estimates that by the 2020s or early 2030s, tobacco will be responsible for 10 million deaths per year, with 70% of them occurring in developing countries. Most of these deaths and all of the millions of potentially tobaccorelated deaths before 2020 will occur among people who already smoke. Failure to take serious preventive action now will result in tens of millions of people dying prematurely from an epidemic that is entirely preventable. 55Yet the costs of tobacco go far beyond the tragic health consequences. Tobacco is also a significant economic burden on families and societies. In 1995, a number of international organizations and individuals met at the Rockefeller Foundation's Study and Conference Centre in Bellagio, Italy, under the auspices of the Canadian International Development Research Centre and concluded that:  X(  55 "Tobacco consumption is a major threat to sustainable and equitable development...In the developing world, tobacco poses a major challenge, not just to health, but also to social and economic development, and to  X* environmental sustainability." %"5*-++Ԍ X 55A 1994 study by an economist at the World Bank has estimated that the use of tobacco results in a global net loss of US $200 billion per year, with half of these losses occurring in developing countries. These costs include direct medical care for tobaccoinduced illnesses, absenteeism from work, fire losses, reduced productivity and foregone income due to early mortality. There are also substantial costs that, although not quantifiable, are just as real. These include reduced quality of life for not only the smoker and those affected by secondhand smoke, but also the suffering brought upon those people whose lives are affected by the loss or illness of a loved one. The tobacco burden can also be determined on a local scale. For example, the U.S. Congressional Office of Technology Assessment estimated in its 1993 report that the total financial cost of smoking to the U.S. society in 1990 was about US$ 2.60 per pack of cigarettes (the cost of a pack of cigarettes in the U.S. in 1990 was US$ 1.44).  X  Patterns of tobacco use and mortality in developed and developing countries 55Despite this widespread knowledge about the harm caused by smoking, only modest  X- success has been achieved in global tobacco control. Worldwide, consumption of manufactured cigarettes more than doubled from 1967 to 1992, from 2.8 to 5.7 trillion cigarettes, with per capita cigarette consumption increasing by 25% during the same period. 55In developed countries, where smoking became widespread during the 1940s and 1950s, the effects of past smoking trends can now be seen. Almost 20% of all deaths in the 1990s in developed countries are due to tobacco products. In the 35 to 69 year old age group, about 35% of deaths among males and 15% among females are caused by tobacco. Although smoking rates have generally declined among adults in developed countries, smoking prevalence has been on the rise in developing countries. C*-++Ԍ X  World Health Assembly Resolutions ``-  X  55Reflecting the increasing concern of the international public health community with the burgeoning epidemic of tobaccorelated disease, the World Health Assembly (WHA), the governing body of WHO, has adopted 14 resolutions on both national and international tobacco control measures since 1970 (reproduced in Appendix I.1). From 1986 to 1995, the WHA passed nine major resolutions concerning tobacco or health issues, and the WHA continues to reaffirm its commitment to tobacco control.  X 55  XE  55 Resolution WHA39.14 (1986) is particularly noteworthy in that it calls on Member States to implement comprehensive tobacco control strategies. It goes on to describe nine elements that as a minimum, should be included in such strategies:   XE  551.NNmeasures to ensure that nonsmokers receive effective protection, to which they are entitled, from involuntary exposure to tobacco smoke, in enclosed public places, restaurants, transport, and places of work and entertainment.%"N 552.NNmeasures to promote abstention from the use of tobacco so as to protect children and young people from becoming addicted;%"N 553.NNmeasures to ensure that a good example is set in all healthrelated premises and by all health personnel;%"N 554.NNmeasures leading to the progressive elimination of those socioeconomic, behavioral , and other incentives which maintain and promote the use of tobacco;%"N 555.NNprominent health warnings, which might include the statement that tobacco is addictive, on cigarette packets, and containers of all types of tobacco products;%"N 556.NNthe establishment of programmes of education and public information on tobacco and health issues, including smoking cessation programmes, with active involvement of the health professions and the media;%"N 557.NNmonitoring of trends in smoking and other forms of tobacco use, tobaccorelated diseases, and effectiveness of national smokingcontrol action;%"N 558.NNthe promotion of viable economic alternatives to tobacco production, trade and taxation;%"N *-++Ԍ559.NNthe establishment of a national focal point to stimulate, support, and  X coordinate all the above activities. %"N 55 55Elements one and four of this list were readdressed again in 1990, with the adoption of WHA 43.16, urging all Member States:  X  551.NNto implement multisectoral comprehensive tobacco control strategies which, at a minimum, contain the nine elements outlined in Resolution WHA39.14;%"N 552.NNto consider including in their tobacco control strategies plans for legislation or other effective measures at the appropriate government level providing for:%"N 55NNa.