World Health Organization Framework Convention on Tobacco Control

The Effect of Tobacco Control Measures during a Period of Rising Cardiovascular Disease Risk in India: A Mathematical Model of Myocardial Infarction and Stroke.

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Abstract

Background

We simulated tobacco control and pharmacological strategies for preventing cardiovascular deaths in India, the country that is expected to experience more cardiovascular deaths than any other over the next decade.

Methods and Findings

A microsimulation model was developed to quantify the differential effects of various tobacco control measures and pharmacological therapies on myocardial infarction and stroke deaths stratified by age, gender, and urban/rural status for 2013 to 2022. The model incorporated population-representative data from India on multiple risk factors that affect myocardial infarction and stroke mortality, including hypertension, hyperlipidemia, diabetes, coronary heart disease, and cerebrovascular disease. We also included data from India on cigarette smoking, bidi smoking, chewing tobacco, and secondhand smoke. According to the model’s results, smoke-free legislation and tobacco taxation would likely be the most effective strategy among a menu of tobacco control strategies (including, as well, brief cessation advice by health care providers, mass media campaigns, and an advertising ban) for reducing myocardial infarction and stroke deaths over the next decade, while cessation advice would be expected to be the least effective strategy at the population level. In combination, these tobacco control interventions could avert 25% of myocardial infarctions and strokes (95% CI: 17%–34%) if the effects of the interventions are additive. These effects are substantially larger than would be achieved through aspirin, antihypertensive, and statin therapy under most scenarios, because of limited treatment access and adherence; nevertheless, the impacts of tobacco control policies and pharmacological interventions appear to be markedly synergistic, averting up to one-third of deaths from myocardial infarction and stroke among 20- to 79-y-olds over the next 10 y. Pharmacological therapies could also be considerably more potent with further health system improvements.

Conclusions

Smoke-free laws and substantially increased tobacco taxation appear to be markedly potent population measures to avert future cardiovascular deaths in India. Despite the rise in co-morbid cardiovascular disease risk factors like hyperlipidemia and hypertension in low- and middle-income countries, tobacco control is likely to remain a highly effective strategy to reduce cardiovascular deaths.

Discussion

Substantial evidence links tobacco use to CVD, yet tobacco use in India and several other LMICs is on the rise . This worsening trend led the UN High Level Meeting on Prevention and Control of Non-Communicable Diseases to recommend that countries accelerate implementation of the FCTC. Our findings indicate that full implementation of key FCTC articles in India would yield substantial reductions in mortality from myocardial infarctions and stroke, despite projected increases in other risk factors for CVD such as hypertension and diabetes. Far from achieving “diminishing returns,” vigorous implementation of these tobacco control policies would be expected to avert 25% of all predicted CVD deaths, equivalent to over 9 million averted deaths, over the decade 2013 and 2022 under a reasonable set of modeling assumptions.

Furthermore, the population-level benefits of implementing strong tobacco control policies were five times greater than a similarly aggressive program to implement pharmacological interventions (Figure 3), assuming that India’s implementation of pharmacological therapy is no faster than in high-income nations like the UK. However, critically, we would anticipate additive benefits of implementing pharmacological interventions concurrently with strong tobacco control policies: the combined package of both pharmacological and tobacco control interventions would not be redundant, and could avert nearly a third of cardiovascular and cerebrovascular mortality over the next decade by tackling multiple risk factors for myocardial infarctions and strokes.

Among the interventions we simulated, smoke-free legislation and tax increases on both cigarettes and bidis were the most effective at the population level. Smoke-free legislation, an advertising ban, and a mass media campaign had wide confidence intervals because their degree of population effectiveness was subject to the degree of effective enforcement.

We used, to our knowledge for the first time, population-representative data to represent the co-morbid risks of CVD among both urban and rural populations in India, and among both men and women in multiple agegroups. We found that nearly all sectors of Indian society were likely to benefit from both tobacco control and pharmacological therapies. However, the populations benefiting most were urban males and persons in the 60- to 69-y-old age category. This is due to the higher baseline prevalence of co-morbid risk factors among urban males and this older age group; hence, these populations achieve greater risk reduction from the simulated interventions.

 

Conclusion

Given the complexities of India’s tobacco and CVD epidemics, it is important to understand how heterogeneities within the large Indian population may affect both the risk of disease as well as the impact of various policy and health care interventions. In this study, we provide to our knowledge the first model that incorporates population-representative data from India disaggregated by age, gender, and location for all of the major CVD risk factors as well as for specific types of tobacco use. Prior models have either used “average” Indian or regional disease rates, have not captured various types of tobacco use other than smoking, or have not incorporated the multiple risk factors affecting CVD in addition to tobacco use. This means that, for the first time, we can study some health disparities in CVD and in tobacco use within the large and varied Indian population, as well as heterogeneity in the impact of proposed interventions. These results provide clear justification for India’s Ministry of Health and Family Welfare to engage in greater enforcement of the FCTC and the Indian legislation that enacts the FCTC in the country, the Cigarettes and Other Tobacco Products Act.

