The most cost-effective tobacco control measures -- including higher tobacco taxes, elimination of tobacco advertising and promotion, smoke-free environments and strong, graphic health warnings on tobacco packaging -- help achieve all of these goals. For example, increased tobacco taxes prevent smoking initiation and also motivate smokers to quit or to cut down. Smoke-free environments are implemented to protect nonsmokers but also result in reduced consumption and quitting by smokers. They also create an environment that decreases the social acceptability of smoking, which helps prevent smoking initiation.
Programs that are specifically targeted at specific populations or behavior change, such as smoking cessation or youth smoking prevention programs, are popular among governments, educators and many health professional organizations. However, these programs are extremely expensive and/or usually have a very limited impact in the absence of broader policy measures.
For example, a study conducted recently in Minnesota, USA, compared the impact of free nicotine replacement therapy (NRT) programs with smoke-free workplaces. It found that after one year, the NRT program generated 18,500 quitters at a cost of $7020 per quitter. The smoke-free workplace policy generated 10,400 quitters at a cost of $799 per quitter. In other words, smoke-free policies function very effectively as cessation programs.
Reviews of school-based youth smoking prevention programs have found that they have no lasting impact on smoking behavior. The few that have shown a short-term impact require intensive training and class time and other large resource investments.
Therefore, PAHO recommends that all countries, but particularly those with limited resources, focus first on achieving higher taxes, eliminating tobacco promotion, making all public places and workplaces smoke-free, and requiring effective graphic warnings on tobacco packaging. These strategies can later be supplemented by program measures targeted at groups among whom reducing tobacco use remains a large challenge.
Increasing the price of tobacco products through taxation is the most cost-effective measure a government can take to reduce tobacco use. Economic studies by the World Bank and others show that for every 10% increase in the real price of tobacco, consumption drops by about 4% in high-income countries and 8% in low- and middle-income countries. Higher prices have the greatest impact on those with the least disposable income: low socio-economic groups and youth. The cost effectiveness of tax increases – as well as most other tobacco control policies – is comparable to that of immunization in terms of life-years saved relative to the cost of implementation.
Why are governments reluctant to increase tobacco taxes?
Some governments are reluctant to raise tobacco taxes because they fear that this will reduce tobacco tax revenue and increase smuggling. However, evidence from many economically diverse countries shows that this is not the case. In fact, when tobacco tax rates go up, tax revenue also increases.
Furthermore, evidence shows that cigarette taxes and prices are not the most important factor in cigarette smuggling. Many high-tax countries have low levels of smuggling and many low-tax countries have high levels of smuggling.
Corruption is a better predictor of smuggling than cigarette prices. In addition, countries can significantly reduce smuggling through tracking and tracing systems that can quickly identify where and when products “disappear” into the illegal market and through strengthened enforcement and higher penalties. Spain provides a good case study for the reduction of smuggling through these measures.
Background papers on tobacco taxation:
The design, administration and potential revenue of tobacco excises
Effectiveness and cost-effectiveness of price increases and other tobacco control policies
Power Point Presentations
Price, tobacco control policies and youth smoking
Tool for researching on tobacco taxation
Secondhand smoke (SHS) is a mixture of thousands of chemicals, at least 250 of which are known to be toxic and/or to cause cancer in humans. There is no safe level of exposure to SHS. Exposure to secondhand smoke causes serious disease and death in nonsmoking adults and in children. The most recent major report on SHS risks was released in September, 2005 by the California Environmental Protection Agency Air Resources Board. It confirmed that, in adults, secondhand smoke causes:
In US: California, Connecticut, Delaware, Maine, Massachusetts, New York, Rhode Island, Vermont, Washington State
In Canada: Manitoba, Saskatchewan, New Brunswick and Newfoundland; and territories of Nunavut and Northwest Territories
Plus dozens of municipalities!
- lung cancer;
- nasal sinus cancer;
- breast cancer in younger (primarily pre-menopausal) women;
- heart disease and heart attacks;
- asthma induction and exacerbation; and
That SHS harms children, infants and reproductive health through
- acute lower respiratory tract illness (such as pneumonia and bronchitis);
- asthma induction and exacerbation;
- chronic respiratory symptoms;
- middle ear infection;
- lower birth weight babies; and
- sudden Infant Death Syndrome (SIDS).
