by Jihye Suk and Hanati Hailati
Smokers are great supporters of positive psychological effects of smoking. However, according to the CDC, smoking causes diseases such as lung cancer, diabetes, and erectile dysfunction on males. Smoking not only harms people with various diseases, but it will also cause 8 million deaths annually in 2030 if current trend continues [1]. What we need to focus on here is that the 8 million people are mostly from developing countries or from low-educated population. The correlation between education level and smoking in India, as Dr. So indicated in class, supports this presumption. Moreover, as he emphasized, while tobacco consumption in developed countries decreases by 0.2%, it is increasing by about 3.4% in developing countries each year.
Tobacco industry is getting smarter and more powerful based on their wealth. In contrast, our countermeasures are still stymied by the barrier of individual freedom issue. If it is truly personal choice, why does research show that developing country populations are more likely to choose smoking? Why even among developed countries, disadvantaged population is the group of main smokers?
Today, commonly utilized smoking cessation strategies are as follows: cigarette taxes, comprehensive bans on tobacco advertising and promotion, prominent warning labels, restrictions on smoking in public places, and increased access to nicotine replacement treatments.
As one of the readings by Dr. So noted, the economics of global tobacco control, written by Prabhat Jha and Frank J. Chaloupka, the threat posed by smoking to global health is extraordinary, but so is the potential for preventing millions of smoking related deaths with highly effective policies [2]. This article also states that tax increases are the single most effective intervention to reduce demand for tobacco [2]. WHO also notes that the most potent and cost-effective option for governments everywhere is the simple elevation of tobacco prices by use of consumption taxes [3]. Tobacco includes excise taxes, value added taxes (VAT) or general sales taxes and import duties.
According to the "WHO Report on the global tobacco epidemic 2015," 33 countries levy cigarette taxes that represent more than 75% of the retail price of a packet of cigarettes, but many countries have extremely low tax rates, and some countries even have no special tax on tobacco products at all [4]. Take China as an example. China has the largest smoking population in the world and bears the largest disease burden from smoking as the chart shows below. A research model in China suggests that raising cigarettes taxes so that they account for 75% of retail prices- up from 40% of the share of price in 2010- would prevent nearly 3.5 million deaths that would otherwise be caused by cigarette smoking [4]. However, levying cigarette taxes still faces lots of challenges. Recently the City of Beijing, one of top three populated city in China, just started its strictest bans on smoking in public places since this October.
Dr. So finished his lecture with suggesting our new challenge at the emerging of e-cigarette. The latest released presentation [5] by CDC indicates very few clinical trials are conducted to evaluate the impact of e-cigarette. Cultivating adolescent as a future smoker seemed to be e-cigarette industry’s main aim, but it is not yet regulated in many countries.
Source: Institute for Health Metrics and Evaluation
[1] World
Health Organization. (2011). WHO Report on the Global Tobacco Epidemic, 2011.
Geneva: World Health Organization, 2011. [accessed 2015 Nov 5]
[2] Jha, P., & Chaloupka, F. J. (2000). The Economics of
Global Tobacco Control. BMJ: British
Medical Journal, 321(7257), 358.
[3] World
Health Organization. (2010). WHO Technical Manual on Tobacco Tax
Administration. Geneva:
World Health Organization, 2010.
[accessed 2015 Nov 5]
[4] World
Health Organization. (2015). WHO Report on the Global Tobacco Epidemic, 2015. Geneva: World Health Organization,
2015. [accessed 2015 Nov 5]
[5] CDC. E-cigarettes: An Emerging Public Health Challenge
(10.20.2015.) by Brian King, PhD,
MPH, Jonathan M. Samet, MD, MS, John Wiesman, DrPH, MPH, Matthew L. Myers,
President of Campaign
for Tobacco-Free Kids.
