Death by Tobacco: A Big Problem Needs Bigger Action

Recently, I had the privilege of attending a meeting to discuss tobacco control in New York City where I was reminded of the massive loss of life associated with tobacco use, the extremely cost-effective approaches available to combat tobacco use, and some very exciting progress around the world over the last five years. Nevertheless, controlling tobacco is still extremely challenging on the social and political fronts. Unlike most illnesses, tobacco-related cancers and cardiovascular diseases (CVD) have witting (tobacco companies) and unwitting (academic apologists) human allies.  After attending this meeting, I felt more than ever before that we need to mobilize bigger ideas and bigger actions against this senseless disease burden.

Big? Well, if you don’t know yet, deaths from tobacco use each year exceed the number of deaths from HIV/AIDs, TB, and malaria combined. If we were to put one-tenth as much effort into reducing tobacco use as into combating these major infections, we could save millions of lives. The presentations at the meeting reminded me once again of how strong the evidence is about the links of tobacco use to cancer deaths. Just a few more striking facts:

- Half of all smokers will die from diseases related to tobacco (e.g. cancers, stroke).

- Of the 130 million children born each year, 40 million per year will die in middle-age and one-quarter of these (10 million per year) will be attributable to tobacco use.

- Unless tobacco use is severely curtailed, 1 billion people will die of tobacco-induced disease over the course of the 21^st century.

Can we do anything about it? You bet. The evidence is overwhelming and unlike many public health topics that require fine statistical testing to detect small average effects, the impact of controlling tobacco is obvious. While sophisticated studies have demonstrated the effectiveness of different approaches, you can visually see the effects in simple time-series charts for the U.S., the U.K. and France. They demonstrate rapid reductions in tobacco use and subsequent declines in mortality from tobacco-related illnesses, in response to raising tobacco taxes, enforcing smoke free public places, instituting advertising bans, introducing warning labels, and restricting sales.Before talking about what to do, though, I want to recognize how much has been accomplished. The WHO Framework Convention on Tobacco Control is the first international agreement of its kind and creates substantial space for signatories to make progress. The Bloomberg Initiative (BI) deserves recognition for having financed a very comprehensive set of initiatives within the MPOWER framework, transparently targeting high burden countries. They have contributed to substantial progress over the last five years in tobacco control initiatives around the world. More countries are actively engaged in tobacco control efforts than ever before. Countries which seemed very unlikely to ever undertake measures like smoke free public places are doing so every day. I, for one, would never have believed that the day would come when Buenos Aires would restrict smoking in public places!Yet we’re struggling against a sinister and intelligent foe, and I’m not using that language sarcastically or lightly. The tobacco industry is cynically engaged in a wide range of efforts to resist public health initiatives and thereby expand their sale of addictive products. They don’t take on the United States or Britain, but they do initiate costly lawsuits against small countries like Uruguay. They are multiplying the range of addictive products (nicotine candies anyone?) and blurring the distinctions between highly toxic and less toxic products. They are imaginatively creating new advertising and promotion strategiesto bypass restrictions and enlisting workers and local businesses to raise fears about economic loss. They are regularly implicated in corrupting political processes in many different places.Cash on Delivery Aid (COD Aid) would be one new big idea to bring into this picture. At the meeting, I presented ideas for applying COD Aid to tobacco, an idea elaborated by Tom Bollyky in his CSIS working paper and JAMA article and which was also the subject of a CGD workshop this spring led by Tom Bollyky and Amanda Glassman. The general idea would be for foundations or governments to put money into a COD Aid agreement that would pay low- or middle-income countries in proportion to reducing tobacco use, raising cessation rates, or some other appropriate and verifiable outcome measure. Such an agreement could rely on independent surveys to measure the outcomes. The agreement would provide countries with flexible money to address this multisectoral problem and raise its profile in the policy agenda.Being relatively new to this topic and coming from experiences in other areas, though,  I had lots of other ideas about what is needed to reduce the future burden of disease from tobacco use, which are listed below. Some of these ideas may already be in the works. Some of them may be mistaken, based on my misunderstanding of the relevant laws or political strategies. The ideas are presented to provoke more thinking and acting.1. Go after the tobacco companies. As long as the tobacco companies are free to use their revenues to resist public restrictions and advertise, the cost of controlling tobacco use will be extremely high and tobacco control efforts will always be playing “catch-up” to the latest tobacco industry strategy – whether through new products, new marketing, new lawsuits, or new legislation. Furthermore, the tobacco companies use all kinds of dirty tricks (including bribing legislators) to protect their drug-pushing industry.