Our simulations suggest that the implementation of recommended tobacco control interventions in India would yield substantial and rapid health benefits, but those benefits may accumulate most among males, urban dwellers, and older adults. Effective implementation of FCTC provisions remains a major challenge in India. At present, smoke-free legislation in India is not comprehensive and is poorly enforced . There is little indication that brief cessation advice is routinely administered, and additional resources may be required to strengthen implementation. Tobacco taxes in India would also need to be substantially increased and harmonized between different tobacco products to comply with WHO recommendations, and achieve desired population-level disease reductions . Cigarettes are currently taxed according to their physical length in India, meaning that uniform tax increases will encourage product substitution unless large price differentials between products are addressed.

Optimizing preventive interventions for CVD remains a significant challenge for developing countries like India. Our model demonstrates synergies between tobacco control and pharmacological therapies for key CVD risk factors. It does not, however, support the idea that enhanced prevalence of key risk factors renders diminished results from tobacco control interventions. Rather, policymakers should take note that fuller and faster implementation of existing FCTC provisions would likely be a substantial boon to efforts to reduce CVD mortality in India and other LMICs.

Source: PLOS

Tobacco control—political will needed.

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Tobacco use kills about 6 million people per year, and most of the deaths are in Asia. In WHO’s South East Asian region, an estimated 1·3 million people die every year from tobacco-related disease, whereas in the Western Pacific region, two people die every minute. All these premature deaths are preventable.

Tobacco smoking is a commercially driven behaviour, and policies that prevent smoking have been under development for decades. As always in public health, these effective policies operate at population level, and could cost little or nothing to implement—eg, price rises, promotion of bans, smoke-free policies, or media campaigns. However, implementation of these policies, as measured across Europe at country level with the Tobacco Control Scale 2010, remains far from comprehensive. The introduction of effective policies to prevent smoking in European countries could be of profound benefit to the health of millions of people. However, the necessary political, and medical, leadership has been lacking so far.

The UK Government commissioned a systematic review on standardised packaging, launched on April 16, 2012, to inform its own consultation process. The report concluded that standardised packaging increases noticeability and effectiveness of health warnings and messages, and reduces use of designs that mislead consumers about harmfulness of tobacco products. However, as yet there has been no follow-up 8 months since the close of the consultation. Although the UK’s Public Health Minister Anna Soubry recently came out publicly in favour of standardised packaging of tobacco products for the first time, there is no sign that the Health Minister—Jeremy Hunt—has put standardised packaging forward to the Cabinet for discussion. This is despite the fact that Hunt supposedly prioritised reducing premature mortality when he became Health Minister. His call to action published on March 5, 2013, stated clearly that “Tobacco use is the single biggest behavioural risk factor for premature death”, and he committed to make a decision on whether to introduce standardised packaging. To reduce premature mortality, Hunt needs to do more to tackle smoking, and introduction of standardised packaging is essential. There is little time until the Queen’s speech on May 8, 2013, when the UK Government’s legislative programme for the 2013—14 Parliamentary Session is finalised.

In Asia, major challenges also remain in tobacco control. For example, associations between governments and national tobacco monopolies in countries such as China create a conflict of interest—ie, the Chinese Ministry of Industry and Information Technology is responsible for tobacco control, but is also in charge of the State Tobacco Monopoly Administration. Other issues such as scarce funding, continuing legal challenges against governments undertaking tobacco control measures, meeting WHO’s global monitoring target of reduced prevalence by 2025, and obligations within WHO’s Framework Convention on Tobacco Control (FCTC) still remain on the political, social, and economic agenda.

Although difficulties remain, there is some good news worth celebration. In December, 2012, Australia became the first country to introduce standardised tobacco packaging, comprising large and graphic health warnings and limiting brand information to a name and descriptor in standardised font on a plain background. New York City is proposing to raise the legal age at which cigarettes can be bought from 18 years to 21 years, following moves by other US counties and states to raise the age to 19 years or 21 years. Finally, Cancer Research UK has recently won its second victory through the Advertising Standards Authority against Gallaher, leading to a ban on the tobacco company attacking proposals for standardised packaging. This reflects this year’s World No Tobacco Day‘s theme—ban tobacco advertising, promotion, and sponsorship.