The only way to provide protection from SHS is to make ALL indoor environments (and in some cases outdoor environments) 100% smoke-free. Shared smoking and non-smoking areas, or smoking rooms in buildings with a common ventilation system, contaminate the clean air with the polluted air. Increased ventilation can increase the comfort level but does NOT provide protection from SHS toxins. A ventilation system that could clean the air of smoke would have the force of a hurricane.
Separately ventilated smoking rooms do not protect those who have to work in them, let smoke into nonsmoking areas when the door opens and closes, are very expensive to install and are difficult to enforce.
Just as tobacco companies refuse to acknowledge that SHS is harmful, they (and restaurant, hotel and bar associations that they fund) also claim that smoke-free environments will cause restaurants and bars to lose business. But dozens of studies of sales, tax and employment data from smoke free jurisdictions show that, without exception, smoke free laws have either a neutral or a positive impact on bar and restaurant revenue.
PAHO’s Smoke Free Americas initiative raises awareness of the harm caused by SHS and promotes smoke free environments. For more information, please go to the Smoke Free Americas website.
Smokefree Europe 2005 Conference:
The tobacco pack is a critical advertising vehicle for tobacco companies. It is referred to as a “badge” product because of its close identification with the image of the smoker. Brands can convey sophistication, toughness, rebelliousness, femininity or masculinity, and a whole host of other images. These images are particularly important to adolescent smokers, who are still trying to establish their identity.
Conversely, tobacco packages can be used to discourage tobacco use, through package health warnings or through plain packaging.
Contrary to popular opinion, many smokers are not aware of the risks of tobacco use. They may know that tobacco “is bad for them,” but few realize the magnitude of risk relative to other behaviors (like eating junk food, for example), or their likelihood of dying from a tobacco-caused disease (half of all smokers die from smoking). Few smokers can name specific diseases, other than lung cancer, caused by smoking.
Experience in Brazil, Canada and other countries shows that strong health warnings on tobacco packages – particularly warnings with images – can be an important source of information for young smokers, and that warnings increase smokers’ knowledge of risk and their motivation to try to quit smoking.
Tobacco advertising, sponsorship and promotion is widespread in the Americas. In addition to direct tobacco advertising, it includes promotion of brand logos on t-shirts, caps, stores and cars, sponsorship of sporting or arts events, "power walls" of cigarette packages at point of sale, giveaways of products and portrayal of smoking in movies.
ARTICLE 13 of the WHO Framework Convention on Tobacco Control (WHO FCTC) requires parties to the treaty to prohibit all tobacco advertising, promotion, and sponsorship. Here's why.
The brand switching argument
Tobacco companies claim that promotion does not stimulate demand for cigarettes and is targeted solely at current smokers to encourage brand switching.
This claim is untenable. Tobacco monopolies advertise cigarettes where there is no competition for customers. And only 10% of smokers switch brands in any given year, and most switch within a brand category (for example, Marlboro to Marlboro Lights). By this reasoning, based on advertising expenditures in the US, tobacco companies are actually losing hundreds of advertising dollars for every switcher they attract.
Emerson Foote, former CEO and president of McCann-Erickson, one of the world's largest advertising agencies and which has handled millions of dollars in tobacco accounts, further clarified the ridiculousness of the brand switching claim:
"In recent years the cigarette industry has been artfully maintaining that cigarette advertising has nothing to do with total sales. Take my word for it, this is complete and utter nonsense. The advertisers know it is nonsense, the industry knows it is nonsense, and I suspect, the public knows it is nonsense. I am always amused by the suggestion that advertising, a function which has been shown to increase consumption with virtually every other product, somehow miraculously fails to work for tobacco products." (Journal of the American Medical Association, 1981; 245: 1667-1668)
The real purpose and impact of advertising
One of the primary aims of tobacco advertising is to attract new customers. Almost all of the tobacco industry's new customers are youth. In public, tobacco companies deny that they target new, young smokers. In private, they quite candidly admit that “starters” and youth are critical to the continued survival of the industry. “Marlboro’s biggest source of smokers continues to be smokers with “no previous brand,” roughly half of whom are starting smokers.”
Studies show that advertising expenditures are linked to overall consumption, that advertising influences smoking initiation and that the elimination of tobacco advertising reduces tobacco consumption.
Tobacco contains nicotine, an addictive drug on par with heroin and cocaine. The primary purpose of smoking tobacco is to deliver a dose of nicotine rapidly to the brain. Nicotine dependence and withdrawal, which may develop with the use of all forms of tobacco, are identified by the International Statistical Classification of Diseases and Related Health Problems as a disease under ‘Toxic effect of other and unspecified substances’. Read about neuroscience of psychoactive substance use and dependence.
