Smoking Research Proposal - West Bengal

A Research Proposal: Countering the Use of Tobacco What Has Worked and What Hasn't: The Case of West Bengal: What Strategies to Focus On I. The Construct of Study: Tobacco Use: How to Counter it? Oscar Wilde wrote in the 19th century, “You must have a cigarette. A cigarette is the perfect type of a perfect pleasure. It is exquisite, and it leaves one unsatisfied. What more can one want?” That was then. Smoking was considered a patrician luxury. Fast forward to 2013. Smoking and tobacco use are dreaded public health threats. What brought about the change in global attitude towards tobacco use and what is the reason for continued inability to fully grasp the danger in some parts of the world? How serious are the challenges in the developing world and the developed world and what needs to be done to seriously eliminate the global epidemic of tobacco use? The origins of the tobacco can be traced to the Mayans in the Americas from where (following the discovery of America by Columbus), it was exported to Europe and beyond. There is evidence that tobacco was in use in the seventeenth and eighteenth centuries, albeit sporadically (http://globalhealth.stanford.edu/education/tobacco_global_nature.pdf). However, the manner of its use has been varied over the years. It has been, smoked, chewed and snuffed. Cigarette smoking became popular only in the nineteenth century. With the growth of technology, cigarette production significantly increased towards the end of the nineteenth century. Cigarette smoking became very fashionable soon and spread fast, spurred on by aggressive marketing. In the First World War, this was even one of the items in the rations given to soldiers. Its ill effects were quite unknown. Taxes levied on the production and/or consumption of cigarettes was a major part of government revenues in the twentieth century. In Germany, it constituted more than 10% of total Government revenues in the 1930s. In China, even in the early 21st century it was around 10% (Ibid). II. Dangers of Tobacco Use Although the link between tobacco and cancer, especially of the mouth, was not unknown in the eighteenth and nineteenth centuries, it was the rise of lung cancer in the twentieth century (it was almost unknown earlier) that ultimately made it possible to establish the direct link between smoking and cancer (ibid). It is now known that tobacco use results in the highest number of deaths in humans among the killers that claim human lives. Tobacco-related mortality falls under lethal diseases that can be clearly prevented from occurring (http://globalhealth.stanford.edu/education/tobacco_global_nature.pdf). The World Health Organization has estimated that the average of more than 5 trillion cigarettes smoked yearly near the end of the last century would be a prime mover of 10 million casualties by the end of the third decade of the new millennium. There is one case of lung cancer for every three million cigarettes lit (Ibid). Tobacco use (smoke or smokeless) results in many types of cancers. The lion’s share of tobacco related cancer is taken by lung cancer. Tobacco consumption, smoked or chewed, is the primary cause of the worldwide lung cancer scourge (Ibid). Research has continued right through the 20th century to establish the use of tobacco as a major cause of cancer and other ailments like heart disease. Notwithstanding, the many efforts by tobacco companies to obfuscate this fact, there is now worldwide acceptance of this link. The good news is that from the 1980s, smoking in the developed countries has started to systematically decline. The response of the tobacco companies has therefore been to tap into the developing countries of Asia, Africa and South America. However, the world’s leading exporters of tobacco-based products continue to be in the US. According to the WHO, by 2030, tobacco use will cause 10 million deaths per year. In fact, tobacco use, after peaking in the 1990s has started to fall. However, deaths from tobacco use and onset of many heart diseases and types of cancers will continue to increase (Ibid) because of the time lag between the use of tobacco and the start of the disease. According to Robert Proctor (Ibid), about 25 % of such deaths will be from lung cancer and most of them will be from the developing countries. In another way of expressing this statistic, WHO calculates that over the next thirty years 100 million people will die from tobacco use and this number is more than the total combined number of deaths from AIDS, tuberculosis, murders, homicides and car accidents. If tobacco use rates do not decline from what they were at the end of the 20th century, the 21st century could see as many as 1 billion deaths from tobacco use. The key, of course, would be what happens in terms of anti-tobacco use strategies in India, China, Japan and the countries of the former Soviet Union. III. Incidence of Tobacco Use and Trends (a) Tobacco consumption declining in the developed countries The most encouraging trend worldwide, as pointed out earlier, is the fact that the developed countries, have registered significant and steady declines in the incidence of smoking especially over the last 40 years. For example, in the US, in 1965, 42% of adults smoked. In 2006, only 20.8% of adults smoked. In 2012, this number came down to 18% (http://en.wikipedia.org/wiki/List_of_countries_by_cigarette_consumption_per_capita). According to the Center for Disease Control, the number is now stagnating at around 18 % - 19 %, i.e. around one in five adults still smoke in the US (http://www.cancer.org/cancer/news/cdc-adult-smoking-rates-remain-steady). Year to year decreases are, however, inconsistent. About 43.8 million people still smoke in the US. However, among daily smokers, there is a trend towards smoking fewer cigarettes. The proportion of those who smoked more than 30 cigarettes per day decreased from 12.6% in 2005 to 9.1% in 2011. The proportion of those who smoked less than 10 cigarettes increased from 16.4% in 2005 to 22% in 2011 (CDC Ibid). There are also certain demographic and socioeconomic trends noticeable. With age, the extent of smoking goes down. In general, young adults are the most likely to smoke in all countries. Again, the positive trend for the US (and for most developed countries) is that the proportion of smokers aged 18 to 24 years has been decreasing. It decreased in the US from 24.4% in 2005 to 18.9% in 2011, the biggest decline in any age group. This age group had the highest smoking prevalence in 2005, and now has the lowest of any group younger than 65 (CDC: Ibid). There are, however, many regional differences within the country. We will examine this later with a special reference to New York City. In Australia, similarly in 2001, 22.4% of adults smoked. This number came down to 16.1% in 2011-2013. Similarly, unlike in the 17th and 18th century, smoking is less of a patrician pursuit today. Smoking is more common among the most disadvantaged communities. (b) Tobacco use rising in the developing countries As Wikipedia reports, in the developing countries tobacco consumption continues to rise at about 3% - 4% per annum. This is one of the biggest public health challenges today. According to the CDC (http://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/globalsmoking.html), smoking in the developing countries is rising by 4.4% every year. In its report on the Global Tobacco Epidemic 2011 (http://whqlibdoc.who.int/hq/2011/WHO_NMH_TFI_11.3_eng.pdf?ua=1), WHO estimated that of the 6 million people dying every year from ailments caused by tobacco use, most deaths would take place in low and middle-income countries. An article in the Guardian (http://www.theguardian.com/news/datablog/2012/mar/23/tobacco-industry-atlas-smoking), in 2012, reproduces a tobacco map (from the American Cancer Society and the World Lung Foundation), which reinforces this reporting that 80% of these 6 million deaths are now happening in the low and middle-income countries. Per Capita Consumption, Cigarettes Per Person Legend: 8 – 150: Dark Green: 151 – 502: Light Green 503 – 999: Light Blue 1000 – 2000: Dark Blue 2001 – 2865: Very Dark Blue A few selected country profiles are presented below (a detailed table is attached in Annex 1): India
 96 cigarettes consumed per person per year In 2004, 12% male deaths and 0.9% female were caused by tobacco In India, 26.2% of men and 3.6% of women were smoking any tobacco product in 2009. 13.4% of health professionals smoke and illicit tobacco is 10% of the whole market Children and smoking Youths Exposed to Secondhand Smoke in Home, Ages 13–15, - 26.6% Youths Who Have an Object With a Tobacco Logo on It –% Boys’ Current Cigarette Use, Ages 13–15, - 5.4% Girls’ Current Cigarette Use, Ages 13–15, - 1.6% China
 1711 cigarettes consumed per person per year In 2004, 12.1% of male deaths and 10.9% of female deaths were caused by tobacco In China, 51.2% of men and 2.2% of women were smoking any tobacco product in 2009. 11.9% of health professionals smoke and illicit tobacco is 7.6% of the whole market Children and smoking Youths Exposed to Secondhand Smoke in Home, Ages 13–15, - 47% Youths Who Have an Object With a Tobacco Logo on It, - 9.5% Boys’ Current Cigarette Use, Ages 13–15, - 2.7% Girls’ Current Cigarette Use, Ages 13–15, - 0.8% United States of America: 
