Presentation by Eduardo Bianco, M.D., Framework Convention Alliance, Uruguay, at the Global Bridges Preconference at the 15th World Conference on Tobacco OR Health in Singapore.

1. The critical importance of healthcare
worker leadership in the tobacco
control movement
The Uruguayan Case
Dr Eduardo Bianco, MD.
Centro de Investigación para la Epidemia del Tabaco- CIET
The Tobacco Epidemic Research Centre
Uruguay
1

2. Outlines
 Why and how HCP should involve on
tobacco control and treatment?
 A real world story: Uruguayan’s
medical doctor engagement on
tobacco control and treatment.
 Did it work?
2

3. Why and How?
3

4. The tobacco epidemic
 The leading preventable cause of death and diseases worldwide. The list of conditions
caused by tobacco consumption has grown. 1
 Those who consume tobacco are not the only ones exposed to its negative effects.
There is conclusive evidence linking passive smoking to an increased risk of many
adult and children diseases . 2
 Tobacco dependence itself is a chronic relapsing disease and frequently requires
proper treatment 3
 But… tobacco consumption continues to increase worldwide, expanding to less-
developed countries
 The tobacco industry, the vector of the epidemic, has a huge potential market in
developing countries:, weaker tobacco control measures and find a great number of
possible new customers.
1.The Health Consequences of Smoking: A Report of the Surgeon General, 2004
2. DRAFT Health Effects Assessment for ETS. SRP Review. 2005
3. International Statistical Classification of Diseases and Related Health Problems, 10th revision,WHO, 2003.
4

5. The tobacco epidemic
 A social problem.
 A environmental problem.
 An economic and development
problem.
BUT MAINLY….
5

6. …IS A HUGE GLOBAL
HEALTH PROBLEM
Who should take care
about it ?
6

7. Of course …
 Government and legislators .
 Society at large.
 But one group of professionals has a
special role to play:
HEALTH CARE WORKERS
7

8. We have the knowledge
 Implementing a comprehensive, continuous, sustainable and adequately
funded tobacco control strategy.
 Tobacco control efforts should be focused on several fronts:
• preventing people from taking up tobacco consumption;
• promoting cessation;
• protecting non-smokers from the exposure to tobacco smoke; and
• regulating tobacco products and preventing Tobacco Industry
Interference.
We have the tool:
ACCELERATING FCTC IMPLEMENTATION.
8

9. PREAMBLE OF THE WHO FCTC
HIGHLIGHT HCP ROLE
“…Emphasizing the special contribution of
nongovernmental organizations and other
members of civil society not affiliated with the
tobacco industry, including health professional
bodies, women’s, youth, environmental and
bodies
consumer groups, and academic and health-care
institutions, to tobacco control efforts nationally
and internationally and the vital importance of
their participation in national and international
tobacco control efforts…”
9

10. Professional Societies Are Credible
They Are Trusted and Valued, Because They:
 Are seen as trustworthy, objective and politically
neutral
 Are known and respected by policy makers
 Draw information and experience from scientific
evidence
 Policy makers are interested to hear from them
 Are legitimate to speak on behalf of those they
purport to represent or those affected by the issue
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11. HOW TO GET IT DONE: Advocacy
 To support, plead, defend a cause
 To express your views to:
Create a shift in the
environment
Mobilize resources
Change public opinion, or
Influence someone’s perception or
understanding of an issue
11

12. Health Professional´s Roles
 Role model
 Clinician
 Educator
 Scientist
 Leader
 Opinion-builder
 Watch out for tobacco industry activities
12

13. Barriers to health professional involvement in
tobacco control
1. Lack of knowledge and skills about
tobacco and tobacco control.
2. Lack of organizational leadership.
3. Tobacco consumption among health
professionals.
13

14. Health Professional Societies
Do/Could/Should:
Raise awareness of
importance of TC/SC
among HCPs
Bridge research and
policy
Promote, develop and
disseminate evidence
Empower their Advocate for
members
policy change Develop and
implement clinical
guidelines
Communicate clear
messages
Deliver training
Be a platform to share
evidence, information,
concerns, good
practices
14

