Implementation

Four steps should be considered to implement primary prevention for tobacco control nationally.

• Establish a national anti-tobacco council that will include membership from the national cancer control program, but that will also include other stakeholders (e.g. the agricultural or finance ministries) to generate the intersectoral approach that will be needed.
• Appoint a leader/administrator for the program and provide appropriate advisory and infrastructural support.
• Perform a sampling survey to determine the prevalence of tobacco use.
• Establish a primary prevention program against tobacco using the threefold strategy of education, legislation and national leadership as summarized on slide 6 and discussed in more detail below.

Tobacco Dependency

From 65-85% of global tobacco consumption is in the form of cigarettes including bidis (tobacco wrapped in a temburni leaf and widely consumed on the Indian subcontinent) and kreteks (clove-flavoured cigarettes which are popular in Indonesia). An additional 15-35% of tobacco is consumed in the form of all other tobacco products.

Typically young people take up the habit under peer pressure. The social habit is then reinforced by addiction (physiological dependence) to the nicotine in the tobacco. Stopping tobacco precipitates withdrawal symptoms within hours including irritability, anxiety, restlessness, and drowsiness. Concentration and psychomotor function may become impaired. Symptoms may persist for weeks or months.

Health Significance

There are more than 3000 chemical constituents in tobacco and its smoke, including many known carcinogens. When the smoke is inhaled the lungs are affected, and the oral cavity is affected when tobacco is chewed. For other sites the carcinogens are absorbed into the blood stream from the lungs and transported to the organs at risk.

Although rare in North America and Europe in the early 20^th century, the incidence of lung cancer began to increase significantly about 15 years after the First World War when members of the armed forces smoke heavily. A similar increase in incidence was seen with women in the 1960’s, associated with the heavy use of cigarettes during the Second World War 15-20 years earlier. More than 6% of deaths in several developed countries is now due to lung cancer. The same is occurring in developing countries where national and multinational tobacco companies market tobacco products with increasing vigor. In general tobacco is responsible for 30% of cancer deaths, including 80-90% of lung cancer deaths and 40% of bladder cancer deaths, and some cancers of the larynx, pharynx, esophagus, stomach, pancreas, kidney and cervix (references listed below). Ninety percent of oral cancers are attributed to tobacco chewing and smoking habits. In addition to morbidity and mortality from atherosclerosis, hypertension, cerebrovascular and peripheral vascular disease, 25% of ischemic heart disease deaths are due to smoking, as are 75% of deaths from chronic bronchitis and emphysema (Stanley, 1993). Maternal smoking slows fetal growth, reducing birth weights by 200 grams, and increases twofold the risk of spontaneous abortion and of complications during pregnancy and labor (Stanley, 1993). The perinatal risk is increased by 35% as is the risk of cardiovascular disease in women taking contraceptive pills (Stanley, 1993). The risk of lung cancer in nonsmokers married to smokers is increased by 25-35%. Addiction to nicotine is by far the world's largest substance abuse problem. Mechanisms of this addiction are similar to those of heroin and cocaine. In addition to effects on the environment from cultivation of tobacco, there are adverse economic effects on the family and in the workplace (Stanley, 1993). Passive exposure to tobacco smoke increases the risk of lung cancer and probably cancer at other site in non-smokers.

Tobacco Control

A substantial literature is available on details of legislative and other controls for tobacco, which should be consulted directly (references listed below). Only some general comments can be given here.

The extent of national legislation and its enforcement is one of the best indicators of national commitment to tobacco control (Stanley, 1993). Its role is to help establish nonsmoking as normal social behaviour. It expresses public policy, sending a clear message to the population that tobacco use is harmful. If it is not too far ahead of public opinion and is accompanied by effective education programs, it can be implemented without being expensive or difficult to enforce, and will change social attitudes and reduce tobacco consumption (Stanley, 1993).

The tobacco industry will oppose strongly the most effective legislative measures - price increases and advertising bans, often by appealing to fears that rights to freedom are being taken away (Stanley, 1993). But smoking control programs without a legislative component will be unsuccessful. A broadly defined education program airing anti-smoking messages aimed at reducing smoking must be complemented by multifaceted legislative measures controlling advertising and introducing rotating warnings and price increases (Stanley, 1993; Smoking Control Strategies WHO, 1983). Such programs have resulted in substantial reduction in tobacco consumption, for example in Finland and Norway (Roemer, 1987)).