Thank you for sharing this great post. I have been thinking about the question you mentioned in the article: why in developing country populations are more likely to choose smoking? I think culture norms may play a important role on this. The culture norms encourage people to think about group more than individual, valuing the sense of belonging more than others. The culture norms exist in many developing countries especially among Asian region. I have heard many business persons said that how cigarettes helped them get involved in their workforce, how the habit of smoking got them emotionally closer to their clients. The short-term benefits from cigarettes may offset the long-term intangible harmless of it. Culture norms are more powerful than we thought, sometimes it takes years and years to eliminate its power. Establishing laws and regulations of prevention of smoking is just a start, it is still a long way to go.
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ReplyDeleteCigarette smoking is on the rise in the US again in the first year-over-year increase in sales since 2006, it is speculated that there is a connection between decreased gas prices along with e-cigarette usage by youth is a reason for this increase. Both of these have been posited towards increased tobacco sales because it is estimated that 3/4 of e-cigarette smokers are also smoking tobacco. The battle against smoking and big tobacco still occurring.
ReplyDeleteThe smoking population in China may be the most concerning factor mentioned here in the battle against tobacco since there is such a large population there. It seems that if a majority of the Chinese population smokes, it is the result of a cultural norm around smoking and there is not motivation to stop.
It seems that there is a cycle in the sales goes up and down and that effects of smoking around the world are ever present and impacting the most vulnerable populations. The burden of disease is a reminder that the health implications around smoking, i.e., lung cancer, emphysema, and lifelong illness are still as present as ever globally. The laws may not be enough to change the trend of increased tobacco use and different tactics may need to be created in order to ultimately change the culture of tobacco usage.
This lecture was extremely interesting. Interactions about scientific research on the harmful effects of smoking, the tobacco industry and the health community are still influencing the regulatory policies of many countries. As you might remember, Dr. So told us about the negotiations of the Trans-Pacific Partnership (a trade and investment agreement).
ReplyDeleteMany people worry that such agreements can limit the possibility of countries to enact regulations implementing the Framework Convention on Tobacco Control. In fact, Australia and Uruguay have been sued by Tobacco Industry due to their regulations requiring plain packaging and limiting marketing strategies for the Industry.
The final TPP text has been finally released (you might remember Dr. So mentioned that the only available text before that were those published by wikileaks). The final text confirms that an exception has been included for tobacco. This means that in the future, for the signatory countries of the TPP, the industry will not be able to sue in the ISDS (investor to state dispute settlement).
The ISDS has been accused of being a biased and less transparent forum than other dispute mechanisms used in international law. So this seems good news. However, there are still many investment and free trade agreements out there with ISDS provisions. And the fact that we now have an exception for tobacco should made us think more broadly about the implications of dealing with public health measures in the context of trade and investment agreements.
Rebecca's comment about the increase in American youths smoking got me thinking. What would cause these rates to increase after a the rate steadily decreasing for some time now. The CDC reports that the reported use of e-cigarettes among high school students increased from 1.5% to 13.4% between 2011 and 2014. That represents almost a ninefold increase in use. These numbers are extremely concerning especially in light that cigarette use dropped over 6% over the same period. After doing some digging I came across this article from USAtoday: http://www.usatoday.com/story/news/nation/2014/06/02/e-cigarettes-tv-ads-youth/9760425/.
ReplyDeleteThe article states that the increase in prevalence of e-cigarettes is down to a heavy increase in advertising aimed at this demographic from the e-cigarette companies. Interestingly enough these e-cigarette companies are owned by the major tobacco companies who have a history of targeting youth (See Joe Camel adds from the 1990s). This would appear as a play to get back into the American market by big tobacco. With their hands being tied with legislation regarding advertising of any kind as well as graphic warnings on cigarettes, e-cigarettes are the perfect tool to get the next generation of americans hooked on their product.
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ReplyDeleteThanks for the post - this is super interesting.
ReplyDeleteI think about point you made about the individual freedom issue and I wonder what would happen if we used that justification for other addictions that are incredibly taxing on health. What if someone said something like "Well its their choice to be addicted to alcohol". I think people often over look blame when thinking about something such as smoking.
We have overcome many hurdles (to some extent) such as blaming sexuality and "promiscuity" for aids. And to some extent I believe people are beginning to see and accept the links between drug abuse and socioeconomic status - or quite frankly drug abuse and life occurrences.
