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This goal can be accomplished through a combination of the following: X1.XM M Helping nontobacco users stay tobaccofree.%"M X2.XM M To promote cessation of tobacco use and to encourage and assist in cessation efforts.%"M X3.XM M To protect the health and rights of children and adults by preventing involuntary exposure to environmental tobacco smoke.%"M   The examples of planning structures and successful tobacco control plans highlighted in this book are not to be taken as mandates to be rigorously followed. Instead, they should serve (along with examples of successful actions from other countries and by other organizations) as guides to the planning process. However, the plan will ultimately have to be practical and workable in the country for which it is prepared, meaning that it must be carefully adapted to the unique cultural features of that country. The creation of a formal structure or planning and building of capacity are not goals in themselves. Rather, they are only tools to achieve significant action and should be very goal oriented. They have value only insofar as they facilitate the achievement of these goals. Often, it is an informal group of individuals who can effect the greatest change; therefore, their efforts should be supported. The following, derived from WHA resolutions along with recommendations from other international and intergovernmental bodies, lists elements that should be included in comprehensive national tobacco control programmes. (They are in no particular order of priority). *-++Ԍ X1.XM M establishment and maintenance of an active national focal point to stimulate, support and coordinate tobacco control activities;%"M X2.XM M establishment of an adequately financed and staffed national coordinating organization on tobacco and health issues;%"M  3.M M monitoring of trends in smoking and other forms of tobacco use, tobaccorelated diseases, and effectiveness of national smoking control action;%"M X4.XM M effective programmes of promotion and education aimed at smoking prevention and cessation of smoking;%"M X5.XM M effective protection from involuntary exposure to tobacco smoke in transit vehicles, public places and workplaces;%"M X%" X6.XM M health care workers and institutions to set a good example by not smoking themselves, by making their institutions smokefree and who through their own training, and counselling and advocacy activities, emphasize the benefits of a smokefree life;%"M X7.XM M tobacco taxes that increase faster than the growth in prices and incomes;%"M X8.XM M a portion of tobacco taxes used to finance tobacco control measures and to sponsor sports and cultural events;%"M X9.XM M a ban on all forms of tobacco advertising, promotion and sponsorship;%"M X10.XM M a legal requirement for strong, varied warnings on packages of cigarettes;%"M X11.XM M restriction of access to tobacco products including a prohibition on sale of tobacco products to young people;%"M X12.XM M effective and widely available support of cessation of smoking; %"M X13.XM M limitations on the levels of tar and nicotine permitted in manufactured cigarettes;%"M X14.XM M mandatory reporting of the levels of toxic constituents in the smoke of manufactured tobacco products.%"M X15.XM M strategies to provide economic alternatives to tobacco agricultural workers.%"M :&-++ P!"~e4 Xdd8FtXXExamples of the implementation of tobacco control policies are now quite numerous. For example, Nepal was able to implement many elements of its very practical national plan for tobacco control, three years after preparing the plan of action. It has a national focal point on tobacco, and there is effective protection from involuntary exposure to tobacco smoke in health care institutions, public places, workplaces and public transport. In addition, there are improved programmes of health promotion and education aimed at smoking prevention and smoking cessation, and a special tax has been imposed on tobacco products, with the new revenue being used for public health improvement. XXActivities, timetables and resource requirements were identified for most of these possible elements of a comprehensive national tobacco control programme. However, it was decided that the sophisticated infrastructure required to implement, monitor and enforce items 7,11,13 and 14 were not available in Nepal, one of the world's poorest countries. Therefore, it was resolved that no action be undertaken on these four elements, and action would be concentrated instead on the other elements, where real progress would be possible.P$%"%"%"%"K!$"$ Strengthening tobacco control policies is a complex and serious matter. To be successful, it requires careful planning, and the plans need to be kept up to date. The Tobacco or Health programme at WHO Headquarters was following a Plan of Action that had been endorsed by the World Health Assembly for the period 1988 to 1995. Recently, the WHO Executive Board endorsed a draft Tobacco or Health Action Plan for the period 19962000. Should the plan be endorsed by the 49th World Health Assembly in May 1996, it will guide WHO's global activities to strengthen tobacco control. Briefly, the draft WHO Headquarters Plan of Action outlines objectives, approaches and activities under three main programme components:  W# X WHO Headquarters: Tobacco or health plan of action for 19962000%"  X% X Programme component I: National and international tobacco control programmes%" 0)-++$"!0Ԍ X XXM M Objective:  ,To promote the development and strengthening of national and international tobacco control programmes to prevent and reduce tobacco use.%" M M  The plan provides further details of three approaches and six activities to be pursued to fulfil this objective.  X X Programme component II: Advocacy and public information %"  XE XXM M  Objective:  ,To promote the concept of tobaccofree societies.