 1028 cigarettes consumed per person per year In 2004, 22.9% male and 23.3% female deaths were caused by tobacco In United States of America, 32.8% of men and 24.7% of women were smoking any tobacco product in 2009. 3.3% of health professionals smoke and illicit tobacco is 6.4% of the whole market Children and smoking Youths Exposed to Secondhand Smoke in Home, Ages 13–15, - 12% Youths Who Have an Object With a Tobacco Logo on It, - 12.3% Boys’ Current Cigarette Use, Ages 13–15, 9.7% Girls’ Current Cigarette Use, Ages 13–15, - 7.9% Russian Federation
 2786 cigarettes consumed per person per year In 2004 - the latest data available shows that 28.2% of male deaths were caused by tobacco and 4.4% of female deaths were caused by tobacco In Russian Federation, 59.4% of men and 24.3% of women were smoking any tobacco product in 2009. 38.9% of health professionals smoke and illicit tobacco use is 0.5% of the whole market. Children and smoking Youths Exposed to Secondhand Smoke in Home, Ages 13–15, - 76.4% Youths Who Have an Object With a Tobacco Logo on It, - 14.7% Boys’ Current Cigarette Use, Ages 13–15, - 26.9% Girls’ Current Cigarette Use, Ages 13–15, - 23.9% Clearly, the Russian Federation has the highest per capita cigarette consumption. Of the remaining 3, China is the highest, followed by the US and India. When it comes to tobacco consumption, the following are the top tobacco producers in 2009: Top ten tobacco producers, 2009 China Brazil India United States... Malawi Indonesia Argentina Italy Pakistan Zimbabwe Therefore, China was the biggest tobacco producer in 2009 with Brazil and India following behind. Below are some of the findings of the report: • More than 43 trillion cigarettes have been smoked in the last ten years 
 • Tobacco use causes 1.2m deaths annually in China and is the number one killer of the country. The report findings state that this is expected to rise to 3.5m deaths annually by the year 2030
 • Tobacco use is responsible for the greatest proportion of male deaths in Turkey and Kazakhstan at 38% and 35% respectively
 • The greatest proportion of female deaths due to tobacco use were in the Maldives and the United States at 25% and 23% respectively. Today, 84% of smokers live in the developing countries (CDC: Ibid). The CDC report cites a Gates Foundation statistic that in Bangladesh the poorest households spend on tobacco10 times as much as they do on education. Professors Gary Giovino, Sara Mirza et al, writing in the Lancet (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2961085-X/abstract?_eventId=login) analyze the Global Adult Tobacco Survey (2012) to show that in in 14 low-income and middle-income countries (Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines, Poland, Russia, Thailand, Turkey, Ukraine, Uruguay, and Vietnam), 48.6% of men and 11.3% of women were tobacco users. While 82% favored smoking manufactured cigarettes, in India and Bangladesh, smokeless tobacco and bidis were quite popular particularly among the poor. The figures also showed early initiation rates among women and overall low quit ratios (less than 20% overall) in China, India, Egypt, Russia and Bangladesh. Thus, we see that about nearly half of men in 14 developing countries are tobacco users and that women are starting to smoke at younger ages. Overall, researchers predict smoking will cause one billion deaths in the 21st century (http://scopeblog.stanford.edu/2012/08/22/smoking-rates-increasing-in-the-developing-world/). IV. What has been the Strategy Tool Box and What Has Worked So Far? The literature and the WHO list the following as the key strategies that every country and the global international community should put in place. These are listed as follows: 1. Putting in place surveillance mechanisms that monitor the tobacco epidemic and its incidence worldwide every year. The two main ones are: a. The Global Adult Tobacco Survey or GATS. The WHO defines this as, “The Global Adult Tobacco Survey (GATS) is a nationally representative household survey that was launched in February 2007 as a new component of the ongoing Global Tobacco Surveillance System (GTSS).” It enables countries to collect data on adult tobacco use and key tobacco control measures. Its results help countries in the formulation, tracking and implementation of effective tobacco control interventions, and compare results with results from other countries.
GATS has been implemented in more than 19 low- and middle-income countries with the tobacco use rates. The list includes India and within India, West Bengal (http://www.who.int/tobacco/surveillance/survey/gats/en/). b. WHO Annual Reports on the Global Tobacco Epidemic. WHO has started issuing them since 2010 and they present the status of anti- tobacco measures world wide also known as MPOWER (explained in the following paragraph) measures. 2. Evidence based and effective tobacco control policymaking and their implementation. This requires having a nationally owned tobacco control strategy whose main policy elements should comprise the following: a. Creating smoke free environments whose goal is protecting employees and the public from secondary smoke inhalation such as heart attacks. These are policies such as banning smoking in public spaces, something that US including New York City has done. These include making all restaurants, bars, parks, offices and other public places smoke free. These encourage people to quit, prevent initiation, and change social norms around tobacco use and exposure. b. Raising the cost of tobacco through taxes and non-tax policies (banning price discounts etc.). These pricing policies make tobacco less affordable and therefore reduce tobacco use and change social norms. c. Promoting and enforcing restrictions on the point of sale: These regulate youth access and seek to counter some $8 billion that the tobacco industry spends on promoting the use of tobacco. d. Restricting access by raising the legal age of smoking e. Media interventions: Banning tobacco advertisements and mandatory statutory warnings on tobacco products (http://cphss.wustl.edu/Products/Documents/CPHSS_TCLC_2014_PolicyStrategies1.pdf). 3. The WHO Framework Convention on Tobacco Control (WHO FTC) along with guidelines provides the member states to constitute the policy template for members to roll out. The term MPOWER is an acronym for the six different steps visualized in the WHO FTC and constitutes a ready reckoner: a. Monitor tobacco use and prevention policies; b. Protecting People from tobacco smoke; c. Offering help to quit tobacco use; d. Warning about the dangers of tobacco; e. Enforcing bans on tobacco advertising, promotion and sponsorships; and f. Raising tobacco taxes (http://www.who.int/tobacco/mpower/publications/mpower_2013.pdf). V. How are tobacco control measures working? Policies and strategies are as effective as their implementations are. The WHO’s report on the Global Tobacco Epidemic 2013, communicates the following headline messages: ➢ Tobacco Companies are still spending tens of billions of dollars on tobacco advertisements, promotions and sponsorships. ➢ One third of youth experimentation with tobacco occurs as a result of exposure to tobacco advertisements. ➢ Complete bans on tobacco advertisements, sponsorships and promotions definitely decrease tobacco use (24 countries have a ban). Partial bans have no or little effect as companies find ways of marketing. ➢ Globally, the population covered by at least one effective tobacco control measure (i.e. one of the MPOWER measures) has more than doubled: about 2.3 billion people are now covered by at least one measure. ➢ Millions of lives stand to be saved: We have the tools and we have the will. We must act together now. Tobacco use is the world’s leading cause of preventable death. Of all epidemics, perhaps, the tobacco epidemic, while, certainly one of the most pernicious and dangerous ones, is at the same time a fully preventable one. Yet, while smoking rates are declining in the developed world, the rate of decline is slow. Most developed countries, including the United States, are facing something of a “last mile” problem as the rates of decline slow down and stagnate. On the other hand, the pervasive influence of tobacco companies is aggravating the situation in the developing world (See Section III above). What is then the state of implementation of MPOWER? A report card by WHO shows a mixed bag. Currently, half of countries – and two in three in the developing world – do not have even minimal information about tobacco use. Even acknowledging that every person has a right to breathe air free of tobacco smoke and evidence from pioneering countries showing that smoke-free laws do not harm businesses and are popular with the public, only 5% of the global population is protected by comprehensive national smoke-free legislation, which enables the creation of smoke free public spaces. Similarly, despite evidence, three out of four smokers who are aware of the dangers of tobacco, want to quit, national comprehensive services such as counseling and education towards this end are available only in 9 countries, adding up to only 5% of the world population. It is well known that relatively few tobacco users fully grasp the health dangers and therefore hard-hitting anti-tobacco ads and graphic pack warnings do