Tobacco and Society: How We Can Make a Difference in Public Policy

Home , American Tobacco Company, Nil (cigarette)

Richard D. Hurt, M.D. Professor, College of Medicine Director, Nicotine Dependence Center Mayo Clinic http://ndc.mayo.edu

and thus began the globalization of tobacco--- sad but true.” Glynn T, et al, CA Cancer J Clin 60:50, 2010 © 2013 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED Early Cigarettes

• 1883 - Allen & Ginter contest for mechanical cigarette roller • James Bonsack won contest. Roller produced 120,000 cigarettes/day • James Buchanan “Buck” Duke obtained rights and in 1884 Bonsack machines went on line in Durham, NC • 1889 American Tobacco Company formed

Bonsack Machine- 120,000 cigarettes/day

• 1898 – Acquired R. J. Reynolds plug tobacco company • 1899 – Controlled 93% of cigarettes, 80% of snuff, 62% of plug tobacco, and 59% of pipe tobacco in USA • 1903 – Deal with Imperial Tobacco Company of Britain created British American Tobacco • 1906 – Duke successfully lobbied Congress to NOT include tobacco in the Food and Drug Act © 2013 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED American Tobacco Company

• 1907 - Antitrust suit filed • 1909 - 3rd largest industrial enterprise in USA • 1911 - US Supreme Court dissolved Duke Trust - ATC, RJR, L&M and P. Lorrilard • 1913 – “Year of the Camel” - RJR

The world’s first public health treaty aimed to protect present and future generations from the harms of tobacco use and exposure to tobacco smoke.

Now ratified or acceded by more than 170 countries

Conference of Parties (COP4) meeting in Uruguay

© 2013 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED FCTC Measures to reduce demand • Price & tax (Art. 6, Art. 7) • Protection from exposure to tobacco smoke (Art. 8) • Regulation of contents and disclosures of products (Art. 9, Art. 10) • Packaging and labeling (Art. 11) • Education, communication (Art. 12) • Advertising, promotion & sponsorship (Art. 13) • Tobacco dependence and cessation (Art. 14) © 2013 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED

Endgame in New Zealand by 2025

Drs. Richard Edwards and Hayden McRobbie

Vision The vision for this tobacco control plan is for New Zealand to be a country where smokefree lifestyles are the norm. Goals The goals of this tobacco control plan are:  to significantly reduce levels of tobacco consumption and smoking prevalence  to reduce inequalities in health outcomes  to reduce the prevalence of smoking among Māori to at least the same level as among non-Māori  to reduce New Zealanders’ exposure to second-hand smoke.

Clearing the Smoke: A five-year plan for tobacco control in New Zealand (2004–2009). Wellington: Ministry of Health, 2004. © 2013 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED Facets of the endgame

 Zero (or very close to) smoking prevalence  Zero or close to zero uptake of tobacco  Nil or close to zero supply of tobacco – e.g. prohibition, no commercial supply  Full denormalisation of tobacco use i.e. smoking seen as an undesirable and aberrant behaviour, unacceptable for children  Zero or close to zero tobacco related mortality and morbidity  Time-limited

1. Tobacco is a uniquely hazardous product:  Major cause of ill health, premature death and health inequalities  Tobacco smoking is highly addictive  most smokers want to quit and regret starting  but only about 2% per year quit successfully spontaneously  max quit success around 20% at 1 year with support  Secondhand smoke (SHS) is a significant acute and chronic health risk for non-smokers (inc children)  Tobacco products are legal only due to historical accident

2. Smoking starts mainly among children and young adults:  Hardly anyone starts smoking as a mature adult  Children do not (cannot) make informed decisions about smoking

3. Protecting children from known hazards is generally viewed as a moral imperative and is a societal responsibility.

“Sixteen-year-olds are in no position to assess the dangers of binge-drinking. Fifteen, 14 and 13-year-olds even less so. If the industry cannot find a way to keep alcohol out of the hands of children, society must.”

