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For example, it is possible to implement policy measures based on international data before substantial local data have been collected. An automobile that has been proven defective in twenty other countries need not be subject to rigorous testing in the twentyfirst before action is taken. With this example in mind, enough information is already available to undertake such policy changes as providing better protection from involuntary exposure to tobacco smoke. In other cases, however, it may be helpful to have specific national or local information for further strengthening arguments in support of tobacco control policies. For example, conducting a national or local prevalence survey (as outlined in Chapter VIII) or estimating future health effects of current smoking patterns (as outlined in Chapter IX) would provide valuable additional information. Many countries will have already available information on their own tobacco situation which may be used to inform policy research, development and debate in favour of strengthened tobacco control activities. For example, a country may have decades of taxation information readily accessible from its Ministry of Finance, which can be used to support increasing taxation of tobacco products. Where there is existing information on such indicators as measures of tobacco consumption and prevalence, tobaccorelated mortality and morbidity, knowledge, attitudes and opinions concerning tobacco and health issues, knowledge of groups and institutions that are likely to support or oppose tobacco control policies, this should be documented. It is also worthwhile to document additional information about social, economic and political factors related to tobacco control issues. Although some information is available from the tobacco industry, their reports should be reviewed critically before accepting the information contained in them. Comprehensive, factual and credible information will prove helpful in combatting*-++ arguments (for example, those initiated by the tobacco industry) against tobacco control. This information will also be useful in the resulting public debate. Carefully organized systems of documentation, reference and retrieval for relevant documents will be an important feature of keeping track of information. Information will be even more useful if shared with others. Many such examples of tobacco and health documentation systems exist, ranging from fairly simple collections of documentation on tobacco or health issues maintained by an individual in a small nongovernmental organization, to sophisticated technical information collections that have been in existence for many years. The World Health Organization maintains a health data base covering the entire world. Another outstanding example of a sophisticated information collection is the Technical  X\ Information Centre of the United States Office on Smoking and Health."\k yO ԍXX` ` Technical Information Centre"` XX` ` Office on Smoking and Health"` XX` ` National Centre for Chronic Disease Prevention and Health Promotion"` XX` ` Centres for Disease Control"` XX` ` 1600 Clifton Road"` XX` ` Rhodes Building, MS K12"` XX` ` Atlanta, Georgia 30333"` XX` ` United States of America"` XX` ` Tel: 1 404 488 5708" This office maintains the world's most complete bibliographical source on smoking and health issues. Information from this source is available at no charge to any one in the world requesting it. While few will find it necessary to have such extensive documentation on the tobacco epidemic as is available from the U.S. Office on Smoking and Health, all countries would benefit from having a readily accessible repository of some of the key national and international documents on tobacco and health issues. What is desirable is a minimum set of data and information capable of delineating the population groups most affected by the epidemic, the presence and significance of the tobacco industry in the country, and the policy responses which have already been implemented, or are in the process of being implemented. Based on many countries' experiences with tobacco control measures, WHO has prepared a list of indicators which should be monitored by each country in order to effectively support the health policy"-++ process. These indicators can be grouped under six broad headings:  sociodemographic characteristics;  tobacco production, trade and industry;  tobacco consumption:  prevalence of tobacco use;  mortality and morbidity;  tobacco control measures, organizations and institutions. The full list of recommended indicators under each of these sections is given in Appendix V.1 Even in cases where official statistics are not available or are incomplete, there are many other sources to draw upon. For example, much information is publicly available from tobacco companies, in the form of annual and quarterly reports, and other periodically issued reports. Information from commercial surveys of public opinion, media placements and industrial activity can also be valuable sources of information, along with news reports (including business news), and tobacco trade journals. Public computer networks such as Internet and computer networks of persons working on tobacco control (such as SCARCNET, operated by the Advocacy Institute, Washington, D.C., U.S.A. and Globalink, operated by the International Union Against Cancer (UICC), Geneva, Switzerland) can also offer valuable information and advice. International organizations, such as the United Nations Statistical Office, the World Health Organization, the United Nations Conference on Trade and Development, the Food and Agriculture Organization, the Organization for Economic Cooperation and Development, and the European Union can also provide important information required for international comparisons. A brief description of the where to find data relevant to social, economic and political factors is given below.  