Challenges for Tobacco Control in Romania

1. Challenges for Tobacco Control in Romania Silviu Radulescu Health Specialist The World Bank, Romania Office Effective Advocacy and Movement Building for Tobacco Control, April 24-26, Bucharest Romania

2. Outline of the presentation The context - tobacco epidemic in ECA Effective measures for tobacco control What is known to work A closer look to price measures in ECA What Governments could do How the World Bank can help

3. Tobacco Epidemic in ECAHighest adult prevalence rates in the world, but women catch up as economics improve and cultural norms change Male prevalence rates in many ECA countries are among the highest in the world. Due to several reasons, culture, income, tradition, few women in some parts of the region smoke. But in countries that are closer to Western Europe, women have high smoking prevalence rates, comparable to or even higher than prevalence rates among Western women. Prevalence rates among women in Slovak Rep., Poland, Bulgaria, Estonia, Hungary,and Slovenia are between 20 and 30%, and an astonishing almost 50% in Turkey,. Male prevalence rates in many ECA countries are among the highest in the world. Due to several reasons, culture, income, tradition, few women in some parts of the region smoke. But in countries that are closer to Western Europe, women have high smoking prevalence rates, comparable to or even higher than prevalence rates among Western women. Prevalence rates among women in Slovak Rep., Poland, Bulgaria, Estonia, Hungary,and Slovenia are between 20 and 30%, and an astonishing almost 50% in Turkey,.

4. Smoking attributed male deaths increasing, especially in Romania We see higher smoking attributed death toll among men in East and Central Asia. Poland, the Czech Republic, and the Slovak Rep have turned the trend around, Hungary has slowed the upward trend slightly. In Romania things seem to be getting steadily worse. We see higher smoking attributed death toll among men in East and Central Asia. Poland, the Czech Republic, and the Slovak Rep have turned the trend around, Hungary has slowed the upward trend slightly. In Romania things seem to be getting steadily worse.

5. Smoking-attributed deaths also increasing fast among women in the region Women started smoking in significant numbers from the 1950s on � and 20-40 years later, the inevitable rise in the death toll from diseases caused by smoking is clearly evident. And these numbers will continue to rise, unless large numbers of smokers quit. Women started smoking in significant numbers from the 1950s on � and 20-40 years later, the inevitable rise in the death toll from diseases caused by smoking is clearly evident. And these numbers will continue to rise, unless large numbers of smokers quit.

6. High smoking-attributed deaths, especially in ECA In 2000, tobacco caused more than 750 thousand male deaths and about 75 thousand female deaths in Western, Central and Eastern Europe. But the heaviest burden was on the lower income countries in Europe. 3/4 of all male deaths from tobacco in Europe and � of female tobacco deaths were in the Eastern and Central European countries. EU countries have 45% of total population in the region (total ECA and Europe). In 2000, tobacco caused more than 750 thousand male deaths and about 75 thousand female deaths in Western, Central and Eastern Europe. But the heaviest burden was on the lower income countries in Europe. 3/4 of all male deaths from tobacco in Europe and � of female tobacco deaths were in the Eastern and Central European countries. EU countries have 45% of total population in the region (total ECA and Europe).

7. Romania has one of the highest cigarette consumption in the region

8. �and some of the heaviest smokers in ECA

9. Increasing Trend in Cigarette Consumption in most ECA As seen here, cigarette consumption in countries with lower tax are experiencing increasing trend in cigarette consumption. Specifically, except, Hungary and Poland, other countries have been experiencing increasing cigarette consumption. As seen here, cigarette consumption in countries with lower tax are experiencing increasing trend in cigarette consumption. Specifically, except, Hungary and Poland, other countries have been experiencing increasing cigarette consumption.

