Do Does Globalization Weaken Nat National Polic licy Autonomy an - PowerPoint PPT Presentation

Do Does Globalization Weaken Nat National Polic licy Autonomy an and Ha Harm Public Hea Health? Eviden ence fr from Tobacco ASHLEY M. FOX, PHD, MA ASHWIN RAMASWAMY, MD ACADEMYHEALTH, GLOBAL HEALTH SESSION 28 JUNE 2016, BOSTON, MA

Background MEN Whereas smoking prevalence has been decreasing in industrialized countries, it is on the rise in many low and middle WO- income countries. MEN

Background • Public health advocates link rising smoking rates in developing countries to international trade agreements that preempt national implementation of policies designed to curb smoking. • International trade agreements, such as the Trans-Pacific Partnership, contain provisions that enable tobacco companies to challenge domestic public health policies that are viewed as barriers to trade. • These include: • the banning of flavored cigarettes, • advertising restrictions, • graphic warning labels and • tobacco taxation.

Examples of How Trade Agreements infringe on National Policy Autonomy Challenges to Banning Flavored Cigarettes in US US, 2009, Family Smoking Prevention and Tobacco Control Act was signed into law ◦ Banned the sale of flavored cigarettes in the US, including candy, fruit, and spice flavors to reduce teen smoking ◦ In 2010, Indonesia—the world’s largest producer of clove cigarettes—alleged that the law was inconsistent with US trade obligations under various World Trade Organization’s (WTO) agreements.

Examples of How Trade Agreements infringe on National Policy Autonomy, cont. Challenges against Australia’s Plain Packaging Law In 2011 Australia passed legislation to create uniform cigarette packaging with brand names would be listed in small font and large pictorial warnings/a quit-line phone number comprising the remainder. Philip Morris Asia sued Australia, arguing that the bill violates conditions of a 1993 investment agreement between Hong Kong and Australia. The case is being heard by a tribunal at the UN. Separately, several tobacco-producing nations (Honduras, Ukraine, Cuba, and the Dominican Republic) claim that Australia’s policy is overly restrictive and contradicts trademark protections afforded by various WTO agreements.

Examples of How Trade Agreements infringe on National Policy Autonomy, cont. Disputes against Uruguay’s Warning Labels In 2006, the Uruguayan government passed regulations to tough its warning labels. In 2010, the Swiss operational hub of Phillip Morris filed suit at the World Bank, claiming that government’s regulations violate a 1991 bilateral investment treaty between Uruguay and Switzerland.

Examples of How Trade Agreements infringe on National Policy Autonomy, cont. In US Trade Agreements with the following countries, cigarette imports are required to be tariff free: ◦ Chile (2004), ◦ Singapore (2004), ◦ Peru (2009), ◦ South Korea (2011), ◦ Colombia (2011), and ◦ Panama (2011) This means that these countries cannot tax the importation of a product into their country that is known to be harmful to the health of their public.

Research Question Little empirical evidence exists regarding the effects of trade openness on domestic tobacco policies and smoking prevalence. ◦ Country smoking rates may be more a function of economic development (modernization theory) ◦ Rise of unhealthy lifestyles as citizens have more disposable income ◦ Cultural globalization may give rise to increased smoking rates to appear “modern” or “western” (diffusion theory) ◦ Countries may ignore trade rules or find ways around them Do countries that are more economically or culturally globalized smoke more and have weaker anti-smoking laws?

Methods 1. We assess predictors of smoking prevalence across countries over time (1989-2012). 2. We examine characteristics of countries with stronger anti- smoking policies to assess whether globalization reduces national policy autonomy (2008, 2010, 2012). ◦ Main IV: Globalization indices ◦ Controls: GDP per capita, cigarette imports/exports, age structure of country, democracy, region.

Methods: Data and Sources DVs= Smoking Prevalence (150 countries, 1989+) . ◦ Prevalence of daily smoking for all types of tobacco. Source: The IHME houses the data published in the study, Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA. doi:10.1001/jama.2013.284692. Anti-Smoking Policies . (128 countries, 2008, 2010, 2012). Source: WHO Data Repository IV= Globalization. Source: Konjunkturforschungsstelle (KOF) index of globalization, Swiss Economic Institute. ◦ Economic globalization : Trade flows-FDI, stocks, portfolio investment, income payments to foreign nationals; Trade restrictions- hidden Import barriers, mean tariff rate, taxes on international trade. ◦ Social globalization : Information flows- number of internet users per 1000 people, televisions per 1000 people, and trade in newspapers as a percent of GDP; Personal contacts-international telephone and mail traffic per capita, transfers (% GDP), international tourism, % population that is foreign. ◦ Cultural globalization : Number of McDonald's restaurants per capita; number of Ikea per capita and trade in books.