The most significant reductions in tobacco consumption are produced by a combination of regular price increases through taxes on tobacco products with effective health education. The fall in consumption is greater for teenagers, especially young men and those in lower socioeconomic groups, and plays an important role in reducing the number starting a tobacco habit. Raising cigarette prices is one of the most effective public health tools available to reduce cigarette consumption, but only half the effect is a real reduction in consumption, the other half being a restructuring of the market (Stanley, 1993) with a switch to lower-priced brands, other tobacco products and eventually to an increase in bootlegging. This problem is solved by market-neutral simultaneous increases in the cost of all tobacco products, with greater proportional increases in least expensive products of more than three to one (Stanley, 1993). Although a price increase decreases consumption, that decrease is proportionately smaller than the increase in tax revenues so that tobacco taxes raise tax revenues for a country (Stanley, 1993).

A high priority of legislation should also be a total ban on tobacco advertising on television, radio and other mass media. Industry sponsorship of sports and cultural events should be restricted.

Other types of legislation include the use of strong rotating health warnings on tobacco product packages, and restrictions also on the use of low-tar cigarettes. Smoking should be banned, or areas for smokers set aside, in public places, government institutions, schools, hospitals, restaurants, public transport and the workplace. These restrictions protect nonsmokers from the effects of passive smoking and give the message that smoking is not a normal social behaviour and can harm nonsmokers. Legislated sales restrictions and prohibition in schools supported by strong education programs will reduce the number of young people who start smoking. It should be illegal to sell tobacco to minors and selling tobacco in vending machines should be prohibited. Legislation should also be enacted to eliminate government subsidies of the growing and manufacturing of tobacco. The cultivation of tobacco should be discouraged in favor of alternative food crops.

The relative effectiveness of these various measures is summarized in table 11 (adapted from Stanley, 1993).

TABLE 11: COMPONENTS OF A NATIONAL TOBACCO CONTROL PROGRAM

Success in getting legislation enacted requires not only extensive efforts at public information and education, but also strong citizen advocacy to persuade legislators (Chapman & Lupton, 1994). In countries such as Canada and Australia tobacco control through legislation has come more from organized citizen advocacy than from the medical profession. It is recommended that the NCCP through its National Office examine in detail this experience in other countries as it formulates its strategies. In Canada advocacy processes have been particularly effective as organized through the Canadian Cancer Society and its many partners in the anti-tobacco effort. The Vic Health model, which began in 1987 in the state of Victoria in Australia, should also be examined. It has been praised by WHO as a model for taxing cigarettes and using the proceeds to replace tobacco company advertising with anti-smoking campaigns, and sponsorships with health promotions, especially of sport, the arts and cultural events. It operates alongside a ban on all cigarette advertising and promotion. It now competes with tobacco companies for new markets in Asia and the Pacific Islands that have the highest cigarette consumption in the world and are being targeted by the tobacco companies.

Evaluation

Any successful programming requires ongoing feedback so that it can be self-correcting and one can know if it is effective. Process, impact and outcome measures are needed (WHO 1995). Process measures examine the effectiveness of program operations – how well program components work and interact. Impact measures look at immediate short-term effectiveness, effects that may not have long-term consequences. Outcome measures examine program effects that have long-term consequences with attitudinal, behavioral or biological changes in the population. Such effects can be in the short, medium or long term.

For tobacco control, WHO (1995) recommends the following indicators as examples.

Process Measures
Over 80% of schoolchildren aged 10 years and over get antismoking education .
Over 50% of adults get an anti-smoking message yearly.
Half of possible anti-tobacco legislative measures are implemented.

Impact Measures
Over 80% of schoolchildren aged 10 years and over are aware of the
hazards of smoking (population survey).
Over 50% of adults are aware that smoking causes lung cancer (population survey).
More than a third of adult smokers intend to quit within a year.

Outcome Measures
Short term: Less than a third of adolescents are regular smokers.
Less than half of adult men and less than a third of adult women smoke.
Medium term:Reduced incidence of cardiovascular and respiratory diseases.
Long term: Reduced mortality from diseases like lung cancer.

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