All countries should now implement and enforce FCTC smoke-free policies, close exemptions and concessions that many countries provide, and explore extensions that will reduce exposure to children, as seen in New York where smoking is prohibited in parks and other outdoor public areas. Exposure of children to smoke in private vehicles remains a problem and can be addressed through media campaigns and legislation; prevention of smoking in the home is more challenging. The worldwide epidemic of tobacco use causes an enormous burden of morbidity and mortality, one that is entirely preventable. Yet the solution will not only be found in doctors’ clinics and hospitals, but also in the political and legislative arena.

Source: Lancet

 

Judith MacKay: self-made scourge of the tobacco industry.

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Judith MacKay learned early on in her career to wear insults as a badge of pride. “A gibbering satan”, prone to the use of “diatribes full of putrid corruption, lies, conspiracy, and total censorship” is just a taste of the many slurs that came MacKay’s way in the early 1990s. What MacKay had done to merit such attacks from US smokers’ rights groups was what she has been doing since the early 1980s: tirelessly and effectively advocating for better control of tobacco products around the world, but in Asia in particular.

As MacKay and her colleagues explain in their paper on Tobacco Control in The Lancet, as well as being one of the biggest markets for tobacco, Asia has also been at the forefront of efforts to control its use. MacKay has been a central figure in that cause. Born in Saltburn by the Sea on the UK’s northeast coast, MacKay moved to Hong Kong with her husband in 1967 after graduating in medicine from the University of Edinburgh at the age of just 22 years. And after a brief hiatus to do what she calls “a few traditional things like having babies”, and brushing up on her Cantonese, her increasing involvement with the feminist movement led MacKay to think more seriously about a long-term career.

She went back to medicine, and as a specialist in internal medicine at Hong Kong University’s hospital MacKay started to see more and more patients with tobacco-related diseases. It dawned on her that there was a pressing need “to go further up the river in public health terms”, and at the same time, she says, she was “very interested in health education, and was writing 1000 words a week for the South China Morning Post for a column on women’s health”. It was the “ballistic”, vitriolic response of the tobacco industry to a series of MacKay’s articles on women and tobacco that finally affirmed tobacco control in her mind as the cause to which she should devote her life’s work. “I left clinical medicine in 1984”, she says, “and I never looked back really”.

So how do you go about setting yourself up to influence government tobacco policy? It’s not something, as a rule, that tends to come up in medical curricula. “I was never trained on how to lobby a finance minister for a tax increase, or put out a press release, or front up to a very powerful industry”, says MacKay. But she was steadfast in the face of industry intimidation and, importantly, “she had the ear of governments because she has a persuasive style rather than confrontational approach—a skill much appreciated when dealing with conservative style Asian governments”, says Mary Assunta, Director of the International Tobacco Control Project run by Cancer Council Australia.

Working alone and often unpaid for 25 years, MacKay’s appointment in 2006 as Senior Advisor to both the World Lung Foundation component of the Bloomberg Initiative to Reduce Tobacco Use in low-income and middle-income countries and the Bill and Melinda Gates Foundation reflects the huge change in attitudes towards tobacco over the intervening years. “It’s institutionalised now”, she says: “it’s become mainstream public health in a way, whereas back in the 70s and 80s it was seen as very quirky. There was a caution and a real feeling that somehow I’d gone off the main tracks of medicine, but nowadays the understanding is much wider than it was before.” Through the WHO Framework Convention on Tobacco Control to new funding from Bloomberg and the Bill and Melinda Gates Foundation, there is a real momentum now behind tobacco control. “Almost every day I get something in the inbox about a new law that’s been created or expanded or implemented”, MacKay says. But there is also a real need to ensure that progress does not breed complacency.

The tobacco industry is no different than it has ever been, MacKay warns, although their tactics have evolved. “They’ve tried to attack the science, then moved on to attacking individuals like myself, and now they’ve moved to attacking governments”, she says. The Australian Government’s recent decision to introduce plain packaging for cigarettes attracted a lengthy challenge in the Australian High Court, along with an ongoing dispute in the World Trade Organisation. It’s a familiar story according to MacKay. “In the same week, the Minister of Health from Scotland and the Minister of Health from Iran said the same thing to me: ‘we’re bogged down with legal challenges’. It’s a delaying tactic, and they’ve delayed some legislation in India for example for almost a decade”, she notes. But apart from delaying the adoption of graphic warning labels on cigarette packaging in the USA, these challenges have been unsuccessful. “It’s a paper tiger”, she says.

The same can’t be said of MacKay herself, and she is in no doubt that over the next few years she can help persuade more governments to start setting targets and consider endgames, such as New Zealand’s recent announcement of a goal to reduce smoking prevalence to 5% by 2025. An endgame for MacKay, though, is something she’ll not be considering any time soon. “That’s the wonderful thing about public health, you can go on forever”, she says. “I really quite seriously think I’ll be campaigning on my 100th birthday.” And for the tobacco industry representatives who she assures me will be poring over this article, there can’t be much worse news than that.

Source: Lancet