X,&  Economic information Many governments collect and publish economic statistics on the status of the tobacco industry. Even if the information is not published, it may be available inC*-++ unpublished form from the relevant government departments which could include a central statistical office, the Departments of Finance, Revenue, Agriculture, Industry, Consumer Affairs and Communication. Tobacco industry Since tobacco control policies will ultimately have an impact on the tobacco industry, it will be important to have a thorough understanding of this industry's structure. Governments collect some of this information. Other sources include the tobacco industry itself (annual and quarterly reports, etc.), reports on the tobacco industry by stock market analysts, reports from commercial market monitoring agencies (media tracking agencies and others), and various international data sources. There may also be a number of notforprofit organizations working to promote continued and increased tobacco use. Tobacco industry associations, tobacco growers' associations, smokers' freedom societies, and various organizations defending "freedom to advertise" may be found in this category. However, these organizations will almost always have close ties to the tobacco industry, usually including some form of financial support. Since many of these will be dedicated to delaying or derailing any public health actions to control tobacco, particular attention should be paid to discovering as much as information as possible about such organizations in order to be wellprepared to defend public health policy proposals in favour of tobacco control. If there is a tobacco growing industry in the country, the nature of this industry should be fully documented according to operating revenues, the number of farmers, the proportion of agricultural production, the proportion of exports accounted for in monetary terms by tobacco growing, the proportion of all tobacco produced for local consumption and for export, and an overall assessment of historical trends and future prospects for tobacco agriculture. Analysis should also extend to describing the manufacture, production and trade of finished tobacco products. Topics to be covered here include the structure of theC*-++ tobacco industry, and the role of the transnational tobacco companies in production, import and export of tobacco. The analysis should extend to describing the number of factories, the number of workers in manufacturing, wholesale and retail trade, the proportion of all workers in the tobacco sector, and the value of tobacco production, wholesale and retail trade, as well of the value and importance of tobacco imports and  X exports.  X Tobacco in the national economy It is important to ascertain the nature of the tobacco industry in the national economy. In developing countries where foreign exchange reserves may be low or in deficit, it will be particularly important to document the amount of foreign currency reserves spent to purchase tobacco leaf, tobacco machinery, and other goods and services related to tobacco production in the country. The nature and extent of government support to tobacco growing and manufacturing industries, as well as the government support by the tobacco industry should also be documented. Frequently, economic analyses of the place of tobacco in the national economy are produced on behalf of the tobacco industry. Tobacco industry reports frequently state the number of persons, or fulltime equivalent persons, who work in the tobacco industry. Such presentations often overstate the number of persons employed in the tobacco industry by several times by one or more of the following means: XXM M counting employment indirectly created by tobacco industry jobs (e.g. by counting a fraction of the jobs created in goods and services industries because tobacco workers, like everyone else, buy goods and services with their employment income);%"M XXM M counting all tobacco company family members as employed in or dependent on the tobacco industry;%"M XXM M counting farmers who grow tobacco as one of many crops as fulltime tobacco workers;%"M XXM M counting parttime or transient workers as fulltime workers.%"M C*-++ԌIf resources were not devoted to tobacco, they would be employed in other productive economic activities which would also generate employment and tax revenues. It would then be fair to conclude that aggregate economic results would be about the same, with and without tobacco. In fact, some studies show that the overall effect on the economy is positive, with a net increase in jobs as tobacco consumption declines.  X.  