I co-authored a book called Global Tobacco Control: Power, Policy, Governance and Transfer (Palgrave, 2012) with Donley Studlar and Hadii Mamudu. It raises two key questions: Why is there often such a wide gap between the size of the tobacco policy problem and the government response? Why, if the tobacco problem is the same across the globe, does policy vary so markedly across political systems?
It is hardback only, which means that it costs £57.50 to buy a physical copy. Or, it is a snip at £38 if you only want to own the words). Still, the chances are that you won’t own a copy and only libraries will stock it (perhaps reinforcing a not very good academic mantra: books are to be written, not read). Instead, you can read the introduction for free here or have it read to you in an annoying monotone here. This blog provides a summary of the whole argument.
The starting point for the study is to identify the size of the problem. For example, smoking represents the number one preventable cause of death and disease in the world. There are 1.35 billion smokers in the world, smoking is still rising in many countries, and it contributes to one in ten deaths worldwide (over six million per year and rising). The book discusses various ways in which we can express these figures, including breaking them down according to gender and comparing so called ‘developed’ and ‘developing’ countries (and discussing the ‘Tobacco Epidemic Model’ in that context – to follow up this point, see Thun et al’s revision) . The latter distinction is highly problematic (some prefer, for example, high-income countries, HICs, and low- and medium-income countries, LMICs) but also quite useful for our purposes (the United Nations Statistics Division lists developed countries as the US, Canada, Japan, New Zealand, Australia and certain (generally Western, not ‘transitional’ Central and Eastern) European countries). Indeed, the well-discussed ‘tobacco epidemic model’ serves partly to describe the smoking equivalent of a ticking time bomb in many ‘developing’ countries.
Our aim is not to complain that governments are not doing enough to address this problem, or to claim that many government actors are in cahoots with tobacco companies to minimise tobacco regulation – largely because the public health literature (and sites such as the Legal Tobacco Documents Library) does a good job of that already. Further, we do not want to get sued and this paragraph is making me nervous enough already (I kid you not – I don’t even want to give the potentially-slanderous impression that tobacco companies are excessively litigious).
Instead, the study seeks to explain why different governments have responded to this problem so differently. Some countries – like Australia, Canada, Finland, Norway, Sweden, New Zealand, the UK and almost the US (it has more limited controls but, generally, played a huge part in the international tobacco control effort) – now have ‘comprehensive’ tobacco control, which means that they combine a large number of mutually-reinforcing policy instruments designed to reduce smoking in the population (see the WHO ‘MPOWER’ report which identifies six key tobacco control measures: 1) ‘monitor tobacco use and prevention policies’; 2) ‘protect people from tobacco smoke’; 3) ‘offer help to quit tobacco’; 4) ‘warn about the dangers of tobacco’; 5) ‘enforce bans on tobacco adverting, promotion and sponsorship’, and 6) ‘raise taxes on tobacco’). Others do relatively little to address the problem. For example, Germany and Japan are often described as ‘laggard’ developing countries while most developing countries (with exceptions such as Brazil, Singapore, Thailand and Uruguay) have relatively limited tobacco controls.
We also want to know why tobacco control in many countries is now so comprehensive when it was minimal until the 1980s. Many countries which now have comprehensive tobacco control regimes did very little to regulate tobacco until the 1980s. In other words, the gap between the initial identification of smoking (and then passive smoking) related ill health and the initiation of a major policy response was, in most cases, 20-30 years, followed by gradual policy change often over a similar period. The book identifies a history of minimal tobacco control, linked to the power of the tobacco industry (careful now), then charts the extent to which governments, aided by public health advocates, have regulated tobacco domestically and internationally in the modern era.
We explain ‘comprehensive’ change in ‘leading developed’ countries with reference to five key factors:
1. Institutional Change. Government departments, and other organisations focused on health policy, have taken the main responsibility for tobacco control, largely replacing departments focused on finance, agriculture, trade, industry and employment.
2. The Problem Is ‘Framed’ Differently. Tobacco was once viewed primarily as a product with economic value, and tobacco growing and manufacturing was often subsidised or encouraged. Now, it is largely viewed as a public health problem; an epidemic to be eradicated aggressively (or, at least, a problem to be minimised).
