Tobacco Use
While some diseases—HIV/AIDS, TB, cancer—seem to stalk people, some behaviors seem to seek out disease.6 Addictive behaviors put people into the latter category.
"Worldwide, tobacco use accounts for 1 of every 5 deaths among men and 1 of every 20 deaths among women over the age of 30."
Worldwide, tobacco use accounts for 1 of every 5 deaths among men and 1 of every 20 deaths among women over the age of 30. In 2000, 4.8 million premature deaths could be attributed to diseases caused by tobacco, including CVD, lung cancer, and chronic obstructive pulmonary disease. In low- and middle-income countries, smoking is also associated with respiratory illnesses such as asthma and TB. Among men in China, smoking was responsible for an estimated 12 percent of deaths from TB. In India, TB was four times more likely in smokers than nonsmokers, suggesting that smoking is a contributory factor in about half of all TB deaths among men. The eventual risk of death from smoking is high: about one-half to two-thirds of long-term smokers will die from diseases caused by their addiction. Smokers also impose health risks on others, with passive smoking being a significant risk factor for children in developing asthma, throat inflammations, and respiratory illnesses.
". . . one-half to two-thirds of long-term smokers will die from diseases caused by their addiction."
An estimated 1.1 billion people currently smoke, and four-fifths of these smokers reside in low- and middle-income countries. Smoking prevalence is highest in Eastern Europe and Central Asia, where 35 percent of all adults smoke. However, East Asia and the Pacific currently accounts for most tobacco-related deaths, about 40 percent. Men smoke more than women, although the gap is smaller in high-income countries.
The global trends in smoking are worrisome. If the proportion of young people taking up smoking continues its current pattern—about half of men and 1 in 10 women—each year will see some 30 million new long-term smokers. As a result, by 2030 the number of tobacco-related premature deaths will rise to 10 million per year (figure 5.2).
[Figure
5.2]
Yet these deaths are avoidable, as demonstrated by experiences in countries where quitting has become common. Serious tobacco control efforts first began in the United Kingdom and the United States in the 1960s. Their sustained impact has discouraged young people from smoking and helped millions of smokers to quit. As a direct result, lung cancer rates in the United Kingdom and the United States have dropped rapidly. In the United Kingdom, where the main increase in smoking began before World War II, the incidence of lung cancer among men age 35 to 44 fell from 18 cases per 100,000 people in 1950 to 4 cases per 100,000 in 2000 (figure 5.3a). By contrast, smoking became common in France much later, efforts to discourage smoking did not have an impact until the 1990s, and the incidence of lung cancer among French men has continued to climb (figure 5.3b).
[Figure
5.3]
"In the United Kingdom . . ., the incidence of lung cancer among men age 35 to 44 fell from 18 cases per 100,000 people in 1950 to 4 cases per 100,000 in 2000."
The addictive substance in tobacco is nicotine, a psychoactive drug. Inhalation is the most effective way of getting nicotine to receptors in the brain. Nicotine creates positive sensations when it is administered and leads to unpleasant sensations when it is withdrawn. In this regard, it is on a par with such other powerfully addictive drugs as heroin and cocaine.
Behavioral influences strengthen the biochemically addictive nature of tobacco. Unlike illicit drugs that entail risks of incarceration and social disapproval, social mores and licit commercial interests have favored tobacco. Tobacco companies and governments have encouraged smoking through advertising and other forms of promotion. Mass marketing also presents smokers with many opportunities and frequent cues to both purchase and use tobacco, making cessation that much more difficult.
Prevention is the best way to address diseases caused by tobacco. Anything that reduces smoking, whether reducing the number of people who start smoking, increasing the number who quit, reducing the number who relapse, or decreasing smoking among those who continue, will ultimately reduce the burden from tobacco-related illnesses such as CVD, cancer, and TB. The addictive nature of tobacco has implications for discouraging its use. Educating consumers that tobacco is an addiction and causes health problems is insufficient, because people regularly underestimate their future health risks and because young people are more prone to adopting risky behaviors. Once people are addicted, cessation is difficult. Interventions proven effective at reducing smoking include increasing tobacco taxes, disseminating information about tobacco's health risks, restricting smoking in public places and workplaces, banning advertising, and increasing access to cessation therapies.
". . . governments are increasingly using tobacco tax policy to raise the cost of the habit and discourage the use of tobacco."
Nearly all governments tax tobacco to generate revenue, but as awareness of the dangers of smoking has grown, governments are increasingly using tobacco tax policy to raise the cost of the habit and discourage the use of tobacco. In some cases, countries have even earmarked tobacco taxes to finance health programs aimed at reducing exposure to tobacco.
