Public Health, National Economies Suffer from Tobacco Scourge
by Harley Stanton, Dr. P.H., Health Promotion Adviser – Tobacco and Alcohol,
Secretariat of the Pacific Community, Noumea, New Caledonia

There’s no such thing as minimal damage when it comes to tobacco. In fact, tobacco use continues to be the single most preventable cause of death in the world, with 5 million people dying from it in 2001 alone.

Sixty-one percent of this premature disease affects people age 15 to 59, and 39 percent afflicts those aged 60 or more, revealed Rodgers, et al. in their current “Global Burden of Disease” study. Until recently, the majority of these tobacco-related deaths occurred in developed countries; but now, the burden is shifting to developing countries, where the majority of tobacco-related deaths will take place during the 21st century.

Health in a Handbag
When people start smoking early and for lengthy periods of life, they are likely to develop disease and die prematurely from their addiction. In fact, half of all long-term smokers die from tobacco use, and one in two of them lose between 15 and 25 years of life due to their habit. The seminal work of the late Sir Richard Doll and others in a 50-year study of British doctors showed that smokers died an average of 10 years earlier than non-smokers. According to a 2005 review by Bjartveit and Tverdal, people who consume even small numbers of cigarettes are 1.5 times more likely to die sooner than those who have never smoked, with the steepest increase in risk occurring with those consuming up to four cigarettes per day.

In a discussion paper in 2003, Guindon and Boisclair emphasized that, assuming a 2 percent decrease in prevalence every year to 2025, the world would still be host to 1.1 billion smokers in two decades. Without changes in prevalence and per capita consumption, 1.9 billion users will be consuming more than 9 billion cigarettes per year by 2025. Sadly, recent data shows only modest changes in global consumption in the period from 2000 to 2004, indicating that few, if any, reductions are likely to be achieved in the near future.

The Economics of Tobacco Use
Close to 60 percent of the nearly 6 billion cigarettes and 75 percent of today’s tobacco users are now in developing countries. Research from a broad range of nations shows that as much as 25 percent of household income is spent on tobacco, meaning that, in many cases, tobacco is given priority over other basic necessities of life, including food, clothing, health care and education. In Vietnam, for example, expenditures on tobacco are often 1.5 times the moneys spent on education and five times higher than expenditures on health care. And they can be one-third of the budget spent on food.

Poorer households spend a greater percentage of their income on tobacco than wealthier ones, and often children suffer most. In Bangladesh, for example, the poorest citizens are twice as likely to smoke as the wealthiest ones and spend up to 10 times more on tobacco than they do on education. According to a 2004 report by the World Health Organization (WHO), more than 10 percent of expenditures in lower-income Egyptian households went towards cigarettes or other tobacco products; the lowest income group in Indonesia spent 15 percent of its total expenditures on tobacco; and even homeless children in India spent a significant portion of their income purchasing tobacco, often prioritizing it over food.

Even within developed countries, the same trends apply. A recent U.S. study by Armour, Pitts, Lee, Woollery and Carabalio found that poor families spent up to 12 percent of their income on tobacco as compared to non-poor ones. Meanwhile, a host of studies in the United Kingdom in the early 1990s by Marsh and McKay showed that out-of-work families spent an average of 12 percent of their net household income on cigarettes, while those with moderate incomes spent an average of 5 percent.

And the Poor Get Poorer
Studies in more than 80 countries have shown that trade liberalization increases tobacco consumption, especially in low- and middle-income nations. “Tobacco has a negative impact on the balance of payments of many countries,” report Esson and Leeder in the 2005 WHO Millennium Development Goals and Tobacco Control: An Opportunity for Global Partnership. “Two-thirds of 161 countries, where data are available, are net importers of tobacco, losing more hard currency in cigarette imports than they gain by exporting tobacco. Several countries, including Cambodia, Malaysia, Nigeria, Republic of Korea, Romania and Viet Nam, have a negative tobacco trade balance of more than $100 million [per annum],” they assert.

Several key documents published within the last five years, including the WHO Commission on Macroeconomics and Health (CMH), affirm that a high national disease burden correlates with low national wealth and reduced productivity, that people who are sick cannot earn full wages, that poverty increases vulnerability to disease, and that tobacco is a link between poverty and illness. They note that significant changes can be achieved through modest investments in tax increases, ad bans and strong health warnings on cigarette packages.

Pockets of Progress
A challenge bordering on a crisis, global tobacco control is not all doom and gloom. While no other area of health and medicine is so well financed to oppose change, international developments are encouraging. For the first time in recent history, a number of developed countries have prevalence rates below 20 percent, including Australia, Canada and Sweden. Meanwhile, Singapore and Hong Kong maintain low prevalence rates due to a minimal incidence of smoking among women, and several other Asian countries are making progress.

Smoking rates among Thai women have declined below 5 percent and male smoking rates continue to fall since Thailand introduced strong legislation to ban tobacco advertising and sponsorship, and instituted other control measures. Thanks to tax increases, counter marketing, smoke-free policies for public buildings and workplaces, and support to cessation in Korea, smoking rates among Korean men have dropped from around 70 percent to 50 percent in less than five years, one of the most significant declines in smoking rates observed worldwide.

A Chance, and the Choice, to Change
Among the most encouraging development of the last five years is the enactment of the WHO Framework Convention on Tobacco Control (FCTC). As of December 12, 2005, 115 countries had ratified the FCTC, making it the most rapidly supported global treaty ever implemented. Unfortunately, two large producer countries, the United States and Indonesia, have yet to ratify it and will not participate in the first meeting of the Conference of Parties in Geneva on February 6-17, 2006.

The binding obligations of FCTC-ratifying countries have placed tobacco on the global agenda in a way that cannot be undone. The treaty requires resources and funding to be allocated for tobacco control within national agendas, opening the door for a worldwide “sea change” on tobacco control. With development agencies increasingly aware of the poverty-related aspects of tobacco and by reducing smoking prevalence and reliance on tobacco within country budgets, nations will foster better health and economic improvements.

Both the CMH and the recent World Development Report show that investment in health yields excellent returns. Since national wealth and productivity are low where the disease burden is high, health improvement is an economic imperative; and efforts to reduce tobacco-caused illness will significantly boost global health, while enhancing development and FCTC success.

Still, many countries hesitate to reduce tobacco use. They are, in a statement made at the 2003 World Bank meeting in Brussels on the Economics of Tobacco Control, concerned that “…the harm caused by tobacco may be offset by the economic benefits that the country derives from growing, processing, manufacturing, exporting and taxing tobacco. The argument that ‘tobacco contributes revenues, jobs and incomes’ is a formidable barrier to tobacco control.”

But tobacco control may be good for business as well as health. The recent experiences of Ireland and Italy show that tobacco-control legislation makes economic and physical sense. For example, despite recent smoking bans, the hospitality industry in these countries continues to thrive, possibly attracting people who avoided these establishments when they were smoke-filled, instead of smoke-free.

Tobacco control is about preserving the future for generations to come. For too many years in too many places, the tobacco industry has sought to pervert truth and justice by litigation, lobbying and lies. Finally, some progress is being made — and it is hoped that development resource agencies will begin to give stronger support to these important issues in acknowledgement.