- I’ve heard that an NGO had investigated tobacco company strategies in Indonesia and Russia; what did these investigations reveal, how were they used and were they effective? Publication of internal tobacco company memoranda seems to have played a key role in turning public opinion in the U.S.; can it be done elsewhere?

- Intelligence Agency: Could we create an international “Center for Tobacco Control” that would be staffed with investigators, marketers, and strategists to monitor the tobacco company strategies and design responses in real time?

- Find new ways to pressure tobacco companies: In the 1980s, New York State threatened to take LILCO shares by eminent domain as a way to pressure it to stop resisting closure of its nuclear power plant (http://bit.ly/j3Y88r). Are there ways to pressure tobacco companies through purchasing shares and electing board members? Could the U.S., EU and Japan be convinced to expropriate the shares of multinational tobacco companies on the grounds that they are threatening international health and security? This may sound absurd but it is even more absurd that governments protect tobacco companies under international and domestic laws. The tobacco companies have no qualms about using these protections to sue Uruguay and Australia for trying to protect their citizens against cancerous substances. I see no reason that tobacco control advocates shouldn’t use whatever means possible, through markets, shareholders, or contract liability laws, to confront them. The LILCO example shows that a seemingly absurd idea can be very real and very effective.

2. Campaign to change international trade laws that protect tobacco companies. My understanding is that tobacco companies are protected by patent laws, trademark laws, and international trade laws because their products are legal and therefore cannot be discriminated against. In reality, all kinds of legal commodities are subject to a range of restrictions – whether we’re talking about toxic chemicals that are hazardous, advanced technology that we don’t want to get into the hands of criminals, or foodstuffs that require special handling to make sure they’re not harmful. Building on the FCTC, would it be possible to establish special international trade laws or regulations that would prohibit tobacco companies from contesting restrictions enacted by countries that are endorsed in the FCTC? What would it take to make this happen? What leverage would there be on the international level and local level to effect this?3. Campaign to increase tobacco taxes. There is clearly more effort required in this direction. Particularly in countries where incomes are rising very rapidly, the real cost of tobacco is falling. Some ideas:

- Disseminate information on how the cost of tobacco is falling (a recent study in Mexico does this).

- Enlist the World Bank at the highest level (e.g. President) to include raising tobacco taxes as part of their Policy Lending. (World Bank staff are working on this but the institution has not taken a visible high profile position yet).

- Enlist the IMF to make very public statements (including at the UN General Assembly in September) that, as the organization responsible for promoting good fiscal policies, they consider high tobacco taxes to be an appropriate and recommended part of a sound public tax system. (IMF staff do support implementation of tobacco taxes but higher profile commitments would help).

- Design specific strategies for target countries to campaign in legislatures for tobacco tax increases.

- Create a $30 million trust fund (over 5 years) at the IMF or World Bank to support technical expertise for any country expressing interest in raising its tobacco tax. ($30 million is the size of an existing trust fund at the IMF for technical support on fiscal matters).

- Create trust funds at Regional Development Banks (IADB, AfDB, Asian Dev Bank, European Bank) to finance collective harmonization of tobacco restrictions, taxes, and anti-smuggling initiatives.