Tobacco taxes have a greater effect on reducing consumption among lower-income groups, youths, and those who are less educated. Taxes are also more effective in the long run than in the short run, because addicted consumers change their habits slowly. Higher tobacco prices appear to be particularly effective in preventing young smokers from moving beyond experimentation to becoming regular smokers. Studies have estimated that the effect of raising tobacco prices may be twice as high in low- and middle-income countries than in higher-income countries, implying that significant increases in tobacco taxes in the former would be effective in reducing tobacco use. Taxes account for more than two-thirds of the retail price in most high-income countries but less than one-half in low- and middle-income countries.
In addition to raising the price of tobacco, many countries have effectively discouraged smoking by restricting it in public areas. The justification for such measures is to protect nonsmokers from harm caused by inhaling secondhand smoke, but such measures also create a hindrance to smokers, forcing them to change their habits and seek out special smoking areas. This can help raise barriers to smoking and also stigmatize the practice, thereby inducing changes in social norms. To have an impact, such regulations require enforcement, particularly when they are first introduced.
Interventions that affect people's attitudes toward and knowledge about the dangers of smoking can also be extremely helpful. Cigarettes are among the most heavily advertised and promoted products in the world. Information and education campaigns can counter the impact of this marketing by publicizing reports about the dangers of smoking, putting warning labels on packages, and broadcasting antismoking messages in the media. Comprehensive bans on advertising and promoting tobacco may reduce smoking and make public awareness campaigns more effective.
While the dangers of smoking have become widely known in most high-income countries, awareness of the risks of mortality and disease posed by smoking is still not widespread in low- and middle-income countries. The key messages that need to be transmitted are that addiction will eventually kill one-half to two-thirds of all smokers; that, on average, smokers will lose 20 to 25 years of life and will die between the ages of 35 and 69; and that quitting raises the chances of survival no matter how long an individual has smoked.
". . . quitting raises the chances of survival no matter how long an individual has smoked."
The recent development of drugs that counter the effects of nicotine improve the chances that smokers who would like to quit can succeed. Ironically, nicotine-containing tobacco products are often cheaper and easier to purchase than nicotine replacement therapies. Policies that redress this imbalance by decreasing the costs of nicotine replacement therapies and increasing their availability can help smokers quit. These therapies become more effective when coupled with counseling and peer support. Promoting cessation is particularly important, because the bulk of tobacco-related deaths between now and 2050 will be among current smokers. By contrast, policies aimed at preventing young people from taking up smoking will have their main impact after 2050.
Interventions aimed at reducing the supply of tobacco do not seem to be particularly effective. Some of these programs, such as prohibiting the sale of tobacco products to young people, are difficult and costly to enforce. Restrictions on the importation of tobacco products might raise domestic prices, but also violate international trade agreements. Programs aimed at encouraging farmers to stop growing tobacco are ineffective because other farmers can expand their production to fill the gap. Hence, low- and middle-income countries would be well advised to concentrate their efforts on reducing demand.
"A 70 percent increase in the price of tobacco could avert 10 to 26 percent of all smoking-related deaths worldwide."
Fortunately, most demand-side interventions are cost-effective, and even cost saving. Tobacco taxes aimed at raising the cost of smoking are the most cost-effective way to reduce smoking. A 70 percent increase in the price of tobacco could avert 10 to 26 percent of all smoking-related deaths worldwide. The effect would be particularly strong in low- and middle-income countries, among young people, and for men. Using a base-case scenario of a 33 percent price increase yields a cost-effectiveness ratio of US$3 to US$42 per DALY averted in low- and middle-income countries and US$85 to US$1,773 per DALY averted in high-income countries. Successful interventions in Poland and South Africa went well beyond such a modest price increase, almost doubling cigarette prices over a short time (DCP2, chapter 8; Levine and others 2004). Despite price increases being the most cost-effective approach to controlling tobacco consumption, this public health measure is grossly underutilized. Indeed, when adjusted for purchasing power, the price of tobacco products actually fell in most developing countries between 1990 and 2000.
". . . when adjusted for purchasing power, the price of tobacco products actually fell in most developing countries between 1990 and 2000."
Increasing access to nicotine replacement therapies to assist smokers who want to quit is more expensive, costing between US$75 and US$1,250 per DALY averted, but is still relatively cost-effective, especially where the direct cost of therapies is low. Other nonprice interventions could be implemented for between US$233 and US$2,916 per DALY averted. The cost-effectiveness of nonprice measures is extremely sensitive to context. In countries where the public readily absorbs public health messages, the costs could be low.
"Tobacco-related deaths are the fastest growing cause of death in low- and middle-income countries, on a par with the HIV/AIDS epidemic."
Tobacco-related deaths are the fastest growing cause of death in low-and middle-income countries, on par with the HIV/AIDS epidemic. The availability of cost-effective control measures eliminates any excuse for inaction. The obstacles to forestalling a rapid increase in tobacco-related deaths, which requires strong and skillful responses to those who market tobacco products and lobby against reform, lie squarely in the political realm.