%" XXM M The plan goes on to outline the approach to be taken to advocacy and public information and 9 activities to be undertaken, including the regular  X\ publication of Tobacco Alert.%"M  X X Programme component III: Tobacco or health research and information  Xv centre %"  X0 XXM M  Objective:  ,To collect, collate, prepare and disseminate valid information on tobaccoorhealth epidemiology and on strategies to control tobacco consumption.%" XXM M The plan outlines one approach and four activities to be undertaken to achieve this objective.%"M A number of WHO's Regional Offices have also been active in reviewing and updating their regional tobacco or health action plans.  W$ X Region of the Americas: %" Partnership is the cornerstone of the Latin American Interagency Plan of Action on Tobacco or Health. Launched in 1995, this plan draws on the resources of all its partner agencies " the Pan American Health Organization (PAHO), the Latin AmericanF*-++ Coordinating Committee for Tobacco Control (CLACCTA), the U.S. Centres for Disease Control and Prevention (CDC), the U.S National Cancer Institute (NCI), the American Cancer Society (ACS), the International Union Against Cancer (UICC), and Health Canada.  X  Purpose  X X  XM M To provide technical support to participating countries to strengthen national tobacco control efforts.%"M  X  Targets  X\   M M Establishment of a diagnostic baseline in six countries;%"M  X X XM M  Establishment, mobilization and optimization of national coalitions for proper national and interagency programme implementation;%"M  X- X  XM M Development of an evaluation instrument and system for monitoring the progress and products of the programmes.%"M The Interagency Plan of Action goes on to describe in some detail how the first stage will be implemented. It describes three expected results, 11 results indicators, eight specific activities and budgets for all activities. The Plan provides an excellent framework to implement and monitor progress on tobacco control. As time goes on, there is every reason for optimism that this will lead to strengthened tobacco control throughout Latin America. C*-++Ԍ W ԙ Eastern Mediterranean Region:  X Items for action on tobacco or health in Eastern Mediterranean countries:  Xt X  XM M Research to address issues related to smoking prevalence among youth and tobaccorelated mortality;%"M  X X  XM M Maintaining close working relationship with nongovernmental organizations;%"M  X X XM M  Assisting and supporting those Member States which have not yet evolved clear tobacco or health policies and programmes to do so, and assisting in strengthening the tobacco control programmes of those countries which already developed such programmes; %"M  Xs X  XM M Encouraging public health administrators to promote legislation to protect individuals from the hazards of involuntary exposure to environmental tobacco smoke.%"M  X X Items for action at the intercountry or regional levels: %"  X X XM M  Development of regional guidelines for comprehensive policies and programmes outlining various promotional activities to reduce tobacco consumption;%"M  X" X  XM M Preparation and dissemination of health education materials in Arabic and other languages on smoking hazards and the need for tobacco control measures.%"M C*-++Ԍ W X European Region:%"  The current Regional Action Plan for a TobaccoFree Europe proposes a number of specific projects under the following six action areas: XXM M 1.X $Alliances for a tobaccofree Europe%" XXM M 2.X $Multisectoral tobacco policies%" XXM M 3.X $Smokefree environments%" XXM M 4.X $Nonsmoking generations%" XXM M 5.X $Support to smokers for quitting%" XXM M 6.X $Stronger leadership and implementation capacity%"  XWestern Pacific Region%"   X The Regional Office for the Western Pacific has prepared An Action Plan on  Xv Tobacco or Health for 19951999 that proposes five objectives, together with related targets, activities and a timetable for implementation. The five proposed objectives are as follows:  XXM M 1.X $to develop, implement and strengthen comprehensive national policies and programmes on tobacco control;%" XXM M 2.X $to collect data on tobacco use;%" XXM M 3.X $to support health advocacy, education and information;%" M M 4.X $to support implementation of appropriate legislation; and%" XXM M 5.X $to achieve pricing policies in the region that deter tobacco use.%"  The current Regional Action Plan for a TobaccoFree Europe proposes a number of specific projects under the following six action areas: M*-++ԌXXM M 1.X $Alliances for a tobaccofree Europe%" XXM M 2.X $Multisectoral tobacco policies%" XXM M 3.X $Smokefree environments%" XXM M 4.X $Nonsmoking generations%" XXM M 5.X $Support to smokers for quitting%" XXM M 6.X $Stronger leadership and implementation capacity%"  X B:XHEALTH PROMOTION AND PROTECTION ACTIVITIES %" It is often claimed that the health hazards of tobacco use are so well known that it is no longer necessary to provide people with this information. But even in developed countries there is insufficient appreciation of the magnitude of the risks of tobacco use and the benefits of, and assistance for, quitting. The result is that vast numbers of people are not empowered to make fully informed decisions about their own health. In developing countries, this lack of sufficient information is even more acute. Considerable efforts are needed to ensure that relevant messages are constantly and repeatedly brought to public attention in every corner of the globe. In addition, there must be means whereby children can learn about the health hazards of tobacco use. As detailed later in this chapter, the other key component to comprehensive tobacco policies will involve legislation, including adjustments to fiscal policy. Since budgetary constraints often require choices to be made, the best plans will include an optimal mix of culturally relevant and costeffective strategies. Such a mix can be constructed from the various categories of activities discussed below.  