reduce the number of children who begin smoking and increase the number of smokers who quit. Pictures speak a thousand words and are therefore more powerful deterrents than words on tobacco packaging warnings. However, only 15 countries, representing 6% of the world’s population, have laws mandating pictorial warnings. Just five countries, with 4% of the world's population, meet the highest standards for cigarette packet warnings. Studies have found that advertising bans can significantly reduce tobacco consumption. However, only 5% of the world’s population currently lives in countries with comprehensive national bans on tobacco advertising, promotion and sponsorship. About half of the children of the world live in countries that do not ban the free distribution of tobacco products. Tobacco taxes are known as the most effective way to reduce tobacco use, especially among young people and the poor. Increasing tobacco taxes by 10% can decrease tobacco consumption by 4% in high-income countries and by about 8% in low- and middle-income countries. Tobacco tax increases also increase government revenues. Only four countries, representing 2% of the world's population have tax rates greater than 75% of the retail price. In countries with available information, tobacco tax revenues are more than 500 times higher than spending on tobacco control. In low-income and middle-income countries, tobacco tax revenues are more than 9000 and 4000 times higher than spending on tobacco control, respectively (WHO: Tobacco Free Initiative: http://www.who.int/tobacco/mpower/facts_findings/en/). VI. The Case for Research in Specific Locales in Developing Countries Clearly, the major burden of gaps in the implementation of policy measures as encapsulated under the acronym MPOWER lie with the developing countries where the prevalence is actually increasing with China, Brazil and India also emerging as the top three tobacco producers of the world (section III above). Tobacco companies are aggressively pursuing markets in the developing countries. By 2030, out of the anticipated 10 million deaths per year, 7 out of 10 deaths will be in the developing countries. (Guindon and Boisclair: Past, Current and Future Trends in Tobacco Use, 2003), WHO Tobacco Control Papers: https://escholarship.org/uc/item/4q57d5vp eScholarship University of California). Research in developed countries shows that the raising of taxes and increasing the prices of tobacco is the most effective way of curbing tobacco use in particular among young people. Youth demand for cigarettes is highly price elastic (World Bank Study cited in Guindon et al Ibid). Yet, developing countries hesitate to implement such measures. Most of the research and evidence base in support of anti-tobacco measures are from developed countries, although, the battleground has shifted to the low-income and middle-income countries. This probably is a reason for sub optimal implementation of anti-tobacco measures in the developing countries. They, therefore, contend that there is a great need for country specific research to provide a firm basis for evidence-based policy making in the developing countries. WHO and the World Bank have already initiated this. WHO has through research in a number of countries demonstrated how reduced tobacco directly impacts on cardio vascular and respiratory diseases and of course on cancer. Their research has shown that the policy package comprising higher tobacco prices through taxation, bans on advertising, and information campaigns through counter advertisements using disturbing pictorial messages is quite affordable while being effective too in most countries. World Bank studies have also confirmed that both price (taxes) and non-price (advertisements bans, information campaigns, smoking restrictions etc.) measures are as effective in developing countries as elsewhere. Yet, many governments continue to go slow because of fears that this might impose an economic cost. As a case in point, India, the third largest producer of tobacco in the world merits a special look and within that, West Bengal, a major tobacco producer and consumer is the special focus of this paper. VII The Situation of West Bengal, India According to the Directorate of Tobacco Development, Ministry of Agriculture, Government of India on an all India basis, the tobacco crop provides employment to over 4.4 million people while the bidi industry provides employment of 6 million unskilled, often, informal sector, home-based workers (http://dtd.dacnet.nic.in/handbook/intro.htm). In India, only 25% of tobacco users smoke cigarettes. The rest smoke hand rolled tobacco called bidi and various kinds of chewed and snuffed tobacco. ( http://npcs.in/profiles/profiles/tobacco-pan-masala-khaini-gutkha-supari-zarda-mouth-freshener-kimam-cigarettes/z,,5c,0,a/index.html). Very recent survey shows about 6 million farmer and 20 million farm labor being engaged in tobacco farming spread over 15 states. Bidi rolling provides employment to 6 million people in addition to 2.2 million tribal people involved in tendu leaf collection. Nearly 4 million people are engaged in the trade and related activities. The main beneficiaries are the small and marginal farmers, rural women and tribal youth (http://www.cghr.org/wordpress/wp-content/uploads/Jha-Estimates-of-the-economic-contributions-of-the-bidi-manufacturing-industry-in-India.pdf). The state of West Bengal is a producer of tobacco crop as well as a major producer of cigarettes, bidi, gutka and other tobacco products. In fact, ITC, the major conglomerate, 56% of whose revenue comes from cigarettes has its headquarters and key production facilities in this state. At the national level, bidi contributes 0.1% of India’s GDP and West Bengal is also the highest producer of bidis in India. A Global Adult Tobacco Survey (GATS) was conducted in West Bengal in 2009-2010 by the International Institute of Population Sciences, coordinated by the Government of India (the International Institute for Population Sciences (IIPS), under the coordination of the Ministry of Health and Family Welfare, Government of India (http://www.cancerfoundationofindia.org/activities/tobacco-control/advocacy/pdf/GATS%202010%20West%20Bengal%20data.pdf ). The key highlights of the findings of this survey are as follows: ➢ 36% of adults (52% males and 19% females) consume tobacco in some form or the other. ➢ Average age of initiation into tobacco use: 18.5 years (19 years for females). ➢ 55.7% of tobacco users consumer tobacco in some form within half an hour of waking up. ➢ 62.4% of adults were exposed to secondary smoke at home. ➢ 29.8% of adults were exposed to secondary smoke in public places. ➢ Adults who noticed any advertisement or promotion: 28.6% for cigarettes; 31.1% for bidis; 36.2% for smokeless tobacco. ➢ Current users who thought of quitting after seeing warning labels: 25.2% for cigarettes; 24.7% for bidis and 17% for smokeless tobacco. ➢ Adults, who saw counter anti-tobacco information on radio or television: 40.7 % (men: 38.7%, women 43.3%). The situation is clearly quite serious. Rates of tobacco use are very high: half of all males and one fifth of women! The age of initiation is quite low. Exposure to secondary smoke at home is too high. Further, almost a third are exposed to smoking in public spaces. There is therefore a huge missed opportunity for government to check this and protect non-smokers. Tobacco promotion advertisements seem quite ubiquitous. This is despite India being a signatory of the WHO Framework Convention on Tobacco Control, which introduced the MPOWER package, which includes interventions to address all these aspects. VIII: Broad Research Needs for low-income and middle-income countries The experiences of the WHO in assisting Member States in the implementation of the provisions of the WHO Framework Convention on Tobacco Control has uncovered a series of research needs and priorities (http://www.world-heart-federation.org/fileadmin/user_upload/documents/Advocacy/Resources/Meetings_-_Activities_and_Partnerships/Research%20priorties%20in%20tobacco%20control_01.pdf ). The following four topics have been identified as the highest priorities for advancing tobacco control in low-income and middle-income countries: 1. Impact of tobacco taxation on tobacco use. 2. Economic impact of tobacco use and tobacco control. 3. Effectiveness of demand reduction interventions. 