Tobacco Control in Developing Countries Tobacco Control in Developing Countries The World Bank World Health Organization
Curbing the Epidemic Curbing the Epidemic Governments and the Economics of Tobacco Control Governments and the Economics of Tobacco Control The World Bank The World Bank
Why this book? Why this book? Economic arguments around tobacco control are unclear Economic arguments around tobacco control are unclear and often debated and often debated I In 1996 In 1996 , an Asian Health Minister stated “cigarette , an Asian Health Minister stated “cigarette I producers are making large contributions to our economy... producers are making large contributions to our economy... we have to think about workers and tobacco farmers” we have to think about workers and tobacco farmers” In 1997, In 1997, The Economist I The Economist commented "most smokers (two- commented "most smokers (two- I thirds or more) do not die of smoking-related disease. They thirds or more) do not die of smoking-related disease. They gamble and win. Moreover, the years lost to smoking come gamble and win. Moreover, the years lost to smoking come from the end of life, when people are most likely to die of from the end of life, when people are most likely to die of something else anyway” something else anyway” Source: Tobacco Control 1996, The Economist 1997
Methodology Methodology I Consultation workshops Consultation workshops: : Washington D.C. Washington D.C. I 1996, Beijing 1997, Cape Town 1998 1996, Beijing 1997, Cape Town 1998 N Cape Town Proceedings published in 1998 Cape Town Proceedings published in 1998 N I 19 Background papers 19 Background papers I N 40 economists, epidemiologists, and control experts 40 economists, epidemiologists, and control experts N from 13 countries. from 13 countries. N Reviews of literature Reviews of literature N N New analyses New analyses N N 2 rounds of peer review 2 rounds of peer review N I Synthesized in World Bank Report Synthesized in World Bank Report I “Curbing the Epidemic ” “Curbing the Epidemic ”
Outline of Book Outline of Book I Tobacco use and its consequences Tobacco use and its consequences I I Analytics of tobacco use Analytics of tobacco use I I Demand for tobacco Demand for tobacco I I Supply of tobacco Supply of tobacco I I Policy directions Policy directions I
Per capita cigarette consumption Per capita cigarette consumption has increased in developing has increased in developing countries countries 3500 Annual per adult cigarette consumption 3000 2500 2000 Developed Developing 1500 World 1000 500 0 1970-72 1980-82 1990-92 Year Source: WHO 1997
Large and growing number of deaths Large and growing number of deaths from smoking from smoking Past and future tobacco deaths (in millions) Time Millions of deaths 1901-2000 100 (mostly in developed countries) 1,000 (mostly in developing 2001-2100 countries) N 500 M among people alive today N 1 in 2 of long-term smokers killed by their addiction N 1/2 of deaths in middle age (35-69) Source: Peto and Lopez, 2000
Trends in Smoking in Norwegian Males Trends in Smoking in Norwegian Males by Income Group by Income Group 85% 75% High income Male smoking prevalence 65% 55% Low income 45% 35% 25% 1955 1960 1965 1970 1975 1980 1985 1990 Year Source: Lund et al. , 1995
Smoking is more common among the less educated Smoking is more common among the less educated Smoking prevalence among men in Smoking prevalence among men in Chennai, India, by education levels Chennai, India, by education levels 6 4 % 5 8 % 6 0 % Smoking prevalence 4 2 % 4 0 % 2 1 % 2 0 % 0 % Illiterate < 6 y e a r s 6 - 1 2 > 1 2 years years L e n g t h o f s c h o o l i n g Source: Gajalakshmi and Peto 1997
Smoking accounts for much of the mortality gap Smoking accounts for much of the mortality gap between rich and poor between rich and poor Risk of death of a 35 year old male before age 70, Risk of death of a 35 year old male before age 70, by education levels in Poland, 1996 by education levels in Poland, 1996 60% 50% Other causes 40% 28% Attributed to SMOKING 30% but would have died anyway at ages 35-69 5% 22% Attributed to SMOKING 20% 21% 1% 10% 19% 1% 9% 5% 0% Higher Secondary Primary Source: Bobak et al. , 2000
Why should governments intervene? Why should governments intervene? Economic rationale or “market failures” Economic rationale or “market failures” I Smokers do not know their risks Smokers do not know their risks I I Addiction and youth onset of smoking Addiction and youth onset of smoking I N Lack of information and unwillingness to Lack of information and unwillingness to N act on information act on information N Regret habit later, but many addicted Regret habit later, but many addicted N I Costs imposed on others Costs imposed on others I N Costs of environmental tobacco smoke Costs of environmental tobacco smoke N and health costs and health costs Source: Jha et al. , 2000
