Photo Credit: Matilde Campodonico, Associated Press
In the public health world, it’s always a struggle to show the impact of health interventions, programs, or policies. Changes in key health outcomes – improved health behaviors, declines in deaths or the number of cases, or people living longer, healthier lives – usually take a long time to capture. By the time you see those changes, it’s often very hard to say “that policy saved x number of lives.”
More than 1,000 collaborators working on the Global Burden of Disease (GBD) study – coordinated by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington – are starting to make it easier to connect those dots. The GBD collaboration is now providing annual updates on mortality trends – and most importantly, specific causes. Published this week in The Lancet, their latest work tracks how many people are dying and from what causes for 188 countries over time.
Literally millions of stories can be found in this new body of results (or explored online with IHME’s data visualization suite). Today, we’re taking a deeper dive into a public health success story where the link between policy efforts and improved health outcomes is only tightening: tobacco control, and in particular, Uruguay’s efforts to take on its tobacco epidemic
Between 1990 and 2013, when the global rate of lung cancer mortality was increasing by 16%, Uruguay recorded a 15% decline. To what can Uruguay attribute this decline? The South American nation’s tobacco control policies have been heralded as some of the world’s most successful. Smoking is a leading risk factor for developing – and dying from – lung cancer later in life. From 1980 to the mid-1990s, about 31% of Uruguayans were daily smokers. By 2012, daily smoking rates fell by 23%. Further, rates of early death and illness associated with smoking decreased 20% between 1990 and 2010.
So what exactly did Uruguay do? Although the country technically had some smoking restrictions for public places during the 1990s, they were minimally enforced until Uruguay stepped up its tobacco control programs during the 2000s. In 2004, Uruguay ratified the international Framework Convention on Tobacco Control and its president declared that all health institutions would be smoke-free.
One year later, Dr. Tabaré Vásquez, a well-known oncologist, was elected president and made tobacco control a national priority for Uruguay. A series of national laws then followed, including a range of smoking bans, in 2005 and 2006. Nationwide media campaigns celebrated Uruguayans’ dedication to not smoking in public places, applying principles of positive reinforcement through messaging like “Un Millón De Gracias” (Thanks a Million [for not smoking]). The country also instituted such graphic cigarette packaging (left) that Philip Morris, one of the largest tobacco companies in the world, filed a lawsuit against Uruguay in September 2014.
One of the most innovative components of Uruguay’s tobacco control activities was the country’s approach to policy enforcement. The Ministry of Health oversaw formal enforcement, but both Ministry inspectors and citizens teamed together to find institutions that were violating smoking laws. Surveys showed very high public acceptance of smoke-free regulations, which could be a result of this partnership.
An exhaustive evaluation of Uruguay’s tobacco control policies and their impact on health has yet to occur, and it is important that we don’t overestimate what a given set of interventions can do. At the same time, we now have the data to start piecing together what is really happening in places like Uruguay – and to better understand how public health programs can save lives.