Xr# X Notobacco days %" The World Health Organization sponsors an annual World NoTobacco Day (on 31 May), for which it produces a variety of materials reflecting the theme chosen for that year. Celebration of that day, as well as other national notobacco days, weeks, and months celebrated in some countries, have proven successful as promotional tools forC*-++ focusing public and media attention on tobacco issues, and would also be appropriate days for making policy announcements on tobacco issues. Even for countries where very little in the way of strengthening tobacco control seems feasible, it should still be possible to celebrate World NoTobacco Day. To the extent that these events are used as a tool to advance comprehensive tobacco control efforts, they can be extremely useful. This is especially true for promoting long term policy development related to the theme of the celebration.  X X Media advocacy %" The news value of tobacco or health issues is of great potential interest to the media. Therefore, it may be possible to provide them with interesting information and encourage them to prepare news, features and opinion articles about this topic. However, improved news coverage of tobacco or health issues will not simply happen by itself, it is up to public health workers to make this happen. Fortunately, ample advice and experience exists on how this can be done.  X- It is important to realize that news media are primarily interested in news; therefore, the surest way to gain exposure for tobacco issues in news media is to make  X the issues newsworthy. There has to be new information, a new activity or event, effectively and quickly communicated to the media, worthy of catching their attention. It can also be very worthwhile to use influential or wellknown personalities to create newsworthy events. Public health workers should constantly strive to produce new surveys, new reports, new antismoking activities, new policy initiatives, new notobacco events and to make sure that this new information is effectively communicated to the media. In this way, continuing public attention on tobacco or health issues can be sustained, at little or no cost. For example, in places such as Canada, Finland, Hong Kong, New Zealand, and Norway, where there have been extensive public debates leading to the implementation of tobacco control policies, these events have received prominent and prolonged media coverage, with frequent references to the health hazards of tobacco. While these policyF* -++ debates were going on, the countries experienced sharp declines in tobacco consumption, with further declines after comprehensive tobacco control policies were implemented. There may also be other ways for the media to play an important role in health education. Frequently, media will accept without charge, or are required to play, due to licensing requirements, public service messages. Health groups can urge the prominent positioning of tobacco or health messages. It might also be possible, in countries where tobacco advertising is still allowed, to require the production and broadcast of health messages as a condition for the broadcast of tobacco advertising.  X Paid media advertising In countries where tobacco advertising is permitted, the tobacco industry typically devotes substantial resources for advertising and promoting tobacco products. In the United States alone, tobacco companies spent US$ 6.2 billion on tobacco advertising and promotion in 1993. While spending on tobacco advertising may be more modest in other countries, it undoubtedly vastly exceeds the total amount that public health interests could expect to spend on media advertising to discourage tobacco use. For example, the amount spent on tobacco advertising in the U.S. alone in 1993 was nearly five thousand times more than the entire budget of WHO for tobacco or health activities in the same year. Health interests can never hope to match the spending by tobacco interests on paid media advertising, and probably should not try. Nevertheless, paid media advertising, when used with precision, can be an effective tool in a comprehensive effort to discourage tobacco consumption. One way of funding this would be to earmark a portion of tobacco taxes for this purpose. ,& -++  X The 1994 report of the United States SurgeonGeneral, Preventing tobacco use  X` among young people proposes that the following principles should apply to the design of paid media campaigns to discourage and prevent tobacco use.  XXM M 1.X $Carefully identify and differentiate target groups.%" XXM M 2.X $The planning of prohealth campaigns for young people should attend to the critical issues of message design identified in the literature. These issues include appealing to the needs and interests of the target group (e.g., peer approval, freedom, autonomy); using peer models, image appeals or lifestyle appeals instead of cognitive appeals; providing novelty and humour; avoiding exhortation; using celebrity spokespersons cautiously; and demonstrating preventive skills.%" XXM M 3.X $Messages should be carefully scrutinized by knowledgeable persons and by representatives of target groups to ensure that these messages are not conveying unintended effects that may eclipse their positive value.%" XXM M 4.X $Diagnostic and formative research, including surveys and focus groups, should be employed at appropriate points throughout the creative process.%" XXM M 5.X $Campaigns should be intense enough to ensure impact.%" XXM M 6.X $Carefully designed and targeted campaigns can be costeffective.