4. Social determinants of tobacco use. Additionally, the following are also important research areas for poor and low-income countries: 5. Links between poverty and tobacco use 6. What works in communication, education and training 7. Economically viable alternatives to tobacco IX. The Current Research Proposal This proposal is to move beyond a broad descriptive research and instead conduct an action research in selected urban and rural communities of West Bengal. Action Research is defined as “ a disciplined process of inquiry conducted by and for those taking the action. The primary reason for engaging in action research is to assist the “actor” in improving and/or refining his or her actions.” (http://www.ascd.org/publications/books/100047/chapters/What-Is-Action-Research.aspx) The Association of Society & Science and Harlem Children’s Society has the advantage of being involved in community based initiatives to promote attitude changes particularly towards scientific education and creating a scientific temper amongst disadvantaged communities in the districts of 24 Parganas, Bankura and Midnapore for the last 5 years. The Harlem Children’s Society in its part has been at the forefront of efforts to promote STEM (Science, Technology, Engineering and Mathematics) Education in the United States, Kenya, Tanzania, and Punjab etc. for several years. Its work in the US started 14 year’s ago under the leadership of its visionary founder and CEO, Dr. Sat Bhattacharya, a Molecular Geneticist, Doctor and Scientist at the Memorial Sloan Kettering Cancer Center, New York. Dr. Bhattacharya, a Bengali by origin, is well known in the US and other countries as a dedicated and visionary leader who has relentlessly pursued the goal of inculcating a scientific temper and education amongst children and young adults as part of his life’s mission of “Vasudhaiva Kutumbakam”. The research will be unique in the following respect: 1. It will not be a descriptive research but will be an action research, which will try out small scale interventions and test results. 2. It will be carried out by young staff and student interns and volunteers of the society and will seek to involve school students and teachers. 3. It will derive the interventions from the MPOWER framework and apply them to smaller scales. The research is proposed to be carried out in a state (West Bengal) which has the distinction of raising tax on tobacco in two budget years in quick succession: 2011 and 2013 (http://articles.economictimes.indiatimes.com/2011-08-29/news/29941217_1_tax-rates-tobacco-tax-administration and http://articles.economictimes.indiatimes.com/2013-03-11/news/37623626_1_cigarette-prices-cigarette-industry-price-hike). In a state, where tobacco production has such a large economic foot print, this is not an easy political decision. It is important to see how this is impacting communities to reduce the tobacco epidemic. The Action research will be trying out different policy initiatives in the selected communities. These will include: • Creating smoke free public spaces. • Preventing the sale of tobacco and tobacco products to persons below 18 from local shops that sell tobacco products. • Preventing the sale of tobacco and tobacco products near educational institutions in the localities • Graphic pictorial counter advertisements and bill boards. The purpose will be to generate evidence that when combined with the raising of tobacco taxes, in which West Bengal is today a leader in the country, can make a very significant difference in tobacco prevalence and use. It is expected with such evidence, the revenues generated from higher tobacco taxes will be used to create other non-price policy initiatives, which can have a transformative effect in terms of reducing tobacco use. The action research will, therefore, in essence respond to the five key provisions of India’s anti Tobacco Law tilted “ Cigarettes and other Tobacco Products Prohibition (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution Act (COTPA), 2003” (http://pib.nic.in/newsite/PrintRelease.aspx?relid=86676). These provisions relate to: 1. Prohibition of smoking in public places 2. Prohibition of direct and indirect advertisements 3. Prohibition of sale of cigarettes and other tobacco products to persons below the age of 18 4. Prohibition of sale of tobacco products near education institutions 5. Statutory display of warning labels, including pictorial displays on tobacco packs The action research will, in effect, implement the provisions of law in a microcosm as it were and demonstrate the effectiveness of such measures. This Act along with its Rules came into effect in 2011 and financial resources were also made available to state governments to combat the problem. X: The Research Hypothesis: The hypotheses that the action research will seek to validate is that, as in the case of developed societies, the non price initiatives viz., combination of banning of advertisements, aggressive anti-tobacco campaigns, checking sales to under 18 youth, smoke-free zones to uphold people’s right to smoke free environments are both (a) feasible and (b) cost effective and (c) in tandem with the Government of West Bengal’s aggressive and bold tobacco tax hikes and can result in significant reduction in smoking and tobacco use prevalence. This, therefore, can constitute a good practice for the rest of India to emulate. The Action Research will also, as by-products, generate lessons on precautions and pitfalls that need to be guarded against in rolling out such initiatives in the state as a whole. XI. Research Methodology A total of three sites will be selected for the research. One in Salt Lake City, one in Jhargram and one in South 24 Parganas. The Action Research will involve the following steps: 1. An initial door to door survey to ascertain tobacco use prevalence both in the selected sample population (experimental group) and in a control group which will comprise a population of similar size and characteristics 2. A set of interventions that involve trying out the following interventions: a. Enforcing the ban on advertisements in respective sample communities b. Ensuring tobacco is not sold to below 18 year olds from the local “paan” and grocery shops c. Ensuring tobacco is not sold at shops near educational institutions d. Working with the local body: municipality or gram panchayat to ensure to establish certain smoke free public areas e. Putting up anti-tobacco hoardings and advertisements with pictorial representations f. Door to door periodic campaigns distributing material to discourage smoking 3. An end of “action research” prevalence survey going back to the same community 4. The action research will be carried out for a whole year The coverage in Salt Lake (Bidhannagar) will be that of a municipal ward and in each of the other locations a gram panchayat electoral constituency. For a gram panchayat this will mean covering adult population of about 1,000. The research will have to be carried out in very close consultation with the concerned local body: the gram panchayat or the municipality as the case may be. This is because only the local government has the authority and capacity to enforce and implement all the actions as listed above under 2 a, b, c, d, and e. The arrangement will be that, under the directions of the state government, the three selected local bodies will carry out these actions in the selected sample populations, which will act as the experimental group. It is proposed that the costs of the interventions in the experimental sample will be borne by the local body directly from its own budget (with assistance from the state government as needed). XIII. Research Budget The budget included in this proposal does not include the intervention costs as it is expected that the local body will fund it out of its own budget (with or without the assistance of the state government as needed). The budget only includes the estimated costs of the Association of Society & Science to carry out the door-to-door before and after prevalence surveys, the campaigns, working with the local bodies to roll out the initiatives, the analysis etc. Budget items Amount Research project leader (1) Rs. 40.000x12 months: 480,000 Deputy Research Leaders (3:one for each site) Rs. 30,000x3x12 months: 1,080,000 Research Analysts (6) Rs. 20,000x6x12 months: 1,440,000 Enumerators/surveyors (lump sum) Rs. 200,000 Rent of project offices with utilities 10,000 x 12=120,000 Cost of stationary 50,000 Cost of transportation 50,000 Cost of laptop/handled computers 2,00,000 Total 3,620,000 XIV: The Research Team

Research Proposal on Tobacco - NYC

A Research Proposal: Countering the Use of Tobacco What Has Worked and What Hasn't: The Case of New York City: The Last Mile Problem: What Strategies to Focus On I. The Construct of Study: Tobacco Use: How to Counter it? Oscar Wilde wrote in the 19th century, “You must have a cigarette. A cigarette is the perfect type of a perfect pleasure. It is exquisite, and it leaves one unsatisfied. What more can one want?” That was then. Smoking was considered a patrician luxury. Fast forward to 2013. Smoking and tobacco use are dreaded public health threats. What brought about the change in global attitude towards tobacco use and what is the reason for continued inability to fully grasp the danger in some parts of the world? How serious are the challenges in the developing world and the developed world and what needs to be done to seriously eliminate the global epidemic of tobacco use? The origins of the tobacco can be traced to the Mayans in the Americas from where (following the discovery of America by Columbus), it was exported to Europe and beyond. There is evidence that tobacco was in use in the seventeenth and eighteenth centuries, albeit sporadic (http://globalhealth.stanford.edu/education/tobacco_global_nature.pdf). However, the manner of its use has been varied over the years. It has been, smoked, chewed and snuffed. Cigarette smoking became popular only in the nineteenth century. With the growth of technology, cigarette production significantly increased towards the end of the nineteenth century. Cigarette smoking became very fashionable soon and spread fast, spurred on by aggressive marketing. In