ONLY two causes of death are large and growing worldwide: HIV and tobacco. While most countries have begun, at least, to respond to HIV, the response to the global tobacco epidemic has so far been limited and patchy. In this chapter, we discuss some of the factors that might influence governments' decisions to act and propose an agenda for effective action.

All governments recognize that, in forming their policies, they take ac-count of many factors, and not only economics. Tobacco control policies are no exception. Most societies are concerned about protecting children, although the degree to which this is true varies from culture to culture. Most societies would wish to reduce the suffering and emotional losses wrought by tobacco's burden of disease and premature death. Economic studies have not yet brought any consensus to valuing that burden. For the policymaker seeking to improve public health, tobacco control is an attractive option. Even modest reductions in a disease burden of such large size would bring highly significant health gains. The consensus between societies that health gains are desirable is reflected in the tobacco policies and actions of the World Health Organization and in other international organizations (see Boxes 7.1 and 7.2 and Appendix A).

Overcoming political barriers to change

To be effective, any government that decides to implement tobacco controls must do so in a context in which the decision has broad popular support. While it might seem that smokers would be strongly opposed to tobacco control, the reality is rather different: in studies of high-income countries with successful tobacco control programs, most adult smokers have been found to support at least some controls, such as widely available information. Governments alone cannot achieve success without the involvement of civil society, the private sector, and interest groups. Programs are more likely to succeed if there is collective agreement in and ownership of them across a broad coalition of social interests with the power to implement and sustain change.

There have been few attempts to quantify the combined impact of a mix of interventions. As chapter 4 showed, each individual intervention is capable of preventing millions of deaths, but whether a package of measures would save even more lives than the sum of each individual intervention together is as yet unknown. In implementing a package, each country would probably give different emphasis to different interventions, depending on the country's circumstances. For example, a country whose cigarette tax rates are currently lower than those of its neighbors is likely to see a particularly strong effect of tax increases on cigarette consumption. Similarly, a relatively well-educated and affluent population will respond less to price, and more to new information, than less educated and poorer populations. Cultural factors, such as a history of totalitarian rule, might also affect the ease with which some measures, such as smoking bans in public places, are accepted. These generalizations are simplistic, but policymakers may find them a useful starting point.

Governments contemplating action to control tobacco face major political obstacles to change. Yet, by identifying the key stakeholders on both the supply and demand sides in each country, policymakers can assess the size of each constituency, whether it is dispersed or concentrated, and other factors that may affect the constituency's response to change. For example, policymakers might note that winners, such as nonsmokers, may be a scattered and dispersed group, while losers, such as tobacco farmers, may have a powerful political and emotional voice. Careful planning and political mapping would be essential to achieve a smooth transition from reliance on tobacco to independence from it, whatever the nature of the economy and the national political framework. Such mapping exercises have been conducted, for example, in Vietnam.

Research priorities

Demand-reducing measures such as higher taxes and bans on advertising and pro-motion have already been seen to work in high-income countries, and enough is known already to implement these measures without delay. At the same time, however, a concurrent research agenda, both in epidemiology and economics, will be needed to help governments to adjust their packages of interventions to achieve the greatest chance of success. Some key research areas are outlined below.

Research into the causes, consequences, and costs of smoking at national and regional levels

Research is needed at national and regional levels to "count the tobacco dead" and classify deaths by cause. A simple and low-cost measure is to place questions on past smoking on death certificates, permitting comparisons of smoking excess among tobacco-attributable and other deaths. The benefits of such research go farther than their practical value of informing governments of the status of their tobacco epidemic or a baseline against which to monitor the impact of control efforts. They stimulate policy responses and may have a significant impact on tobacco consumption.

While epidemiological research into the consequences of smoking has at least begun to spread outside the high-income countries, research into the causes of smoking, the addictive nature of tobacco use, and the behavioral factors associated with smoking uptake remains heavily biased toward North America and Western Europe. While control interventions are being implemented, parallel research activities into these issues may help to refine the targeting of interventions, such as those designed to improve health information for the poor, for maximum effect.

For economists, research into the cost-effectiveness of each intervention at the national level is also a priority. Further data on price elasticity in low- and middle-income countries would be valuable, as would estimates of the social and healthcare costs of tobacco use in these countries.

Research into tobacco control has received less funding than might be expected in light of the size of the disease burden of smoking. During the early 1990s, the most recent time period for which data are available, investment in research and development in tobacco control amounted to $50 per 1990 death (a total of $148-$164 million). In contrast, HIV research and development received about $3,000 per 1990 death (a total of $919-$985 million). Spending on both diseases is concentrated primarily in high-income countries.

Recommendations

This report makes two recommendations:

1. Where governments decide to take strong action to curb the tobacco epidemic, a multipronged strategy should be adopted. Its aims should be to deter children from smoking, to protect nonsmokers, and to provide all smokers with information about the health effects of tobacco. The strategy, tailored to individual country needs, would include: (1) raising taxes, using as a yardstick the rates adopted by countries with comprehensive tobacco control policies where consumption has fallen. In these countries, tax accounts for two-thirds to four-fifths of the re-tail price of cigarettes; (2) publishing and disseminating research results on the health effects of tobacco, adding prominent warning labels to cigarettes, adopting comprehensive bans on advertising and promotion, and restricting smoking in workplaces and public places; and (3) widening access to nicotine replacement and other cessation therapies.
2. International organizations such as the United Nations agencies should review their existing programs and policies to ensure that tobacco control is given due prominence; they should sponsor research into the causes, consequences, and costs of smoking, and the cost-effectiveness of interventions at the local level; and they should address tobacco control issues that cross borders, including working with the WHO's proposed Framework Convention for Tobacco Control. Key areas for action include facilitating international agreements on smuggling control, discussions on tax harmonization to reduce the incentives for smuggling, and bans on advertising and promotion involving the global communications media.

