Saving 150 million lives: the case for global tobacco control

Saving 150 million lives: the case for global tobacco control

By Prabhat Jha

A pandemic is brewing in the developing world. We know the symptoms. We know the cause. We even know something about prevention.

Yet this global killer is ripping through the world’s poorer countries largely unchecked. Within 25 years, it will be responsible for 10 million deaths a year, according to the World Health Organization (WHO). At least half of these deaths will be at ages 35 to 69, losing about 25 years of life expectancy.¹

The culprit? Smoking. The same addiction that became the top preventable cause of death in the United States and other Western countries has already made inroads elsewhere. In fact, unless something changes soon, we are seeing history repeat itself—a massive uptake in smoking followed by a massive health toll years down the line. 

Worldwide, only HIV-1 and tobacco use appear to be large and growing causes of death. While we do not know how many tens (or even hundreds) of millions may be killed by AIDS, it is more certain that following current smoking patterns, tobacco use will kill about 1 billion people in the 21st century. This is a 10-fold increase over tobacco deaths in the 20th century. Most tobacco deaths in this century will occur in developing countries.²

Many of these deaths will be among the poor: Smoking is already more common among poor than among rich men worldwide. In developed countries, smoking deaths account for more than half of the difference in adult death rates between rich and poor men.³ In India, smoking causes about half of tuberculosis deaths—which are already more common among the poor.⁴

But the reality of the last few decades in developed countries doesn’t have to become the developing world’s future. Findings from Disease Control Priorities in Developing Countries, 2nd edition (DCP2), and earlier evidence demonstrate that we know how to control tobacco.⁵ A meaningful reduction in tobacco deaths over the next few decades would only occur if a substantial percentage of the 1.1 billion current smokers quit. Reduced uptake of smoking by children would yield benefits chiefly after 2050. Cessation is highly effective: Sir Richard Doll and Sir Richard Peto’s 50-year study of UK physicians shows that those who quit smoking even in their 40s remarkably lowered their risk of death, and those who quit in their 30s had death risks close to lifelong nonsmokers.⁶

Numerous studies worldwide provide robust evidence that tobacco tax increases, timely dissemination of information about the health risks from smoking, restrictions on smoking in public and in workplaces, comprehensive bans on advertising and promotion, and increased access to cessation therapies are effective in reducing tobacco use and its consequences. Of these, tobacco taxes are especially effective. A tripling of the world’s excise tax would roughly double the price of cigarettes—as has happened in New York City—and would avoid about 3 million deaths a year by 2030 (Figure 1).⁷ As DCP2 points out, tobacco control is probably the single most cost-effective intervention for adult health in the world.⁸

Figure 1. Tobacco control can prevent 3 million deaths worldwide by 2030.

When tobacco control has been taken seriously (as it has been in the United Kingdom), tobacco deaths have fallen sharply. A useful barometer of control in developed countries is lung cancer deaths among young adults (because lung cancer is not often confused with other causes of death at young ages, and because lung cancer is almost entirely attributable to smoking). The age-standardized rates of lung cancer among men ages 35 to 44 per 100,000 in the United Kingdom fell by nearly 80 percent between 1960 and 1990.⁹ In contrast, comparable French male lung cancer rates show the reverse pattern (Figure 2). In France, the increase in smoking occurred some decades later than in the United Kingdom, and declines in smoking began only after 1990. Similarly, a large increase in female lung cancer at young ages was avoided in the United Kingdom, but female lung cancer continues to rise in France.

Figure 2. Decline in smoking-attributable male and female deaths at ages 35-44 in the United Kingdom and France, 1950-1999

Source: Peto et al ⁹

Highly effective tobacco control measures should be underway in the developing world. For the most part, however, they are not. Whereas taxes are about 80 percent of the legal retail price of cigarettes in Canada, taxes are less than 30 percent of the retail price in India or China. Moreover, in many countries, taxes on tobacco have fallen over the past decade, after adjusting for inflation.¹⁰ Only a few developing countries, notably South Africa, have significantly raised tobacco taxes. Knowledge of the health risks associated with tobacco use—information that drove down demand in the developed world—is insufficient in poor countries. In China, for example, 61 percent of smokers questioned in 1996 thought tobacco did them “little or no harm”.¹¹

There is considerable evidence that opposition from the tobacco industry and economic arguments against tobacco control help to explain why control measures are not widely implemented. However, there is also good evidence that the economic arguments against tobacco control have little validity.¹² Contrary to what some have argued, reducing the demand for tobacco—through taxes and increased information—would not increase unemployment in most countries. Indeed, the hospitality sector in cities such as Dublin and New York with aggressive tobacco control have seen job gains, not losses. And, money not spent on tobacco would be spent on other goods and services. Higher cigarette taxes don’t cause such drops in demand that the government loses revenue. Quite the contrary, these price hikes lower consumption and raise revenue.¹³ A 10 percent higher tax means about 7 percent higher revenue. In China, a 10 percent higher price would drop consumption by 5 percent and raise enough revenue to pay for a basic health program for 33 million poor rural Chinese.¹⁴

A commonly heard claim against tobacco control is that if people are not harming others, then governments should not interfere with their individual decisions.¹⁵ This view is at odds with an increasing body of evidence on smoking decisions. Most people begin to smoke as children, when short-sightedness and lack of information make rational decisions difficult. By the time child smokers become adults, over 80 percent of them in developed countries wish they never started. Recent economic work that incorporates tobacco addiction has begun to repudiate two major arguments against tobacco taxation: that the external costs of tobacco smoking are small (since the health costs to smokers themselves from uninformed smoking are uniquely large) and that cigarette taxes hurt the poor (since the self-control value of higher taxes helps the poor more).¹⁶ Nobel laureate Amartya Sen wisely reminds us that “it is important that the practical case for tobacco control is not dismissed on the basis of an incomplete libertarian argument.”¹⁷

The agenda is clear. Developing countries and international development agencies must take tobacco seriously as the leading killer of adults worldwide. International poverty reduction goals must include reducing tobacco, especially tracking whether adult smokers quit. A worldwide network to monitor this great epidemic and its control must be strengthened. Developing countries must not be dissuaded by the same arguments that mired tobacco control efforts in developed countries for so long and allowed smoking to be the killer it is in those settings today.