the First World War, this was even one of the items in the rations given to soldiers. Its ill effects were quite unknown. Taxes levied on the production and/or consumption of cigarettes was a major part of government revenues in the twentieth century. In Germany, it constituted more than 10% of total Government revenues in the 1930s. In China, even in the early 21st century it was around 10% (Ibid). II. Dangers of Tobacco Use Although the link between tobacco and cancer, especially of the mouth, was not unknown in the eighteenth and nineteenth centuries, it was the rise of lung cancer in the twentieth century (it was almost unknown earlier) that ultimately made it possible to establish the direct link between smoking and cancer (ibid). It is now known that tobacco use results in the highest number of deaths in humans among the killers that claim human lives. Tobacco-related mortality falls under lethal diseases that can be clearly prevented from occurring (http://globalhealth.stanford.edu/education/tobacco_global_nature.pdf). The World Health Organization has estimated that the average of more than 5 trillion cigarettes smoked yearly near the end of the last century would be a prime mover of 10 million casualties by the end of the third decade of the new millennium. There is one case of lung cancer for every three million cigarettes lit (Ibid). Tobacco use (smoke or smokeless) results in many types of cancers. The lion’s share of tobacco related cancer is taken by lung cancer. Tobacco consumption, smoked or chewed, is the primary cause of the worldwide lung cancer scourge (Ibid). Research has continued right through the 20th century to establish the use of tobacco as a major cause of cancer and other ailments like heart disease. Notwithstanding, the many efforts by tobacco companies to obfuscate this fact, there is now worldwide acceptance of this link. The good news is that from the 1980s, smoking in the developed countries has started to systematically decline. The response of the tobacco companies has therefore been to tap into the developing countries of Asia, Africa and South America. However, the world’s leading exporters of tobacco-based products continue to be in the US. According to the WHO, by 2030, tobacco use will cause 10 million deaths per year. In fact, tobacco use, after peaking in the 1990s has started to fall. However, deaths from tobacco use and onset of many heart diseases and types of cancers will continue to increase (Ibid) because of the time lag between the use of tobacco and the start of the disease. According to Robert Proctor (Ibid), about 25 % of such deaths will be from lung cancer and most of them will be from the developing countries. In another way of expressing this statistic, WHO calculates that over the next thirty years 100 million people will die from tobacco use and this number is more than the total combined number of deaths from AIDS, tuberculosis, murders, homicides and car accidents. If tobacco use rates do not decline from what they were at the end of the 20th century, the 21st century could see as many as 1 billion deaths from tobacco use. The key of course would be what happens in terms of anti-tobacco use strategies in India, China, Japan and the countries of the former Soviet Union. III. Incidence of Tobacco Use and Trends (a) Tobacco consumption declining in the developed countries The most encouraging trend worldwide as pointed out earlier, is the fact that the developed countries, have registered significant and steady declines in the incidence of smoking especially over the last 40 years. For example, in the US, in 1965, 42% of adults smoked. In 2006, only 20.8% of adults smoked. In 2012, this number came down to 18% (http://en.wikipedia.org/wiki/List_of_countries_by_cigarette_consumption_per_capita). According to the Center for Disease Control, the number is now stagnating at around 18 % - 19 %, i.e. around one in five adults still smoke in the US. (http://www.cancer.org/cancer/news/cdc-adult-smoking-rates-remain-steady). Year to year decreases are however inconsistent. About 43.8 million people still smoke in the US. However, among daily smokers, there is a trend towards smoking fewer cigarettes. The proportion of those who smoked more than 30 cigarettes per day decreased from 12.6% in 2005 to 9.1% in 2011. The proportion of those who smoked less than 10 cigarettes increased from 16.4% in 2005 to 22% in 2011 (CDC Ibid). There are also certain demographic and socioeconomic trends noticeable. With age, the extent of smoking goes down. In general, young adults are the most likely to smoke in all countries. Again, the positive trend for the US (and for most developed countries) is that the proportion of smokers aged 18 to 24 years has been decreasing. It decreased in the US from 24.4% in 2005 to 18.9% in 2011, the biggest decline in any age group. This age group had the highest smoking prevalence in 2005, and now has the lowest of any group younger than 65 (CDC: Ibid). There are, however, many regional differences within the country. We will examine this later with a special reference to New York City. In Australia, similarly in 2001, 22.4% of adults smoked. This number came down to 16.1% in 2011-2013. Similarly, unlike in the 17th and 18th century, smoking is less of a patrician pursuit today. Smoking is more common among the most disadvantaged communities. (b) Tobacco use rising in the developing countries As Wikipedia reports, in developing countries tobacco consumption continues to rise at about 3% - 4% per annum. This is one of the biggest public health challenges today. According to the CDC (http://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/globalsmoking.html), smoking in the developing countries is rising by 4.4% every year. In its report on the Global Tobacco Epidemic 2011 (http://whqlibdoc.who.int/hq/2011/WHO_NMH_TFI_11.3_eng.pdf?ua=1), WHO estimated that of the 6 million people dying every year from ailments caused by tobacco use, most deaths will take place in low and middle income countries. An article in the Guardian (http://www.theguardian.com/news/datablog/2012/mar/23/tobacco-industry-atlas-smoking), in 2012, reproduces a tobacco map (from the American Cancer Society and the World Lung Foundation), which reinforces this reporting that 80% of these 6 million deaths are now happening in the low-income and middle-income countries. Per Capita Consumption, Cigarettes Per Person Legend: 8 – 150: Dark Green: 151 – 502: Light Green 503 – 999: Light Blue 1000 – 2000: Dark Blue 2001 – 2865: Very Dark Blue A few selected country profiles are presented below (a detailed table is attached in Annex 1): India
 96 cigarettes consumed per person per year In 2004, 12% male deaths and 0.9% female were caused by tobacco In India, 26.2% of men and 3.6% of women were smoking any tobacco product in 2009. 13.4% of health professionals smoke and illicit tobacco is 10% of the whole market Children and smoking Youths Exposed to Secondhand Smoke in Home, Ages 13–15, - 26.6% Youths Who Have an Object With a Tobacco Logo on It –% Boys’ Current Cigarette Use, Ages 13–15, - 5.4% Girls’ Current Cigarette Use, Ages 13–15, - 1.6% China
 1711 cigarettes consumed per person per year In 2004, 12.1% of male deaths and 10.9% of female deaths were caused by tobacco In China, 51.2% of men and 2.2% of women were smoking any tobacco product in 2009. 11.9% of health professionals smoke and illicit tobacco is 7.6% of the whole market Children and smoking Youths Exposed to Secondhand Smoke in Home, Ages 13–15, - 47% Youths Who Have an Object With a Tobacco Logo on It, - 9.5% Boys’ Current Cigarette Use, Ages 13–15, - 2.7% Girls’ Current Cigarette Use, Ages 13–15, - 0.8% United States of America: 
 1028 cigarettes consumed per person per year In 2004, 22.9% male and 23.3% female deaths were caused by tobacco In United States of America, 32.8% of men and 24.7% of women were smoking any tobacco product in 2009. 3.3% of health professionals smoke and illicit tobacco is 6.4% of the whole market Children and smoking Youths Exposed to Secondhand Smoke in Home, Ages 13–15, - 12% Youths Who Have an Object With a Tobacco Logo on It, - 12.3% Boys’ Current Cigarette Use, Ages 13–15, 9.7% Girls’ Current Cigarette Use, Ages 13–15, - 7.9% Russian Federation
 2786 cigarettes consumed per person per year In 2004 - the latest data available shows that 28.2% of male deaths were caused by tobacco and 4.4% of female deaths were caused by tobacco In Russian Federation, 59.4% of men and 24.3% of women were smoking any tobacco product in 2009. 38.9% of health professionals smoke and illicit tobacco use is 0.5% of the whole market. Children and smoking Youths Exposed to Secondhand Smoke in Home, Ages 13–15, - 76.4% Youths Who Have an Object With a Tobacco Logo on It, - 14.7% Boys’ Current Cigarette Use, Ages 13–15, - 26.9% Girls’ Current Cigarette Use, Ages 13–15, - 23.9% Clearly, the Russian Federation has the highest per capita cigarette consumption. Of the remaining 3, China is the highest, followed by the US and India. When it comes to tobacco consumption, the following are the top tobacco producers in 2009: Top ten tobacco producers, 2009 China Brazil India United States... Malawi Indonesia Argentina Italy Pakistan Zimbabwe Therefore, China was the biggest tobacco producer in 2009 with Brazil and India following behind. Below are some of the findings of the report: • More than 43 trillion cigarettes have been smoked in the last ten years 