10. Smoking epidemic is also higher among health professionals in the region In order to convince smokers on the street, we first have to educate and inform our health professionals who are important role models for their patients. Unfortunately, as long as we have high prevalence rates among our health professionals, we are facing an uphill battle in trying to persuade other smokers of how dangerous smoking is to health, and in persuading them to take the difficult step of quitting. In order to convince smokers on the street, we first have to educate and inform our health professionals who are important role models for their patients. Unfortunately, as long as we have high prevalence rates among our health professionals, we are facing an uphill battle in trying to persuade other smokers of how dangerous smoking is to health, and in persuading them to take the difficult step of quitting.

11. Tobacco does not affect only health but also budgets of smokers� families Smokers in the region spent significant amount of their monthly income on tobacco products. In Armenia the average smoker apparently spends 28% of his monthly income on cigarettes. In Ukraine a smoker spends 17% of his annual income on cigarettes. These are very high opportunity costs for smokers. Given the low income status of countries, it is a huge financial burden on families where 6% to 28% of smokers� monthly salaries are spent on tobacco. Most smokers do not realize the volume of these expenses. When smokers quit, they have more money in their wallets to spend on other family needs: healthy food, health care, education, etc.Smokers in the region spent significant amount of their monthly income on tobacco products. In Armenia the average smoker apparently spends 28% of his monthly income on cigarettes. In Ukraine a smoker spends 17% of his annual income on cigarettes. These are very high opportunity costs for smokers. Given the low income status of countries, it is a huge financial burden on families where 6% to 28% of smokers� monthly salaries are spent on tobacco. Most smokers do not realize the volume of these expenses. When smokers quit, they have more money in their wallets to spend on other family needs: healthy food, health care, education, etc.

12. Cigarette expenditures are significant part of GDP in many countries Cigarette consumption per adult in ECA is higher than the consumptions in other regions. 8% of total world�s population smokes 16% of global cigarette production Therefore, it generates high expenditures that are equivalent to 9% to 1% of GDP in most ECA countries. Cigarette consumption per adult in ECA is higher than the consumptions in other regions. 8% of total world�s population smokes 16% of global cigarette production Therefore, it generates high expenditures that are equivalent to 9% to 1% of GDP in most ECA countries.

13. Measures that we know that work for controlling the tobacco epidemic Higher cigarette taxes Non-price measures: Better consumer information: strong warning labels, counter-advertising & disseminate research findings Comprehensive ban on advertising and promotion Restrict/ban smoking in public and work places Cessation help (NRT)

14. Tobacco Tax Rates and Prices: Where ECA fits in the Globe! When the tax rates on cigarettes are examined in the ECA region, although tax per pack is almost equivalent to lower middle income countries, the average price is similar to that of low income countries. Data for ECA represents the following countries:Albania, Armenia, Belarus, Bulgaria, Croatia, Cyprus, Czech, Estonia, Hungary, Georgia, Kazakhstan, Kyrgyz Rep. Latvia, Lithuania, Macedonia, Poland, Romania, Russia, Slovenia, Slovak Rep. Turkey, Yugoslavia, Ukraine, Uzbekistan When the tax rates on cigarettes are examined in the ECA region, although tax per pack is almost equivalent to lower middle income countries, the average price is similar to that of low income countries. Data for ECA represents the following countries:Albania, Armenia, Belarus, Bulgaria, Croatia, Cyprus, Czech, Estonia, Hungary, Georgia, Kazakhstan, Kyrgyz Rep. Latvia, Lithuania, Macedonia, Poland, Romania, Russia, Slovenia, Slovak Rep. Turkey, Yugoslavia, Ukraine, Uzbekistan

15. Total and Excise Tobacco Taxes as % of Retail Price Romania has excise tax as 34% of average retail price in 1999 and when the VAT is added, the total tobacco tax as % of price increases to 54%. Romania has excise tax as 34% of average retail price in 1999 and when the VAT is added, the total tobacco tax as % of price increases to 54%.