& & effective protection from involuntary exposure to tobacco smoke in indoor workplaces, enclosed public places and public transport, with special attention to risk groups such as pregnant women and children;%"& 55NNb.& & progressive financial measures aimed at discouraging the use of tobacco;%"& 55NNc.& & progressive restrictions and concerted actions to eliminate eventually all direct and indirect advertising, promotion and  Xe sponsorship concerning tobacco. %"& 55These and other tobacco or health resolutions of the World Health Assembly are  X| also entirely consistent with the  Ottawa Charter for Health Promotion , which encourages the adoption of healthy public policies and the creation of supportive environments as part of broad multisectoral approach to health promotion. Major nongovernmental organizations (NGOs), such as the International Union Against Cancer (UICC), the International Union Against Tuberculosis and Lung Disease (IUATLD), as well as the 9th World Conference on Tobacco or Health have adopted similar stands to WHO. In addition, the World Health Assembly has requested WHO to assist countries in implementing comprehensive tobaccocontrol policies and to closely monitor the evolution of the global epidemic of tobaccorelated diseases. *-++Ԍ X 55Although these various resolutions specify  what  should be done, they do not,  X_ however, give indications of  how  they should be implemented. In subsequent chapters of this book, frequent references will be made to these resolutions, and guidance will be  X offered on their implementation.  X The Social Acceptability of Tobacco Use 55Effective tobacco control begins with the realization that tobacco is powerfully addictive. Researchers have rated nicotine as even more addictive than heroin, cocaine or marijuana. Smokers often find their cessation efforts futile, despite a strong desire to quit. They are not helped in their efforts by ubiquitous tobacco advertising and promotion. Other factors that must be considered when planning tobacco control strategies include personal considerations such as selfesteem, selfefficacy, and selfimage, as well as external factors such as peer pressure, price and perceived social acceptability. With the exception of social norms in some cultures and some religions which discourage smoking among women, there are few societallevel hindrances to smoking. Thus, since tobacco use is both legal and not widely discouraged, it is permissible to manufacture, market, and in most countries, advertise tobacco products. 55It is also permissible to sell tobacco products at the wholesale and retail levels (in some countries even in pharmacies and hospitals), to trade them internationally and to promote the establishment and growth of new markets for tobacco products. Ultimately, all of this creates a web of government and economic interests that may consider themselves to be dependent on tobacco for all or part of their income. Entities as diverse as Ministries of Agriculture, advertising firms, small retailers, theatre groups and sports clubs may receive income or sponsorship money from the tobacco industry, and are likely to support continued tobacco trade and consumption. This web of interests serves to reinforce the social acceptability of smoking, and the cycle begins again. 55The social acceptability of tobacco use stands in direct contradiction to the strong health education and health promotion messages discouraging tobacco use. Adolescent psychologists have found that teenagers, with stilldeveloping cognitive abilities, areG*-++ likely to react to the contradictory messages from health education and health promotion on the one hand, and publicly sanctioned tobacco advertising, marketing and widespread tobacco use on the other, by taking such contradiction as licence to believe nothing at all. They are then especially prone to cite these contradictions as a way of justifying any course of action that suits their immediate desires or purposes, such as smoking.  X.  Experience with partial and comprehensive national tobacco control strategies 55Many countries have been undertaking health promotion programmes and health education programmes to ensure that people are aware that tobacco is hazardous. However, they are continually counteracted by the tobacco industry. Over forty years of experience with health education and health promotion measures show that these measures alone are not sufficient to control the tobacco problem. If smoking is still perceived as socially acceptable, educational campaigns focused mainly on health hazards of tobacco use will have only modest results in getting large numbers of adults to stop smoking, or in successfully preventing teenagers from ever starting. The net effect will be a wellinformed population of continuing smokers. For greater results, education and health