Methods: Data and Sources Controls GDP per capita. Source: World Development Indicators Democracy. Polity IV measure-ranges from full autocracy (0) to full democracy (100) Domestic Cigarette Imports and Exports. Source: FAO stats Region : North America; Latin America and the Caribbean; Eastern Europe and Central Asia; Western and Northern Europe; East Asia and the Pacific; sub-Saharan Africa; Middle East and North Africa. Population over age 65. Source: World Development Indicators

Hypotheses Countries with rising degrees of economic globalization should have increasing rates of smoking and fewer anti-smoking laws over time. On the other hand, it is possible that entering trade regimes and engagement in global economic activity has no direct effect on national policy autonomy or the degree to which people smoke. Rather, smoking rates may be increasing in countries due to processes of economic development and Westernization. ◦ In this instance, we would expect to see that as country GDP increases, smoking rates increase. ◦ Likewise, countries with rising degrees of cultural globalization should see higher increases in smoking rates.

Analysis Smoking Prevalence Models ◦ GEE models (xtgee command in Stata 13), which takes into account the over-time correlations of the data for the period 1989-2012. ◦ All countries, LMICs only Anti-Smoking Policy Models ◦ Ordered logistic random effects models (xtologit command in STATA 13)

Results: Smoking Prevalence Models All countries LMICs (1) (4) (1) (4) VARIABLES prevalence prevalence prevalence prevalence Overall Globalization 0.06*** 0.02** • Globalization (0.040 - 0.077) (0.000 - 0.042) Econ Globalization 0.04*** 0.02*** positively (0.022 - 0.048) (0.006 - 0.035) Social Globalization 0.01 -0.01 predicts smoking (-0.015 - 0.042) (-0.043 - 0.020) Cultural Globalization -0.00 0.01 prevalence, and (-0.013 - 0.011) (-0.009 - 0.019) this is mostly GDP per capita -0.00*** -0.00*** 0.00*** 0.00*** (-0.000 - -0.000) (-0.000 - -0.000) (0.000 - 0.000) (0.000 - 0.000) driven by Over 65 pop -0.18*** -0.12** -0.30*** -0.25*** (-0.268 - -0.084) (-0.212 - -0.019) (-0.444 - -0.149) (-0.412 - -0.090) economic Cigarette Exports -0.00* -0.00* -0.00*** -0.00*** globalization. (-0.000 - 0.000) (-0.000 - 0.000) (-0.000 - -0.000) (-0.000 - -0.000) Cigarette Imports -0.00 -0.00** 0.00 0.00 (-0.000 - 0.000) (-0.000 - -0.000) (-0.000 - 0.000) (-0.000 - 0.000) Polity IV 0.05*** 0.04*** 0.04*** 0.03** • Higher GDP also (0.019 - 0.072) (0.013 - 0.069) (0.014 - 0.064) (0.004 - 0.056) North America (ref) ref ref predicts smoking Europe and Central Asia 6.08 5.66 ref ref prevalence (-1.623 - 13.779) (-2.064 - 13.377) Latin America and the Carribean -7.56* -8.05** -14.22*** -14.73*** among LMICs. (-15.453 - 0.339) (-15.983 - -0.112) (-18.003 - -10.435) (-18.625 - -10.827) Middle East and North Africa -4.75 -4.75 -8.37*** -7.80*** (-12.716 - 3.222) (-12.826 - 3.335) (-12.543 - -4.205) (-12.355 - -3.255) East Asia and the Pacific 2.04 1.71 -1.30 -1.48 (-5.935 - 10.018) (-6.298 - 9.714) (-5.492 - 2.884) (-5.712 - 2.758) South Asia -2.32 -2.19 -5.64** -5.54** (-11.260 - 6.613) (-11.167 - 6.783) (-11.157 - -0.131) (-11.066 - -0.021) Sub-Saharan Africa -12.00*** -12.72*** -16.42*** -16.93*** (-19.786 - -4.206) (-20.560 - -4.875) (-19.712 - -13.132) (-20.342 - -13.520) Constant 23.51*** 24.03*** 28.87*** 28.99*** (15.835 - 31.186) (16.304 - 31.754) (25.867 - 31.869) (25.854 - 32.135) *Year included but not shown Observations 3,032 3032 1,997 1997 Number of groups 150 150 102 102 ci in parentheses, *** p<0.01, ** p<0.05, * p<0.1