Read more about the efficacy, safety, demographics and health effects, health economics, and related policies of nicotine dependence treatments. Consult the database and educational resources for treatment of tobacco dependence.
An individual approach (behavioral and/or pharmacological interventions) to treatment of tobacco dependence must be complemented with a supportive environment to encourage tobacco consumers in their attempts to quit. Treatment of tobacco dependence should be part of a comprehensive tobacco control strategy along with measures such as taxation and price policies, advertising restrictions, dissemination of information and establishment of smoke-free public places. Read about WHO´s policy recommendations for smoking cessation and treatment of tobacco dependence.
There are many helpful on-line resources available to help you quit smoking. PAHO does not officially endorse any of these resources, but we provide some links here for your convenience. For other resources, we suggest that you contact your local cancer society, lung association or heart foundation, who may run free programs. You can consult your doctor, public health worker or pharmacist for advice and referrals.
Please click on the following links to access useful information on how to quit smoking
Please click on the following links to access useful information on smoking cessation programs
Please click on the following links to access useful information on how to help your patients quit smoking.
School-based prevention programs
School-based prevention programs are popular and enjoy strong political support. Educators and public-health professionals have long believed that, because most of current adult smokers began experimenting with cigarettes before they were 18 years of age, we should prevent youth experimentation and smoking initiation. And what better place to reach youth than the schools?
New evidence raises serious questions about the wisdom of existing school-based smoking prevention programs (read about it). Although some short-term follow-up studies of these programs have reported lower youth smoking, the review of long-term effectiveness convincingly shows that they are not effective. They may increase students’ knowledge of the dangers of smoking but they do not lead to lower youth smoking in the long run. Existing school guidelines were developed before the current evidence that school-based and youth-access programs were ineffective at actually decreasing smoking. The logical appeal of these programs, combined with their lack of effectiveness in actually decreasing smoking, explains why the tobacco industry has long supported these youth smoking prevention strategies.
What, then, should the schools be doing to help decrease smoking? The schools can, at minimal cost, use tobacco as an ideal example to teach critical thinking with real world problems: the science of addiction, the effects of second-hand smoke, the role of marketing in selling cigarettes and politics in protecting the tobacco industry, and cost of use. Understanding these issues relates to science, social science, mathematics, and economics. Integrating tobacco issues into the curriculum in this way will help schools focus on what they should be doing and do best: teaching kids critical thinking skills.
Existing school-based smoking prevention programs do not work, but there are other effective strategies to reduce youth smoking. As with adults, concern about the effects of second-hand smoke on nonsmokers is a more powerful cessation message for youth than concern about the effects of active smoking. Smoke free environments decrease the likelihood that adolescents will be smokers by approximately 25% and increase the odds that they will stop smoking if they have started experimenting. Increased cigarette prices that come with tax increases also decrease youth smoking. Banning advertising and promotion of tobacco products also decreases tobacco uses among adolescents.
Youth access programs
It seems logical that making it more difficult for teenagers to obtain cigarettes would reduce the likelihood that a teen would become a smoker. The broad political appeal of this logic has led to the widespread enactment of so-called "youth access" laws, which make it illegal to sell cigarettes to teenagers. Although these laws do make it difficult for teens to buy cigarettes they do not decrease youth smoking. Youth access interventions are not associated with consistent positive effects on youth smoking prevalence. Furthermore, there is no evidence that increased compliance is associated with decreased prevalence (read about it). One reason why these policies may not affect youth smoking although they do affect the ease with which children can purchase cigarettes is that as teens find it harder to buy cigarettes they may simply shift to these other sources.
Although some tobacco control advocates have argued for attempting to restrict access to these other sources, doing so with a high level of effectiveness is a practical impossibility and could reinforce the tobacco industry’s efforts to present tobacco control advocates as unreasonable and extremist. It would also shift the focus of tobacco control efforts further away from the tobacco industry and its marketing practices.
Some have argued that youth access programs should be part of a comprehensive tobacco control program, even absent of evidence of effectiveness in reducing teen smoking, because they are politically popular and useful for coalition building. This argument ignores the fact that youth access programs consume limited resources for tobacco control and have created an opportunity for the tobacco industry to build coalitions with local merchants, expanding the industry’s political base. In addition, youth access programs reinforce the tobacco industry’s central marketing message that kids should smoke because it will make them appear more "adult."