promotion must be accompanied by other actions, particularly legislation and tobacco tax measures, that will reduce the social acceptability of tobacco use. 55Favourable results are being seen in countries that have adopted comprehensive tobacco control programmes that include bans on tobacco advertising, strong warnings on packages, controls on the use of tobacco in indoor locations, and high tobacco taxes, along with traditional programs of health education and smoking cessation. In the period from 1970 to 1995, comprehensive tobacco control policies were implemented, maintained and upgraded in Australia, Finland, France, Iceland, New Zealand, Norway, Portugal, Singapore, Sweden, and Thailand. In these countries, tobacco consumption has remained low, or is falling rapidly, providing clear evidence that the more comprehensive the policy, the more effective the solution. In other countries, partial tobacco control programs and policies have produced only partial solutions to this very serious public health problem. C*-++Ԍ X ԙ The importance of effective tobacco control in all countries 55Effective and comprehensive tobacco control is desirable in every country, whether to minimize the problem where tobaccorelated deaths are already numerous, or to  Xt prevent the development of a serious public health problem in countries where the use of tobacco is not yet widespread. In many developing countries, particularly among women, there is still time to avoid repeating the experience of the industrialized countries, where tobacco use quickly became widespread, long before the serious health effects of  X smoking were known. Now that the hazards are widely known and accepted, this  XE information can and should be used to prevent the appalling global predictions for the tobacco epidemic from becoming a reality. Tobacco control might inevitably rank low on the priority list of countries striving for economic and social development, while attempting to reduce the burden of infectious diseases. Yet, unless strong tobacco  X control measures are taken now, those lives saved through the prevention of early death from infectious diseases may yet be lost in middle age if new generations of adolescents and young adults take up smoking. Monitoring the tobacco epidemic  X  55Policies and programmes to control tobacco use need to be supported by reliable, relevant, and timely information on tobacco use and its health consequences, and the sociocultural factors which underlie its use. Given the already prominent role of tobacco as a major health hazard, and the likelihood that the health effects will increase dramatically in the future, it is essential that the regular assessment of tobacco use and associated disease trends become an integral part of a country's health information system. Since the tobacco epidemic is constantly evolving, the gathering of appropriate information at regular intervals (from monthly to every few years, as appropriate) is clearly helpful to monitor and control it. I*-++Ԍ55Clearly, these efforts will be much more effective if health promotion policies and programmes are based on internationallycomparable information. Standardized approaches facilitate global, regional, and national monitoring of the tobacco or health situation, and the evaluation of effectiveness of policies and programmes. Policy decision makers, health planners, and nongovernmental organizations will all find practical, helpful guidance in this monograph on how to undertake effective surveillance of the tobacco epidemic by regularly monitoring tobacco consumption and prevalence, as well as disease and death caused by tobacco.  X  STRUCTURE AND PURPOSE OF THIS GUIDEBOOK  X\  55 Even though countries are working towards the implementation of World Health Assembly tobacco or health resolutions, lack of knowledge and experience of how to implement comprehensive, multisectoral policies may hinder further progress in this area. Those who have interests or responsibilities for the implementation of one or more aspects of tobacco control policies and programmes will find this book especially useful. The book offers practical guidance for proceeding towards a structured and orderly implementation and management of longterm, multisectoral, comprehensive tobacco control policies and programmes. The experiences of a number of countries have been reviewed, and the results distilled into various subjects that need to be addressed as  X countries seek to develop or improve their tobacco control policies. 55However, tobacco control is not simply rigid application of guidelines. Rather, countries are encouraged to take the general principles, suggestions and examples presented in this book and adapt them according to their specific needs. Thus, it will be individual Member States who will ultimately determine what strategy must be taken to achieve comprehensive tobacco control. C*-++Ԍ55The contents of this book are organized into two parts:  X] 55 NNPart A: Action for tobacco control%"N 55NNPart B: Monitoring the tobacco epidemic.