15. What We Really Need to Do Now Is:
Plan and Act !
 Make a clear, basic, action plan with relevant
stakeholders, including:
People directly affected by the problem (smokers
& their families)
Decision makers
Groups interested in solving the problem
(tobacco control coalitions, other professional
societies, etc)
 Identify few clear key messages to push forward
 Be aware of the policy making
processes. To have influence, you need to:
Know them
Respect them
Use them 15

16. Level of Intervention
Individual level Clinical Practice, research, trainer
Local Level SFE and provide treatment at local health
facilities
National Level Engaging National Medical Association,
Scientific Associations
Regional Level Engaging Regional Medical/Scientific Networks
16

17. A real world story:
Uruguayan medical doctors
engagement in tobacco control and
treatment .
17

18. The pioneers
 Dr Saralegui Padrón (60-70s).
 Prof. Dr. Helmut Kasdorf (80-90s)
 Prof. Dr. Milton Portos and Dr. Beatriz
Goja created first Smoking Cessation
Clinic at the Public School of
Medicine in 1989.
 1997, first Smoking Cessation
Program at the pre-paid Health Care
System (At the Spanish Association in
Montevideo).
18

19. The influence of the International tobacco
control community
• 1998: IAHF- Heart & Stroke Foundation Train
the Trainers workshop in Ottawa, Canada.
•1999: European Congress Tobacco and Health,
Las Palmas, GC, Spain.
• 2000: 11th WCTOH in Chicago, US.
WHO-FCTC negotiating process began.
19

20. Was the tobacco epidemic a problem
for Uruguay?
 Uruguay : one of the highest tobacco consumption
prevalence in L.A. 1
 5.000 people died yearly due to tobacco related diseases. 2
 The highest lung cancer mortality in men in L.A. 3
 The highest COPD prevalence in L.A. 4
 Argentina and Uruguay with the highest ETS indoor air
contamination levels. 5
 Ineffective tobacco control dispositions.
 No accurate data on the tobacco consumption prevalence.
 Well organized tobacco industry lobby.
1. Organización Panamericana de la Salud (OPS). El tabaquismo en América Latina, Estados Unidos y Canadá (Período 1990-1999).OPS, Junio 2000.
2. Comisión Honoraria para la Salud Cardiovascular. Datos de Mortalidad por Tabaquismo en Uruguay, 2000-2002. Área de Epidemiología y Programación.
• Mackay, J ; Jemal, A; Lee, N; Parkin, D. The Cancer Atlas (2006). American Cancer Society.
• Dres. Adriana Muiño, María Victoria López Varela, Ana María Menezes. Prevalencia de la enfermedad pulmonar obstructiva crónica y sus principales factores de riesgo:
proyecto PLATINO en Montevideo. Rev Med Uruguay 2005; 21: 37-48. http://wwwscielo.edu.uy/pdf/rmu/v21n1/v21n1a06.pdff
5. Navas-Cien,A. JAMA. 2004;291:2741-2745
20

21. Uruguay – MD engagement
Timeline
• Creation of a Tobacco Control Commission from the Medical Union Association.
• Engaging in WHO-FCTC: SMU sent submission.
• Built a National Tobacco Control Alliance: Civil Society, MOH, PAHO
WNTD celebrations: Sports and Tobacco
Started to ‘dream’: Uruguay first smoke free country in LA
Participating in Regional FCTC related events.
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
• First National TC Forum
• Medical Survey on Tobacco
consumption:27%
• MD educational process.
• Identify journalists.
• Identify a champion at the
MOH. 21

22. Article related to Tobacco
Control at the National
Medical Bulletin
22

23. SMU Newspaper –May 2002
23

24. 2003
Creation of the Uruguayan Smoke Free Network
(RULTA): consolidate CS movement.
FCTC gets to the Parliament for discussion.
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
• The battle for FCTC ratification.
• A tobacco control lobbyist at the Parliament.
• Mobilizing medical doctor at the Parliament and Political Parties. Dr.
Tabaré Vázquez.
• Using the power of the media
24

25. National Journalist Contest - 2003
25

26. 2004 -SMU challenged FNR
 Are you going to help smokers to quit?
 Jan 2, 2004: Smoking cessation program
for patients from FNR.
 Feb: Media awareness campaign.
 March: they doubted…
 April: SC program opened to the general
public .
 Sept: 9 weekly SC groups (word of mouth
spreading).
 July: sent letter to the Parliament asking
for FCTC ratification.
26