%"   X X Schoolbased health promotion programmes%"  X   The school is an extraordinary setting through which to improve the health of students, school personnel, families and members of the community. It offers opportunities to achieve significant health and educational benefits with investments of scarce education and health resources. Programmes that help build skills for resisting social influences to smoke, and those which have led to children encouraging their parents to quit, have been shown to have at least shortterm effectiveness. Although a great deal of effort has been expended on schoolbased smoking prevention programmes, in many cases longterm evaluation results have been disappointing. The reason for this lack of success could be explained by the fact that these programs were undermined by the social environments in which the programmes took place. However, when theseQ* -++ programmes are situated in the context of more comprehensive community interventions, modest longterm effects have been found.  X In designing schoolbased smoking prevention programmes there is guidance  Xt available from the evaluation of previous efforts. At the same time, a major responsibility of schools could be to have elements related to tobacco and health integrated into the curriculum for all subjects where this is appropriate (e.g. biology, social sciences, mathematics, physics, chemistry, art.) and to encourage changes in the social environment that complement the messages delivered in schools. XCommunitybased health promotion programmes%"  X  Comprehensive health promotion programmes which feature the involvement of community institutions along with complementary local policy changes have shown considerable promise in both developed and developing countries. These types of  X programmes would also have the potential to reach children not in regular attendance  Xs in schools , who may represent very high proportions of all children in some developing countries. Other specific programmes targeted to street children are recommended. A: e ddT : One successful community project, took place in the rural Kathmandu valley of Nepal. A communitywide effort, involving schoolchildren, the school Headmaster, parents, teachers, health care workers and the village council worked together to promote the  S benefits of a smokefree life.4 The main promotional technique employed was persontoperson communication in the school and in people's homes. Before the intervention, 85% of the men and 62% of the women were smokers. After the intervention, smoking dropped markedly, while remaining high in a nonintervention community in the same valley.$%"%"-%"%" A$"$  X" X Sponsorship of cultural, sporting and community events %" Sponsorship can occur in many forms, and even health groups or governmental agencies on a limited budget can get their message across through the sponsorship of selected events. For example, in some cases, governments are already sponsoring sporting teams or events, and it would be relatively easy to take on the nonsmoking theme, even with a simple logo on the athletes' uniforms. Other cost efficient examples follow:0* -++$"%A 0ԌXXM M In 1994, The Hellenic Action Against Cancer (with WHO as a cosponsor) organized an international antismoking youth festival in Athens, Greece. Participants were asked to create their own nonsmoking messages through essays, athletics, music, or other forms of artistic expression.%"M XXM M Brazil Tobacco Control Service hosts an annual "Run to Quit Smoking". %"M XXM M A boat which was sponsored by, and named after, a smoking cessation aid registered to sail in a prestigious longdistance yachting race from South Africa to Brazil. After months of preparation, the captain was informed that, due to protests from the tobacco company which sponsors the race, the boat could not compete unless its name was changed. Considerable media coverage was generated, as health advocates asserted that tobacco companies have always been enthusiastic promoters of their own freedom of expression, yet appeared to have less enthusiasm for these principles when counter to their own interests. The sponsors eventually agreed to let the boat participate in the race. %"M  Although these types of limited activities serve a useful purpose, wherever possible, countries should strive for a more encompassing sponsorship program, as exemplified by health promotion foundations in a number of countries. a te 0ddStXXPioneered by the state of Victoria, health promotion foundations are now operating in several Australian states, funded by a small portion of state tobacco taxes. These foundations have sufficient resources to replace all the sports and cultural events, previously funded by tobacco companies, with health promotion sponsorships that promote a comprehensive range of healthy lifestyles, including the benefits of a tobaccofree life. In addition, the foundations fund a variety of community sports, cultural events and organizations, as well as community development and tobacco policy research projects. The creation of these health promotion foundations had the effect of converting potential opponents of comprehensive tobacco control (former recipients of tobacco sponsorship monies) into supporters of the policy. Abundant documentation is available on the establishment and operation of these health promotion foundations. XXAnother effective sponsorship strategy was achieved in New Zealand, where comprehensive tobacco control legislation which banned nearly all forms of tobacco advertising, promotion and sponsorship was instituted. They have established a highly successful Health Sponsorship Council, funded by general taxation revenue, which conducts a broad range of health promotion activities, including those in favour of a tobaccofree life. & e tddS & XXCreative use of health sponsorship is also possible in countries with no legislative restriction on tobacco advertising and sponsorship. For example, in Geneva, Switzerland,  S local government agency, CIPRET (Centre d'Information pour la Prevention du  S Tabagisme), has adopted a very creative approach to health sponsorship. With municipal funding, CIPRET has sponsored a number of carefully chosen sport and cultural activities including rock concerts, a longdistance car rally team, a racing yacht, a basketball team, and a motorcycle racer. At the sponsored events, positive messages help promote the benefits of a tobaccofree life. CIPRET also maintains a constant presence at community events, ranging from health fairs to car shows. Active participation in community events can thus be a very valuable and cost effective health promotion strategy.