%"N Part A: Action for tobacco control 55Chapter II discusses how to prepare a national action plan on comprehensive tobacco control, with emphasis on a collaborative approach. Addressed at some length in this chapter is the issue of using tobacco tax to promote public health. Recognizing that there may be substantial resistance to increased tobacco taxes, specific counterarguments are offered. This chapter also offers some operational suggestions for the management and evaluation of comprehensive tobacco policies and programmes, once they are implemented. 55There are a number of countries that have achieved certain successes in tobacco control. Chapter III provides recommendations on actually implementing comprehensive tobacco control, based largely on their experiences. Arguments to counter ojections to effective tobacco control measures are also provided in this chapter. 55In order to build a comprehensive tobacco control policy, countries will find it useful to assess their current tobacco situation " what has already been accomplished and what needs to be done. Chapter IV discusses which groups or institutions play a key (or supporting) role in tobacco control, and which may oppose these policies and programmes. The information support needed for comprehensive tobacco control is discussed in Chapter V. Once relevant information has been collected and documented, it can be very helpful to put it into a form that is functional and accessible. Chapter V goes on to offer guidance in preparing comprehensive country profiles on tobacco or health issues, which are intended to serve as an integral component of the information support that will aid greatly in implementing and monitoring the effectiveness of comprehensive tobacco control policies. C* -++Ԍ55  X]  Part B: Monitoring the tobacco epidemic 55Chapters VI through IX are concerned with data collection and analysis relating to  Xt the tobacco epidemic, i.e. epidemiological surveillance. These data, along with the additional information suggested in Chapter IV and V constitute information that will be very helpful to countries in monitoring and documenting the tobacco epidemic, information that will provide valuable support to strengthening tobacco control policies and programmes. 55Reliable data on how the epidemic is evolving, particularly among population subgroups is extremely useful for supporting tobacco control efforts. Chapter VI discusses the principles and issues in the surveillance of the tobacco epidemic, including the importance of disaggregated data for these population subgroups. This chapter provides an overview of the major data collection methods and analytical strategies, and provides an assessment of indicators and information sources useful in monitoring tobacco consumption and disease occurrence. These principles hold true for both developed and developing countries. 55Chapter VII provides specific information on how to measure tobacco consumption based on production, sales and trade data. Advantages and limitations of various approaches to measuring tobacco consumption are discussed. Indicators such as per capita consumption of cigarettes can provide information on overall levels of tobacco consumption, but do not provide any information on the smoking status of population subgroups. Population surveys are needed for this kind of information, as addressed in the next chapter. 55Chapter VIII discusses how to use population surveys to provide information on tobacco use that will be helpful in the focusing of tobacco control policies. Revised and updated WHO recommendations for the measurement of prevalence of tobacco use are given. In order to promote global standardization of the measurement of prevalence, all  XF* countries are strongly urged to follow these guidelines in conducting surveys of tobaccoF* -++ use prevalence. Surveys of knowledge and opinion are highly dependent on the cultural context in which they are conducted, and so could lend themselves less well to international standardization. Nevertheless, guidance is given on survey techniques that will elicit policyrelevant information about knowledge of the health effects of tobacco use and public opinions about tobacco control policy options. 55Support for tobacco control policy development is greatly enhanced by reliable and timely data on the health effects of tobacco use. Chapter IX presents an overview of the principal data sources for mortality and morbidity, and discusses methods for estimating current and future tobaccoattributable mortality.  X\  The Need for Action Now  X 55 The remarkable growth in consumption of this hazardous product is testimony to the powerfully addictive nature of nicotine, and the unparalleled ability of tobacco companies worldwide to continue to aggressively market their products, despite strong public health efforts to discourage their use. At the same time, because of the roughly 30 to 40 year lag time between the onset of smoking and the peak in the deaths that it causes, the health risks of tobacco are still vastly underestimated by a large percentage of the population, including many of those authorities responsible for protecting and promoting public health. These two factors underscore the urgency for effective global action against this epidemic. This book provides practical guidelines about how to do so. The sooner such action is truly global and effective, the sooner the epidemic will be overcome.