Dominion Post editorial (response to death of James Webster, aged 16); 13th May 2010

 Further tax increases  Ban retail displays- In place in Canada.To be implemented in large stores in UK in 2012 & all retailers 2015  Tobacco sellers > 18 years  Compulsory reporting of additives by brand  Prohibit covert sponsorship  Action to enforce illegal sales laws

 Ban vending machines  NRT available at all tobacco retailers  Pharmacists -> Quit Card providers  Ban or restrict duty free imports

 Plain packaging- Australia implemented 2013  Tobacco industry funds all treatment support including pharmacotherapy  Regulate nicotine and additives  Explore alternative (safer) nicotine delivery systems  Control retailer numbers, density, and proximity

© 2013 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED © 2013 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED © 2013 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED © 2013 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED Summing up

We need:  to switch to endgame thinking  a clear vision of the endgame and a defined time period to achieve it  a comprehensive endgame strategy, including overarching measures to achieve the desired rapid reductions in smoking prevalence  health professionals’ support

• Deny access to tobacco for citizens born in or after the year 2000 • Gradual phase out → less disruption • Aligns with tobacco industry assertion “We do not want children to smoke” • Affixing to easily identifiable year facilitates identity checking • 70% of Singaporeans support the proposal

Khoo D. et al Tobacco Control 19:355, 2010

. Created in 2005 by President Bill Clinton “to help turn good intentions into real actions and results.” . Convenes over 1,000 global leaders to devise and implement innovative solutions to some of the world’s most pressing problems . CGI members make commitments to improve the lives of people across the globe

26 27 Global Bridges Mission

Create and mobilize a global network of healthcare providers and organizations dedicated to advancing effective tobacco dependence treatment and advocating for effective tobacco control policy.

www.globalbridges.org

28 Primary Aims

. Build a network… Create opportunities to share treatment and advocacy expertise among network members within and across regions . Provide training… State-of-the-art, evidence-based training in tobacco dependence treatment and advocacy . Article 14 implementation… Facilitate the implementation of FCTC Article 14 in every nation . Sustain the mission… Ensure the long-term financial sustainability of the initiative

Global Bridges Regional Partners

Latin America Region

Gustavo Zabert, MD – Regional Director Middle East Region

Feras Hawari, MD – Regional Director Africa Region

Lekan Ayo-Yusuf, BDS, MPH, PhD – Regional Director

GB Accomplishments Summary

. Since April 2011, Regional Partners have trained over 1500 HCPs from 52 countries Over 16,273 person-hours of training, impacting thousands of patients . Presented at national, regional, and global meetings with combined attendance of over 18,000 . www.globalbridges.org launched in 6 languages 724 members have joined via website . Active collaborations with ATTUD, treatobacco.net, Global Nurses Network, American Academy of Pediatrics, Global Smokefree Partnership, Hong Kong Dept of Health, INWAT, American Association of Anesthesiologists, and others

Global Smoke-free Worksite Challenge

. Winter meetings of CGI participants helps implement commitments and also generate new ideas . Ask all CGI members to develop and implement smoke-free worksites . Leaders of the new commitment: Mayo Clinic, ACS, J&J, DHSS, Campaign for Tobacco-free Kids

32 33 34 Howard K. Koh MD, MPH Assistant Secretary for Health US DHHS

35 http://www.clintonglobalinitiative.org/ourmeetings/2011/meeting_annual_multimedia_player.asp?id=53

36 Advocacy at Different Levels

• Institution • School • Community • State • National • International

© 2013 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED Being an Effective Advocate • Call or write decision-maker • Contribute to political or nonprofit advocacy organization • Cultivate relationship with decision makers • Letter to editor • Volunteer or run for board positions • Testify before legislative body

WE DO NOT HAVE TO AND WE SHOULD NOT!

September 2009

We owe it to our grandchildren

BUT WE OWE IT TO THEIR CHILDREN AND GRANDCHILDREN, TOO! December 2012 20th Century-100 Million Deaths

21st Century-1 Billion Deaths