Sunday, May 31, was World No-Tobacco Day sponsored by the World Health Organization. The focus of WHO's campaign this year is the effectiveness of warning labels in getting people to stop smoking and using other forms of tobacco. A recent CDC review found that health warnings on tobacco product packages are effective in highlighting the perception of health risk and that prominent displays of health warnings increase their effectiveness, especially larger warnings with pictures.
Placing health warnings on tobacco product packages was one of the interventions agreed upon at the World Health Organization Framework Convention on Tobacco Control in 2005, the first ever public health treaty negotiated under WHO auspices, said mark Nichter, a Regents' Professor of Anthropology at The University of Arizona. Within 3 years, participating countries agreed to implement health warnings describing the harmful effects of all tobacco products, Nichter said.
Since then, in 2008 data reported from 176 member states, 77 countries (44 percent) did not require any warnings on cigarette packs. Another 71 (40 percent) required warnings covering less than a third of the principal display area. Only 15 (9 percent) required pictorial warnings. "Clearly we have a long way to go," Nichter said.
Placing warning labels on packages and raising tobacco taxes are necessary and important steps in the right direction, but they are clearly not sufficient to reduce tobacco uptake and tobacco- related death in the developing world where cigarettes and other forms of tobacco products are marketed aggressively, he said.
"The challenge posed by tobacco control in countries like China where there are more smokers than there are people in the U.S. is great and the time to do something about the spread of tobacco is urgent," said Scott Leischow, a professor of family and community medicine at the UA. Leischow also is the associate director for behavioral and social science research at the Arizona Cancer Center, past president of the Society for Research on Nicotine and Tobacco and helped establish the Arizona Smokers' Helpline (see sidebar) to help Arizonans quit smoking. "If tobacco use continues as it has globally, the WHO projects that one billion people will die prematurely due to tobacco use by the end of the century," Leischow said.
Nichter and two other UA professors are working to prevent this from becoming a reality. Along with Mimi Nichter, an associate professor of anthropology, and Myra Muramoto, an associate professor of family and community medicine, they have been introducing tobacco cessation use in two of the most populated countries in the world, India and Indonesia. In India, about half of males use tobacco, while in Indonesia, more than 60 percent of males smoke.
Along with China, India and Indonesia represent a large and growing market for tobacco companies. Although most women in these countries do not smoke, they are the targets for the industry, as they are viewed as a large potential market.
For the past seven years, the UA group has been working on Project Quit Tobacco International together with their research partners at the Achutha Menon Centre in Kerala, South India, and at the Gadjah Mada University in Java, Indonesia. The project, funded by the Fogarty International Center at the National Institutes of Health, is a pioneering attempt to develop culturally appropriate approaches to tobacco cessation within the health sectors of those two countries as an exemplar for other countries, and to lay the groundwork for an emerging community of tobacco cessation practice.
Project Quit Tobacco International aims to work on tobacco cessation by introducing the topic at "Ground Zero," in medical schools and clinics in India and Indonesia. "We are working to make sure that tobacco education is being fully integrated into the curriculum and not simply added on as one more extra topic," Mark Nichter said.
"In order to be successful in tobacco prevention, cessation is necessary. And to do this, we clearly need to change the norms of the medical profession," Nichter said. "At present, about 20 percent of doctors in India and Indonesia are smokers. Doctors there need to both quit smoking themselves and become role models for their patients, and they need to advise each patient not to smoke as part of their normal medical practice. Both doctors and the general public need to become better educated about the harm of tobacco consumption, not just as a risk factor for cancer, but a behavior predisposing to tuberculosis and childhood respiratory complaints, and exacerbating the symptoms of diseases such as diabetes."
Project QTI also is developing "culturally sensitive counseling" that is designed to appeal to particular cultural ideas about smoking. But the project's work does not stop there, said Nichter. A positive image of a male non-smoker is being promoted to replace the advertised image of male smokers as sexy, macho and modern. Men's responsibility toward their families is being emphasized in informational campaigns which explain how tobacco-related illnesses impacts the whole family, not just the smoker. Nichter said that one goal of the project is to emphasize to men that giving up smoking is an important act that benefits their families including their wives children and elders in the household.
"Smoking is an irresponsible behavior that negatively effects everyone in the household, not just from secondhand smoke, but financially. Body counts of the number of deceased smokers masks the real tobacco harm denominator - all those who are effected when an ill or deceased smoker can no longer work and support their families," he said.
Mimi Nichter noted that another intervention being promoted by Project QTI is turning tobacco into a women's issue.
"We need to turn tobacco use into a women's issue. We are trying to involve women's groups to develop smoke-free households. While this is difficult for an individual woman to convince her husband or father to quit, as a collective effort, women can work to establish community norms for smoke free households," she said.
Mark Nichter emphasized that cessation is an urgent global health priority. "It's very important that people start quitting tobacco now. Worldwide, tobacco use is among the greatest causes of preventable death and disease. Approximately 500 million people alive today will die because of tobacco," he said.
"In terms of its significance as a global health issue, tobacco smoking kills more people than malaria, maternal and major childhood conditions, and tuberculosis combined. By 2030, the annual number of deaths caused by tobacco will rise to 10 million, with half of these deaths occurring within the 35-to-69 year-old age group. As a consequence, smoking will be the cause of one-third of all deaths in the next 20 years,"
The good news said Mark Nichter is that the potential to save lives globally through aggressive cessation initiatives is huge. "It is estimated that by the year 2020, if adult consumption were to decrease by 50 percent, approximately 180 million tobacco-related deaths could be avoided."