3. The Balance Of Power Has Shifted Between Participants. The tobacco industry was an ally of government for decades before and after WWII. When policy was coordinated by finance and other departments, tobacco companies were the most consulted. Now, public health or anti-tobacco groups are more likely to be consulted and tobacco companies are often deliberately excluded.
4. The Socioeconomic Context Has Changed Markedly. The economic benefit of tobacco production and consumption has fallen (for example, tax revenue is less important to finance departments once protective of the industry) and the number of smokers and opposition to tobacco control has declined.
5. The Role Of Beliefs And Knowledge. The production and dissemination of the scientific evidence linking smoking (and now passive smoking) to ill health has been accepted within most government circles. The most effective policies to reduce smoking are increasingly adopted and transferred across countries.
Change in these factors has been mutually reinforcing. For example, increased acceptance of the scientific evidence has helped shift the way that governments understand the tobacco problem. The framing of tobacco as a health problem allows health departments to take the policy lead. Tobacco control and smoking prevalence go hand in hand: a decrease in smoking rates reduces the barriers to tobacco control; more tobacco control means fewer smokers.
We explain the lack of policy change in other countries with reference to the same factors:
1. Health departments are often key players, but their voices are often drowned out by other departments, such as agriculture, finance and trade.
2. Tobacco policy arises on the policy agenda rarely and, when it does, the public health frame competes with attempts to frame tobacco as an economic good.
3. Tobacco companies are powerful and the capacity of anti-tobacco groups is often low.
4. Tobacco growing and manufacturing is an important source of jobs, exports and revenue and smoking prevalence is rising.
5. The medical-scientific knowledge has had less of an effect on the policy agenda. Domestic anti-tobacco groups have the motivation but not the resources to ensure the acceptance of tobacco control ideas within their political systems.
In this context, the book identifies the role of international action to close the gap between ‘leading’ and ‘laggard’ countries – a gap which is often linked specifically (but not exclusively) to the fortunes of developed/ developing countries. In particular, the World Health Organisation (WHO) Framework Convention for Tobacco Control has 175 ‘Parties’ (174 countries plus the European Union). The FCTC represents a significant short-term success, because it commits a huge number of countries to comprehensive tobacco control. However, we describe it largely as a tool for agenda-setting rather than a guarantee of long term policy implementation.
Our current work, based on the book and subsequent articles, highlights one of life’s ironies: the countries best placed to deliver on their treaty commitments are the ones which don’t need a treaty so much. They are already well on the road towards comprehensive tobacco control. In contrast, the countries that do need the treaty are the least likely to deliver its aims. This argument is backed up by statistics that we are currently gathering (ooh, the excitement of anticipation) and expert surveys like the one produced by Warner and Tam. We make this argument on the basis of the 5 factors outlined above, which help us identify an unfavourable environment in which to implement the FCTC.
Consider, for example, the experience of China as the world’s largest tobacco using and producing population (one third of the world’s smokers and 38% of tobacco production) (see a paper by Jin). It maintains a state monopoly over tobacco production which provides 8-11% of government revenue. Tobacco control is low on the domestic policy agenda and the health image competes with an unusually strong economic image based on the importance of its tobacco industry and economic growth to the legitimacy of the Chinese government. Tobacco policy (and the implementation of the FCTC) is led by an economic development agency which consults regularly with the tobacco industry, and the health ministry is ‘sidelined’. Public health groups are neither well resourced nor engaged. Public *and physician* knowledge of tobacco harm is low and smoking rates are very high among the police force held responsible for the implementation of bans on smoking in public places. If we combine these factors, we can reasonably expect much slower progress towards comprehensive tobacco control than in (say) the UK even though both have signed up to the same agreement.
Overall, we should not take comprehensive tobacco control for granted. If we live in countries like the UK we are starting to take it for granted, and may even come to accept new measures such as bans on smoking among foster parents and/ or in cars. If we travel elsewhere and smell smoke indoors, we should be quickly reminded that tobacco control varies markedly across the globe, and is likely to vary for decades to come.