 • Tobacco use causes 1.2m deaths annually in China and is the number one killer of the country. The report findings state that this is expected to rise to 3.5m deaths annually by the year 2030
 • Tobacco use is responsible for the greatest proportion of male deaths in Turkey and Kazakhstan at 38% and 35% respectively
 • The greatest proportion of female deaths due to tobacco use were in the Maldives and the United States at 25% and 23% respectively. Today, 84% of smokers live in the developing countries (CDC: Ibid). The CDC report cites a Gates Foundation statistic that in Bangladesh the poorest households spend on tobacco10 times as much as they do on education. Professors Gary Giovino, Sara Mirza et al, writing in the Lancet (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2961085-X/abstract?_eventId=login) analyze the Global Adult Tobacco Survey (2012) to show that in in 14 low-income and middle-income countries (Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines, Poland, Russia, Thailand, Turkey, Ukraine, Uruguay, and Vietnam) 48.6% of men and 11.3% of women were tobacco users. While 82% favored smoking manufactured cigarettes, in India and Bangladesh, smokeless tobacco and bidis were quite popular particularly among the poor. The figures also showed early initiation rates among women and overall low quit ratios (less than 20% overall) in China, India, Egypt, Russia and Bangladesh. Thus, we see that about nearly half of men in 14 developing countries are tobacco users and that women are starting to smoke at younger ages. Overall, researchers predict smoking will cause one billion deaths in the 21st century (http://scopeblog.stanford.edu/2012/08/22/smoking-rates-increasing-in-the-developing-world/). IV. What has been the Strategy Tool Box and What Has Worked So Far? The literature and the WHO list the following as the key strategies that every country and the global international community should put in place. These are listed as follows: 1. Putting in place surveillance mechanisms that monitor the tobacco epidemic and its incidence worldwide every year. The two main ones are: a. The Global Adult Tobacco Survey or GATS. The WHO defines this as, “The Global Adult Tobacco Survey (GATS) is a nationally representative household survey that was launched in February 2007 as a new component of the ongoing Global Tobacco Surveillance System (GTSS).” It enables countries to collect data on adult tobacco use and key tobacco control measures. Its results help countries in the formulation, tracking and implementation of effective tobacco control interventions, and compare results with results from other countries.
GATS has been implemented in more than 19 low- and middle-income countries with the tobacco use rates. The list includes India and within India, West Bengal. (http://www.who.int/tobacco/surveillance/survey/gats/en/) b. WHO Annual Reports on the Global Tobacco Epidemic. WHO has started issuing them since 2010 and they present the status of anti- tobacco measures world wide also known as MPOWER (explained in the following paragraph) measures. 2. Evidence based and effective tobacco control policymaking and their implementation. This requires having a nationally owned tobacco control strategy whose main policy elements should comprise the following: a. Creating smoke free environments whose goal is protecting employees and the public from secondary smoke inhalation such as heart attacks. These policies such as banning smoking in public spaces, something that US including New York City has done. These include making all restaurants, bars, parks, offices and other public places smoke free. These encourage people to quit, prevent initiation, and change social norms around tobacco use and exposure. b. Raising the cost of tobacco through taxes and non-tax policies (banning price discounts etc.). These pricing policies make tobacco less affordable and therefore reduce tobacco use and change social norms. c. Promoting and enforcing restrictions on the point of sale: These regulate youth access and seeks to counter some $8 billion that the tobacco industry spends on promoting the use of tobacco. d. Restricting access by raising the legal age of smoking e. Media interventions: Banning tobacco advertisements and mandatory statutory warnings (http://cphss.wustl.edu/Products/Documents/CPHSS_TCLC_2014_PolicyStrategies1.pdf). 3. The WHO Framework Convention on Tobacco Control (WHO FTC) along with guidelines provides the member states to constitute the policy template for members to roll out. The term MPOWER is an acronym for the six different steps visualized in the WHO FTC and constitutes a ready reckoner: a. Monitor tobacco use and prevention policies; b. Protecting People from tobacco smoke; c. Offering help to quit tobacco use; d. Warning about the dangers of tobacco; e. Enforcing bans on tobacco advertising, promotion and sponsorships; and f. Raising tobacco taxes (http://www.who.int/tobacco/mpower/publications/mpower_2013.pdf). V. How are tobacco control measures working? Policies and strategies are as effective as their implementations are. The WHO’s report on the Global Tobacco Epidemic 2013, communicates the following headline messages: ➢ Tobacco Companies are still spending tens of billions of dollars on tobacco advertisements, promotions and sponsorships. ➢ One third of youth experimentation with tobacco occurs as a result of exposure to tobacco advertisements. ➢ Complete bans on tobacco advertisements, sponsorships and promotions definitely decrease tobacco use (24 countries have a ban). Partial bans have no or little effect as companies find ways of marketing. ➢ Globally, the population covered by at least one effective tobacco control measure (i.e. one of the MPOWER measures) has more than doubled: about 2.3 billion people are now covered by at least one measure. ➢ Millions of lives stand to be saved: We have the tools and we have the will. We must act together now. Tobacco use is the world’s leading cause of preventable death. Of all epidemics, perhaps, the tobacco epidemic, while, certainly one of the most pernicious and dangerous ones, is at the same time a fully preventable one. Yet, while smoking rates are declining in the developed world, the rate of decline is slow. Most developed countries, including the United States, are facing something of a “last mile” problem as the rates of decline slow down and stagnate. On the other hand, the pervasive influence of tobacco companies is aggravating the situation in the developing world (See Section III above). What is then the state of implementation of MPOWER? A report card by WHO shows a mixed bag. Currently, half of countries – and two in three in the developing world – do not have even minimal information about tobacco use. Even acknowledging that every person has a right to breathe air free of tobacco smoke and evidence from pioneering countries showing that smoke-free laws do not harm businesses and are popular with the public, only 5% of the global population is protected by comprehensive national smoke-free legislation, which enables the creation of smoke free public spaces. Similarly, despite evidence, three out of four smokers who are aware of the dangers of tobacco, want to quit, national comprehensive services such as counseling and education towards this end are available only in 9 countries, adding up to only 5% of the world population. It is well known that relatively few tobacco users fully grasp the health dangers and therefore hard-hitting anti-tobacco ads and graphic pack warnings do reduce the number of children who begin smoking and increase the number of smokers who quit. Pictures speak a thousand words and are therefore more powerful deterrents than words on tobacco packaging warnings. However, only 15 countries, representing 6% of the world’s population, have laws mandating pictorial warnings. Just five countries, with 4% of the world's population, meet the highest standards for cigarette packet warnings. Studies have found that advertising bans can significantly reduce tobacco consumption. However, only 5% of the world’s population currently lives in countries with comprehensive national bans on tobacco advertising, promotion and sponsorship. About half of the children of the world live in countries that do not ban the free distribution of tobacco products. Tobacco taxes are known as the most effective way to reduce tobacco use, especially among young people and the poor. Increasing tobacco taxes by 10% can decrease tobacco consumption by 4% in high-income countries and by about 8% in low- and middle-income countries. Tobacco tax increases also increase government revenues. Only four countries, representing 2% of the world's population have tax rates greater than 75% of the retail price. In countries with available information, tobacco tax revenues are more than 500 times higher than spending on tobacco control. In low-income and middle-income countries, tobacco tax revenues are more than 9000 and 4000 times higher than spending on tobacco control, respectively. (WHO: Tobacco Free Initiative: http://www.who.int/tobacco/mpower/facts_findings/en/). VI: A Global Report Card: There are more than a billion adults (estimated 1.25 billion people) globally who smoke tobacco and one fifth of adolescents in schools who have succumbed to the charms of tobacco (http://www.tobaccoinaustralia.org.au/chapter-1-prevalence/1-13-international-comparisons-of-prevalence-of-sm). A cross-country global comparison of smoking among grown-ups reveals that smoking rates in that cohort has drastically reduced in USA, Canada, Western Europe, Northern Europe, Australia and New Zealand while the opposite holds true for Asia, Africa and South America (Ibid). The human toll from tobacco consumption, in all its forms, will predictably show a marked shift from the rich countries to the middle and poor countries (Ibid). Four-fifths of global tobacco smokers are in developing and least developed countries. 