$%"%"D%"%" $"$ @v( -++!$"a$"* @ $%"%"%"%"a$"$  Xc Cessation of smoking Considering that the goal for smoking control is a reduction of smokingrelated mortality, a special emphasis must be given to maximizing the number of individuals who quit smoking. As documented in the 1990 report of the US Surgeon General, cessation of smoking prevents diseases; it prevents the occurrence of disease (primary prevention), and it reduces the risk of further disease in those who quit smoking (secondary prevention). This means that cessation of smoking is a major means of reducing smokingrelated mortality. Further, cessation reduces mortality within just a few years, while prevention of onset of smoking does not influence mortality statistics until some 3050 years later, when today's young people reach the ages where smokingrelated deaths occur. Nicotine has now been clearly recognized as a drug of addiction in the 1988 US Surgeon General's Report and WHO's International Classification of Diseases, ICD10, in the same category as heroin or cocaine. For the individual smoker, quitting requires two things, motivation to quit and ability to overcome dependencerelated obstacles. Intermediate objectives for smoking0)-++$"a0 control policies should therefore include both: "Strengthening, smokers' motivation to quit" and "weakening dependencerelated difficulties". Different smokers have different needs according to the nature and strength of their dependence. Although 7580% of smokers, where this has been measured, want to quit and about a third have made at least three serious attempts, less than half of smokers succeed in stopping permanently before the age of 60. Nicotine dependence is clearly a major barrier to successful cessation. Therefore, smoking control policies should contain both activities to strengthen smokers' motivation to quit, (health education, public information, price policies, smokefree policies, behavioural treatments etc.) and activities to reduce dependencerelated difficulties for smokers to quit (behavioral and pharmacological treatment).  Y #Xw P7XP#In countries with welldeveloped health care systems, a majority of people consult a physician or dentist at least once a year and attach great credibility to their advice. Brief, but firm, advice has been associated with sustained smoking cessation among 5% of smokers, considerably more than the 1% or 2% per year that quit in the absence of such advice. When coupled with nicotine replacement therapy (NRT), brief advice from a physician can result in still further improvements in oneyear smoking cessation rates. Although there can be an initially higher cost for NRT, it can be more cost efficient in the long run for both individuals and governments. There are also reasons to consider alternative nicotine replacement maintenance systems for those individuals who are unable to break their dependency on nicotine, but wish to reduce the health consequences associated with obtaining their nicotine from tobacco products. It must be remembered, however, that nicotine is a drug, and it's use may carry with it certain risks, particularly when used other than as advised. Cardiac patients, in particular, risk further cardiovascular complications if they continue to smoke while using NRT. Current  Y$ evidence indicates that NRT, when used as advised, has few adverse affects. However, those using NRT should be warned that smoking while using NRT is inadvisable. As a rule, advice and information from trained persons is important for all potential users of NRT, in order to ascertain proper use. F*-++ԌIn order to achieve successful cessation of smoking on a very large scale, special "cessation programmes" are far from enough. Currently, only a few health professionals are trained in the treatment of tobacco dependence. All health professionals, including doctors, nurses, and pharmacists should given both basic and inservice training so that they are capable of providing advice and/or treatment for tobacco dependence. In preparing national tobacco control plans and strategies, planners may wish to encourage the provision of a broad range of smoking cessation strategies that would include combinations of the most effective group programmes of smoking cessation, physician advice and, where appropriate, nicotine replacement therapy. Countries with national health systems are encouraged to include counselling and treatment for nicotine addiction as a covered benefit in their national health insurance programmes. Mass media programmes can not only create a climate for quitting smoking, but can also run electronic or print media programmes on advice and tips on "How to quit smoking". These may reach millions of people and are a useful adjunct to individual  Y advice from a health professional.  X Legislative measures  "*e (dd& S  KEY LEGISLATIVE MEASURES NEEDED FOR COMPREHENSIVE TOBACCO  S CONTROL #&`\  P6"&P#Legislation is critical to comprehensive tobacco control. The range of legislative measures is necessarily broad given the number of things which must be done in order to achieve effective control of the tobacco epidemic. The necessary measures are such that it can be best to take the position followed by many governments when dealing with other drugs and have a single piece of legislation giving broad regulatory control over all aspects of tobacco manufacturing, importation, marketing and use of the product. Alternatively, it may be necessary to pass several different laws. In any case the relevant laws can give authority for the following: 1)XXXLaws to ensure the accessibility of tobacco products reflects the gravity of harm associated with use. This should include:hX XXi)A taxation law that reduces affordability;h XXii)An end to tobacco sales