There are hopeful signs. The global tobacco control treaty of the WHO has been signed by most countries, but this now needs to be implemented with specific economic and epidemiological expertise at a country level. The Michael Bloomberg Foundation has committed $125 million to global tobacco control. DCP2 can help also—both by emphasizing the importance of controlling chronic diseases, which now account for the largest proportion of avoidable deaths worldwide, and by showing that tobacco control is highly effective. Indeed, I was privileged to join one post DCP2 consultation with the government of Trinidad and Tobago led by Sir George Alleyne, Director Emeritus of the Pan American Health Organization and DCP2 co-editor. The consultation had an immediate impact. Two weeks after presenting the case for higher tobacco taxes, the government raised tobacco taxes in its budget.

By using powerful tax and information tools, developing countries can achieve tobacco control, as measured by rapid increases in ex-smoking rates, within a decade. In contrast, it took the United States, Canada, and other developed countries nearly three decades to achieve comparable results. Indeed, Poland and Thailand have seen notable increases in adult cessation—likely as a result of restrictions on tobacco advertising and informational campaigns on smoking hazards. If the proportion of adults in developing countries who quit smoking increases from about 5 percent today to between 30 percent and 40 percent by 2020, then some 150 million to 180 million tobacco deaths would be avoided over the next five decades.¹⁸ Half of these lives saved would be in productive middle age. Social inequalities in adult mortality could be halved.¹⁹ Given that control policies deter children from taking up smoking, even greater benefits can be expected beyond 2050.

A history of tobacco deaths need not be a destiny of tobacco deaths. We know much more than we did even one decade ago. The only question is whether we will use it.

Professor Prabhat Jha is the Canada Research Chair of Health and Development at the University of Toronto and Director of the Centre for Global Health Research, Li Ka Shing Knowledge Institute, at St. Michael's Hospital. He can be reached at prabhat.jha@utoronto.ca.  



References

¹Peto R and Lopez AD. 2001. “The future worldwide health effects of current smoking patterns.” In Critical Issues in Global Health, ed. Koop EC, Pearson CE, Schwarz MR. New York: Jossey-Bass, 154-161.
²Peto R and Lopez AD. 2001. “The future worldwide health effects of current smoking patterns.” In Critical Issues in Global Health, ed. Koop EC, Pearson CE, Schwarz MR. New York: Jossey-Bass, 154-161.
³Jha P, Peto R, Zatonski W, Boreham J, Jarvis M, and Lopez AD. 2006. “Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America.” Lancet 368: 367-370.
⁴Gajalakshmi V, Peto R, Kanaka T, and Jha P. 2003. “Smoking and mortality from tuberculosis and other diseases in India: retrospective study of 43,000 adult male deaths and 35,000 controls.” Lancet 362: 507-515.
⁵Jha P and Chaloupka FJ. 1999. Curbing the epidemic: governments and the economics of tobacco control. Washington, DC: World Bank; and Jha P, Chaloupka FJ, Moore J et al. 2006. “Tobacco Addiction.” In Disease Control Priorities in Developing Countries, 2nd ed., ed. Jamison DT, Measham AR, Breman JB et al., 869-886. New York: Oxford University Press. Accessed online at http://files.dcp2.org/pdf/DCP/DCP46.pdf on June 1, 2006.
⁶Doll R, Peto R, Boreham J, and Sutherland I. 2004. “Mortality in Relation to Smoking: 50 Years’ Observation on Male British Doctors.” British Medical Journal 328 (7455): 1519-1528.
⁷Jha P, Chaloupka FJ, Moore J et al. 2006. “Tobacco Addiction.” In Disease Control Priorities in Developing Countries, 2nd ed., ed. Jamison DT, Measham AR, Breman JB et al., 869-886. New York: Oxford University Press. Accessed online at http://files.dcp2.org/pdf/DCP/DCP46.pdf on June 1, 2006.
⁸Laxminarayan R, Mills AJ, Breman JG, Measham AR, Alleyne G, Claeson M, Jha P, Musgrove P, Chow J, Shahid-Salles S, Jamison DT. 2006. “Advancement of global health: key messages from the Disease Control Priorities Project.” Lancet 367: 1193-1208.
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¹³Jha P, Chaloupka FJ, Moore J et al. 2006. “Tobacco Addiction.” In Disease Control Priorities in Developing Countries, 2nd ed., ed. Jamison DT, Measham AR, Breman JB et al., 869-886. New York: Oxford University Press. Accessed online at http://files.dcp2.org/pdf/DCP/DCP46.pdf on June 1, 2006.
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¹⁷Sen A. “Unrestrained smoking is a libertarian half-way house,” Financial Times, page 16, February 12, 2007.
¹⁸Doll R, Peto R, Boreham J, and Sutherland I. 2004. “Mortality in Relation to Smoking: 50 Years’ Observation on Male British Doctors.” British Medical Journal 328 (7455): 1519-1528.
¹⁹Jha P, Peto R, Zatonski W, Boreham J, Jarvis M, and Lopez AD. 2006. “Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America.” Lancet 368: 367-370.