27. EL PAIS: Treaty against dead
Sep, 2003 El País
27

28. SMU looks for a quick approval of anti-
tobacco treaty
A mistake…that
helped a lot!
Jun 9, 2004
28

29. 2004-2005
Congress approved FCTC Ratification
Sept 9- Uruguay ratified
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
FNR: Training and offering
medication for free. More than 100
SC programmes around the
country.
In 2010, almost 20.000 treated
29

30. 2005
• Dr. T. Vazquez took office as President
• MOH Advisory Commission advice
Minister of Health on FCTC Implementation
and request Dr Vazquez as speaker on
WNTD 2005.
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
• Jan: Creation of the MOH TC • President Vazquez Launched first Decrees to
advisory Commission implement FCTC at national level.
• Other advisors suggest not applying the
smoking ban to all of locations and facilities.
30

31. Getting the ‘impossible’ just needs
more time…
• Small business criticized the
regulation: ‘It is unfair. Better you
go directly to a total ban’
•Shopping mall surveys: less than
4% of customers against a total
smoking ban.
•A Parliamentarian Tobacco
Control Workshop in B. Aires
(August 18, 2005).
• First, international speakers
participated in a Workshop at the
Congress and, then visit Vazquez
at the Presidency (August 17).
• Sept 5, Pte Vazquez launched a
new decree on SFE.
31

32. 2005 -2006
A champion at the Uruguay became first Smoke Free Country in
Congress: Americas Region
Dr. Miguel Asqueta
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
• At same time Dr Bachelet
was President of Chile…it is Creation of The Tobacco Epidemic
not yet a Smoke Free Country Research Centre – CIET Uruguay
32

33. The tobacco epidemic research
center
• Developing high quality research
• Capacity building
• Disseminating information.
• Advocacy
• Multidisciplinary : physicians, lawyers,
psychologist, economists, journalists, dentists,
sociologists, academics, stakeholders, etc.
33

34. 2007
• Advocating for a Comprehensive TC law development at the
Congress.
• The importance of the a MD to champion at the Congress
• New evaluation of Tobacco consumption in MD: 17%
• 2nd MD and Tobacco Workshop
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
• CIET/SMU and others launched RESPIRA Uruguay (Breathes
Uruguay)-.Youth Exhibition.
34

35. BREATHES URUGUAY
• Dr. Chan (WHO) visited and requested
taking the interactive exhibition to COP 3 (South Africa)
35

36. Respira is still a valuable educational resource from Uruguayan’s
Government perspective
Governmental
Educational Webpage.
Feb 9, 2012
Recently a Scotish
delegation visit
Respira to reproduce
the exhibition there
36

37. Proactively and reactively SMU advocated at the Parliament for a
Comprehensive National Tobacco Control Law/ Nov 2007
1. The Tobacco Industry representative
Main
Tobacco
lobbyst
2. Advertising Associations
3. National Medical Association
SMU
37

38. 2008
• March: A comprehensive national tobacco control law passed.
• CS wrote President Vázquez asking for hosting COP 4 (as a protective
measure)
• Respira Uruguay in COP 3 in South Africa
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
38

39. WHO MPOWER- Feb 2008:
Uruguay as a tobacco control leader
39

40. 2009
• SMU elected as host of 2011 WMA General Assembly, asked for Tobacco
Control as topic for the Scientific Session.
• Tobacco Control Commission asked to organize the event and request to
the Executive Committee to develop actions to set MD tobacco consumption
below 10%.
• Creation of the Uruguayan Society of Tabaccology
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
• Development of the National Guidelines for Smoking Cessation and
Treatment.
• Uruguayan Cardiology Society and its commitment to tobacco control
influenced South American Cardiology Society to set Tobacco Control as
priority topic in 2010 Regional Congress.
• Creation of Alerta Tabaco (Tobacco Alert network).
40

41. Feb 2010:
PMI vs URUGUAY
PMI : URUGUAY VIOLATES
INVESTMENT BILATERAL AGREEMENT
SWITZERLAND-URUGUAY
ICSID- International Centre for Settlement of
Investments Disputes.
1. The prohibition of using different
presentations of a brand.
2. Health warnings that cover 80% of the
packaging.
3. Images do not fit reality.*
*PMI has quit this claim
41

