Review ArticleGlobal tobacco prevention and control in relation to a cardiovascular health promotion and disease prevention framework: A narrative review
Introduction
Cardiovascular disease (CVD) is the leading cause of death worldwide (WHO, 2012), and is especially prevalent in low- and middle-income countries (LMICs) where over 80% of CVD deaths occur (Hoyert and Zu, 2012). Comprehensive tobacco control is a critical global public health strategy for cardiovascular health (CVH) promotion and CVD prevention. Four fundamental strategies are distinguished in a CVH/CVD framework: 1) preserving CVH/low CVD risk; 2) controlling increased CVD risk; 3) detecting and treating acute CVD events; and 4) reducing disability and risk of recurrent CVD events. Tobacco control within each of these domains requires a different approach, with tobacco prevention being a key component for maintaining ideal CVH and tobacco cessation being a key component for restoring ideal CVH, controlling increased CVD risk, and treating individuals who have survived CVD events (Fig. 1).
Here, we consider the role of comprehensive tobacco prevention and control within this CVH promotion and CVD prevention framework. We conducted an expert review using electronic databases (e.g., PubMed), manual searches of peer-reviewed journals most likely to publish global tobacco control research or commentaries (e.g., Tobacco Control, Global Heart), and reference lists of included articles, policy reports, and treatment practice guidelines. To better inform cardiovascular health professionals unfamiliar with tobacco prevention and control strategies, we review recent developments in this arena and the current state of global tobacco prevention and control. We include strategies that have led to the declines in tobacco use in high-income countries (HICs) and those that are gaining traction in LMICs, as well as topical challenges to global tobacco control in the context of CVH promotion and CVD prevention. We then describe the possible role of cardiovascular health professionals within the larger global tobacco control movement. We conclude with a focus on the tobacco endgame as a critical component of global CVH promotion and CVD prevention.
Section snippets
Viewing tobacco control from the perspective of CVH promotion and CVD prevention
A priority for global CVH promotion and CVD prevention should be to end the tobacco epidemic through comprehensive, integrated, and coordinated tobacco prevention and control strategies (Reddy et al., 2012). The World Bank (1999) estimated that cumulative tobacco-attributable deaths through year 2050 would number 520 million with then-current prevention and intervention efforts, but could be reduced to 500 million if initiation rates were reduced by 50%, or to 340 million if adult consumption
Developing and implementing the Framework Convention on Tobacco Control (FCTC)
The Framework Convention for Tobacco Control (FCTC) represents a comprehensive approach to global tobacco control, and is the successful amalgamation of several international human rights proposals to address the global epidemic of tobacco use (WHO, 2003). With membership comprising 168 Signatories and 180 Parties,1
Successes in global tobacco control: “best buys”
To enact cost-effective interventions against noncommunicable diseases (NCDs) globally, the WHO Global Burden of Disease project proposed a list of “best buy” policies – strategies that require relatively low investment for their great projected impact and support both primordial and remedial tobacco control (WHO, 2011b, World Economic Forum and the Harvard School of Public Heal). This list of best buys was adopted by the WHO as priority interventions for FCTC signatories.
Barriers to tobacco control implementation in LMICs
Although tobacco control policies have led to significant and often swift reductions in population smoking rates, and corresponding declines in CVD, there are important barriers to implementation of tobacco control policies in LMICs. Tobacco control research and policy are strategically interdependent (Mackay, 2013), however, there is often a lag in the process of policy research, implementation, evaluation, and optimization (FCTC Article 20; Gupta et al., 2012, Warner and Tam, 2012). To
Ending the tobacco epidemic
Discussion of the “tobacco problem,” as termed by the Institute of Medicine, has now advanced to “ending the epidemic” (USDHHS, 2010). Since the first U.S. Surgeon General's Report in 1964, an estimated 8 million lives and 157 million life-years have been saved as a result of tobacco control efforts (Holford et al., 2014). Although the proportion of the population who are smoking has decreased significantly, with the growing global population the actual number of current daily smokers has
The Tobacco Endgame
Ending the Tobacco Epidemic (USDHHS, 2010) cited “a historical opportunity to rekindle the momentum of previous decades and achieve the vision of a society free from tobacco-related death and disease.” Four strategic actions were proposed: 1) strengthening implementation of evidence-based interventions and policies in states and communities; 2) changing social norms around tobacco use; 3) leveraging health and human service systems and resources to create a society free of tobacco-related
Conclusion
The 20th anniversary issue of Tobacco Control included a critical appraisal of the relation between the tobacco control movement and prevention of NCDs (among which CVD predominates) (Wipfli and Samet, 2012). Integration and synergy of these efforts would be supported by a global commitment to the United Nations Sustainable Development Goal 3.4 to reduce mortality due to NCDs (and CVD in particular) by one third by the year 2030 (http://www.un.org/sustainabledevelopment/health/) and the WHO
Conflict of interest statement
We do not have any financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. DRL and MDH receive grant support from the World Heart Federation to serve as a consultant and the senior program advisor, respectively, for the World Heart Federation's Emerging Leaders program, which is supported by Boehringer Ingelheim and Bupa. BH has served on a scientific
Funding
Allison Carroll was supported by a Predoctoral Individual National Research Service Award (F31 HL129494).
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