Banking on health

Dr Prabhat Jha: Sustainable growth must address tobacco toll

orld-wide tobacco consumption is increasing by about 2 percent a year, with the greatest rise in the non-industrialised countries of the South, as well a eastern Europe. China is the world's leading consumer of cigarettes (31 percent), followed by the US (10 percent), the CIS countries (7 percent) and Japan (six percent).

The World Bank upholds WHO estimates that the annual global tobacco death toll is about three million--a third in the developing countries--and given the current trend will rise to about 10 million by the 2020s. Developing nations will experience most of this increase, accounting for an estimated seven million death by this time.

With tobacco consumption declining in parts of the west, the tobacco industries targeted Asian markets intensively during the 1980s, and women in particular. Attention then shifted to eastern Europe and central Asia with their enormous marketing opportunities, but spreading neo-liberalism and deregulation in the developing world makes it the frontrunner on the tobacco road to nowhere.

Economic toll

A chief source of misunderstanding about the health effects of tobacco is the long delay between cause and full effect.

A chief source of misunderstanding about the health effects of tobacco is the long delay between cause and full effect. For the first 25 years of increased smoking within a particular population there is little effect on the country's overall death rate. Thereafter comes a tidal wave of tobacco-induced deaths.

The International Development Research Centre (IDRC) of Canada estimates that there are about 800 million smokers at present in developing countries, and the numbers are increasing. Some half of the men and about 10 percent of the women in southern countries smoke. The tobacco market is being directed increasingly at women and youth.

In industrialised countries where smoking has been common for many years, direct health care costs plus indirect costs for lost productivity are significantly higher than the market value of tobacco. The net economic toll of tobacco is profoundly negative, and costs of treatment, mortality and disability exceed estimates of the economic benefits to producers and consumers by some $200 billion each year.

Development issue

The World Bank has an official policy of not lending for tobacco production, processing or marketing.

The IDRC stresses that in the developing world, tobacco poses a major challenge, not to health but also to social and economic development. Development agencies also should start to take up the issue as part of their assistance and partnership agendas. The Centre argues that resources available from the donor community to assist research and respond to the tobacco pandemic are inadequate in view of the growing global burden of tobacco-induced diseases.

Dr Prabhat Jha, health specialist at the World Bank Group based in Washington DC, believes that developmental organisations like the World Bank can help low and middle-income countries to avoid tobacco's health and economic losses in several ways.

"First, the World Bank has an official policy of not lending for tobacco production, processing or marketing. Bank activities in the health sector--including analytic work, policy dialogue and lending--discourage the use of tobacco products. The Banks Policy also permits exemption of tobacco and tobacco-related producer or consumer imports from borrowers' agreements with the Bank to liberalise trade and reduce tariff levels.

Effective control

"Second, international organisations can work with governments on a more coordinated tobacco control strategy that aims to: make tobacco control a more prominent development priority; illustrate the health-care costs and other economic costs of tobacco use through analytic work; focus on appropriate effective and cost-effective interventions for tobacco control; increase the number of research studies on causes and consequences of tobacco use; develop global or regional regulatory and taxation approaches; and invest in capacity in low and middle-income countries to study and monitor the epidemic of tobacco and to promote effective control."

Jha says that international organisations can also contribute to national efforts to cut tobacco consumption by encouraging a range of initiatives that isolate tobacco in society.

"They can encourage and finance evidence-based tobacco policy that comprises high prices above inflation; serious and prominent health warnings; complete bans on advertising and promotion of all tobacco-associated products or trademarks, as in Turkey; focused mass-media education messages; and the capacity to monitor tobacco burdens. These efforts contribute to economic development in low and middle-income countries by improving health status and minimizing cost-escalation."

The focus by the tobacco industry on expanding its markets in east Europe is seen by many observers as bad news and potentially responsible for a catastrophic impact on people's health--particularly men's--and chances for sustainable economic growth.

Economic growth and health

Sustainable economic growth must address improved adult health, and this means cutting tobacco use.

"The story of declining male health status in eastern and central Europe is often told but cannot be taken for granted: one in two males aged 35 will die before age 70, about the same as in sub-Saharan Africa. Since 1987, annual death rates in males aged 55-64 have fallen by over 30% in England and Wales and Mexico, but have increased by 60% in Russia. Most of this increase in the eastern and central European area is driven by ischemic heart disease, much of which is caused by tobacco. Effective tobacco control could reduce substantially this excess male mortality, but to do so would require much more attention of governments to public health in general, and tobacco specifically."

According to Jha, the implication for economic planners in central and eastern Europe is clear: sustainable economic growth must address improved adult health, and this means cutting tobacco use, reducing saturated fat intake, controlling high blood pressure and ensuring broad access to low-cost treatments for established disease.

"To not do so will lead to loss of productive members of society and household income earners, a marked cost escalation in health services, and social erosion. As is demonstrated by economic analysis in the US, these losses exceed greatly any short-term economic gains from investment in tobacco production or marketing. Moreover, any arguments that smokers pay their own way through reduced use of pensions may be grossly inaccurate in central and eastern Europe: such analyses fail to account for value of human life, and for the lower pension coverage and benefits in these countries."

Production limits

The conversion from tobacco production to other viable forms of enterprise appears to be the only way to turn the tide of tobacco expansion, and surely in the long-run would be more effective than anti-smoking campaigns.

"As I mentioned, the World Bank's Policy encourages diversification away from tobacco, especially in countries with a high dependence on tobacco as a source of income and foreign exchange earnings--that is, those where tobacco accounts for more than 10% of exports.

"Given the global demand and increasing trade, efforts at limiting production should be considered. These, however, require further research on their effectiveness and cost-effectiveness, especially as economies open. One such study is underway in India, supported by the IDRC. The World Bank's current focus on tobacco control has been demand reduction through the steps I have outlined, including advertising and promoting bans to prevent supply-induced demand. Disclosure of production procedures and the chemical content of cigarettes should be part of any production policies." n

Interview by Mark Waller

Their Gains, Our Loss

In its first quarterly report for 1997, British American Tobacco announced a 6% rise in profits. Total trading profit from financial services rose by 3% to 266 million. Total tobacco profit rose by 2% to 370.3 million, slightly less than anticipated due to the closure of a cigarette factory in Germany. Nevertheless, the company announced a rise in total cigarette volumes "with good gains in Asia-Pacific, Amesca (Africa/Middle East/Asia) and Europe more than compensating for reduced volumes in North America."

Smoke Free Europe - A Forum for Networks - 14 AUG 1997

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