42. A WELL PLANNED STRATEGY
• A new Government, open to dialogue.
• A recent painful international litigation with
Argentina .
• They offered a “reasonable” solution .
INGRAVESCENT
• New Government felt alone.
42

43. Civil Society Intelligence gathering…
Civil Society
denounced
Government was
negotiating with PM
and there would be a
set back
July 7, 2010 43

44. Minister of Health publicly announced the set
back
July 25, 2010
July 23 , 2010
44

45. SMU and Civil Society rejected set back
in tobacco control policy
July 25-26 2010
45

46. MUJICA and VÁZQUEZ FACED BY TOBACCO
CONTROL POLICY
46

47. 2010
• October- South American Congress of Cardiology: “ For a Smoke Free South
America”, in Montevideo. Congress with a Plenary on Tobacco Control and
Treatment.
• November- COP 4 in Punta del Este, Uruguay. SMU as representative of
WMA.
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
• Anecdote: President of the Uruguayan Cardiology Society , the evaluation
of the smoking ban impact on the AMI admissions , and the 2010 Cardiology
Congress in Venezuela.
47

48. 2011
• SMU convened creation of the National NCD Alliance.
• WMA General Assembly Scientific Sesion: Tobacco Control.
• MD tobacco consumptiom prevalence survey
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
48

49. Did it have any impact?
49

50. Tobacco consumption prevalence
35% Medical Doctors
27% 1
30%
Adults
25%
20% 17%
1
Youth
15%
10% 2
5% 9.8%
0%
1998 2001 2006 2009
1. Encuestas Junta Nacional de Drogas 1. SMU, Sindicato Médico del Uruguay
2. ENPTA 2008-CIET y GATS 2009 2. CIET; SMU; FEMI, Federation of Medical Doctors
of Inland Cities 50

51. 2011 MD tobacco consumption survey
 Attempts to quit last year: 61%
 Received help to quit: 33%
 Intention to quit:
• National Tobacco Control Policy support:
78,8% strongly agree, 18,3% agree
51

52. 2011 MD tobacco consumption survey
• SMOKING CESSATION TRAINING: 46,6%
• ALWAYS OFFER PATIENTS ADVICE TO QUIT: 82%
• INITIATE TREATMENT
• SENT PATIENTS TO SPECIALIZED SMOKING CESSATION
PROGRAMMES
52

53. SFE impact on AMI admissions in
Uruguay
22%
Hospital admissions for acute myocardial infarction before and after implementation of a comprehensive
smoke-free policy in Uruguay. E. Sebrie´, E.Sandoya, A. Hyland, E. Bianco, S. A Glantz, K M Cummings,
Tobacco Control (addmited, to be published in short).
53

54. Trade and Economic Impact
Annual Tobacco Sales* TOBACCO FISCAL REVENUES*
350
300
250
200
150
100
50
0
2004 2005 2006 2007 2008 2009 2010 2011
* Data from Fiscal Authority US$ million dollar 54

55. Uruguay´s Tobacco Control Policies:
A regional model.
 SFE legislations: Most of S.A. and
C.A. countries passed SFE laws. 6 are
already implementing that.
 Regional Cooperation.
 “Pilot Case”: First evaluations showed
that FCTC implementation works…
even in a Latin American country.
55

56. Conclusions
 Health professionals have a prominent role to play in tobacco control.
 Have the trust of the population, the media and opinion leaders, and our voices are
heard across a vast range of social, economic and political arenas.
 At the individual level, we can educate our patients on the harms of tobacco use and
exposure to second-hand smoke and help tobacco users overcome their addiction.
 At the community level, we can be initiators or supporters of some of the main
tobacco control policy measures, for example, promoting smoke-free workplaces and
extending the availability of tobacco cessation resources.
 At the society level, we can add our voice and experience to national and global
tobacco control efforts .
 Health professional organizations can show leadership and become a role model for
other professional organizations and society by embracing the tenants of the Health
Professional Code of Practice on Tobacco Control.
56

57. THANKS !
biancoeduardo1@gmail.com
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