Tobacco elimination: an economic and public health imperative

21 January 2017:

Last week, the National Cancer Institute (NCI) of the US National Institutes of Health, in collaboration with WHO, released The Economics of Tobacco and Tobacco Control—the 21st volume in a series of monographs on tobacco control produced from the NCI. The almost 700-page report contains an impressive body of work from more than 60 authors worldwide. It provides a comprehensive summary of the latest evidence and research, and what needs to be done on two areas. First, the economics of tobacco control, including tobacco use and growing, manufacturing and trade, and tobacco control interventions and policies to reduce tobacco consumption and its effects on health and disease burden. Second, the economic implications of global tobacco control efforts since the coming into force of the WHO Framework Convention on Tobacco Control in 2005. Will this report make a difference?

Currently, around 6 million people die from tobacco use every year, a figure that is projected to rise to 8 million by 2030 unless stronger measures are taken. Most (80%) of deaths are expected to occur in low-income and middle-income countries, and everywhere tobacco use is concentrated in the poorest and most vulnerable people. The report highlights the huge economic burden on countries and societies. Tobacco use costs global economies more than US$1 trillion annually through loss of productivity and health-care expenditure.

Demand reduction policies and programmes for tobacco products, including comprehensive bans on tobacco industry marketing activities, implementation of smoke-free policies, strong graphic health warning labels, and tobacco cessation programmes are all highly effective and cost-effective in reducing tobacco use. But of all the interventions, the monograph reaffirms that substantial tax and price increases are the most effective tobacco control measures. Higher prices reduce consumption. Tax generates considerable revenues for governments, but the report shows only a fraction is being used for tobacco control or invested in other health programmes. For example, in 2013–14, around $269 billion in government revenues was generated from global tobacco excise taxes, but globally, governments spent less than $1 billion on tobacco control activities. The monograph does well to dispel the economic arguments that tobacco companies maintain against tobacco control measures. For example, sizeable increases in taxes do not increase illicit trade in tobacco products, nor do they harm economies. On the contrary, tobacco control, especially tax increases, reduces the disproportionate burden that tobacco use imposes on the poor.

The report’s overall message that tobacco control interventions and policies are good for public health and benefit economies, especially in poor countries, is not new. But the report’s focus on low-income and middle-income countries is welcome since implementation of these policies is lagging behind in these regions, mainly due to the tobacco industry’s tactics and strategies to undermine or subvert tobacco control efforts. Worryingly, the monograph concludes that the market power of tobacco companies has increased recently, posing new challenges to control efforts. The eastern Mediterranean region, where tobacco use is increasing, and Africa, where the epidemic is beginning, are already being targeted as a last chance for the tobacco industry to profit.

To reduce smoking prevalence quickly, taxation is crucial to meet WHO’s goal to cut worldwide tobacco consumption by 25% by 2025 and the Sustainable Development Goal target to reduce premature deaths from non-communicable diseases by a third by 2030. These targets will only be met with large tax hikes. However, only 33 countries are using comprehensive strategies that include substantial tax increases. In places such as China and India (home to about 400 million of the world’s estimated 1·1–1·3 billion smokers), tax increases are too small. It is imperative to convince Ministries of Finance of the importance of tobacco control and increase the visibility of tobacco to the World Bank and other mainstream development groups. A recent Comment in The Lancet Public Health on the New Zealand experience, points to the importance of political champions, a government committed to dramatically reducing tobacco use, and a tireless and fearless non-governmental sector. Only with these types of leadership can real progress be made. The evidence and research needs in this monograph should be accompanied by a bold vision—an action report with ambitious goals that supports the tobacco “endgame”, and which energises the tobacco community and policy makers to make sure we get there.