In addition to laws, Taxation is an economic driver that can be used by national and state governments to influence health related behaviors which is the focus of this lecture. If you look at here at some of the activities that are text, we can see that there is overlap between legislative and taxation responses. Which are both forms of government regulation. Tobacco is a good example of this. Here we can compare the prevalence of daily smoking, slightly older date I'm afraid in people older than 15 years in OECD countries. It is interesting to appreciate that there is over a 3 fold difference in the prevalence of smoking between those countries with the highest prevalence such as Greece, Chile, Ireland and Turkey. And those countries with the lowest prevalence such as Mexico, Iceland, and Sweden. Differences in legislation and taxation account for a major proportion of this discrepancy. Back in the 1990s, Murray and Lopez used modeling to suggest that ahead of us was a highly changing pattern of disease and that we needed to ensure that global and national policies and investments what cognizant of these likely changes? They projected significant reductions in the global burden of disease from acute infectious diseases such as diarrhea, as well as HIV is shown here and a dramatic upswing in the burden of disease from tobacco. And they were right. As in the rest of the world, there are highly variable rates of smoking between countries in Latin America. More than 40% of Chileans smoke compared with 27% of Argentines and 17% of Brazilians. In 2013, Chile's health minister reported that treating tobacco victims consumed a quarter of Chile's $10 billion public healthcare budget. A quarter. Smoking tobacco is not a natural act, rather it is a preventable behavior that is promoted by huge transnational tobacco companies that derive equally huge profits from tobacco. Over the past decade, one of the things that has changed in Chile is that smoking is starting younger, and is increasingly a female behavior, largely driven by marketing. In 2010, nearly 40% of girls aged 13 to 15 in Santiago smoked, double the rate from 2003. And the Chilean Minister for Health said Chile has always been a very metro country but that is changing. For women, smoking in public is somehow a sign that they are liberated. This change in gender norms have been driven by tobacco industry marketing with the knowledge that the market for smoking in males in Chile is now relatively mature. Smoking is a newer phenomena in China, which sadly however, has caught up fast. There are now more than 300 million smokers in China who smoke one in every three of the world's cigarettes. More tobacco is smoked in China. Than in the other top four tobacco consuming countries combined, namely Indonesia, Japan, the Russian Federation and the United States of America. However, in China, smoking is still overwhelmingly a behavior of males. Over one in two Chinese men smoke, with far fewer women smoking. The WHO Framework Convention on Tobacco Control was developed in response to this globalization of the tobacco epidemic. By 2004, the WHO Famework Convention on Tobacco Control had 168 signatories which makes it one of the most widely embraced treaties in United Nation history. While policy can be established globally, as we've said again and again, it must be implemented nationally and then locally. The Framework Convention articulates that the most effective tobacco controlled programs are comprehensive, sustained and accountable. Such programs have been shown to reduce smoking rates, as well as tobacco related diseases and deaths. In any country, a comprehensive tobacco controlled program requires a coordinated effort to establish smoke free polices and social norms. To promote and assist tobacco users to quit and to prevent initiation of tobacco use. Such a comprehensive approach combines educational, clinical, economic, regulatory and social strategies. And these include legislative and regulatory responses such as banning tobacco advertising, and limiting minor's access to tobacco, and graphic health warnings on cigarette packs. A more recent element that is still a subject of an international legal challenge is plain paper packaging. Other approaches are economic, such as tobacco taxes that increase the cost of tobacco. The importance of tobacco taxation is that when tobacco is more expensive, people smoke less. It has been shown that every 10% increase in the retail price of cigarettes results in a 4% decline in unit sales. Because they have less disposable income, adolescents are more price sensitive than adults. One of the reasons to ban selling single sticks of tobacco, rather than a pack, is because the reduced price of loose cigarettes or loosies as they are known increases children's access. But let's turn back to Chile with it's major tobacco problem in young people that we discussed earlier. It is exciting to see that having signed the Framework Convention on Tobacco Control, that new tobacco control legislation was introduced in 2013 which included additional taxation. As well as advertising bans and restrictions on sponsorship. Chile is now the 14th country in Latin America to ban smoking in all enclosed public places. And already consumption has been reduced by 7% in the first year of these new legislative interventions. Consistent with the framework convention, China has also introduced far ranging legislation to control tobacco, which will reap benefits for its national health in the decades to come. Tobacco control interventions have been largely universal in their approach targeting the whole population as with taxation for example. In Australia, it is instructive to look at change in patterns of smoking in school students in the past 30 years. Rates declined during the 1980s, but then increase into the 1990s. The return to a downward trend coincided with the launch of a high profile media campaign together with higher tobacco taxes. Introduction of smoke-free environments and stricter enforcement of sales to minors, as well as smoking bans in public places. It is useful to consider which of these elements you might think is more adolescent sensitive and which might be most cost-effective. While such low rates of smoking in young adolescents is a great success story in my country and increasingly in many other high-income countries, it is sobering to compare these rates to young people in other parts of the world. As shown here in this graph of tobacco use in 13 to 15 year old males, the heavy hitters here are middle-income countries such as Indonesia at the far right, which has been the target of marketing from big tobacco. And there's Chile, sixth from the right whose rates of smoking on 13 to 15 year old males are far higher than in most high-income countries. And if anyone had any doubts about the tremendous impacts of marketing by big tobacco on the rates of smoking in people but particularly young people in low and middle-income countries. Look no further than this wonderful YouTube clip that overviews the history of tobacco control if it's highlighting the perniciousness and power of big tobacco to undermine public health efforts to curb tobacco use. It's long, it's about 18 minutes and comes with a language warning but I really urge you to stay to the second half where some amazing data represented about low and middle-income countries. It's pretty sobering. However, as the Director-General of the WHO, Margaret Chan said, it's not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda and Big Alcohol. Denmark was the first country to introduce what's known as a Fat tax in 2011, although the tax was sadly repealed six months later for various reasons. In 2013, Mexico introduced an 8% tax on foods high in salt, sugar and saturated fat. And a 4% tax on added sugar drinks. And I understand the legislation still stands. In New York, supported by the previous mayor, Mayor Bloomberg a law was passed in 2013 to limit soft drink size to half a liter. Sadly, this was later repealed by a higher court following intense opposition from the food and beverage industry. Remember, this was not about banning sugary drinks but simply limiting the size of drinks to half a liter. Recently, a number of companies including Coca-Cola and PepsiCo, voluntarily pledged to reduce to US calorie consumption and sugary drinks by an average of 20% by 2015. Now, one might be cynical about the agreement to this in the face of such forceful recent opposition to the previous legislation. However, the successful brokering of this agreement by a non-government organization raises the possibility that new alliances that engage industry will be necessary to combat food and beverage legislation.