in health care, educational and athletic facilities;h XXiii)An end to tobacco sales in vending machines and from selfservice displays;h XXiv)The effective elimination of tobacco sales and distribution to children.h XX 2)XXXThere should be full and free consent among users and potential users of tobacco products. This should include:hX XXi)Because tobacco advertising is inherently misleading, all direct and indirect forms of tobacco advertising should come to an end;h XXi)An end to the misleading messages conveyed on tobacco labelling and packaging;h XXii)Prominent, detailed and frequently updated health information on (and possibly in) tobacco packaging and at point of sale; ppJQh XXiii)Full public disclosure of all product toxins and additives; ppJQ RRh XXiv)Mandated public health education efforts, including efforts to educate the public about the role of the tobacco industry; h XXv)Guaranteed assistance to those who wish not to be using tobacco products, and assistance for tobacco users seeking compensation for their harm.h XX 3)XXXThere should be protection for the health, rights and wellbeing of those who do not use tobacco products. This should include:hX XXi)A guarantee of smokefree public spaces, workplaces and public transit;h XXii)Guaranteed and simplified methods of redress for those harmed by ETS;h XXiii)Legislated protection from (or compensation for) fires and other environmental harm caused by tobacco products.h 4)XXXThe legislation should control the product itself. This should include:hX XXi)The ability to ban specified categories of any nicotine delivery products;h XXii)Control over the additives which can be, or must be, added to tobacco products;h XXiii)Control over allowable levels of toxic ingredients found in tobacco products;h XXiv)The ability to require modification in tobacco products.  A number of World Health Assembly Resolutions call for comprehensive tobacco control measures. Many analysts have concluded that, ultimately, the most effective action on these kinds of measures will require the creation of legislation (See Box). Countries have been specifically counselled against accepting voluntary regulation of advertising and package labelling from the tobacco industry. World Health Assembly Resolution WHA43.16 specifically urges consideration of legislative, not voluntary, controls on tobacco advertising. Environmental tobacco smoke has been easier to deal with through voluntary and administrative arrangements because employers often recognize the benefits of a smokefree workplace. Ultimately, though, legislation is the only way of guaranteeing protection. A range of measures, from voluntary to legislative, and practical ways of implementing 0C*-++$" 00Ԍ$%"%"%"%"+$"$ԙ0+-++$" 00Ԍthem, have been the subject of Advisory Kits prepared in support of World NoTobacco Days of 1991 to 1993 addressing the subjects of smoking in public places, smoking in workplaces and smoking control in health care institutions, respectively. These documents should prove useful resources in designing staged approaches to progressively improving protection from involuntary exposure to tobacco smoke. Countries with successful comprehensive tobacco control strategies have legislated in all the areas mentioned above. Taxation law, usually dealt with by Departments of Finance, will be addressed separately later in this chapter. However, other matters that are addressed most effectively by legislation will be discussed here.  Y Appendix II.1 contains the full text of the New Zealand Smokefree Environments  Y_ Act, a good example of tobacco control legislation that, apart from taxation issues, addresses all of the legislative issues raised by Resolutions WHA39.14 and WHA43.16.  Y Appendix II.2 contains the full text of the Canadian NonSmokers' Health Act, an example of legislation that provides effective protection from involuntary exposure to tobacco smoke in all workplaces under the jurisdiction of Canada's federal government for occupational health and safety matters. Both laws have been in place for a number of years and are effectively meeting their legislative objectives. Since cultures, languages, systems of government and legislative processes differ widely from country to country, countries will need to study the examples of tobacco control legislation from New Zealand and Canada given in Appendices II.1 and II.2, together with those from other countries, as appropriate. Those responsible for drafting new tobacco control legislation should also consider how to use the legislative experience from other countries to best serve their own particular legislative requirements. Systems of regulation and enforcement differ so widely from country to country that no suggestions are offered in that area. Nevertheless, health and legislative officials may wish to study the enforcement and regulatory experience of other countries in preparing enforcement and regulatory provisions for their own countries. aa=L*-++ԌSome countries may not be able to adopt truly comprehensive legislation in a single step. Although WHO recommends such laws for all countries, many countries may require a series of steps to attain this goal. Each step along the way should be seen as part of the long term effort, taking into consideration the specific situation existing in each country. At the same time, in order to avoid having to pass numerous small pieces of legislation it is often better to pass broad laws. The limits of what is politically possible to achieve at any point in time can be accounted for in the drafting of these laws. For example: XXM M some requirements can be stipulated to not come into force until a later time;%"M XXM M if some current activities promoting tobacco cannot be stopped, they might be able to be phased out and new activities prevented;%"M XXM M general requirements can contain regulatory authority allowing for further health protection measures to be developed by regulation or ministerial order.