Project Syndicate - A global killer is ripping through the world’s poorer countries largely unchecked. Within 25 years, it will cause 10 million deaths a year worldwide –more than malaria, maternal deaths, childhood infections, and diarrhea combined. Over half of the dead will be aged 30 to 69, losing about 25 years of life expectancy. The culprit? Tobacco. The same addiction that became the top preventable cause of death in Western countries has made big inroads in developing countries. Smoking killed 100 million people in the twentieth century, mostly in developed countries. On current trends smoking will kill about one billion people in the twenty-first century, mostly in developing countries.

In India, smoking triples the risk of death from tuberculosis in men and women and may even contribute to the spread of tuberculosis to others. About 1 million people per year will soon die from smoking in China and India. Perhaps 150 million young adults will be killed by tobacco in these two countries alone, unless there is widespread cessation.

But the death tolls of the past need not become the world’s future. We know how to control tobacco use. Cessation by the 1.1 billion current smokers is needed to lower tobacco deaths over the next few decades. Reduced uptake of smoking by children would save lives chiefly after 2050. Quitting works: even those who stop smoking in their 40’s lower their risk of death remarkably, and those who quit in their 30’s have death risks close to lifelong non-smokers.

Tobacco tax increases, dissemination of information about the health risks of smoking, smoking bans in public, complete bans on advertising and promotion, and cessation therapies are effective in helping smokers to quit. Tobacco taxes are probably the single most cost-effective intervention for adult health in the world. A tripling of the excise tax would roughly double the price of cigarettes (as has happened in New York City), preventing about three million deaths per year by 2030. Most OECD countries began to take tobacco control seriously in the last two decades, and have decreased male tobacco deaths since. But effective tobacco control measures are not underway in developing countries. Taxes are about 80% of the street price of cigarettes in Toronto, but less than 30% in Beijing or Delhi. In many countries, tobacco taxes have fallen in real terms. Knowledge of the health risks from smoking is low: 61% of Chinese smokers in 1996 thought tobacco did them “little or no harm.”

Opposition from the tobacco industry is an obvious obstacle to tobacco control. Spurious economic arguments against higher taxes have been debunked in the West, but are still commonly repeated in the finance ministries of developing countries. Money not spent on tobacco would be spent on other goods and services. Indeed, even sharply reduced demand for tobacco would not mean unemployment in most countries. Tax hikes lower consumption and raise revenue in the medium-term: a 10% higher tax means about 7% higher revenue over the medium term. These funds are a precious resource in fighting poverty. In China, a 10% higher price would reduce consumption by 5% and raise enough excise revenue to pay for a basic health package for 33 million poor rural Chinese.

Even in the face of smuggling, higher taxes reduce consumption and raise revenue. Smuggling is abetted by the tobacco industry in order to gain market share and scare finance ministers into lowering taxes. But governments can counter it in several ways: local language warnings with a prominent tax stamp on cigarette packs are one example.

Another common argument against tobacco control – that if people are not harming others, governments should not interfere with their individual decisions – is at odds with both common sense and the evidence. Most smokers become addicted as adolescents or young adults, when shortsightedness and lack of information make rational decisions difficult. In countries with good information about tobacco risks, by the time child smokers become adults, more than 80% wish they never started. Recently, no less than William F Buckley has argued that nicotine addiction cannot be dismissed as free choice.

Moreover, recent economic research finds that higher taxes are justified on welfare grounds, because the costs to smokers are huge (even though the external costs to others might be small), and that higher cigarette taxes do not hurt the poor (since the self-control value of higher taxes helps the poor more). Nobel laureate Amartya Sen wisely reminds us that “it is important that the practical case for tobacco control is not dismissed on the basis of an incomplete libertarian argument.” The agenda is clear. Governments must take tobacco seriously as a leading killer of adults worldwide. International poverty goals must include tobacco control. Developing countries must not be fooled by the empty economic arguments that paralyzed control efforts in the West for so long. The Gates Foundation can fund action and research. There are hopeful signs: more than 160 countries have signed the World Health Organization’s global tobacco control treaty, and the Caribbean heads of state have recently declared they want to tackle tobacco together.

About 150-180 million tobacco deaths would be avoided before 2050 if the proportion of adults in developing countries who quit smoking increases from below 5% today to 30-40% by 2020 (like current quit rates in Canada). Because control policies deter children from starting, even greater benefits can be expected beyond 2050.

Benjamin Franklin once said, “In this world, nothing can be said to be certain, except death and taxes.” Yet we have a tax that could prevent hundreds of millions of premature deaths. It is time to use it.

Prabhat Jha is Professor of Health and Development at the University of Toronto and Director of the Centre for Global Health Research, St. Michael's Hospital.

Copyright: Project Syndicate, 2007.
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