Relative cost to consumer Consumer expenditures on tobacco should also be tracked, and this can be done in a variety of ways: as a proportion of all consumer expenditure, as a percentage of per capita gross national product, as a percentage of per smoker gross national product, or as the average number of minutes of labour required to earn the price of 20 cigarettes. Even with only the knowledge of the prevailing price of the most popular local brand of cigarettes and the local minimum wage, it is still possible to calculate the minutes of labour required to earn the price of a package of cigarettes. For example, it was calculated that a smoker earning the minimum wage in the Ivory Coast must devote almost two and a half hours of every working day just to earn the price of his daily package of cigarettes. Alternatively, the price of cigarettes could be equated to staple goods or desirable consumer goods.  XD  Overall economic costs of tobacco The economic consequences of tobacco can also provide valuable information for future campaign planning. A World Bank official has estimated that the global net economic loss from tobacco is US$ 200 billion per year. There are also many analyses that provide similar information for a number of developed countries. Summary information on the economic costs for one country, Canada, is given in Table V.1. Even partial analysis of the economic costs of tobacco, as has been done for China, can be a very useful form of policy research. C*-++Ԍ X  Table V.1 Selected costs of tobacco use, Canada, 1989 ($CAN x 109) Y ddx !ddx ###Y   z" X FF Age groupsz"\ q" X $  Costs" X CX 3564"Ow65 +"Z*Totalqqz  Xs  Health costs \#J\#U\#`!qa  X X Direct care#G1.3#R0.6#] 1.9aa\ XPremature mortality#G4.1#R2.7#] 6.8aa XDisability #G0.6 #R0.1 #] 0.7aa XPerinatal mortality #J #U #] 0.1aa  Property and forest firesA #JA #UA #] 0.1aa  Retail expenditures on tobacco #J #U #`!aaA  XTobacco taxes#J#U#] 5.5aa  XManufacturers' and trade marginsd#Jd#Ud#] 2.7a  X Total expenditures related to tobacco #J#U#\) 17.8 d  The economic costs of health care attributable to smoking have been estimated  X using several different methodologies. Rice et al. used an attributable risk methodology to estimate both the direct costs (due to tobaccorelated illnesses) and the indirect costs (due to work loss, premature death, and loss of housekeeping services). For the U.S., this methodology relied on the reported utilization of medical care for neoplastic, cardiovascular, and pulmonary diseases, obtained from large national surveys. Coupled with the prevalence of smoking, these relative rates of utilization for current and former smokers compared with never smokers were used, like the relative risks for death among exposed smokers, to calculate a smokingattributable fraction (SAF) that could be applied to the U.S. total health care costs by cost category to produce a national estimate of smoking attributable direct costs. A SAF was also developed for workloss days and lost housekeeping to estimate smokingattributable indirect morbidity costs, and the estimated losses for a given year of life lost for a man or woman dying prematurely due to a smoking related illness at a given age were summed to obtain indirect mortality costs. In the 1980's, these total losses were US$ 65 billion, of which US$ 24 billion was for direct medical care. *-++Ԍ X Variations on the methodology developed by Rice et al. have been used to estimate the costs of tobacco use in other countries as well. The attributable risk  X methodology relies on the assumption that smokers and never smokers do not differ from each other with respect to other risk factors, access to care, health status, and utilization patterns for medical care. Clearly, these assumptions must be addressed. In 1994, researchers at the University of California, Berkeley, made a more sophisticated estimate of the marginal (or excess) health care costs attributable to smoking using data from the National Medical Expenditure Survey II (NMESII). This survey collected detailed medical utilization histories from 35,000 persons on four separate occasions during 198788. In addition, the costs for the utilization were obtained directly from providers, and the individual risk factor histories were obtained from the participants on a supplemental survey. Thus, utilization, demographics, risk profiles, and costs could be estimated on average for each individual (Duan et al.; Miller et al.) This model provides the most precise estimate and methodology on the economic costs of smoking to date. Projecting to 1993, the smoking attributable economic costs for the United States were US$ 50 billion, more than twice the previous estimate (CDC, 1994). These costs reflected the high rates of medical inflation, but did not include costs due to cigarette caused fire deaths and injuries, perinatal disease costs generated by smoking among mothers and pregnant women, or indirect losses associated with disability and premature death. The estimate is, hence, a minimum estimate of the economic costs of smoking, and the objections raised by the previous methods have been largely overcome. The most important ingredient in the above methodology has been the development of a survey that can link health risk behaviour, health status, costs and medical care utilization patterns. For most developing countries, this will not be possible, However, by including smoking history on surveys of household expenditures (which are performed by many countries