Tobacco addiction starts early in life Tobacco addiction starts early in life U S (both sexes, 100 born 1952-61) C h i n a (males,1996) Cumulative uptake in percent U S 80 (both sexes, born 1910-14) India 60 (males, 1995) 40 20 0 15 20 25 Age I Every day 80,000 to 100,000 youths Every day 80,000 to 100,000 youths I become regular smokers become regular smokers Source: Chinese Academy of Preventive Medicine 1997, Gupta 1996, US Surgeon General Reports, 1989
Underestimated risks of smoking Underestimated risks of smoking N 7 in 10 of Chinese smokers thought smoking does 7 in 10 of Chinese smokers thought smoking does N them “little or no harm” them “little or no harm” N Risks not Risks not internalized internalized: personal risks perceived : personal risks perceived N lower than average risks lower than average risks N Risks of addiction downplayed: only 2 in 5 of US Risks of addiction downplayed: only 2 in 5 of US N adolescents intending to quit actually do adolescents intending to quit actually do N in high-income countries, 7 in 10 smokers wish they in high-income countries, 7 in 10 smokers wish they N had not started had not started Source: Kenkel and Chen, 2000; Weinstein, 1998; SGR, 1989 and 1994
Smoking versus other risks Smoking versus other risks (alcohol, fast driving) (alcohol, fast driving) N Risk of addiction is greater for smoking Risk of addiction is greater for smoking N N No “learning” from youthful excesses No “learning” from youthful excesses N N Risk of death from smoking is much higher: of Risk of death from smoking is much higher: of N 1000 males smokers aged 15 1000 males smokers aged 15 N 125 die from smoking in middle-age 125 die from smoking in middle-age N N 20 die from road accidents or violence (30 from all 20 die from road accidents or violence (30 from all N alcohol-related conditions) alcohol-related conditions) Source: Jha et al., 2000
Healthcare costs from smoking Healthcare costs from smoking I Annual (gross) healthcare costs: Annual (gross) healthcare costs: I N 0.1-1.1% of GDP, or 0.1-1.1% of GDP, or 6 -15% of total health costs 6 -15% of total health costs in high- in high- N income countries income countries N proportionally similar in lower-income countries proportionally similar in lower-income countries N I Net (lifetime) healthcare costs: Net (lifetime) healthcare costs: I N Differences in lifetime costs are smaller than annual Differences in lifetime costs are smaller than annual N costs costs N Best studies do suggest there are net lifetime costs Best studies do suggest there are net lifetime costs N N Pension or “smokers pay their way” arguments are Pension or “smokers pay their way” arguments are N complex complex Source: Lightwood et al. , 2000
Government roles in intervening Government roles in intervening I To deter children from smoking To deter children from smoking I I To protect non-smokers from others’ smoke To protect non-smokers from others’ smoke I I To provide adults with necessary information to To provide adults with necessary information to I make an informed choice make an informed choice N First-best instrument, such as youth restrictions, are First-best instrument, such as youth restrictions, are N usually ineffective. Thus, tax increases are justified, usually ineffective. Thus, tax increases are justified, and are effective. and are effective. N Tax increases are blunt instruments. Tax increases are blunt instruments. N Source: Jha et al ., 2000
Adam Smith on tobacco tax Adam Smith on tobacco tax " Sugar, rum, and tobacco, are commodities which are no where necessaries of life, which are become objects of almost universal consumption, and which are therefore extremely proper subjects of taxation” Source: An Inquiry into the Nature and Causes of The Wealth of Nations , Book V, Chapter III, pages 474-476, 1776;
Unless current smokers quit, smoking deaths Unless current smokers quit, smoking deaths will rise dramatically over the next 50 years will rise dramatically over the next 50 years 520 Baseline 500 500 Tobacco deaths (million) 400 340 If proportion of 300 young adults 220 taking up smoking 200 halves by 2020 190 100 70 If adult consumption 0 0 halves by 2020 1950 2000 2025 2050 Year Source: Peto and Lopez, 2000
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