%"M These latter provisions are key components of a comprehensive legislative approach to tobacco control. For example, large and prominent health warnings, covering 10% or more of the package face, are now required in a number of countries, including Australia, Iceland, Singapore, South Africa, and Thailand. In many jurisdictions, positive enforcement strategies to help enforce restrictions on sale of cigarettes to minors have been found to be helpful. Typically these strategies involve recruiting youth under the age for legally purchasing cigarettes to assist in surveillance and enforcement of legislative provisions restricting the sale of cigarettes to  Y" minors. r#-++  X X Fiscal measures %" 8 $W !dd$#&`\  P6"&P#FISCAL MEASURES: HIGHLIGHTS XXXIn addition to the devastating health consequences, it has been estimated that tobacco use is responsible for a global net loss of US $200 billion each year, half of which is occurring in developing countries. X XXXRaising the price of tobacco products through tobacco tax changes is likely to be the single most significant step toward reducing consumption of tobacco products.X XXXIncreasing tobacco taxes and designating a portion of these taxes to replace tobacco sponsorships of sports, arts and cultural programs will reduce the economic clout of the tobacco companies while promoting healthful messages.X XXXEstablishing minimum allowable pricing for tobacco products will keep pricesensitive consumers (particularly youth) out of the market, and may prevent them from ever starting to smoke.X XXXIn the absence of government intervention, tobacco use can be expected to rise as disposable incomes rise. This is particularly significant for the many developing countries which are experiencing very high growth rates.X XXXThus, prices for tobacco products should rise regularly to cover normal inflation, to ensure that they do not become more affordable as incomes rise, and to give existing smokers the incentive to quit.X XXXEnsure that tax structure on all tobacco products are taxed to the extent that substitution of other tobacco products (including smokeless tobacco and tobacco for rollyourown cigarettes) is not encouraged.X XXXHigh tobacco taxes bring not only health, but financial benefits to governments. This addition revenue could be used to fund such things as health care or health promotion, or may allow reductions in other taxes.X XXXTobacco taxes are relatively easy to administer, thus only a small portion of the revenue raised needs to be spent on collection. X XXXTobacco tax increases have been shown to be relatively popular among the public, even among smokers, especially if the purpose of preventing young people from starting smoking is understood.8 $%"%"%"%":&"$ 0(-++W"-0 The WHO Advisory Kit prepared for World NoTobacco Day 1995 (Selected articles from this Advisory Kit are reproduced in Appendix II.3), on the theme of the economics of tobacco control, reviews the reasons why tobacco taxation should be used as a tool to achieve funding for improved tobacco control programming, increased government revenue, and reduced tobacco consumption (See Box). It offers compelling reasons for a fiscal policy of progressively increasing tobacco taxes, as part of a plan for strengthened national tobacco control.  YE A major role of tobacco taxation policy is the reduction of the affordability of  Y tobacco products , which reduces consumption. To reduce affordability it is often  Y necessary to increase prices beyond what is necessary simply to surpass inflation. The reason for this is that income growth can also stimulate the demand for tobacco, a problem which is particularly acute in some developing countries with rapidly growing economies. In countries where there is a high prevalence of tobacco use but restrained consumption due to low incomes, economic growth without compensatory tobacco tax increases can lead to rapid growth in tobacco use unless restrained by tax increases that keep pace with growth in the affordability of tobacco products.  Y  Increased tobacco taxes (above the rate of inflation) and the use of the proportion of the proceeds to finance the other tobacco control measures that make up the comprehensive national tobacco control programme have been repeatedly recommended. Adoption of such measures will make all tobacco control measures both effective and selffinancing. This is especially important in developing countries where financing of new public health initiatives may be especially problematic.  Yz# Another fiscal measure that can be used is to limit the pretax selling prices of  Y$ tobacco products. This compensates for the extremely high profits tobacco companies could otherwise obtain due to the monopolistic nature of the industry, and allows increased tobacco tax revenue without additional changes in retail prices. The result of such a system was witnessed in Brazil in the 1980's when an inflation control strategy prevented price increases by tobacco companies. Since profits could not be enhancedO*-++ through price increases the alternative to tobacco companies was to lower costs. The result was a significant reduction of advertising and promotional activities, which was reversed when price controls were relaxed. There are some arguments which may be raised in opposition to tobacco taxes. These range from concerns about smuggling to those who see a cheap tobacco policy as a benefit for poor people (often, oddly, when the revenue tobacco could generate could provide true benefits such as basic health care for the poor). These sorts of arguments are dealt with in Appendix II.3.  