Addiction is classified under the DSM5 as an illness so why do people still seem to argue the idea of personal choice. At SOME point, it is no longer about personal choice and starts becoming a conversation about addiction.
I believe if people started seeing it this way- maybe they would start limiting the power of big tobacco.
To piggyback off of Rebecca and Daniel about youth smoking, this is such an interesting phenomena because youth have access to education and knowledge that so many in the past didn't. Yet for various reasons big tobacco manages to seduce countless young persons each year- maybe, as Daniel eludes, by making sexier products such as "e-cigs".
Thanks for the post and previous comments. This is a really valuable discussion and one that I think is often overlooked because those in the health fields see smoking as obviously harmful without any further debate. When I was living in Brazil I anecdotally observed that a lot more people seemed to smoke, and when I actually looked into the statistics I found that there is an estimated smoking prevalence in adults of 21%. Unlike the U.S., where individual choice/freedom still hold a lot of significance in political debates, the national government took steps this past year to ban smoking in all public places. While there are large problems and questions of enforcement of such laws, I think the effort highlights an interesting aspect of the debate.
ReplyDeleteI think the lack of political will to reduce smoking in the U.S. can easily be attributed to the enormous influence of corporate special interests. The individual freedom/expression argument falls short when you consider that tobacco smoke is known to harm others. Both constitutionally and otherwise there are restrictions on individual freedoms when those action would either infringe upon the rights of others or threaten a common good. These include laws such as those against operating a vehicle after drinking, or restrictions on public speech if it can be classified as hate speech targeted against certain groups. So, there's definitely strong legal arguments to be made for banning smoking in all public places. However, given the political climate in the U.S. I think such action is unlikely and that global health organizations should take stronger positions against smoking and highlight the issue more as to help reshape the debate.
This is a great discussion everyone! I think it would be remiss if we didn't discuss tobacco companies huge role in smoking regulation, as Adriana mentioned. Their interest in the bottom line has influenced legislation regarding tobacco and smoking since the beginning of their existence. In the past they attempted to confuse the public about the ill effects of smoking by hiring their own scientists to perform research. They employ similar tricks to this day but moreso in LMICs. They're prevalence in LMICs can be attributed to many economic factors such as monopolizing the market. However, in the past they have faced backlash from LMICs (Thailand) who equated their presence in the country to colonization, which makes a lot of sense to me. Also, the only treaty the WHO ever wrote was the FCTC which recognizes the role of tobacco corporations in health. So I think we're making great strides here but we definitely have a lot more work to do.
ReplyDeleteThanks for everyone's comments!
ReplyDeleteI forgot to add the strategy of smoking company: advertising positive value with smoking behavior like Hiba mentioned, the tobacco company employ this trick in LMICs. Influencing U.S. trade policy, like Dr. So mentioned the TRIP negotiation in Doha conference. I guess for this anti-smoking combat, we need to integrate knowledge and experiences from various of subject, medicine, public health, law, business, etc.
By Hanati Hailati
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ReplyDeleteI agree on Adriana's argument that political will of controlling tobacco is not enough to be implemented in real action. Political power as well as political will is another big issue in tobacco control legislation. The reason why tobacco company has always been successful is because of their political power based on their wealth. Therefore,to control tobacco, there should be collaboration of several actors to maximize political power. First, we should propose a concrete timeline like millennium development goals to achieve definite targets such as halve the smokers by 2020. Second, fund raising for researches and administration is critical to fight for a long war like this. Third, government and world organization should involved and protect people who fight against tobacco, because it might be easy for tobacco companies to handle individuals.
ReplyDeleteLast year, South Korea National Health Insurance Service sued international/domestic Tobacco companies in Korea. We expect NHIS to win this war, because tobacco company should follow the Product Reliability Act that every product should be safe for human being. If a sanitizer caused cancer by using it 5-10 years, the product company should be responsible to that. This is not different for tobacco, that tobacco company should be responsible for their products. Since there is no sanitizer have risk phrase like tobacco that "this sanitizer might cause cancer". Governments are just too generous to let tobacco companies sell harmful products.