16. Price and Tax per pack in Accession Countries, 1999 The good news from public health perspective is that accession countries who are in a process of joining to the EU in the next rounds, have increased their tax share in average price of a pack of cigarettes, but some still lack well behind the level such as Latvia 49% of price is tax and Lithuania 33% of price is tax. The good news from public health perspective is that accession countries who are in a process of joining to the EU in the next rounds, have increased their tax share in average price of a pack of cigarettes, but some still lack well behind the level such as Latvia 49% of price is tax and Lithuania 33% of price is tax.

17. Tobacco taxes are a highly variable part of total tax revenues Tobacco taxes are also significant part of total revenues in most ECA countries where it is difficult to collect income taxes. Taxes from tobacco �cigarettes- vary from 8% of total taxes in Armenia and Macedonia to 2% in Lithuania. Tobacco taxes are also significant part of total revenues in most ECA countries where it is difficult to collect income taxes. Taxes from tobacco �cigarettes- vary from 8% of total taxes in Armenia and Macedonia to 2% in Lithuania.

18. But low value of tobacco tax revenue (US$) Who earns how much? As we have seen before, tobacco tax revenues were significant part of total government revenues in most ECA countries, but compared to West European receipts, tobacco tax earnings are not significant revenue in terms of USD value. As we have seen before, tobacco tax revenues were significant part of total government revenues in most ECA countries, but compared to West European receipts, tobacco tax earnings are not significant revenue in terms of USD value.

19. High value of tobacco tax revenue (US$) How much could be earned? Although tobacco tax revenues do not have significant share in total government revenues in the West, in fact, in terms of USD value, tobacco generates significant amount of revenues.Although tobacco tax revenues do not have significant share in total government revenues in the West, in fact, in terms of USD value, tobacco generates significant amount of revenues.

20. Smuggling is a chronic problem in the region, but we know tobacco smuggling tends to rise in line with the degree of corruptionSmuggling as a function of transparency index

21. Tobacco control efforts varyGood legislation is not enough � enforcement matters! It is encouraging to see more and more countries are implementing tobacco control measures. Unfortunately, smoking prevalence is still high in some countries that have well written and comprehensive tobacco control measures. This may point to a problem of poor enforcement of laws and regulations. Unless laws are enforced, they cannot have their full potential positive impact. It is encouraging to see more and more countries are implementing tobacco control measures. Unfortunately, smoking prevalence is still high in some countries that have well written and comprehensive tobacco control measures. This may point to a problem of poor enforcement of laws and regulations. Unless laws are enforced, they cannot have their full potential positive impact.

22. Treating Nicotine Dependence Willingness to quit smoking is an important step Increase smokers� knowledge on adverse health affects and availability of cessation help Cessation support from health professionals is key Smoke free hospitals, and health professionals is essential Cessation treatments should be easily available and affordable Quit lines, community support, etc., work Nicotine treatment therapies have a particular importance. There are 1.1 billion smokers around the world who are addicted to nicotine. Evidence shows that large numbers of smokers want to quit smoking and have tried at least once to quit. It is important to help those who want to quit.. Evidence also shows that advice from health professionals to patients to quit can make a substantial difference, but there is also a clear need in many countries to reduce the number of smokers among health professionals themselves. Nicotine treatment therapies have a particular importance. There are 1.1 billion smokers around the world who are addicted to nicotine. Evidence shows that large numbers of smokers want to quit smoking and have tried at least once to quit. It is important to help those who want to quit.. Evidence also shows that advice from health professionals to patients to quit can make a substantial difference, but there is also a clear need in many countries to reduce the number of smokers among health professionals themselves.

23. Recommendations Governments can control the tobacco epidemic with sound economic and health policies adopt a comprehensive set of proven measures, tailored to each country implement and enforce policies increase prices/taxes to effectively reduce demand, especially in children, adolescents and lower income groups help current smokers quit inform the public well educate & enlist health professionals

24. World Bank support for tobacco control measures of the Romanian Government Knowledge sharing Curbing the Epidemic translation http://www.worldbank.org/tobacco/ Policy advice Lending � Health Sector Reform Project Public information campaigns Setting up smoking cessation services � training of staff Health education in schools Building capacity in public health