X X Economic Alternatives to Tobacco %" Given the powerfully addictive nature of tobacco, only slow and gradual changes in tobacco consumption can be expected even in the best of circumstances. This means that there will be plenty of time for smooth economic adjustment as displaced tobacco workers move to alternate forms of economic activity.B Nevertheless, good longrange planning can take account of expected longterm declines in the tobacco industry. Addressing the issue of economic alternatives for tobacco workers can also be good strategy. It can convert Departments of Agriculture, tobacco agricultural workers, and others who currently receive financial benefit from the tobacco industry from potential sources of opposition to tobacco control plans into supporters of a comprehensive national tobacco control strategy. Countries that have large tobacco growing areas could ask for assistance in the development of alternative crops from the United Nation's Food and Agricultural Organization (FAO). Part of Canada's successful comprehensive tobacco control strategy included subsidies to tobacco farmers to take up alternate forms of economic activity. Onetime cash payments were also made to tobacco farmers who agreed to retire from the tobacco business. In one decade, tobacco consumption dropped by about 40% in Canada, the number of tobacco farmers fell by half, and the tobaccogrowing regions of the country experienced strong economic growth as new forms of economic activity opened up. ThereC*-++ are a number of other countries, including Malaysia, Philippines, and Brazil that are already looking into economically feasible alternatives to tobacco. In Bangladesh, a successful community demonstration project in a tobaccogrowing region succeeded in not only reducing rates of tobacco consumption in the community, but in converting a large number of farmers from tobacco to food production. Additionally, in this region, food production was shown to be more lucrative than tobacco production.  X  C. BUILDING CAPACITIES Building capacities involves building up of human, financial, and structural resources to support tobacco control, which should have longterm sustainability. In developing the infrastructure to institute tobacco control measures it is necessary to keep the goals in mind. Sometimes a process or activity that can help on one issue can be unnecessary or even counterproductive on another. For example, a focal point for tobacco control can be a catalyst for significant improvements in public health, but could also be an impediment to action if its mandate or direction is not clearly focused on achieving the best results for tobacco control. The optimal level of capacity for tobacco control is whatever is needed to achieve the determined goals. In practice, tobacco control often starts with a single committed person or a small group of people, and certain issues may remain in their sphere. In other cases, it will require the development of detailed information, broad coalitions and a sustained funding base. The development of issuespecific strategies can allow the appropriate level of resources to be applied to each situation while the development of a general overall capacity can ensure the resources for future actions. However, to achieve sustained, comprehensive tobacco control, it will be necessary to attain broad popular support. Assuming the goalorientation of capacity building, it can play a key role in tobacco control. These include: C*-++ԌM M giving newly interested individuals or groups the basis for successful tobacco control work;%"M M M providing those already working on tobacco control additional sources of information and evaluation;%"M M M developing an infrastructure for tobacco control that can continue operating regardless of changing conditions in the country.%"M  In some countries this capacity building is assisted through the offering of courses or seminars to interested people, and the development of an information system to exchange and distribute information. The building of the capacity for tobacco control will also be greatly influenced through the ability to gain and use information, increase support within and beyond government and neutralize opposition. It is to these issues that we will turn in the following chapters.  X  D:XMONITORING AND EVALUATION%" Good national plans for tobacco control will also include a programme of continuous monitoring of all relevant factors related to tobacco or health issues, as detailed in Chapters IV to IX. Some of this can be done relatively easily and with limited resources. Good planning will also include provision for careful evaluation of progress, successes and failures as policy and programme implementation proceeds. The results of such evaluation will then be used to revise and update planning and programming, in a continuous effort to be ever more successful at discouraging tobacco consumption. Evaluating tobacco control can require careful advance planning. To incorporate sound evaluation strategies into national tobacco control programmes, readers should refer  Y& to a companion volume entitled Evaluating tobacco control: Experience and guiding  W( principles.(-++  X  CONCLUSION: KEY ISSUES IN PREPARING ACTION PLANS FOR  X] COMPREHENSIVE TOBACCO CONTROL   Y  Establish a national tobacco control policy and organization  Y  Implement a national programme with the following key components:  Y2  Health education , including assistance with cessation.  Y  Legislation to achieve such measures as X` hp x (#%'0*,.8135@8:@bans on sales of tobacco products to children; legislation to ban direct and indirect advertising of tobacco products; prominent health warnings on tobacco products; guarantee of smokefree public spaces, workplaces, and public transit; legislation to establish control and require reporting of levels of toxic ingredients found in tobacco products.  Yd   Tax and price policies including reducing the affordability of tobacco products by increasing taxes above the rate of inflation, and using a portion of tobacco taxes to fund health promotion activities and for sponsorship of sports and cultural events. %"  Y   Build up human, financial and structural resources to support tobacco control, which should have longterm sustainability.  Y   Where possible, monitor and evaluate tobacco control programmes.