The threat posed by smoking to global health is unprecedented, but so is the potential for reducing smoking-related mortality with cost-effective policies. This report shows the scale of what might be achieved: moderate action could ensure substantial health gains for the 21st century.

___________________________________________

BOX, FIGURES, TABLES

FIGURE 7.1 UNLESS CURRENT SMOKERS QUIT, TOBACCO DEATHS WILL RISE DRAMATICALLY IN THE NEXT 50 YEARS Estimated cumulative tobacco deaths 1950-2050 with different intervention strategies [graph] Tobacco deaths (millions) 0-500 Year: 1950 2000 2025 2050 0 Baseline o If proportion of young adults taking up smoking halves by 2020 o If adult consumption halves by 2020. Note: Peto and others estimate 60 million tobacco deaths between 1950 and 2000 in developed countries. We estimate an additional 10 million between 1990 and 2000 in developing countries. We assume no tobacco deaths before 1990 in developing countries and minimal tobacco deaths worldwide before 1950. Projections for deaths from 2000 are based on Peto (personal communication [1998]). Sources: Peto, Richard and others. 1994. Mortality from Smoking in Developed Countries 1950-2000. Oxford University Press; and Peto, Richard, personal communication.
_____________________________________________

BOX 7.1 THE WORLD HEALTH ORGANIZATION AND THE FRAMEWORK CONVENTION FOR TOBACCO CONTROL

At the World Health Assembly in May 1996, WHO's member states adopted a resolution calling upon the Director-General of WHO to initiate the development of a framework convention for tobacco control. WHO, under the leadership of Director-General Gro Harlem Brundtland, has assigned priority to reinvigorated work on tobacco control, and has established a new project, the Tobacco Free Initiative (TFI). A corner-stone of TFI's work is the WHO Frame-work Convention for Tobacco Control (FCTC). The WHO FCTC would be an international legal instrument designed to circumscribe the growth of the global tobacco pandemic, especially in developing countries. If entered into force, the convention will be a first for WHO and a first for the world. This will be the first time that the 191 WHO member states exercise WHO's constitutional authority to serve as a plat-form for the development of a convention. In addition, this will be the first multilateral convention focusing specifically on a public health issue. The development of the WHO FCTC will be helped by knowledge of the addictive and lethal qualities of tobacco use, combined with many countries' interest to improve tobacco regulation through international instruments. The international regulatory strategy being used to promote multilateral agreement and action on tobacco control is the framework convention-protocol approach. This strategy pro-motes global consensus in incremental stages by dividing the negotiation of separate issues into individual agreements: States first adopt a framework convention that calls for cooperation in achieving broadly stated goals and establishes the basic institutions of a multilateral legal structure. Separate protocol agreements containing specific measures designed to implement the broad goals called for by the framework convention. The framework convention-protocol approach has been used to ad-dress other global problems, for example, the Vienna Convention for the Protection of the Ozone Layer and the Montreal Protocol. The negotiation and implementation of the WHO FCTC would help to curb tobacco use by mobilizing national and international awareness as well as technical and financial resources for effective national tobacco control measures. The convention would also strengthen global cooperation on aspects of tobacco control that transcend national boundaries, including global marketing/promotion of tobacco products and smuggling. Though the negotiation of each treaty is unique and depends upon the political will of states, the WHO FCTC Accelerated Work Plan foresees adoption of the convention no later than May 2003.
____________________________________________

BOX 7.2 THE WORLD BANK'S POLICY ON TOBACCO

The World Bank has since 1991 had a policy on tobacco, in recognition of its harmful effects on health. The policy contains five main points. First, the Bank's activities in the health sector, such as policy dialogue and lending, discourage the use of tobacco products. Second, the Bank does not lend directly for, invest in, or guarantee in-vestment or loans for, tobacco production, processing, or marketing. However, in a few agrarian countries that are heavily dependent on tobacco as a source of income and of foreign exchange earnings, the Bank aims to deal with the issue by responding most effectively to these countries' development requirements. The Bank aims to help these countries diversify away from tobacco. Third, the Bank does not lend indirectly to tobacco production activities, to the extent that this is practicable. Fourth, tobacco and its related processing machinery and equipment cannot be included among imports financed under loans. Fifth, tobacco and tobacco-related imports may be exempt from borrowers' agreements with the Bank to liberalize trade and reduce tariffs. The Bank's policy is consistent with the arguments for ending subsidies made in this report. However, the emphasis on supply-side measures has not reduced tobacco consumption in any measurable way from 1991 to today. In the interim, the Bank's work on tobacco control, comprising about 14 countries with total project costs of more than US$100 million, has largely been on health promotion and information. Extending this work to focus on pricing and regulation was sup-ported in principle by the Bank's 1997 Sector Strategy Paper. This report confirms the importance of focusing on price as an effective means of reducing demand.