to assess economic conditions and capabilities) similar economic studies may be possible. Here, data development is a priority, and the use of extensive economic models is necessary to make an accurate assessment of the economic impact of smoking on a national health care system.F*-++ԌNot all of the costs of tobacco are relatively easy to measure, or in fact even capable of measurement. But that does not preclude useful documentation. For instance, the tobaccorelated death of a prominent local person in arts, politics or business might be seen as one of the most wellrecognized costs of tobacco use. The same applies to the cost of supporting an incapacitated family member or the cost associated with lower educational achievements of children due to tobacco expenditure by, or early death of, a parent. The truly significant costs of tobacco use are measured not in money but in the tragic and unnecessary loss of human health and lives and all the things these people are precluded from ever doing.  X  Tobacco advertising Where advertising is permitted (even if there are restrictions), funds devoted to advertising and promotion will be the largest single expenditure by tobacco companies, even exceeding the amount spent to purchase tobacco leaf. Within the United States alone, US $6.2 thousand million was spent on tobacco advertising and promotion in 1993. Since tobacco companies attach such great importance to the advertising, promotion and marketing of their products, it is also essential for tobacco control advocates to gain an understanding of this realm. It is important to document the most popular forms of tobacco advertising, promotion and marketing present in the country, in addition to gathering comprehensive information on the brands available, their tar/nicotine levels and their target markets. It is worthwhile for tobacco control advocates to document the nature, the extent, and the effectiveness of all legislation or regulation of tobacco marketing, advertising and promotion, as well as the status of any voluntary agreement operated either by the tobacco companies themselves, or through some formal or informal agreement with the government. C* -++ԌAll enterprises and associations that benefit from tobacco advertising and promotion can be identified and documented. These will cover a surprising range, including everything from small enterprises that install billboards, to municipal transportation authorities that receive revenue for advertising cigarettes on city buses, to theatre and dance groups that receives financial support from tobacco companies. Some estimate of the total number of people involved in tobacco advertising and promotion activities could also prove useful in understanding the extent of tobacco industry influence in the advertising sector.  X Documenting national tobacco control policies On a positive note, in many countries, some form of government activity to control tobacco is already taking place. About half of all countries have some form of antitobacco legislation or regulation, and most countries have some form of antitobacco activity. Whatever activities are going on, it is important that they be documented, since it will be very difficult to improve the comprehensiveness of tobacco control policies without a sound knowledge of its current status. In the governmental sector, it will be important to identify the nature, extent and effectiveness of tobaccorelated health promotion and health education activities, as well as prevailing practices to support cessation of smoking. In reviewing national policies it is possible to use the following framework: X1)XM M Does the accessibility of the product reflect the gravity of harm associated with their use? Clearly a product that has no safe level of consumption and kills half of its users should not be sold cheaply, in health care facilities, in vending machines or to children.%"M C* -++ԌX2)XM M Does the legislation promote full and free consent among users and potential users of tobacco products? Misleading images and messages, such as those of tobacco advertising and alluring packaging should be prevented. There should be prominent and detailed health information on (and possibly in) tobacco packaging and at point of sale. There should be full public disclosure of all product toxins and additives. There should also be appropriate mandated public health education efforts, including efforts to educate the public about the role of the tobacco industry. There should also be a requirement for the provision of assistance to those who wish not to be using tobacco products.%"M X3)XM M Does the legislation ensure that the use of tobacco products does not put at risk the health of those other than the direct user of the product? This means effective protection from involuntary exposure to tobacco smoke in such places as public spaces workplaces and public transit.%"M X4)XM M Does the legislation give authority to require product modification? Virtually all other consumer products are subject to rigorous government controls. Controls over the manufacturing of tobacco products, and limits on which tobacco products will be allowed for sale has the potential to greatly influence future addiction and death rates.