70% of tobacco-induced deaths are forecasted to be in these countries. The predatory promotion and marketing tactics of tobacco companies in these countries, which also have weak laws, policies and enforcement on the tobacco front, is well known for its notoriety (Ibid). According to Lopez A, Collishaw N and Piha T. (“A descriptive model of the cigarette epidemic in developed countries. Tobacco Control 1994;3:242–7”: http://tobaccocontrol.bmj.com/cgi/reprint/3/3/242.pdf) cited in ibid, tobacco use generally progresses in four stages. In the 1st stage of low prevalence, less than 20% of the population engages in low amount of smoking. In this stage, smoking is a leisure that is exclusively enjoyed by men. Tobacco is not a major cause of health concern for countries in this initial phase (Ibid). Some countries may even encourage and promote tobacco growth and consumption, as it is beneficial for their incipient, agrarian economies to do so. (Ibid). The country fitting into this mold is Zimbabwe (Ibid). Zimbabwe is among the largest producers of tobacco in the world and is a major exporter; concerns about the health consequences of tobacco use are not high on the national agenda. The next stage, or 2nd stage, is when half of the population of males in countries has started to consume tobacco. Tobacco smoking is abundant and the age for the first contact with tobacco is declining. Smoking has become fashionable even among females and is steadily increasing (Ibid). Studies have corroborated a causal relationship between tobacco use and chronic diseases like lung cancer (Ibid). Notwithstanding such research, there is scarce propagation of knowledge of these acute ailments and insignificant steps taken by the government to combat the problem. Japan, China, South-East Asia, Latin America and North Africa fit into this second stage (Ibid). In the 3rd stage, smoking tobacco has reached its peak in humans (males and females) and is already in decline (Ibid). Nevertheless, tobacco related morbidities and mortalities continue to accelerate due to a considerable time lag between the use of tobacco and its pernicious effects. Health-related programs for the benefit of society are in full flow in countries and the educated classes, men and women, frown upon the use of tobacco (Ibid). Anti-tobacco policies are enacted. The countries in this third stage comprise those of East and South Europe (Ibid). In the 4th stage smoking of tobacco sees the maximum drop or reduction in both sexes (Ibid). Deaths due to smoking decrease in men while they increase in women as women were later to take up smoking (Ibid). There are well-equipped health programs to tackle the tobacco menace and continuous monitoring is needed to overwhelm the small, but stubborn, last obstacle (Ibid). USA, Canada, Northern Europe, Western Europe, Australia and New Zealand fall in this last stage (Ibid). Figure 1.13.1 
Four stages of the tobacco epidemic Source: Lopez et al. Table 1.13.1 
Prevalence of tobacco use among adults in selected other countries—males and females, age-standardized† Country Males % Females % Albania 41 4 Bangladesh 47 4 Cambodia 41 7 Chile 42 34 China 59 4 Cook Islands 36 20 Ethiopia 8 <1 Fiji 24 5 Gambia 29 3 India 33 4 Indonesia 66 5 Islamic Republic of Iran 30 6 Israel 31 18 Jordan 63 10 Kazakhstan 43 10 Kenya 27 2 Malaysia 54 3 Mauritius 36 1 Myanmar 47 14 Namibia 39 11 Nigeria 13 1 Papua New Guinea (crude rates) 46 28 Philippines 42 10 Russian Federation 70 27 Samoa 58 23 Singapore 26 5 South Africa 28 9 Sri Lanka 30 3 Thailand 40 3 Ukraine 64 23 United Arab Emirates 17 3 Tanzania 25 4 Vanuatu 49 8 Vietnam 46 3 Zimbabwe 26 4 * Year of study reported, and definition of 'adult' and 'smoker' varies between countries. For further information, refer to primary sources cited by The Tobacco Atlas, which provides prevalence for over 190 countries. † Percentages are rounded Source: The Tobacco Atlas (Third Edition).1 VII The Prevalence in New York City According to the New York City Department of Health and Mental Hygiene the adult smoking prevalence rate in New York City has declined faster than the national rate since 2003. From 2002 to 2010, the adult prevalence rate in New York City declined from 22% to 14%: a 35% decline. During the same period the national prevalence rate declined from 22% to 19%: a 13% decline only. As on 2011, NYC had 850,000 adult smokers, i.e. 450,000 fewer smokers than in 2002. (http://www.nyc.gov/html/doh/downloads/pdf/epi/databrief12.pdf) However, even at this level, smoking related causes still kill about 7000 New Yorkers aged 35 and above every year. The Department of Health and Mental Hygiene estimates that a third of New York City smokers will die of smoking related causes. A disaggregated view of the situation shows that smoking prevalence varies inversely with the level of education. Thus in New York City, those with high school education or less the prevalence is 17% while those with at least some college education, the rate is 12%. In terms of boroughs, the greatest decline in smoking has been registered in Staten Island (50%) followed by Bronx: 36% decline, Brooklyn: 29% decline, Manhattan: 39% decline and Queens: 32% decline. Further, smoking rate declines were higher among young adults in the age group of 18-24 than among older people: (43%) compared with older adults (ages 25- 44: 35% decline, ages 45-64: 34% decline, ages 65 and older: 24% decline. This is very significant. As a New York Times report of 2011 (http://www.nytimes.com/2011/09/16/nyregion/survey-finds-14-percent-of-new-yorkers-smoke-a-decline.html?_r=0) highlighted, “a new generation was not picking up the habit, and might avoid the heavy toll of lung cancer, heart disease and other health problems linked to smoking.” Further the report went on to highlight, “the rate also dropped among public high school students, to a startlingly low 7 percent in 2010, from about 18 percent at the beginning of the decade.” VIII Implementation of Anti Tobacco Measures in NYC: What led to the Decline: The following graph answers this question well. The sharp declines from 2002 coincided well with a number of clear tobacco control measures being put in place: 1. In 2002 a major state and city wide increase in tobacco tax 2. In 2003, a ban on smoking at work places, bars and restaurants 3. In free patch programmes 4. Media campaigns through 2006-2007 5. In 2008-09 state and federal tax increases In May 2011, too late to be reflected in this survey, the city also banned smoking in public parks and beeches to protect people from second hand smoking. Tax increases are also a major factor. In 2010, city, state and federal cigarette taxes amounted to $6.86 a pack, compared with $1.58 in taxes in 2000. IX Reducing Smoking Among Young Adults: Is it Now Flattening? The most critical goal of anti tobacco measures anywhere is to reduce smoking among young adults. This is because most adult smokers get into the habit when they are in their teens. Therefore youth smoking is carefully monitored through the biennial New York Youth Tobacco Survey. Youth smoking is defined as smoking a cigarette on one or more days in the past 30 days. Although the latest data from New York State does show that smoking rates among young adults have at last started declining faster than for older adults, clearly the rate among young adults 18-24 at about 12.6% in 2010 (down from 23.8% in 2002) is still unacceptably high. (Ibid) In 2012 the smoking rate among high school students continued at 11.9%. The reduction from 2010 to 2012 is not significant and this is worrying (https://www.health.ny.gov/prevention/tobacco_control/reports/statshots/volume6/n2_trends_in_smoking_prevalence_among_new_york_youth.pdf). The situation is similar when looking at New York City. After registering rapid decline teen smoking in New York City stopped falling. It reached a remarkably slow prevalence rate of 8.5% in 2011, which is below the national teen smoking average of 18.1% and the NY state average of 11.9%. However, thereafter the decline seems to have flattened off. Actually this is a national, state and city trend and raises questions as to whether something has gone wrong throughout the country. The Wall Street Journal (http://online.wsj.com/news/articles/SB10001424127887323415304578370931423159620) in a report by Sophia Hollander dated March 19th 2013 links this to the decline in the availability of funds for anti smoking efforts throughout the country while the tobacco industry responds with more and more innovative marketing efforts. From $749.7 million in 