4. Workplace Initiative. Multinational companies from sneakers to diamond producers have been enlisted to monitor the conditions under which their goods and services are produced and live up to basic standards of human rights. Multinational companies based in the US, Canada, and Europe have accepted the idea of smoke free workplaces, restaurants, and travel (airplanes). Why not mount an international campaign for multinational companies (e.g. McDonald’s) to adopt smoke free policies in their restaurants, factories and offices by insisting that they follow the health measures that they follow in their home countries?5. Tourism Initiative. Use tourism as a positive lever to encourage smoke free restaurants, hotels and public spaces in low- and middle-income countries. Part of this would be research to determine what the short-term costs and benefits would be (survey tourists to see what they would say). This may show that the arguments about driving away tourists are specious or it may demonstrate the scale of the costs. A second part would be to demonstrate how smoke-free preferences are evolving in tourismorigin countries to convince tourist destinations of the long term benefits of being a smoke free tourist destination. That is, if you don’t adopt smoke free, you’ll be left behind. A third part of this would be a broader campaign to link tourism from countries with smoke-free policies (e,g, U.S., Canada, UK, France) to tourism campaigns in destination countries that have adopted smoke-free policies – come to our country where you can enjoy a meal, a concert, a cabaret, without suffering from second hand smoke.6. Media as an ally in tobacco control. Celebrities are everywhere. Pop stars and movie stars have a huge impact on social norms. How can they become allies in fighting tobacco?

- Enlist celebrities in the campaign against tobacco (like the UNICEF ambassadors). This is helpful for raising awareness and can be particularly effective in countries with their own well-loved national stars.

- Enlist celebrities to change how tobacco is depicted in music and especially film. A legislative approach would be to ban the appearance of people smoking in films – unless the film specifically shows the person dying from cancer or CVDs. Convincing a major producer or star to make Bollywood films (India) or Telenovelas (Brazil) that show the effects of smoking would be a voluntary way to move it forward. One way or another, smoking in public media has to be turned from something glamorous to something obnoxious and even dangerous.

- Social Networking. The new world of tweets and facebook is effective in many middle-income countries and could be utilized to make smoking “uncool.” There must be people who understand the new social networking world and the best ways to approach teenagers on this.

7. China. China is big enough, growing quickly enough, and with its own entwined tobacco company interests that it requires special attention. China’s political centralization is a challenge but could also be a boon to tobacco control. Who are the people in China who could take this issue forward within the Communist Party and how would you influence them? China’s leadership has taken U-turns on big public policy matters before – ranging from market liberalization to creating public health insurance for rural areas. They could also make a U-turn on tobacco. What would be the most convincing argument? Could they be swayed by the costs of treating cancers in the future? Would they be persuaded that reducing tobacco consumption would lead people to spend their tobacco money on industries of the future rather than on this industry of the past? Getting China on board would remove a serious future threat – the expansion of China’s tobacco company into exporting cheap tobacco products.8. Tobacco Economics Initiative. Economists are often unwitting allies to tobacco companies because they apply basic economics to tobacco as if it were a normal good and provide strong arguments against restrictions on advertising, sales, etc. A Tobacco Economics Initiative could conduct research, write papers, and engage economists in debates (in key places like the Journal of Economic Perspectives) to demonstrate how specific features of tobacco (e.g. addictive, corporate oligopoly, preference altering, low salience of future effects) undermine the usual policy prescriptions from welfare and consumer economics regarding limitations on regulation, trade, advertising, and use.9. Information for social marketing. A wide range of information can be useful for campaigning against tobacco. Some examples:

- Scorecards comparing countries on the basis of the prevalence of smoking among youth and adults, rate of initiating smoking and the rate of cessation.

- Scorecards comparing countries on the basis of their compliance with FCTC provisions, passage of smoke free legislation, enforcement of restrictions, etc.

- Tables comparing the profits and marketing budgets of tobacco companies to the GDP and government budgets of the countries they are attacking (e.g. Australia, Uruguay) or massively marketing.

- Job impact research calculating the number of jobs that would be eliminated in each country by reducing tobacco relative to the jobs that would be created from the equivalent consumer spending on other products.

10. Technical Assistance and Public Goods. The international community can make it easier for countries to introduce tobacco control measures by providing technical assistance and public goods at low cost and at those moments when a country is ready to move. Technical assistance includes supporting experts to go to countries with their experience from introducing tobacco control measures in other places. They can advise and design legislation, enforcement strategies, regulations, warning labels, ad campaigns, etc. Public goods include stock materials that can be adapted in different places such as model legislation, warning labels, and video materials. Much of this is already being done, with funding from Bloomberg Philanthropies, the Bill & Melinda Gates Foundation and others.