%"M  To an increasing extent, protection from involuntary exposure to tobacco smoke is being provided in health care institutions, transit vehicles, public places and workplaces, with varying degrees of effectiveness. Much of this protection is provided through a variety of national, regional and local legislation, through various administrative rules and voluntary agreements. Documentation and analysis of both the extent and effectiveness of current levels of protection from involuntary exposure to tobacco smoke will form part of the initial documentation needed for moving towards further improvements in the comprehensiveness of national tobacco control policies. C* -++ԌAnother aspect of tobacco control policies that needs to be recorded is the status of laws or regulations that prohibit selling or giving tobacco products to children and adolescents. If the laws are in place, yet not enforced (as is often the case), this also needs to be documented.  X.  Taxes, prices and consumption Tobacco taxes are a very important element of comprehensive tobacco control. Typically, tobacco taxation policy is set in the Ministry of Finance, while the actual tax collection is performed by the Ministry of Revenue. In federal states, two or even three levels of government may collect tobacco taxes. Whatever the state of current tobacco taxation, improvement of the comprehensiveness of tobacco control policies requires a thorough understanding of the current nature and extent of tobacco taxation, and its relative importance as a source of government revenue. For every 10% increase in real price (the price after inflation is taken into account), consumption will fall by a smaller amount, ranging from 2% to 8%. Among adolescents and people with low incomes, even larger decreases in consumption have been observed for every 10% increase in price. The significance of this observation for public health is that price can be increased through tobacco taxation, causing a fall in tobacco consumption, while simultaneously increasing government taxation revenue. This phenomenon can be used to good advantage in constructing tobacco control strategies.  Xr# Public opinion surveys In Chapter VIII, questions on public opinions about various tobacco control policy options are identified as suitable candidates for inclusion in surveys of knowledge, attitudes and practices concerning tobacco consumption. Documentation of the state of public opinion on various tobacco control measures, derived from the findings of suchC* -++ surveys, will be particularly vital information for improving the comprehensiveness of tobacco control policies and, in particular, of supporting proposed government action. The majority of surveys that have already been conducted show that a majority of the population favours all of the elements of a comprehensive tobacco control policy as recommended by the World Health Assembly, with a number of measures even supported by smokers.  X  Types of Country Profiles Country profiles can serve a variety of purposes. Therefore, different levels of detail may be needed, ranging from a concise summary of tobacco and health issues on just a few pages, like those given for each country in the world in the WHO publication,  X Tobacco or Health: First Global Status Report, to more extensive country profiles, like those published for countries in the Region of the Americas in the publication of the  Xv PanAmerican Health Organization (PAHO) entitled Tobacco or Health: Status in the  X Americas (see Reading List for Chapter V). If countries have not already done so, it is recommended that they prepare profiles with at least basic information related to their situation concerning tobacco. These should be revised and updated annually.  A question that will inevitably be asked in any national policy debate on tobacco and health issues is, "How does the tobacco and health situation in our country compare to that of other countries?" Information obtained from other countries will, of course, be helpful in providing answers to this question.  X" Publications of WHO like Tobacco or Health: First Global Status Report,  X~# Tobacco or Health: Status in the Americas and the quarterly journal, International  X$ Digest of Health Legislation, can be very valuable in providing a sound information base for planning and programming for international tobacco control. Publications of WHO's affiliated agency, the International Agency for Research on Cancer, and other international organizations like International Union Against Cancer are also useful sources of information on international tobacco control. Examples of concise and moreU* -++ comprehensive country profiles are given in Appendices V.2 and V.3 (concise: Indonesia, Appendix V.2; more comprehensive: Jamaica, Appendix V.3).  X  CONCLUSION: KEY ISSUES IN INFORMATION SUPPORT  X  To most effectively support strengthened tobacco control policies and programmes, it is useful to have a current and reliable picture of the tobacco situation specific to that country. For many countries, there is already a wealth of available data that is easily accessible. Where possible, the following information is desirable:  Sociodemographic characteristics  Tobacco production, trade and industry  Tobacco consumption  Prevalence of tobacco use  Tobaccoattributable mortality and morbidity  Tobacco control measures, organizations and institutions  Tobacco in the national economy  Tobacco advertising and promotion  Public opinion on tobacco issues