2002, this declined to $459.5 million in 2013, according to the Campaign for Tobacco-Free Kids. New York state has slashed its funding by more than half since 2008. In 2013 it budgeted $41.4 million, down from $89.2 million in 2008.As against this according to the Wall Street Journal report, tobacco companies spent $8.5 billion in 2010 alone on advertising and promotion. The WSJ quotes a Federal Trade Commission report to say that “The largest expense was funding steep discounts and coupons to compensate for increased taxes (Ibid).” X Stocktaking: New York City New York State has clearly made significant progress in the implementation of anti tobacco measures and the impact is noticeable. When it comes to New York City the robustness of the measures and their impact on the ground are very impressive: the graph on page 13 above from the NYC Community Health Survey, shows the clear inflection points following some of these actions. As the American Lung Association in its state of tobacco control report explains the NY State continued to be proactive in its anti tobacco driver in 2013 when it passed an order to make all hospital grounds completely smoke free. (http://www.stateoftobaccocontrol.org/state-grades/new-york/highlights.html) to protect patients, staff and visitors from secondary smoke inhalation. This was however struck down in court. The state is now garnering strength in the legislature to pass a proper law on this. In New York City, however, such a law has been in place since 2011. Michael Johns, Shanon Farley, Deepa Rajulu, Susan Kansagra and Harlan Juster (http://tobaccocontrol.bmj.com/content/early/2014/04/30/tobaccocontrol-2013-051335.abstract) studied the impact of this legislation (which banned smoking in parks, beaches in 2011) in New York City using the rest of the state as an experimental group and found significant decrease in smoking in these public spaces. In 2011 NYC also celebrated ten years of the Smoke Fee Air Act, which banned smoking in restaurants and bars. Perhaps the most significant and unprecedented step that New York City has taken is raising the minimum legal age for buying cigarettes from 18 to 21. This is a first among the big cities of America. The law took effect on 19th November 2013 and from April 2014 also extends to 29 e-cigarettes as well. While adult smoking rates have been steadily declining in the country, the smoking rate among young people as already discussed earlier in this paper has been steady at about 8.5% since 2007. This law is hoped to cut smoking rates among the 18-20 group by at least half. This when viewed against the other measures which the City has promulgated including the fact that cigarette tax in New York City is the highest in the country ($5.85 a carton, which brings the overall price to around $12), clearly makes NY City a leader in anti-tobacco measures. However, as already noted, both NY state and the city have failed to sustain adequate funding for anti-tobacco efforts in the recent past. For instance, while NY State collects over $2 billion in taxes from tobacco, it is now spending only about $39 million on tobacco control: almost half of what it was sending in 2008. This is at a level considerably lower almost 19% of the amount of $203 million (http://www.tobaccofreekids.org/what_we_do/state_local/tobacco_settlement/new_york) what the Center for Disease Control and Prevention recommends for NY state. (http://news.msn.com/us/new-york-raises-minimum-age-to-buy-cigarettes-to-21-1). Another effect of decline in spending on tobacco control is that the program does not reach the most vulnerable sections of the population, i.e. those with the lowest incomes, who also have the highest rates of smoking. This means the burden of tobacco taxes falls most heavily on the poor. Limited funding prevents the Tobacco Use Prevention and Control Program from reaching the most vulnerable populations with the highest rates of smoking – those areas with the lowest incomes. As a result, increasingly the burden of tobacco taxes falls most heavily on those least able to pay. Thus, while decline in smoking has not occurred among the poor so much, the burden of cigarette taxation is also higher on them (http://acscan.org/ovc_images/file/action/states/ny/NY_Cancer_Brief_1A.pdf). “Since 2000, smoking cessation rates have been greater, and smoking prevalence is now lowest, among New Yorkers with incomes over $35,000 a year. Those with incomes below $25,000 have the highest smoking rates, and smoking prevalence among the very poorest is practically unchanged in ten years. Among those with household incomes less than $15,000 a year, the smoking rate has not changed in the past 10 years. According to the latest Census, over 13 percent of New York households have incomes below $15,000 (Ibid).” The above stocktaking shows a picture, which is characterized on the one hand by impressive overall improvements in terms of smoking prevalence and robust tobacco control measures, in particular, tax and price initiatives. However, on the other hand, a disaggregated analysis shows three major problems, which contribute to the “last mile” challenge that the tobacco epidemic confronts in the US. These are: a. Teenage/young adult smoking prevalence rates are leveling off since 2007 at about 8.5%. Given that most adult smokers start at teenage, this is very worrying b. An income and education based disaggregation shows that smoking decline among the poor and among the less educated has not been as significant as among the rest of the population c. Very clearly, since 2008, spending on tobacco control measures has been registering very significant declines in the entire state of New York adding up to at best 2% of the revenue from tobacco taxes. XI The Case for Further Research in developed countries with particular reference to New York Despite considerable progress in reducing tobacco use, the overhang of tobacco use and the toll are still fairly substantial. Even in 2011, 14,200 New Yorkers were diagnosed with lung cancer and nearly 9,000 died. According to the American Cancer Society, the health care cost on account of ailments from tobacco use in 2011 in New York State cost $8.17 billion (http://acscan.org/ovc_images/file/action/states/ny/NY_Cancer_Brief_1A.pdf). When these costs along with the human costs involved are weighed against the fact that out of the revenue from tobacco taxes, only 2% is being spent on tobacco control measures, and that too in a way that doesn't make much of a dent on the poor and less educated and the teenage smoking rate seems to be stubbornly resisting further decline, the need for further research is underscored. As Derek Yach, Angela Pratt, Thomas Glynn, K. Srinath Reddy make the point that (http://www.globalizationandhealth.com/content/10/1/39: Globalization and Health: Research to Stop Tobacco Deaths 21st March 2014) that research and evidence on the impact of different policy interventions in reducing tobacco use have played a critical role in driving the progress of policy making and implementation in country after country. Therefore, continued attention to research and the collection of evidence on how different policies are working is important not just in developing countries but also in developed countries which as seen earlier are facing the typical last mile problem with heavy costs. The authors have also pointed to the findings of the US Congress that tobacco companies are targeting the youth for focused advertising (Ibid). Member states adopted WHO’s Framework Convention on Tobacco Control in 2003 with express purpose “to protect present and future generations from the devastating consequences of tobacco consumption and exposure”. The FCTC underscores the importance of research and surveillance as crucial for tobacco control. As the authors (Ibid) go on to say, “A decade after the adoption of the FCTC, global tobacco control is at a critical juncture”. For a decade after FCTC, investment on tobacco control continued to increase. Of late, however, there are clear trends, as in New York, of definite and sharp decline in expenditure on tobacco control. Therefore, the need for research to establish the efficacy of specific policy measures is urgent and imperative. XII The Current Research Proposal for New York City In view of the major problems identified in the previous section, as contributing to the “last mile problem”, the Harlem Children Society with its one and a half decades experience of working with young adults and children (promoting STEM education in US and abroad) is proposing to focus on two aspects: A. How one specific selected measure is working to reduce tobacco use: ➢ First, the extent to which the most recent policy measure of raising the legal age of smoking to 21 is working ➢ Secondly, the extent to which this measure is working in some of the most disadvantaged pockets of New York City B. The extent of exposure of low income population in disadvantaged pockets of New York City to the following different anti tobacco measures: ➢ Creating smoke free public spaces. ➢ Preventing the sale of tobacco and tobacco products to persons below 21 from local shops that sell tobacco products. ➢ Preventing the sale of tobacco and tobacco products near educational institutions in the localities ➢ Graphic pictorial counter advertisements and billboards.