How to Save 150 Million Lives

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 occur at ages 35 to 69, which translates into a life expectancy loss of about 25 years.(1)

The culprit? Cigarette smoking. The same addiction that became the top preventable cause of death in the US and other Western countries has already made dramatic inroads abroad. 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. Although we do not know how many tens (or even hundreds) of millions may be killed by AIDS, it is more certain that with current smoking patterns, tobacco use will kill about 1 billion people in the 21st century. This is a ten-fold increase over tobacco-related deaths in the 20th century. Most of the tobacco deaths in this century will occur in developing countries.(1)

A high proportion of these deaths will be among the poor: smoking is already more common in poor than rich men worldwide. In Western countries, smoking deaths account for more than half of the difference in adult death rates between rich and poor men.(2) In India, smoking causes about half of tuberculosis deaths--which itself is more common in the poor.(3)

But the Western reality of the last 60 years does not have to become the developing world’s future, not with what we know today. We know how to control tobacco. Cessation by the 1.1 billion current smokers is central to meaningful reductions in tobacco deaths over the next few decades. Reduced uptake of smoking by children would yield benefits chiefly after 2050. Tobacco cessation can be 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 mortality rates close to those of lifelong nonsmokers.(4)

Numerous studies worldwide provide robust evidence that tobacco tax increases, timely dissemination of information on the health risks from smoking, restrictions on smoking in public and work places, comprehensive bans on advertising and promotion, and increased access to tobacco cessation therapies are effective in reducing tobacco use and its consequences. Of these, tobacco taxes are singularly effective.(5) 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 each year by 2030.(6) Tobacco control is thus probably the single most cost-effective intervention for adult health in the world.(7)

When tobacco control has been taken seriously (as in the United Kingdom), tobacco deaths have fallen sharply. A useful barometer of control in the West is lung cancer deaths among young adults. Age-standardized male lung cancer rates at ages 35 to 44 per 100,000 in the United Kingdom fell by nearly 80%..(5,8) In contrast, comparable French male lung cancer rates show the reverse pattern. In France, the increase in smoking occurred some decades later than in the United Kingdom, but 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.

Highly effective tobacco control measures should be underway in the developing world. But for the most part, they are not. Whereas taxes are about 80% of the street price of cigarettes in Canada, taxes are less than 30% of the street price in India or China. In many countries, taxes on tobacco have fallen, after adjustment for inflation..(9) Only a few 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% of smokers questioned in 1996 thought tobacco did them “little or no harm.”(10)

Ruthless political opposition from the tobacco industry and economic arguments against tobacco control help to explain why control measures are not widely implemented. Spurious economic arguments against tobacco control have been systematically debunked.(6,11) Reducing the demand for tobacco--through tax and information increases--would not mean unemployment in most countries. Money not spent on tobacco would be spent on other goods and services. Indeed, cities with aggressive tobacco control, such as Dublin and New York, have seen job gains, not losses. 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. A 10% higher tax means about 7% higher revenue.(5) Such funds are precious resources to fight poverty. In China, a 10% higher price would drop consumption by 5% and raise enough revenue to pay for a basic health program for 33 million poor rural Chinese.(12)

A commonly heard claim against tobacco control is that if people are not harming others, then governments should not interfere with their individual decisions.13 This libertarian view is at odds with both common sense and an increasing body of evidence. 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% of them in developed countries wish they had never started. Recent economic work(14,15) that incorporates addiction has begun to repudiate two major arguments against tobacco taxation: that the external costs to others are small (since the health costs to smokers are huge), and that cigarette taxes hurt the poor (since the self-control value of higher taxes helps the poor more). 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.”(16)

The agenda is clear. Developing countries and international development agencies must take tobacco seriously as the leading killer of adults worldwide. International poverty goals must include reducing tobacco (specifically tracking if 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 empty arguments that mired the tobacco control efforts in the West for so long and allowed smoking to be the killer it is here today. There are hopeful signs. WHO’s global tobacco control treaty 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. Other enlightened souls should follow.

With use of 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 US, Canada, and other Western countries nearly three decades to achieve comparable results. Indeed, Poland and Thailand have seen recent increases in adult cessation--likely as a result of advertising restrictions and information on smoking hazards. If the proportion of adults in developing countries who quit smoking increases from about 5% today to 30%-40% by 2020, then some 150-180 million tobacco deaths would be avoided over the next five decades..(6) Half of these lives saved would be in productive middle age, and social inequalities in adult mortality could be halved.(2) Given that control policies deter children from starting, 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.

References

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3. Gajalakshmi V, Peto R, Kanaka T, et al. Smoking and mortality from tuberculosis and other diseases in India: retrospective study of 43 000 adult male deaths and 35 000 controls. Lancet. 2003;362:507-515.
4. Doll R, Peto R, Boreham J, et al. Mortality in Relation to Smoking: 50 Years’ Observation on Male British Doctors. BMJ. 2004;328:1519-1528.
5. Jha P, Chaloupka FJ. 1999. Curbing the epidemic: governments and the economics of tobacco control, World Bank, Washington DC, USA
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10. Chinese Academy of Preventive Medicine, 1997. Smoking in China: 1996 National Prevalence Survey of Smoking Pattern. Beijing: China Science and Technology Press
11. Jha P, Chaloupka FJ. Tobacco Control in Developing Countries. Oxford: Oxford University Press, 2000.
12. Hu TW, Mao Z. Effects of cigarette tax on cigarette consumption and the Chinese economy. Tob Control. 2002;11:105-108.
13. Wolf F. The absurdities of a ban on smoking. Financial Times, page 14, June 23, 2006.
14. Gruber, J., and S. Mullainathan. 2002. “Do Cigarette Taxes Make Smokers Happier?” NBER Working Paper No. 8872. Cambridge, Mass.: National Bureau of Economic Research.
15. Kan K. Cigarette smoking and self-control. J Health Economics. 2007;26:61-81.
16. Sen A. Unrestrained smoking is a libertarian half-way house. Financial Times, page 16, February 12, 2007.